Amnesic Syndromes in War
with William Sargant
Proceedings of the Royal Society of Medicine, October 1941, Vol. 34, No. 12, pp. 757-764
Loss of memory is much commoner in soldiers in war‑time than in civilian practies in peace. From the previous records of some of our patients, it seems that the cooditiot is often overlooked in civil life; in the Army a stricter routine and discipline make this impossible. Attention in the past has been mainly directed to states of fugue, and civilian practice suggests that behind these there often lies a criminal act or a situation from which an immediate, even though an illusory, escape is desired. Cases occurring in was however, indicate that other causes, such as terror, bomb blast and exhaustion, may produt' not only fugues both at the time and subsequently, but also large gaps retrospectively it the patient's memory of the past.
In the first thousand military eases admitted to the Neurological Unit of Sutton Emergency Hospital we found no fewer than 144 in which loss of memory was a prominent symptom. These comprise the complete series of states of fugue and retrospective losses of memory of a functional type: eases of interference with memory due to disease of the brain, and of transient loss of consciousness after head injury are not included. Severs psychological stress was an important factor in these syndromes, as will be seen from Table I.
Classified diagnostically, amnesic syndromes were found rarely in epilepsy and schizophrenia, more commonly in head injury, but predominantly in psychoneurotic states. This may he partly caused by the selective admission of psyehoneuruties to our hospital. We have found only two eases of epilepsy, both showing a functional type of syndrome and not the classical post‑epileptic automatism.
Fugues are a classical though uncommon manifestation of schizophrenia. Typically they represent a disturbance of consciousness in which catatonic phenomena or paranoid and hallucinatory experiences dominate the patient. But in the three schizophrenics in our material the fugue took a form superficially hysterical in appearance, and in one of them the patient had suffered from fugues since childhood. One of the others has points of interest.
Case 1. (2001S) A man of 24, of psychopathic family, said he had suffered from headaches for many years and had been unhappy in the Army. After a period of leave be returned to his unit; he was worried about his wife's ill‑health and a day or two later took, without permission, an Army motor‑cycle to go home and visit her. On the way he had an accident in which he was not injured but £20 worth of damage was done to the cycle. He got back to his unit, but knew he was in for trouble. He began to feel dizzy, fell down, was taken to hospital mute, and when he came round two days later was unable to remember the events of the immediate past. Attempts were made without success to clear up the amnesic patch, both by hypnotism directly and under the influence of sodium amytal. But under the drug florid schizophrenic symptoms were for the first time revealed. Ever since he had joined the Army he had felt that it was a matter of general knowledge that his father had been in prison for raping a daughter and that he, the patient, was the object of public contempt on this account. He described auditory hallucinations and interference with his thinking by which his mind was made to go blank at times.
Head injury was a causative factor in ten of our eases. In half its effect was indirect; permanent impairment of the personality by cerebral trauma, with a resulting increased tendency to hysterical types of reaction, provided a basis for the operation of psychogenic stimuli months or years later. In the remainder the effect was more direct, the unconsciousness produced by concussion passing without intermission into the dissociation of a fugue. Besides the traumatic there is a constitutional factor: there was a history of neurosis or psychosis in the first‑degree relatives of six of the ten patients, and in four the personality of the patient was psychopathic, even before any head injury had occurred It was interesting to find that of the 129 psychoneurotic patients, 30, or nearly a quarter, date their amnesic disturbance from concussion or from being blown over and dazed by a bomb. This is a high proportion. In many of these eases, though subsequent treatment cleared up the major part of the amnesic period, there remained a small gap, presumably due to organic disturbance.
From Table II it will be seen that indications of constitutional inferiority were more frequent in the 32 men who broke down in the absence of any military stress than in the remainder. Nearly all (28) had fugues; three others did not actually wander off, but passed into a confused state necessitating admission to hospital, where they were found to have lost most of their memory of their past life; and one man under examination for a minor military crime lost his memory for the events on which he was being examined. In all, 6 of these 32 men showed symptoms of hysterical pseudo‑dementia on admission to Sutton. Evidence of constitutional factors was strong, a positive family history and previous nervous breakdown being very common. In the families of three men a father, a mother and a sib were said to he subject to the same sort of amnesic attacks as the patient; in another a sib suffered from epilepsy. Six men had had fugues in earlier life, before entering the Army, two for the first time before puberty. Two others had suffered in earlier life from dizzy attacks and faints. In ten eases in all, fugues had occurred not once but several times. There were similar but less frequent findings in the men who went through stress (Groups IIa and IIb); four of these patients had had previous fugues, and eight others had had other types of disturbance of consciousness, such as sleep‑walking, hysterical fits and faints. These findings suggest the possibility of a constitutional behaviour pattern.
