Commentary: Dissociative and the Future of Forensic Psychiatric Assessment

Robert P. Granacher, Jr., MD, MBA

J Am Acad Psychiatry Law 42:214–8, 2014

In their article, Pyszora et al.1 present the results of tive defects may be noted on careful neuropsycholog- research in which they re-examined 50 violent of- ical testing.3 fenders from an original case study. In the earlier Dissociative amnesia, on the other hand, as dis- study, they evaluated 59 amnesic violent offenders cussed in DSM-5 describes an inability to im- who received a life sentence in 1994 in England and portant autobiographical information (incidental Wales and compared them against a group of ), usually of a traumatic or stressful nature, nonamnesic offenders (n ϭ 148). In the current fol- which is inconsistent with ordinary . It of- low-up study, the authors reinterviewed 31 of the ten consists of localized or selective amnesia for a original 59 violent offenders and applied neuropsy- specific event or events. The symptoms cause clini- chological and psychological measures, as noted cally significant distress or impairment in other im- within the body of their research report.2 portant areas of functioning. The disturbance is not Amnesia is the generic term for a severe nondisso- attributable to physiological effects of a substance, a ciative memory deficit, regardless of cause.3 The Di- neurological or other medical condition, or other agnostic and Statistical Manual of Mental Disorders, neurological disease. The disturbance is not better Fourth Edition, Text Revision (DSM-IV-TR)4 gives explained by dissociative identity disorder, posttrau- four clinical characteristics that are typical of most matic stress disorder, acute stress disorder, somatic amnesic patients: , retrograde symptom disorder, or major or mild neurocognitive amnesia, , and intact intellectual func- disorder.5 No methods for measurement or labora- tion. Anterograde amnesia is the hallmark of an am- tory verification of putative dissociative amnesia are nestic disorder and refers to the inability, after the offered in DSM-5. onset of the disorder, to acquire new information for Jean-Martin Charcot6 and Pierre Janet7 are the explicit retrieval. refers to diffi- French neurologists most responsible for providing culty in retrieving events that occurred before the the beginning theories of dissociation. In the era of onset of the amnestic disorder, often demarcated at these two physicians, dissociative disorders were the time of onset by head trauma, stroke, or other studied in great depth and detail, but after 1890, they injury. Retrograde amnesia is more variably present received minimal for nearly 80 years. In the in different . Confabulation does not occur late 1980s and into the 1990s, there was a renaissance in all amnesias, and it is often present only in the of interest. However, virtually no funds were made acute stage. Finally, in the classic amnestic disorders, available for their systematic investigation. Virtually the patient’s intellectual function remains relatively all of the literature with regard to dissociative disor- intact, even though some specific secondary cogni- ders was based on using multiple personality disorder nomenclature. Controlled studies about the basic Dr. Granacher is Clinical Professor of Psychiatry, University of Ken- phenomena of the dissociative disorders were rela- tucky College of Medicine, Lexington, KY. Address correspondence 8 to: Robert P. Granacher, Jr, MD, MBA, 1401 Harrodsburg Road, tively few until the 1990s. The original theories of Suite A400, Lexington, KY 40504. E-mail: [email protected]. Janet were the first to show systematically a direct Disclosures of financial or other potential conflicts of interest: None. psychological defense against overwhelming trau-

