Dissociative Amnesia – A Challenge to Therapy

The psychiatric disease of dissociative amnesia is described and illustrated with case reports. It is emphasized that dissociative amnesia has a stress or trauma-related etiology and that affected individuals, contrary to the still dominant clinical belief, are frequently more severely and enduringly affected. That means, most of them show severe retrograde amnesia for their biography, usually accompanied by changes in their personality and sometimes also by alterations in other cognitive and emotive domains. As many patients show the phenomenon of “la belle indifference”, their motivation for therapy or treatment of their amnesia is reduced. Patients also seem to a high degree to possess immature, unstable personality features. Nevertheless, a number of quite divergent, though largely not evidence-based, therapeutic approaches exist and are described. They are divided into (a) psychopharmacological and somatic treatments, (b) psychotherapeutic interventions, and (c) neuropsychological rehabilitation. Furthermore, detailed treatment strategies are provided. DOI : 10.14302/issn.2574-612X.ijpr-18-2246 Corresponding author: Angelica Staniloiu, M.D., PhD, University of Bielefeld, Bielefeld, Germany, Phone: +49 1755977297, Email: astaniloiu@uni-bielefeld.de


Introduction
Dissociative amnesia is characterized by amnesia in the episodic-autographical domain.Usually patients "forget" (or alternatively said: have no conscious access to) their total personal past. 1,2 antic memory, which is memory for neutral facts, and procedural memory and priming (cf.They can read, write, calculate, behave in a normal social way, and know details about the world and famous people.All the more their lack of access to their personal past appears puzzling to their social environments (partners, friends, etc.).In very rare cases the reverse amnesia picture may be true, namely a preservation of old episodic-autobiographical memories, but an inability to store new personal information long-term. 4,5 7][8] While it was stated in classical textbooks that the amnesia is usually transient and functional recovery will be complete, more recent research shows that patients with dissociative amnesia may remain amnesic for years and decades, though those with the retrograde version of dissociative amnesia can learn about their past in a neutral, emotionally distant manner.
Dissociative amnesia as a psychiatric condition has a long background, which reached increased awareness with Charcot, Janet, and Freud. 9At their time and even until after the Second World War it was labeled 'hysteria'.Later it was termed psychogenic amnesia.This term has remained until today though its use is nowadays much rarer than that of dissociative amnesia. 10Other, closely related terms are 'functional amnesia', 11 implying that the amnesia has a function for the patient, and 'mnestic block syndrome' 12 -indicating that the "forgotten" memories are not lost, but just blocked from access to consciousness and subsequently may at a later stage recover.
][15] Such stress or trauma situations make individuals especially vulnerable, if they occur in childhood and youth and if there is later "revival" of such stress or trauma conditions in adult (or later) life ("two-hit hypothesis", cf.ref. 1).For example, patients with a background in migration are frequently affected, 16 which is a confirmation for the stress hypothesis of dissociative amnesia.Also, a forensic background can be found in a minority of the patients. 1,2,11 Mrkowitsch 17 proposed a model (cf.his Table 23.2),20] Dissociative amnesia is considered, in comparison to many other psychiatric diseases, to be relatively rare, although prevalence rates have ranged between 0.2% and 7.3%, apparently depending on cultural background and methodology. 1,2 evertheless, it has been diagnosed with increasing frequency.
Recently two studies with comparatively large groups of patients with dissociative amnesia were published: one with 53 cases 21 and one with 28 cases. 22With a few exceptions all patients in the study of Staniloiu et al. 22 had persistent, long-lasting amnesia.Furthermore, many patients show a tendency towards depression and an affective predisposition, named since Janet and Freud "belle indifference". 8The latter is coupled with apparently little caring about their future.While the condition of "la belle indifference" may contribute to the persistence of their amnesia, it cannot solely explain why a substantial number of patients remains in a long-lasting disease condition, which appears severe to the outsider.In order to address the question, why therapy frequently does not work or is not sought or pursued by the patients with this condition, we will first describe a few cases and then review the possible treatment or therapy modalities and their strengths and shortcomings.

Case Reports
Case A

Case D
This man in his 50ies was found sitting on a park bank without knowing who he was and where he belonged to.He was brought into a psychiatric clinic where he was diagnosed as probably having a psychogenic fugue (a dissociative amnesic condition accompanied by leaving the usual place of living, presently subsumed under 'dissociative amnesia').He was convinced to provide a photo of himself for the press in order to find out who he was.Due to this, his identity was revealed and he was brought into his home city and treated there in a university clinic.
A journalist from a prominent magazine contacted him and did an investigation on his past life.
He found that the patient had been an orphan and had apparently been maltreated in several institutions.
During his third adoption his parents wanted him to learn to play piano which he hated.He chopped himself several finger tips off in order to no longer have to play.
Apparently, he was sexually abused by priests while attending a boarding school.In his later life he worked as a tourist guide in North Africa.Due to therapy or because of other conditions some of his early childhood memories came back; most of his past, however, remained inaccessible to him even after years.

