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Psicologia Clínica

versão impressa ISSN 0103-5665versão On-line ISSN 1980-5438

Psicol. clin. vol.28 no.2 Rio de Janeiro  2016




Uma revisão exploratória na demência e esquizofrenia: sobreposições, diferenças e personalidade psicodinâmica


An exploratory review on dementia and schizophrenia: overlaps, differences and psychodynamic personality


Una revisión exploratoria en la demencia y la esquizofrenia: superposiciones, diferencias y la personalidad psicodinámica



Joana Henriques-CaladoI; Maria Eugénia Duarte-SilvaII

IUniversidade de Lisboa, Faculdade de Psicologia, Alameda da Universidade 1649-013 – Lisboa, Portugal
IIUniversidade de Lisboa, Faculdade de Psicologia, Alameda da Universidade 1649-013 – Lisboa, Portugal




Neste estudo são salientadas algumas das sobreposições e diferenças na demência e esquizofrenia. A análise entre uma estrutura psíquica de personalidade e os respetivos diagnósticos é o objeto de exploração desta revisão. A angústia de fragmentação e a relação de objeto fusional apresentam-se relacionadas com a esquizofrenia e, por seu turno, a angústia de abandono e a relação de objeto anaclítica com a demência. Num continuum, a estrutura psicótica surge associada à esquizofrenia e a estrutura borderline à demência.

Palavras-chave: demência; esquizofrenia; personalidade; psicodinâmica; psicopatologia.


This study sets out to review some of the overlaps and differences in dementia and schizophrenia, and to analyze the relationship between a specific personality structure and diagnosis. The anxiety of abandonment and the anaclitic object relationship are related to dementia, while the anxiety of fragmentation and fusional object relationship are associated with schizophrenia. On a continuum, the borderline structure appears associated with dementia and the psychotic structure with schizophrenia.

Keywords: dementia; schizophrenia; personality; psychodynamic; psychopathology.


En este estudio se destacan algunas de las superposiciones y diferencias en la demencia y la esquizofrenia. El análisis de una estructura psíquica de la personalidad y el diagnóstico respectivo es objeto de revisión. La angustia de la fragmentación y la relación de objeto fusional parecen estar relacionadas con la esquizofrenia y, a su vez, el angustia de la abandono y la relación de objeto anaclítica con la demencia. En el continuum, la estructura psicótica aparece asociada con la esquizofrenia y la demencia con la estructura borderline.

Palabras clave: demencia; esquizofrenia; personalidad; psicodinámica; psicopatología.




There is a classical tradition that looks upon neurological disorders as "organic" and psychiatric disorders as "functional", and this dichotomy has been the subject of numerous debates over the last decades (Baldwin & Capstick, 2007; Cheston & Bender, 1999; Kitwood, 1997; Steen, 2007). According to Damásio (2000), the distinction between diseases of the brain and the mind, i.e., between neurological and psychological disorders, only reflects ignorance of the relationship between the brain and the mind, which are inseparable. This points to an extensive overlap of causes, symptoms and treatments of disorders that, when taken together as both neurological and psychiatric/psychological, will lead to a more comprehensive understanding of the pathologies (Steen, 2007). As with the psychiatric disorder schizophrenia, neurological/organic diseases also illustrate an interaction between the brain and the mind, including Alzheimer’s disease, thought to be a typical neurological disease, thus shedding light upon the complex interrelationships between the various biopsychosocial aspects of human experience (Downs, Clare, & Anderson, 2008; Garner, 2004; Schore, 2001; Waddell, 2007; Steen, 2007; Terracciano et al., 2014). Furthermore, not only is Alzheimer’s Dementia presented as the most prevalent etiology of Dementia and prioritized in research, it has also shown high dependency on psychological aspects and psychiatric symptomatology (e.g., Downs et al., 2008; Garner, 2004; Terracciano et al., 2014).


