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Dissociative Amnesia and DSM-IV-TR Cluster C Personality Traits

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CASE N째1

Case n째1 The patient was a 19-year-old male military service member who was hospitalized on two separate occasions after he was found to have toxic salicylate levels. Both times, he presented to a primary care clinic with complaints of

nausea, disequilibrium,

Laboratory evaluations revealed

labored breathing, dia-

toxic salicylate levels, but the pa-

phoresis, and hemeteme-

tient denied ingesting any medi-

sis.

cation,

HE denied memory loss, and was without psychiatric com4


CASE N째1

plaint. He was admitted to the psychiatric ward, where he was noted to be polite but anxious, speaking with a stutter, appearing inhibited in the milieu, and avoiding most interpersonal contact.

He continued to deny ingestion of aspirin, he then also denied ingesting any medication, despite physical signs and laboratory evidence of overdose. At the time of his second hospitalization, he reported finding an 5


CASE N°1

empty aspirin bottle in his room. He was also more forthcoming with some of his current stressors. He shared that

he had joined the military after September 11 and the fantasy of serving with

with a sense of

“heroes.” He had not anticipated

patriotism

the difficulty he would have separating from his family, nor the disappointment he would experience upon finding that his military peers did not meet his expectations of the idealized hero. He disclosed that previously,

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CASE N째1

he had witnessed an assault on his roommate by other service members, who had then made threats against his life. Poisoning was considered, but was deemed unlikely since the perpetrators were in jail pending trial. A benzodiazepine-assisted interview was conducted, but it failed to elicit memories of either ingestion. The patient underwent psychological testing to assist in diagnosis. The Minnesota Multiphasic Personality Inventory, Second Edition (MMPI-2) indicated 7


CASE N°1

that he was experiencing a significant level of distress. The validity profile suggested over-reporting of symptoms, which was thought to be related to an inability to express his needs in a more sophisticated manner,

his brain erasing what HE couldn’t handle The Structured Interview of Reported Symptoms (SIRS) suggested that there was a low probability that he was feigning symptoms, and the most prominent theme in the patient’s Rotter Incomplete Sentence Blank (RISB) involved feelings of inter8


CASE N째1

personal rejection and alienation. The patient was discharged from the inpatient psychiatric ward with an

Axis I diagnosis of dissociative amnesia, an inability to recall per-

and an Axis II diagnosis of avoi-

sonal information, usually

dant personality disorder. He re-

of a traumatic or stressful

mained unable to recall details of

nature,

the ingestions while hospitalized and in the months that followed, and was eventually discharged from active duty service with no further psychiatric sequelae.

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Case 2 The second patient was a 24-yearold man who suffered an episode of

global amnesia while driving

Authorities found him sitting at a gas station in a disheveled, exhausted, and disoriented state. They brought him to the nearest hospital, where he was identified by means of his military identification (“dog�) tags, and was admitted for evaluation. At the hospital, he underwent a comprehensive medical workup that was completely normal. His medical team consulted psy10


chiatry for further diagnostic assistance. Following a thorough review of his history, including collateral data from his friends and family,

HE WAS DIAGNOSED WITH DISSOCIATIVE AMNESIA and was transferred to the inpatient psychiatry ward for treatment. In the psychiatric milieu, he was cooperative and pleasant, but

had no memory of his life or the events 11


CASE N°2

leading to his hospitalization. He could identify his emotional states, including “scared,” “frustrated,” “worn out,” and “a little sad,”

but had no idea why he was experiencing such feelings. He received hypnosis two to three times a week in addition to the standard milieu therapies, and regained most of his memory over the course of three weeks. Collateral information from his friends and family revealed him to be “easygoing,” “hardworking,” and “a nice guy to be around.” 12


CASE N째2

They reported that he liked to please others and was very uncomfortable with confrontation or interpersonal conflict, traits that also became evident in the psychiatric ward milieu. It was eventually discovered that these aspects of his personality greatly contributed to the events leading up to his hospitalization. The patient had recently completed Army basic training. While in training,

he had left his personal possessions to his girlfriend, 13


CASE N°2

who took unfair advantage of him. He was angry and had taken leave

She depleted his bank

to find her, break up with her, and

account, took his car and

reclaim his possessions. However,

relocated.

when he found her, she was very apologetic and affectionate. She suggested they get married, citing concerns about her children’s health and her lack of medical insurance. The patient recalled having reservations about marriage, but he felt guilty about wanting to end the relationship in light of the children’s medical problems. Over the course of the evening, they became intimate and

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CASE N°2

she accidently called him by another man’s name Feeling devastated by this event, the patient went to a park, where he spent the remainder of the night contemplating whether or not he should take his life. The next morning, he began the drive back to his duty station. Along the way, he ruminated over the events of the previous evening and experienced conflicting feelings of guilt and rage. For reasons he

for reasons he could not explain he pulled over to the side of the 15


CASE N°2

road and started walking toward what he described as “home,” the town where his girlfriend lived.

the gas station where he was THEN found was 12 miles away from his car Despite

comprehensive

milieu

treatment, he never fully regained

HE NEVER REGAINED THE MEMORIES OF THAT DAY Following discharge from the hospital, he participated in weekly insight-oriented

psychotherapy

sessions. Additional suggestions 16


CASE N°2

of character pathology became increasingly evident. Psychological testing supported

the diagnosis of dissociative amnesia and suggested “dependent and passive-aggressive

[personality]

features.” Additionally, the examining

psychologist

reported

that the patient “doesn’t appear capable of healthy intimacy and may continually choose partners with similar difficulties.” He was discharged from the military five months after his amnestic episode with the diagnoses of DA and dependent personality traits. 17


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Dissociative Amnesia and DSM-IV-TR Cluster C Personality Traits Stephanie Leong, MD,corresponding author Wendi Waits, MD, and Carroll Diebold, MD All from the Department of Psychiatry, Tripler Army Medical Center, Hawaii

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Dr. Stephanie Leong, Department of Psychiatry, Tripler Army Medical Center, 1 Jarrett White Rd., TAMC, HI 968595000 Phone: (808) 433-2722 or 433-6418; Fax: (808)433-4591

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PTA TBI AND DA