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Home , Fugue state, Psychogenic amnesia

Indian Journal of , 2002,44(3)283-288

AMNESIA FOR AUTOBIOGRAPHICAL : A CASE SERIES

R.K.CHADDA, N.SINGH & D.RAHEJA.

ABSTRACT

Functional for is a rare but pathognomic sign of dissociative disorders. Amnesia for part of one's personal history is sometimes also seen in other functional disorders like and but autobiographical amnesia in these disorders is relatively rare. Phenomenologically the autobiographical memory loss, amnesia for events during the amnestic episode and change of identity (as in fugae and dissociative identity disorder) are all expressions of altered memory organisation. This paper reports three cases of autobiographical amnesia with clinical diagnoses of unspecified type, dissociative amnesia and schizophrenia that were treated successfully. The phenomenon of autobiographical amnesia is discussed in the background of these cases.

Key Words: Amnesia, memory, autobiographical, dissociative disorders

Memory disturbances are a common disturbances occur in the context of impaired complaint in clinical practice in psychiatry. The consciousness, with reduced ability to focus, disturbance usually refers to of day to day sustain or shift , whereas in , events, finances, or some personal information memory impairment may co exist with multiple like addresses, phone numbers, etc. In severe cognitive deficits like aphasia, apraxia, agnosia, cases, the patient may even forget the names of etc. his or her immediate family members and may Organic amnesia involves impairment in not be able to recognise them (Kopelman, 1987). learning and recall of new information, which is Amnesia is a general term for memory disturbance typically absent in dissociative amnesia. Transient and includes both partial as well as complete loss amnesia of organic origin may be, like dissociative of memory that may be anterograde and amnesia, circumscribed to a particular time period retrograde, defined in terms of the onset of an or event with no difficulty in learning and recalling injury or illness. Common causes of amnesia may new information, but in these organic cases, there include organic disorders like , is "shrinkage" of . This dementia and organic amnesic disorders or indicates a well-observed fact of recall impairment functional illnesses like depression and diminishing as patient recovers Apart from these, dissociative disorders. Amnesia occurring in the the organic amnesia patients during the amnestic absence of any identifiable injury or disease episode have confused or bewildered demeanour. affecting the brain structure is called functional or There is a gradation in degree of memory (Kopelman, 1987; Khilstorm impairment of pre-insult events. The most remote & Schacter, 1995). In delirium, memory events being the least affected and events more

283 R.K.CHADDA etal. closure to the insult, more seriously affected. or implicit (unconsciously expressed memory). Both of these above features are usually not seen The concerns people's in amnesia of dissociative origin (Caine & knowledge of particular events that they Lyness,2000). themselves have experienced and is inherently Amnesia for autobiographical memory is autobiographical (Tulving, 1983). A complete relatively rare and is seen more often in media episodic memory describes an event that has reports or movies rather than in general occurred in the past, but it also makes reference psychiatric practice. Functional amnesia involving to the spatiotemporal context, the time and place autobiographical memory is a pathognomic sign in which that event took place. It also necessarily in a major class of mental illnesses known as makes reference to the self as the agent or dissociative (conversion) disorders. Amnesia for experiencer of the event (Khilstorm & an or part of one's personal history is a common Schacter,1995). The episodic memory is feature of dissociative amnesia, dissociative fugue, predominantly explicit in nature but some times and dissociative identity disorder (multiple behaviours acquired during an experience or event ). may remain implicit. In dissociative amnesia, the core symptom The consists of generic is an inability to remember important personal knowledge about the world with respect to oneself, information, typically a traumatic experience (what as self-referent semantic memory. It includes has happened as well as what one has done). In knowledge of one's own name, residence, dissociative fugue, the core symptom is confusion occupation, family members and other information about one's identity, loss of identity, or the that is not associated with a particular time and assumption of a new identity. This amounts to place. The non-self referent semantic memory who one is, not just what one has done. concerns with knowledge about language, general The change in identity is typically accompanied mathematical rules and facts of life and the world by a loss of memory for events and experiences around us. Semantic memory can be expressed associated with the former identity (Khilstorm & in explicit (facts) or implicit (language rules) Schacter, 1995). This is some times accompanied manner. by moving away from one's native place. When The is defined as the resolves, the person reverts to his individual's repertoire of learned skills like driving, or her original identity, and is able to recall the cooking, singing, playing games and musical original (old) . However, the instruments, and writing. This type of memory is autobiographical memories associated with the mainly expressed in implicit or unconscious newly assumed identity are lost. Dissociative manner. The procedural memory is relatively intact identity disorder resembles fugue, except that the in organic amnestic disorders, as opposed to the shift between identities, and associated sets of episodic memory. Similar is the case with the autobiographical memories, is cyclical. It appears dissociative disorders. as if two or more separate identities exist within In pure cases of dissociative amnesia, there the same individual, alternating in control over is loss of episodic, but not semantic memory experience, thought and action (Khilstorm & about oneself. Patient forgets what he did or what Schacter, 1995). Each of these identities (some happened to him, during a specified period of time; times called alter egos) has its own fund of but he does not forget who he is. Mostly the autobiographical memories in form of events and amnesia is reversible in such cases and access experiences and self-referent semantic knowledge. to the episodic (autobiographical) memories The memory is variously categorised as covered by amnesia is eventually restored. episodic, semantic (or declarative) and procedural. In fugue, there is loss of autobiographical It can be expressed as explicit (conscious recall) (self referent) semantic memory as well as

