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Dissociative amnesia

Amnesia (or amnaesia in Commonwealth English) is a condition in which memory is disturbed. The causes of amnesia are organic or functional. Organic causes include damage to the brain, through trauma or disease, or use of certain (generally sedative) drugs. Functional causes are psychological factors, such as defense mechanisms. Hysterical post-traumatic amnesia is an example of this. Amnesia may also be spontaneous, in the case of transient global amnesia. This global type of amnesia is more common in middle-aged to elderly people, particularly males, and usually lasts less than 24 hours. more...

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Types of amnesia

  • In anterograde amnesia, new events are not transferred to long-term memory, so the sufferer will not be able to remember anything that occurs after the onset of this type of amnesia for more than a few moments. The complement of this is retrograde amnesia, where someone will be unable to recall events that occurred before the onset of amnesia. The terms are used to categorise patterns of symptoms, rather than to indicate a particular cause or etiology. Both categories of amnesia can occur together in the same patient, and commonly result from damage to the brain regions most closely associated with episodic/declarative memory: the medial temporal lobes and especially the hippocampus.
  • Traumatic amnesia is generally due to a head injury (fall, knock on the head). Traumatic amnesia is often transient; the duration of the amnesia is related to the degree of injury and may give an indication of the prognosis for recovery of other functions. Mild trauma, such as a car accident that could result in no more than mild whiplash, might cause the occupant of a car to have no memory of the moments just before the accident due to a brief interruption in the short/long-term memory transfer mechanism. "Traumatic amnesia" is also sometimes used to refer to long-term repressed memory that is the result of psychological trauma.
  • Long-term alcoholism can cause a type of memory loss known as Korsakoff's syndrome. This is caused by brain damage due to a Vitamin B1 deficiency and will be progressive if alcohol intake and nutrition pattern are not modified. It will usually improve little over time even if they are. Other neurological problems are likely to be present.
  • Lacunar amnesia is the loss of memory about one specific event.
  • Fugue state is also known as dissociative fugue. It is caused by psychological trauma and is usually temporary. The Merck Manual defines it as "one or more episodes of amnesia in which the inability to recall some or all of one's past and either the loss of one's identity or the formation of a new identity occur with sudden, unexpected, purposeful travel away from home" .
  • Childhood amnesia (also known as Infantile amnesia) is the common inability to remember events from your own childhood. Whilst Sigmund Freud attributed this to sexual repression, others have theorised that this may be due to language development or immature parts of the brain.
  • Global amnesia is total memory loss. This may be a defence mechanism which occurs after a traumatic event. Post-traumatic stress disorder can also involve the spontaneous, vivid retrieval of unwanted traumatic memories. It is believed that Mauritania's Silent Flute Man suffered from this condition.
  • Posthypnotic amnesia is where events during hypnosis are forgotten, or where past memories are unable to be recalled.
  • Psychogenic amnesia is when one loses the ability to remember who oneself is. It is a common type of amnesia in popular culture; it may or may not be a real phenomenon.
  • Source amnesia is a memory disorder in which someone can recall certain information, but they do not know where or how they obtained it.
  • Memory distrust syndrome is a term invented by the psychologist Gisli Gudjonsson to describe a situation where someone is unable to trust their own memory.

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Multiple personality disorder
From Gale Encyclopedia of Medicine, 4/6/01 by Rebecca J. Frey

Definition

Multiple personality disorder, or MPD, is a mental disturbance classified as one of the dissociative disorders in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). It has been renamed dissociative identity disorder (DID). MPD or DID is defined as a condition in which "two or more distinct identities or personality states" alternate in controlling the patient's consciousness and behavior. Note: "Split personality" is not an accurate term for DID and should not be used as a synonym for schizophrenia.

Description

The precise nature of DID (MPD) as well as its relationship to other mental disorders is still a subject of debate. Some researchers think that DID may be a relatively recent development in western society. It may be a culture-specific syndrome found in western society, caused primarily by both childhood abuse and unspecified long-term societal changes. Unlike depression or anxiety disorders, which have been recognized, in some form, for centuries, the earliest cases of persons reporting DID symptoms were not recorded until the 1790s. Most were considered medical oddities or curiosities until the late 1970s, when increasing numbers of cases were reported in the United States. Psychiatrists are still debating whether DID was previously misdiagnosed and underreported, or whether it is currently over-diagnosed. Because childhood trauma is a factor in the development of DID, some doctors think it may be a variation of post-traumatic stress disorder (PTSD). DID and PTSD are conditions where dissociation is a prominent mechanism. The female to male ratio for DID is about 9:1, but the reasons for the gender imbalance are unclear. Some have attributed the imbalance in reported cases to higher rates of abuse of female children; and some to the possibility that males with DID are underreported because they might be in prison for violent crimes.

