dissociative amnesia homayoun amini m.d. assis. prof. of psychiatry roozbeh hospital tums
TRANSCRIPT
DISSOCIATIVE AMNESIA
Homayoun Amini M.D.Assis. Prof. of Psychiatry
Roozbeh HospitalTUMS
INTRODUCTION Two main elements of dissociation :
1- they lack evidence of proximate organic illness or pathophysiological disturbance;
2 – the symptoms correspond to ideas of the patient about how parts of the body or mind malfunction or fail to function;
DEFINITION Dissociative phenomena are limited to
amnesia Key symptoms is the inability to recall
information, usually about stressfull or traumatic events in person’s lives
There may be a loss of knowledge of personal identity with preservation of other information, often including complex learned information or skills
DEFINITION It cannot be explained by ordinary
forgetfulness There is no evidence of an
underlying brain disorder Persons retain the capacity to
learn new information
SUBTYPES Localized: a circumscribed period of time Selective: some, but not all, of the events
during a circumscribed period of time Generalized: the person’s entire life Continuous: events subsequent to a
specific time up to and including present Systematized: certain categories of
information
EPIDEMIOLOGY Amnesia is the most common
dissociative symptoms More often in women than in men More often in young adults than in
older adults Incidence increases during times of
war & natural disasters
EPIDEMIOLOGY In civilian cases, a history of head
trauma or brain damage is often present
The condition may be more frequent amongst criminals or soldiers in distress
Tends to present to accident & emergency departments and then to neurologists, but is only seen secondarily in psychiatric departments
ETIOLOGY Psychoanalytic approach:
emotional conflict, primary & secondary gain
Hx of child abuse ?? Amnesia seems to be related to
immediate adult adjustment problems, rather than the consequences of early child abuse
The theory of state-dependent learning
DIAGNOSIS(DSM-IV-TR) A. The predominant disturbance is one or more episode
of inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness.
B. The disturbance does not occur exclusively during the course of dissociative identity disorder, dissociative fugue, PTSD, ASD, or somatization disorder, and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a neurological or other GMC (e.g., amnestic disorder due to head trauma).
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important
areas of functioning.
DIAGNOSIS(ICD-10) G1. There must be no evidence of a physical disorder that
can explain the characteristic symptoms of this disorder (although physical disorders may be present that give rise to other symptoms).
G2. There are convincing associations in time between the onset of symptoms of the disorder and stressful events, problems, or needs.
G3. There must be amnesia, either partial or complete, for recent events or problems that were or still are traumatic or stressful.
G4. The amnesia is too extensive and persistent to be explained by ordinary forgetfulness (although its depth and extent may vary from one assessment to the next) or
by intentional simulation.
CLINICAL FEATURES Onset is often abrupt Patients are usually aware that they have
lost their memories Some patients are upset but others
appear to be unconcerned Amnestic patients are usually alert before
and after the amnesia occurs Depression and anxiety are common
predisposing factors Distortions in time perception
DIFFERENTIAL DIAGNOSIS Clinicians should conduct:
- a medical history- a physical
examination - a psychiatric history
- a MSE- a laboratory workup
DIFFERENTIAL DIAGNOSIS… Is the amnesia a result of
an organic disease?a psychiatric
disorder? a dissociative disorder?
DIFFERENTIAL DIAGNOSIS… Amnestic disorders:
- epileptic seizures: short duration, less identity confusion, stereotypic -head injury: brief retrograde amnesia + longer anterograde amnes - korsakoff’s syndrome: significant anterograde amnesia + variable
rerograde amnesia, intact other cognitive functions
DIFFERENTIAL DIAGNOSIS… Transient Global Amnesia:
- Acute- Transient(prompt
return of memory) - Recent memory is often impaired
- Highly complex mental & physical acts are preserved
DIFFERENTIAL DIAGNOSIS… TGA can be differentiated from
dissociative amnesia:- anterograde amnesia
- more upset and concerned - personal identity is retained - more generalized
- most common in 60s & 70s
DIFFERENTIAL DIAGNOSIS… Dementia: multiple cognitive
deficits, Delirium: altered consciousness,
impaired attention, fluctuation, Cerebral infections & neoplasms Metabolic disorders ….
DIFFERENTIAL DIAGNOSIS… Organic amnesias have several
distinguishing features:- no recurrent
identity alteration - not selectively limited to personal information - do not focus on or result from an emotionallt traumatic event
- more often anterograde than retrograde
DIFFERENTIAL DIAGNOSIS… Organic amnesias have several
distinguishing features….- usually permanent
(excluding substance abuse, TGA, metabolic, delirium,…)
- the erasure or destruction of memory or not registration
DIFFERENTIAL DIAGNOSIS… Substance use disorders: - alcohol
- sedative hypnotics - anticholinergics - steroids
- lithium carbonate - beta blockers - hypoglycemic agents - marijuana - hallucinogens - pentazocine -
phencyclidine
DIFFERENTIAL DIAGNOSIS… Psychiatric disorders:
- depression- PTSD- acute stress disorder
- somatoform disorders- sleep disorders
- factitious disorder- malingering
Other dissociative disorders:- fugue- identity
COURSE & PROGNOSIS Recovery is usually complete and
termination may be rapid in localized or selective subtypes
Recovery is usually gradual in generalized subtype
Functional impairment varies from mild to severe, depending on the extent of the amnesia
The more acute & the more recent the instance of dissociative amnesia, the more likely & the more quickly it is to be resolved
TREATMENT Intrusive attempts to retrieve memories
can result in retraumatization if the patient is not properly prepared
This risk is especially great for longstanding or childhood-onset amnesias
The clinician should control the pace of suggested recollection, usually within the framework of a broader psychotherapy
In extreme cases, hospitalization may be necessary
TREATMENT… Group psychotherapy: especially
successful in helping combat veterans and survivors of childhood abuse
Hypnosis Drug-assisted interview