Journal of Trauma & Dissociation, 16:100–113, 2015

Copyright © Taylor & Francis Group, LLC

ISSN: 1529-9732 print/1529-9740 online
DOI: 10.1080/15299732.2014.969469

A Case of Dissociative Fugue and General

Amnesia with an 11-Year Follow-Up

EDWARD HELMES, PhD, JULIE-MAY BROWN, DPsych,

and LINDA ELLIOTT, BA (Hons)
Department of Psychology, James Cook University, Townsville, Australia

Dissociative fugue refers to loss of personal identity, often with

the associated loss of memories of events (general amnesia).
Here we report on the psychological assessment of a 54-year-old
woman with loss of identity and memories of 33 years of her life
attributed to dissociative fugue, along with a follow-up 11 years
later. Significant levels of personal injury and stress preceded the
onset of the amnesia. A detailed neuropsychological assessment was
completed at a university psychology clinic, with a follow-up assess-
ment there about 11 years later with an intent to determine whether
changes in her cognitive status were associated with better recall of
her life and with her emotional state. Psychomotor slowing and
low scores on measures of attention and both verbal and visual
memory were present initially, along with significant psychological
distress associated with the diagnosis of posttraumatic stress disor-
der. Although memories of her life had not returned by follow-up,
distress had abated and memory test scores had improved. The pas-
sage of time and a better emotional state did not lead to recovery
of lost memories. Contrary to expectations, performance on tests of
executive functions was good on both occasions. Multiple stressful
events are attributed as having a role in maintaining the loss of
memories.

KEYWORDS amnesia, dissociation, memory, dissociative fugue

Received 12 January 2014; accepted 19 August 2014.

Address correspondence to Edward Helmes, PhD, Department of Psychology, James
Cook University, Townsville, Qld 4811, Australia. E-mail: Edward.helmes@jcu.edu.au

100
 Journal of Trauma & Dissociation, 16:100–113, 2015 101

Dissociation is relatively common as a symptom and can be controversial

as a diagnosis (Ross, 1996, 2009). The diagnostic category of dissociative
disorders includes six diagnostic labels (American Psychiatric Association,
2013) and occurs in about 10% of cases in psychiatric settings (Sar, 2011).
In dissociative amnesia, there is a loss of memory for “important auto-
biographical information . . . that is inconsistent with ordinary forgetting”
(American Psychiatric Association, 2013, p. 298). In dissociative fugue, there
is also “apparently purposeful travel or bewildered wandering that is asso-
ciated with amnesia for identity” (American Psychiatric Association, 2013,
p. 298). Dissociative or psychogenic fugue is the more inclusive term for the
loss of identity as well as memories for events, and it is often comorbid
with affective and anxiety disorders (Loewenstein, 1996). The definition of
psychogenic or dissociative fugue involves some debate as to what aspects
of altered memory functions are widely observed to be affected and which
are necessary for the diagnosis of the disorder (Kihlstrom & Schacter, 2005).
Some writers on the topic include the loss of semantic and procedural
memory (e.g., writing) within the definition.
Van der Hart and Nijenhuis (2001) summarized 32 cases dating from the
early 20th century and noted that altered performance in cognitive domains
in addition to memory has often been observed. Stressful events are impli-
cated in the onset of most cases, with evidence of brain trauma in only some
of the cases in the literature. Kihlstrom (2005) summarized the evidence for
stress or psychological trauma as a cause for dissociation and argued that it
is not as unambiguous as assumed by clinicians, whereas physical damage to
the brain is widely accepted as a cause of physiological generalized amnesia.
Comparatively few cases document factors associated with the recovery of
lost memories.
Dissociation has long attracted interest from both theoretical and clini-
cal perspectives. Interpretation of the older literature is complicated by the
then-common psychoanalytic orientation of practitioners that emphasized
intrapsychic processes in dissociative disorders (Edelson, 1990; Loewenstein,
1996). Kihlstrom and Schacter (2005) discussed variations of case presenta-
tions and diagnostic criteria, whereas Dalenberg et al. (2012) reviewed the
evidence for trauma and the development of dissociation. The more recent
literature presents results of positron emission tomography and functional
magnetic resonance imaging scans. For example, Brand et al. (2009) pre-
sented 14 cases of dissociative amnesia with positron emission tomography
scans that showed evidence of lowered neural activity, especially in the right
inferior lateral prefrontal cortex.
In this context, Staniloiu, Markowitsch, and Brand (2010) argued that
both dissociative fugue and amnesia involve changes in self-consciousness,
emotion processing, and executive functions. Here we present a case of
dissociative memory disorder with a detailed assessment of memory, psy-
chosocial, emotional, and executive functions that address this issue. We also
102 E. Helmes et al.

provide data on the same case from a follow-up assessment almost 11 years
after the original evaluation that inform the current data on the recovery
from dissociative fugue. As part of the evaluation, we address the issue of
the relationship of symptoms of lost memories to emotional distress and the
association of executive functions to the amnesia. If dissociative amnesia is
protective against unbearable psychological pain (Loewenstein, 1996), then
reduced distress should be associated with return of memories.