Returning to the group of men who broke down under trifling stress, one might legitimately cast some doubt on the complete sincerity and trustworthiness of all of them; but in nine of the 32 deliberate lying was observed, or there arose otherwise a strong suspicion of malingering. This, however, generally occurred in an affective setting, in which hysterical features were as a rule combined with anxiety, depression or hypoehondriasis. The following ease illustrates most of the features shown by Group I.
Case II. (414S) Aged 21. This man's father was discharged from the Army in 1918 with neurasthenia ". The patient could remember him wandering off on four occasions and being away for a period lasting from a day to five weeks. He never knew, where he had been, and on getting home it might he another fortnight before he would or could speak. He was a moderate drinker, but of irritable sulky temper. The mother also was neurotic. The patient was nervous as a child, timid, frightened of policemen and soldiers, and in later life was unaggressive and would not strike another man hack. Before the war he had thoughts of becoming a conscientious objector, and would lie awake at night in a pool of sweat thinking about it. He did not like the Army at all. For a week before his fugue he hardly slept, suffered from headaches and knew something was going to happen. On the Saturday morning he felt worse. He remembers going to the hoard to read Orders ; he went away, felt faint, and knew nothing more until, feeling as if he were coming out of a faint, he found himself five days later outside a cinema in Barking, 74 miles away. Apart from needing a shave, he was clean and well‑eared for. His mother let the hospital know that he had paid a flying visit on the evening of the Saturday of his disappearance, just dashing in and out again. In hospital he was unremarkable but was the life and soul of amateur theatricals among the soldiers, which he organized. He, steadfastly refused to allow any attempt to be made to recover the memory of the five days of the fugue. He was invalided. There is, of course, a strong suspicion of malingering in this case, and it is quite likely that the exhibition of fugues by both father and son is not so much inheritance as mutation.
In the remaining 97 psyehoneurotics (Groups IIa and IIb) who broke down under strain, the amnesic symptoms took two forms, a prolonged disturbance of consciousness, nearly always in the form of a fugue, and a retrospective forgetfulness for distressing events of the past occurring when the period of stress was over. A colleague, Dr. Denis Hill, has pointed out in private discussion an important difference between these two types of symptom. The fugue, he considers, is an escape from the events of the present, a gross form of behaviour disorder, very often malingered, and shown, apart from the psychotic, as a rule only by severely psychopathic personalities. The an'inesie gap in the memory of the past is, he thinks, a simple protective mechanism by which the continued recollection and presence in consciousness of painful events is avoided, a mechanism shown in minor degree by the normal person in everyday life. There is much to he said for this view, but the two types of manifestation cannot be so simply and certainly separated. Some of these men broke down under stress and passed into a fugue which provided them with some form of escape. Others first broke down after return to safety and passed into fugue that served no detectable purpose. In sonic of the cases of retrospective amnesia breakdown had occurred at the time of stress, in others only later; in some of these the amnesia for the period of stress was diffuse and patchy, in others it was so complete and circumscribed as to resemble a fugue of the past We have seen both fugues and retrospective amnesias in the same individual, and we have not found that the fugue is exclusively associated with grosser degrees of departure from normal behaviour. Nevertheless the figures of Table II, showing a slight but fairly consistently higher incidence of abnormal findings in the fugue cases (Group IIa) than in the eases of retrospective amnesia (Group IIb), indicate that the fugue is to he classed as the more abnormal manifestation. The high incidence of signs of constitutional abnormality in all groups in Table II will he noted. This is evidence against the view that the acute nervous breakdown of war is a phenomenon to which even the most normal personalities are liable. It is true that in a fifth of the acute cases of Group II no history indicating pre‑existing instability was elicited. This does not mean it did not exist. A weakness of these figures is that in only occasional cases was an independent history available.
