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Understanding Dissociative Amnesia
- 1. DISSOCIATIVE AMNESIA by Grace Lim Shinn Yee
- 2. DISSOCIATIVE AMNESIA • A potentially reversible memory impairment that primarily affects autobiographical information. • Dissociative amnesia cannot be explained by ordinary forgetfulness. • Patient is aware that they are having trouble remembering, they are not bothered by it. Conway & Pleydell-Pearce (2000); Ganti eti al., (2016); APA (2013)
- 3. MISSING MAN Benjamin Kyle (his new name), woke up in a dumpster behind a Burger King with no idea who or where he was… August 24th, 2004, Wikipedia
- 4. DISSOCIATIVE AMNESIA Unable to recall important personal information, usually involving traumatic or stressful experiences Amnesia is not normal forgetfulness The memory loss is reversible Recall of memories may happen gradually but often occurs suddenly and spontaneously May be associated with dissociative fugue Lacks evidence of organic illness or pathophysiological disturbance Spiegel (2017); APA (2013); Conway & Pleydell-Pearce (2000)
- 5. DISSOCIATIVE AMNESIA DIAGNOSTIC CRITERIA • A. An inability to recall important autobiographical information, that is inconsistent with ordinary forgetfulness. • B. Symptoms cause distress or impairment in social, occupational, or other functioning. • C. Disturbance is not due to the effects of a substance, neurological, or general medical condition. • D. Disturbance is not better explained by another psychiatric disorder. Also, important to specify if associate with dissociative fugue. APA, (2013)
- 6. HISTORY OF DISSOCIATIVE AMNESIA • Amnesia- from the Greek roots (a=“not”, mnastai=“to remember”) • Formerly known as ‘psychogenic amnesia’ • These disorders have been previously classified as ‘hysteria’. • Only treated as a new disorder since it emerged in the DSM-III. • In DSM-V, Dissociative fugue has been incorporated into dissociative amnesia and is no longer a separate diagnosis. Zasshi, (2011)
- 7. EPIDEMIOLOGY • The most common type of dissociative disorders • Approximately 6% of the general population • A minimum of 2% of people in the US population have dissociative amnesia. • Increased incidence of comorbid major depression and anxiety disorders • Females more affected than males • Mostly reported in late adolescence and adulthood • Younger adults more affected than older adults • Increased incidence during times of war and natural disasters (Ganti et al., 2016; Sar et al., 2007; Foote et al., 2006)
- 8. 32-YEAR OLD TEENAGER Naomi Jacobs woke up to a house she did not recognize and a son she did not know. She truly believed she was her teen self. June 21st , 2015, The Sydney Morning Herald
- 9. DIFFERENTIAL DIAGNOSIS Upset by memory loss Trying to recall memories Dissociative amnesiaDementia Encyclopedia of Mental Disorders (2018)
- 10. DIFFERENTIAL DIAGNOSIS Alcohol abuse Anxiety Factitious disorders Disorders Depression Malingering Ganser syndrome Encyclopedia of Mental Disorders (2018); APA (2013)
- 11. SUBTYPES OF DISSOCIATIVE AMNESIA Localized amnesia Selective amnesia Generalized amnesia APA (2013)
- 12. LOCALIZED AMNESIA Lack of autobiographical memory for a specific time period For example: • The person cannot recall a specific stressful or traumatic incident, such as a car accident.
- 13. SELECTIVE AMNESIA Forget parts of memory for a period of time. For example: • A soldier may recall most of a battle, but not the death of his buddy.
- 14. GENERALIZED AMNESIA Profound loss of memory for personal history and loss of personal identity Personal information cannot be recalled; but habits, tastes, and skills are retained. For example: You would still know how to read, although you would not recall your elementary school teachers.