214 The Journal of the American Academy of Psychiatry and the Law Granacher matic experiences. He demonstrated that dissociative of new learning (anterograde amnesia) are present, as phenomena played an important role in the widely is a variable retrograde amnesia, usually with a so- divergent posttraumatic stress responses, which were called temporal gradient.13 Preservation of the im- included under the 19th century diagnosis of hyste- mediate memory span is a point of importance clin- ria. His nine concepts of dissociation have been ele- ically. Performance on a test of digit span is usually gantly described elsewhere.9 normal, and therefore this test will fail to reveal the Dissociative amnesia is rarely diagnosed in mod- existence even of a severe amnesic syndrome. More- ern times.3 In the classic hysteria study by Perley and over, current and recent memory (new learning) is Guze,10 symptoms such as dizziness, headache, fa- severely impaired, and disorientation in time is al- tigue, and abdominal pain occurred at high rates in most universal. In the most extreme cases, new learn- more than 70 percent of patients. Amnesia was found ing may be reduced to virtually nil, so that as time in only eight percent of cases. Second, patients with goes by, there is a continuing and extending antero- dissociative amnesia typically have several other psy- grade amnesia. If recovery subsequently occurs, a chiatric disorders or manifest the amnesia after a very dense and permanent gap will be left for the duration stressful trauma. Current nosology excludes a diag- of the illness. In less severe examples, the problem nosis of dissociative amnesia in many such instances. reveals an uncertainty about events that occurred A functional amnesia does not necessarily interfere minutes, days, or weeks before. The retelling of sim- with social or occupational functioning, as noted. ple stories is marked by gross omissions, incorrect Dissociative amnesia is more common among fe- juxtapositions, and condensations of material.13 males, and it is thought to occur more often in ado- There are no similar models for describing or mea- lescents and young adults. Most cases show rapid suring dissociative amnesia accurately. recovery of memory. The classic studies of Ables and The neuropsychiatry of nondissociative amnesic Childer,11 and Herman,12 revealed that in 63 cases of disorders is well delineated at this time in medical dissociative amnesia, 27 individuals recovered within history.14 Three patterns of remote memory impair- 24 hours, 21 within five days, 7 within a week, and 4 ment in amnesic subjects have been described in the within three weeks or more (59/63 cases recovered medical literature. The first is impairment that is within a week). temporally limited, involving primarily the few years From a clinical psychiatric standpoint, the neuro- before the onset of the amnesia, with complete or psychological pattern of deficits seen in classical non- near-complete sparing of more remote time periods. dissociative amnesic states are described in a some- This is documented in the famous amnesic patient, what arbitrary division as immediate, recent, and H. M.15 The second pattern of impairment involves remote memory.13 Immediate memory span is re- a temporal gradient affecting all time periods, with flected in the reproduction of material, such as brief greater impairment of derived from recent digit sequences, which fall within the span of atten- periods. This pattern of remote memory disturbance tion. This represents a short-term memory mecha- is said to be typical of patients with alcoholic Korsa- nism. Recent memory is the ability to acquire and koff’s syndrome.16 The third pattern described in the retain new information or knowledge, and it is often medical literature is an impairment affecting all time described as new learning. Clinically, it is assessed by periods equally; it has been described in patients sur- testing for the ability to recall simple information viving herpes simplex encephalitis17 and in certain (exceeding the memory span) after at least a minute other amnesic subjects, as well as in patients with has elapsed. Remote memory is reflected in the abil- Huntington’s disease.18 ity to recall events or facts acquired at a considerable In evaluating the nondissociative amnesic person, distance in time, certainly before the onset of the there are two main goals to meet: establish the sever- claimed memory difficulties. An impairment in re- ity of the in the context of other mote memory indicates retrograde amnesia, whereas cognitive complaints; and characterize the nature of the inability to learn new information indicates an- the memory impairment at its basis in , terograde amnesia. , and retrieval operations.14 For the first goal, In the classic nondissociative amnesia clinical pic- memory testing should be embedded in a compre- ture, perception is unimpaired, and the immediate hensive mental status and/or neuropsychological ex- memory span is well preserved. Severe impairments amination that includes assessment of general intel-

