A Case of Psychogenic Fugue: I understand, aber ich verstehe nichts Glisky, E.L., Lee, R., Reminger, S., Hardt, O., Hayes, S.M., Hupbach, A. Neuropsychologia 42 (2004) 1132–1147. Vipa Bernhardt April 11, 2006

Case History Patient F.F., 33 years old Patient F.F., 33 years old Experienced a psychogenic fugue, a disorder of memory that occurs following emotional or psychological trauma and results in a loss of one‘s personal past including personal identity Experienced a psychogenic fugue, a disorder of memory that occurs following emotional or psychological trauma and results in a loss of one‘s personal past including personal identity Traumatic events that might have triggered his amnesic episode include robbery and shooting of which he was the victim, motorcycle accident, problems with his business, impending divorce Traumatic events that might have triggered his amnesic episode include robbery and shooting of which he was the victim, motorcycle accident, problems with his business, impending divorce Fled from Germany to U.S. to start anew Fled from Germany to U.S. to start anew

Neuropsychological profile Full scale IQ of 113, performance IQ of 133 Full scale IQ of 113, performance IQ of 133 Normal retrieval of general knowledge of the world and information about famous people and events of the past several decades Normal retrieval of general knowledge of the world and information about famous people and events of the past several decades Acquisition of new episodic memories intact Acquisition of new episodic memories intact Discrepancies between verbal and visual memory, on tests of both immediate and delayed testing, as well as working memory (right prefrontal region dysfunction → retrieval of visuospatial information) Discrepancies between verbal and visual memory, on tests of both immediate and delayed testing, as well as working memory (right prefrontal region dysfunction → retrieval of visuospatial information) Inhibition of autobiographical memories (frontal lobe executive control system dysfunction) Inhibition of autobiographical memories (frontal lobe executive control system dysfunction)

Activations in frontal and parietal regions during lexical decision task in German-English bilingual controls simulating a loss of German In F.F. greater parietal activation, decreased activity in prefrontal cortex → compensation by increasing phonological and lexical aspects of the words rather than relying on access to the semantic representation

Paired Associate Learning Task To test F.F.‘s ability to learn and remember German- English paired associates compared to English-English pairs and German non-word–English pairs To test F.F.‘s ability to learn and remember German- English paired associates compared to English-English pairs and German non-word–English pairs Control groups included English monolingual subjects and German-English bilinguals Control groups included English monolingual subjects and German-English bilinguals 6 lists of 10 paired associates 6 lists of 10 paired associates 5 pairs in each list related, 5 unrelated 5 pairs in each list related, 5 unrelated 2 lists Eng-Eng pairs, e.g. cow-dime 2 lists Eng-Eng pairs, e.g. cow-dime 2 lists Ger-Eng pairs, e.g. boden-ceiling 2 lists Ger-Eng pairs, e.g. boden-ceiling 2 lists Ger non-word–Eng pairs, e.g. pflonge-lake 2 lists Ger non-word–Eng pairs, e.g. pflonge-lake

Paired Associates Results Eng-Eng pairs, no significant differences Ger-Eng F.F. shows exaggerated relatedness effect, recalling all related pairs but only 30% of unrelated pairs None of the simulators exhibited similar pattern Implicit knowledge fascilitated F.F.s learning performance

Explanations for memory deficits Emotional stressors could lead to a depression of some aspects of frontal function, which inhibit access to autobiographical memories Emotional stressors could lead to a depression of some aspects of frontal function, which inhibit access to autobiographical memories F.F.‘s low performance on visuospatial episodic and working memory tasks could reflect impaired retrieval processes dependent on right prefrontal brain regions F.F.‘s low performance on visuospatial episodic and working memory tasks could reflect impaired retrieval processes dependent on right prefrontal brain regions Extension of the amnesia into the language domain possibly because F.F.‘s emotional turmoil occurred in Germany, and the robbery and shooting was only the last straw Extension of the amnesia into the language domain possibly because F.F.‘s emotional turmoil occurred in Germany, and the robbery and shooting was only the last straw

F.F.‘s descriptions of his “blackout“ 10 days after the initiating episode, a more complete understanding of German began to return, some confusion persisted for weeks 10 days after the initiating episode, a more complete understanding of German began to return, some confusion persisted for weeks Disorientation and a feeling of being unable to access the truth because of a “blocking“ or “barrier“ Disorientation and a feeling of being unable to access the truth because of a “blocking“ or “barrier“ Mixture of fantasy and reality, some islands of memory, and awareness of some aspects of the past Mixture of fantasy and reality, some islands of memory, and awareness of some aspects of the past “The break even point, where not knowing the answers and ignoring the knowledge of the answers is difficult to find…” “The break even point, where not knowing the answers and ignoring the knowledge of the answers is difficult to find…”

Questions and Problems It is impossible to be certain that F.F. was not feigning his amnesia; the processes engaged by simulators and malingerers are not necessarily the same It is impossible to be certain that F.F. was not feigning his amnesia; the processes engaged by simulators and malingerers are not necessarily the same Psychogenic fugues demonstrate many variable characteristics, no clear pattern Psychogenic fugues demonstrate many variable characteristics, no clear pattern More studies including measures of executive function and brain imaging are needed before the role of frontal function in patients wich psychogenic amnesia can be determined with any certainty More studies including measures of executive function and brain imaging are needed before the role of frontal function in patients wich psychogenic amnesia can be determined with any certainty