Combat-Induced Dissociative Amnesia

Abstract

Dissociative amnesia following combat trauma in various wars has been extensively documented. In this article, we describe theoretical constructs related to dissociative amnesia, and integrate them with clinical practice through the presentation of a case. Although there is ample documentation of this condition in combat soldiers, in actual clinical practice such dissociative amnesia is probably underdiagnosed and undertreated. This may be detrimental to therapeutic progress, given the fact that ongoing memory deficits constitute one of the core symptoms of chronic PTSD in combat veterans. As illustrated in our case example of combat-induced generalized dissociative amnesia, combat-induced amnesia may also reflect previously existing dissociated traumatic memories that become reactivated during trauma. In this case, intensive treatment using hypnosis within a larger therapeutic milieu involved both the uncovering and processing of recent dissociated traumatic experiences, and, by necessity, other traumas of the past.     

Hypnosis and Traumatic Dissociation: Therapeutic Opportunities

ABSTRACT

Hypnosis and the related phenomenon of dissociation have long been linked to trauma. Evidence is reviewed regarding the relationship between trauma and dissociation, the prevalence of these dissociative symptoms in the acute aftermath of trauma, and their salience in predicting the development of later PTSD symptoms. The evidence reviewed regarding the prevalence of dissociative and other symptoms in the immediate aftermath of trauma formed the basis for including Acute Stress Disorder (ASD) as a new diagnosis in the DSM-IV. Dissociative amnesia is described as the key commonality between formally induced hypnosis and dissociative symptomatology, and controversy regarding traumatic amnesia is discussed. Finally principles of psychotherapy involving hypnosis and related techniques for dissociative and other post-traumatic symptoms are reviewed.     

Drug-Induced Dissociative States of a Sleep Terror Patient

ABSTRACT

Frightening negative hallucinations as a side effect of fencamfamine (a central nervous system stimulant), aggressive behavior and amnesia due to interactions between metoprolol (a beta adrenergic blocking agent) and alcohol, chronic and severe sleep terrors and conversion disorder are described in a middle-aged man with high social status and no personality disorder. Rare mental side effects should draw attention to the possibility of a latent dissociative disorder. The relationship between beta-blocker induced disturbing dreams, dissociative disorders and sleep terrors is discussed.     

Tracking scientific interest in the dissociative disorders: a study of scientific publication output 1984-2003

OBJECTIVE: We attempted to track scientific interest in dissociative amnesia and dissociative identity disorder by estimating the annual output of publications regarding these entities over the last 20 years. METHODS: Using a standard medical index, PsycINFO, we counted the number of indexed publications involving dissociative amnesia and dissociative identity disorder listed for each year. We then compared these rates with those of well-established diagnoses such as anorexia nervosa, alcohol abuse, and schizophrenia. We also systematically reviewed all publications involving dissociative amnesia that appeared in 2003. RESULTS: Annual publications involving dissociative amnesia and dissociative identity disorder rose from low levels in the 1980's to a sharp peak in the mid 1990's, followed by an equally sharp decline to only about one quarter of their peak levels by 2002 and 2003. In contrast, all of the 25 comparison diagnoses in our survey showed constant or steadily rising publication rates; none showed the 'bubble' pattern of the dissociative disorders. Of the 34 papers involving dissociative amnesia identified by PsycINFO for 2003, 10 (32%) appeared skeptical of the validity of dissociative amnesia and/or recovered-memory therapy. Despite a detailed search using multiple medical indices and search terms, we could find only 13 explicit cases of individuals with dissociative amnesia worldwide in the 2003 literature. CONCLUSIONS: Dissociative amnesia and dissociative identity disorder have not generated consistent scientific interest over the years, but instead apparently enjoyed a brief period of fashion that now has waned. Overall, our observations suggest that these diagnostic entities presently do not command widespread scientific acceptance.     

Dissociation and Schizophrenia

Abstract

Comorbidity of psychotic and dissociative disorders often is not reported. This 38 year-old female with a history of schizophrenic symptoms displayed evidence of dissociative identity disorder (DID) during admission to an inpatient psychiatric unit. The case illustrates how the presence of a dissociative disorder may influence the presentation of a co-morbid psychosis. The historical association and differential diagnosis between DID and schizophrenia is described. Implications of various treatment approaches for patients exhibiting dissociation in the context of psychosis are discussed.     

