Psychosomatics 44:346-347, August 2003
© 2003 The Academy of Psychosomatic Medicine
Intravenous Diazepam for Dissociative Disorder: Memory Lost and Found
Laurie Ballew, D.O., Ed.D.,
Yasser Morgan, M.D., and
Steven Lippmann, M.D.
Received Sept. 13, 2002; revised Dec. 2, 2002; accepted Dec. 13, 2002. From the University of Louisville School of Medicine. Address reprint requests to Dr. Ballew, University of Louisville Hospital, 5 South, 530 South Jackson St., Louisville, KY 40202; lkballew{at}bellsouth.net (e-mail).
Increasing recognition of dissociative disorder has led to the development of greater clinical awareness and identification of this syndrome. Dissociation is a presentation that can be explained as an emergency defense mechanism that shields against overwhelming anxiety at times of severe emotional distress.1 Several forms of dissociative disorders have been categorized, including depersonalization disorder, dissociative fugue, trance disorder, identity disorder, and amnesia. The latter type is defined as an episode of profound inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.2 Amnesia may occur alone or can be part of a constellation of dissociative symptoms, such as being detached from the reality of one's body, perceiving reality in a grossly distorted way, or having a persistent feeling of not being real.3 Memory retrieval is approached often through interpersonal and/or psychotherapeutic techniques. If unsuccessful, pharmaceutical considerations may follow.
The medicinal use of chemicals to recover otherwise repressed or forgotten material dates back to the mid-1800s with the use of anesthetics and therapeutic sedation for mentally disturbed patients.4 Many drugs have been researched for this purpose, including opium, hashish, scopolamine, chloral hydrate, and other anesthetics. Initially, the barbiturates amobarbital and pentothal were the favored agents.5 Administration of barbiturates enables recipients to reduce anxiety that seems unbearable if expressed in a conscious state. Suppression of consciousness and anxiety are pharmaceutically achieved by lowering the amount of cellular energy available through metabolic interference of glucose, lactic acid, and pyruvic acid oxidation. Barbiturates, however, have the significant complication of a low therapeutic index and are no longer universally recommended for that reason. In recent decades, because of their safety, benzodiazepines have been the drug of choice for conscious sedation. A 10-year review of the literature6 voluminously documented a beneficial outcome of the use of benzodiazepines for conscious sedation in various interventional and endoscopic procedures; however, we found no such reports of this therapy for memory retrieval in psychiatric citations. Case experience and anecdotal lore among psychiatrists have maintained this technique over the years in the armamentarium of treatment options. The following clinical vignette documents a recent case of a man with profound amnesia that was successfully reversed by treatment with intravenous diazepam.
Case Report
Mr. A, a 74-year-old white man, was brought to the hospital emergency room after awakening on a park bench not knowing who or where he was. He reported having no memory of how he got to the park nor did he know his name or where he was from. He had no identification in his possession. Mr. A did not know his occupation or if he had any medical problems or physical trauma; he reported no use of alcohol or drugs. He was admitted to a general medical floor, where results of a thorough workup, including a neurological examination, an EEG, and a computerized tomography scan of his head, were normal. Later, he remembered being a smoker and was allowed to go outside the hospital for a cigarette, but he got lost and was returned by police escort. The psychiatric service was then consulted.
Mr. A was transferred to a psychiatric floor. There he reported being concerned about his amnesia, but he did not appear to be uncomfortable. Results of a mental status examination revealed that Mr. A was alert, oriented, and had no changes in his sensorium. Results of cognitive testing of his new learning capacity were unremarkable. Mr. A exhibited a normal range of mood and affect. No evidence of psychosis was present. There were no suicidal or other dangerous ideations. In a discussion of treatment options, Mr. A refused hypnosis. After multiple conversations and reassurance, conscious sedation became his chosen method to facilitate memory retrieval. There were no contraindications for an anesthetic procedure. Mr. A gave his consent to receive intravenous diazepam.
Before he received diazepam through induction, Mr. A went without food and fluids for 12 hours. The conscious sedation session was conducted in a quiet atmosphere with subdued lighting in a surgical recovery room suite. Over a period of 90 minutes, a total of 30 mg of diazepam was slowly administered intravenously by means of individualized titration. Cardiac monitoring was continuous, with backup anesthesia. Mr. A's electrocardiographic tracings remained in a normal sinus rhythm, and his blood pressure was unremarkable. His oxygen saturation was close to 100% during the entire procedure, without any respiratory compromise.
Once Mr. A was relaxed, his diazepam dose was gradually increased, and he was able to answer questions regarding his identity, past medical history, and family background. He remembered his date of birth, social security number, and other personal facts. He also recalled that one of the precipitating factors of his leaving home was significant marital discord. Mr. A tolerated conscious sedation well and remained physically stable.
Mr. A was most appreciative for the retrieval of his memory. His family was then contacted and verified all of his responses. Two days later, they came to the hospital for a conference. Mr. A was released to go home with his sister. She reported that when under stress he had disappeared from home on two different occasions during his lifetime. Subsequent follow-up revealed that Mr. A continued to do well. Mr. A is now living in his own apartment; he shows no evidence of problems with memory or cognition.
Discussion
We report successful use of intravenous diazepam for a patient with amnesia. It has been documented in the literature that diazepam is an effective form of treatment for acute anxiety, and it is well tolerated.7 Our patient suffered no side effects. Diazepam was intravenously titrated slowly over a period of 1 hours. Too-rapid administration can overly sedate a patient, causing sleep and precluding accurate memory retrieval or inducing respiratory suppression. Cautious dosing can result in a calm, communicative patient who remains able to participate in the memory-retrieval process. Other than oversedation and safety concerns, this procedure has few risks. Conscious sedation was successful in this patient's memory retrieval. He subsequently reported no cognitive difficulties.
Conscious sedation with slow intravenous administration of diazepam is endorsed for consideration as a treatment option for people with amnestic disorders. Safe monitoring during the procedure is of paramount importance. All vital signs, including respiration, must be closely monitored. Some hospitals require specific guidelines for performing conscious sedation, such as having selected personnel present and completing the procedure in a recovery room suite with specific careful monitoring. Before development of such a plan, a complete evaluation should rule out any potential complications regarding the use of intravenous sedation, such as respiratory disorder or sleep apnea. Liver diseases may mandatorily lower conventional dosing. First, ensure a nonpregnant status. A 12-hour fast before an induction is recommended. After conclusion of conscious sedation, a patient should be observed until fully alert and physiologically stable. Intravenous diazepam is an effective, safe intervention to consider for facilitation of memory retrieval in amnestic patients.
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- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, APA, 1994, pp 156-164
- Dissociation/dissociative disorders, in Gale Encyclopedia of Psychology:2nd ed. Farmington Hills, Mich, Gale Group, 2001. http://www.findarticles.com/cf_dls/g2699/0001/2699000100/p1/article.jhtml
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