- 15. CLINICAL FEATURES Overt dissociative amnesia • Present with dramatic, profound loss of memory for personal history and loss of personal identity Covert dissociative amnesia • Is more common • Usually do not reveal the presence of dissociative symptoms unless directly asked about it. Franklin (1988)
- 16. COURSE AND PROGNOSIS • Sometimes memories return quickly once the person is removed from traumatic or overwhelming circumstances. • In other cases, amnesia, particularly in patients with dissociative fugue, persists for a long time. • The capacity for dissociation may decrease with age. • Some patients are profoundly disabled and require high levels of social support (i.e. nursing home placement or intensive family caretaking) • Most patients recover their missing memories, some never able to reconstruct their missing part. • The prognosis is determined mainly by the following: • Life circumstances • Overall mental adjustment Spiegel, (2017); Loewenstein (1994)
- 17. FACTORS DISTINGUISHING DISSOCIATIVE AMNESIA Sudden, dramatic disturbance in vast amount of memories related to personal information 1 Individuals are aware of deletion in continuous memory and ordinarily do not complain of memory loss 2 Sharon et al., (2016)
- 18. CASE ILLUSTRATION A 28-year old woman was brought into the Emergency Department (ED) for an evaluation after police found her at a local clothing store selecting outfits for customers. The woman said that she worked there, but the store manager denied this. The woman was not able to tell officers her name, date of birth or address – they came to glean some information only after looking through her wallet and finding her driver’s license. The woman, named Alice, had a home address that was over 300 miles away. The police brought her to the ED. In the hospital, Alice only talked about her nephew’s tenth birthday party. https://www.youtube.com/watch?v=4VedBaY7AVU&index=1&list=PLX-gK_4-kAGb9Fa-M0isCaL_WxgUe_5Ei
- 19. WHAT TYPE OF AMNESIA IS ALICE EXPERIENCING? Localized amnesia Selective amnesia Generalized amnesia Overt dissociative amnesia Covert dissociative amnesia With dissociative fugue
- 20. AETIOLOGY Overwhelming stress Usually the results of traumatic events War, abuse, natural disaster Lucchelli & Spinnler (2003); Abeles & Schilder (1935); APA (2013)
- 21. GENES AND ENVIRONMENTAL Environmental Trauma (physical or sexual abuse in childhood, sexual assault, trafficking, military combat, natural disaster, torture) Genetic: 50% of variance variance in dissociative disorders could be accounted for by genetic factors. Leong, Waits, & Diebold (2006); Brown et al., (1998); Markowitsch (2003)
- 22. DIATHESIS-STRESS MODEL • People who are prone to fantasize, are highly hypnotizable, and are open to altered states of consciousness, may be more likely than others to develop dissociative experiences. • People who are not prone to fantasize will experience anxious, intrusive thoughts associated with posttraumatic stress disorder (PTSD) following traumatic stress, rather than dissociative disorders. • Continuous debate on the role of ‘fantasy proneness’ as a risk factor for dissociation in response to trauma. Butler, Duran, Jasiukaitis, Koopman & Spiegel (1996)
- 23. PSYCHODYNAMIC VIEWS The ego protects itself from anxiety by blotting out disturbing memories or by dissociating threatening impulse Involve the massive use of repression from unacceptable impulses and painful memories, resulting in the splitting off from consciousness Dissociative amnesia may serve an adaptive function of disconnecting one’s conscious self from awareness of traumatic experiences, psychological pain or conflict. Spermon, Darlington & Gibney (2010)
- 24. SOCIAL-COGNITIVE THEORY Dissociative amnesia as a learned response involving the behavior of psychologically distancing oneself from disturbing memories or emotions. The habit of psychologically distancing oneself, such as by splitting them off from consciousness, is negatively reinforced by relief from anxiety or removal of feelings of guilt or shame. Gleaves (1996)
- 25. SIMILARITIES WITH OTHER CULTURE- BOUND DISSOCIATIVE SYNDROMES • Amok • Occur in primarily southeast Asian and Pacific Island cultures • Involves a trancelike state in which a person suddenly becomes highly excited and violently attacks other people or destroys objects • People who ‘run amuck’ may later claim to have no memory of the episode or recall feeling • Zar • Term used in North Africa and the Middle east countries to describe spirit possession • Describes individuals who engage in unusual behaviour, ranging from shouting to banging their heads against the wall Manuel & Martin, (1999); Rahim (1999)
- 26. SYMPTOMS SCREENING MEASURES • Dissociative experience scale (DES) • Somatoform Dissociative Questionnaire (SDQ-20) Bernstein & Putnam (1986); Njenhuis (1996)
- 27. DIAGNOSTIC INTERVIEWS • Two DSM-based structured interviews: 1. The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D-R) • Presence/severity of amnesia, identity confusion and alteration, depersonalization and derealization 2. The Dissociative Disorder Interview Schedule (DDIS) • Child abuse history, major depression, somatic complaints, substance abuse, and paranoid experience Steinberg et al., (1994); Ross et al., (1989)
- 28. Who the person is; what he or she did; where he or she went; with whom he or she spoke; what was said; what was thought and felt. The central feature of dissociative amnesia is the unavailable memory related to autobiographical information. Differentiating Types of Amnesia
