A case of persistent retrograde amnesia following a dissociative fugue: Neuropsychological and neurofunctional underpinnings of loss of autobiographical memory and self-awareness

Dissociative Amnesia: Remembrances Under Cover

The existence or questionability of "repressed memories" can be discussed as being a matter of definition. It seems, however, far-fetched to consider all "lost" memories as caused by encoding problems, brain damage, forgetfulness, failure to disclose events, and so on. We argue that dissociative amnesia (DA) (or "psychogenic amnesia," or "functional amnesia," or, as we favor to call it, "mnestic block syndrome") is caused by psychic alterations, but ultimately they can be traced to changes in the physiology of the brain, as we are of the opinion that all memory processes-positive or negative-alter brain functions, sometimes more permanently, sometimes transiently. We have proven this idea using functional imaging techniques, in particular fluoro-deoxy-d-glucose positron emission tomography. Having investigated dozens of patients with severe and long-lasting DA conditions, we believe it to be disrespectful to many (but not to all) of the affected patients to question their disease condition, which can be proven to be not caused by feigning, malingering, or direct brain damage.

What are the neural correlates of dissociative amnesia? A systematic review of the functional neuroimaging literature

AIM

Dissociative amnesia is an emblematic psychiatric condition in which patients experience massive memory loss ranging from focal to global amnesia. This condition remains poorly understood and this review aims to investigate the neuroanatomical feature of this disease.

METHODS

We conducted a systematic review of the scientific literature available on PubMed, up to December 1, 2022, using a combination of keywords referring to dissociative amnesia. We included every scientific report involving patients undergoing a functional imaging procedure.

RESULTS

Twenty-two studies met our inclusion criteria (gathering 49 patients). Only one was a controlled study with a large sample. The other 21 were case reports and case series. In resting state, neuroimaging studies mostly showed a hypo-activated right inferolateral prefrontal cortex, associated with limbic hypoactivity and lesser activation of the hippocampal and para-hippocampal structures. The patients also presented abnormal patterns of cerebral activation when performing memory tasks. When testing recognition of memories from the amnestic period, patients showed increased activation across temporal areas (hippocampal and para-hippocampal gyri) and the limbic network. When trying to recollect memories from an amnestic period compared to a non-amnestic period, patients failed to activate these structures efficiently. Most of these patterns tended to return to normal when symptoms resolved.

CONCLUSION

This review identified a paucity of controlled studies in the field of dissociative amnesia neuroimaging, which restricts the extrapolation of results. Patients with dissociative amnesia present a broad prefronto-temporo-limbic network dysfunction. Some of the brain areas implicated in this network might represent potential targets for innovative treatments.

"This looks like a movie": a case report of post-surgical amnesia

A 52-year-old male patient with a background of adaptive personality disorder was admitted for mitral valve repair and cardiac ablation for atrial fibrillation. He suffered intraoperative complications with severe mitral insufficiency that suffered ischemia.. Post-operatively, he demonstrated acute loss of retrograde autobiographical memory, prosopagnosia and a loss of public semantic memory. His CT scan was normal and MRI was not possible due to intra-cardiac leads. An initial diagnosis of hypoxic-ischemic encephalopathy was considered. A neuropsychological examination undertaken 20 days after his surgery showed a severe alteration of retrograde autobiographical memory, marked alteration of semantic knowledge and prosopagnosia. He demonstrated an average performance in tasks measuring constructional praxis, visuospatial ability, and executive functions. 34 days after surgery, and after a short nap, the patient "returns" to the day before admission and consequently recovers his memory. Repeat neuropsychological assessment demonstrated performance within the normal range across all previously tested domains. This sudden recovery of memory, together with a normal MRI, led to a rethinking of the diagnosis of dissociative amnesia. This case illustrates the long-standing discussion about the organic or functional origin of some memory disorders, in which, despite advances in neuroimaging techniques, it is still difficult to know their etiology    .

Episodic Autobiographical Memory Impairment and Differences in Pronoun Use: Study of Self-Awareness in Functional Amnesia and Transient Global Amnesia

The subjective experience associated to memory processing is the core of the definition of episodic autobiographical memory (EAM). However, while it is widely known that amnesia affects the content of memories, few studies focused on the consequences of an impairment of EAM on the subjective self, also called the I-self. In the present study, we explored the I-self in two puzzling disorders that affect EAM: functional amnesia, which has an impact on autobiographical memory, and transient global amnesia (TGA), which only affects episodic memory. I-self was assessed through an original measure of self-integration in autobiographical narratives, namely the use of general or personal pronouns. Results showed that patients with functional amnesia tended to use general pronouns, whereas patients with TGA preferentially used the first person. The link between I-self and depersonalization-derealisation tendencies was also explored, showing dissociative tendencies in patients with functional amnesia but not in patients with TGA. We discuss these results from a combined neuropsychological and psychopathological perspective, with a view to proposing an explanatory model of the links between self-awareness and the episodic component of autobiographical memory.