Memory Fragmentation in Dissociative Identity Disorder

ABSTRACT

This study examined the quality of self-reported memories of traumatic experiences in participants with dissociative identity disorder (DID) and compared them with their memories of non-traumatic, but emotionally significant life experiences. Systematic interview data were gathered from 30 DID patients in The Netherlands. All participants reported a history of severe childhood abuse; 93.3% reported some period of amnesia for the index traumatic event, and 33.3% reported periods of amnesia for significant non-traumatic childhood experiences. All participants who had been amnestic for their trauma reported that their memories were initially retrieved in the form of somatosensory flashbacks. This suggests that, like PTSD patients, DID patients at least initially recall their trauma not as a narrative, but as somatosensory re-experiencing. Surprisingly, however, DID participants also recalled emotionally charged non-traumatic life events with significant somatosensory components, a phenomenon that has not been previously reported. This finding raises important issues regarding basic memory processing abnormalities in DID patients.     

Utilizing Religious Resources in the Treatment of Dissociative Trauma Symptoms

Abstract

The religious faith and spirituality of patients suffering from dissociative disorders has a vital though often undervalued role to play in the treatment process. This article will examine some reasons for this state of affairs, provide a rationale and strategy for the assessment of patient religiousness, and suggest some practical avenues for utilizing the religious and spiritual dimension in psychotherapy. Concluding recommendations derived from this analysis for the dissociative disorders field are presented.     

Somatoform Dissociation

Abstract

In most of the recent scientific and clinical literature, dissociation has been equated with dissociative amnesia, depersonalization, derealization, and fragmentation of identity. However, according to Pierre Janet and several World War I psychiatrists, dissociation also pertains to a lack of integration of somatoform components of experience, reactions, and functions. Some clinical observations and contemporary studies have supported this view. Somatoform dissociation, which can be measured with the Somatoform Dissociation Questionnaire (SDQ-20), is highly characteristic of dissociative disorder patients, and a core feature in many patients with somatoform disorders and in a subgroup of patients with eating disorders. It is strongly associated with reported trauma among psychiatric patients and patients with chronic pelvic pain presenting in medical healthcare settings. Motor inhibitions and anesthesia/analgesia are somatoform dissociative symptoms that are similar to animal defensive reactions to major threat and injury. Among a wider range of somatoform dissociative symptoms, these particular symptoms are highly characteristic of patients with dissociative disorders. The empirical findings reviewed in this article should have implications for the contemporary conceptualization and definition of dissociation, as well as the categorization of somatoform disorders in a future version of the DSM.     

Dependency in the Treatment of Complex Posttraumatic Stress Disorder and Dissociative Disorders

Abstract

Dependency is a major and ubiquitous issue in the treatment of chronically traumatized patients, such as those with complex posttraumatic stress disorder (PTSD), trauma-related borderline personality disorder, and dissociative disorders. Within this context, the concept of dependency is often paired with pejorative adjectives, and is dichotomized and negatively compared to a preferred state of independence. This paper explores prevailing sociocultural and theoretical beliefs regarding dependency in the psychotherapy of trauma survivors, provides a working definition of dependency, offers an analysis of its complex nature, and describes the theory of structural dissociation, which helps illuminate the often contradictory manifestations of dependency in chronically traumatized patients. A distinction is made between secure and insecure dependency. Finally, this paper outlines the collaborative therapeutic process required to manage insecure dependency productively within a phase-oriented treatment model. Countertransference responses that interfere with a patient's conflicts regarding dependency are also discussed.     

A Study of Recovery of Memory Function in a Case of Witnessed Functional Retrograde Amnesia

We describe a case of transient functional retrograde amnesia that had features of a fugue state, and that was accompanied by loss of personal identity and significant autobiographical amnesia. Uniquely, we were able to gather information from witnesses who observed the episode from its onset, and we were also able to monitor the acute stages of recovery of memory function over the subsequent four-week period. The profile of memory loss was characterised by impaired performance on both autobiographical and public events memory tasks, in the context of normal anterograde memory test scores. Shrinkage of retrograde amnesia took place over a four-week period, with autobiographical and public events components of retrograde memory recovering at the same rate. We discuss the possible role of unconscious processes underlying the episode, as compared to conscious simulation. We argue that most cases of functional retrograde amnesia may represent a combination of conscious simulation and unconscious processes.     

The dissociation questionnaire (DIS-Q): Development and characteristics of a new self-report questionnaire

A new self-report instrument for the screening of dissociative symptoms, the Dissociation Questionnaire (DIS-Q), has been administered to a representative sample of the Dutch and Flemish population on two occasions (N = 374 and N = 378). Four subscales were found, which together accounted for 77% of the common variance: (1) identity confusion; (2) loss of control over behaviour, thoughts and emotions; (3) amnesia; and (4) absorption. The DIS-Q shows good to excellent internal consistency and test–retest reliability together with good construct and congruent validity. The authors conclude that the DIS-Q might be of great help in the assessment of dissociative symptoms.     