HISTORY

The person at the center of this report is a 54-year-old married woman with
two adult children who was seen through a university psychology clinic. Ms.
X’s initial appearance at a mental health service was shortly after she experi-
enced the sudden onset of retrograde amnesia for the previous 33 years and
for her own current identity. She reportedly was unable to recall memories
from the age of 21 years. She was found by police driving near a railway
crossing in the rural community in which she lived, apparently searching for
her childhood home, which was actually in another community several hun-
dred kilometers away. According to reports at the time, she did not appear
to recognize either her husband or her children, nor did she recognize her
own photo on her driver’s license, and she believed she was 18.
Developmentally speaking, she reportedly had a normal birth and early
developmental milestones. Ms. X attended public school up to the age of 14,
then attended boarding school to the end of Grade 10. No records of objec-
tive tests during her school years were available. Her childhood included
a period of sexual abuse by family members and the deaths of two close
friends in diving accidents. She worked in a variety of positions immedi-
ately after leaving school, the longest position being for 4 years as a radio
operator for a trucking company. Her performance at work was good, and
she moved to positions of increased responsibility and independence as
her work experience increased. For example, she began working for a real
estate agent, becoming self-employed some years later as a real estate bro-
ker. Difficulties with this business and further complications in her personal
life led to severe financial problems resulting in bankruptcy near the time of
onset of the amnesia.
In terms of her adult and family relationships, the father of her first
daughter died prior to their official marriage and the birth of his daughter.
Her first marriage lasted 11 years, with her first daughter being born during
this relationship, which also involved the four children of her husband’s first
marriage. This husband reportedly was physically and emotionally abusive
and also had several extramarital affairs during their marriage. Incidents of
domestic violence in her first marriage contributed to a divorce in the 1980s,
 Journal of Trauma & Dissociation, 16:100–113, 2015 103

and there is no continuing relationship. Five years after the divorce she mar-
ried her current husband, with whom she apparently has a stable and loving
relationship, although he reportedly moved out of the house temporarily in
order to give Ms. X additional time to recover.
As for her physical health, she experienced an episode of uterine cancer
for which she received chemotherapy in the early 1970s. Somewhat later she
had a gallbladder removal, followed some years further on by a hysterec-
tomy to relieve ovarian cysts and bleeding. Two years after that surgery she
was diagnosed with diabetes, and at the time of the initial assessment she
was also diagnosed with hypertension, elevated cholesterol levels, and gas-
troesophageal reflux. Shortly before the incident in question, she had been
hospitalized for pneumonia.
Her living situation at the time of amnesia onset had its stressful relation-
ships. Her older daughter lived next door with her two young children, but
the relationship with this daughter apparently was quite stressful because the
daughter’s husband’s family owned the house in which Ms. X lived together
with her younger unmarried daughter, with whom she did have a positive
relationship. Her history revealed a number of other events that created
additional stress prior to her loss of memories. The closure of her real estate
business was associated with funds missing from a trust account and with
the bankruptcy that was pending at the time of the loss of memory. Over a
period of 6 years preceding the critical incident, she lost seven close acquain-
tances and family members, including the suicide of a family member, and
experienced two serious automobile accidents.
According to the client and her husband, her current problems began
some 6 months prior to her memory loss following a motor vehicle accident
in which another vehicle struck the front driver’s side of her own vehi-
cle. There was no reported loss of consciousness in the accident, nor was
she taken to hospital. Since that accident she had been experiencing severe
headaches radiating from the right top portion of her head to behind her left
eye, and reports from her partner were of a gradual decline in her memory
from the time of the accident. These headaches reportedly differed from her
previous experience of headaches, but she was not taking any prescription
medication for them.
Following the incident in which she was found by police and taken to
the local hospital, she was referred from the local hospital to the regional
hospital psychiatric services, where she was admitted and stayed 3 weeks.
Following inpatient discharge, she was referred back to the local community
mental health services. There were no reports from either facility of a formal
diagnostic interview for a dissociative disorder.
The initial cause for referral for neuropsychological assessment was
a request from the mental health service for the evaluation of func-
tional abilities in order to determine her eligibility for a disability
pension.
104 E. Helmes et al.