Some overlaps and differences between schizophrenia and dementia

Although schizophrenia and dementia are two different conditions, they sometimes touch and overlap at both cognitive and organic levels, and at the psychopathological, functional level (e.g., Andreasen, 2010; Fatemi & Folsom, 2009; Keshavan & Jindel, 2010; Lewis & Levitt, 2002; Owen, O’Donovan, Thapar, & Craddock, 2011; Sachdev, 2010; Urfer-Parnas, Mortensen, & Parnas, 2010; Vannorsdall & Schretlen, 2013). Both the development and the profile of late-onset cognitive impairments in schizophrenia appear to be inconsistent with Alzheimer’s disease, however, it may be that the acute cognitive decline in some schizophrenic patients is a result of comorbidity between schizophrenia and Alzheimer’s disease (Cardinal & Bullmore, 2011; Harvey, 2005). However, the prevalence of neuropathological evidence in post-mortem studies, consistent with Alzheimer’s disease, has been found, for the most part, to be consistent with that of the general population (Cardinal & Bullmore, 2011; Harvey, 2005). On the other hand, neuropsychiatric symptoms are common in Alzheimer’s disease, but these psychotic symptoms may differ from those in schizophrenia (Lautenschlager & Kurz, 2010; Vannorsdall & Schretlen, 2013). There is a current debate which sets out to ascertain whether the psychotic symptoms displayed in Alzheimer’s disease represent a subtype of this dementia, or whether genetic factors determine vulnerability to these psychotic symptoms (Lautenschlager & Kurz, 2010; Vannorsdall & Schretlen, 2013). More recently, it has been suggested that the psychotic symptoms must be present before the diagnosis of dementia, as part of a prodromal syndrome or as part of a subsyndromal personality structure (Lautenschlager & Kurz, 2010).

It should be noted that around 100 years ago, Kraepelin originally conceptualized schizophrenia as dementia praecox, placing it in the same category as degenerative disorders and, thus, sparking a heated debate in psychiatry (Barak, Swartz, & Davidson, 1997; Cardinal & Bullmore, 2011; Ferrey & Le Gouès, 2000). There is seemingly a neuronal model of cortical modulation of base acetylcholine that is common to both schizophrenia and dementia. However, subsequent bi-directional deviations underlying the development of schizophrenia and dementia must occur, since there is some evidence of genetic commonalities (Barak et al., 1997; Gelder, Mayou, & Geddes, 2002; Karon & VandenBos, 1998). The pathological and biochemical markers of dementia are not conclusively demonstrated in elderly schizophrenics, and there is a body of evidence which tends to suggest that dementia is not an outcome of schizophrenia (Harvey, 2005; Gelder et al., 2002; Karon & VandenBos, 1998).


Neuropsychological and neurological evidence

We are currently faced with an issue that has led to extensive research and which continues to generate considerable interest, namely the fact that the distinction "cortical" and "subcortical" dementia is also applicable to schizophrenia (Hill, Ragland, Gur, & Gur, 2002; Turetsky et al., 2002). In other words, it is clear that in neuropsychological and neuroanatomical terms, schizophrenia may correspond to the pattern of "cortical" dementia (e.g. Alzheimer’s) or to the pattern of "subcortical" dementia (e.g. Parkinson’s) (Turetsky et al., 2002). The fact that there are schizophrenic patients who do not present any type of neuropsychological deficit should also be noted (Palmer et al., 1997), so seemingly the mechanisms that underlie neurocognitive functioning must be distinct from those involved in the production of psychiatric (psychopathological) symptoms. This is currently an open scientific question (Karon & VandenBos, 1998; Palmer et al., 1997; Steen, 2007).

Some studies report that it is possible to have healthy ageing even when there is a pathology of the brain, since there is post-mortem evidence of neurodegenerative disease in people who were cognitively and mentally intact and resisted the effects of the disease through mechanisms that are still unknown (Steen, 2007; Terracciano et al., 2014). There are also individuals who mimic Alzheimer’s disease and show no neurodegenerative disease in the post-mortem (Evans, 2008; Terracciano et al., 2014), which leads to a questioning of whether the neurological lesions are the "cause" or "effect" of dementia (Chevance, 2005).


Overview of the psychodynamic perspective

Turning to the classical discussion and indistinctness between schizophrenia and dementia (Barak et al., 1997; Balfour, 2007; Urfer-Parnas et al., 2010), it should be noted that there is an interesting parallel with the fact that, initially, the term borderline was equally considered an attenuated form of schizophrenia or hebephrenia (psychosis) (Bergeret, 2008). In psychological terms, for some authors, dementia presents clinical symptoms resembling the psychic structure of borderline pathology, as shall be explained further ahead.