A study of recovery of memory function in a case of witnessed functional retrograde amnesia

We describe a case of transient functional retrograde amnesia that had features of a fugue state, and that was accompanied by loss of personal identity and significant autobiographical amnesia. Uniquely, we were able to gather information from witnesses who observed the episode from its onset, and we were also able to monitor the acute stages of recovery of memory function over the subsequent four-week period. The profile of memory loss was characterised by impaired performance on both autobiographical and public events memory tasks, in the context of normal anterograde memory test scores. Shrinkage of retrograde amnesia took place over a four-week period, with autobiographical and public events components of retrograde memory recovering at the same rate. We discuss the possible role of unconscious processes underlying the episode, as compared to conscious simulation. We argue that most cases of functional retrograde amnesia may represent a combination of conscious simulation and unconscious processes.     

Dissociative Amnesia in Dissociative Disorders and Borderline Personality Disorder: Self-Rating Assessment in a College Population

Dissociative amnesia (DA) among subjects with a dissociative disorder and/or borderline personality disorder (BPD) recruited from a nonclinical population was examined. The Steinberg Dissociative Amnesia Questionnaire (SDAQ), the Childhood Trauma Questionnaire, and the self-report screening tool of the BPD section of the Structured Clinical Interview for DSM–IV(SCID-BPD) were administered to 1,301 college students. A total of 80 participants who were diagnosed with BPD according to the clinician-administered SCID-BPD and 111 nonborderline controls were evaluated using the Structured Clinical Interview for DSM–IV Dissociative Disorders (SCID-D) by a psychiatrist blind to diagnosis and scale scores. Internal consistency analyses and test–retest evaluations suggested that the SDAQ is a reliable instrument for the population studied. Of the participants, 20.6% reported an SDAQ score of 20 or above and impairment by DA. Those who had both dissociative disorder and BPD (n = 78) had the highest SDAQ scores. Both disorders had significant effects on the SCID-D total and amnesia scores in the variance analysis. On SDAQ scores, however, only BPD had this effect. There was a significant interaction between the 2 disorders for the SCID-D total but not for the SDAQ or SCID-D amnesia scores. BPD represented the severity of dissociation and childhood trauma in this study group. However, in contrast to the dissociative disorders, BPD was characterized by better awareness of DA in self-report. The discrepancies between self-report and clinical interview associated with BPD and dissociative disorders are discussed in the context of betrayal theory (J. J. Freyd, 1994) of BPD and perceptual theory (D. B. Beere, 2009) of dissociative disorders.     

Dissociation and Schizophrenia

ABSTRACT

The authors administered the Dissociative Experiences Scale (DES), the Dissociative Disorders Interview Schedule (DDIS), the Scale for the Assessment of Positive Symptoms, and the Scale for Assessment of Negative Symptoms to 60 participants with schizophrenia. Participants were divided into two groups: those with scores below 10 on the DES and no dissociative disorder on the DDIS; and those with scores above 25 on the DES and/or a dissociative disorder on the DDIS. The dissociative participants had more severe trauma histories, more comorbidity and higher scores for both positive and negative symptoms. The authors interpret their findings as evidence in support of a trauma-dissociation subgroup within schizophrenia.     

Ganser Syndrome,Organic Dementia and Hypnosis–A Case Study

ABSTRACT

Ganser Syndrome is a rare and controversial disorder, a form of pseudodementia, which has often been associated with prison environments. It is classified under dissociative disorder, not otherwise specified in the DSM-IV, and as a dissociative disorder with its own code in the ICD-10. In the literature, it has also been described as a psychotic illness, a factitious disorder, a histrionic disorder, and an organic illness. Despite special interest in dissociative disorders, we have diagnosed only one case of Ganser Syndrome during six years in Mental Hospital for Prisoners (that houses) with about 300 treatment periods per year of 3,000 male prisoners from a base population of five million people. While dissociative symptoms were clear, the patient also suffered from progressing organic dementia. Antipsychotic medication had no beneficial effect, but hypnosis clearly ameliorated the patient's symptoms. We conclude that Ganser Syndrome is rare, and may co-occur with organic dementia. The positive effect of hypnosis, apparently here described for the first time, may confirm the dissociative nature of the syndrome.     

