Dissociative amnesia

Dissociative Fugue is a somewhat rare condition that therapists may see only once or twice over the course of a professional career. A brief review of the uses of hypnosis in the treatment of Dissociative Fugue is followed by a presentation of the case of a 51 -year-old man who presented with the clinical picture of Dissociative Fugue State and who experienced complete amnesia for the time prior to the fugue state. This article focuses on the pitfalls that the psychotherapist in a general practice may face when working with such a patient and offers specific recommendations and scripts that may be useful in proceeding with treatment.

Keywords: Consultant, Dissociative Identity Disorder (DID), dissociation, ethics, education, fugue, hypnosis, pitfalls, training

Introduction

"Joe" went to work at his usual time of 4:30 a.m. on Monday morning. On the following Tuesday evening at 10:00 p.m., he wandered into a K-Mart 150 miles from home and said, "Could you please help me? I don't know who I am or how I got here. Would you call the police for me?"

The police took his truck keys and located his truck. They discovered his identity took him to the emergency room, and called his hometown where his wife had reported him missing. When he returned, he did not recognize his home, his wife, or his children.

Dissociative Fugue is a "sudden, unexpected, travel away from home or one's customary place of daily activities, with inability to recall some or all of one's past" (American Psychiatric Association, 1994, p. 481). The most common hypothesis is that acute traumatic experiences are linked with this kind of dissociation (Frankel, 1996; Coons, 2000; Steinberg, 2000). Reports of childhood trauma, particularly physical and sexual abuse, reach a prevalence of up to 90% in dissociative disorders and especially Dissociative Identity Disorder (Spiegel, 1993; Coons & Milstein, 1986; Coons, 2000; Frischholz, 1985; Putnam et al., 1986; Kluft, 1993). There is only one recent empirical study of the fugue state. Coons (1999) reported on five consecutive cases that presented themselves to his dissociative clinic over a period of ten years.

A prevalence rate for Dissociative Fugue is estimated at 0.2% of the general population (American Psychiatric Association, 1994). Coons (1999) reported that Dissociative Fugue accounted for 1.6% of all dissociative disorders at his dissociative disorders clinic. Since this disorder is so rare, it is unlikely that clinicians will encounter more than a single case in their entire career, unless they specialize in dissociative disorders.

Discussions of psychogenic fugue in standard psychiatric references offer suggestions of sodium amobarbital interviews or hypnosis (Ford, 1989; Linn, 1989; Wilbur & Kluft, 1989; Putnam & Loewenstein, 2000; Gilmore & Kaufman, 1996/97; Nemiah, 1985). These references give little guidance as to how to conduct these interviews. However, all indicated that it was critical to address the initial stressors so that the experience would not be repeated.

Hypnotizability itself may be a diathesis for dissociative symptomology, especially when combined with acute traumatic stress (Butler, Duran, Jasiukaitis, Koopman, & Spiegel, 1996). Spiegel (1997, p. 1161) thought that hypnosis could be helpful in the treatment of Dissociative Fugue "by accessing otherwise unavailable components of memory and identity." The structure of hypnotic induction may elicit dissociative phenomena, and the patient in a Dissociative Fugue is usually capable of entering a deep level of hypnosis. Age regression can be used as the framework for accessing information available from a previous time (Spiegel, 1997).

There is relatively little information about how to proceed with hypnosis in therapeutic interventions for fugue states. Much of the material on hypnosis and dissociation focuses on Dissociative Identity Disorder which is more common (Kluft, 1982; Wilbur & Kluft, 1989; Spiegel, 1997; Butler et al., 1996). Kluft (1995) has described 22 specific ways to utilize hypnosis with Dissociative Identity Disorder. Loewenstein (1995) recommended using hypnosis for ego strengthening and to promote the integration of repressed material.

