Dr Raj Persaud in conversation with Institute of Psychiatry neuropsychiatrist Professor Tony David: Does the latest neuroscience research support Freud?
Neural correlates of recall of life events in conversion disorder.
Aybek S, Nicholson TR, Zelaya F2, O'Daly OG, Craig TJ, David AS, Kanaan RA.
JAMA Psychiatry. 2014 Jan;71(1):52-60. doi: 10.1001/jamapsychiatry.2013.2842.
The paper is a brain imaging investigation of conversion disorder or hysteria. The study probes a neuroscience explanation for conversion symptoms, where a traumatic experience is transformed into a symptom, such as paralysis of a leg.
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A related article which may be of interest originally published in The Huffington Post
The UK media reports that a man with severe amnesia, who still cannot remember even his own name, or where he comes from, but who was discovered in Peterborough, suffering from severe amnesia two months ago, is baffling mental health experts.
They are now appealing to the public for help, in the hope that someone might recognise him.
'Robert' is reportedly suffering from an upsetting and very severe case of amnesia where he cannot recall any details of his life, including his own name, age, where he is from; or his job.
One key clue is that although 'Robert' (a name given to him by hospital staff) speaks English, his accent seems to be eastern European, and he also appears to understand some Lithuanian and Russian.
Similar cases, which could explain this mysterious incident, include a clinical case report, published in 2010, entitled 'Running towards a different life: A case of Dissociative Fugue', by Dr M. Santos and Dr E. Gago from Hospital Magalhães Lemos, Portugal.
The paper, published in the academic journal 'European Psychiatry', explains that the diagnosis of fugue in psychiatry derives from the Latin word for flight-- fugere. Dissociative fugue is an extremely rare psychological condition - the sufferer suddenly and without warning travels far from home, completely unable to recall their past.
These episodes are usually linked, explain Santos and Gago, with severe stress or trauma, such as disasters, losses of loved ones or intolerable burdens at work or home. The amnesia appears completely genuine, with patients displaying no conscious understanding of the psychological reason for the flight. This is usually accompanied by muddles over personal identity and sometimes even complete assumption of a new self.
Santos and Gago report that the journeying associated with 'Dissociative Fugue' can last for several months. Some patients travel thousands of miles from home while in this state.
Another recent study entitled 'Dissociative memory impairments and immigration' also published in 'European Psychiatry' in 2010, by Dr A. Staniloiu, Dr S. Borsutzky and Dr H.J. Markowitsch, suggest there is even a possible link between this kind of psychological problem and immigration.
The authors from the University of Bielefeld, Germany, argue that stressful experiences arising during migration could precipitate these symptoms, though a delayed onset at times occurs reflecting an 'incubation' effect.
Another recent study suggests an effective treatment for 'Dissociative Fugue' which appears to have fallen out of favour recently, which might explain why it may not have been used in more current cases.
The case study entitled 'Amytal interview using intravenous lorazepam in a patient with dissociative fugue', reports a middle-aged white female picked up by emergency medical services in the USA, who could not remember her name, address, and did not know the name of the city.
Lorazepam (a sedative drug a bit like Valium) was given intravenously by the psychiatrist. Although relaxed and sleepy the patient was kept awake by asking her to restate the name of her present in-patient psychiatrist, whom she had become close to. She was led back in fantasy to the gas station where she was picked up and was requested to identify it. Once she successfully named a location from her personal history, she was led to give her name, hometown, birthday, social security number, employment, motherhood and marital status.
The investigation, published in the journal 'General Hospital Psychiatry' in 2006, reports that after she awoke the patient described past and recent sexual assaults. The recent rape was about 10 days before hospitalization. A final diagnosis of Dissociative Fugue was made, and the patient was discharged to outpatient follow-up and the Victims of Violent Crime clinic.
The authors of this paper, Dr Sunday Ilechukwu, from the Ann Arbor Health Care System and Dr Thomas Henry, then at Wayne State University, USA, argue that procedures like this provide the patient with an opportunity for the recall and review of recent emotional crisis, linkage to past trauma and provision of context to current experience.
The authors contend that the simple but critical process of naming her identity under sedation, probably helped her come to terms with the precipitating conflict.
The authors also argue care needs to be taken to minimize the risk of introducing false or distorted memories. The use of video-recorded feedback may also help consolidate gains made during the interview.
The authors conclude that the so-called 'sodium amobarbital' interviews have been in use for about 70 years and refers to the use of an older barbiturate type drug, could be brought back into modern psychiatric practice. The study suggests that such pharmacological-facilitated interviews continue to be a useful procedure with such cases, but that a safer more modern drug, such as lorazepam, can be used as an alternative.
But why should trauma lead some people to forget even who they are? Another study entitled 'A case of persistent retrograde amnesia following a dissociative fugue: Neuropsychological and neurofunctional underpinnings of loss of autobiographical memory and self-awareness', argues that, since memories can be vivid, threatening and painful, they may be removed from consciousness as a way of protecting the self-concept.
The authors, Kristina Hennig-Fast, Franziska Meister , Thomas Frodl , Anna Beraldi , Frank Padberg, Rolf Engel , Maximilian Reiser , Hans-Jürgen Möller and Thomas Meindl, brain scanned an individual suffering from these fugue like symptoms. The results highlighted the key role of visual and emotional properties of autobiographical memory in the maintenance of this kind of amnesia.
The study published in the journal 'Neuropsychologia', found reduced neural activity within the brain network producing autobiographical memory retrieval. The authors based at Ludwig-Maximilians-University, Munich, Germany, posit a protective defence mechanism caused by neuronal inhibition that serves to prevent an overﬂow of intensive aversive emotions.
The authors suggest that visual imagery plays a central role in the recall of autobiographical memories. Defects in the way the brain visually processes memory which might help explain puzzling phenomena such as Dissociative Fugue.
Their patient regained only three remote and strongly negative childhood memories dating from the time before the dissociative fugue. All were highly negative, vivid and fragmented episodes comparable to frozen images, e.g. of the cofﬁn at his grandfather's funeral.
It must surely be one of the most disturbing experiences of all, not to recall anything of our past except alarming fragments. Psychiatric investigation of this kind of suffering is helping to reveal how the normal sense of personal identity is achieved. Visual aspects of memory may be more important than we previously realised. The fact that it can be lost suggests we shouldn't take it for granted.
Trying to uncover who 'Robert' really is, could also help us find ourselves.
Raj Persaud is joint podcast editor for the Royal College of Psychiatrists and also now has a free app on iTunes and google play store entitled 'Raj Persaud in conversation', which includes a lot of free information on the latest research findings in mental health, plus interviews with top experts from around the world.