Amnesia In Romance (AIR Syndrome)

(January 15, 2001)

Return to Issue #109 of At the Back Fence

The hero rescues a beautiful head-injured woman who turns out not to know her own name. The heroine meets a stranger who goes under a pseudonym because he's an amnesiac. Who assaulted our brave little amnesiac? We have to find the culprits before they return. Too bad the victim can't remember any clues.

Ring any bell?

The incidence of amnesia among romance novel characters appears a lot higher than in the general population. Lost identity is a convenient narrative device to make the characters start anew, and blank history provides beautifully for Big Secrets, Big Misunderstandings and Suspense. An amnesia story can be engaging drama.

Unfortunately, the dramatic effect is often spoiled for me by the realization that the injury story is a complete fabrication. The word amnesia may sound scientific and impressive but Amnesia In Romance (AIR) has nothing to do with medicine and everything to do with air-headed research. Many novels romanticize head injury and portray amnesia patients in a completely unrealistic manner.

A few facts and terms about memory and amnesia:

  • Memory has many components. You'd have difficulty with short-term memory (STM) if you forgot where you put your keys a minute ago, difficulty with long term memory (LTM) if you forget important events that happened years ago. Episodic memory means remembering one's own experiences and semantic memory stores facts. Knowing Kennedy is a dead president would be semantic memory, remembering where you were when he was shot belongs to episodic memory.

  • Information has to be processed a bit and usually we have to pay some attention to it before a short term memory trace can be formed (encoding). Most things we fleetingly sense or think about are forgotten right away but those that are more important or more frequent enter a long term storage. Later, when the information is recalled, one must somehow be able to access and retrieve this memory trace.

  • The word amnesia is usually used to refer only to severe memory problems. Mild forgetfulness is generally not thought to be amnesia. A person with anterograde amnesia might remember pre-injury things pretty well but is unable to form new memories. Someone who's forgotten the last three or twenty years before the injury has retrograde amnesia.

  • Amnesia may be caused by brain injury, oxygen deprivation, stroke, brain hemorrhage, brain infections, delirium, substance abuse, transient global amnesia and a number of dementing illnesses.

  • In romance novels the characters get amnesia usually after a head injury. This is perhaps an obvious choice, since there's nothing romantic about alcoholic delirium and many of the above conditions would at least temporarily require hospitalization or physically disable the patient, thus preventing her from going out after the criminals. Also, having the twentysomething heroine to develop Alzheimer's disease would be a stretch.

Rant rant rant

So, what's my problem then? If there are lots of different kinds of memory disorder why can't I accept AIR?

Well…(*sigh*).

You know the drill. The heroine gets hit on the head by a villain, loses her consciousness, might stay comatose for a while, wakes up feeling comparatively healthy despite a slight headache and says: "I can't remember who I am." She does not recognize her own mirror image nor the faces of her most intimate friends and family. The hero who rescued her invites her to live with him and falls in love with her. They go on a quest to solve a complex mystery involving the heroine's identity and a number of dangerous situations, and the heroine appears to be fully functional if not for the small problem that she can't remember anything about her past. They have mind-blowing sex. She starts to get painful flashbacks of her past and then, suddenly, everything comes back to her just when the villain is planning another attack on her. The hero foils the evil plan and everything's perfect again.

In technical terms the AIR patient has retrograde amnesia, which damages her long term memory about everything that happened to her since early childhood, and her knowledge about facts that concern herself. In contrast, she seldom has any anterograde amnesia since she's perfectly able to remember things that she has learned after the onset of her amnesia and her short term memory seems alright as she's got no problems with following conversations etc.. Also, the whole of her semantic memory is not affected since she understands what words refer to, usually has a pretty good idea about what's going on in the world about her and might even be able to tell you who Kennedy is.

The memory loss is highly specific. She does not usually have problems in speaking, reading, writing, motor function, perception or concentrating. concentration.

