Therapist concerns and process issues in grappling with functional autobiographical amnesia.

Dissociative amnesia is relatively rare form of the dissociative disorder. This paper aims at describing the salient features of a case of functional autobiographical amnesia in a young adult and the approach adopted in the psychological management of this case. The case highlights concerns of the therapist at various stages of the therapy process.

INTRODUCTION

Being able to remember is a critical ability that provides coherence and meaning to our life and pervades all aspects of our day to day functioning. Memory disturbances are commonly reported complaints in the clinical practice though these can be very heterogeneous in nature, severity, and etiology. Dissociative amnesia refers to autobiographical memory loss often involving stressful/traumatic life events wherein organic etiology cannot explain the memory deficit and psychological factors can be implicated in the amnesia. Amongst the various kinds of dissociative disorders, dissociative motor disorders and dissociative convulsions are considered more common[1] and dissociative amnesia is described as rarer in occurrence.[2] In this paper, we report a case of functional autobiographical amnesia. The paper focuses on describing the salient features of amnesia in this case and the approach adopted in the psychological management of this case. The concerns of the therapist at various stages of the therapy process are also highlighted.

CASE REPORT

Ms. A, 20-year-old unmarried undergraduate student hailing from an urban middle socio-economic status background was brought by the parents with the complaints of sudden loss of personal memory from the previous 2 weeks. A detail evaluation revealed the following features of this case.

The onset was acute; the parents reported that memory loss was noticed immediately after Ms. A woke up from sleep one morning. The parents did not report any major event in the preceding 1 month period. Following further inquiry, it was reported that a relatively minor event (an argument with a sibling) had happened on the previous evening. During this argument, the sibling had reportedly commented that the mother's health was being affected due to Ms. A's behavior (talking with friends for a long time over the phone, after coming home from college).

Ms. A was able to recognize her immediate family members which included three younger siblings but was unable to recognize her relatives, friends, and school name, class in which she was studying, her study materials and personal belongings. Ms. A reported no memory of events prior to 2 weeks in her life and this included her inability to recollect her early school days. There was some patchy and vague recollection of the past experiences; however, this was for less than a handful of facts. The parents also reported that she was not being able to remember how to do tasks that she had learnt earlier such as painting, doing arithmetic sums etc. On the whole, there was a loss of autobiographical (episodic) memory for the past several years, as well as some loss of semantic, and procedural memory. However, Ms. A did not exhibit significant anterograde amnesia.

In addition, Ms. A was observed (and also reported) to be behaving in a childlike fashion in terms of her manner of talking and her demanding behaviors as well as her interests and play behaviors. Although Ms. A repeatedly reported inability to execute tasks or recollect events in her life, she did not express high distress about this. She reported that she was being informed about past events as well as other facts of her life by others. However, she could not remember them herself or experience these as her own memories.

The family members were extremely distressed as they felt that Ms. A was suffering from a major neurological problem from which she might never recover. They were coping with the situation by treating Ms. A with a lot of overt attention and affection, prompting/helping in carrying out chores, narrating various life events and experiences and showing photographs etc., to help her regain lost memories.

After a thorough evaluation and ruling out history suggestive of organic causes, a diagnosis of dissociative amnesia was made and the case was taken up for psychological management.

Therapy stages and process

Initial phase

The initial phase in therapy revolved around sessions with the family members. These were aimed at exploring potential sources of stress in the client as well as in the family as such. The sessions were also aimed at conveying the nature of the diagnosis, providing emotional support and hope building in addition to helping them to change their behaviors, which seemed to be reinforcing the maintenance of Ms. A's regressive behaviors. These sessions resulted in additional information about Ms. A's temperament and personal history. She was described to be a sensitive child. The parents also reported history of her having gone away from home and staying in a women's hostel for a period of about 20 days (6 months ago). The matter was discussed amongst the family members and Ms. A at that point reported that she had gone away as she was upset with the parents for “not loving her” or “understanding her.” Her parents assured her of their care and concern and persuaded her to come back home. This entire episode was considered by the parents as a past event that did not have any apparent connection to the sudden onset of amnesia that occurred a few months later. The parents were explained about the possible psychogenic nature of the amnesia.

The therapist, while validating their distress and empathizing with them about their sense of social embarrassment about the past episode, discussed alternate ways in which they could respond to the current problem. They were advised to try minimizing excessive emotional expression about the amnesia in the client's presence and attempt normalizing of family routines and their own behaviors to the extent possible. They were also advised to use minimal verbal prompts to guide her actions and encourage her to engage in small tasks appropriate for her age as well as reinforce her for doing so (e.g. treating the younger siblings as younger rather than of the same age, helping in house hold chores etc.). The family members had completely shut off Ms. A's interactions with distant relatives, friends and acquaintances and avoided taking her out for any function or social occasion. This was due to the fear of embarrassment about her inability to remember significant others or behave in age appropriate fashion. The parents were advised to try prompting Ms. A in advance in a non-obtrusive manner and take her to social gatherings/for general outings etc., while making such outings contingent on her age appropriate behavior. Supportive work with parents and coaching them in the use of a behavioral approach significantly helped in normalization of interactions and activities as well as a reduction in regressive behaviors. Over time, there was a decrease in the prompts required to complete day-to-day tasks too.

