161 Dissociative Amnesia (300.12)

Dissociative Amnesia could be brought on by a Traumatic Event.

It used to be known as Psychogenic Amnesia. The crucial feature of this type of dissociative disorder is the failure to recall important personal information more extensive than explained by an individual’s normal forgetfulness. The nature of the information is usually traumatic or stressful. (American Psychiatric Association, 2000)

Mental illness

• Patient is alert or oriented.
• Patient is subadequately related with limited eye contact.
• Speech is slow and logical.
• Attention and concentration are limited.
• Energy level is not characterized by hyperactivity or slowing.
• Recent memory may be slightly impaired.
• Remote memory is intact.
• Mood is anxious or dysphoric.
• Affect is constricted.
• A negligible degree of conceptual disorganization is present.
• Reasoning and judgment are limited, and insight is lacking.
• An increased likelihood of passive suicidal ideation as well as violent ideation, sometimes even homicidal, is present, most likely due to severe frustration of the dissociation.

The DSM-IV-TR criteria according to the American Psychiatric Association (2000) includes the following:

• A. “The predominant disturbance is one or more episodes of inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness” (p. 523).
• B. “The disturbance does not occur exclusively during the course of Dissociative Identity Disorder, Dissociative Fugue, Posttraumatic Stress Disorder, Acute Stress Disorder, or Somatization Disorder and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a neurological or other general medical condition (e.g., Amnestic Disorder due to head trauma)” (p. 523).
• C. “The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning” (p. 523).

Associated features for dissociative amnesia according to the American Psychiatric Association (2000) are:

• Dissociative amnesia occurs when a person blocks out certain information, usually associated with a stressful or traumatic event.
• With this disorder, the degree of memory loss goes beyond normal forgetfulness and includes gaps in memory for long periods of time or of memories involving the traumatic event.
• Some individuals with this disorder report trance states, spontaneous age regression, anxiety, depersonalization, analgesia, depressive symptoms, and they may provide approximate, though incorrect, answers to questions.
• This disorder may be accompanied by sexual dysfunction, self-mutilation, suicidal impulses and acts, and impairment in social functioning, and they may meet criteria for Conversion Disorder, Mood Disorders, Substance-Related Disorders, or Personality Disorders. There is a lack of damage to the brain, but brain images do show abnormal activity. Results of FMRI’s suggest that, during an amnesiac episode, patients are unable to retrieve emotional memories normally, suggesting possible changes in the limbic system.

Child vs. Adult presentation

• Dissociative Amnesia is more common among young adults than in older adults but can occur at any age past infancy. It is difficult to assess in preadolescent children, as it may be confused with inattention, anxiety, psychosis, oppositional behavior, or developmentally appropriate childhood amnesia.

• Gender and cultural differences in presentation.

• Dissociative Amnesia is more common among women than men.

Epidemiology

• “There has been an increase in reported cases of Dissociative Amnesia that involves previously forgotten early childhood traumas. This increase has been subject to very different interpretations. Some believe that the greater awareness of the diagnosis among mental health professionals has resulted in the identification of cases that were previously undiagnosed. In contrast, others believe that the syndrome has been over-diagnosed in individuals who are highly suggestible.” (American Psychiatric Association, 2000)
• “Dissociative Amnesia can be present in any age group. The main symptom is a retrospective gap in memory. The reported duration of the forgotten events varies. Only a single episode may be reported, although there are commonly two or more episodes described. Individuals who have had one episode may be predisposed to develop amnesia for subsequent traumas. Acute Amnesia may resolve spontaneously after the individual is removed from the circumstances with which it is associated. Some may begin to recall distant memories, while others may develop a chronic form of amnesia.” (American Psychiatric Association, 2000)

Etiology

Dissociative amnesia has been linked to overwhelming stress, which might be the result of traumatic events—such as war, abuse, accidents or disasters—that the person has experienced or witnessed. There also might be a genetic link to the development of dissociative disorders, including dissociative amnesia, people with these disorders usually have close relatives who have had similar conditions. (American Psychiatric Association, 2000)