In the management of this case, I immediately encountered the pitfalls that awaited someone not familiar with treatment of dissociative disorders. I present some of these pitfalls and offer some recommendations that may help the general practitioner to engage in a clinically beneficial manner should encounters with this rather rare disorder arise in his/ her practice. I also offer some practical suggestions and actual scripts.

Clinical Material Continued: Background and History

Joe was hospitalized and had a thorough evaluation by an internist, a neurologist, and a psychiatrist. After an extensive diagnostic work up that included x-rays, blood work, CAT scan, MRI, spinal tap, and thyroid function tests, the only abnormality found was a slight amount of protein in Joe's cerebral spinal fluid. Joe's internist pronounced him "the healthiest 50-year-old he had ever seen." Thus, the physicians eliminated organic causes for the fugue, which is an essential step in the diagnosis (Coons, 1998; Loewenstein, 1993).

The significant omission in Joe's work up was psychological testing which he resisted. Bernstein and Putnam's (1986) Dissociative Experiences Scale (DES) and Steinberg's (1993, 1994a & 1994b) Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) would have helped to clarify the diagnosis, especially the issue of whether he might be suffering from Dissociative Identity Disorder.

I met Joe three weeks after the onset of his fugue. The referring psychiatrist summarized the situation for me five minutes before my initial appointment with him. He told me to "hypnotize him so he can get his memory back."

I found Joe to be a large, healthy, bright, articulate engineer He was extremely tense and high strung and appeared to be a hard-driving Type-A personality (Friedman & Rosenman, 1997). When I asked about anything prior to Monday, his responses consisted either of "I can't remember " or "They tell me. . . " He described returning to his home and his wife as a deja vu experience. He felt he had seen this woman before, but he couldn't quite place her

At work he did not recognize any of his coworkers. When he read papers that he had written, he indicated that he could understand about 10% of the material. He had some "vague recollection that it was familiar. " Even cases that coworkers said were critically important to him were only "vaguely familiar "

In escorting his wife to the waiting room, I discovered that she knew almost nothing about Joe's childhood and that he never talked about it. She said that their marriage was good, and that Joe seemed to be relatively happy. The only stress she seemed to be aware of (besides some family illness) that he might be experiencing was from his work. The earliest experiences Joe ever discussed with her were of his being in the armed services. He also told her that his nickname there was "Rusty. " I used his nickname to immediately regress him to his Navy days.

Childhood trauma appears to enhance the tendency to dissociation and acts to preserve into adulthood the child's normatively elevated tendency to dissociation (Putnam, 1993; Steinberg, 2000). Putnam (1997) has also summarized considerable evidence that childhood trauma also increases abnormal dissociation. The brief description of Joe's history offered by his wife suggested that Joe had dissociated his entire childhood from his day-today memory and that recollections of that time had not been accessible to him even prior to the fugue state. Thus, he also met criteria for dissociative amnesia (American Psychiatric Association, 1994).

The history obtained from the psychiatrist was skimpy. He reported that Joe had served in the military, had been married for 27 years, had two children, and worked at a good job as an engineer. There was no information about his childhood, family of origin, adolescence, or anything prior to his navy experience, which began when he was 17. There was no known history of prior fugue states.

Treatment

Following my usual short-term therapy approach, I rather brashly ventured immediately into treatment addressing the amnesia. This short-term therapy mindset structured the treatment so that his long-standing issues would be difficult to address later on in treatment.

Since I had never dealt with complete amnesia before, I decided to follow Crasilneck and Hall's (1985) advice to proceed cautiously and not force the patient to examine the traumatic event or to have his memory return too quickly. I adopted a permissive and non-directive approach. I decided to use ideomotor signaling as the safest way to proceed. It was my hope that this would help avoid any direct contamination of Joe's memory experiences in case something illegal was involved. Since recovery of memory material is fraught with legal implications, an informed consent is imperative (Hammond et al. 1995; Brown, Scheflin & Hammond, 1997; Scheflin & Shapiro, 1989).