Many authors describe the pre-dementia personality as traumatophobic, given the analogy of symptoms between dementia and post-traumatic syndromes, which occurred throughout life, beyond childhood (Clement, Darthout, & Nubukpo, 2003; Hybler, 1998; Vignat, Bragard, & Suchet, 1987). In a study by Clement et al. (2003), individuals with dementia exhibited personality traits of dependency, avoidance, obsessive symptoms and alexithymia, and were subject to a higher number of traumatic memories/situations throughout life. There seems to be considerable evidence of dementia being related to anxiety and the anaclitic object relationship and to the fear of abandonment/loss of the object, which are pathognomonic characteristics of borderline pathology (Abraham & Walter, 2008; Chevance, 2005; Gerardin & Maheut-Bosser, 1998; Myslinski, 1994, 1998).

Importantly, however, the investment in internal objects is conserved in dementia up to an advanced stage of the disorder, while in schizophrenia the loss is total and premature (Abraham & Walter, 2008; Evans, 2008; Garner, 2004). The anxiety of the psychotic is fragmentation – withdrawal and death, strangeness, persecution. It is also the anxiety of annihilation, depersonalization and unfulfillment (Bergeret, 2008; Coimbra de Matos, 2002; Grotstein, 1989; Spear & Sugarman, 1984; Steiner, 1991; Willick, 2001).

The anxiety of the borderline is the anxiety of loss of the object (narcissistic incompleteness) – anaclitic depression, despair and helplessness, fear of abandonment; it comes before the separation-individuation (Bergeret, 2008; Coimbra de Matos, 2002; Masterson & Rinsley, 1975; Spear & Sugarman, 1984; Tuttman, 1990; Westen, 1990).

Such risk factors, experienced as early trauma, may cause continued stress reactions throughout the life cycle. Associations between this phenomenon and the early and pathologic mental aging have been established (e.g., Wilson et al., 2003, 2006).

The psychotic object relationship remains fusional to the object, leading to the expression of negative symptomatology, divestment of the objects of reality and an object neoconstruction. A unipolar record, in which there is a somatopsychic indifferentiation, lacking a boundary between the "I" and the object, is characterized by not exceeding the pre-object recording, absorption and dissemination mechanisms, lack of distinction between the "inner" and "outer" (Bergeret, 2008; Coimbra de Matos, 2002; Grotstein, 1989; Spear & Sugarman, 1984; Steiner, 1991; Willick, 2001).

The object relationship of the borderline remains a two-way relationship, but differs from the primitive psychosis dyad; cleaved object/anaclitic relationship. In anaclitism, there is separability between the "I" and the object, although the limits are perforated or permeable (Bergeret, 2008; Coimbra de Matos, 2002; Masterson & Rinsley, 1975; Spear & Sugarman, 1984; Tuttman, 1990; Westen, 1990).

Moreover, the defense mechanisms of the psychotic structure are mainly splitting, projective identification and omnipotence, while projection, withdrawal from reality and denial are equally important (Bergeret, 2008). The defense mechanisms of the borderline structure are mainly splitting, projection and acting-out, while denial, projective identification, omnipotence and avoidance are equally important (Bergeret, 2008). Some researchers have tried to establish a distinction between the use of defense mechanisms in both groups, arguing that the borderline structure has a specific and identifying spectrum/style. The borderline tends to make greater use, above all, of splitting and primitive devaluation, idealization, denial and projective identification than the schizophrenic (Lerner, 1990; Lerner, Sugarman, & Gaughran, 1981).



In the psychodynamic construct, object relationships are viewed as structuring the organization of past and future experiences (e.g., Kandel, 1998, 1999; Priel, Kantor, & Besser, 2000). There is a continuum between the representative function of internal objects and representations, namely a continuum in the diachrony of child development and a continuum in the unconscious processes of adult thought (e.g., Imbasciati, 2003; Kandel, 1998, 1999; Schore, 2001).

In addition to a possible genetic background common to schizophrenia and dementia (e.g., Barak et al., 1997; Hill et al., 2002; Karon & VandenBos, 1998; Keshavan & Jindel, 2010; Palmer et al., 1997; Turetsky et al., 2002; Urfer-Parnas et al., 2010; Vannorsdall & Schretlen, 2013), it may be that different personality structures are associated with different diagnoses, whereby the psychotic structure emerges as being connected to schizophrenia and the borderline structure to dementia.



