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Psychogenic and Organic Amnesia. a Multidimensional Assessment of Clinical, Neuroradiological, Neuropsychological and Psychopathological Features

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Psychogenic and Organic Amnesia. a Multidimensional Assessment of Clinical, Neuroradiological, Neuropsychological and Psychopathological Features Behavioural Neurology 18 (2007) 53–64 53 IOS Press Psychogenic and organic amnesia. A multidimensional assessment of clinical, neuroradiological, neuropsychological and psychopathological features Laura Serraa,∗, Lucia Faddaa,b, Ivana Buccionea, Carlo Caltagironea,b and Giovanni A. Carlesimoa,b aFondazione IRCCS Santa Lucia, Roma, Italy bClinica Neurologica, Universita` Tor Vergata, Roma, Italy Abstract. Psychogenic amnesia is a complex disorder characterised by a wide variety of symptoms. Consequently, in a number of cases it is difficult distinguish it from organic memory impairment. The present study reports a new case of global psychogenic amnesia compared with two patients with amnesia underlain by organic brain damage. Our aim was to identify features useful for distinguishing between psychogenic and organic forms of memory impairment. The findings show the usefulness of a multidimensional evaluation of clinical, neuroradiological, neuropsychological and psychopathological aspects, to provide convergent findings useful for differentiating the two forms of memory disorder. Keywords: Amnesia, psychogenic origin, organic origin 1. Introduction ness of the self – and a period of wandering. According to Kopelman [33], there are three main predisposing Psychogenic or dissociative amnesia (DSM-IV- factors for global psychogenic amnesia: i) a history of TR) [1] is a clinical syndrome characterised by a mem- transient, organic amnesia due to epilepsy [52], head ory disorder of nonorganic origin. Following Kopel- injury [4] or alcoholic blackouts [20]; ii) a history of man [31,33], psychogenic amnesia can either be sit- psychiatric disorders such as depressed mood, and iii) uation specific or global. Situation specific amnesia a severe precipitating stress, such as marital or emo- refers to memory loss for a particular incident or part tional discord [23], bereavement [49], financial prob- of an incident and can arise in a variety of circum- lems [23] or war [21,48]. Apparently, patients who stances, resulting in post-traumatic stress disorder (e.g., have previously experienced transient organic amne- committing an offence, being a victim of an offence or sia and then become depressed are particularly likely of child abuse). Instead Global psychogenic amnesia, to develop psychogenic amnesia if faced with severe precipitating stress [33]. also called Fugue State [21], is characterised by a sud- Although non organic memory impairment may be den loss of autobiographical memories generally going suspected in psychogenic amnesics based on the quali- back many years and frequently associated with a loss tative features of their memory loss (which differ from of personal identity – that is, knowledge and conscious- those typically seen in organic amnesia [36]), on its abrupt onset generally related to psychological dis- ∗ tress [39] and on a lack of clinical and instrumen- Corresponding author: Laura Serra, Fondazione IRCCS Santa Lucia, Via Ardeatina, 306, 00179 Roma, Italy. Tel.: +39 06 tal evidence of damage to cerebral regions known to 51501576; E-mail: [email protected]. be involved in memory functioning, in a number of ISSN 0953-4180/07/$17.00 2007 – IOS Press and the authors. All rights reserved 54 L. Serra et al. / Psychogenic amnesia: Multidimensional assessment cases the great variability among patients raises per- man’s view “although it is difficult to prove psycho- plexities about the exact nature of the memory deficit. logical causation, the logical difficulties in attributing Table 1 reports some of the clinical, neuroradiologi- causation where brain lesions are either very subtle or cal and psychopathological findings in a selection of multiple have been considerably underestimated in the cases of global psychogenic amnesia reported in the neuropsychological literature” [32, p. 585]. literature in the last decade. In most cases a mild head Here we present a comparison of clinical, neuroradi- trauma was the precipitating event. However, cases ological, neuropsychological and psychopathological were reported in which no precipitating event could findings in a new case of global psychogenic amnesia be found. Neuroradiological (MRI or TC) and perfu- and in two patients with amnesia underlain by organic sional (PET or SPECT) exams were generally negative brain damage. Our aim was to outline differential fea- for organic brain damage; thus, when evidence of or- tures useful for discriminating psychogenic from or- ganic damage was found it was generally interpreted ganic forms of memory impairment. We diagnosed our as incidental. However, Markowitsch [41] suggested