An analysis of personality traits was undertaken, but apart from two findings showed little of interest. The distribution of hysterical and of obsessional traits of personality differed sharply from expectation, the former showing a positive and the latter a negative correlation with abnormality of behaviour (see Table II). There was, however, a much more important finding which could not be conveyed in crude percentages. In examining our records we were struck by the frequency of a certain type of personality among the more normal of the men who broke down under stress (Group II). This type is best described by quotation from the records: “go‑getter, energetic and active"; "sociable, fond of singing"; "high‑spirited, interested in sports"; " knock‑about, likes parties and jokes"; "many friends, simple type"; "high‑spirited, self‑confident, whisky drinker”, "rolling stone, fond of company, drinks a good deal"; "devil‑may‑care, likes making and taking jokes"; "generally gay, low‑brow interests, exaggerated idea of own abilities”. Nearly half of the patients of Group II were of this type, and they made up a very high proportion of those whose personalities were regarded as within normal limits. Summarizing, one may say that they are an outgoing type, popular with their mates, perhaps over‑keen on popularity, not fond of their own company, quickly responsive emotionally but with affects tending to be shallow and lacking in persistence, not gifted with insight. The personalities classed as abnormal in Group II did not conform to the same type, showing the development, relatively to other traits, of paranoid tendencies, unsociability and poverty of energy output.
The clinical picture presented by the men who broke down under severe stress (77 of the 97 patients of Group II) frequently showed a very acute neurotic disturbance combined with a state of exhaustion resembling physical illness. This was particularly true of the earliest patients admitted after the Dunkirk evacuation. Many looked pale and drawn; others wore a blank or confused expression, and occasionally some degree of disorientation and objective confusion were seen. Headache was a prominent symptom. Symptoms of acute anxiety were not infrequently combined with others of a contradictory type, such as apathy, belle indifference or even a mild euphoria. Hysterical conversion symptoms were occasionally seen, such as loss of voice, paralysis or gross tremors, even of the pill‑rolling type. Physical exhaustion, as shown by a weight far below normal for the individual in question, was often present; and it is probable that this physical factor is responsible for much of the deviation from familiar neurotic pictures. The history that the patient gave was often confused, hazy and full of amnesic gaps; on other occasions it was fairly coherent, and the suppressions of memory were only found by investigations with hypnosis or barbiturate narcosis. The following patient of Dr. Debenham's is illustrative. ‑
Case III. (1379S): A man of 24 was admitted from Millbank Hospital, having broken down at the end of a period of leave after return from Dunkirk. He described himself later as a sociable man, fond of parties and keen on his work, but easily upset by a mistake and liable to get out of spirits. On admission he was inarticulate and it was impossible to get a connected statement from him. His head and upper trunk were constantly shaking, and he held his head bent forwards, looking out of the corners of his eyes. He muttered or mumbled to himself, or moved his lips as if in speech, but was only able to answer questions slowly and softly and with a stammer and many repetitions of words and phrases. He picked restlessly at his hands and clothes and looked round anxiously at the slightest noise. He said that a bomb had fallen near him in Belgium, and he had subsequently been much upset by the scenes of dead and dying; when speaking of the bomb tears came into his eyes. There was a suggestion of something histrionic in his behaviour. Under intravenous barbiturate he lost his inhibition, tremors and ties, and was able to give a full account of his experiences with a good deal of emotional abreaction. No one experience had upset him more than another, but he had felt deserted and helpless, harrowed by the sight of slaughtered civilians and of his own comrades being killed and, as he thought, ' losing their reason ". On the bench at Dunkirk he had kept a bullet in his rifle for use on himself, to save himself from being ' cut up " by the Germans. After this session he was much improved ; but though the retardation and apparent confusion largely disappeared for good, the tremor of the head later returned to some degree. He eventually required invaliding.
As July and August came, the post‑Dunkirk eases ceased to bear this hyperacute aspect. Symptoms of physical exhaustion were more seldom seen, though the patients were still often underweight. Anxiety symptoms remained much to the fore, but the patients' complaints came to bear a more hysterical quality. These later cases have been more difficult to treat and have not done so well from the Army point of view. We sent back to duty more than half of the patients admitted in May and June, but little more than 40% of those admitted later. The following ease of Dr. Craske's, admitted towards the end of July, is an example of fugues appearing comparatively late in the course of an acute neurosis.