The initial sessions with the client were aimed at building a therapeutic alliance. However, this was one of the major challenges as it paradoxically required the therapist to intermittently connect to Ms. A by (initially) behaving with her “as though” she was a child and not a young adult. This stance was a temporary one within sessions, during which the therapist, at appropriate junctures attempted to convey to the client the context of their interaction, the distress of the family members, and that the therapist would attempt to help her regain her lost memories. It was also conveyed that her problems were understood as possibly resulting from difficult/painful experiences in life. On the whole, the therapist attempted to connect to the “child-self” while gradually introducing content that aimed at drawing out the “adult-self” of the client in conversation. Here, the term child-self and adult self are referred to denote the states during which the client behaved in a regressive fashion and those brief periods during which her behavior was more age appropriate respectively. During both the states, the client reported the same problems with her memory. Whenever, she was suggested to make efforts to recall something from the past, Ms. A. reported experiencing headache while making an effort to do so.

During this phase, Ms. A was reinforced by the therapist (as well as the parents) for gradually reducing engagement in regressive/child-like behaviors.

Middle phase

The therapist repeatedly conveyed to Ms. A that slowly there would be a recovery of her memory and also that he would support the process of dealing with the difficulties that may be experienced as a consequence of recollecting any painful events/issues in her life. As the client reported a lot of strain and headache while trying to remember past events, it was planned to use abdominal breathing technique to induce a relaxed state followed by a guided imagery procedure for facilitating recovery of memories. A script was prepared that included a few factual details of Ms. A's life in a chronological sequence from early school years onwards (e.g. name of the primary school, outing with the family etc.). Only a few general factual details were included and mention of any difficult/stressful past events was avoided. The guided imagery procedure was conducted in a story like narrative format that encouraged the client to imagine undertaking a journey and (re-) discovering some experiences of her life. It also incorporated suggestions that Ms. A would be able to recollect many more events and experiences in her life outside the sessions, beyond what was being narrated. The entire process was aimed at helping Ms. A to maintain a relaxed state while exposing herself gradually to some of the factual details of her past. This allowed the availability of clues for further recovery of memories while providing a safe therapeutic setting to re-own the memories being narrated. This procedure continued for three sessions. The client was co-operative for the same. Though, she did not report a dramatic recovery of her memories, over time her complaints about not being able to remember decreased, and she was able to recollect several personal facts across sessions.

Late phase

Her behaviors became more and more age appropriate during the sessions. She also became more amenable to discuss some of the difficult incidents in her life when prompted by the therapist about the same. She mentioned a few other experiences in bits and pieces that she did not feel ready to discuss with the parents at that point of time. These involved her fears about her future. The prospect of disclosing her fears with the parents was discussed in the session, in order to mobilize their support for her. However, Ms. A was reluctant to discuss the specific matters and hence her concerns were discussed with her parents in general terms without divulging very specific details and they were guided regarding ways of providing her the support she would require. Ms. A repeatedly indicated that she had started understanding how to handle the issues related to her difficult experiences and beyond a point she expressed unwillingness to talk about these in sessions. The client was assured about the availability of a safe setting to disclose and discuss painful material when she chose to do so and at the pace at which she wanted to do so. The focus then shifted to discussion regarding resuming studies, and regaining a sense of confidence by being meaningfully engaged. The client re started going to college, and also joined a few short-term courses. The quality of relationship with the parents improved significantly, who were able to manage their anxieties and reinforce the gains made over time in terms of symptom reduction as well as functional recovery. The client occasionally complained of headache, which she attributed to thinking about the stressful experiences in the past and its possible repercussions on the future. However, she was able to deal with the same through engaging in therapy sessions (on once a month basis), as well as dialog with the parents. The follow-up/booster sessions were gradually spaced out to once in 3-4 months.

DISCUSSION

The case illustrates the occurrence and gradual dissolution of functional autobiographic amnesia in an adolescent. In the present case, the onset of amnesia was sudden and the precipitating event was objectively a minor one; however, it may have triggered anxieties related to various other events that had occurred during the previous 1 year. Available literature too suggests that in some cases, functional amnesia may result from an accumulation of a series of events and experiences over time rather than from a single major proximal event, as objectively defined.[3] The period for which the client was amnesic was difficult to determine accurately as it extended for several years and included the client's childhood. This case is more similar to general or generalized amnesia rather than amnesia for a circumscribed period surrounding a traumatic event. Moreover, as noted earlier, the type of amnesia involved not just episodic memory but also involved some extent of difficulties with semantic and procedural memory. This is in keeping with other case reports, which suggest that varying kinds and degree of amnestic losses may be involved in the functional amnesia.[4] In the present case too, the procedural memory impairments resolved very rapidly. Unlike organic amnesia, there was no temporal gradient evident in terms of more dense memory loss for recent episodes and relatively more persevered memories of the remote past.[5]

The management of the case entailed a few challenges. The first challenge involved being open to the idea of building a therapeutic alliance with the client at her level when she was exhibited regressed behaviors and at the same time intermittently using therapeutic opportunities to relate to her age appropriate self. In the middle and later phases, the biggest challenge for the therapist was to withhold/keep aside the natural inclination to explore/discover the nature of stressful experiences underlying the amnesia and focus on strengthening the client's internal and external resources for improving functioning and handling current life demands.

Towards the later phase of therapy, the therapist had to accept the client's decision to deal with certain aspects of her past experiences by herself while supporting her in normalization of day to day life and moving ahead in terms of learning new skills and being meaningfully engaged. The utility of this stance can be debated in as much as the trauma and the repercussions of the traumatic experiences could not be addressed fully in therapy and there remained a sense of uncertainty regarding its long-term implications on the client's mental health. However, the therapeutic stance was guided by the assumption that clients need to be given the space to decide what they wish to talk about and when while the therapist can help them reflect as clearly as possible on their choices and decisions. This stance seemed especially, appropriate for the index client in the background of consistent symptomatic and the functional recovery as well as some indication that the she was attempting to process and resolve her life events/experiences using her own internal resources. The client has been symptom free and functioning well at follow-up 1½ year subsequent to her initial contact.