[123I]Iomazenil SPECT Detects a Reversible Lesion of the Left Medial Temporal Lobe in a Case of Global Autobiographical Amnesia

Global autobiographical amnesia is a rare disorder that is characterized by a sudden loss of autobiographical memories covering many years of an individual's life. Generally, routine neuroimaging studies such as CT and MRI yield negative findings in individuals with global autobiographical amnesia. However, in recent case reports, functional analyses such as SPECT and fMRI have revealed changes in activity in various areas of the brain when compared with controls. Studies using iomazenil (IMZ) SPECT with individuals with global autobiographical amnesia have not been reported. We report the case of a 62-year-old Japanese woman with global autobiographical amnesia who had disappeared for ∼4 weeks. [123I]-IMZ SPECT showed reduced IMZ uptake in her left medial temporal lobe and no significant reduction on N-isopropyl-[123I] p-iodoamphetamine (IMP) SPECT in the identical region. Because IMZ binds to the central benzodiazepine receptor, this dissociation between IMZ and IMP SPECT was thought to reflect the breakdown of inhibitory neurotransmission in the left medial temporal lobe. Moreover, when the woman recovered most of her memory 32 months after fugue onset, the IMZ SPECT-positive lesion had decreased in size. Because the woman had long suffered verbal abuse from her former husband's sister and brother, which can also cause global autobiographical amnesia, it is difficult to conclude whether the IMZ SPECT-positive lesion in the left medial temporal lobe was the cause or the result of her global autobiographical amnesia. Although only one case, these observations suggest that IMZ SPECT may be useful in uncovering the mechanisms underlying global autobiographical amnesia.

Natural recovery from long-lasting generalised dissociative amnesia and of cerebral blood flow

A 40-year-old man presented with generalised dissociative amnesia. At 2 weeks after onset, N-isopropyl-[¹²³I] p-iodoamphetamine-single-photon emission CT imaging of the brain revealed hypoperfusion in the right medial temporal area. Organic brain damage was ruled out. His inability to recall information was attributed to psychological stress related to his employment. Consistent with this diagnosis, his generalised dissociative amnesia lasted 6 years and 10 months; however, he recovered from amnesia naturally on starting a new job. Perfusion of his right medial temporal area also returned to normal levels. Longitudinal reports for generalised dissociative amnesia with natural recovery are exceedingly rare. It is important to confirm whether dissociative amnesia and cerebral blood flow recover in parallel, even in cases where dissociative amnesia is long-lasting.

Anomalies of Autobiographical Memory

OBJECTIVES

In this paper, I review three 'anomalies' or disorders in autobiographical memory: neurological retrograde amnesia (RA), spontaneous confabulation, and psychogenic amnesia.

METHODS

Existing theories are reviewed, their limitations considered, some of my own empirical findings briefly described, and possible interpretations proposed and interspersed with illustrative case-reports.

RESULTS

In RA, there may be an important retrieval component to the deficit, and factors at encoding may give rise to the relative preservation of early memories (and the reminiscence bump) which manifests as a temporal gradient. Spontaneous confabulation appears to be associated with a damaged 'filter' in orbitofrontal and ventromedial frontal regions. Consistent with this, an empirical study has shown that both the initial severity of confabulation and its subsequent decline are associated with changes in the executive function (especially in cognitive estimate errors) and inversely with the quantity of accurate autobiographical memories retrieved. Psychogenic amnesia can be 'global' or 'situation-specific'. The former is associated with a precipitating stress, depressed mood, and (often) a past history of a transient neurological amnesia. In these circumstances, frontal control mechanisms can inhibit retrieval of autobiographical memories, and even the sense of 'self' (identity), while compromised medial temporal function prevents subsequent retrieval of what occurred during a 'fugue'. An empirical investigation of psychogenic amnesia and some recent imaging studies have provided findings consistent with this view.

