Reflecting on Psychosocial Perspectives

Neurobiological models have made a key contribution to progress in the field of cognitive impairment and dementia. However, the assumption that biological determinism underlies all clinical manifestations, together with a sometimes excessively reductionist focus on finding biological, neuronal bases for signs and symptoms, have given way to more person-centered approaches. In persons with dementia, some neuropsychiatric symptoms may be interpreted in nonbiological ways. For instance, deep frustration underlies Goldstein’s “catastrophic reactions,” with sudden outbursts of tears, fears, or anger: these are psychologically understandable in situations where the patient is asked a series of questions in rapid succession or posed problems that overwhelm them. Nevertheless, for these reactions to occur while dealing with stress, the person’s brain reserve must be diminished. Revisiting the classical Jasperian distinction between explaining behaviors through the observation of their regularity and patterns (erklaren) and understanding subjective “meanings” (verstehen), our perspectives on BPSD will be enriched if purely biological explanations are supplemented by a psychosocial understanding of the phenomena involved.

Surprisingly, the feelings and thoughts of persons with dementia are still largely neglected. Part of the literature on informal caregiving, formal care, and clinical interventions reflects the image of the patient as a “sufferer” who has “to be managed” due to so-called challenging behaviors [7]. Algase et al. argued that the designation “disruptive behavior” is more adapted to the caregiver’s point of view than to that of the person with dementia [14]. Vocalization, repeated questions or shadowing may represent ways of expressing needs. Likewise, aggression may reflect diminished ability to deal with frustration or uncertainty; both wandering and screaming may relate to loneliness; and persons with poor opportunities for meaningful social interactions may shout and repeat words or phrases as a form of stimulation [14, 15] . It is also worth reflecting on how unhelpful caregiver behaviors impact the person with dementia. Patients are often innocently infantilized and their views not taken into account: this “malignant positioning” [16] exists not only in institutions but also in families and may even be reproduced by professionals. Moreover, although there is a self in dementia, an “I experience” [17], these patients are sometimes treated like objects rather than persons [18].

On the contrary, person-centered approaches emphasize that persons with dementia are not passive victims of the disease but active agents, seeking meaning and attempting to act [19]. In the last 20 years, impressive work has been done to validate these patients’ perspectives. Examples include Kitwood’s contributions to notions of personhood within the context of brain dysfunction, which does not imply person failure [16]. Sabat highlighted that “a person is a person through others,” discussing how social constructionism and malignant positioning contribute to humiliation, catastrophic reactions, and BPSD [19]. The dominant social identities of “Alzheimer patient” or “burdensome patient” are based on attributes that are certainly not ego-syntonic and have also been renamed “behavioral and personal symptoms of distress” (logical responses to painful situations rather than examples of organically based pathology) [19]. Within the need-driven dementia-compromised model, BPSD are seen as the most integrated and meaningful responses that individuals with dementia can possibly make to their environment [14]. Challenging behaviors may be interpreted as attempts to express or meet psychological or physical needs or to express will [16, 20]. The primary goal should therefore not always be to eliminate behaviors but rather to understand them and adequately meet patients’ needs [9,14]. An additional example is the research on the personal meaning of psychotic symptoms in dementia [21].

Cortesao defined “situation” as a dynamic interaction between personality and circumstances, namely, a family matrix, an occupational matrix, and a sociocultural matrix [22]. This group-analytical psychotherapist actually adopted a systemic view, in line with Engel’s seminal papers on the biopsychosocial model [23]. Adapting this conceptual framework to dementia, persons experiencing BPSD should always be considered “within their situation” or condition.

These perspectives are crucial to a full understanding of BPSD and have clear implications for clinical practice. Non-pharmacological interventions are still neglected to some extent, due not only to implementation difficulties but also to a prejudiced lack of confidence in their effectiveness. However, it is increasingly being recognized that they ought to be the first interventions to be considered in hierarchical approaches to BPSD, as acknowledged in both clinical guidelines and the literature. For instance, Kales et al., in the USA, have published influential papers on the assessment and management of BPSD [6], and the same authors are enriching the discussion on non-pharmacologic interventions in dementia [24]. Their conceptual framework is multifactorial: neurodegeneration associated with dementia, patient factors, caregiver factors, and environmental factors, all deter?mining increased vulnerability to stressors, followed by clinical manifestations in the form of BPSD. One major contribution made by this group has been an insistence on a paradigm shift toward tailored treatments in routine clinical care [6].

 
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