- 29. TREATMENT PROCESS • Differentiating between organic and dissociative memory loss as an essential first-step in effective treatments. • Important to establish the patient’s safety • Treatment begins by creating a safe and supportive environment. • Treatment often revolved around trying to discover what traumatic event had caused the amnesia. • Once the amnesia is lifted, treatment helps with the following: • Giving meaning to the underlying trauma or conflict • Resolving problems associated with the amnestic episode • Enabling patients to move on with their life Leong, Waits,& Diebold (2006); Sargant & Slater (1941); Spiegel (2017); Ganti et al., (2016)
- 30. TREATMENT OPTIONS • Psychotherapy & Supportive Therapy • Cognitive Therapy • Hypnosis • Drug-induced semi-hypnotic state (i,.e. barbiturate, benzodiazephines) • Family Therapy • Creative Therapies (i.e. Music & Art Therapy) Spiegel (2017); Croft (2017); Ganti, Kaufman, Blitzstein (2016); Peterson (2015)
- 31. OTHER TREATMENT APPROACH • Memory Retrieval Techniques • Hospitalization • No medications have demonstrated efficacy in dissociative amnesia. • However, some patients were found to spontaneously recover from their amnesia Spiegel (2017); Croft (2017); Ganti, Kaufman, Blitzstein (2016); Peterson (2015)
Editor's Notes
- Have you ever experience forgetting someone’s name? or where you left your car keys? Do you think you have dissociative amnesia? How about forgetting who you are, what your name is?
- Autobiographical information- who they are, what their name is, or their past. Ordinary forgetfulness
- August 24, in 2004, a man is found in a dumpster behind Burger King with no collections of who or where he was.. The man later named by himself Benjamin Kyle, till these days remains the only American who went missing, even with his whereabouts now. His true identity remains a mystery.
- 1) The main feature of dissociative amnesia is unable to recall important personal information, usually of traumatic or stressful experiences. 2) Amnesia is not ordinary forgetfulness (such as forgetting someone’s name or where you left you car keys). Memory loss in amnesia is more profound and wide ranging. 3) The memory loss is reversible although it may last for days, weeks, or even years 4) The recall of memories may happen gradually but often occurs suddenly and spontaneously. 5) Dissociative amnesia may be associated with dissociative fugue, in which the person may travel to a new location and start a new life under a different identity. When the fugue ends, they often feel shame, discomfort, depress, or frightened. 6) There is lack evidence for loss of memory and is usually not able to be explained biologically. Also, there is no structural damage to the brain or brain lesion is evident.
- Dissociative fugue-apparent purposeful traveling, bewildered waandering
- The term ‘amnesia’ rooted from Greeks, means not to remember
- According to multiple researchers, dissociative amnesia is the most common type of dissociative disorders Dissociative amnesia occurs in up to 6% of the general population. 2% of people in the US population have dissociative amnesia. There is an increased comorbidity with major depression and anxiety disorders More females were proved to be affected than males , , ,
- 32-year old Naomi Jacobs woke up to a house she did not recognize, and a son she did not know. The British mother truly believe that she was her teen self. But the thing is she din serve for any trauma to her head. Instead her amnesia was caused by stress. The last memory she had was falling asleep on a bunk bed she shared with her sister as a teenager.
- The differential diagnosis include dementia. What’s the difference between dementia and dissociative amnesia? First, we look at upset by memory loss. In one disorder, patient will be very upset with their memory loss. Which one is it? Dementia. Dissociative amnesia individuals tend not to be upset with their memory loss. How about which disorders has people trying to recall memories. That’s usually seen in Dementia whereas in dissociative amnesia, individuals appeared quite aloof even you ask them to recall details about their life.
- What other diagnoses must be ruled out when considering dissociative amnesia? Alcohol abuse, Anxiety, Factitous disorders, Medical Disorders- there are organic basis for memory loss such as Alzheimer, brain damage, brain tumor but there is no organic basis for dissociative amnesia Malingering- people sometimes claim they cannot recall certain events of their lives, such as criminal acts, promises made to others, and so forth intentionally. Malingering can usually be detected with Hypnotic Induction Profile (HIP) to evaluate whether the patient is easily hypnotized. Patients with genuine dissociative amnesia usually score high on test of hypnotizability. Ganser syndrome refers to patient who suffers from approximation or giving absurd answer to simple questions that make absolute no sense)
- There are three main types of dissociative amnesia
- Remembering only parts of a traumatic event
- The prognosis is determined mainly by the following: The patient’s life circumstances, particularly stresses and conflicts associated with the amnesia as well as the patient’s overall mental adjustment
- So, remember the facts to recognize dissociative amnesia The first is a sudden, dramatic disturbance in which a vast amount of memories related to personal information are not available The second is individuals are aware of the deletion in continuous memory, as opposed to a gradual loss of normal memory. For example, patients may not remember a certain year of schooling or a certain job, even though they remember other years of schooling and other jobs. This is usually due to a traumatic experience during that time period, such as a rape or a kidnapping. In extreme cases, patients cannot remember their teenage years or other periods of their lifetime and they ordinarily do not complain of memory loss.
