Journal of Trauma & Dissociation, 16:100–113, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1529-9732 print/1529-9740 online DOI: 10.1080/15299732.2014.969469

A Case of Dissociative Fugue and General Amnesia with an 11-Year Follow-Up EDWARD HELMES, PhD, JULIE-MAY BROWN, DPsych, and LINDA ELLIOTT, BA (Hons) Department of Psychology, James Cook University, Townsville, Australia

Dissociative fugue refers to loss of personal identity, often with the associated loss of memories of events (general amnesia). Here we report on the psychological assessment of a 54-year-old woman with loss of identity and memories of 33 years of her life attributed to dissociative fugue, along with a follow-up 11 years later. Significant levels of personal injury and stress preceded the onset of the amnesia. A detailed neuropsychological assessment was completed at a university psychology clinic, with a follow-up assessment there about 11 years later with an intent to determine whether changes in her cognitive status were associated with better recall of her life and with her emotional state. Psychomotor slowing and low scores on measures of attention and both verbal and visual memory were present initially, along with significant psychological distress associated with the diagnosis of posttraumatic stress disorder. Although memories of her life had not returned by follow-up, distress had abated and memory test scores had improved. The passage of time and a better emotional state did not lead to recovery of lost memories. Contrary to expectations, performance on tests of executive functions was good on both occasions. Multiple stressful events are attributed as having a role in maintaining the loss of memories. KEYWORDS amnesia, dissociation, memory, dissociative fugue

Received 12 January 2014; accepted 19 August 2014. Address correspondence to Edward Helmes, PhD, Department of Psychology, James Cook University, Townsville, Qld 4811, Australia. E-mail: [email protected] 100

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Dissociation is relatively common as a symptom and can be controversial as a diagnosis (Ross, 1996, 2009). The diagnostic category of dissociative disorders includes six diagnostic labels (American Psychiatric Association, 2013) and occurs in about 10% of cases in psychiatric settings (Sar, 2011). In dissociative amnesia, there is a loss of memory for “important autobiographical information . . . that is inconsistent with ordinary forgetting” (American Psychiatric Association, 2013, p. 298). In dissociative fugue, there is also “apparently purposeful travel or bewildered wandering that is associated with amnesia for identity” (American Psychiatric Association, 2013, p. 298). Dissociative or psychogenic fugue is the more inclusive term for the loss of identity as well as memories for events, and it is often comorbid with affective and anxiety disorders (Loewenstein, 1996). The definition of psychogenic or dissociative fugue involves some debate as to what aspects of altered memory functions are widely observed to be affected and which are necessary for the diagnosis of the disorder (Kihlstrom & Schacter, 2005). Some writers on the topic include the loss of semantic and procedural memory (e.g., writing) within the definition. Van der Hart and Nijenhuis (2001) summarized 32 cases dating from the early 20th century and noted that altered performance in cognitive domains in addition to memory has often been observed. Stressful events are implicated in the onset of most cases, with evidence of brain trauma in only some of the cases in the literature. Kihlstrom (2005) summarized the evidence for stress or psychological trauma as a cause for dissociation and argued that it is not as unambiguous as assumed by clinicians, whereas physical damage to the brain is widely accepted as a cause of physiological generalized amnesia. Comparatively few cases document factors associated with the recovery of lost memories. Dissociation has long attracted interest from both theoretical and clinical perspectives. Interpretation of the older literature is complicated by the then-common psychoanalytic orientation of practitioners that emphasized intrapsychic processes in dissociative disorders (Edelson, 1990; Loewenstein, 1996). Kihlstrom and Schacter (2005) discussed variations of case presentations and diagnostic criteria, whereas Dalenberg et al. (2012) reviewed the evidence for trauma and the development of dissociation. The more recent literature presents results of positron emission tomography and functional magnetic resonance imaging scans. For example, Brand et al. (2009) presented 14 cases of dissociative amnesia with positron emission tomography scans that showed evidence of lowered neural activity, especially in the right inferior lateral prefrontal cortex. In this context, Staniloiu, Markowitsch, and Brand (2010) argued that both dissociative fugue and amnesia involve changes in self-consciousness, emotion processing, and executive functions. Here we present a case of dissociative memory disorder with a detailed assessment of memory, psychosocial, emotional, and executive functions that address this issue. We also

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provide data on the same case from a follow-up assessment almost 11 years after the original evaluation that inform the current data on the recovery from dissociative fugue. As part of the evaluation, we address the issue of the relationship of symptoms of lost memories to emotional distress and the association of executive functions to the amnesia. If dissociative amnesia is protective against unbearable psychological pain (Loewenstein, 1996), then reduced distress should be associated with return of memories.

