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Book Forum: Aging and Geriatric Psychiatry   |    
Handbook of Aging and Mental Health: An Integrative Approach
HOWARD S. SUDAK, M.D.
Am J Psychiatry 2000;157:1715-1716. doi:10.1176/appi.ajp.157.10.1715
View Author and Article Information
Philadelphia, Pa.

Edited by Jacob Lomranz. New York, Plenum, 1998, 539 pp., $85.00.

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Should "handbook" connote a small how-to-do-it book, like those which residents often tote, you may be surprised by this heavy book. No spiral binding but 500-plus pithy pages will confront you. This carefully edited work, a volume in the Plenum Series in Adult Development and Aging, derives from the first Herczeg International Forum on Aging: Towards Theories on Aging and Mental Health, sponsored by the Herczeg Institute on Aging at Tel Aviv University, where the editor is in the Department of Psychology. Attendees at the forum had distributed their papers to one another beforehand, and their final chapters frequently cross-refer to one another’s material. Although the forum was held in Israel, only four of the 23 chapters are from centers in Israel, one is from Germany, and the rest are from the United States.

The book’s focus is both gerontological and geriatric. The gerontological share (roughly 50%) is largely developmental and quite theoretical. The geriatric portions are more clinical and empirical. There are more contributing psychologists and social workers than psychiatrists, and there is a clear bias toward nonbiological explanations of pathology (Ira Katz’s excellent chapter notwithstanding). The book is divided into seven sections: 1) Well-Being, Adjustment, and Growth Behaviors in Later Life; 2) Stress, Coping, and Mental Health; 3) The Adult Developing Self; 4) Psychodynamics and Psychopathology in Later Life; 5) The Role of the Family in Later Life; 6) Memory and Dementia; and 7) Depression and Aging. Each section consists of three chapters except sections 2 and 5, each of which comprises four chapters.

Reviewers typically complain that space constraints prevent them from adequately giving the reader a sense of the book, but this is certainly one of the most difficult books to summarize that I have ever reviewed. The chapters are dense and complex (especially for someone like me, a nonexpert in the field). In part 1, Shmotkin’s interesting chapter is about subjective well-being and its subtypes; the chapter by Perlmuter and Eads on cognitive and motivational implications of control is very theoretical, introducing a multitude of complex variables; and Ryff, Singer, Love, and Essex advance the concept of resilience from adolescence to old age.

In part 2, Gatz focuses on a developmental diathesis-stress model (while complaining that "much current literature overinvests in biological explanations"). Hobfoll and Wells write about conservation of resources, stress, and aging, looking at the "caravan of resources" obtained, protected, or lost throughout earlier life as well as gains that may come in later life. War trauma and the aged is the focus of Solomon and Ginzburg’s chapter, which shows that there was less posttraumatic stress disorder among Israeli aged when they were exposed to risk equal to the remainder of the population (e.g., the Gulf war) but higher when younger persons were at far higher risk than the rest of the population (e.g., the Lebanon war). (This phenomenon might be similar to that posited in the status-integration theories of Gibbs and Martin [1].) Solomon and Ginzburg also write of the deterioration of health many Holocaust survivors and former prisoners of war suffer as they age, but they do not include the role of altered physiology that such victims may have experienced (e.g., secondary to stress). Kahana and Kahana write of a temporal-spatial model of cumulative life stress.

Part 3 contains the three chapters I found most difficult and most interesting. Hazan’s tour-de-force chapter, "The Double Voice of the Third Age: Splitting the Speaking Self as an Adaptive Strategy in Later Life," indicates that the elderly may reveal only what they perceive society wishes to hear. Kegan’s chapter, "Epistemology, Expectation, and Aging: A Developmental Analysis of the Gerontological Curriculum," presents a sort of developmental line from the socialized mind to the self-authoring mind and, ultimately, the self-transforming mind (which few of us attain, perhaps like the genital character level). The editor, Jacob Lomranz, presents his concept of "aintegration," stating that the prefix "a" denotes "not" (I would have thought it denotes "without" rather than "not," but perhaps he eschewed coining "sintegration" or "imtegration" for the concept). What he is trying to measure is the person’s ability to feel well without necessarily having integrated all the biopsychosocial levels or entities into an overriding whole.

In part 4, Cohler’s chapter, "Psychoanalysis, the Life Story, and Aging: Creating New Meanings Within Narratives of Lived Experiences," indicates that the order in which we report our life stories may reflect more our attempts to maintain a sense of continuity than a veridical life trajectory, with the past continually reconstructed and reworked as need be. Gutmann’s chapter, "The Psychoimmune System in Later Life," deals with the homeostatic decline that often accompanies aging and contains one of the more egregious biological omissions. Gutmann writes of Hemingway’s psychotic depression being the result of his "weakened boxer’s body" and his inability to find "adoring sexually-compliant daughters." Consequently, according to Gutmann, "his final recourse was to alter reality through paranoia." What about Hemingway’s genes, his family history of depression and suicide—even employing the exact same methods? Peskin’s "Uses of the Past in Adult Psychological Health" concludes the section.

Part 5 begins with Pearlin and Skaff’s "Perspectives in the Family and Stress in Late Life," which reveals the problematic aspects of the family within the family and in external roles as well as the family as a positive resource for the elderly. They point out that giving support as well as receiving support can be therapeutic for the elderly because it enhances the elderly individual’s sense of "mattering." Cicirelli provides a research reference guide regarding the relationship between adult attachment and mental health in aging families. In his chapter, "Multigenerational Families and Mental Illness in Late Life," Lieberman cites work with families of patients with Alzheimer’s disease revealing, for instance, that families ranked high on parent-offspring separation, frequency of family rituals, and tolerance of family conflict had better health and well-being scores. Cicirelli also looks at the role of emotional expression and its vicissitudes (compare with families with high levels of expressed emotion and schizophrenia). Silver reports on a study of Japanese compared with U.S. families in "Cross-Cultural Perspective on Attitudes Toward Family Responsibility and Well-Being in Later Years."

In part 6, Niederehe writes of the frequency of memory complaints compared with actual decrements in memory performance in the elderly. In "Age-Related Cognitive Decline (ARCD) and the Dementia Threshold," Reischies explicates their interrelationships, and the chapter by Korczyn, Kahana, and Friedland shows how education correlates inversely with dementia.

The final part begins with Katz’s "Depression as a Pivotal Component of Secondary Aging: Opportunities for Research, Treatment, and Prevention," the chapter with the most prominent biological focus, highlights the role of medical illness in the elderly and its role in depression and vice versa. Meador and Blazer’s chapter, "The Variability of Depression in Old Age," stresses the need for inclusion of the historical narrative in a biopsychosocial formulation. The final chapter, "Aging and Behavioral Medicine," by Mostofsky, suggests a triaxial model of disease, illness, and predicament as we apply behavioral understanding to psychopathology. He appears a bit too ready to include non-evidence-based alternative approaches for my taste, however.

The book concludes with a brief epilogue on future perspectives by the editor. This is, all-in-all, a comprehensive and multifaceted book, and, despite its nonbiological biases, I recommend it to all mental health professionals, not just geriatric specialists.

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