Joe went into a deep trance (Spiegel grade 4, possibly grade 5) very rapidly (Spiegel & Spiegel, 1976). He responded with clear ideomotor signals, and I rapidly established a positive response set (as follows):

Therapist: It's quite distressing for you to have lost your memory, isn't it?

Patient: Yes.

Therapist: Would you like to remember things about your wife and family?

Patient: Yes.

Therapist: Would you be willing to answer some questions about your memory?

Patient: Yes.

Therapist: Would it be helpful for you to regain your memory?

Patient: Yes.

Therapist: Would you be willing to return to the events of Monday in the safety of this trace?

Patient: No.

Therapist: Would you be willing to allow your memory to return gradually at a rate that is just right for you?

Patient: Yes.

Joe indicated (through ideomotor signaling responses) a desire to regain his memory, especially for his family, his work and his earlier life. He also responded that he had little memory before his adolescent years, as his wife indicated. So, I concluded that he used dissociation as a way to cope with early life experiences. He indicated that the fugue began Monday after a meeting with his boss. It was also clear that he did not want to return to the events that happened that day, no matter how safe or distant I made it. Finally, he grabbed his yes finger with his other hand and I knew that the use of ideomotor signaling was over for that session. This gesture could indicate the presence of a Dissociative Identity Disorder (inasmuch as it could represent one alter interfering with the ideomotor responses of another alter), and it clearly indicated intense internal conflict regarding the questioning (Steinberg, 1994a; Kluft, personal communication, March 23, 2001). It is likely that this reaction during the session could also have reflected the intense internal conflict Joe experienced with his boss.

At the conclusion of the session, I gave Joe the suggestion that you will be able to remember all that you need to know and all that you want to know at a time that is just right for you. People, places and things will remind you of events and your memory will return gradually when the time is ready, but not before then. You will be able to remember only those things that you are capable of coping with at the time. " I attempted to provide a sense of safety and security so he could gradually allow his memory to return (Loewenstein, 1995).

When Joe came out of the trance, he had complete amnesia for what we had discussed. He also said that he had felt he was in a "better mood. " I tried to reframe the amnesia in a positive way as an "internal circuit breaker" that prevented him from being totally overwhelmed. I gave him the assignment to go home and look at his picture albums with his wife. I also suggested that he continue to talk with his coworkers and review his work products.

I had only two references to psychogenic amnesia or fugue states in my hypnosis library-Crasilneck and Hall (1985), and Olness and Kohen (1996) who quoted Crasilneck and Hall verbatim. I consulted with an American Society of Clinical Hypnosis certified consultant who taught at both regional trainings (anonymous personal communication, February, 1998) and had expertise with hypnoanalysis. This senior consultant confirmed the direction I was taking and suggested that I record all the sessions in case something illegal had occurred during the fugue state. He also thought it might be helpful in reviewing memories with Joe when he was in an alert state. I did not attempt this review because Wilbur and Kluft (1989) had reported that it was not helpful.

When Joe returned three days later he was recognizing people but couldn't remember their names. At work he estimated that his knowledge base was where he was four years ago when he started with the company. He was feeling more comfortable with his family but still had no memories of the past. In looking at the photographs, there was a "slight familiarity. " "I've been there before, but I don't remember all of the details, like where the photo was taken or what the occasion was. " He noticed that he was starting to recall things prior to Monday on his own. His memory was "gradually coming back. "

In trance I established the pattern of focusing on remembering positive events from his family, his military service, his early life, his work. Positive age regression was a prelude to my attempts to approach the event or events that had precipitated the fugue state. Joe spoke freely about numerous events in trance until we got to that Monday. Then he simply shook his head vigorously "No. " I ended the session using the previous suggestions that I thought were helpful.

During the next several sessions, Joe made considerable progress. However, he consistently refused to look at what occurred at work before he left on Monday for "an emergency." He recalled some of the events from his earlier life with incredible detail, and some of them were externally verifiable.