Developmental Needs Meeting Strategy: A New Treatment Approach Applied to Dissociative Identity Disorder

ABSTRACT

This article describes the use of the Developmental Needs Meeting Strategy (DNMS) for the treatment of dissociative identity disorder (DID). The DNMS is an ego state therapy which guides a client's own internal resources to meet developmental needs that were not met in childhood. After 17 months of DNMS treatment, a client with DID reported a near total elimination in frequency and severity of symptoms of depression, anxiety and suicidal thoughts, her Trauma Symptom Inventory scores indicated no trauma-related symptoms, and her Multidimensional Inventory of Dissociation scores indicated she no longer met the diagnostic criteria for DID. She was functioning well without any medication. Further research concerning this treatment strategy is warranted.     

The Interrelatedness of Disconnection: The Relationship Between Dissociative Tendencies and Alexithymia

ABSTRACT

This study explored the extent to which alexithymia can be seen as a dissociative phenomenon, examining three facets of dissociation in relationship to the five dimensions of alexithymia. The dissociative facets were: pathological psychoform dissociation (amnesia and derealization/depersonalization), non-pathological psychoform dissociation (absorption) and somatoform dissociation. The alexithymia facets were: difficulties emotionalizing, fantasizing, identifying, verbalizing and analyzing emotions. Various self-report measures were used including the latest developed measure of alexithymia, the Bermond Vorst Alexithymia Questionnaire (BVAQ). Canonical correlation results indicated that somatoform dissociation was the strongest predictor of alexithymia. For younger males, somatoform dissociation was directly related to all facets of alexithymia except for fantasizing. Males with somatoform dissociation, irrespective of age, appeared to have the highest difficulties emotionalizing and identifying emotions. Whilst somatoform and pathological psychoform dissociation were related to difficulties identifying emotions for younger females, no type of dissociation directly influenced the development of any alexithymia dimension for women.     

The Treatment of Dissociative Identity Disorder with Cognitive Analytic Therapy: Experimental Evidence of Sudden Gains

ABSTRACT

The central aim of this study was to assess the effectiveness of cognitive analytic therapy (CAT) with a patient presenting with DID. The methodology employed an A/B single case experimental design with six-months continuous follow-up in seven experimental measures. A and B represent the assessment of seven dissociative experimental variables under two conditions: baseline (A) and treatment (B). Treatment consisted of 24 sessions of CAT with four follow-up sessions, which is standard within the CAT model for personality disorder patients. A battery of measures of general psychological functioning was also completed at assessment, termination, and follow-up. During treatment the intensity of a range of dissociative symptoms was observed to be reduced, with sudden gains evident due to specific CAT interventions in specific dissociative symptoms. The long-term effectiveness of the intervention was established by the illustration of either continued stability or continued improvement in experimental variables across the follow-up period. Analysis of the general measures illustrates clinically significant change across a variety of robust psychometric measures. The study illustrates the utility of single-case approaches with dissociative disorders and the potential for utilizing CAT generally with such presentations.     

Temporal Disintegration in Depersonalization Disorder

ABSTRACT

Distortions of the experience of time are central to some types of dissociative experiences. In this study, we investigated the relationship between a self-report measure of temporal disintegration and symptoms of dissociation in depersonalization disorder (DPD). Fifty-two DPD and thirty non-clinical control participants were administered the Dissociative Experience Scale (DES) and Temporal Integration Inventory (TII). The DPD group had significantly higher TII scores than the control group. Within the DPD group, there was a significant positive correlation between DES total score and TII total score, and between TII-time distinction subscale score and TII-agency subscale score. In the DPD group, TII scores were not associated with age of onset or duration of illness. Of the three dissociative domains of absorption, amnesia, and depersonalization/derealization, only absorption was a significant predictor of TII total and subscale scores by stepwise linear regression analyses. We conclude that the experience of temporal disintegration in DPD is not directly related to the core symptoms of depersonalization/derealization, but exists when the depersonalized experience involves more prominent absorption.     

Measuring Dissociative Experiences in a College Population

Abstract

Because the phenomenon of dissociation has been difficult to define and disentangle from other constructs, further study of the nature of dissociative experiences and the validity of instruments measuring dissociation was conducted. In this study, multiple measures of dissociative experiences were compared with instruments measuring a variety of theoretically related constructs in a sample of 225 college students. The results supported the convergent validity of the measures of dissociative experiences, but they demonstrated relatively poor discriminant validity. However, poor discriminant validity was not specific to dissociation measures and was found for almost all of the constructs studied. This suggests that dissociation can be seen as a distinct, valid, and reliable phenomenon, and that available instruments measure the phenomenon with similar precision as instruments measuring depression, anxiety, borderline, antisocial, and posttraumatic symptoms.