Cases E and F
We studied two patients with the rare condition of anterograde dissociative amnesia. 1 One patient was Patient E had superior memory for personal and general events from the time prior to amnesia onset which was tested in great detail.It also was found that the reference point for conscious recall coincided in time with her second car injury.However, aside from whiplash injury, brain scan results remained inconspicuous.
The same held true for patient F, who had two identical incidents during his work.He had been a nine-year old child, when his parents had sent him to live with relatives in another country (He moved from Bulgaria to East Germany).Though he did not understand any word in his new country, he adapted, finished school and became an engineer.After the re-unification of Germany, he lost his job and had to work as a distributor for cigarettes, where he had to fill vending machines.His wife told that he hated this job.
On two occasions, separated by several years, cigarettes fell out from the vending machines and while he grabbed them to put them back into the machines, the door of the vending machine hit his head and he apparently became unconscious for very short periods of time.Thereafter he panicked, thinking that his money or his car were stolen, which, however, was not the case.Nevertheless, after the second incident he became anterogradely amnesic and remained so since then.
Similar to patient E, his memory span was about four hours.Interestingly, a memory span of four hours had also been described in another patient with a similar condition of psychogenically caused anterograde amnesia. 30ile patient E refused therapy for her amnesia, patient F made some attempts (motivated by his wife) but gave up after some sessions.

Discussion and Implications for Therapy
The This is also reinforced by the fact that the child's brain develops slowly during childhood and depending on environmental stimulation.Some brain regions within the frontal lobe even change until about age 22 40 and for fiber systems such as the uncinate fascicle (which interconnects the frontal and anterior temporal lobes and is implicated in synchronizing emotional colorization with memory) a process of maturation increase has been found even after age 30. 42In maltreated and neglected children, as well as in monkeys growing up without their mothers, similar brain changes in the frontal and cingulate cortex were reported. 43,44 7][48][49][50][51] Such changes are not only related to an increase in the stress hormone levels, but also to a chronic decrease in the level of binding, prosocial hormones: as Fries et al. 52 showed, orphans who had been adopted by caring parents, still manifested significantly lower oxytocin and vasopressin levels after years after adoption, compared to children who from the beginning of their life grew up with nurturing families.
These findings demonstrate that stress and trauma experiences during childhood have severe and long-lasting consequences on brain and behavior during later life.It should consequently be not too surprising -especially also not given the data from genetics and epigenetics -that behavioral constellations are difficult to change or to break once they are established (cf., e.g., the findings from Davis et al. 41 ).
One of the authors of the study on binding hormones in children 52 stated in a TV interview that once the conditions are set in early childhood, they cannot be changed ("treated"), as a bullet cannot change its direction after it has left the gun.We nevertheless do not wish to and are far away from embracing a stance of generalizing negative effects in patients and therefore will discuss the current treatments as well as possibilities for novel treatment and therapy, which may open a pathway of hope in this condition.

Therapeutic Approaches
In general, there are three groups of possible therapeutic approaches for patients with dissociative amnesia, though no evidence-based therapy studies exist for this patient group 1 : • Psychopharmacological and somatic treatments for dissociative amnesia

• Psychotherapeutic interventions for dissociative amnesia
• Neuropsychological rehabilitation for dissociative amnesia

Psychopharmacological and Somatic Treatments
Somatic therapies consist in the prescription of anti-depressants (tricyclic antidepressants or selective serotonin re-uptake inhibitors) in order to rise their mood status and to support psychotherapeutic approaches, 19,30 with positive results.Barbiturates or benzodiazepines had been employed for drug-assisted interviews. 53Electroconvulsive therapy (ECT) in combination with a serotonin noradrenalin re-uptake inhibitor antidepressant was reportedly successful in a case of dissociative fugue. 54However, in another case, ECT treatment precipitated an episode of persistent anterograde dissociative amnesia. 55rthermore, there is -though very rarely applied -the so-called sodium amytal abreaction.This consists of injecting a barbiturate which should lower existing resistances and let the patient retrieve his or her autobiographical memories.Stuss and Guzman, 56 several decades ago, described a patient for whom this therapy worked at least short-term (namely for the time, the drug was effective).One possibility why this treatment is rarely used is the possible side-effect of respiratory depression. 1

Psychotherapeutic Interventions
On the psychotherapeutic site, there is conventional psychotherapy (cognitive-behavioral therapy, psychodynamic therapy), hypnosis, or Eye Movement Desensitization and Reprocessing (EMDR).
Most therapeutic approaches follow a specified -more holistic -scheme which starts with an attempt to stabilize the personality.This seems to be important, as it is indeed an established observation that patients with dissociative amnesia frequently have a more fragile, insecure personality with low self-esteem (making them prone to influences from others).Personality stabilization also helps to motivate the patient to participate in therapy and to establish a psychosomatic model of his or her illness. 1Improvement of well-being seems to be crucial as well as a prerequisite for starting specific therapy.
In Typically, a phasic treatment approach is employed in dissociative amnesic conditions, which encompasses as main early tasks the development of symptom management skills, modulation of dissociation and securing safety. 53,60 he treatment is guided by the psychological trauma paradigm.4][65] The reconnection phase 65 has as goals integration/ resolution, new coping skill learning, solidifying and maintaining gains.