Abraham, V. G., & Walter, M. (2008). À propos d’une psychopathologie de la démence [On psychopathology of dementia]. NPG Neurologie-Psychiatrie-Gériatrie, 47, 32-37.

Andreasen, N. C. (2010). The lifetime trajectory of schizophrenia and the concept of neurodevelopment. Dialogues in Clinical Neuroscience, 12(3), 409-415.         [ Links ]

Baldwin, C., & Capstick, A. (2007). Tom Kitwood on dementia: a reader and critical commentary. London: McGraw-Hill.         [ Links ]

Balfour, A. (2007). Facts, phenomenology, and psychoanalytic contributions to dementia care. In R. Davenhill (Ed.), Looking into later life: a psychoanalytic approach to depression and dementia in old age (p. 222-247). United Kingdom: Karnac.         [ Links ]

Barak, Y., Swartz, M., & Davidson, M. (1997). Dementia in elderly schizophrenic patients: Reviewing the reviews. International Review of Psychiatry, 9, 459-463.         [ Links ]

Bergeret, J. (2008). Abrégé de psychologie pathologique (10th ed.) [Psychopathologic psychology]. Paris: Masson.         [ Links ]

Cardinal, R. N., & Bullmore, E. T. (2011). Primary psychiatric disease. In R. N. Cardinal, & E. T. Bullmore (Eds.), The diagnosis of psychosis (p. 152-167). UK: Cambridge University.

Cheston, R., & Bender, M. (1999). Understanding dementia: the man with the worried eyes. United Kingdom: Kingsley.         [ Links ]

Chevance, A. (2005). Désir d’oubli chez le patient alzheimer, un concept clef pour une prise en charge psychothérapique [Wish of neglect at the alzheimer patient, a key concept for a psychotherapeutic change]. In J. M. Talpin (Ed.), Cinq paradigmes cliniques du vieillissement (p. 107-146). Paris: Dunod.

Clement, J. P., Darthout, N., & Nubukpo, P. (2003). Événements de vie, personnalité et démence [Life events, personnality and dementia]. Psychologie & NeuroPsychiatrie du Vieillissement, 1(2), 129-138.         [ Links ]

Coimbra de Matos, A. (2002). O desespero. Lisboa: Climepsi.         [ Links ]

Damásio, A. R. (2000). The feeling of what happens. USA: Harvest Books.         [ Links ]

Downs, M., Clare, L., & Anderson, E. (2008). Dementia as a biopsychosocial condition: implications for practice and research. In B. Woods & L. Clare (Eds.), Handbook of the clinical psychology of ageing (p. 145-160). London: Wiley.         [ Links ]

Evans, S. (2008). Beyond forgetfulness: how psychoanalytic ideas can help us to understand the experience of patients with dementia. Psychoanalytic Psychotherapy, 22(3), 155-176.         [ Links ]

Fatemi, S. H., & Folsom, T. D. (2009). The neurodevelopmental hypothesis of schizophrenia revisited. Schizophrenia Bulletin, 35(3), 528-548. doi: 10.1093/schbul/sbn187        [ Links ]

Ferrey, G., & Le Gouès, G. (2000). Psychopathologie du sujet âgé. Paris: Masson.         [ Links ]

Garner, J. (2004). Dementia. In S. Evans & J. Garner (Eds.), Talking over the years: a handbook of dynamic psychotherapy with older adults (p. 215-230). U.S.A.: Brunner-Routledge.         [ Links ]

Gerardin, P., & Maheut-Bosser, A. (1998). En partance, ou à la recherche de soi [Wandering]. La Revue Française de Psychiatrie et de Psychologie Médicale, 20, 52-53.         [ Links ]

Gelder, M., Mayou, R., & Geddes, J. (2002). Psiquiatria (M. L. Q. A. Brasil, trad., 2ª ed.). Brasil: Guanabara Koogan. (Obra original publicada em 1999)        [ Links ]

Grotstein, J. S. (1989). A revised psychoanalytic conception of schizophrenia: an interdisciplinary update. Psychoanalytic Psychology, 6(3), 253-275.         [ Links ]

Harvey, P. D. (2005). Dementia and schizophrenia: similarities and differences. In P. D. Harvey (Ed.), Schizophrenia in late life: aging effects on symptoms and course of illness (p. 101-117). Washington, DC: American Psychological Association.

