This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders.
Dissociative Amnesia in the Media and Real Life by Amy Brewer
Many are familiar with characters like Jason Bourne from the Bourne Identity films, Evan Treborn from Butterfly Effect or Walter White from Breaking Bad. In these shows, a disorder known as dissociative amnesia was used as a plot device for each of these characters; in fact, much of what the general public knows about this disorder (also known as psychogenic amnesia) comes from the media. Though there are documented case studies dating back to the 1800’s, there is still very little empirical evidence in regards to causes of the disorder, authenticity, and effective treatment.
The DSM-5 characterizes dissociative amnesia (DA) as an inability to recall autobiographical information and states that it is usually associated with a traumatic event. Though the diagnosis for DA is rare, there are several types of amnesia described in the literature. Localized amnesia is memory loss that is focused on a specific period surrounding an event, as in the portrayal of Evan Treborn. Another type is selective amnesia, meaning that some but not all memories of the event can be recalled. Lastly, an acute and seldom reported form is generalized amnesia, which refers to a complete memory loss for one’s life history and can include identity loss, much like the movie character Jason Bourne. In order for a diagnosis of DA, physiological effects of substances and other disorders such as PTSD must be ruled out, and this type of amnesia is not caused by a brain injury or neurological condition.
Another component to dissociative amnesia is the fugue state. Fugue is associated with generalized amnesia and is the act of wandering, usually in search of identity or other autobiographical memories. The APA made a significant change to this fugue element, changing it from a disorder in DSM-IV to a specifier of dissociative amnesia in the DSM-5. Now a person diagnosed who meets the criteria for dissociative amnesia will either be notated as with or without fugue.
Generally, a fugue state is prompted by individuals when they become aware of their memory loss. Reports from across the world typically begin as a missing person report, with family members stating that an individual left for work or to an event and did not return. Months or years later, the person is found, sometimes miles away in a nearby town or state, wandering in a confused condition.
Much is still unknown about dissociative amnesia. The documented cases of DA are descriptive instances and are difficult to validate. Among individuals who have recovered their memories, many report experiencing a traumatic event such as a physical or sexual assault or combat in warfare, but some have reported more common life stressors such as a death of a family member or divorce. With the stressful events associated with this disorder, scientists have puzzled over the reasons that some people report memory loss while many others who experience similar events do not, asking if it is a difference in coping mechanisms or in brain chemistry. Scientists have attempted to investigate brain mechanisms associated with dissociative amnesia. Though they have been able to point to differences in brain pattern activity before and after memory recovery with F-MRI technology, no causal relation can be inferred from the results.
Because there is no way to truly cite cause, there is also not a viable way to detect authenticity in cases. One concern psychologists have with DA diagnosis is malingering, which is defined as a person feigning the disorder, possibly to escape punishment or circumstances, such as in (spoiler alert!) the case of Walter White from Breaking Bad who fakes a fugue state to get out of a bad situation. Feigned amnesia is reported to be more common for those with acute symptoms, those with financial, sexual, or legal trouble, and those wishing to escape stressful issues. The APA also points out that these can all be similar characteristics for those with authentic symptoms, which makes them indistinguishable from malingering cases.
It is difficult to ascertain effective treatment because the causes and validity of the disorder are still unclear. With little evidence-based studies in this area, some in the field are using pseudo-scientific methods that lack efficacy. For example, numerous past studies give accounts of therapists using hypnosis or narcotherapy in an attempt to restore lost memories. Neither treatment has supporting evidence, and much of the literature discourages their use for the danger of making matters worse or planting false memories.
Researchers are still in the process of discovering effective treatments for dissociative amnesia. Considerations such as type of amnesia (localized or generalized with fugue), loss of function, such as social or occupational, and significant distress are important when determining if treatment is necessary. It is also important to clarify whether treatment is being used to attempt to restore memories or to help patients cope with the loss or sudden return of memories. In many cases in the literature, patients often report spontaneous recovery of their memories, which could indicate that treatment to restore memories is, for the most part, unwarranted.
Even with little research in this area, there are indications of effectiveness with cognitive behavioral therapy, which gives support to patients and teaches coping skills on an individual basis. These treatments involve psycho-education to better understand the problem and skill building to decrease symptoms and the stress associated with these symptoms. Rather than using means such as hypnosis to restore memories, particularly in fugue situations, in supportive therapy, patients are taught coping techniques and given encouragement as stressful events prior the fugue begin to return.
One treatment that is in early stages of development is the additional use of mindfulness in supplement to CBT therapy for clients diagnosed with DA with fugue. Mindfulness is an ancient Buddhist practice that has gained popularity in western culture and psychological practice in recent years. In this practice, individuals are taught to focus awareness on the present state of consciousness. Empirical studies have indicated that mindfulness practice can help to decrease stress and emotional reactivity and increase focus. It has also shown promising results in tandem treatment with CBT with patients diagnosed with PTSD symptoms and borderline personality disorder. The idea of mindfulness in conjunction with CBT treatment is to diminish the onset and maintenance of distressing emotions while increasing acceptance and self-compassion. This technique helps clients focus attention and objectively monitor thoughts in a non-reactive way as negative memories re-emerge. Though there is yet to be empirical backing for the use of mindfulness as a part of supportive therapy, early reports indicate its potential in reducing symptoms and aiding in effective coping for clients who meet criteria for dissociative amnesia.
It is clear that more empirical studies are necessary in learning the causes, authenticity, and treatments for dissociative amnesia. It is important to continue work in this area as cases will continue to surface in forensic and legal cases where it is important to distinguish credibility. It is also necessary to validate efficacy for individualized treatment for the welfare of those who are in distress and meet criteria for this disorder.