A second and even more recognized authority renowned as an expert in hypnoanalysis was then consulted (anonymous personal communication, March 14, 1998). This expert confirmed the direction I was taking and suggested that I have Joe write in trance. A third consultant, also renowned (anonymous personal communication, March 18, 1998), additionally confirmed the direction of my treatment of Joe and suggested regression to key events like birthdays.

In trance Joe wrote key words that he could elaborate on outside of trance. Again, he produced incredible detail about these events. When asked about Monday morning, he wrote nothing and just shook his head "No ". Only one key event stood out for him-a high school football game, his earliest recollection, at age 16.

In the next session Joe was very concerned about an upcoming out-of-state trial in which he was the chief witness in a product liability case. We focused on "all that he needed to know and all that he wanted to know" about this case. Again, he wrote some detailed notes in trance which helped him to manage the deposition "very well. " His memory for the case had completely returned-100%-when he reviewed his notes at work. He was feeling more confident and eager to return to work, his major motivator The immediate and complete recall of the trial material seems to indicate that the return of his memory was due to the hypnosis and not to spontaneous recovery.

I signed a release for Joe to return to work with the stipulation that he attend twice weekly sessions. However Joe reported that his boss immediately sent him out of town for four weeks. Since his schedule was determined on a day-to-day basis by his boss, the cancellations were all at the last minute. He also did not want me to contact his boss so I could not get his impression of what had occurred.

Joe reported feeling more confident. Now he could remember people as they relate to specific projects but not personal data. "People information is project specific. " Coworkers told him that that was good because they were glad he couldn't remember the rest because he had a "violent temper." In his typical engineering style, he reported, "My memory is coming back in an exponential way work-wise. " He was pleased that he was able to remember 90% of the details at work. He figured that was about as good as anyone could do.

Joe's boss again was reported to have kept him out-of-town for a month. When he returned a month later, he had "figured it out". He was finally able to confront what had been stressing him before the fugue state. He described the boss as a "control freak. " A month before the event, coworkers said that he had threatened bodily harm to their boss. He ran out of the office yelling, "I'm going to rip his f----- head off!" No one made an attempt to stop him. He,figured out that he had threatened his boss on Monday morning and that it shook both of them so badly that they both changed. His coworkers had noticed "personality changes" in Joe and in his boss. They credited Joe with a change that had improved the situation for all of them

Whenever I attempted to explore the dynamics underlying the Dissociative Fugue, Joe resisted and simply remained silent or changed the subject, both in trance and out of trance. He also was unable to work through some of the emotionally laden issues that prompted the episode. So, the interpersonal and intrapsychic issues remained unexplored for the most part.

In trance, Joe recalled listening to a very critical phone mail message from his boss. The message was delivered in a situation in which the boss did not have all the facts. This was the trigger for the fugue state. However, Joe again refused to discuss what happened in the boss's office. Using a TV screen for distance always produced a "blank screen. " He wrote nothing on the pad. He did describe the long ride in his truck with no significant events. He could not recall how he lost his wallet.

During the next several months, Joe canceled and rescheduled his appointments. He said once on the phone that he had ". . . figured out closely enough what happened" so that he could go on. He attended seven sessions with me over a period of three months with seven cancellations. He did not return to treatment, in spite of my encouragement that he needed to address the core problem of anger so that the condition would not occur again.