INITIAL EVALUATION

Ms. X was first formally assessed in depth at the regional hospital during
her inpatient admission. Investigations there revealed a Mini-Mental State
Examination (Folstein, Folstein, & McHugh, 1975) score of 25/30. A SPECT
(Single Photon Emission Computed Tomography) image obtained after her
discharge showed “borderline reduction in cerebral perfusion involving the
left cerebral hemisphere particularly the temporal lobe and frontal pole,
with associated cross cerebellar diaschisis.” A subsequent magnetic reso-
nance imaging scan did not identify any specific abnormalities. The staff
psychiatrist diagnosed amnestic/dissociative disorder. Psychological inves-
tigations suggested a moderate to severe degree of depression, moderate
levels of hopelessness, and a severe level of anxiety. Information was also
obtained from Ms. X’s daughter and husband and two family friends. These
reports suggested no history of episodes of depression, mania, or psychosis
that predated the amnesia. There was no formal contact with mental health
services until after the onset of amnesia. None of the admission and dis-
charge documentation from the various services with which she was in
contact mentioned her using a different name, having an altered personality,
or showing other signs of dissociative identity disorder. A second consul-
tant psychiatrist at the regional hospital confirmed the initial diagnosis of
amnestic/dissociative disorder for the discharge diagnosis.

INITIAL NEUROPSYCHOLOGICAL ASSESSMENT

At the time of the initial evaluation at the university psychology clinic, Ms.
X was experiencing severe headaches, insomnia, and panic attacks. She
had difficulty falling asleep and staying asleep, and she often awoke with
nightmares that she was unable to recall. Since the critical incident she had
recurrent suicidal thoughts several times a day, but these had reduced in fre-
quency to being weekly by the time of the assessment. She was relearning
practical skills such as how to cook; shop; drive; and operate equipment
such as dishwashers, microwave ovens, automatic teller machines, and com-
puters. She was also reacquainting herself with family members and friends,
including her husband. It is notable that she could not recall any aspects
of any relationships that occurred during the previous 33 years, including
her first marriage. She also reported periods of confusion and disorientation
in which she would forget her immediate goals, such as the sequence of
activities required to prepare a meal.
In the initial assessment, Ms. X completed the Wechsler Adult
Intelligence Scale–III (Wechsler, 1997a), the Wechsler Memory Scale–III
(Wechsler, 1997b), the California Verbal Learning Test–2 (CVLT-2; Delis,
Kramer, Kaplan, & Ober, 2000), the Tower of London Test (Delis, Kaplan,
& Kramer, 2001), the Rey Complex Figure Test (RCFT; Meyers & Meyers,
 Journal of Trauma & Dissociation, 16:100–113, 2015 105

1995), a verbal fluency test (Spreen & Benton, 1977), the Test of Everyday
Attention (TEA; Robertson, Ward, Ridgeway, & Nimmo-Smith, 1994), the
Kaplan variant of the Stroop Test (Stroop, 1935), and the Trail Making Test
for the neuropsychological component. To cover other relevant areas, she
completed the Posttraumatic Stress Diagnostic Scale (Foa, 1995), Personality
Assessment Inventory (PAI; Morey, 1991), Depression Anxiety Stress Scales
(DASS; Lovibond & Lovibond, 1995), Beck Depression Inventory–2 (Beck,
Steer, & Brown, 2000), and Questionnaire of Experiences of Dissociation
(QED; Riley, 1988). Norms for 50-year-old females were taken from
Mitrushina, Boone, Razani, and D’Elia (2005) where appropriate.