Volume 42, Number 2, 2014 215 Commentary lectual capacity, language functions, visuoperceptual/ ments of their participants. Their problem demon- visuospatial skill, frontal-executive skills, and motor strates the general lack of capacity for forensic psy- functions, including an evaluation of psychopathol- chiatrists to perform a scientific assessment of a claim ogy and emotional dysfunction.14 The second goal is of dissociative amnesia. This handicap in our profes- achieved by assessing memory functions relevant to sion is striking and potentially hazardous to the fu- the diagnostic descriptive task faced by the clinician. ture of forensic psychiatry. (In the case examples in Pyszora et al.,2 that would be There are almost no clinical or forensic measures dissociative amnesia for criminal behavior.) In con- of any significance used by psychiatrists on a daily temporary cognitive science models, memory assess- basis to assess patients or examinees clinically. There ment is performed by using elements from the cog- are a few, such as the Beck Depression Scale,24 the nitive information-processing literature, which is Mini-Mental State Examination,25 the Montreal applied to the clinical evaluation of memory-disor- Cognitive Assessment,26 and the MacArthur Com- dered patients. petence Assessment Tool (MacCAT-CA),27 which Pyszora et al.2 document in their article that in are well researched and widely used among psychia- their second study of a previously studied cohort of trists. Beyond that, we in forensic psychiatry have life-sentence prisoners, they use two memory tests to few, if any, scales and measurement techniques for document the memory functioning of the study clinical and forensic assessment that meet even the group.1 For the first test, no normative standardiza- basic standards of scientific measurement. Currently, tion for the WMS-III19 or the WMS-R20 contains a move is afoot among scientists and statistical math- subjects with hysterical or dissociative amnesia. The ematicians to increase the statistical evidence stan- second set of memory tests that they administered dards on hypothesis testing to a degree that will man- were the Camden Memory Tests,21 which contain date the conduct of such tests at the .005 or .001 level five subsections: The Pictorial Recognition Memory of significance. Without a focus on reproducibility of Test, The Topographic Recognition Memory Test, assessments and testing in forensic psychiatry, we as a word pairs from the Paired-Associate Learning Test, profession may come to a position of having our and two brief forms of the Warrington Recognition work and research significantly restricted for publi- Memory Test.22,23 The Camden Memory Tests, cation or testimony. Reproducibility of scientific re- used as a test battery, contain no normative data for search is being examined critically on a regular basis, hysterical or dissociative amnesia. The other psycho- and researchers and statisticians are bemoaning the metric measures listed by Pyszora et al.2 are the Dis- apparent lack of reproducibility in general and the sociative Experiences Scale, the Perry Traumatic Dis- risk that it will threaten the credibility of the scien- sociation Questionnaire, the Regressive Coping Style tific enterprise.28 Questionnaire, the Experience of Shame Scale, the Forensic psychiatrists, being physicians, may wish Memory Characteristics Questionnaire, and the Im- to observe their forensic pathology colleagues. No pact of Events Scale. one would equate the practice of psychiatry with the The Pyszora et al. papers1,2 are a bellwether for the practice of pathology, but there is much to be learned potential future limitations of forensic psychiatric as- by observing the scientific approach of our fellow