CASE REPORT
NEAL A. KLINE, M.D.
Reversal of post-traumatic
amnesia with lithium
Lithium has found rapidly expanding use in disorders
other than manic-depressive illness, including several
conditions characterized by lability of affect and be-
havior: emotionally unstable character disorders, I ag-
gressiveness,2.3 and cyclothymia. 4 A case of hysterical
personality treated effectively with lithium was also
described recently. 5
The case I am now reporting is one of post-traumatic
amnesia, with anterograde aspects felt to be postcon-
cussive and retrograde elements diagnosed according to
the criteria of DSM-II as hysterical neurosis, dissocia-
tive type. With the introduction of lithium into the
treatment regimen, we were able to reverse the retro-
grade amnesia.
C.sereport
A 26-year-old woman was referred by her neurologist for
psychiatric evaluation and treatment. She complained of
severe headaches. night terrors, daytime episodes of ex-
treme irritability, and amnesia for the events that led up to
her being struck on the head while working as a private
security guard. She could only recall that she had been
making her rounds at a construction site and sustained a
head injury from unknown causes. Her amnesia for that
evening persisted for the seven months prior to her being
referred for psychiatric evaluation. During that time, post-
concussive headaches (skull films had shown no fracture)
Dr. Kline is clinical instructor ofpsychiatry at the University of
California, San Diego, School of Medicine, and psychiatric
consultantfor the Jewish Family Service ofSan Diego. Reprint
requests to him at 3355 Fourth Avenue, San Diego, CA 92103.
MAY 1979· VOL 20· NO 5
were treated with analgesics. muscle relaxants, anti-inflam-
matory agents. and minor tranquilizers. She noted that
diazepam increased her irritability and made her feel more
agitated. intensifying her headaches. Muscular spasms of
the region over the cervical spine had been treated with
physical therapy and a neck collar. with minimal results.
Initial mental status examination revealed her to be ear-
nest, cooperative. and neither tangential nor circumstantial.
She was notably anxious and depressed. demonstrating a
full and labile affective range, tears frequently flooding forth.
She gave no history of delusional systems. persecutory
ideation. or auditory hallucinosis. She showed excellent
ability to abstract. She was oriented to time, place, and
person; immediate recall and remote memory showed no
impairment other than the amnesia for the evening when the
head trauma occurred.
The severe headaches were almost a daily occurrence.
and the patient felt she would "jump out of her skin" if the
night terrors and daytime tension continued unabated. I
prescribed propoxyphene napsylate (100 mg) with acet-
aminophen (650 mg). three times daily as needed, and
chlordiazepoxide (10 mg), four times daily as needed.
No significant conflicts were elicited in the nuclear family
during the initial history-taking. There was no family history
of treatment for neurologic or psychiatric disorders. The
patient had been engaged at age 16; her fiance was killed In
an automobile accident. From age 17 to 20, her new
boyfriend was being rehabilitated following head wounds
caused by enemy fire in Vietnam. At age 21. pregnant. she
married another man. Six weeks before her wedding, she
miscarried. Her husband, in the military service. was or-
dered overseas soon after their wedding. Five months after
being married. she was raped and became pregnant; she
spontaneously miscarried at 11 weeks. Three and a half
J63
Case report
years prior to the present evaluation she had borne a male
child. He suffered two postpartum apneic episodes. At two
months of age, he suffered a third and died. The woman
subsequently bore two additional sons, now age 27 months
and 14 months.
The analgesics and minor tranquilizers were ineffective
after a three-week trial, and her agitation and depreSSion
worsened. In our sessions she described wakirig up ter-
rified, unable to recall the substance of her nightmares. Her
days were punctuated with anXiety reactions whenever a
blue car drove by. She was sure that this was related to the
forgotten events on the evening of her injury. Her head-
aches were more immobilizing. Her anguish had become
unmanageable and she requested. respite.
I prescribed lithium carbonate, 300 mg three times a day.
Blood levels stabilized at 1.0 mEq/liter. After the first week,
her night terrors and headaches were notably less frequent.
After the second week, the improvement included more
daytime calm. The reaction to blue cars persisted but was
significantly less intense. The woman called me during the
third week of lithium treatment to report: "I remember what
happened the night I was hit on the head. It's all come back,
and it's horrible!"
During her next visit she told of seeing a blue car parked
near a ravine while she made her rounds. She looked into
the ravine, and saw several men gang-raping a woman and
beating a man. When they saw her, one of the men un-
leashed his dog, which charged her. She ran, saw head-
lights approaching, was knocked to the ground by the dog,
and hit her head on the pavement. She next remembered
being sutured in the emergency room.
The memory surge into conscious awareness of the
events preceding her head trauma exacerbated her symp-
toms. Hospitalization was considered, but with the addi-
tional calming effect of thioridazine, 50 mg three times daily,
her condition stabilized. Both lithium and thioridazine were
continued during the next two months of psychotherapy. As
the woman began to be able to tolerate the memory of that
traumatic evening, her need for medication became less. As
she explored many emotionally charged memoties that had
been rekindled-her own rape, pregnancies, miscarriages,
and the death of her son-her depression and agitation
lessened. Thioridazine was dropped; lithium was continued
for the next six months. Her night terrors, headaches,
depression, and agitation had become minimal. She con-
tinues in psychotherapy and, to date, no other amnesic
episodes have occurred and no symptom substitution is
evident.
364
Discussion
When this woman failed to respond to analgesics and
minor tranquilizers, 'lithium was prescribed-not only
as a treatment for her headaches, but also in an effort to
control her affective overload and her extreme episodic
irritability and agitation. Previous reports have de-
scribed the efficacy of lithium for neuropsychiatric
over-responsiveness. 6•7 The nature of what she had
witnessed and its recapitulation of earlier personal
trauma indicated a likely basis for her hysterical disso-
ciative reaction and the resulting amnesia.
The return to memory-the derepression-and the
conscious perception of cognitive data and its affective
associations when lithium was introduced raises ques-
tions of placebo effect, coincidence, and contributory
causality. While not discounting the possibility of pla-
cebo effect or coincidental symptom change, I am
suggesting that lithium's thymoleptic 8 mode of action is
consistent with the possibility of affective modulation,
in this case, such that the pressure toward dissociation
was reduced below a critical threshold and the process
reversed. With lithium, not only may stimulus signifi-
cance 9 have been reduced, but also the response reac-
tivity patterns may have been damped, with overall ego
reintegration of cognitive-affective linkages and the
return of memory.
Similar responses in cases of multiple personality
have had promising short-term outcomes, with de-
creased ego-splitting. I shall report these cases in depth
when longer term follow-up is available. 0
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PSYCHOSOMATICS