HISTORY The person at the center of this report is a 54-year-old married woman with two adult children who was seen through a university psychology clinic. Ms. X’s initial appearance at a mental health service was shortly after she experienced the sudden onset of retrograde amnesia for the previous 33 years and for her own current identity. She reportedly was unable to recall memories from the age of 21 years. She was found by police driving near a railway crossing in the rural community in which she lived, apparently searching for her childhood home, which was actually in another community several hundred kilometers away. According to reports at the time, she did not appear to recognize either her husband or her children, nor did she recognize her own photo on her driver’s license, and she believed she was 18. Developmentally speaking, she reportedly had a normal birth and early developmental milestones. Ms. X attended public school up to the age of 14, then attended boarding school to the end of Grade 10. No records of objective tests during her school years were available. Her childhood included a period of sexual abuse by family members and the deaths of two close friends in diving accidents. She worked in a variety of positions immediately after leaving school, the longest position being for 4 years as a radio operator for a trucking company. Her performance at work was good, and she moved to positions of increased responsibility and independence as her work experience increased. For example, she began working for a real estate agent, becoming self-employed some years later as a real estate broker. Difficulties with this business and further complications in her personal life led to severe financial problems resulting in bankruptcy near the time of onset of the amnesia. In terms of her adult and family relationships, the father of her first daughter died prior to their official marriage and the birth of his daughter. Her first marriage lasted 11 years, with her first daughter being born during this relationship, which also involved the four children of her husband’s first marriage. This husband reportedly was physically and emotionally abusive and also had several extramarital affairs during their marriage. Incidents of domestic violence in her first marriage contributed to a divorce in the 1980s,

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and there is no continuing relationship. Five years after the divorce she married her current husband, with whom she apparently has a stable and loving relationship, although he reportedly moved out of the house temporarily in order to give Ms. X additional time to recover. As for her physical health, she experienced an episode of uterine cancer for which she received chemotherapy in the early 1970s. Somewhat later she had a gallbladder removal, followed some years further on by a hysterectomy to relieve ovarian cysts and bleeding. Two years after that surgery she was diagnosed with diabetes, and at the time of the initial assessment she was also diagnosed with hypertension, elevated cholesterol levels, and gastroesophageal reflux. Shortly before the incident in question, she had been hospitalized for pneumonia. Her living situation at the time of amnesia onset had its stressful relationships. Her older daughter lived next door with her two young children, but the relationship with this daughter apparently was quite stressful because the daughter’s husband’s family owned the house in which Ms. X lived together with her younger unmarried daughter, with whom she did have a positive relationship. Her history revealed a number of other events that created additional stress prior to her loss of memories. The closure of her real estate business was associated with funds missing from a trust account and with the bankruptcy that was pending at the time of the loss of memory. Over a period of 6 years preceding the critical incident, she lost seven close acquaintances and family members, including the suicide of a family member, and experienced two serious automobile accidents. According to the client and her husband, her current problems began some 6 months prior to her memory loss following a motor vehicle accident in which another vehicle struck the front driver’s side of her own vehicle. There was no reported loss of consciousness in the accident, nor was she taken to hospital. Since that accident she had been experiencing severe headaches radiating from the right top portion of her head to behind her left eye, and reports from her partner were of a gradual decline in her memory from the time of the accident. These headaches reportedly differed from her previous experience of headaches, but she was not taking any prescription medication for them. Following the incident in which she was found by police and taken to the local hospital, she was referred from the local hospital to the regional hospital psychiatric services, where she was admitted and stayed 3 weeks. Following inpatient discharge, she was referred back to the local community mental health services. There were no reports from either facility of a formal diagnostic interview for a dissociative disorder. The initial cause for referral for neuropsychological assessment was a request from the mental health service for the evaluation of functional abilities in order to determine her eligibility for a disability pension.