284 * AUTOBIOGRAPHICAL AMNESIA

episodic memory. These patients forget who they patient had never been to Varanasi and the family are as well as what they have done. If the patient had no connections in Varanasi. There was no assumes a new identity, a new set of past psychiatric illness and no family history of autobiographical memories (episodic as well as psychiatric illness. semantic) become associated with the new Birth and early developmental history were mental representation of self. When the fugue unremarkable and there was no history of child resolves, the new self as well as associated abuse. During examination, though tense at being autobiographical memories are lost as well. in a hospital in Delhi, she was generally Somewhat similar happens in dissociative cooperative and communicative. Physical and identity disorder, except that there is a kind of neurological examination revealed no abnormality. alteration or exchange of identities and associated She was diagnosed as a case of dissociative autobiographical amnesia. disorder, unspecified type. Abreaction with It is quite interesting to note that while the diazepam was conducted. During abreaction, she dissociative disorders involve profound narrated that she was going with her husband to impairments of autobiographical memory (episodic a hill station On the way they met with an accident as well as self referent semantic, specially the in which her husband was seriously injured. At explicit part of both), the other knowledge stored this , it was suggested that her husband was in memory specially the one that is expressed dead, and she would go to sleep after a while, implicitly (procedural, semantic and sometimes, and on waking up would become 'Ms A'. She woke episodic, when certain event related behaviours up after one hour and was absolutely normal with memorised during some experiences of the no memory of the episode. past are expressed in implicit manner) appears Case 2: Ms. B, a 17-year-old , unmarried female to be relatively unimpaired. The individual's fund studying in 12th standard, presented with a history of world knowledge (the non self referent semantic of loss of memory including personal identity for memory) and repertoire of learned skills (i.e. three days and episodes of loss of consciousness procedural memory) remains relatively unimpaired for five days. She had appeared in one of the paper (Khilstorm & Schacter, 1995). of 12th standard examinations 5 days earlier Here we report three patients who presented and had performed miserably. She had been with autobiographical amnesia. Detailed preoccupied with her bad performance before the assessment led to the diagnoses of dissociative onset of episode of unconsciousness. She gave disorder, unspecified type; dissociative amnesia impression of assumption of alternate personality, and schizophrenia. All the three cases were which was not her actual identity. She could not treated successfully. reveal exact characteristics of the new or alternate Case I: Ms. A, 17- year- old, unmarried female identity and did not know her name. She was not from a conservative Muslim family, was brought responding when called by her actual name and to the outpatient department from her school as was not able to tell who she was and how she she had become unconscious in her class in was in hospital. She was taking personal care, presence of her friends. On regaining but was not aware of her whereabouts and not consciousness after about three minutes, she recognising family members. During examination claimed that she was a 25-year- old Hindu girl, she was adequately dressed and fairly kempt Her daughter of a rich businessman from Varanasi psychomotor activity was reduced and she was (a city of pilgrimage for Hindus) married to a Hindu. withdrawn and inattentive She appeared sad and She also claimed that she had done her education was not recognizing her mother. No psychotic from Varanasi. During the spell of symptoms could be elicited. Physical examination unconsciousness, there were no involuntary was normal and there were no features suggestive movements, injury or incontinence. In reality, the of an epileptic phenomena or any characteristics