Differential diagnosis

• The differential diagnosis of DA are any organic metal disorders, dementia, delirium, transient global amnesia, Korsakoff’s disease, post-concussion amnesia, substance abuse, other dissociative disorders, and malingering, factitious disorders.
• Memory loss in organic metal disorders is typically gradual and incomplete. Clinicians may encounter difficulty in differentiating between substance abuse and DA because many patients minimize their abuse and also misattribute their amnesia to alcohol or drugs because of their of a diagnosis of dissociation. Obtaining a careful history from multiple informants is often necessary to clarify the situation. However, unlike DA, memory loss due to substance abuse is seldom reversible.
• Korsakoff disease may also be confused with DA. This disease, also known as alcohol amnestic disorder, is associated with heavy and prolonged alcohol abuse and is not associated with psychological stress. However, unlike DA, patients with Korsakoff disease are not able to learn new information and they often experience significant deterioration in personal functioning.
• Amnesia from brain injury or head trauma can be differentiated from DA based on a history of trauma; patients usually have retrograde amnesia before the trauma, unlike patients with DA, who have anterograde amnesia. In addition, patients with brain injury do not show the susceptibility or response to hypnosis so frequently observed in patients with dissociative disorders. Because dissociative disorders are associated with some evidence of biology causality, not every case of trauma results in symptoms that produce the disorder, nor does every person with the disorder have a history of childhood or adult trauma. (American Psychiatric Association, 2000)

Indications for hospitalization

In most instances in which patients present a clear and present danger to themselves or others, when medication effects must be evaluated, and in instances in which a diagnosis has not been determined, hospitalization is often necessary. Hospitalization allows patients to separate themselves from the environmental stimuli, sexual and physical abuses, and stresses that may be contributing to their reactions and episodes of amnesia, compulsive behaviors, and recklessness. It also protects them during a perplexing period of their lives when they honestly d not know who they are. Other indications are suicidal behavior or gesturing. Patients may experience problems with concentration and feelings of rejection, re-occurrence of preexisting psychiatric conditions, intrusive re-experiencing of trauma or negative thinking, feelings of emotional overwhelm, paranoia or general distrust, and episodes of schizophrenia and fear.

Empirically supported treatments

• Like most other disorders, Dissociative amnesia uses a combination of psychotherapy, cognitive therapy, medicine, family and creative therapy and a new approach- clinical hypnosis.
• Psychotherapy
  • In psychotherapy, the first phase of the treatment is to provide support to the patient. This involves creating a comfortable and supportive atmosphere in the treatment room. Generally the therapist will be there helping the patient to regain their memory, but one study reports that patients regain their memories while at home or surrounded by close friends and family. The patients denied that their memory was regained due to the therapist, but that the therapy did help.
  • The second phase of treatment occurs once the patient has recovered enough of their memories and has had a strong sense of self. The second phase involves helping the patient cope with the traumatic effects as well as the aftereffects.
• Cognitive Therapy
  • Therapy that focuses on changing the thinking pattern and the resulting behaviors.
• Family Therapy
  • Therapy for the family to help teach them about the causes of the disorder. This therapy can also help the family recognize the recurrence of symptoms.
• Creative Therapy
  • Forms of therapy that helps the patient express and explore their thoughts and feelings in a creative and safe manner.
• Medications
  • There is no medicinal cure for amnesia. However, patients may be given antidepressants to help with the anxiety, depression, insomnia, or other symptoms that are associated with dissociative amnesia.
• Clinical Hypnosis
  • Clinical hypnosis is a new approach to amnesia that is used if memories do not return spontaneously. In this treatment, hypnosis or the drug sodium amytal, which puts the patient in a hypnotic state, is used to try to make the memories emerge. Use of intense relaxation and concentrations. This approach allows the patient to explore feelings, thoughts, and memories that may be hidden from their conscious minds.
• “More controversy surrounds the use of hypnotically facilitated techniques to explore areas of amnesia, or to further explore fragmentary images or recollections. Some authorities who support hypnosis for these indications point to the recovery of material that has been confirmed at a later date or to the therapeutic progress often achieved irrespective of the veracity of what is found. Others believe that use of these methods carries the risk that hypnotically facilitated memory processing will increase the patient’s chances of mislabeling fantasy as real memory. They believe that these are strong disincentives to this use of hypnotic exploration.” (Chu, 2005)
• Dissociative amnesia

Proposed Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V)

• A. Inability to recall important personal information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting.
  • Note: There are two primary forms of Dissociative Amnesia: (1) localized amnesia for a specific event or events, and (2) Dissociative Fugue: generalized amnesia for identity and life history. Fugue may be accompanied by either purposeful travel or bewildered wandering.
• B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• C. The memory loss is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a neurological or other general medical condition (e.g., Amnestic Disorder Due to Head Trauma).
• D. The memory loss is not restricted to the symptoms of another mental disorder (e.g., inability to remember an important aspect of the traumatic event in Posttraumatic Stress Disorder or Acute Stress Disorder, or amnesia occuring as a symptom of Dissociative Identity Disorder or Somatization Disorder).