Treatment

The diagnosis and treatment of dissociative amnesia became controversial

in the 1990s due to disputes over delayed recall of childhood sexual abuse. Prior to this,
dissociative (psychogenic) amnesia and delayed recall for combat or other forms of
trauma had not been considered controversial, although some authors from the World
War I and II eras opined that many of these wartime cases were malingered. As
described above, controversy exists not only for the existence of dissociative amnesia,
but also for how to treat it.
Critics of the dissociative amnesia construct have invented the term recovered
memory therapy (RMT) to characterize treatment in which clinicians are thought to
make aggressive efforts to have patients recall allegedly forgotten traumas as the
central focus of treatment. RMT does not represent a known school of therapy or of
scholarly research. It may more accurately describe individual fringe practitioners or
media or layperson views of trauma treatment. As noted in prior sections, reviews of the
literature on trauma treatment report that the predominant model for work on traumatic
memories involves a focus on symptom stabilization and safety, integration of
posttraumatic memories, beliefs, cognitions, affects, somatic representations, and
object relations, not on memory recall per se.
Phase-Oriented Treatment. As for dissociative identity disorder, phaseoriented
treatment is the current standard of care for the treatment of dissociative amnesia,
although there are no systematic studies with large cohorts of dissociative amnesia
patients. Treatment of the acute classic dissociative amnesia patient follows a similar
phasic model. However, here, memory recall is a central issue, because loss of memory
for personal identity and large gaps in current autobiographical memory are acutely
disabling symptoms that require relatively rapid intervention.
In general, as described in the section on dissociative identity disorder,
three basic phases are recognized. This structure is heuristic to some extent, because
aspects of each phase may be worked on during another. First, there is a stabilization
phase, with a focus on safety, symptom control, containment of affects and impulses,
and education about trauma treatment. Once adequate personal safety and clinical
stability are established, if indicated, the individual may engage in a second phase that
focuses on the integration of traumatic material in greater depth. This processing may
involve attempts to overcome persistent amnesia and to resolve material that is not
dissociated or less completely dissociated.
Finally, there is a third phase of resolution or reintegration, in which the
traumatized person is reconnected to ordinary life. In this phase, the focus is less on the
trauma per se and more on the development of a renewed, reinvigorated life that
overcomes the lack of freedom imposed by symptoms of the trauma disorder and the
dominance of the person’s psychology by issues related to traumatization.
In general, studies of treatment outcome in survivors of rape and childhood
sexual abuse have shown better outcome when patients directly discuss trauma
material in the context of a carefully designed, phasically structured individual or group
psychotherapy. Nonetheless, it is a matter of clinical judgment and the patient’s
individual decision whether the patient has achieved sufficient stability and has sufficient
ego strength to move from the stabilization phase of treatment to the phase of memory
integration. In this regard, in clinical case series, serious suicide attempts,
and even completed suicide, have been reported in patients with dissociative amnesia
when amnestic barriers are removed precipitously with inadequate stabilization.
Safety in Acute Dissociative Amnesia. In the case of the patient with an ASD
primarily characterized or accompanied by dissociative amnesia, the establishment of
the person’s physical safety is the first concern. This involves removing the individual
from the traumatizing environment (e.g.,acute combat), evaluating and treating medical
problems, and providing shelter, food, and sleep. The paradigm of psychological first aid
may be helpful in the initial stabilization of the acutely traumatized, amnesic individual.
Sedative medications, such as the benzodiazepines, may be indicated to assist the
patient with sleep. Patients with acute amnesia for personal identity or life
circumstances, or both, frequently have a relatively rapid spontaneous remission of
symptoms once brought to the safety of the hospital or other protected environment. If
immediate spontaneous remission does not occur in patients with acute amnesia after
removal from traumatic environments, symptoms may abate later simply in the course
of the clinician’s taking a psychiatric history or merely with suggestions and
reassurance.