ASSESSMENT RESULTS

In terms of general overall cognitive ability, Ms. X had an overall Full Scale IQ
score that placed her at the 19th percentile in comparison to individuals her
own age (Full Scale IQ = 79). Her scores on the various verbal subtests were
primarily in the average range, with the exception of low scores on Digit
Span and Letter–Number Sequencing. Her scores on the performance tests
were within the average range for tests requiring the ability to manipulate
objects and to arrange them according to patterns to assemble objects, but
she showed particularly low scores on two speeded tests, Symbol Search and
Digit Symbol-Coding (two measures on the Processing Speed Index), and on
Digit Span.
Ms. X consistently scored below average on subtests of the Wechsler
Memory Scale–III, with her best scores being in the low average range for the
Auditory Immediate and Auditory Delayed Indices. Her scores for measures
of working memory and recall of visual material were notably poor. She
exhibited an inverted-U learning curve over the five trials of the CVLT-2,
with performance on Trial 5 only marginally better than on Trial 1, resulting
in a learning slope 2 SD below the norm group. Her recognition memory
was marked by a bias to say “no” for yes/no tasks. Her accuracy (hit rate)
was below the cutoff (Millis, 2008) for suspected incomplete effort for the
yes/no task. In terms of visual memory, her immediate recall of the Rey
complex figure was at the 4th percentile, and delayed recall and recognition
trials were both below the first percentile.
Her performance on the TEA was uniformly poor, with her best score at
about the 25th percentile on the two Elevator Counting subtests. Performance
on the other subtests was consistently at or below the 10th percentile.
Performance on timed tests was consistently slow. Her time was below
the 1st percentile on Trails A but at the 27th percentile on Trails B. Scores on
all trials of the Stroop task were slow, with all at least 4 SD below the mean
for women her age. She did show the normal interference effect. Verbal
106 E. Helmes et al.

fluency was 1.75 SD below the mean for the phonemic (letter) ‘FAS’ cues but
1.2 SD above the mean for the animal prompt. Performance on the Tower
Test was at a T score within the average range for her age.
Her PAI profile showed a T score of 70 on the Negative Impression
Management scale. Such scores suggest some exaggeration of distress, with
the scores on the remaining clinical scales not being exaggerated to the
point of suspect validity (Morey, 1996, p. 113). The PAI profile showed
elevations over T70 for the scales measuring anxiety, stress, and suicidal
thoughts. Physiological symptoms of anxiety were prominent, along with
disturbed and dysfunctional thought patterns. A similar pattern of very high
levels of anxiety was reported on the DASS, with severe levels of depression
reported on the Beck scale and moderate levels on the DASS Depression
scale. Her reported symptoms on Foa’s (1995) posttraumatic stress disorder
(PTSD) measure met all of the criteria for that disorder, with her identifying
the childhood sexual abuse as the index event. Her score on the QED was
above the average score reported by Riley by 1.7 SD units.

FOLLOW-UP ASSESSMENT

During the follow-up assessment 11 years later, Ms. X completed the CVLT-
2, Rey Complex Figure Test, Beck Depression Inventory–2, Beck Anxiety
Inventory (Beck, Epstein, Brown, & Steer, 1988), TEA, Tower Test, and PTSD
Checklist–Civilian Version (Weathers, Litz, Herman, Huska, & Keane, 1993).
IQ testing was not repeated because of the introduction of a new edition in
the intervening years that would have introduced additional error into any
comparisons.

RESULTS

At the follow-up assessment, Ms. X reported having a stroke about 1 year

following the initial assessment that left her with some residual pain and
weakness on her right side. She also reported a substantial reduction in
the frequency of panic attacks, with the most recent being 6 months
previous. Her insomnia was largely resolved, and she was on a stable med-
ication regime for her diabetes, high cholesterol, and hypertension. She
also reported that relationships in the family were much better and more
amicable.
At follow-up, Ms. X reported that she remained amnesic for events in
her life from ages 21 to 54 but retained memories from before and after that
period. She had continued monthly sessions with a local psychologist for
about a year after her discharge from the regional hospital and had adopted
 Journal of Trauma & Dissociation, 16:100–113, 2015 107

some of the strategies for dealing with her memory problems that had been
recommended in the initial report.
Her scores on the CVLT-2 and Rey Complex Figure memory tests were
almost uniformly better than on her initial assessment, as can be seen in
Table 1. The hit rate for the yes/no CVLT-2 recognition task was not con-
sistent with incomplete effort (Millis, 2008). Her scores on the TEA were
also much improved, with the majority of subtests well above the 10th per-
centile (see Table 1). Using a different variant of the Tower of London Test on
follow-up, her score improved to above average. Her scores on the measures

TABLE 1 Scores and Interpretive Values for Tests Administered at Both the Initial and Follow-
Up Assessments