The most distinctive feature of DID is the formation and emergence of alternate personality states, or "alters." Patients with DID experience their alters as distinctive individuals possessing different names, histories, and personality traits. It is not unusual for DID patients to have alters of different genders, sexual orientations, ages, or nationalities. Some patients have been reported with alters that are not even human; alters have been animals, or even aliens from outer space. The average DID patient has between two and 10 alters, but some have been reported with over one hundred.

Causes & symptoms

The severe dissociation that characterizes patients with DID is currently understood to result from a set of causes:

  • An innate ability to dissociate easily
  • Repeated episodes of severe physical or sexual abuse in childhood
  • The lack of a supportive or comforting person to counteract abusive relative(s)
  • The influence of other relatives with dissociative symptoms or disorders

The relationship of dissociative disorders to childhood abuse has led to intense controversy and lawsuits concerning the accuracy of childhood memories. The brain's storage, retrieval, and interpretation of childhood memories are still not fully understood.

The major dissociative symptoms experienced by DID patients are amnesia, depersonalization, derealization, and identity disturbances.

Amnesia

Amnesia in DID is marked by gaps in the patient's memory for long periods of their past, in some cases, their entire childhood. Most DID patients have amnesia, or "lose time," for periods when another personality is "out." They may report finding items in their house that they can't remember having purchased, finding notes written in different handwriting, or other evidence of unexplained activity.

Depersonalization

Depersonalization is a dissociative symptom in which the patient feels that his or her body is unreal, is changing, or is dissolving. Some DID patients experience depersonalization as feeling to be outside of their body, or as watching a movie of themselves.

Derealization

Derealization is a dissociative symptom in which the patient perceives the external environment as unreal. Patients may see walls, buildings, or other objects as changing in shape, size, or color. DID patients may fail to recognize relatives or close friends.

Identity disturbances

Identity disturbances in DID result from the patient's having split off entire personality traits or characteristics as well as memories. When a stressful or traumatic experience triggers the reemergence of these dissociated parts, the patient switches -- usually within seconds -- into an alternate personality. Some patients have histories of erratic performance in school or in their jobs caused by the emergence of alternate personalities during examinations or other stressful situations. Patients vary with regard to their alters' awareness of one another.

Diagnosis

The diagnosis of DID is complex and some physicians believe it is often missed, while others feel it is over-diagnosed. Patients have been known to have been treated under a variety of other psychiatric diagnoses for a long time before being re-diagnosed with DID. The average DID patient is in the mental health care system for six to seven years before being diagnosed as a person with DID. Many DID patients are misdiagnosed as depressed because the primary or "core" personality is subdued and withdrawn, particularly in female patients. However, some core personalities, or alters, may genuinely be depressed, and may benefit from antidepressant medications. One reason misdiagnoses are common is because DID patients may truly meet the criteria for panic disorder or somatization disorder.

Misdiagnoses include schizophrenia, borderline personality disorder, and, as noted, somatization disorder and panic disorder. DID patients are often frightened by their dissociative experiences, which can include losing awareness of hours or even days of time, meeting people who claim to know them by another name, or feeling "out of body." Persons with the disorder may go to emergency rooms or clinics because they fear they are going insane.

When a doctor is evaluating a patient for DID, he or she will first rule out physical conditions that sometimes produce amnesia, depersonalization, or derealization. These conditions include head injuries; brain disease, especially seizure disorders; side effects from medications; substance abuse or intoxication; AIDS dementia complex; or recent periods of extreme physical stress and sleeplessness. In some cases, the doctor may give the patient an electroencephalograph (EEG) to exclude epilepsy or other seizure disorders. The physician also must consider whether the patient is malingering and/or offering fictitious complaints.