Safety in Nonclassic Dissociative Amnesia. Patients with nonclassic, covert
amnesia presentations generally should be managed within the framework of a longer-
term psychotherapy directed at resolution of the complex psychological sequelae of the
events producing the amnesia, usually severe traumatization due to childhood abuse,
combat, rape, domestic violence, or other forms of adult victimization. Here, too, the first
tasks of treatment are restoration of the patient’s physical well-being and safety and
establishment of a working alliance. The clinician must be prepared to intervene actively
if the patient is acutely dangerous to self or others or is abusing substances in an
uncontrollable way. Typically, these patients’ difficulties involve suicide attempts, self-
mutilation, eating disorders, alcohol or substance abuse, involvement in abusive or
destructive relationships, episodes of rage or violence, abuse of the individual’s own
children or family members, and lack of adequate food, clothing, or shelter.
Hospitalization may be necessary for stabilization, as may referral to specialty
resources, such as treatment for substance abuse or eating disorders.
In individuals with severe intrusive PTSD symptoms alternating with amnesia,
containment and management of intrusive recollections rather than detailed processing
of the traumatic material are usually the main goals of the stabilization phase of
treatment. This may be accomplished with supportive psychotherapy, pharmacotherapy,
imagery or hypnotic techniques for containment and symptom control, and/or dialectical
behavioral and cognitive therapy techniques, or a combination of these.
Although there is no pharmacological agent that specifically targets dissociative
amnesia, specific psychopharmacological treatment of the patient’s PTSD, mood,
impulsive, psychotic, obsessive-compulsive, or anxiety symptoms with medications may
help stabilize severe symptoms that prevent the patient’s meaningful participation in
psychotherapy.
Long-term treatment for these patients is focused on the manifold dimensions of
dysfunction that chronic trauma engenders. These include problems with mood, anxiety,
and impulse regulation; disordered attachment schemas engendering troubled
relationships and problems with interpersonal boundaries; spontaneous altered states of
consciousness and dissociation; memory problems; cognitive distortions and disordered
meaning systems; perceptual abnormalities; problems with the sense of self
and body image; somatoform symptoms; and self-destructiveness.
Treatment of Amnesia. Treatment of patients with nonclassic forms of
dissociative amnesia necessitates that the clinician familiarize him- or herself with the
current controversies about trauma and memory to provide adequate informed consent
to the patient. Factors that usually contraindicate intensive memory integration work are
listed in Table 20– 25 (see also Table 20–21 in the section on dissociative identity
disorder).
Free Recall. Patients with the acute and chronic forms of dissociative amnesia
may respond well to free-recall strategies in which they allow memory material to enter
into consciousness. The clinician is supportive and nondirective but focuses on
reluctance or resistance to allowing free recall to take place. Classic free-association
suggestions are often the most helpful in understanding factors that interfere with recall
and in allowing recall to occur at a pace that the patient can tolerate. Most clinicians
think that memory accuracy is improved if the clinician asks nonleading questions,
whether in a free-recall situation or with methods that facilitate memory recall. Distress
at recall may be titrated by techniques for distancing and fractioning emotion. For
example, the patient may be asked to give a brief “headline” or two, as if reading a
newspaper, but not to go into more detail (e.g., reading the newspaper article in full)
until more able to do so.
Transference Interpretations. Studies of transference in patients with combat-
related PTSD and severe dissociative disorders indicate that a traumatic transference is
usually the predominant initial transference theme in these individuals. This is a set of
unconscious perceptions of the clinician, based on relationships formed under traumatic
circumstances. For instance, the therapist becomes the buddy who was killed next to
the patient in battle, the persecutory abusive parent, the incompetent officer who sent
the patient into battlefield disaster, the neglectful relative unconcerned about the
patient’s abuse, or the patient him- or herself who is subject to the sadistic, abusive
behaviors of an implacable other.
Identification of the overt patterns of traumatic transference observed by the
therapist may be another route to undoing amnesia. A recent study of corroborated
trauma memory found that transference-based recall was more accurate than other
forms of facilitated recall.