The last visit in the ED is for a suicide attempt with overdose of an unknown quantity of unspecified pills. Ms. A talks to a social worker, who reports that Ms. A needed answers to such questions as why her grandfather abused her sister? Could she have stopped them and made a difference for the family?
The authors’ observations
Conversion disorder arises from unconscious psychological conflicts, needs, or responses to trauma. Ms. A’s consistent conflict about her sister and grandfather’s relationship was evident from occasions when she tried to confide in hospital staff. During an ED visit, she reported her sister’s abuse to a staff member. Another time, while recovering from sedation, she spontaneously spoke about her sister’s abuse. When asked again, she said she did not remember saying it.
Freud said that patients develop conversion disorder to avoid unacceptable conflicting thoughts and feelings.10 It appeared that Ms. A was struggling with these questions because she brought them up again when she visited the ED after the suicide attempt.
Dissociative symptoms arise from unstable parenting and disciplining styles with variable family dynamics. Patients show extreme detachment and emotional unresponsiveness akin to attachment disorder.11 Ms. A had inconsistent parenting because both her stepfather and biological father were involved with her care. Her mother had relinquished her parental rights to her sister, which indicated some attachment issues.
Ms. A’s idea that her mother was indifferent stemmed from her uncaring approach toward her sister and not able to understand her emotionally. Her amnesia could be thought of as “I don’t know you because I don’t remember that I am related to you.” The traumas of infancy (referred to as hidden traumas) that were a result of parent-child mismatch of needs and availability at times of distress might not be obvious to the examiner.11
Although Ms. A’s infancy was reported to be unremarkable, there always is a question, especially in a consultation-liaison setting, of whether conversion disorder might be masking an attachment problem. Perhaps with long-term psychotherapy, an attachment issue would be revealed.
Excluding an organic cause or a neurologic disorder is important when diagnosing conversion disorder10; Ms. A’s negative neurologic tests favored a diagnosis of amnesia due to conversion disorder. It appears that, although Ms. A presented with “transient amnesia,” she had underlying psychiatric symptoms, likely depression or anxiety. We were concerned about possible psychiatric comorbidity and recommended inpatient hospitalization to clarify the diagnosis and provide intensive therapy, but her family declined. She may have received outpatient services, but that was not documented.
Bottom Line
Psychogenic amnesia can be a form of conversion disorder or a symptom of
malingering; can occur in dissociative disorder; and can be factitious in nature.
Regardless of the cause, the condition requires continuous close follow up. Although organic causes of amnesia should be ruled out, mental health care can help address comorbid psychiatric symptoms and might change the course of the illness.
Related Resources
• Byatt N, Toor R. Young, pregnant, ataxic—and jilted. Current Psychiatry. 2015;14(1):44-49.
• Leipsic J. A teen who is wasting away. Current Psychiatry. 2013;12(6):40-45.
Drug Brand Names
Aripiprazole • Abilify Quetiapine • Seroquel
Levetiracetam • Keppra Valproic acid • Depakote
Oxcarbazepine • Trileptal
Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.