Too Many Words for Dementia?

DSM5I’m still trying to learn how to use the Diagnostic and Statistical Manual (DSM)-5 and just found out that the diagnostic category Dementia was removed. It’s been replaced by the 3 word term, “Major Neurocognitive Disorder.” He strongly advises against its use.

Why is delirium not a “major neurocognitive disorder”? I’m having a little trouble  seeing why replacing one word with three makes any sense when this is unlikely to change our clinical management in any substantial way.

I should probably also tell you that the DSM-5 category “Minor Neurocognitive Disorder” doesn’t really impress Dr. Allen Frances, who wrote “Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5” [1].high res image essentials of psychiatric dx allen frances And he still uses the word “dementia.”

If physicians have had a difficult time opening and having the difficult conversation of what dementia means to their patients, and just what can be done about it, how does creating a three word term make it easier?

“You have Major Neurocognitive  Disorder.”

“Oh my god, that sounds terrible, Major Neurocognitive Disorder. Does that mean I’m crazy?”

“Er, no. We used to call it “dementia.”

“Oh, yeah. My grandmother had that.”

I’m not saying that Major Neurocognitive Disorder (soon to be shortened to MND, no doubt) might not be an improvement in reconceptualizing the diseases in this category, at least for clinicians. I just wonder how much it changes what the diseases mean to patients and their families and what we do for them. The word “dementia” is at least recognizable.

I asked a couple of colleagues what they thought of the change, and got some interesting train-of-thought responses:

There was a well-intended thought (but I never agreed) that “dementia” was a frightening term and stigmatizing like “retardation” – so the idea was to avoid it…. BUT my personal view is that the result is confusion for both the field and our patients!   So I will keep using the term dementia!

…it’s just the latest in a series of name changes, I like this one better than previous…“Dementia” is so tied to “loss of memory”, and there are progressive-cognitive-loss syndromes which are devastating and don’t include much memory loss. This is a more inclusive term, and one that lets me look judges and lawyers in the eye and say yes, it’s a real disorder.

...colloquially I will use “dementia”, but I do like neurocognitive disorder a whole lot better than “organic brain syndrome” or “primary degenerative dementia” or whatever.

“organic brain syndrome” means both the patient and the doctor have stopped thinking. Just a historical note.

I entirely agree …that for purposes of communicating with other fields and attorneys – it does sound much more like a “real disorder” to use “neurocognitive” – the only flip side is that to families and patients it will be confusing and vague doctor-speak. Also … I think it is amusing to consider whether this is a cognitive disorder that is not “neurocognitive”?    So is the “neuro” necessary to distinguish it from a “peripheral” cognitive disorder?   Or a viscero-cognitive disorder or what?

My concern is with frontal “dementia”—which doesn’t have memory loss, and is therefore a hard sell (I am thinking of the 4 hour appeal hearing on one of my frontal dementia patients—their expert witness, a neurologist in private practice, couldn’t see it).  If I can say yes, we call it “dementia” shorthand, but the official book says this syndrome with no memory loss but very impaired social/etc functioning IS a disorder, well, life is easier; we may get more attention to this devastating form of dementia, etc.  Families are just confused by “Alzheimer’s” vs “dementia” vs “Dad still talks about the 1950s” etc.

I was also a little puzzled about the change of “Somatization Disorder” to “Somatic Symptom Disorder.” Changing the name did not change how I talk to patients and families about it and what I tell primary care physicians to do about it–or more properly, what not to do, i.e., referrals to multiple specialists, invasive procedures, prescriptions for many drugs with toxic and addictive potential, all in a misguided attempt to fix it.

The Elements of Style Will StrunkThis whole thing reminded me of Will Strunk’s book, The Elements of Style [2]. In the section on Elementary Principles of Composition, there are guidelines on how to “Omit Needless Words.” Strunk says,

“A sentence should contain no unnecessary words, a paragraph no unnecessary sentences, for the same reason that a drawing should have no unnecessary lines and a machine no unnecessary parts. This requires not that the writer make all his sentences short, or that he avoid all detail and treat his subjects only in outline, but that every word tell.”

Maybe we have too many words.

1. Frances, A., MD (2013). Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5. New York, The Guilford Press.

2. Strunk, W. and E. B. White (2009). The elements of style. New York, Pearson Longman.