Initial assessment Follow-up assessment

Raw
Measure score Interpretation Raw score Interpretation

CVLT-2
Trial 1 5 −1 SD 6 0 SD
Trial 5 7 −2.5 SD 11 −0.5 SD
Total 1–5 38 T 37 50 T 54
Trial 6 4 −1 SD 4 −1 SD
1–5 slope 0.4 −2 SD 1.1 −0.5 SD
Short delay free recall 5 −2 SD 9 0 SD
Long delay yes/no 7 −4.5 SD 12 −2.0 SD
recognition
Long delay forced-choice 10 −4.5 SD 13 −4.5 SD
recognition
Rey Complex Figure Test
Immediate 12 4th percentile 26.5 98th percentile
Delay 10.5 <1st percentile 21 84th percentile
Recognition 6 <1st percentile 12 20th percentile
Test of Everyday Attention
Map Search 2 22 <1st percentile 52 ∼25th percentile
Elevator Counting 4 Abnormal 7 Normal
Elevator Counting: 6 10th–25th 10 75th percentile
Distraction percentile
Visual Elevator: Accuracy 5 10th percentile 7 10th–25th
percentile
Visual Elevator: Time 11.25 <10th percentile 3.9 75th percentile
Elevator Counting: Reversal 3 25th percentile 3 25th percentile
Telephone Search 6.25 <1st percentile 5.8 10th–25th
percentile
Telephone Search: Counting 11.8 10th percentile 1 50th percentile
Lottery 3 <1st percentile 7 5th percentile
BDI-2 30 Severe 15 Mild
QED 16 1.4 SD 13 0.7 SD
PTSD diagnosis PDS 6/6 criteria PCL-C 47
3/3 criteria
Notes: CVLT-2 = California Verbal Learning Test–2; BDI-2 = Beck Depression Inventory–2; QED =
Questionnaire of Experiences of Dissociation; PTSD = posttraumatic stress disorder; PDS = Posttraumatic
Stress Diagnostic Scale; PCL-C = PTSD Checklist–Civilian Version.
108 E. Helmes et al.

of anxiety and depression were both significantly lower, in the range of mild
distress, although she remained symptomatic for PTSD and continued to
meet those diagnostic criteria as assessed by a different measure.

DISCUSSION

On initial assessment, Ms. X’s test scores reflected high levels of emotional
distress and well-below-average levels of scores on measures of attention
and memory. Lower performance on formal tests of memory is reasonably
common in dissociation (Van der Hart & Nijenhuis, 2001). Although poor
performance on memory tests might be expected during the peak of an
amnestic fugue, this report notes the role of both emotional distress and
limited attention to process sensory information. The motor vehicle accident
that occurred about 6 months prior to the onset of the fugue is a compli-
cating factor, but it is important to note that it did not lead to a recorded
loss of consciousness or hospitalization. Although there is wide variability
in outcomes after known traumatic brain injury (McAllister, 2011; Mittenberg
& Roberts, 2008), the majority of cases are fully recovered within 6 months.
In addition, Ms. X’s scores on the initial QED are less likely to be consistent
with traumatic brain injury. Nonetheless, the motor vehicle accident undoubt-
edly complicates the interpretation of the initial set of tests and whether the
observed deficits were due to physiological or psychological factors. The
delay of 6 months between the accident and the onset of the fugue is more
consistent with a psychological cause, however.
Ms. X’s condition remained largely unchanged in two important respects
after the passage of almost 11 years. First, her memory of a large piece of
her previous life remained missing and had been only partially replaced by
relearning of events in her previous life. Second, her symptoms of PTSD
remained largely unchanged, and the diagnosis remained applicable after
the passage of more than 10 years. It is perhaps significant that she retained
memories of the abusive events in her childhood but lost the more recent
memories of events in her adult life, despite her identifying the childhood
events as the causal index for her PTSD. Although no doubt increasing her
vulnerability for dissociation, this pattern of memory loss may not be con-
sistent with some conceptions of the nature of events that are subject to
amnesic fugue. The two instruments used to document symptoms of PTSD
are both self-report measures but they differ in format, making agreement
on the diagnosis less likely to arise from a method factor. Her scores on
the QED remained above average but to a lesser extent than on the initial
assessment.
The aspects of her condition that did change included a notable reduc-
tion in the level of her emotional distress and improvement in performance
on measures of learning and memory and of attention. Her distress had been
 Journal of Trauma & Dissociation, 16:100–113, 2015 109