CONCLUSIONS

Taken together, these various observations point to the importance of frontal 'control' systems (in interaction with medial temporal/hippocampal systems) in the retrieval and, more particularly, the disrupted retrieval of 'old' memories.

State-Dependent Memory: Neurobiological Advances and Prospects for Translation to Dissociative Amnesia

In susceptible individuals, overwhelming traumatic stress often results in severe abnormalities of memory processing, manifested either as the uncontrollable emergence of memories (flashbacks) or as an inability to remember events (dissociative amnesia, DA) that are usually, but not necessarily, related to the stressful experience. These memory abnormalities are often the source of debilitating psychopathologies such as anxiety, depression and social dysfunction. The question of why memory for some traumatic experiences is compromised while other comparably traumatic experiences are remembered perfectly well, both within and across individuals, has puzzled clinicians for decades. In this article, we present clinical, cognitive, and neurobiological perspectives on memory research relevant to DA. In particular, we examine the role of state dependent memory (wherein memories are difficult to recall unless the conditions at encoding and recall are similar), and discuss how advances in the neurobiology of state-dependent memory (SDM) gleaned from animal studies might be translated to humans.

Functional (dissociative) retrograde amnesia

Retrograde amnesia is described as condition which can occur after direct brain damage, but which occurs more frequently as a result of a psychiatric illness. In order to understand the amnesic condition, content-based divisions of memory are defined. The measurement of retrograde memory is discussed and the dichotomy between "organic" and "psychogenic" retrograde amnesia is questioned. Briefly, brain damage-related etiologies of retrograde amnesia are mentioned. The major portion of the review is devoted to dissociative amnesia (also named psychogenic or functional amnesia) and to the discussion of an overlap between psychogenic and "brain organic" forms of amnesia. The "inability of access hypothesis" is proposed to account for most of both the organic and psychogenic (dissociative) patients with primarily retrograde amnesia. Questions such as why recovery from retrograde amnesia can occur in retrograde (dissociative) amnesia, and why long-term new learning of episodic-autobiographic episodes is possible, are addressed. It is concluded that research on retrograde amnesia research is still in its infancy, as the neural correlates of memory storage are still unknown. It is argued that the recollection of episodic-autobiographic episodes most likely involves frontotemporal regions of the right hemisphere, a region which appears to be hypometabolic in patients with dissociative amnesia.

Self, memory, and imagining the future in a case of psychogenic amnesia

We report a case of psychogenic amnesia and examine the relationships between autobiographical memory impairment, the self, and ability to imagine the future. Case study JH, a 60-year-old male, experienced a 6-year period of pervasive psychogenic amnesia covering all life events from childhood to the age of 53. JH was tested during his amnesic period and again following hypnotherapy and the recovery of his memories. JH's amnesia corresponded with deficits in self-knowledge and imagining the future. Results are discussed with reference to models of self and memory and processes involving remembering and imagining.

Ganser-like syndrome after loss of psychic self-activation syndrome: psychogenic or organic?

Very few data are available on the long-term changes in the cognitive abilities of patients with loss of psychic self-activation syndrome (LPSAS). Here, we present a 25-year follow-up study on a case of LPSAS resulting from bilateral pallidal lesions caused by carbon monoxide intoxication. Typical signs of LPSAS were observed, showing no changes in severity, but Ganser syndrome (GS) gradually developed and worsened during the follow-up period. GS is generally assumed to be a psychogenic syndrome, but an organic etiology has been suspected by the authors of several case reports. Here, atypical features of GS plead against the independence of GS and LPSAS. DaTSCAN and brain 18FDG-PET were performed. Since left hippocampal hypometabolism has been previously described in patients with functional amnesia, it is possible that long periods of mental inactivity may have psychological consequences, but the atypical features of GS also suggest that an organic mechanism may be involved.

Dissociative amnesia

Dissociative amnesia is one of the most enigmatic and controversial psychiatric disorders. In the past two decades, interest in the understanding of its pathophysiology has surged. In this report, we review new data about the epidemiology, neurobiology, and neuroimaging of dissociative amnesia and show how advances in memory research and neurobiology of dissociation inform proposed pathogenetic models of the disorder. Dissociative amnesia is characterised by functional impairment. Additionally, preliminary data suggest that affected people have an increased and possibly underestimated suicide risk. The prevalence of dissociative amnesia differs substantially across countries and populations. Symptoms and disease course also vary, indicating a possibly heterogeneous disorder. The accompanying clinical features differ across cultural groups. Most dissociative amnesias are retrograde, with memory impairments mainly involving the episodic-autobiographical memory domain. Anterograde dissociative amnesia occurring without significant retrograde memory impairments is rare. Functional neuroimaging studies of dissociative amnesia with prevailing retrograde memory impairments show changes in the network that subserves autobiographical memory. At present, no evidence-based treatments are available for dissociative amnesia and no broad framework exists for its rehabilitation. Further research is needed into its neurobiology, course, treatment options, and strategies to improve differential diagnoses.

