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Memory Loss Without Organic Cause and Dissociative Wandering States, Features and Intervention
Abnormal Psychology · Chapter 15: Dissociative Disorders: Fragmentation of Identity and MemorySection 15.1 · lesson 55 of 9715 min · free with a free account
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In this lesson
Memory loss without organic cause - and the most contested debate in the course.
- Define dissociation and the dissociative continuum
- Describe dissociative amnesia and the fugue specifier
- Explain why exclusion of other causes comes first
- Compare the 2 competing models, and the memory controversy
Transcript
Everything said in the video, section by section (1,876 words). Read along, or search it.
Dissociative Disorders: Fragmentation of Identity and Memory
Dissociative Amnesia and Wandering States
This chapter turns to dissociation, and to conditions that disrupt memory, identity, and the sense of reality. This first section introduces dissociation itself, and then covers memory loss without an organic cause, called dissociative amnesia. We look at why other explanations must always be excluded first. And we lay out the two competing models of dissociation, and the controversy over recovered memories, as fairly as possible.
Read This First
A Contested Area, Handled Carefully
A few things first. This section concerns memory, adverse experience, and how both are assessed. Some viewers may find it personally affecting. If any of it is difficult, it is reasonable to pause. And anyone affected should speak with a qualified professional. This is the most scientifically contested group of conditions in the course. Two principal models are presented, a trauma-related model and a sociocognitive model. The debate between them is unresolved, and this section does not settle it. Adverse and traumatic experiences are referred to at the level of category only. And memory-retrieval techniques are named, but not described in any way that could be attempted. Suggestive retrieval methods have produced confident false memories, and caused documented harm.
Dissociation
When Integration Comes Apart
Dissociation is a disruption in the normally integrated functions of consciousness, memory, identity, emotion, perception, body representation, and sense of self. Ordinary experience is a seamless assembly of those functions. Dissociation is that assembly coming apart, to some degree. Because integration is a matter of degree, dissociation is too. It sits on a continuum. At one end are ordinary experiences most people have regularly. Being absorbed in a book, or arriving somewhere with no memory of the journey. Those need no explanation. Dissociation is not in itself abnormal. What distinguishes the clinical end is involuntariness, persistence, and distress or impairment, not the kind of experience. Each condition in this chapter disrupts a different function. Dissociative amnesia disrupts autobiographical memory. Dissociative identity disorder disrupts identity and the sense of agency. And depersonalization and derealization disrupt the sense of reality.
How Memory Works
Reconstructive, Not Reproductive
None of this can be assessed without understanding how ordinary memory works. Encoding is the initial registration of an experience. It is selective from the start, shaped by attention, significance, and what we already know. Consolidation is the process by which a new memory becomes stable, over hours and longer. It can be disrupted. Retrieval brings stored information back. It is cued, so what is available depends heavily on what is present when we try to remember. Ordinary forgetting is extensive. Most of what is encoded is not retrievable later, and most ordinary days cannot be recovered at all. So any claim that a memory gap is abnormal has to be judged against that large baseline. And here is the most important fact in this section. Memory is reconstructive, not reproductive. Recall is not the replay of a recording. It is a reconstruction, from partial information, general knowledge, expectation, and the context of remembering. That is why memories change over time, and why confidence and accuracy are only loosely related.
Dissociative Amnesia
Autobiographical Memory, Lost
Dissociative amnesia is an inability to recall important autobiographical information, usually of a stressful or traumatic nature. The loss is inconsistent with ordinary forgetting. It causes significant distress or impairment. And it is not due to a substance, or to a neurological or other medical condition. What is lost is information about the person's own life. General knowledge and skills are characteristically preserved. Several types are described. Localized amnesia is loss of all memory for a bounded period, with memory before and after intact. Selective amnesia is loss of some, but not all, events within a period. Generalized amnesia is loss of identity and life history, with skills preserved. It is rare, and dramatic in presentation. Continuous amnesia is failure to retain each new event from a point onward. It is also rare. Notice that the two rare types are exactly the ones where a neurological explanation is most likely, and must be pursued hardest.
Fugue and Course
A Specifier, Not a Separate Diagnosis
Dissociative fugue is apparently purposeful travel, or bewildered wandering, together with amnesia for identity or other personal information. In earlier editions of the classification system, fugue was a separate diagnosis. It is now a specifier of dissociative amnesia. Fugue never occurs without amnesia, so it describes a feature of the amnesia, not a distinct condition. It is rare in clinical practice. Its prominence in the public imagination far exceeds its actual frequency. Onset of dissociative amnesia is characteristically sudden, and often follows an identifiable stressor. Its duration varies widely, from hours to considerably longer. And recovery of memory is common, and frequently spontaneous. That matters for treatment, as we will see.
Figure 15.1.3
The Exclusion Pathway
No dissociative explanation may be applied until other explanations have been worked through. This figure shows the order. Step one is medical and neurological causes. Step two is the effects of substances. Step three asks whether the presentation might be feigned. It is shaded because it differs in kind. It is a specialist, sometimes forensic, judgment, and it is frequently not resolvable. Only at step four is a dissociative formulation considered. And the assessment stops at any step where a cause is found. The order is the point. The dissociative formulation comes last, not first.
