Das „Demenz-Syndrom“ (demenzielles Syndrom)
Unter einer Demenz versteht man einen erworbenen Verlust von höheren psychischen Funktionen, die definitionsgemäss das Gedächtnis betreffen müssen und nicht mit einer Bewusstseinstrübung einhergehen dürfen. Die Störungen können vielgestaltig sein, vorübergehend oder dauerhaft sein, müssen aber, um als Demenz bezeichnet werden zu können, eine verminderte Alltagsbewältigung zur Folge haben. Wegen der möglichen Vielgestaltigkeit der konkreten Symptomatik und der Orientierung an den genannten Leitkriterien spricht man besser von „Demenz-Syndrom“.
Verschiedenen Definitionen der „Demenz“
G. Huber (1999):
Demenzen sind lt. Huber „nach der frühen Kindheit (…) infolge einer Hirnerkrankung erworbene Intelligenzdefekte mit grobem irreparablem und nicht selten progredientem intellektuellem und mnestischem Abbau; stets sind Demenzen mit – oft, z.B. bei Hirngefässprozessen und besonders deutlich beim Morbus Pick (…) vorausgehenden –Wesensänderungen verbunden.
Die Demenz kommt in einer Reduktion von Auffassungs-, Kritik- und Urteilsfähigkeit, in einer groben Störung von Begriffsbildung, logischem Denken, Fähigkeit zur Kombination und Erfassung von Sinnzusammenhängen, in mnestischen, bevorzugt Merkfähigkeit und Frischgedächtnis betreffenden Ausfällen und einer Desorientiertheit hinsichtlich Zeit, später auch Ort und eigener Person (…), zum Ausdruck.“ (Psychiatrie, 6. Aufl., S. 75)
Huber weist darauf hin, dass aus seiner Sicht die Erweiterung des Demenzbegriffes im letzten Jahrzehnt auf leichte Zustände von erworbener Intelligenzminderung einerseits und aufrückbildungsfähige (reversible) organische Psychosyndrome „psychopathologisch, klinisch und auch in sozialer Hinsicht problematisch“ ist.
„Dies bedeutet, dass pauschal und undifferenziert alle organischen Psychosyndrome Demenz genannt werden.“
Dagegen hält Huber seine Definition der Demenz:
„Man kann u.E. erst dann von Demenz sprechen, wenn die Diagnose psychopathologisch nach den genannten Kriterien sicher ist und tatsächlich ein massiver, nicht mehr rückbildungsfähiger, intellektueller und mnestischer Abbauvorliegt, der, in Abgrenzung zur Oligophrenie (…), nach der frühen Kindheit als Folge einer Hirnerkrankung oder Hirnschädigung erworben wurde. Das Ausmass des im intraindividuellen Vergleich eingetretenen Abbaus impliziert auch die aufgehobene Reflexionsfähigkeit und mangelnde Krankheitseinsicht als ein weiteres Merkmal der Demenzdefinition. Die Störungen und Einbussen werden von den Patienten selbst nicht als solche wahrgenommen, vergegenwärtigt und verbalisiert: Verlust der Selbstvergegenwärtigungsfähigkeit der Defizienzen.“ (Psychiatrie, 6. Aufl., S. 76)
Und zur differentialdiagnostischen Abgrenzung gegenüber „pseudoneurasthenischen Syndromen und organischen Persönlichkeitsveränderungen“, bei denen „leichtere intellektuelle und menstische Einbussen vorhanden“ sein können schreibt Huber:
„Die Einbussen sowohl bei pseudoneurasthenischen Syndromen als auch bei leichteren, nur den dynamischen Teil der Persönlichkeit (…) betreffenden organischen Persönlichkeitsveränderungen sind nach Art und Ausmass nicht so, dass dadurch, wie bei der Demenz, Reflexionsfähigkeit, Krankheitseinsicht und „Sich-zu-sich-selbst-verhalten-Können“ aufgehoben werden. Bei der Demenz kommt zu den intellektuellen Einbussen, dem Verlust an Wissen und Können, auch noch der „Verlust des Wissens um diesen Verlust“.“ (Psychiatrie, 6. Aufl., S. 76f)
R. Tölle (1999):
Tölle fasst entsprechend der modernen erweiterten Auffassung des Demenz-Begriffes die Definition unter die Überschrift: „Demenz/Organisches Psychosyndrom“ und grenzt sie insbesondere gegen das Delir und gegen die wichtigste Differentialdiagnose, die Depression, ab:
„Hirnschädigungen und -funktionsstörungen führen beim Erwachsenen zu verschiedenen psychopathologischen Syndromen: zu einer akuten organischen Psychose (Delir) oder zu dem chronischen Syndrom einer Demenz (organisches Psychosyndrom). Die Demenz zeigt eine charakteristische Symptomatik und wird dennoch, besonders in den Anfangsstadien, oft übersehen oder als Depression verkannt.“ (Psychiatrie, 12.Aufl., S. 274)
H.-J. Möller (2001):