alleviated in part by the granting of the disability pension some months after
the initial assessment. This finding suggests that continued memory failure
does not require maintenance of the initial levels of emotional upset but
is also consistent with reduced effort in completing the tests at the initial
assessment. Some measures of effort from the CVLT-2 and Trails are consis-
tent with this, and the PAI Negative Impression Management scale score is
also suggestive. At the time, the scores obtained at the follow-up assessment,
which continued to show deficits, would presumably not have been subject
to any secondary gain, as by that time she had been in receipt of the pension
for several years.
Although recovery of lost memories has been reported in some cases
of dissociative amnesia (Markowitsch, 1996), other cases have reported the
amnesia to persist for years (De Renzi, Luccelli, Muggia, & Spinnler, 1995).
Markowitsch (1996) has proposed that the recovery of lost memories requires
the reinstatement of the integrated operation of the neural networks that
underlie the normal processing of episodic memories. These networks can
be disrupted by both physiological and psychological events. In this case,
it is also notable that attention scores on the TEA were low at the initial
assessment, and scores on several TEA subtests remained below average at
follow-up. This suggests that the hypothesized neural networks remained
disrupted to some extent even 11 years after the development of amnesia
and that some of the poor performance on memory measures initially was
due to poor registration of material to be remembered. It is very likely that
the continuing symptoms of PTSD also played a role in the ongoing amnesia.
Some of Ms. X’s test scores could be interpreted as representing dissim-
ulation, or lack of consistent effort, notably the high score on the Negative
Impression Management scale of the PAI and her better performance on
Trails B than on Trails A. There was some evidence of incomplete effort on
the initial CVLT-2, but her performance on only one of the four recognition
trials was consistent with less than adequate effort. She did show reluctance
to make positive identifications on the yes/no recognition task on both occa-
sions, leading to significant response bias values with acceptable values for
sensitivity on both occasions. Although an incentive was present in the form
of the requested disability pension, on balance Ms. X may have lost more
than she could have gained through obtaining a pension. It appeared more
likely that her high levels of emotional distress at the initial assessment led
to limited and erratically performing attention functions that in turn were
responsible for the anomalous scores. Although limited efforts on tests due
to motivated distortion cannot be ruled out completely, on balance we feel
that her performance on the first assessment was interpretable.
It is unlikely that the stroke that occurred about a year following the
initial assessment had a major impact on the follow-up assessment, arguing
on basis of the resolution of its initial symptoms with the passage of time.
Her test scores largely improved on follow-up, and the intervening 10 years
110 E. Helmes et al.

would likely have seen some recovery of affected cognitive functions, which
were largely sensorimotor in nature. It should be noted that her comorbid
hypertension and diabetes may have contributed as well through their effects
on cortical vasculature. At the same time, the improved scores at the follow-
up assessment rule out the presence of a progressive neurological disorder.
Although the majority of the clinical assessment relied on self-report instru-
ments, the initial assessment at the regional hospital did collect information
from other informants that was consistent with her self-report.
Memory functions assessed at follow-up had largely returned to aver-
age levels in both verbal and visual domains. It is notable that performance
on tests of memory functions was highly variable among the 14 cases of
dissociative amnesia reported by Brand et al. (2009). Improved performance
over RCFT trials was present, particularly so for recognition trials. In addition,
performance on recognition trials of the CVLT did improve notably. Scores
on the immediate recall trial of the CVLT did not change, even though per-
formance on Trials 1 to 5 did improve to the average range. Although most
scores on the follow-up memory assessment were in the normal range in
this case, it is clear that normalization of current memory functions is not
sufficient for the recovery of lost episodic memories (Markowitsch et al.,
2000).
Although she had ongoing psychological support after the onset of the
amnesia, symptoms of PTSD remained prominent. This persistence of symp-
toms is not surprising, as the case notes did not indicate any treatment efforts
directed at the core symptoms of PTSD or of the overlay of dissociation (Van
der Hart, Nijenhuis, & Steele, 2006). At the same time, symptoms of ongoing
emotional distress fell in the mild range for both anxiety and depression at
follow-up. The improvement in performance on the CVLT-2 suggests that
some reintegration of neural networks associated with memory functions
had occurred in parallel with the reduction in emotional distress. It is also
consistent with the conclusion that emotional distress in itself is not associ-
ated with persistence of the amnesia, contrary to our expectation of such an
association.
This case provides only limited support for Markowitsch’s (1996) impli-
cation of the inferotemporal prefrontal cortex in dissociation. Ms. X showed
below-average performance only on a measure of letter fluency, with
average-level scores on other measures of frontal executive functions. It is,
of course, possible that other executive measures would have shown dif-
ferent results, but Ms. X’s SPECT scan showed hypoactivity from the left
hemisphere, opposite from the hypoactivity in the right prefrontal cortex
reported by Brand et al. (2009). It is important to note the variability among
the 14 cases reported by Brand et al. in the involvement of other areas as
well as the right inferior prefrontal cortex.
A limitation of this case report lies in the initial clinical evaluation of
the memory loss, which relied on the professional judgment of psychiatric
 Journal of Trauma & Dissociation, 16:100–113, 2015 111

staff without accompanying standardized assessment with measures such as

the Autobiographical Memory Interview (Wiggins & Brandt, 1988). Since the
initial assessment the Dissociative Experiences Scale (Bernstein & Putnam,
1986) has proven to be more widely used than the QED (Riley, 1988), but
there was a more limited choice of measures then than now.