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INITIAL EVALUATION Ms. X was first formally assessed in depth at the regional hospital during her inpatient admission. Investigations there revealed a Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975) score of 25/30. A SPECT (Single Photon Emission Computed Tomography) image obtained after her discharge showed “borderline reduction in cerebral perfusion involving the left cerebral hemisphere particularly the temporal lobe and frontal pole, with associated cross cerebellar diaschisis.” A subsequent magnetic resonance imaging scan did not identify any specific abnormalities. The staff psychiatrist diagnosed amnestic/dissociative disorder. Psychological investigations suggested a moderate to severe degree of depression, moderate levels of hopelessness, and a severe level of anxiety. Information was also obtained from Ms. X’s daughter and husband and two family friends. These reports suggested no history of episodes of depression, mania, or psychosis that predated the amnesia. There was no formal contact with mental health services until after the onset of amnesia. None of the admission and discharge documentation from the various services with which she was in contact mentioned her using a different name, having an altered personality, or showing other signs of dissociative identity disorder. A second consultant psychiatrist at the regional hospital confirmed the initial diagnosis of amnestic/dissociative disorder for the discharge diagnosis.

INITIAL NEUROPSYCHOLOGICAL ASSESSMENT At the time of the initial evaluation at the university psychology clinic, Ms. X was experiencing severe headaches, insomnia, and panic attacks. She had difficulty falling asleep and staying asleep, and she often awoke with nightmares that she was unable to recall. Since the critical incident she had recurrent suicidal thoughts several times a day, but these had reduced in frequency to being weekly by the time of the assessment. She was relearning practical skills such as how to cook; shop; drive; and operate equipment such as dishwashers, microwave ovens, automatic teller machines, and computers. She was also reacquainting herself with family members and friends, including her husband. It is notable that she could not recall any aspects of any relationships that occurred during the previous 33 years, including her first marriage. She also reported periods of confusion and disorientation in which she would forget her immediate goals, such as the sequence of activities required to prepare a meal. In the initial assessment, Ms. X completed the Wechsler Adult Intelligence Scale–III (Wechsler, 1997a), the Wechsler Memory Scale–III (Wechsler, 1997b), the California Verbal Learning Test–2 (CVLT-2; Delis, Kramer, Kaplan, & Ober, 2000), the Tower of London Test (Delis, Kaplan, & Kramer, 2001), the Rey Complex Figure Test (RCFT; Meyers & Meyers,

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1995), a verbal fluency test (Spreen & Benton, 1977), the Test of Everyday Attention (TEA; Robertson, Ward, Ridgeway, & Nimmo-Smith, 1994), the Kaplan variant of the Stroop Test (Stroop, 1935), and the Trail Making Test for the neuropsychological component. To cover other relevant areas, she completed the Posttraumatic Stress Diagnostic Scale (Foa, 1995), Personality Assessment Inventory (PAI; Morey, 1991), Depression Anxiety Stress Scales (DASS; Lovibond & Lovibond, 1995), Beck Depression Inventory–2 (Beck, Steer, & Brown, 2000), and Questionnaire of Experiences of Dissociation (QED; Riley, 1988). Norms for 50-year-old females were taken from Mitrushina, Boone, Razani, and D’Elia (2005) where appropriate.

ASSESSMENT RESULTS In terms of general overall cognitive ability, Ms. X had an overall Full Scale IQ score that placed her at the 19th percentile in comparison to individuals her own age (Full Scale IQ = 79). Her scores on the various verbal subtests were primarily in the average range, with the exception of low scores on Digit Span and Letter–Number Sequencing. Her scores on the performance tests were within the average range for tests requiring the ability to manipulate objects and to arrange them according to patterns to assemble objects, but she showed particularly low scores on two speeded tests, Symbol Search and Digit Symbol-Coding (two measures on the Processing Speed Index), and on Digit Span. Ms. X consistently scored below average on subtests of the Wechsler Memory Scale–III, with her best scores being in the low average range for the Auditory Immediate and Auditory Delayed Indices. Her scores for measures of working memory and recall of visual material were notably poor. She exhibited an inverted-U learning curve over the five trials of the CVLT-2, with performance on Trial 5 only marginally better than on Trial 1, resulting in a learning slope 2 SD below the norm group. Her recognition memory was marked by a bias to say “no” for yes/no tasks. Her accuracy (hit rate) was below the cutoff (Millis, 2008) for suspected incomplete effort for the yes/no task. In terms of visual memory, her immediate recall of the Rey complex figure was at the 4th percentile, and delayed recall and recognition trials were both below the first percentile. Her performance on the TEA was uniformly poor, with her best score at about the 25th percentile on the two Elevator Counting subtests. Performance on the other subtests was consistently at or below the 10th percentile. Performance on timed tests was consistently slow. Her time was below the 1st percentile on Trails A but at the 27th percentile on Trails B. Scores on all trials of the Stroop task were slow, with all at least 4 SD below the mean for women her age. She did show the normal interference effect. Verbal

