Paul Schilder believes that the conflicts involved in the psychoses and neuroses of middle and old age center around the feeling of sexual, mental and physical incapacity and the fear that one's erotic value is diminished. If the previous life experience has been unsatisfactory and the patient feels of no value to anyone, he may develop a psychosis. In the involutional depression the primaryconflict is the fear of impairment of bodily function and sexual capacity. The patient may ward off his anxiety by using projection as a defense, fears of castration or of being robbed taking the place of the primary anxieties. At other times patients may use the defenses of increased fantasy and sexual tension, which in turn lead to guilt and again projection. The persecutors in the paranoid types of involutional depression often represent the endangered parts of the body. Introjections may alternate with projections to complicate the picture. The tremendous aggressions of these patients lead to extreme guilt feelings and sometimes to suicide. Often the object relationships become more primitive and part-objects take the place of whole-objects. Involutional paranoia and senile paranoia show predominantly sexual conflicts (fear of failure) which are solved by projections. The organic cases show deterioration, which is essentially a regression in both the intellectual and the emotional spheres. Intellectual regression is shown by the return to primitive gestalt principles in drawings and clay modeling. The libidinous regression appears in memory disturbances, which enable the patient to live out his infantile wishes, as, for example, by making himself the hero of every story. Through regression the anxiety of the presenium is overcome. There is a difference, however, from the regression in schizophrenia in that the patient goes back, not to a magical world, but to one which fulfils all his earlier wishes.
M. Ralph Kaufman believes that analysis is applicable to older people both for research and therapy, citing two cases of his own as proof. He discusses Helene Deutsch's views on the menopause as essentially a severe narcissistic blow to the woman, to which she first reacts by attempts at compensation in the form of increased erotic drives. Later a regression occurs in which the genital is devaluated and clitoris masturbation is revived with reversed Oedipus fantasies (the son taking the place of the father and the daughter that of the mother). Kaufman believes that there is a similar conflict in men, occasioned by the loss of potency, and that the differences between the sexes are due to the differences in available sublimations. He cites some material suggesting that in organic brain disease the forgetting is organically determined but the content of the forgotten material is conditioned by emotional factors. The author believes that the rigidity of the ego, arises from a violent attempt to repress anxiety by means of increased fixity of reaction formations. This leads to a certain 'brittleness of the personality' with a tendency to psychotic reactions in the face of severe conflicts. He mentions the ambivalence of the young toward the old, and concludes by repeating that analysis is the method of choice for research and therapy in the aged.
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Samuel Atkin cites two cases showing that the rigidity of the ego is simply a defense against anxiety, expressed by a refusal to admit the possibility of altering one's evaluation of the environment or of the values of life. In his patients, the defense was treatable but it was quantitatively stronger than the defenses usually encountered. The strength of this defense corresponds to the fact that the organs most affected by old age are those having the highest narcissistic investment: the genitals, the brain and the skin. The ego is weakened by the impairment of the special senses and intelligence, whereas the strength of the pregenital instinctual drives remains unaltered. A weakened ego is thus called upon to master relatively greater quantities of anxiety. The need to retest reality either in life or in the therapeutic situation creates more anxiety which threatens to exceed the ego's capacity to master it. This conflict predisposes to psychosis. A certain portion of this rigidity or conservatism may represent an ego attitude developed from life experiences, but practically this quantum cannot be separated from defensive conservatism. When aging is felt to be an objective danger, the regressive fantasies ('I am a baby') express not only early infantile wishes, but are also defenses against the fear of physical impairment. Atkin suggests that the rate of aging is an important factor determining whether the individual's adaptation to old age will be neurotic or normal. Thus the greater frequency of involutional disturbances in women is probably related to the relative suddenness of the menopause in the woman. The greater variety of sublimations available lessens the shock of aging for men.
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Vander, A.H. (1943). Old Age and Aging. Psychoanal. Q., 12:152-153