Dementia has been defined in two very different ways. The first definition, which came into use in the nineteenth century with the establishment of a nosographic framework for the psychoses, culminated in the concept of dementia praecox in the work of Emil Kraepelin. The second definition concerns altered states in memory and ideation following injury to the brain.
The word dementia, which first appeared in a psychiatric sense in Philippe Pinel's work contrasting mania and dementia, underwent changes in meaning during the nineteenth century. In 1911 Eugen Bleuler, in his discussion of the concept of schizophrenia, centered around dissociation or splitting (Spaltung), proposed bringing together the old notion of "vesanic dementia" (the culmination of psychotic development) and Kraepelin's three forms of dementia praecox: hebephrenic, catatonic, and paranoid.
Sigmund Freud approved of Kraepelin's approach but he criticized the term dementia praecox, as well as the term schizophrenia. This despite the fact that he felt it important to distinguish between the two, writing, in "Psycho-Analytical Notes on an Autobiographical Account of a Case of Paranoia (Dementia Paranoides)" (1911 c): ". . . we shall hope later on to find clues which will enable us to trace back the differences between the two disorders (as regards both the form they take and the course they run) to corresponding differences in the patients' dispositional fixations" (p. 62). In reality, he continued to use both terms indiscriminately. He focused his study of the psychoses on paranoia in the essay cited above. After "On Narcissism: An Introduction," (1914) he proposed to distinguish among the neuroses, the psychoses, and the perversions. In Freudian theory, dementia praecox consists of a withdrawal of object libido onto the ego through regression and fixation. Freud later went on to specify its linguistic characteristics (words are subjected to the primary process) and its functioning (reality testing is no longer operant; verbal delusions are an attempt at healing), but essentially it was Freud's successors who developed a psychoanalytic theory of the psychoses.
In current usage, the term dementia refers to erosion of the intelligence caused by many different kinds of damage to the brain: degenerative dementias (dominated by Alzheimer's disease), vascular diseases, infectious diseases, toxic conditions, or metabolic disorders. Clinical treatment of dementia from a psychoanalytic perspective runs up against problems of theoretical elaboration. Psychoanalysis has limited applications for these conditions and is used mainly in the early stages of illness. The goal is to limit the breakdown of identity for a certain time. The gradual erosion of the capacity for symbolization and the work of representation owing to memory loss, the weakening of repression and the breaking through of the protective shield, and the instinctual flooding that ensues, has led to reliance on a therapeutic approach focusing on the reconstitutive function of the affects as the basis for mental activity, since, as Michèle Grosclaude suggested in Le Statut de l'affect dans la psychothérapie des démences (The status of the affects in the psychotherapy of dementia; 1997), verbal therapies are among the first to be affected by the degenerative process. Denial, projective delusions, and heightened anxiety are all typical of these conditions.
See also: Ego; Infantile psychosis; Infantile schizophrenia; Narcissism, secondary; Organic psychoses; Paranoid psychosis; Paraphrenia; "Psycho-Analytic Notes on Autobiographical Account of a Case of Paranoia (Dementia Paranoides)"; Schizophrenia; "Unconscious, The" Bibliography