Hill, S. K., Ragland, D., Gur, R. C., & Gur, R. E. (2002). Neuropsychological profiles delineate distinct profiles of schizophrenia, an interaction between memory and executive function and uneven distribution of clinical subtypes. Journal of Clinical and Experimental Neuropsychology, 24(6), 765-780.         [ Links ]

Hybler, M. (1998). L’horreur de la mémoire et la mémoire de l’horreur [Horror of memory and memory of horror]. La Revue Française de Psychiatrie et de Psychologie Médicale, 20, 17-19.

Imbasciati, A. (2003). Nascimento e construção da mente (J. Serra, trad.). Lisboa: Climepsi. (Obra original publicada em 1998)        [ Links ]

Kandel, E. R. (1998). A new intellectual framework for psychiatry. American Journal of Psychiatry, 155, 457-469.         [ Links ]

Kandel, E. R. (1999). Biology and the future of psychoanalysis: a new intellectual framework for psychiatry revisited. American Journal of Psychiatry, 56, 505-524.         [ Links ]

Karon, B. P., & VandenBos, G. R. (1998). Schizophrenia and psychosis in elderly populations. In I. H. Nordhus, G. R. VandenBos, S. Berg, & P. Fromholt (Eds.), Clinical geropsychology (p. 219-227). Washington, DC: American Psychological Association.

Keshavan, M. S., & Jindal, R. D. (2010). Neurobiology and etiology of primary schizophrenia. In P. S. Sachdev, & M. S. Keshavan (Eds.), Secondary schizophrenia (p. 3-15). United Kingdom: Cambridge University.         [ Links ]

Kitwood, T. (1997). Dementia reconsidered: the person comes first. United Kingdom: Open University Press.         [ Links ]

Lautenschlager, N. T., & Kurz, A. F. (2010). Neurodegenerative disorders and schizophrenia-like psychosis. In P. S. Sachdev, & M. S. Keshavan (Eds.), Secondary schizophrenia (p. 204-213). United Kingdom: Cambridge University.         [ Links ]

Lerner, P. M. (1990). Rorschach assessment of primitive defenses: a review. Journal of Personality Assessment, 54 (1/2), 30-46.         [ Links ]

Lerner, H. D., & Lerner, P. M. (1980). Rorschach assessment of primitive defenses in borderline personality structure. In J. S. Kwawer, H. D. Lerner, P. M. Lerner, & A. Sugarman (Eds.), Borderline phenomena and the Rorschach test (p. 257-274). New York: International University Press.         [ Links ]

Lerner, H. D., Sugarman, A., & Gaughran, J. (1981). Borderline and schizophrenic patients: A comparative study of defensive structure. The Journal of Nervous and Mental Disease, 169, 705-711.         [ Links ]

Lewis, D. A., & Levitt, P. (2002). Schizophrenia as a disorder of neurodevelopment. Annual Review of Neuroscience, 25, 409-432. doi: 10.1146/annurev.neuro.25.112701.142754        [ Links ]

Masterson, J. F., & Rinsley, D. D. (1975). The borderline syndrome: the role of the mother in the genesis and psychic structure of the borderline personality. International Journal of Psycho-Analysis, 56, 163-177.         [ Links ]

Myslinski, M. (1994). Permanence des organisateurs de la vie mentale adulte sous la présentation déficitaire de la femme âgée [Permanence of the inductors of adult mental life under the defective presentation of the elderly woman]. Psychologie Médicale, 26(4), 365-367.         [ Links ]

Myslinski, M. (1998). L’attachment thérapeutique: une réponse humaine à la souffrance de l’abandon dans la démence [Therapeutic attachment: a human response to suffering in dementia]. La Revue Française de Psychiatrie et de Psychologie Médicale, 20, 46-47.