sessment. Unfortunately, the authors were extremely scientists in forensic pathology. It is further suggested handicapped in their ability to assess their prisoners that forensic psychiatrists leaving their fellowship with regard to dissociative amnesia. The facts are training should have learned the contemporary skills that, much as Kluft8 points out, there are still virtu- of scientific measurement; psychometric statistics: ally no tests to measure dissociative amnesia or dis- that is, the use and understanding of forensic and sociative memory disorders. The medical literature is psychological scales and tests as applied to forensic silent on any psychometric techniques that can be psychiatric cases; basic psychiatric genetics and test- used to assess claims of dissociative amnesia. There ing; the base rates of all psychiatric disorders that are no highly standardized psychometric tests avail- come to forensic psychiatric assessment; and brain able that measure the phenomena of dissociation in neuroimaging. Then, the forensic psychiatrist should general. The lack of psychometric resources is a sig- be able to demonstrate these techniques and skills in nificant weakness of modern forensic psychiatry, and the analysis of a forensic case and, particularly, to it left Pyszora et al. unable to make accurate assess- apply them in a scientific study. The forensic psychi-

216 The Journal of the American Academy of Psychiatry and the Law Granacher atrist leaving a fellowship program will be expected to Neuropsychiatry and Behavioral Neurosciences (ed 5). Edited by Yudofsky SC, Hales RE. Washington DC: American Psychiatric use these techniques as scientific evidence criteria Publishing, Inc. 2008, pp 567–94 further develop and advance, or if not, other scien- 4. American Psychiatric Association: Diagnostic and Statistical tific professions may move into traditional forensic Manual of Mental Disorders, Fourth Edition, Text Revision. psychiatry areas and potentially displace us from Washington, DC: American Psychiatric Association, 2000, pp 172–9 medical-legal analyses that are currently the purview 5. American Psychiatric Association: Diagnostic and Statistical of forensic psychiatrists. The current weakness in Manual of Mental Disorders, Fifth Edition. Arlington, VA: standardized metrics for forensic assessment could American Psychiatric Association, 2013, pp 298–302 6. Charcot J-M: Lec¸ons sur les maladies du syste`me nerveux: faites a` result in forensic psychiatry’s lacking the accepted la Salpeˆtrie`re. [Lectures on diseases of the nervous system: deliv- scientific skills to provide opinions after forensic as- ered at La Salpeˆtrie`re.] Paris: Progre`sMe´dical, Delahaye and Le- sessment to triers of fact and adjudicative bodies. For crosnie, 1887 7. Janet P: L’Anesthe´sie systematise´e et la dissociation des phe´- instance, it is generally the standard that neurologists nome`nes psychologiques.[Systematic anesthesia and the dissocia- will order magnetic resonance neuroimaging and tion of psychological phenomena.] Rev Phil 23: 449–72, 1887 chemical laboratory tests in any patient referred to 8. Kluft RP: Dissociative disorders, in Handbook of Aggressive and them with a chief complaint of a memory disorder, Destructive Behavior in Psychiatric Patients. Edited by Hersen M, Ammerman RT, Sisson LA, New York: Plenum Press, 1994, pp who has not been previously imaged; forensic psychi- 237–59. atrists often do not conduct such tests. Psychologists 9. Van der Hart O, Horst R: The dissociation theory of Pierre Janet. are rapidly developing a subspecialty field that scien- J Trauma Stress 2:1–11, 1989 10. Perley M, Guze S: Hysteria: the stability and usefulness of clinical tifically correlates static lesions on magnetic reso- criteria. N Engl J Med 266:421–6, 1962 nance imaging (MRI) or abnormalities on functional 11. Ables M, Childer P: Psychogenic loss of personal identity. Arch (f)MRI against standardized psychometric tests.29,30 Neurol Psychiatry 34:587–604, 1935 Sociologists are increasingly providing sophisticated 12. Herman M: The use of intravenous sodium amytal in psychogenic amnesic states. Psychiatr Q 12:738–72, 1938 statistical algorithms and actuarial methods for the 13. David