Autobiographical Memory, Nonpathological Amnesia, and Dissociative

Amnesia. Nonpathological forms of amnesia have been described, such as

infantile and childhood amnesia, amnesia for sleep and dreaming, and hypnotic
amnesia. Most forms of dissociative amnesia are thought primarily to involve difficulties
with autobiographical memory—rather than implicit or general semantic memory—
although rarely procedural memory may be disrupted. Autobiographical memory may
have episodic and semantic components (e.g., “last year I bought a new car” vs. “every
5 years I buy a new car,” respectively).
Studies of autobiographical memory support the notion that infantile and
childhood amnesia can be experimentally documented. However, there are now data on
preverbal learning and memory in young children. Amnesia may result in later years
owing to the difficulty in translating this preverbal memory into verbal form. However,
experiments designed to overcome this factor in young children have shown that
children can later report preverbal memories accurately in verbal form under suitable
experimental conditions.
Studies demonstrate that normal adult autobiographical memory has a retention
gradient for the last 20 to 30 years of the subject’s life, often with a subjective sense of
wearing away of memories for the past, in contrast to the subjective gaps in memory
typical of dissociative amnesia. Elderly patients in autobiographical memory studies
have a relative decrease in recent autobiographical memories and a reminiscence
component for the events of their youth. Older adults have more semantic
autobiographical memories and fewer episodic autobiographical memories, anchored in
specific time points. Consistent with this, there may be a shift from the first
person (field) to the third person (observer) form of autobiographical
memory.
Autobiographical memory has several complex aspects, including emotion,
mood, and state-based differentials in memory; for example, negative events may be
preferentially recalled in depressed mood states. Schema memory effects may result in
the inclusion of a memory of something one has not experienced into memories of a
sequence of experienced events. Due to a variety of factors, individuals may develop
pseudomemories for events that did not occur. This can include false confessions,
experimentally induced “false memories.” and failures to recall events that did happen
(omissions or “false nonmemory”). It may be difficult to differentiate actual memory
alteration in these situations from the belief that something did or did not occur.
Autobiographical memory for repeated routine events, such as going to work or
school every day, may not be encoded as discrete memories for each day, but rather as
broad memory categories for the events that repeatedly reoccur (regeneric memory).
This is also thought to occur with some traumatic experiences, such as repeated
episodes of childhood sexual abuse that happen recurrently over many years.
Clinically, patients with dissociative amnesia may have a variety of
autobiographical memory deficits. For example, a patient with global dissociative
amnesia after a rape was evaluated with cognitive testing while amnesic and after
memory recovery. As compared to an organically impaired control, the dissociative
amnesia patient was able to recall memories from various points in the life history
without the temporalgradient that characterized the retrograde amnesia of the organic
patient.
 Recall of autobiographical information during dissociative amnesia seemed
related to life events with positive effects that were unconnected with the traumatic
events precipitating the amnesia. In this patient, implicit autobiographical memory
phenomena were also documented. Similar phenomena have been described in
posthypnotic amnesia, with implicit demonstration that the memories for which amnesia
has been suggested have been encoded and stored, but without being directly
accessible for retrieval. Amnesic patients may also have intense reactions to stimuli that
are emotionally significant, without being aware of the reason for the reaction or the
significance of the stimulus, such as when a patient with PTSD has a flashback without
consciously knowing what triggered it and often without clear recall later of the memory
being evoked.
Several studies have confirmed the clinical observation that subjects with
dissociative amnesia for their life history can demonstrate implicit autobiographical
memory while amnesic. When asked to free associate, to imagine, or to make up a
story or when exposed to projective tests, patients with dissociative amnesia include in
their productions elements of autobiographical information without necessarily being
consciously aware of this.

Memory in Normal Aging, Dementia, Delirium, and Amnesia in Cognitive

Disorders. The effects of normal aging on memory are complex, depending on which
systems are being evaluated. For example, a study that compared aging air traffic
controllers with younger controllers found typical age-related declines in speed or recall
of information (names, dates), but aging and younger air traffic controllers showed
equivalent ability on other professional tasks, thought to be related to years of
experience with these complex activities. Older adults may have better implicit than
explicit memory on some tasks, and may be more vulnerable to distraction effects.
Exercise and diet may increase hippocampus size in the aging brain, possibly mediated
through increased expression of brainderived neurotrophic factor (BDNF), its receptor
and other related pathways.
There is no single test or examination that can establish absolutely whether a
memory disorder has a dissociative, neurocognitive, factious, malingered, or mixed
etiology. The clinician evaluating the amnesic patient must have a reasonable index of
suspicion about any of these. In ambiguous cases, thorough reassessment on an
ongoing basis of the clinical situation is helpful. However, most patients with dissociative
amnesia present differently from other disorders with memory impairment (Table
20–23). The evaluation of acute dissociative amnesias is described in Table
20–24.