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favouring an organic illness. She was diagnosed personal information in the initial part of his hospital as having dissociative amnesia. Pentothal stay. This personal memory loss also remitted abreaction was done on the next day. The interview with about 3 weeks of antipsychotic treatment. lasted for 15 minutes during which she talked about Presumably, he had left his native place in an the conflict regarding her performance in the exacerbation of illness and had got lost, and was examination and fear of failing. She was given later brought to our hospital. Even after suggestion that she would regain memory within improvement, he was not able to recall the course a few days. She was treated with oral diazepam of events of the period when he was not able to and supportive psychotherapy during her stay in tell about his name and was missing from his . the hospital. At the time of discharge she had home. recovered completely and all the lost memory details were retrievable. However, she was not DISCUSSION able to tell the details about the period of memory loss. Memory organisation in autobiographical Case 3: Mr.C, a 17-year old male, was admitted amnesia is characterised by loss of with abusive and violent behaviour, inappropriate autobiographically organised episodic and self' crying, and incomprehensible speech in the referent semantic memory indicating a failure of psychiatric emergency service on being referred cognitive process in retrieval of stored information. from a general hospital. He was unable to recall There is relative preservation of skills of daily living his name and address though fully conscious. and learned professional skills, thus showing Detailed examination revealed psychomotor intact implicit or procedural memory. Amnesia for retardation, neglect of personal care, and poverty the episode denotes either poor , of speech along with a general uncooperative elaboration and consolidation of memory during attitude. On the fifth day of admission, he was amnestic episode or retrieval failure after the started on trifluoperazine 15mg/day orally. After 3 episode (Khilstorm & Schacter,1995). The days of treatment, he started communicating and assumption of new identity with varying degree of could recall the day-to day events but no personal elaboration may be due to emergence of new set details. His thought disturbance had remitted and of autobiographically organised episodic and self- speech became relevant and coherent. Gradual referent semantic memories. improvement in personal and social functioning Two of our patients (Ms. A and Ms.B) during was noticed in the next two weeks. On the 18th amnestic phase had probably the kind of memory day of treatment, he told his name and after a organisation described above. Faulty encoding few days about his address and the family. He and/ or poor retrieval were evident from irreversible also informed about hearing voices of the village amnesia for episode. Assumption of new identity people in the past. His family was informed. His by Ms A. was indicated by emergence of new set father arrived on getting the news. His father gave of autobiographically organised episodic and self an additional information that Mr.C had suffered referent semantic memories. This was quite about 18 months earlier from an illness pronounced in form of memories of being from a characterised by socially disorganised behaviour, different religion (Hindu) and belonging to a Hindu aimless , hearing threatening voices, religious city as native (varanasi). However, such and suspiciousness. He was on psychiatric details could not be elicited in Ms. B. The newly treatment but had not regained the premorbid adopted identity was not sustained and got status. He was diagnosed as schizophrenia, terminated within a short span of about an hour undifferentiated type. Mr. C did not show any and there was no shift between two identities. serious cognitive impairment at any stage except Therefore, she did not meet the diagnostic criteria for the predominant memory dysfunction involving of dissociative identity disorder and was

286 AUTOBIOGRAPHICAL AMNESIA diagnosed as A case of dissociative amnesia. resulting in various symptoms of dissociative Mr. C, who was diagnosed to be suffering from disorders. In "Dissociative Detachment", patients schizophrenia, had also not assumed any new are coping by disengaging attention more identity during the amnestic phase and had intact pervasively from the outer as well as inner worlds non-self semantic and procedural memory as (Allen et al.,1999) Both environmental and shown by absence of any other cognitive deficit personal contact may be detached (Butler et except for autobiographical amnesia. Many times al.,1996). The consciousness in dissociative patients of schizophrenia because of their formal detachment is perhaps better characterised as thought disorder or irrelevant talk may appear to diffuse or vacuous than narrowly focused (Allen have memory disturbances which may not actually et al.,1999). be there. Although in our case (Mr. C) thought Intense absorption alters the sense of self disorder and irrelevant speech were present and reality. In dissociative phenomena, it is initially, these had remitted within three days of accompanied by narrowed attention, which start of treatment. However, his autobiographical amplifies the focus of consciousness and amnesia continued till the third week of treatment, excludes the "Metacognitions" (e.g.. awareness excluding any misinterpretation on the basis of that something is imagined and not real) leading presence of communication problems. It seems to experiences of memories as real (Tellegen and that he had disturbance of elaborative encoding Atkinson, 1974). It may so happen that the and consolidation and/or of retrieval, as he could arrangement of consciousness in altered sense not remember details of his behaviour during the of self and reality retrieves memories (Episodic amnestic period. and Semantic) organised around original self and The clinical manifestations of dissociative reality and this manifests as autobiographical disorders are considered to be due to the use of amnesia. The lack of metacognition and dissociation as a defence in which an experience of memories as real may help arrange overwhelmed individual rather than taking fantasised personal, environmental and semantic meaningful or rational action, escapes the memories (now experiences) around the altered stressful situation by altering his or her internal sense of self and reality. This may manifest as organisation (Klurf, 1992). This alteration of assumption, partly or completely, of new identity internal organisation is helped through cognitive by the patient. Some degree of assumption of processes of " Absorption" or imaginative new identity is considered an essential feature of involvement and "Dissociative Detachment', which all dissociative disorders (Khilstorm & are predominating in dissociative states (Allen et Schacter,1995). In the present series of cases, al.,1999). Reorganisation of consciousness by the new identity was well developed in the first these cognitive processes may result in the case, but was not well established or evident in altered memory structure as seen clinically in the other two cases form of autobiographical amnesia. Experiences organised around the altered The process of" Absorption" or imaginative sense of seif and reality would be difficult to retrieve involvement is evident when one is engrossed in when patient's original arrangement of a book, television, movie, fantasies or day dreams consciousness returns and episode of amnesia and remembering past events vividly to the point is over. This would manifest as amnesia for the of reliving them (Carlson,1994). The episode due to retrieval failure Amnesia for the consciousness is focused on the point of episode may also be observed when the part of absorption. At mild levels, such experience are consciousness under the influence of process of indeed normal, common and benign but in the "Dissociative Detachment" is de-linked from the face of anxiety or fear of psychological personal and environmental context, leading to disintegration, these may take pathological form, varying degree of Encoding, Elaboration, and