Neuropsychological Rehabilitation
Data on neuropsychological rehabilitation for dissociative amnesia are sparse.They come mainly from cases of functional amnesia, which were characterized by a mixture of "organic" and "psychological" factors. 66ey suggest that preserved implicit management of information 66, 67 may be used to improve the substantial disability associated with dissociative amnesia and quality of life. 68The neurorehabilitation treatment should be attempted cautiously, in collaboration with mental health treatment providers, who can help with modulating affective responses and preserving and monitoring safety.

Response to Current Treatments and Suggestions for Future Directions
Dissociative amnesias have a high variability with respect to recovery.Many cases of dissociative amnesia follow a chronic course, constituting a major source of disability. 68 therefore propose that there is currently a stringent Psychology Press, Philadelphia, PA, USA 18. Markowitsch, H.J., Kessler, J., Van

Fig. 2
in ref. 1 or the Figure in ref. 3) 3 are usually preserved, implying that the patients on first glance appear quite normal: published in Markowitsch et al. 29 and the other in Markowitsch and Staniloiu. 5The first patient 29 was a 27-years old law student, who had had two consecutive car accidents with whiplash injury.She became anterogradely amnesic after the second accident and remained so from 1997 until the present.She had -under low cognitively demanding conditions -an anterograde memory span of four hours, which diminished to less than one hour under high demanding cognitive loading (with constant intensive memorizing).For instance, she behaved well above the norm in usual tests of memory such as the revised version of the Wechsler Memory Scale, as these tests have no retrieval delays beyond half an hour.She was able to copy the Rey-Osterrieth Figure: however, when asking her to reproduce it by heart after half an hour, one hour and two hours, respectively, she afterone hour showed a rudimentary free recall (Fig.1) and after 2 hours she basically showed a nil free recall.This pattern was found in a testing session that took part three years after becoming amnesic and in another session that occurred five years after the onset of amnesia.

FreelyFigure 1 .
Figure 1.Performance of the anterogradely amnesic patient E in the so-called Rey-Osterrieth Figure, a complex drawing which the patient had to draw repeatedly.The patient first is shown the figure and has to draw it from the original (A).Thereafter she had to draw it a second time by heart after half an hour(B), then a third after an hour (C), and finally a fourth time after 2 hours (E was unable to reproduce it then).Patient E performed the test 3 years (left half of the figure) and 5 years (right half) after amnesia onset.Patient E was able to copy the figure without problems (A), she also was considerably above average when drawing it by heart after half an hour (B); but then, after afurther half hour her performance was massively below expectation, and after 2 hours she -on both occasions -did not even remember having drawn the picture.
a broad theoretical framework57, 69, 70  for rehabilitation of dissociative amnesia.b) Adopting a holistic approach 71-75 that should aim towards achieving optimal physical, psychological, social and vocational wellbeing.69, 70 This holistic approach, involving an enriched therapeutic milieu,76    may show benefits even if years passed after the onset of amnesia,74, 77, 78  or, in the worst scenario it may prevent further cognitive deterioration due to lack of intellectual stimulation. 79c) Establishing a partnership between patients, their families and a multidisciplinary professional team with respect to selecting goals for rehabilitation that are SMART (specific, measurable, achievable, realistic and timely). 57d) Shifting the focus of treatment from the reinstatement of "forgotten" memories to developing strategies or skills that could help with functional adaptation in everyday life and environment and accomplishing selected goals.e)The remediation of executive functions, which are often impaired in these population (6), could be of great importance for a variety of instrumental activities of daily living, interpersonal functioning, theory of mind functions, prospective memory rehabilitation and even for the facilitation of the episodic-autobiographical memory retrieval.74, 80 f) Making use of ecologically valid assessment methods 81, 82 and employing training methods that might allow generalization to the real world are important. 83-86g) For patients with functional amnesia with anterograde memory impairments externally directed assisted devices might be helpful 84, 86-88 with assisting with reducing every day memory and planning problems.h) Social problem-solving interventions, metacognitive training and retraining of theory of mind functions might also be helpful for improving interpersonal relationships, community functioning and the sense of self-efficacy. 74, 89Vol-1 Issue 2 Pg.no.-42 i) Finally, one may think of the availability of web or internet-based therapies for patients with dissociative amnesia, as they are at present already existing, for example, for patients with mild traumatic brain injury, 90-92 a condition that is also observed in patients with dissociative amnesia. 5, 11, 93j) In addition, quality improvement of therapies can be training or therapy programs, which at present are available in the web for people with physical or psychiatric health conditions, 95 could also be implemented for supporting therapeutic change in patients with dissociative amnesia.k) Internet-based self-help and peer-support programs may aid the recovery process in patients with dissociative amnesia 96-99 and a migration background. 100l) Internet-mediated social support and web-based acceptance and commitment therapy (ACT) may offer additional help for stabilizing and grounding the personality, 101-104 a factor of outstanding importance for treating patients with dissociative amnesia. 8, 11consolidation.A case of persistent anterograde amnesia with rapid forgetting following whiplash injury.Neurocase 5, 189-200 5. 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