In patients with dementia, amnestic disorders, and delirium, the memory loss for
personal information is embedded in a far more extensive set of cognitive, linguistic,
attentional, behavioral, and memory problems. Loss of memory for personal identity is
usually not found without evidence of marked disturbance in many domains of cognitive
function.Confabulation may be present to various degrees and is usually implausible
or bizarre. Causes of neurocognitive amnestic disorders include thiamine deficiency
(Korsakoff psychosis), cerebral vascular accident (CVA), postoperative syndrome,
infection, anoxia, and transient global amnesia.
 Electroconvulsive therapy (ECT) may also cause a marked temporary amnesia
and, occasionally, persistent memory problems. In ECT-related amnesia, however,
memory loss for autobiographical experience is unrelated to traumatic or overwhelming
experiences and seems to involve multiple types of personal experience, most
commonly those occurring just before or during the ECT treatments.
Posttraumatic Amnesia. In posttraumatic amnesia due to brain injury, there is
usually a clear-cut physical trauma, a period of unconsciousness or amnesia—or both—
and objective clinical evidence of brain injury. In general, the length of the posttraumatic
amnesia is a reasonable predictor of cognitive outcome. Retrograde amnesia may also
occur. An extensive retrograde amnesia out of proportion to the head injury may warrant
an investigation for dissociative factors.
Seizure Disorders. In most cases of epileptic seizures, the clinical presentation
is different from that of dissociative amnesia, with clear-cut ictal events and sequellae.
Patients with nonepileptic seizures, however, may resemble epileptic patients in some
ways but may also have cognitive dissociative symptoms, such as amnesia, and an
antecedent history of psychological trauma. Rarely, patients with recurrent complex
partial seizures may present with ongoing bizarre behavior, memory problems,
irritability, or violence, making them hard to distinguish from patients with dissociative
amnesia. Some epileptic patients have exhibited wandering or semi- purposeful
behavior, or both, during seizures or in postictal states, for which there is subsequent
amnesia, which may confuse clinicians trying to exclude a dissociative fugue. However,
seizure patients in an epileptic (as opposed to dissociative) fugue often exhibit abnormal
behavior, including confusion, perseveration, and abnormal or repetitive movements, as
well as experiencing an aura, motor abnormalities, stereotyped behavior, perceptual
alterations, incontinence, and a postictal state. Stressful life events may be associated
with an increase in seizure frequency in some susceptible epileptic patients, and thus
this factor alone is insufficient for differential diagnosis. Serial or telemetric EEGs, or
both, usually show abnormalities associated with behavioral pathology.
Substance-Related Amnesia. Several substances and intoxicants have been
implicated in the production of amnesia. Common offending agents are listed in Table
20–23. In most cases, a careful history from the patient and ancillary sources,
sequential clinical observation, and objective testing clarify the substance-related nature
of the amnesia. In some instances of pathological intoxication, in which a small amount
of alcohol or of another substance produces a major behavioral disinhibition, the alcohol
may be producing its effect by facilitating the onset of a dissociative episode in a
susceptible individual. This may be analogous to the disinhibition that occurs in a clinical
pharmacologically facilitated interview. Subjects may report amnesia for violent or other
out-of-character behavior during such an episode.
The most difficult differential diagnostic problem usually involves patients with a
history of substance-induced and dissociative memory problems. Some of these
patients may minimize dissociative amnesia and vice versa. Clinically, the relative
contribution of the substance abuse and the dissociation may only be fully clarified by
sequential clinical observation once the patient has achieved sobriety.
WANDERING BEHAVIOR. Individuals with dissociative amnesia may engage
in confused wandering during an amnesia episode. To qualify for the dissociative fugue
subtype, the individual must exhibit purposeful travel away from home or a customary
place of daily activities and is usually preoccupied by a single idea that is accompanied
by the wish to escape. Wandering behavior during a variety of general medical
conditions, toxic and substance-related disorders, delirium, dementia, and organic
amnestic syndromes could theoretically be confused with the dissociative fugue subtype
of dissociative amnesia. However, in most cases, the somatic, toxic, neurological, or
substance-related disorder can be ruled in by the history, physical examination,
laboratory tests, or toxicological and drug screening. Use of alcohol or other substances
may be involved in precipitating an episode of dissociative fugue.
Transient Global Amnesia. Transient global amnesia may be mistaken
for dissociative amnesia, especially because stressful life events may precede either
disorder. However, in transient global amnesia, there is a sudden onset of complete
anterograde amnesia and learning abilities; pronounced retrograde amnesia;
preservation of memory for personal identity; anxious awareness of memory loss with
repeated, often perseverative, questioning; overall normal behavior; lack of gross
neurological abnormalities in most cases; and rapid return of baseline cognitive
function, with a persistent short retrograde amnesia. The patient is usually over 50 and
shows risk factors for cerebrovascular disease, although epilepsy and migraine have
been etiologically implicated in some cases.