Outcome

I made contact with Joe's wife a year and a half after termination in order to check on his condition. She said he was doing "exceptionally well, remarkably well." He had regained his work knowledge very quickly. He still could not remember things from his childhood. His wife thought that he was the same as he had been before the onset of the fugue state. However his daughter stated that "he's a little different than he was personality-wise. "

Joe's memory continued to improve on a steady basis. There had been no problems or conflicts at work, which was remarkable because of what he reported the others said about him and his violent behavior. There has been no relapse into a fugue state. His wife said that he discontinued therapy because he thought it was "interfering with his work. "

My attempts to deal with the dynamic reasons for Joe's fugue state were futile, even though such understanding is considered necessary for long term remission of symptoms (Orne, Dinges & Bloom, 1995; Spiegel, 1994; Loewenstein, 1993 & 1995; Kluft, 1995; Coons, 2000). He also was unable to express much emotion regarding the relationship with his boss or coworkers or to explore those relationships in detail. "Critical historical data and core psychodynamic issues are generally concealed by the patient's amnesia" (Loewenstein, 1993, p. 67). Spiegel (1988) pointed out that dissociation is used as a defense "not simply against the memories or warded-off unconscious wishes but rather as a defense against the traumatic experience itself." Thus, Joe seemed to effectively defend himself against the traumatic event or intense internal conflict or overwhelming affect in the present situation much as he presumably did by dissociating his childhood experiences. His amnesia acted much as a "circuit breaker" to prevent him from being overwhelmed by the whole experience. Even though he did not directly recall the events with his boss, he was able to allow his memory to return for other important material.

From a psychotherapeutic standpoint several important steps were absent or neglected: remembering and resolving (possibly abreacting) the traumatic event(s), exploring the intrapsychic and interpersonal dynamics of the fugue state, integrating traumatic events, and developing more effective coping strategies (Coons, 2000; Herman, 1992). A colleague suggested that my permissive and rather indirect style during hypnosis may have inadvertently undermined the forming of a therapeutic alliance that would have supported a more definitive therapeutic result. In spite of some of these obvious limitations, however, I was able to help Joe become stabilized and I concluded that he remembered "all that he needed to know and all that he wanted to know at a pace that was just right for him."

Pitfalls and Lessons Learned

1. Dissociative Disorders Are Not Rare. Saxe, van der Kolk, Berkowitz, Chinman, et al. (1994) found that 15 % of the psychiatric inpatient population they studied scored within the dissociative disorder range on the Dissociative Experiences Scale. They concluded that the incidence of dissociative disorders in the general psychiatric inpatient population is much higher than generally thought and that these disorders are generally unrecognized. Others (Horen, Leichner, & Lawson, 1995; Modestin, Ebner, Junghan, & Erni, 1996) have reported similar findings.

2. Dissociative Fugue State Can Exist Co-Morbidly with Other Psychiatric Disorders

Including Other Dissociative Disorders. Joe's history revealed that he had had dissociative symptoms long before the fugue state occurred. His life style was a dissociated one in which his wife and family knew nothing of his family of origin or childhood. He had also displayed poor impulse control in the form outbursts of anger and a threat of bodily harm. During ideomotor exploration Joe displayed behavior suggestive of divided consciousness. In his interactions with me he displayed significant guardedness in his refusal to take psychological tests, and his refusal to have me speak with his employer appeared to be a way of keeping me from discovering that it was he, not his boss, who was limiting his availability for therapy and further diagnostic exploration. It is quite possible that Joe suffered from Dissociative Identity Disorder (DID).

3. Fugue Is A Very Complex Disorder to Treat. Even with more than 25 years of clinical experience, I found I was rapidly in "over my head" with this case. My general knowledge of this area was insufficient to allow me to proceed with my usual confidence. Even though everyone wanted a short-term solution to this problem, that approach may not have been in Joe's best interest. I focused so intently on removing the symptom of memory loss that I missed the larger role that the dissociative disorder played in Joe's life.

4. Diagnosis Should Precede Treatment. Joe refused psychological testing. I would not have known exactly what to look for in the standard personality test battery, and such tests are generally unhelpful when diagnosing dissociative disorders (Putnam, 1989). Indeed, in reviewing the literature on psychological testing, I found little useful information for a general psychotherapist. The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D; Steinberg, 1994a, 1994b) however, provides very useful questions that can be used easily in an informal way to cast more light on the scope and nature of dissociative symptoms or tendencies. I would recommend a familiarity with this instrument, even for those who never use it in a formal assessment.