Exclusion First
Why the Order Matters
Step one covers head injury, seizure activity, stroke, infection, and metabolic disturbance. Several of these are urgent, and some can closely resemble a dissociative presentation. Step two covers intoxication, withdrawal, and the effects of prescribed and other substances. Substance-related memory loss is far more common than dissociative amnesia. The order matters because a psychological formulation delays finding an urgent medical cause, and is hard to undo once recorded. And the two are not mutually exclusive. A person can have a neurological condition and a dissociative presentation at the same time. Feigned memory loss does occur, mainly in criminal proceedings and compensation claims. Naming those contexts is not an accusation against anyone presenting within them. But no feature reliably distinguishes feigned from genuine memory loss on inspection. A presentation that looks dramatic, inconsistent, or convenient is not thereby feigned. That is the error students most reliably make. The judgment is a specialist task, and a wrong call in either direction does serious damage.
2 Competing Models
Trauma-Related vs. Sociocognitive
Now the two competing models. Both are presented at full strength, and neither is presented as established. The trauma-related model holds that dissociation is a response to overwhelming experience that could not be integrated. Dissociation manages what would otherwise be unmanageable. It cites elevated rates of reported adversity in these populations, and the link between dissociation during an event and later difficulty. Its main objection is that it relies heavily on retrospective report, which is hard to corroborate, and that an association does not establish direction. The sociocognitive model holds that the form a presentation takes is substantially shaped by expectation, suggestion, cultural narrative, and clinical context. The experiences are genuine. The form is learned. It is not a claim that anyone is pretending, and reading it that way is its commonest misunderstanding. It cites historical and cultural variation, and experiments on suggestion. Its main objection is that it struggles to explain presentations that arise without prior exposure. Each objection targets a different weakness, which is why neither model has displaced the other. And they agree on more than the public argument suggests. The distress is real, adverse histories are common, and suggestive practice is harmful. In treatment, both put stabilization first.
The Memory Controversy
Neither Automatic Belief nor Disbelief
The highest stakes are in the memory controversy. The position this course takes is stated plainly. Experimental research has repeatedly shown that people can come to report, with confidence and detail, experiences that did not happen. That follows suggestive questioning, repeated imagining of a possible event, misleading information, or someone in authority asserting that an event occurred. Those reports cannot be told apart from accurate ones by their confidence, detail, or emotion. This is among the most robust findings in cognitive psychology. Hypnosis, guided imagery, and drug-assisted interview are named here, and not described. None reliably recovers accurate memory. Each increases confidence in whatever is produced. Their use to recover memories has caused documented harm, both to people who came to believe false events, and to families accused on that basis. The balanced position is this. A recovered memory is not automatically false. People do forget experiences for long periods and later recall them, sometimes with corroboration. And a recovered memory is not automatically true. What distinguishes them is not in the report itself, but in the conditions that produced it, and any independent corroboration. A clinician's task is to help with the person's distress, not to adjudicate historical fact.
In the Clinic
Avoiding Suggestive Questioning
Avoiding suggestive questioning is a technical skill, with a substantial evidence base. Ask open questions before specific ones. Tell me what you remember yields less material, but more accurate material, than a question that supplies content to confirm. Do not supply content. A question naming an event, a person, or a category of experience gives reconstruction something to work with. Do not repeat a question that has already been answered. Repetition signals that the first answer was wrong, and the second often changes to accommodate that. And do not confirm or reward particular content. Interest, encouragement, and relief all tell the person which answers are wanted. None of this is skepticism about the person. It is what protects their account from being altered by the process of taking it, which is in their interest above anyone's.
Treatment
Memory Recovery Is Not the Goal
Treatment follows four principles, described at the level of principle only. Safety and stabilization come first. Current safety, containing crises, and basic daily functioning. Next, address current stressors. Given how often onset follows one, this is a substantive intervention, not a preliminary. Treat co-occurring depression, anxiety, and post-traumatic presentations, which have established treatments. And phased trauma-focused work only where indicated, by trained clinicians, once stabilization is secure. Assessment draws on a careful history, collateral information with consent, and validated instruments, which are screening tools, not diagnostic tests. Here is the point stated explicitly, because intuition runs the other way. Memory recovery is not the goal of treatment. Recovery is common and often spontaneous. The techniques aimed at it have the poorest evidence and documented harm. And people can improve substantially without the gap ever closing. Where memory does return, it is worked with as it arises, rather than pursued.
2 Composite Cases
Margaret and Vincent
Two composite cases, constructed for instruction, show the contrast. They describe no real people or events. Margaret, thirty-nine, was brought to an emergency department with no memory of the preceding four days, which followed a severely stressful circumstance. Her memory before and after is intact, and her skills and knowledge are unaffected. Medical and neurological causes were assessed and excluded, then substances, then the feigned question. Only then was a dissociative formulation considered. Localized dissociative amnesia. Treatment targets her safety, her circumstances, and her distress. Not the recovery of the four days, which may well return on its own. Vincent, forty-four, presented with brief episodes of missing time, and asked whether he had a dissociative condition. But the episodes were brief and stereotyped, with a sensation beforehand, observed unresponsiveness, and confusion afterward. That prompted urgent neurological referral, which identified a seizure disorder. The pathway stopped at step one. His own suggestion of dissociation carried no diagnostic weight. And a psychological formulation at any point would have delayed treatment of a real neurological condition.
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