Dissociative Disorders. As noted previously, dissociative identity disorder
patients can present with acute forms of amnesia and fugue episodes. However, these
patients are characterized by a plethora of symptoms, only some of which are usually
found in patients with dissociative amnesia. Most dissociative identity disorder patients
do report multiple forms of complex amnesia, including recurrent blackouts, fugues,
unexplained objects in their possession, and fluctuations in skills, habits, and
knowledge. Some patients with other dissociative disorder, particularly acute
dissociative reactions to stressful events, may develop microamnesias for the duration
of their acute episodes, in the context of other dissociative symptoms (e.g., perceptual
disturbances). Individuals with more extensive amnestic episodes may qualify for a
dissociative amnesia diagnosis (see section on Other Dissociative Disorders).
Acute Stress Disorder and Posttraumatic Stress Disorder. Many dissociative
amnesia patients meet full or partial diagnostic criteria for ASD, PTSD, a somatic
symptom disorder, or a combination of these. The DSM-5 stipulates that, to be
diagnosed, the dissociative amnesia must be distinct from the course of ASD, PTSD, or
somatization disorder. In practice, clinical judgment usually determines whether the
extent of the amnesia warrants a separate dissociative diagnosis. As
depersonalization/derealization disorder symptoms may occur in dissociative amnesia
patients, research will be needed to determine the prevalence of the dissociative
subtype of PTSD in dissociative amnesia patients who also meet DSM-5 diagnostic
criteria for PTSD.
Other Psychiatric Disorders. State-related memory problems can be observed
in psychotic disorders, neurocognitive disorders, and cyclic mood disorders. Upon
resolution of an acute psychotic episode, many individuals can report lack of recall of
their symptoms, behavior, or life events while psychotic. This lack of recall may also be
observed in many individuals who recover from an episode of delirium. In contrast, a
minority may fully recall their symptoms of psychosis or delirium and become tormented
with fear and shame regarding these experiences.
 State-related transitions between mania, depression, and euthymia may
be accompanied by an autobiographical memory deficit for mood, behavior,
perceptions, and sense of self during the different states. Manic individuals may deny
recall of depressive episodes and vice versa. During euthymic states, the individual may
have difficulty recalling details of being in the other mood states. Wandering and
purposeful travel may occur during the manic phase of bipolar disorder or
schizoaffective disorder, with lack of recall of behavior that occurred after return to the
euthymic or depressed state. In purposeful travel due to mania, however, the patient is
usually preoccupied with grandiose ideas and often calls attention to himor herself
owing to inappropriate behavior. Assumption of an alternate identity does not occur,
although the subjective differences in sense of self, emotions, and behavior may lead
the person to feel like “different people” during the different mood states. Similarly,
peripatetic behavior may occur in some patients with schizophrenia. Memory for events
during wandering episodes in such patients may be difficult to ascertain owing to the
patient’s thought disorder. However, dissociative fugue patients do not demonstrate
a psychotic thought disorder or other symptoms of psychosis.
Malingering and Factitious Amnesia. Feigned amnesia is more common in
patients presenting with the acute, classic forms of dissociative amnesia. However, in
one recent forensic case, an adult attempting to sue an admitted abuser using the
delayed discovery rule was shown to have falsified delayed recall for trauma in an
attempt to overcome the statute of limitations. Investigations showed that the patient
had discussed the abuse with others on many occasions before the purported delayed
recall. On the other hand, some patients may have secondary amnesia for having
remembered and discussed traumatic experiences in the past.
Malingering of dissociative fugue may occur in individuals who are attempting to
flee legal, financial, or personal difficulties, and in soldiers attempting to avoid combat or
unpleasant military duties. These precipitating factors may be present as well in bona
fide dissociative fugue. However, many malingerers confess spontaneously or when
confronted. In the forensic context, the examiner should always give careful
consideration to the diagnosis of malingering when fugue is reported.
As in other dissociative disorders, there is no test, battery of tests, or set of
procedures that invariably distinguish true dissociative symptoms from those that are
malingered. Malingerers have been noted to continue their deception even during
hypnotically or barbiturate-facilitated interviews. As noted previously, many of the
classical cases occurred in a clinical context of financial, sexual, and legal problems or
in soldiers who wished to escape from combat.
On the other hand, in clinical case reports, many malingerers have quickly
confessed their deceptions spontaneously or when confronted by an examiner. In these
nonforensic reports, the malingered amnesiacs were frequently pathetic individuals
whose deception was transparent. Nevertheless, it can often be unclear where the
conscious deception began and the unconscious defenses ended.
In the current clinical environment, a patient who presents to psychiatric attention
asking to recover repressed memories as a chief complaint is most likely to have a
factitious disorder, including the imitative form of dissociative disorder described in prior
sections. Most of these individuals actually do not describe bona fide amnesia when
carefully questioned; but they are often insistent that they must have been abused in
childhood to explain their unhappiness or life dysfunction. As noted above, most
dissociative individuals are fearful, ashamed, and avoidant of recall of traumatic
memories, and minimize and deny the dissociative amnesia.
Memory recall in dissociative amnesia does not present as typical episodic,
autobiographical memory recall. Rather, these usually are experienced as disturbing
intrusive flashbacks with alarming and vivid perceptual, somatoform, and emotional
experiences, followed by attempts to “redissociate” the material.