If the patient appears to be physically normal, the doctor will next rule out psychotic disturbances, including schizophrenia. Many patients with DID are misdiagnosed as schizophrenic because they may "hear" their alters "talking" inside their heads. If the doctor suspects DID, he or she can use a screening test called the Dissociative Experiences Scale (DES). If the patient has a high score on this test, he or she can be evaluated further with the Dissociative Disorders Interview Schedule (DDIS) or the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). The doctor may also use the Hypnotic Induction Profile (HIP) or a similar test of the patient's hypnotizability.

Treatment

Treatment of DID may last for five to seven years in adults and usually requires several different treatment methods.

Psychotherapy

Ideally, patients with DID should be treated by a therapist with specialized training in dissociation. This specialized training is important because the patient's personality switches can be confusing or startling. In addition, many patients with DID have hostile or suicidal alter personalities. Most therapists who treat DID patients have rules or contracts for treatment that include such issues as the patient's responsibility for his or her safety. Psychotherapy for DID patients typically has several stages: an initial phase for uncovering and "mapping" the patient's alters; a phase of treating the traumatic memories and "fusing" the alters; and a phase of consolidating the patient's newly integrated personality.

Most therapists who treat multiples, or DID patients, recommend further treatment after personality integration, on the grounds that the patient has not learned the social skills that most people acquire in adolescence and early adult life. In addition, family therapy is often recommended to help the patient's family understand DID and the changes that occur during personality reintegration.

Many DID patients are helped by group as well as individual treatment, provided that the group is limited to people with dissociative disorders. DID patients sometimes have setbacks in mixed therapy groups because other patients are bothered or frightened by their personality switches.

Medications

Some doctors will prescribe tranquilizers or antidepressants for DID patients because their alter personalities may have anxiety or mood disorders. However, other therapists who treat DID patients prefer to keep medications to a minimum because these patients can easily become psychologically dependent on drugs. In addition, many DID patients have at least one alter who abuses drugs or alcohol, substances which are dangerous in combination with most tranquilizers.

Hypnosis

While not always necessary, hypnosis is a standard method of treatment for DID patients. Hypnosis may help patients recover repressed ideas and memories. Further, hypnosis can also be used to control problematic behaviors that many DID patients exhibit, such as self-mutilation, or eating disorders like bulimia nervosa. In the later stages of treatment, the therapist may use hypnosis to "fuse" the alters as part of the patient's personality integration process.

Alternative treatment

Alternative treatments that help to relax the body are often recommended for DID patients as an adjunct to psychotherapy and/or medication. These treatments include hydrotherapy, botanical medicine (primarily herbs that help the nervous system), therapeutic massage, and yoga. Homeopathic treatment can also be effective for some people. Art therapy and the keeping of journals are often recommended as ways that patients can integrate their past into their present life. Meditation is usually discouraged until the patient's personality has been reintegrated.

Prognosis

Some therapists believe that the prognosis for recovery is excellent for children and good for most adults. Although treatment takes several years, it is often ultimately effective. As a general rule, the earlier the patient is diagnosed and properly treated, the better the prognosis.

Prevention

Prevention of DID requires intervention in abusive families and treating children with dissociative symptoms as early as possible.

Key Terms

Alter
An alternate or secondary personality in a patient with DID.
Amnesia
A general medical term for loss of memory that is not due to ordinary forgetfulness. Amnesia can be caused by head injuries, brain disease, or epilepsy as well as by dissociation.
Depersonalization
A dissociative symptom in which the patient feels that his or her body is unreal, is changing, or is dissolving.
Derealization
A dissociative symptom in which the external environment is perceived as unreal.
Dissociation
A psychological mechanism that allows the mind to split off traumatic memories or disturbing ideas from conscious awareness.
Dissociative identity disorder (DID)
Term that replaced Multiple Personality Disorder (MPD). A condition in which two or more distinctive identities or personality states alternate in controlling a person's consciousness and behavior.
Hypnosis
An induced trance state used to treat the amnesia and identity disturbances that occur in dissociative identity disorder (DID).
Multiple personality disorder (MPD)
The former, though often still used, term for dissociative identity disorder (DID).
Primary personality
The core personality of an DID patient. In women, the primary personality is often timid and passive, and may be diagnosed as depressed.
Trauma
A disastrous or life- threatening event that can cause severe emotional distress. DID is associated with trauma in a person's early life or adult experience.

Gale Encyclopedia of Medicine. Gale Research, 1999.

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