CONCLUSIONS

The mechanisms of dissociative amnesia should accommodate both physio-

logical and psychological causes. Ms. X was under substantial psychological
stress at the time of the onset of her amnesia. To the extent that causality
can be determined, in this case a psychological one appears plausible. At the
same time, details of this case are at variance with other findings, but this
report does extend the duration of amnesia out to 11 years, by which time
emotional distress was much abated, despite limited engagement in therapy,
and performance on some cognitive measures was largely in the normal
range.

ACKNOWLEDGMENTS

Some details of the case have been altered to protect the client’s privacy.
Ms. X provided written consent for other information on her history and test
performance to be published.

REFERENCES

American Psychiatric Association. (2013). Diagnostic and statistical manual of

mental disorders (5th ed.). Washington, DC: Author.
Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring
clinical anxiety: Psychometric properties. Journal of Consulting and Clinical
Psychology, 56, 893–897.
Beck, A. T., Steer, R. A., & Brown, G. K. (2000). Manual for the Beck Depression
Inventory (2nd ed.). San Antonio, TX: Psychological Corporation.
Bernstein, E. M., & Putnam, F. W. (1986). Development, reliability, and validity of a
dissociation scale. Journal of Nervous and Mental Disease, 174, 727–735.
Brand, M., Eggers, C., Reinhold, N., Fujiwara, E., Kessler, J., Heiss, W. D., &
Markowitsch, H. J. (2009). Functional brain imaging in 14 patients with
dissociative amnesia reveals right inferolateral prefrontal hypometabolism.
Psychiatry Research: Neuroimaging, 174, 32–39.
Dalenberg, C. J., Brand, B. L., Gleaves, D. H., Dorahy, M. J., Loewenstein, R. J.,
Cardena, E., . . . Spiegel, D. (2012). Evaluation of the evidence for the trauma
and fantasy models of dissociation. Psychological Bulletin, 138, 550–588.
112 E. Helmes et al.

Delis, D. C., Kaplan, E., & Kramer, J. H. (2001). Delis-Kaplan Executive Function
System: Examiner’s manual. San Antonio, TX: Psychological Corporation.
Delis, D. C., Kramer, J. H., Kaplan, E., & Ober, B. A. (2000). California Verbal
Learning Test (2nd ed.). San Antonio, TX: Psychological Corporation.
De Renzi, E., Luccelli, F., Muggia, S., & Spinnler, H. (1995). Persistent retrograde
amnesia following a minor head trauma. Cortex, 31, 531–542.
Edelson, M. (1990). Defense in psychoanalytic theory: Computation or fantasy? In J.
L. Singer (Ed.), Repression and dissociation: Implications for personality theory,
psychopathology, and health (pp. 33–60). Chicago, IL: University of Chicago
Press.
Foa, E. B. (1995). Posttraumatic Stress Diagnostic Scale manual. Minneapolis, MN:
National Computer Systems.
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-mental state”: A practical
method for grading the organic state of patients for the clinician. Journal of
Psychiatric Research, 12, 189–198.
Kihlstrom, J. F. (2005). Dissociative disorders. Annual Review of Clinical Psychology,
1, 227–253.
Kihlstrom, J. F., & Schacter, D. L. (2005). Functional disorders of autobiographical
memory. In A. D. Baddeley, B. A. Wilson, & F. N. Watts (Eds.), Handbook of
memory disorders (pp. 337–364). New York, NY: Wiley.
Loewenstein, R. J. (1996). Dissociative amnesia and dissociative fugue. In L. K.
Michelson & W. J. Ray (Eds.), Handbook of dissociation: Theoretical, empirical,
and clinical perspectives (pp. 307–336). New York, NY: Plenum.
Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states:
Comparison of the Depression Anxiety Stress Scales with the Beck Depression
and Anxiety Inventories. Behaviour Research and Therapy, 33, 335–343.
Markowitsch, H. J. (1996). Organic and psychogenic retrograde amnesia: Two sides
of the same coin? Neurocase, 2, 357–371.
Markowitsch, H. J., Kessler, J., Weber-Luzenberger, G., Van der Ven, C., Albers, M., &
Heiss, W. D. (2000). Neuroimaging and behavioral correlates of recovery from
mnestic block syndrome and other cognitive deteriorations. Neuropsychiatry,
Neuropsychology, & Behavioral Neurology, 13, 60–66.
McAllister, T. W. (2011). Mild brain injury. In J. M. Silver, T. W. McAllister, & S. C.
Yudofsky (Eds.), Textbook of traumatic brain injury (2nd ed., pp. 239–264).
Washington, DC: American Psychiatric Press.
Meyers, J. E., & Meyers, K. R. (1995). Rey Complex Figure Test and recognition trial.
Odessa, FL: Psychological Assessment Resources.
Millis, S. R. (2008). Assessment of incomplete effort and malingering in the
neuropsychological examination. In J. E. Morgan & J. H. Ricker (Eds.), Textbook
of clinical neuropsychology (pp. 891–904). New York, NY: Psychology Press.
Mitrushina, M., Boone, K. B., Razani, J., & D’Elia, L. F. (2005). Handbook of norma-
tive data for neuropsychological assessment (2nd ed.). Oxford, England: Oxford
University Press.
Mittenberg, W., & Roberts, D. M. (2008). Mild traumatic brain injury and postcon-
cussion syndrome. In J. E. Morgan & J. H. Ricker (Eds.), Textbook of clinical
neuropsychology (pp. 430–436). New York, NY: Psychology Press.
 Journal of Trauma & Dissociation, 16:100–113, 2015 113

