The main hypothesis of the Nottingham Study was that the general neurotic syndrome would have a more complex and likely poorer outcome in the long-term, so follow-up data were critical in evaluating this. Assessments were made of the main outcome measures at 16, 32, 52 (one year) and 104 weeks (two years) after randomisation. At five years, assessment was only made through examination of the patients’ GP and hospital notes.

A life filled with learning is advisable. Tasks involving some degree of cognitive complexity is desirable, but there is no reason to believe that certain forms of learning are better than others. What is critical is that the activity needs to be consistent and persistent. Involvement of cognitive activity at work is important and jobs that involve high stress, passive participation, and lack of complexity are associated with higher levels of cognitive impairment in later life. There is also no reason to believe that mental activities must be limited to the early years of life. People are able to learn at all ages and participation in learning is valuable for the brain throughout life. The concept of diversity refers as well to learning and mental activities. It is good to learn new things! Participation in cognitive activities throughout the lifespan both at home and at work and avoiding multi-tasking can help build cognitive reserve capacity. Cognitive activities directly impair disease processes. Being cognitively active and paying attention to the world helps to protect the brain from free radicals and toxins. Cognitive activities also assists in the management of stress.

As this book is primarily about the general neurotic syndrome, I need to be convincing in creating the groundwork to persuade the reader to continue to read. Some may feel this syndrome is a fictitious creation and so I will have to work even harder to persuade these sceptics; all I would ask at this point is for people to have an open mind. The general neurotic syndrome is not (yet) a familiar term, even though it should be. As it has been a subject I have had in my head for over 45 years – I hope not as an obsession but as a guiding light – I need to put my thinking about it into context.

Important worldwide changes in human aging are developing rapidly. Life expectancy has doubled during the past century. Due to advances in public health, vaccines, and science, people are living longer. The increase in the elderly population is happening in varying degrees all over the world. Although heart disease and cancer rates are falling, Alzheimer’s is increasing because of its strong link to aging and lack of disease-modifying therapies. It is important to consider what can be done about the expansion of aged populations. A forward-looking approach to health care will provide resources to people throughout life to keep them healthy and enhance their four reserve factors. This is ethically and economically preferable to a health care system which only takes care of people when they’re sick and doesn’t strive to prevent illness. Recent advances in diagnosis, metagenomics (studies of gut bacteria), and artificial intelligence will hopefully assist in the growth of preventive measures. Advances in public policy and technology can help people to enhance their four reserve factors and help them to avoid disease and remain fit as they age.

To maintain the highest level of your four reserve factors it is necessary to know how to interact with the medical profession and the medications they prescribe. It is also valuable to understand and appreciate the perspective of clinical research. As patients, we have the right to have our story and voice heard, to be treated like human beings. Our stories are an important part of who we are. Many people are exceptionally passive in their pursuit of medical care and will accept whatever negligence, avoidance, or abuse they receive. It’s up to us to be a powerful advocate for our own welfare and insist on having medical professionals listen to our stories and attend to our needs. Ways to choose physicians are discussed. Also reviewed are how to manage your medications, vaccines, and how to lower the risk of medical errors. Guidelines are presented on the advantages and dangers of participation in clinic research. It is necessary to be an active participant in your own care and fierce in the pursuit of what’s best for you.

There are many things we can do to reduce the risk of Alzheimer’s, including high levels of physical and mental activity, avoidance of hypertension, head injury, high-fat, low-fiber diet, smoking, etc. These risk factors have been documented by decades of human and animal research and have allowed for the development of protective lifestyle measures that lead to a lowered risk of disease. These lifestyle factors apply to all phases of the life cycle, including childhood, as well as late life, and contribute to diminishing the risk of getting dementia, as well as delaying its onset and speed of progression. In the applications section there is a comprehensive discussion of these factors that will lower the risk of neurodegenerative diseases, improve our resilience so that function can be maintained despite development of disease, and enhance the capacity of all of the four reserve factors: cognitive, physical, psychological, and social. The actions recommended are all also valuable for lowering the risk of heart disease and stroke as well as some forms of cancer. Enhancing these reserve factors will enable you to augment your enjoyment of the opportunity aging presents.

Neurosis is passé, neurosis belongs to history, neurosis is dead.  So why am I writing this book?  The reason is that we need to be aware, even if we do not embrace, information that suggests the way we now look at common mental illness is not necessarily the most accurate or productive way of understanding, and more importantly, treating it. I also introduce this book with the foreword to its predecessor (Tyrer, 1989), written by the late Robert Kendell, and this also explains why I am publishing at this time. Robert, whom I will refer to as Bob from now on, was a stickler for accuracy and rarely wrote anything down that he could not defend with facts. His foreword was written 32 years ago but is just as apposite today – he actually could have written it today with the same wording, and this in itself reflects the poverty of attention that this subject has received since 1989. His statement ‘new concepts should not be adopted until they have been validated by long-term follow-up studies, and the patients with a fluctuating mélange of depressive, anxious and obsessional symptoms are so common that the term “general neurotic syndrome” must be retained to describe them’, is the keynote to this book.