5. A Phase-Oriented Treatment Approach Is Required. Even though I was able to use hypnosis for symptom removal and stabilize Joe sufficiently for him to get back to work and his "usual routine," I was unable to address the underlying dissociative disorder that seemed to have its roots in his forgotten childhood. I proceeded too quickly to address the symptom of memory loss and would have benefited from a phase-oriented approach (Herman, 1992; Phillips & Frederick, 1995) to build a sound therapeutic alliance and working relationship. This approach may have engaged Joe so that we could have worked together to discover what his treatment needs really were and to address some of his immediate fears and underlying issues. The major ego-strengthener would have been the therapeutic alliance as opposed to symptom removal.

6. Specific Dissociative Disorder Resources Are Needed for Work with Dissociative Fugue State. I consulted general psychiatric and psychological references. These only provided a very general approach to treatment of dissociative disorders. I recommend consulting references that relate specifically to dissociative disorders, such as Kluft (1984a, 1984b, 1985), Kluft and Fine (1983), Phillips and Frederick (1995), Putnam (1989, 1997), and Spiegel (1993). These focus on the dissociative process and some have very specific suggestions for how to proceed effectively with therapy. Phillips and Frederick (1995) also give concrete ways to utilize hypnosis in the context of therapy.

7. It Is Advisable to Consult with Specialists in Dissociative Disorders. I knew I needed consultation and checked with three experts in hypnosis and hypnoanalysis. Although I received some very helpful suggestions, I also missed structuring the therapy in such a way that a more comprehensive examination could be made and the more pervasive underlying dissociative disorder diagnosed. Without appropriate diagnosis I could not move therapeutically in the direction of a more complete resolution of Joe's conflicts. A consultant's high degree of expertise in hypnoanalytic technique is no guarantee that he/she has even basic knowledge about how to proceed with dissociative patients.

8. Do Not Attempt to Do with Hypnosis That Which You Are Not Trained to Do without Hypnosis. This case brings up educational and ethical issues for all mental health professionals; however, it is of special concern for those who use hypnosis for symptom removal and/or the retrieval of memory material. My telling Joe that he could remember "all that you need to know and all that you want to know at a pace that is just right for you" represents a missed opportunity for this patient to work collaboratively to resolve his serious dissociative pathology. He had spent the greater part of his life remembering all he thought he needed to know and all he wanted to know, and it had left him in a psychologically compromised and vulnerable position. Inasmuch as dissociative disorders are significantly represented in the general population of those who receive mental health services, a case can be made for training in the dissociative disorders as a necessary part of training for general psychotherapists. There is an additional burden for those who use hypnosis and are not infrequently called upon for symptom removal with situations such as Dissociative Fugue, conversion disorders, and various other somatic complaints.

Conclusion

Dealing with fugue disorder can challenge even the most seasoned clinician who does not specialize in this area. However, even though the experience may be rare, it can provide a very interesting opportunity to learn and develop greater competency. My work with Joe gave me the chance to consult with some of the experts in dissociation, to see my errors, and make me more attentive to the dissociative process and more aware of the need for training. The experience also helped me to realize that I need to consult with and refer to an expert in the field of dissociation when I am confronted with such clinical situations. Several months ago two men with diagnoses of Dissociative Fugue State were in our hospital at the same time. Because of my interest and curiosity in learning about Joe, I thought I was able to deal with these men in a much more appropriate and beneficial way than I would have otherwise.

Fugue disorder provides a unique challenge to the psychotherapist in general practice because it is so rare and unusual. If the pitfalls can be avoided, the initial therapy can be a golden opportunity to clarify the diagnosis and to help the patient understand what is going on with him/her and what needs to be done about it. Another benefit is that dealing with Dissociative Fugue can also help therapists work in a more effective way with people who have the less dramatic, dissociative symptoms that we see more frequently.

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