Möller hält sich in seiner Definition an die Vorgehensweise der modernen Klassifikationssysteme ICD-10 und DSM-IV, nach denen die „Demenz“ nur eine von mehreren unterscheidbaren „organischen psychischen Störungen“ darstellt:Unter der Überschrift: „Demenzielle chronische organische Psychosyndrome“ (Synonyma: Hirnorganisches Psychosyndrom (HOPS oder POS), demenzielles Syndrom) definiert er das demenzielle Syndrom wie folgt:
„Chronische organische Psychosyndrome sind die Folge einer chronischen Veränderung des Gehirns. Das Demenz-Syndrom ist durch das Fehlen einer Bewusstseinstrübung gekennzeichnet, charakteristisch ist eine objektiv nachweisbare erworbene Beeinträchtigung des Gedächtnisses (v.a. Lernfähigkeit für neue Informationen, Reproduktion von Erinnerungen) sowie ein zunehmender Verlust früherer intellektueller Fähigkeiten (v.a. abstraktes Denken, Urteilsvermögen, Konzentrationsfähigkeit). Eine weitere Gruppe von Symptomen betrifft Veränderungen der Persönlichkeit (Motivation, Psychomotorik, emotionale Kontrolle, Sozialverhalten).“ (Psychiatrie und Psychotherapie, 2. Aufl., S. 185)
V. Faust (1995):
Faust betont v.a. die soziale Dimension des dementiellen Prozesses:
„Unter einer Demenz versteht man im späteren Leben erworbene Beeinträchtigungen von zerebralen Funktionen, die mit Intelligenzdefekten und Gedächtnisstörungen einhergehen und dabei ein Ausmass erreichen, dass eine selbständige Lebensführung nicht mehr möglich ist. Sie sind ihrer Natur nach irreversibel.“
Die aktuell übliche Erweiterung des Demenz-Begriffes bedenkt, indem er weiter ausführt:
„Aber auch diese Definition wird in vieler Hinsicht dem heutigen klinischen Sprachgebrauch nicht mehr gerecht. So können z.B. Teilaspekte einer Demenz durchaus reversibel sein. Dabei hängt der Grad der Reversibilität von der Beeinflussbarkeit des Grundprozesses ab, durch den die Symptome der Demenz hervorgerufen werden. Damit ist bereits angedeutet, dass die Symptome der Demenz durch verschiedene Krankheiten verursacht sein können, von denen einige behandelbar sind, andere nicht.
Unter Demenz wird damit ein psychopathologisch definierter Symptomenkomplex verstanden, der erst nach Zuordnung zu einer nachgewiesenen Ätiologie zu einer klinischen Diagnose wird.“ (Psychiatrie, S. 387f)
Die möglichen Ursachen eines Demenz-Syndroms sind vielfältig. Sie können im Hirn selber liegen oder im übrigen Organismus.Je nach den Haupt-Symptomen unterteilt man die Demenzen in
- kortikale Demenz:
- betroffen sind v.a. Lernen, Gedächtnis, Sprache, Denken, räumliche Orientierung, Fertigkeiten
- subkortikale Demenz:
- betroffen ist v.a. die Persönlichkeit, das Sozialverhalten und die planerischen Fähigkeiten
- frontale Demenz:
- betroffen ist v.a. die Geschwindigkeit der psychischen Prozesse im Sinne einer allgemeinen Verlangsamung
Nach der Ätiologie (Ursache) unterscheidet man folgende Demenz-Formen:
- Alzheimer-Demenz (75% aller Fälle)
- Zerebro-Vaskuläre Demenz (15% der Fälle)
- Andere Ursachen (10% der Fälle):
- Morbus Pick
- Morbus Parkinson und Parkinson-Syndrome
- Chorea Huntington (erblicher Veitstanz)
- Demenz bei Normaldruckhydrozephalus (NPH)
- Demenz bei entzündlichen Veränderungen und Infektionskrankheiten des Gehirns
- „Neurolues“ bei Syphilis
- Demenz bei AIDS
- Demenz bei Creutzfeldt-Jakob-Krankheit
- Demenz bei Multipler Sklerose
Demenz nach Hirnverletzungen (Traumata)
- Demenz bei metabolischen oder Stoffwechselerkrankungen
- Demenz durch chronischen Alkoholkonsum (Korsakow-Demenz)
Hinsichtlich der zu erfüllenden Kriterien unterscheiden sich die beiden modernen Klassifikationssysteme psychischer Störungen (ICD-10 und DSM-IV) erheblich. Im DSM-IV ist der Begriff der Demenz wesentlich weiter gefasst, auf eine allgemeine Definition des Demenz-Syndroms wird vollständig verzichtet. Die Folge ist, dass zum Einen das DSM-IV der Vielgestaltigkeit des Demenz-Syndroms besser gerecht wird, zum anderen aber Störungen, die im DSM-IV als Demenz zu klassifizieren sind, in der ICD-10 nicht als solche erfasst werden! In der ICD-10 dagegen ist die Klassifikation der Demenz an Zeitkriterien gebunden und es wird eine grobe Schweregradeinteilung vorgenommen.
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