- What type of amnesia is Alice experiencing?
- She has a generalized amnesia. There is a lot of information she can’t recall. And that’s actually an overt dissociative amnesia.
- Let’s look at the causes of dissociative amnesia. Usually caused by overwhelming stress, results of traumatic events, war, abuse, or natural disaster
- Dissociative amnesia has been linked to environmental factors such as environmental trauma. The person may have suffered the trauma or just witnessed it. There also seems to be a genetic (inherited) connection in dissociative amnesia, as close relatives often have the tendency to develop amnesia. **(An overwhelming of traumatic experience during childhood or later in life can trigger expression of a genetic diathesis that otherwise would have been suppressed. )
- This model interestingly explain about why certain people experience PTSD instead of dissociative amnesia following a traumatic experience.
- Psychodynamic views dissociative amnesia as an adaptive function of disconnecting one’s conscious self from awareness of traumatic experiences, psychological pain or conflict.
- Dissociative amnesia shared similar symptoms with other culture bound dissociative syndromes.
- 1) Dissociative experience scale (DES) is one of the best known among general dissociation screening scales. Dissociative Experiences Scale (DES) is a 28-item self-report instrument. 2) Another good screening measure is the 20-item Somatoform Dissociative Questionnaire (SDQ-20). The scale has good reliability and validity for discriminating dissociative disorder patients. **(The scale taps many of the somatosensory and dissociative symptoms including motor inhibitions, loss of function, anaesthesia and analgesia, pain and problems with vision, hearing and smell.)
- Two DSM-based structured interviews have been developed for the formal diagnosis of dissociative disorders: 1) The SCID-D-R is a semi-structured clinician administered interview that assesses the presence and severity of amnesia, identity confusion and alteration, depersonalization and derealization. 2) The DDIS is a clinical diagnostic instrument which inquires about a wide range of phenomena in addition to dissociative symptoms, including child abuse history, major depression, somatic complaints, substance abuse and paranoid experience
- You might want to ask them a little bit about what they can recall. What is happening before you met them, before an isolated event, how did they think, what were they feeling
- Important to establish the patient’s safety by removal from the traumatic situation which will often bring back the memories. Treatment begins with a safe and supportive environment. This measure alone frequently leads to gradual recovery of missing memories. Enabling patients to move on with their life by helping them develop coping skills to improve and restore overall functioning.
- 1)Psychotherapy is supportive in the initial phase. Psychotherapy aimed to build rapport, and create a safe environment a) Cognitive Therapy- Identifying the specific cognitive distortions that are based in the trauma b) c) Questioning patients while they are under hypnosis or in a drug-induced state can be successful but these strategies must be done gently because the traumatic circumstances that stimulated memory loss are likely to be recalled and to be very upsetting. Therapist must carefully phrase questions so as not to suggest the existence of an event and risk creating a false memory. d) Family therapy provides help to family members of persons with dissociative amnesia that is directed towards educating them about the nature of the condition, its symptoms and causes in order to get a better understanding and provide support to the patient. e) Creative Therapy helps a person with dissociative amnesia to express their thoughts and feelings through a creative and safe manner.
- Memory retrieval techniques are also effective adjunct treatments to dissociative amnesia especially when there is difficulty to spontaneously recall past memories. Some cases of dissociative amnesia require treatment in a hospital. These are cases in which the person is a clear and present danger to him or herself or others. Hospitalization is particularly helpful for patients experiencing current abuse. Dissociative amnesia may spontaneously resolve when a person is removed from a traumatic situation. 3) No medication have demonstrated efficacy in dissociative amnesia. Since dissociative amnesia often comorbid with depression and PTSD, the groups of drugs that are best prescribed for patients are anti-depressant and anti-anxiety medicines. 4) However, some patients spontaneously recover from their amnesia