287 R.K.CHADDA eta/.

Consolidation failure. Delirium, Dementia, and Amnestic and other Impairment of autobiographical memory in Cognitive Disorders and Mental Disorders Due to schizophrenia is an unusual finding as happened a General Medical Condition. In. Sadock, B.J. & in our third patient. This has been observed in Sadock, V.A.(eds) Comprehensive Textbook of some cases and is reported to be similar to that Psychiatry. 7th Edition, pp 854-923. Baltimore: seen in psychogenic amnesia (Stip,1994). The Williams & Wilkins. amnesia responded to antipsychotic treatment but the response was delayed as compared to the Carlson,E.B.(1994) Studying the interaction other symptomatology. It is well known that between physical and psychological states with schizophrenic process can lead to poor ego dissociative experiences scale. In Spiegeld (ed), functioning (as evidenced by loss of contact with Dissociation Culture Mind and Body pp, 41-58, reality), and this could lead to cognitive changes Washington DC: American Psychiatric Press. required to induce dissociation,severity of which may vary from patient to patient. This may cause Khilstorm, J.F.& Schacter,D.L. (1995) dissociative kind of memory disturbances in Functional disorders of autobiographical memory schizophrenia as observed by Stip (1994). In Baddeley, A.D., Wilson, B.A., Watts, F.N., Management of underlying schizophrenic process (EDs). Handbook of Memory Disorders pp,337- is likely to bring improvement in the secondarily 364. New York: Wiley. affected cognitive processes as was also seen in our case. The role of antipsychotics in functional Kluft, R.P.(1992) Discussion: A specialist's amnesia remains speculative but it is observed perspective on multiple personality disorder. that some patients of dissociative disorder also Psychoanalytical Inquiry, 12,139-171. experience psychotic symptoms and require antipsychotics (Allen et al.,1999). Kopelman, M.D.(1985) Multiple memory deficits in Alzheimer type dementia: implications REFERENCES for pharmacotherapy. Psychological Medicine, 15,527-541. Allen, J.G., Console, D.A. & Lewis, L.(1999) Dissociative detachment and memory Kopelman, M.D.(1987) Amnesia: organic impairment: Reversible amnesia or encoding and psychogenic. British Journal of Psychiatry, failure. Comprehensive Psychiatry, 40,160-171. 150,428-442.

Bower, G.H.(1981) Mood and memory. Stip, E.(1994) Memory impairment in American Psychologist, 36,129-148. schizophrenia: perspective from and pharmacotherapy. Canadian Journal of Bulter, L.D., Duran.R.E.F., Jasiukaitis, Psychiatry, 41,8 (Suppl 2), 527-534. P., Koopman, C. & Spiegel, D.(1996) Tellegen, A. & Atkinson, G.(1974) Hypnotizability and traumatic experience: a Openness to absorbing and self altering diathesis- model of dissociative experiences ("absorption"): a trait related to symptomatology. American Journal of Psychiatry, hypnotic susceptibility. Journal of Abnormal 153,42-63. Psychology, 83, 268-277. Tulving, E.(1983) Elements of Episodic Caine, E.D. & Lyness, J.M.(2000) Memory. Oxford University Press, Oxford.

RAKESH K CHADDA', M.D.M.A.M.S., Additional Professor, NARENDRA SINGH, M.D., Assistant Professor, DEEPAK RAHEJA, D.P.M., Formerly Senior Resident, Department of Psychiatry, Institute of Human Behaviour & Allied Sciences, Dilshad Garden, P.O.Box, 9520, Delhi-110O9S. * Correspondence

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