The dissociative subtype of posttraumatic stress disorder: rationale, clinical and neurobiological evidence, and implications

BACKGROUND

Clinical and neurobiological evidence for a dissociative subtype of posttraumatic stress disorder (PTSD) has recently been documented. A dissociative subtype of PTSD is being considered for inclusion in the forthcoming Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) to address the symptoms of depersonalization and derealization found among a subset of patients with PTSD. This article reviews research related to the dissociative subtype including antecedent, concurrent, and predictive validators as well as the rationale for recommending the dissociative subtype.

METHODS

The relevant literature pertaining to the dissociative subtype of PTSD was reviewed.

RESULTS

Latent class analyses point toward a specific subtype of PTSD consisting of symptoms of depersonalization and derealization in both veteran and civilian samples of PTSD. Compared to individuals with PTSD, those with the dissociative subtype of PTSD also exhibit a different pattern of neurobiological response to symptom provocation as well as a differential response to current cognitive behavioral treatment designed for PTSD.

CONCLUSIONS

We recommend that consideration be given to adding a dissociative subtype of PTSD in the revision of the DSM. This facilitates more accurate analysis of different phenotypes of PTSD, assist in treatment planning that is informed by considering the degree of patients' dissociativity, will improve treatment outcome, and will lead to much-needed research about the prevalence, symptomatology, neurobiology, and treatment of individuals with the dissociative subtype of PTSD.

The impairment of recollection in functional amnesic states

INTRODUCTION

Functional amnesia refers to various forms of amnesia, which have no direct organic brain basis. Psychological stress and trauma were etiologically linked to its development across various cultures.

METHODS

We have studied several patients with functional amnesia, employing neuropsychological and neuroimaging methods. Herein we provide a review of the current understanding of the phenomenology, neuropsychology and neurobiology of functional amnesia, which we illustrate by reference to five own case descriptions and other cases presented in the literature.

RESULTS

Functional amnesia is mostly of retrograde nature and presents in the form of a memory blockade or repression to recollect episodic-autobiographical events, which may cover the whole past life. Sometimes, the recollection impairment is localized to certain time epochs. In comparison to functional retrograde amnesia, functional isolated anterograde amnesia is much rarer and data on its neurobiology are scant. In patients with functional amnesia with pronounced retrograde episodic-autobiographical memory impairments, we identified changes in brain metabolism, above all reductions in the temporo-frontal regions of the right hemisphere. Recently, even subtle structural changes in the white matter of the (right) frontal cortex were described in functional retrograde amnesia by other researchers.

CONCLUSIONS

The disruption in recollection in functional amnesia is often accompanied by changes in personality dimensions, pertaining to cognition (self-related processing, theory of mind), autonoetic consciousness and affectivity. This suggests that functional amnesia is a multifaceted condition. We hypothesize that the recollection deficit in functional retrograde amnesia primarily reflects a desynchronization between a frontal lobe system, important for autonoetic consciousness, and a temporo-amygdalar system, important for evaluation and emotions. Despite assumptions that functional amnesia can always be reversed, several cases of functional amnesia were found to follow a chronic course, suggesting a need for longitudinal prospective studies to quantify possible global cognitive deterioration over time and its neural underpinnings.

The remains of the day in dissociative amnesia

Memory is not a unity, but is divided along a content axis and a time axis, respectively. Along the content dimension, five long-term memory systems are described, according to their hierarchical ontogenetic and phylogenetic organization. These memory systems are assumed to be accompanied by different levels of consciousness. While encoding is based on a hierarchical arrangement of memory systems from procedural to episodic-autobiographical memory, retrieval allows independence in the sense that no matter how information is encoded, it can be retrieved in any memory system. Thus, we illustrate the relations between various long-term memory systems by reviewing the spectrum of abnormalities in mnemonic processing that may arise in the dissociative amnesia—a condition that is usually characterized by a retrieval blockade of episodic-autobiographical memories and occurs in the context of psychological trauma, without evidence of brain damage on conventional structural imaging. Furthermore, we comment on the functions of implicit memories in guiding and even adaptively molding the behavior of patients with dissociative amnesia and preserving, in the absence of autonoetic consciousness, the so-called “internal coherence of life”.