Owen, M. J., O’Donovan, M. C., Thapar, A., & Craddock, N. (2011). Neurodevelopmental hypothesis of schizophrenia. British Journal of Psychiatry, 198, 173-175. doi: 10.1192/bjp.bp.110.084384

Palmer, B. W., Heaton, R. K., Paulsen, J. S., Kuck, J., Braff, D., & Harris, M. J. (1997). It is possible to be schizophrenic yet neuropsychologically normal? Neuropsychology, 11(3), 437-446.         [ Links ]

Priel, B., Kantor, B., & Besser, A. (2000). Two maternal representations. Psychoanalytic Psychology, 17, 128-145.         [ Links ]

Sachdev, P. (2010). The concept of organicity and its application to schizophrenia. In P. Sachdev, & M. Keshavan (Eds.), Secondary schizophrenia (p. 16-20). NY: Cambridge.

Schore, A. N. (2001). The effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal, 22, 7-66. doi: 10.1002/ 1097-0355(200101/04)22        [ Links ]

Spear, E. E., & Sugarman, A. (1984). Dimensions of internalized object relations in borderline and schizophrenic patients. Psychoanalytic Psychology, 1(2), 113-129.         [ Links ]

Steen, R. G. (2007). The evolving brain: the known and the unknown. New York: Prometheus Books.         [ Links ]

Steiner, J. (1991). A psychotic organization of the personality. International Journal of Psycho-Analysis, 72, 201-207.         [ Links ]

Terracciano, A., Sutin, A. R., An, Y., O’Brien, R. J., Ferrucci, L., Zonderman, A. B., & Resnick, S. M. (2014). Personality and risk of Alzheimer’s disease: new data and meta-analysis. Alzheimer’s & Dementia, 10(2), 179-186. doi: 10.1016/j.jalz.2013.03.002

Turetsky, B. I., Moberg, P. M., Mozley, L. H., Moelter, S. T., Agrin, R. N., Gur, R. C., & Gur, R. E. (2002). Memory-delineated subtypes of schizophrenia: relationship to clinical, neuroanatomical, and neurophysiological measures. Neuropsychology, 16(4), 481-490.         [ Links ]

Tuttman, S. (1990). Exploring an object relations perspective on borderline conditions. Journal of American Academy of Psychoanalysis, 18, 539-553.         [ Links ]

Trull, T., & Widiger, T. (2003). Personality disorders. In J. Graham, & J. Naglieri (Eds.), Handbook of psychology: Clinical psychology (p. 149-172). U.S.A.: Wiley & Sons.         [ Links ]

Urfer-Parnas, A., Mortensen, E. L., & Parnas, J. (2010). Core of schizophrenia: estrangement, dementia or neurocognitive disorder? Psychopathology, 43, 300-311.         [ Links ]

Vannorsdall, T. D., & Schretlen, D. J. (2013). Late-onset schizophrenia. In L. D. Ravdin, & H. L. Katzen (Eds.), Handbook on the neuropsychology of aging and dementia (p. 487-500). NY: Springer.

Vignat, J. P., Bragard, J. J., & Suchet, D. (1987). Démence et psychogenèse. Médecine & Higiène, 45, 1466-1472.         [ Links ]

Waddell, M. (2007). Only connect: the links between early and later life. In R. Davenhill (Ed.), Looking into later life: a psychoanalytic approach to depression and dementia in old age (p. 187-200). UK: Karnac.         [ Links ]

Westen, D. (1990). Towards a revised theory of borderline object relations. International Journal of Psycho-Analysis, 71, 661-693.         [ Links ]

Willick, M. S. (2001). Psychoanalysis and schizophrenia: a cautionary tale. Journal of American Psychoanalytic Association, 49, 27-56.         [ Links ]

Wilson, R. S., Evans, D. A., Bienias, J. L., Mendes de Leon, C. F., Schneider, J. A., & Bennett, D. A. (2003). Proneness to psychological distress is associated with risk of Alzheimer’s disease. Neurology, 61, 1479-1485. doi: 10.1212/01.WNL.0000096167.56734.59

Wilson, R. S., Arnold, S. E., Schneider, J. A., Kelly, J. F., Tang, Y., & Bennett, D. A. (2006). Chronic psychological distress and risk of Alzheimer’s disease in old age. Neuroepidemiology, 27, 143-153. doi: 10.1159/000095761



Recebido em 10 de agosto de 2015
Aceito para publicação em 11 de março de 2016

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