AS, Kopelman MD: Neuropsychology in relation to psy- assessment of dangerousness, violence, and pheno- chiatry, in Lishman’s Organic Psychiatry: A Textbook of Neuro- typical criminal behavior.31 Even in dissociative dis- psychiatry (ed 4). Edited by David AS, Fleminger S, Kopelman orders research, there are at least three recent fMRI MD, et al. Oxford: Wiley-Blackwell, 2009, pp 29–102 32 14. Bauer RM, Grande L, Valenstein E. Amnesic disorders, in Clini- studies. One clear theme from this research is that cal Neuropsychology (ed 4). Edited by Heilman KM, Valenstein the symptom presentation of dissociative disorder, E. New York: Oxford University Press, 2003, pp 495–573 whether clinically diagnosed or simulated by using 15. Milner B, Corkin S, Teuber H-L: Further analysis of the hip- pocampal amnesic syndrome: 14 year follow-up study of H.M. , is associated with increases in prefrontal Neuropsychologia 6:215–34, 1968 cortex activity, suggesting that intervention by the 16. Squire LR, Amaral DG, Zola-Morgan S, et al: Description of executive system in both automatic and voluntary brain injury in the amnesic patient N.A. based on magnetic reso- nance imaging. Exp Neurol 105:23–35, 1989 cognitive processing is common to both hysteria and 17. Damasio AR, Eslinger PJ, Damasio H, et al: Multi-modal amnesic hypnosis. syndrome following bilateral temporal and basal forebrain dam- One potential remedy to our assessment weakness age. Arch Neurol. 42:252–9, 1985 18. Albert M.S, Butters N, Brandt J: Patterns of remote memory in is improved scientific instruction of forensic psychi- amnesic and demented patients. Arch Neurol 38:495–500, 1981 atry fellows, more rigorous standards for the publication 19. Wechsler D: WMS-III: Administration and Scoring Manual. San of forensic psychiatric research, and the improve- Antonio, TX: The Psychological Corporation, 1997 ment of professional science-based and evidence- 20. Wechsler D: Wechsler Memory Scale–Revised. San Antonio: TX: The Psychological Corporation, 1987 based teaching of practicing forensic psychiatrists, in 21. Warrington EK: The Camden Memory Tests. Hove, UK: Psy- turn causing the promulgation of scientifically and chology Press, 1986 statistically sound, evidence-based forensic psychiatry. 22. Lezak MD, Howieson DB, Loring DW (eds): Neuropsychologi- cal Assessment (ed 4). New York: Oxford University Press, 2004 23. Warrington EK: Recognition Memory Test. Los Angeles: West- References ern Psychological Services, 1984 1. Pyszora NM, Barker AF, Kopelman MD: Amnesia for criminal 24. Beck AT, Steer RA, Brown GK: Beck Depression Inventory-II. offences: a study of life sentence prisoners. J Forensic Psychiatry New York: Pearson, 1996 Psychol 14(suppl 3):475–90, 2003 25. Folstein MF, Folstein FE, McHugh JR: Mini-Mental State: a 2. Pyszora NM, Fahy T, Kopelman MD: Amnesia for violent of- practical method for grading the cognitive state of patients for the fenses: factors underlying loss and recovery. J Am Acad Psychiatry clinician. J Psychiatr Res 12:189–98, 1975 Law 42:202–13, 2014 26. Nasreddine ZS, Phillips MN, Chertkow H: Normative data for 3. Stern Y, Sackeim HA: Neuropsychiatric aspects of memory and the Montreal Cognitive Assessment (MoCA) in a population- amnesia, in The American Psychiatric Publishing Textbook of based sample. Neurology 78:765–6, 2012

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27. Hoge SK, Bonnie RJ, Poythress, NG, et al: MacArthur Compe- 30. Bigler ED, McCauley SR, Wu TC, et al: The temporal stem in tence Assessment Tool–Criminal Adjudication (MacCAT-CA), traumatic brain injury: preliminary findings. Brain Imag Behav Lutz, FL: PAR, 1999 4:270–82, 2010 28. Johnson VE: Revised standards for statistical evidence. Proc Natl 31. Dietz PE, Baker SP: Murder at work. Am J Public Health 77: Acad SciUSA110:19313–7, 2013 1273–4, 1987 29. Bigler ED, Wilde EA: Quantitative neuroimaging in the predic- 32. Bell V, Oakley DA, Halligan PW, et al: Dissociation in hysteria tion of rehabilitation outcome following traumatic brain injury. and hypnosis: evidence from cognitive neuroscience. J Neurol Front Hum Neurosci 4:228, 2010 Neurosur Psychiatry 82:1–30, 2010

218 The Journal of the American Academy of Psychiatry and the Law