Dissociative disorders in DSM-5

BACKGROUND

We present recommendations for revision of the diagnostic criteria for the Dissociative Disorders (DDs) for DSM-5. The periodic revision of the DSM provides an opportunity to revisit the assumptions underlying specific diagnoses and the empirical support, or lack of it, for the defining diagnostic criteria.

METHODS

This paper reviews clinical, phenomenological, epidemiological, cultural, and neurobiological data related to the DDs in order to generate an up-to-date, evidence-based set of DD diagnoses and diagnostic criteria for DSM-5. First, we review the definitions of dissociation and the differences between the definitions of dissociation and conceptualization of DDs in the DSM-IV-TR and the ICD-10, respectively. Also, we review more general conceptual issues in defining dissociation and dissociative disorders. Based on this review, we propose a revised definition of dissociation for DSM-5 and discuss the implications of this definition for understanding dissociative symptoms and disorders.

RESULTS

We make the following recommendations for DSM-5: 1. Depersonalization Disorder (DPD) should include derealization symptoms as well. 2. Dissociative Fugue should become a subtype of Dissociative Amnesia (DA). 3. The diagnostic criteria for DID should be changed to emphasize the disruptive nature of the dissociation and amnesia for everyday as well as traumatic events. The experience of possession should be included in the definition of identity disruption. 4. Dissociative Trance Disorder should be included in the Unspecified Dissociative Disorder (UDD) category.

CONCLUSIONS

There is a growing body of evidence linking the dissociative disorders to a trauma history, and to specific neural mechanisms.

How does interoceptive awareness interact with the subjective experience of emotion? An fMRI study

Recent studies in cognitive neuroscience have suggested that the integration of information about the internal bodily state and the external environment is crucial for the experience of emotion. Extensive overlap between the neural mechanisms underlying the subjective emotion and those involved in interoception (perception of that which is arising from inside the body) has been identified. However, the mechanisms of interaction between the neural substrates of interoception and emotional experience remain unclear. We examined the common and distinct features of the neural activity underlying evaluation of emotional and bodily state using functional magnetic resonance imaging (fMRI). The right anterior insular cortex and ventromedial prefrontal cortex (VMPFC) were identified as commonly activated areas. As both of these areas are considered critical for interoceptive awareness, these results suggest that attending to the bodily state underlies awareness of one's emotional state. Uniquely activated areas involved in the evaluation of emotional state included the temporal pole, posterior and anterior cingulate cortex, medial frontal gyrus, and inferior frontal gyrus. Also the precuneus was functionally associated with activity of the right anterior insular cortex and VMPFC when evaluating emotional state. Our findings indicate that activation in these areas and the precuneus are functionally associated for accessing interoceptive information and underpinning subjective experience of the emotional state. Thus, awareness of one's own emotional state appears to involve the integration of interoceptive information with an interpretation of the current situation.

Dissociative disorders in DSM-5

BACKGROUND

We present recommendations for revision of the diagnostic criteria for the Dissociative Disorders (DDs) for DSM-5. The periodic revision of the DSM provides an opportunity to revisit the assumptions underlying specific diagnoses and the empirical support, or lack of it, for the defining diagnostic criteria.

METHODS

This paper reviews clinical, phenomenological, epidemiological, cultural, and neurobiological data related to the DDs in order to generate an up-to-date, evidence-based set of DD diagnoses and diagnostic criteria for DSM-5. First, we review the definitions of dissociation and the differences between the definitions of dissociation and conceptualization of DDs in the DSM-IV-TR and the ICD-10, respectively. Also, we review more general conceptual issues in defining dissociation and dissociative disorders. Based on this review, we propose a revised definition of dissociation for DSM-5 and discuss the implications of this definition for understanding dissociative symptoms and disorders.

RESULTS

We make the following recommendations for DSM-5: 1. Depersonalization Disorder (DPD) should derealization symptoms as well. 2. Dissociative Fugue should become a subtype of Dissociative Amnesia (DA). 3. The diagnostic criteria for DID should be changed to emphasize the disruptive nature of the dissociation and amnesia for everyday as well as traumatic events. The experience of possession should be included in the definition of identity disruption. 4. Should Dissociative Trance Disorder should be included in the Unspecified Dissociative Disorder (UDD) category.