Case IV. (1521S): A man of 24 was admitted complaining of pains in the head, giddiiess, tingling feelings in the legs and hands. His mother was said to he prone to worry find depression and a brother had been nervous since the last war. After school he became an engineer, until called p from the Territorials. He married because he “had to", but the child was stillborn, and he felt cheated and has resented the loss of his freedom ever since. He described himself as a cheerful, easy‑going man, a popular N.C.O., though occasionally subject to mild moods of depression. He enjoyed Army life in France, was not upset when hostilities began and at first was little affected by bombing After a hit, however, he began to suffer from nightmares, disturbed the others by shouting in his sleep, had headaches and felt anxious and irritable. The unit was moved rapidly from place to place and they got little food or sleep. Finally the whole section of 250 men fell into an ambush and were killed or taken prisoner. He was wounded in the shoulder, and was put into an ambulance and taken to a German base hospital. He was sure that some time the Germans would kill him, and when a large number of prisoners were being moved further back, he managed to dive through a hedge and escape. He got to a farm, where he was given food and civilian clothes, and mingled with refugees. He had a number of narrow escapes from Germans and from suspicious French whom he asked for food or water; but at last he got to French occupied territory and was taken to Dunkirk hospital, where he was with a great number of other soldiers and civilians. During the evacuation from Dunkirk he was still in civilian clothes, and was repeatedly stopped and questioned; this even occurred at Margate, where he became acutely upset. He was taken to Westminster Hospital, and his wound was treated. He could do nothing but think about his experiences and cry, and could not speak to his wife when she came to see him. After leave he returned to his unit, but could not do his duties satisfactorily, and became depressed to the point of thinking of suicide.
On arrival at Sutton, he was still depressed, preoccupied with his experiences and dreaming of them at night. He said he hated the vat, the Army, the sight of other soldiers, He felt completely changed, as he had always been so friendly, and now everything he did was wrong. He complained of headaches and tinglings, and was sweaty and shaky. He told his story coherently, and there were no discrepancies or signs of an amnesic gap. In the first fortnight he made no improvement, and was then put on continuous narcosis, during which he became confused and hallucinated and talked constantly, re‑living his experiences. At the end of the course of narcosis he was improved, but began to have frequent attacks of dissociation, lasting about fifteen minutes, during which he was hack in France, usually seeing the Germans coming through the trees at the ambush. In the semi‑hypnotic state induced by amytal further details of his history were obtained. He now related how he had been put in charge by the lad's parents of a boy in his company, and had in fact kept him under his wing. The boy was very nervous and finally in a wild panic had rushed off directly into enemy machine‑gun fire, and must either have been killed or taken prisoner. A letter had now arrived at the hospital from the parents of this boy, asking for news. The patient was induced to answer the letter, and was much better, particularly when he heard a little later that his friend was now known to he a prisoner of war. But the hysterical attacks still continued, and further exploration revealed facts of a different kind. He now said that even before the offensive he had felt depressed and had had “wicked" thoughts about his, wife. When he got depressed in France he got drunk, and had then several times gone with other women, feeling mean and guilty afterwards. The last time his wife visited him he had told her he did not want to see her, and he now felt he must have broken her heart. More than once after this there was improvement followed by relapse, exploration on each occasion releasing painful memories with temporary improvement. In his relapses the patient several times had fugues, one of which led to his waking up in the middle of the night in a neighbouring town; he thought he was back in France, accosted a policeman in a panic, and was taken to the station. Permanent improvement was only obtained when with much difficulty the full data of an incident in which he had deserted a wounded comrade were obtained. After this the period of dissociation were at an end. He then had a course of modified insulin treatment with much benefit. He had a month's leave at home, and returned fit, with no recurrence of the fugues; but it was thought best to invalid him from the Army. He was clearly a severe constitutional hysteric, despite his satisfactory adaptation to ordinary peace‑time life.
Several points of interest are exhibited by this case. The clinical picture shows not only hysterical symptoms, but also a fairly deep degree of depression; in the past there are corresponding foci of guilt and self‑reproach, inadequately dealt with by complete suppression. The amnesic gaps were not apparent on first examination, but came out only in the course of intensive treatment; nevertheless no lasting improvement was possible until the last of the suppressed material had been brought out. Treatment had to be devoted to the physical aspect as well as to the psychological, continuous narcosis and insulin treatment playing their parts, first in dealing with the depression and agitation, finally in stabilizing recovery when attained. In this case the amnesic phenomena, which appeared first only under severe stress, were finally manifesting themselves as fugues in the most facile way, as the behaviour pattern became established.