Morey, L. C. (1991). Personality Assessment Inventory professional manual. Odessa,

FL: Psychological Assessment Resources.
Morey, L. C. (1996). An interpretive guide to the Personality Assessment Inventory
(PAI). Odessa, FL: Psychological Assessment Resources.
Riley, K. C. (1988). Measurement of dissociation. Journal of Nervous and Mental
Disease, 176, 449–450.
Robertson, I. H., Ward, A., Ridgeway, V., & Nimmo-Smith, I. (1994). Test of Everyday
Attention. Bury St. Edmonds, England: Thames Valley Test Company.
Ross, C. A. (1996). History, phenomenology, and epidemiology of dissociation. In
L. K. Michelson & W. J. Ray (Eds.), Handbook of dissociation: Theoretical,
empirical, and clinical perspectives (pp. 3–24). New York, NY: Plenum.
Ross, C. A. (2009). Dissociative amnesia and dissociative fugue. In P. F. Dell & J. A.
O’Neill (Eds.), Dissociation and the dissociative disorders: DSM–5 and beyond
(pp. 429–434). New York, NY: Routledge.
Sar, V. (2011). Epidemiology of dissociative disorders: An overview. Epidemiology
Research International, Article ID 404538. Retrieved from http://dx.doi.org/10.
1155/2011/404538
Spreen, O., & Benton, A. L. (1977). Neurosensory Center Comprehensive
Examination for Aphasia (NCCEA). 1977 revision. Manual of instructions.
Victoria, British Columbia, Canada: University of Victoria, Department of
Psychology.
Staniloiu, A., Markowitsch, H. J., & Brand, M. (2010). Psychogenic amnesia—A
malady of the constricted self. Consciousness and Cognition, 19, 778–801.
Stroop, J. (1935). Studies of interference in serial verbal reactions. Journal of
Experimental Psychology, 18, 643–662.
Van der Hart, O., & Nijenhuis, E. (2001). Generalized dissociative amnesia: Episodic,
semantic and procedural memories lost and found. Australian and New Zealand
Journal of Psychiatry, 35, 589–600.
Van der Hart, O., Nijenhuis, E. R. S., & Steele, K. (2006). The haunted self: Structural
dissociation and the treatment of chronic traumatization. New York, NY:
Norton.
Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993). The
PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Presentation at
the annual meeting of the International Society for Traumatic Stress Studies, San
Antonio, TX.
Wechsler, D. (1997a). Wechsler Adult Intelligence Scale–third edition. WAIS-III.
Administration and scoring manual. San Antonio, TX: Psychological
Corporation.
Wechsler, D. (1997b). WMS-III. Wechsler Memory Scale–third edition. Administration
and scoring manual. San Antonio, TX: Psychological Corporation.
Wiggins, E. C., & Brandt, J. (1988). The detection of simulated amnesia. Law &
Human Behavior, 12, 52–77.
Copyright of Journal of Trauma & Dissociation is the property of Taylor & Francis Ltd and
its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.