CONCLUSIONS

There is a growing body of evidence linking the dissociative disorders to a trauma history, and to specific neural mechanisms.

Memory Repression: Brain Mechanisms underlying Dissociative Amnesia

Dissociative amnesia usually follows a stressful event and cannot be attributable to explicit brain damage. It is thought to reflect a reversible deficit in memory retrieval probably due to memory repression. However, the neural mechanisms underlying this condition are not clear. We used fMRI to investigate neural activity associated with memory retrieval in two patients with dissociative amnesia. For each patient, three categories of face photographs and three categories of people's names corresponding to the photographs were prepared: those of “recognizable” high school friends who were acquainted with and recognizable to the patients, those of “unrecognizable” colleagues who were actually acquainted with but unrecognizable to the patients due to their memory impairments, and “control” distracters who were unacquainted with the patients. During fMRI, the patients were visually presented with these stimuli and asked to indicate whether they were personally acquainted with them. In the comparison of the unrecognizable condition with the recognizable condition, we found increased activity in the pFC and decreased activity in the hippocampus in both patients. After treatment for retrograde amnesia, the altered pattern of brain activation disappeared in one patient whose retrograde memories were recovered, whereas it remained unchanged in the other patient whose retrograde memories were not recovered. Our findings provide direct evidence that memory repression in dissociative amnesia is associated with an altered pattern of neural activity, and they suggest the possibility that the pFC has an important role in inhibiting the activity of the hippocampus in memory repression.

A woman lost in the cemetery: A case of time-limited amnesia

A 43-year-old woman one day experienced a dissociative fugue which she could not recall. She was married, nulliparous, with no history of dissociative disorder or other psychiatric disorders. She had been sexually abused during late childhood-early adolescence. She was examined thoroughly from both psychiatric and medical standpoints to exclude organic causes for her condition. Magnetic Resonance Imaging showed only some non-specific abnormalities. On personality tests, a histrionic structure of personality emerged, with obsessive and narcissistic traits accompanied by rigidity and anxiety, dysphoria and high risk for depression; some impairment was found in executive function tests. Final diagnosis was one of dissociative fugue. In fact, organic traits were not sufficient to establish a diagnosis of Transient Global Amnesia.

Searching for the Anatomy of Dissociative Amnesia

Brain damage was traditionally seen as the product of a neurological disease or injury. Nevertheless, modern brain imaging techniques have provided increasing evidence for alterations in brain tissue and metabolism for a number of psychiatric disorders. Though for a while “dissociated” ( Spiegel, 2006 ) from the clinical and scientific arena, dissociative disorders have in the last several years received a renewed interest among several groups of researchers, who embarked on the work of disentangling their neural correlates. We review data from our own research as well as others, which point to distinct changes in brain regions underlying dissociative amnes(t)ic disorders. These changes may consist of overall reductions in brain metabolism or more selective alterations primarily in the right temporo-frontal cortices. Recent evidence with refined magnetic resonance imaging techniques furthermore reveals selective fiber degenerations in these regions. While these changes may persist and probably even intensify in some patients, they may be reversible in others – especially if treatment is carried out successfully within short time after onset. Implications of these findings for the pathogenetic conceptualization of dissociative amnes(t)ic disorders are outlined.

Ganser syndrome with work-related onset in a patient with a background of immigration

INTRODUCTION

A substantial proportion of the recently published cases of dissociative disorders have a background of immigration (Fujiwara et al., 2008). Among the dissociative disorders, Ganser syndrome is an uncommon form that has as central symptom the giving of approximate answers to questions (vorbeireden). The predisposing and triggering factors of Ganser syndrome are poorly defined. Furthermore, this condition might cooccur with other psychiatric disorders. Here we describe a patient with a background of immigration, who, after an objectively minor work-related head injury, developed severe and persistent psychiatric symptoms, with features of Ganser syndrome.

METHODS

The patient was assessed medically, psychiatrically, and by neuropsychological testing.

RESULTS

The patient is a man with no known previous psychiatric history, who lived in several countries and encountered a series of stressful experiences in the process of migration. Several years after immigrating to his current country of residency, he developed severe psychiatric symptoms of Major Depressive Disorder, with Psychotic Features and Ganser syndrome. The symptoms, which emerged after a mild head injury, have persisted for more than a year, despite treatment.

CONCLUSIONS

The similarity between this case and other reports suggests that psychosocial stresses accompanying immigration may have a catalytic effect in triggering and maintaining dissociative symptomatology.