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fluency was 1.75 SD below the mean for the phonemic (letter) ‘FAS’ cues but 1.2 SD above the mean for the animal prompt. Performance on the Tower Test was at a T score within the average range for her age. Her PAI profile showed a T score of 70 on the Negative Impression Management scale. Such scores suggest some exaggeration of distress, with the scores on the remaining clinical scales not being exaggerated to the point of suspect validity (Morey, 1996, p. 113). The PAI profile showed elevations over T70 for the scales measuring anxiety, stress, and suicidal thoughts. Physiological symptoms of anxiety were prominent, along with disturbed and dysfunctional thought patterns. A similar pattern of very high levels of anxiety was reported on the DASS, with severe levels of depression reported on the Beck scale and moderate levels on the DASS Depression scale. Her reported symptoms on Foa’s (1995) posttraumatic stress disorder (PTSD) measure met all of the criteria for that disorder, with her identifying the childhood sexual abuse as the index event. Her score on the QED was above the average score reported by Riley by 1.7 SD units.

FOLLOW-UP ASSESSMENT During the follow-up assessment 11 years later, Ms. X completed the CVLT2, Rey Complex Figure Test, Beck Depression Inventory–2, Beck Anxiety Inventory (Beck, Epstein, Brown, & Steer, 1988), TEA, Tower Test, and PTSD Checklist–Civilian Version (Weathers, Litz, Herman, Huska, & Keane, 1993). IQ testing was not repeated because of the introduction of a new edition in the intervening years that would have introduced additional error into any comparisons.

RESULTS At the follow-up assessment, Ms. X reported having a stroke about 1 year following the initial assessment that left her with some residual pain and weakness on her right side. She also reported a substantial reduction in the frequency of panic attacks, with the most recent being 6 months previous. Her insomnia was largely resolved, and she was on a stable medication regime for her diabetes, high cholesterol, and hypertension. She also reported that relationships in the family were much better and more amicable. At follow-up, Ms. X reported that she remained amnesic for events in her life from ages 21 to 54 but retained memories from before and after that period. She had continued monthly sessions with a local psychologist for about a year after her discharge from the regional hospital and had adopted

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some of the strategies for dealing with her memory problems that had been recommended in the initial report. Her scores on the CVLT-2 and Rey Complex Figure memory tests were almost uniformly better than on her initial assessment, as can be seen in Table 1. The hit rate for the yes/no CVLT-2 recognition task was not consistent with incomplete effort (Millis, 2008). Her scores on the TEA were also much improved, with the majority of subtests well above the 10th percentile (see Table 1). Using a different variant of the Tower of London Test on follow-up, her score improved to above average. Her scores on the measures TABLE 1 Scores and Interpretive Values for Tests Administered at Both the Initial and FollowUp Assessments Initial assessment Measure CVLT-2 Trial 1 Trial 5 Total 1–5 Trial 6 1–5 slope Short delay free recall Long delay yes/no recognition Long delay forced-choice recognition Rey Complex Figure Test Immediate Delay Recognition Test of Everyday Attention Map Search 2 Elevator Counting Elevator Counting: Distraction Visual Elevator: Accuracy Visual Elevator: Time Elevator Counting: Reversal Telephone Search Telephone Search: Counting Lottery BDI-2 QED PTSD diagnosis

Raw score

Interpretation

Follow-up assessment Raw score

Interpretation

5 7 38 4 0.4 5 7

−1 SD −2.5 SD T 37 −1 SD −2 SD −2 SD −4.5 SD

6 11 50 4 1.1 9 12

0 SD −0.5 SD T 54 −1 SD −0.5 SD 0 SD −2.0 SD

10

−4.5 SD

13

−4.5 SD

12 10.5 6

4th percentile

A case of dissociative fugue and general amnesia with an 11-year follow-up.

Dissociative fugue refers to loss of personal identity, often with the associated loss of memories of events (general amnesia). Here we report on the ...
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