Medically Unexpained Symptoms: Amnesia. Michael Kopelman

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1 Medically Unexpained Symptoms: Amnesia Michael Kopelman

2 Psychological forms of Memory Disorders 1. Global: Entire earlier life + personal identity ( self ) e.g. Fugue state - transient Psychogenic focal retrograde amnesia - persisting 2. Situation-specific: Gaps in memory for specific events: e.g. P.T.S.D. (Post-Traumatic Stress Disorder). Victims of crime e.g child sexual abuse, rape Perpetrators of crime e.g homicide

3 Syndrome consisting of: PSYCHOGENIC FUGUE STATE 1. Sudden loss of memory 2. Involving loss of autobiographical memories and the sense of personal identity. 3. Usually associated with a period of wandering. 4. Normally lasts a few hours or days only (up to about 3-4 weeks). 5. Subsequent amnesic gap on recovery for the period of fugue. 6 If the amnesia persists Psychogenic Focal Retrograde Amnesia.

4 PREDISPOSITIONS TO FUGUES 1. Severe precipitating stress - marital - financial - bereavement - offence - war 2. Depressed mood + suicidal ideas 3. Past history of a transient neurological amnesia - head of injury - alcohol blackout - epilepsy (Kopelman, 1987: see also Brain, 2002)

5 Focal Retrograde Amnesia Term coined by Narinder Kapur (1993). Strictly, R.A. in the absence of any anterograde memory loss. Sometimes, initially accompanied by a transient loss of personal identity Unlike fugue state, the memory disorder persists Often (but not always) follows mild concussion or other cerebral event. Usually has been assumed to reflect underlying brain pathology. Brain imaging usually normal. Some reported cases in the literature are not in fact focal Others may well be psychogenic (Kopelman,2000).

6 PSYCHOGENIC FOCAL RETROGRADE AMNESIA

7 COMPARISON and DIFFERENTIATION OF FUGUE / PSYCHOGENIC AMNESIA versus T.G.A. / T.E.A. In both: - Can be preceded by precipitating stress / significant life-event. - Standard investigations (routine EEG, CT, MRI) can be normal. Differentiation: - Loss of personal identity in fugue (never in 114 cases of TGA: Hodges and Ward, 1989). - Repetitive questioning in TGA / TEA (seldom in fugue/psychogenic, where may get la belle indifference ) - Other signs eg. sensorimotor in TEA, wandering in fugue. - Temporal gradients of retrograde amnesia.

8 Make the diagnosis! MANAGEMENT OF SUCH CASES: Treat any underlying depression. Engage the patient sympathetically: no use confronting. Don t rush in with interview under sedation: may be more useful later. But get as much information as possible: subtle detective work. Emphasise disadvantages of amnesia and advantages of confronting underlying problems and offer help with these. Engage family members If amnesia well entrenched / long-standing and family enmeshed in system - very hard to shift.

9 SOCIAL FACTORS & BRAIN SYSTEMS INFLUENCING MEMORY RETRIEVAL & PERSONAL IDENTITY: Kopelman, Brain (2002)

10 SOCIAL FACTORS & BRAIN SYSTEMS INFLUENCING MEMORY RETRIEVAL & PERSONAL IDENTITY: Kopelman, Brain (2002)

11 Anderson et al., 2004 NEUROIMAGING CORRELATES OF MEMORY SUPPRESSION

12 At least TWO ROUTES TO PSYCHOGENIC FOCAL RETROGRADE AMNESIA Head injury /cerebral event (may be mild) Predisposing psychological factors Predisposing psychosocial factors Fugue episode: not treated appropriately / behaviour reinforced (Persisting) Focal Retrograde Amnesia

13 53 cases of Psychogenic Amnesia: preliminary findings Federica Corno, Kim Friedner, Sarah Casey, Neil Harrison, Kate Johnston, Eli Jaldow, Michael Kopelman

14 53 cases of Psychogenic Amnesia: Psychogenic Fugue N=16 Fugue-like Focal retrograde amnesia N=16 Psychogenic focal retrograde amnesia N=16 eg after minor head injury Gaps in memory N=5 Total N=53 Review of case records and neuropsychological test scores

15 Summary In fugue, the memories return normal: personal semantic facts -- near-normal: episodic incidents Lesser (and variable) improvement in F.R.A. -- reversed temporal gradient still Consistent with memory inhibition.

16 Levels of awareness in psychogenic memory loss: - Deliberate or unconscious mechanism?

17 Psychogenic fugue /Focal retrograde amnesia cases: Very difficult / impossible to know the extent to which people are deliberately avoiding painful / difficult memories or the extent to which that this is a truly unconscious process. It s like a box locked away and I don t really want to open it. I put things in boxes. I choose to put them in the back of my mind. I ve always done that. I know the memories are there but (I) cannot get access to them.

18 Conclusions: Psychogenic amnesias can be interpreted at different levels - cognitive, neurophysiological, or psychodynamic. They involve the avoidance of painful / unpleasant memories - may involve varying degrees of conscious awareness. Frontal inhibitory control mechanisms may well be implicated - some functional imaging support for this.

Psychogenic amnesia MEDICOLEGAL

Psychogenic amnesia MEDICOLEGAL 292 PRACTICAL NEUROLOGY MEDICOLEGAL Following a marital crisis, Agatha Christie disappeared from her home in Berkshire on the evening of Friday 3 December 1926. The following morning, her abandoned Morris