The association of amnesia with guilt was rare, but a prominent feature in some of our cases. Only seven men, six of them fugue cases, showed this association in the 77 who passed through severe stress. The events for which forgetfulness was so desired were lot the most part the horrors and strains of that catastrophic retreat. However 43 of these men broke down at the time of stress, thereby becoming a burden on their fellows, which might have well been a subject for uncomfortable and undesired self‑examination.
A classification of the symptoms shown by the men who came through severe stress is attempted in Table III. Anxiety and hysterical manifestations were the most prominent symptoms, though conversion symptoms were uncommon. Symptoms resembling those of schizophrenic states were very rare, hallucinations and catatonic‑like behaviour being seen in one case each. Malingering also was rare.
The treatment of these states is, of course, the treatment of the patient as a whole. But we have found it best not to ignore the amnesic symptoms, to explore the gaps in memory, and to be on the look‑out for them, even when they are not immediately obvious, or are denied. These patients can certainly get well without interference; but men admitted to us months after return from Dunkirk have seemed to benefit from the restoration of lost memories, from which they had suffered throughout the intervening period. The better the personality, the more is the lack of knowledge of what happened in an amnesic period a source of worry to the patient. The method of exploration is a matter of personal choice; but we have found in our unit that the administration of an intravenous barbiturate is of particular value in these acute patients, who are often rather insusceptible to direct hypnosis. Under the drug it is easier to establish a semi‑hypnotic contact, a point of value to the doctor who is uncertain of his hypnotic powers. The information gained will often be a mixture of truth and fantasy, and will have to be sifted. In any ease the process is only one of the steps in treatment, the next being an emotional synthesis, the restoration of normal physical good health, and the readaptatinn of the patient. When symptomatic recovery is attained, reconditioning should begin. For the best results the patient should be convinced by actual trial that he can face the duties he carried out before breakdown. Unfortunately this is not possible in the hospital framewoik, so that chances of relapse are difficult to estimate. It is here that rehabilitation centres would have one of their main functions.
The progress of these neurotic states would in the uncomplicated ease normally be back towards the patient's natural base‑line, whether that is one of good or ill health. Unfortunately in this interim stage in the war the complicating factors are many. The patients of Group I are largely a constitutionally inferior material, and only a partially satisfactory adaptation could be expected. But it was disappointing to find so many of the more normal personalities of Group II incapable of being brought to the point of facing renewed military duties, even in the less risky circumstances of service at home. It was here that the lack of rehabilitation camps under combined psychiatric supervision and military discipline made itself felt. Even of those whom we did send back to duty about half have had subsequently to be invalided at some other centre. So far as we have knowledge of the invalided patients, they are nearly all at civilian work, but many still suffer from anxiety symptoms in air‑raids. The difficulty is that we have not as yet been able to tackle the pathogenic situation, that of the war, which awaits, not psychotherapy, but curative surgery.
In a complete series of a thousand military neurotic casualties there was found the high number of 144 who presented an amnesic syndrome. The frequency was much the highest in those cases who had undergone severe stress, such as the Flanders retreat. Epileptics, schizophrenics and cases of head injury were been, but the great majority were psychoneurotic. In about a quarter of these eases trivial concussion or dazing seemed to have played a precipitating role in producing states of hysterical dissociation. Those who broke down in the absence of stress were for the most part severe psychopaths, and included many cases of malingering in an affective setting. In 83% of all the psychoneurotic eases there were indications of constitutional instability. Some evidence was obtained that there may be a specific constitutional tendency to fugues and other forms of disorders of consciousness. In cases occurring under rtress the amnesic syndrome showed two main manifestations, fugue and retrospective gaps in the memory of past stress. Evidence tended to show that patients developing fugues had more psychopathic traits than those who showed only a retrospective amnesia. Patients breaking down under stress were, with striking frequency, men of a simple, superficially well‑adapted, extraverted type of personality. The amnesic symptoms were shown in a setting in which affective features were prominent; these were, in descending order of frequency, anxiety, hypochondriasis, depression and paranoid symptoms. The treatment and prognosis of these cases are discussed.