patient’s amnesic syndrome as psychogenic based on that in some cases of psychogenic amnesia the pres- the absence of any anamnestic or neuroradiological ev- ence of reduced right frontotemporal perfusion might idence of brain damage underlying the memory disor- be the functional basis of the autobiographical memory der. From the reports in the literature we expected that impairment. Finally, a history of psychiatric disease our psychogenic patient would differ from the two or- and an emotionally stressful event precipitating the am- ganic amnesic patients due to the following: a history of nesic status were reported in most, but not in all, cases. mild head trauma precipitating the amnesic syndrome, Considering the particular nature of this syndrome, it psychiatric disorder and/or emotional stress in the pe- is surprising that only a few studies have assessed the riod preceding the onset of amnesia, and loss of per- personality profile of patients using ad hoc instruments. sonal identity in the early phases of the syndrome. We The neuropsychological profile of the memory im- were particularly interested in the qualitative character- pairment, which was widely investigated in some cases, isation of the memory loss in our psychogenic amnesic is controversial (see Table 2). Indeed, while the im- because we wished to highlight the neuropsycholog- pairment of retrograde autobiographical memory is the ical indexes differentiating organic from psychogenic cognitive hallmark of the syndrome (but see [28] for forms of amnesia. In this regard, we expected that a case of psychogenic amnesia without a retrograde the psychogenic patient’s memory impairment would deficit), anterograde memory was normal in some cases be characterised mainly by a retrograde autobiograph- and affected in others. Finally, short-term, semantic ical deficit. One difference between patients with psy- and implicit memories, when investigated, were mostly chogenic and organic amnesia is the temporal gradi- normal. In many patients the presence of a selective ent of the retrograde memory impairment. Indeed, in deficit of retrograde memory (e.g. [16,25,30]) raised a a typical patient with organic brain damage the retro- question about the relationship between psychogenic grade memory deficit is particularly severe for the most amnesia and the picture of focal retrograde amnesia (a recent premorbid period [26] (but see [10] for contrast- condition characterised by a disorder in the retrieval of ing data on this issue), while a substantially flat tempo- premorbid events and information in which new learn- ral gradient, indicative of a homogeneous loss of ret- ing is unaffected [24]). In a review of the literature, rograde memories across the entire period examined, Kopelman [32] distinguished cases of focal retrograde is reported in most patients with psychogenic amnesia amnesia in which an organic origin of the disturbance (e.g. [3,30]). Predictions were particularly uncertain could be found from those in which it could not. In the regarding short-term and semantic memory. In fact, as first group he included cases in which a pure retrograde reported in Table 2, in psychogenic amnesic patients deficit represented an evolution from an early antero- both normal and impaired performances were reported grade/retrograde amnesic syndrome [6], cases of pa- in tests investigating these memory functions. Consis- tients with Semantic Dementia [17] and, finally, cases tent with the above-reported literature, implicit mem- with transient epileptic amnesia in which the memory ory was more likely to be spared. Finally, the avail- gap involved only ictal activity [27]. In the second able literature is particularly controversial regarding group Kopelman included patients in which focal retro- declarative anterograde memory (see Table 2). How- grade amnesia was more likely psychogenic in nature, ever, since a disturbance in the declarative anterograde mainly because of a lack of clinical and/or neuroradi- domain is the cognitive hallmark of organic amnesia, ological evidence of organic brain damage. In Kopel- we tried to analyse this memory component in greater L. Serra et al. / Psychogenic amnesia: Multidimensional assessment 55 Table 1 Clinical and neuroradiological data in a selection of cases of psychogenic amnesia from the literature Study History of Recent Precipitating Loss of Neuroradiological Perfusional psychiatric emotional event personal investigation investigation disease stress identity De Renzi et al. [16] Absent Absent Mild head injury Present Normal Normal Kopelman et al. [31] Present Present No Present Modest left ventricle enlargement Kapur [25] Present Present Mild head injury Absent Normal Mackenzie Ross [36] Present Present Mild head injury Present Non-specific white matter abnormalities Kessler et al. [28] Absent No Absent Normal Normal Stracciari et al. [53] Case 1 Absent Absent Mild head injury Absent Normal Hypoperfusion
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