Our attitude is something we carry around with us at all times. As the psychiatrist Victor Frankl said, “Our greatest freedom is the freedom to choose our attitude.” Our attitude is determined in large part by the focusing of our attention. If our attention is focused on losses and regrets, our attitude will be gloomy. If our attention is focused on opportunities, such as the opportunity of aging, our attitude will be more positive. This is a fundamental daily choice. Because the world is too multifaceted for us to process all possible perceptions, it is our attention which is critical for the quality of our experience. Our attitude is determined by the object of our attention. And our capacity of paying attention can be exercised and practiced every day. Viewing aging as an opportunity helps to focus the reality that what happens to us is determined in large part by what we do. Paying attention can enhance all of our reserves. Diet, physical and mental activities, and social and family contacts are all critical. Our enhancement of the four reserve factors will increase our chance to be healthy and fit as we age.

These questions would answer the issue of whether there was value in maintaining the neurotic concept, formulated as described earlier as the general neurotic syndrome.

We need to have three goals for aging. The first two are clear; survival and avoiding disease. Equally important is a third goal, to maintain fitness and a high level of four reserve factors. These reserve factors allow us to successfully respond to the challenges we face as we age. Cognitive reserve is the capacity to maintain effective cognitive function despite age-related changes in the brain. Maintaining high cognitive reserve is not our only goal. We must also maintain high physical, psychological, and social reserves. Physical reserve reflects the capacity of all our body systems. Psychological reserve is our ability to maintain healthy mental function, and social reserve describes our interpersonal network and supports. With aging, our ability to function is dependent upon the interaction of these four reserve factors. Our capacity to respond well to adversity is called resilience and is a fundamental goal of aging. It is important to realize the critical nature of these four reserve factors because through our actions we can enhance our capacity for resilience and enhanced fitness with aging.

Our bodies are home to a vast sea of microorganisms. They reside inside us and on all our body surfaces. There are as many cells of these microbial partners as there are cells inside our bodies. The word microbiota describes all the organisms that are on our body surfaces as well as inside us. The important role of these partners of ours in our health and fitness has only been realized in the past ten years. They are invisible and do not receive the attention they deserve. The microbiota are a key component of our physical reserve and are vital to our health and fitness. The microbiota influence all of our organ systems, assist in digestion, disease resistance, contribute to metabolism, and are critical for the maintenance of health and fitness. A vital feature of the microbiota is their diversity of organisms—a wide variety of organisms are normally present. Our history with the microbiota is best described by the word coevolution - we evolved with them, and they evolved with us.The good news about the microbiota is that it is relatively easy to change bacterial populations in the gut through diet. Ways to do this are comprehensively outlined in the book.

It is never too late to do a long-term follow-up study. Through long-term follow-up, a full knowledge of tardive dyskinesia, a condition once thought to be permanent, has illustrated that this is far from the case (e.g., Cavallaro et al., 1993). But there is bound to be a loss of people to contact when you study follow-up at 30 years. The common word for this is attrition – ‘the gradual reduction in the number of people who are involved in a study that is achieved by not replacing those who leave’. I have always found this word to be a somewhat euphemistic one; the usual cause of attrition is death. In the case of cancer studies, death (mortality) is the primary outcome in most cases. With the general neurotic syndrome, early death is clearly an important outcome, but mental health at follow-up is more so. Following the advice of Sir Richard Doll (see Chapter 3), we decided at this point to choose the dichotomous outcome of the absence or presence of one of the main DSM diagnoses. The very minor diagnoses such as simple phobia and adjustment disorders were not included here.

Memory and cognition are critical parts of who we are. Our capacity for recall allows us to use past experience to guide our actions. Our cognitive abilities allow us to monitor events and evaluate plans for action. In aging there are varying degrees of decline in cognitive function which begin in the 30s and are quite common. They are not a disease and are accompanied by the growth of wisdom which can negate the influence of age-related memory changes. Memory losses with aging can be avoided with consideration of the importance of attention for memory. The role of forgetting as a normal activity of the brain is critical. It is necessary to realize that the influences of aging and age-related disease (such as Alzheimer’s) on brain function are not determined only on the processes of aging and disease -- the effect of these processes on our performance abilities depends upon our cognitive, physical, psychological, and social reserves. We all need to enhance these reserve capacities to decrease the influence of the aging process and developing brain disease on our function. This chapter reviews the functions of memory and how losses that accompany aging can best be managed.

For most of human history few people got to be old. Older persons are not as well pepared to face stresses as younger persons because of evolutionary factors. So, it is necessary for older persons to consider the effects of their lifestyle choices on their ability to age successfully. Awareness of these factors is important for our appreciation of the impact which our activities have on our aging. For most of the past 100,000 years of human history we were living in a different environment than the one we have today. The genes we have now were chosen through natural selection because they enhanced the survival of our ancestors who were living in these different environments. This view provides valuable insights into the role environmental factors have in determining maintenance of function with aging. This chapter presents the vital perspective that what we do affects the accomplishment of our goals for aging. These goals must go beyond survival and avoidance of disease and also strive for maintenance of the highest level of fitness and resistance to loss of function (reserve capacities) so that we can resist the declines with aging, as well as the challenges which inevitably occur.