As far as I know the medical science has never recorded a pure case of AIR. I know I haven't met anybody like that and I meet a lot of amnesiacs and TBI patients in the course of my job. Head injuries do cause amnesia but they are extremely unlikely to cause just that type of amnesia that occurs in romance novels. Head injury patients usually have brain damage (with the possible exception of gunshot wounds) and there are likely to be varied problems, not this kind of very selective but complete amnesia, which leaves thinking ability absolutely intact. (Please prove me wrong if you can, we could write a revolutionary article to Lancet together and get the Nobel prize for Medicine one of these years.)

Head Injury Symptoms in Real Life

People with amnesia frequently forget the accident itself and have patchy memories about the events of the immediately preceding and following days (post-traumatic amnesia, PTA), even if they haven't been in coma or under medication. The longer the memory gap the more serious the accident generally is and the more likely they are to have permanent memory problems. There are reports of patients who have forgotten years of their life. Mild cases might recover with few lasting memory problems and might learn to remember what they've been told about these events but even so, the memories about the accident itself won't return, they are unfortunately usually lost for good. They do not miraculously return with the aid of retrieval clues, in hypnosis, or even worse, after getting a new head injury like in slapstick comedy.

A patient with a serious amnesia is not likely to forget her own name first thing. She might forget who Kennedy was but personal information like her name should be relatively easy to remember. She might be deluded about her age or tell you her previous name or address if the retrograde amnesia spans several years but still, her identity is likely to be relatively well preserved. General disorientation might explain identity confusion but AIR patients are not disoriented as they are in most ways able to function normally and they usually retain their sense of time and place, at least after they've been informed about these things. Also, a severely amnesic patient seldom realizes the extent of her memory problem.

If a person has been injured in this way and has difficulty remembering old information she is likely to have difficulty in other areas. Areas that no AIR patient has trouble in. Take a typical AIR patient who can't tell you her name or recognize her family after the initial post-injury period. If this happened in real life you could confidently say that her head injury is really severe. A patient like this would probably have problems in concentrating in daily tasks, she could be forgetful, impulsive, easily distracted and might have vertigo and terrible headaches. She might lose her initiative, be depressed or be completely unaware that she's not well. She might go through a personality change, become more irritable, have behavioral problems such as temper tantrums or difficulties to control her drinking. She could have trouble filling out her insurance forms or keeping her accounts, be more prone to being taken advantage of if her reasoning ability or judgment are affected or not be able to drive a car any more. If she has a sexual partner their relationship is likely to change. She'd probably not be able to return to work and would need a lot of rehabilitation and support in order to return home. If the complete amnesia persists she might need a legal guardian to assist her in financial and legal matters.

Not all patients have as bleak a prognosis as this and in fact, many people recover close to completely, but in the case of amnesia of average romance severity the road to recovery is not as rosy as romance authors would have us believe. PTA longer than a few hours is a bad prognostic factor and if severe amnesia persists beyond a few days after the injury there are likely to be some permanent deficits or even disability. Some romance novel constants that a TBI patient with total amnesia and identity confusion is not likely to experience include taking good care of her daily business although she can't remember anything, being successful in private detecting, and a sudden improvement in the quality of her sex life. All of these are possible in AIR, as AIR patients do not usually have any cognitive or psychiatric problems worth mentioning, besides the amnesia.

Should AIR really be considered a psychiatric disorder instead?

All in all, the AIR symptom of forgetting one's identity seems to me to be more likely to be caused by conversion hysteria, some sort of confusional state or delirium, dissociative disorder or psychosis rather than a head injury, although romance authors seldom choose these alternatives. Someone might forget a traumatic event to protect herself from severe emotional distress or they might have a multiple personality. In any case, the amnesiac should seek instant medical attention. It's distinctly unethical for the hero to take advantage of the poor amnesiac sexually while she's in a vulnerable emotional state. Abstinence is for his own good as well, because if the amnesia is caused by psychiatric disorder or severe emotional trauma it's more likely that the patient will be able to function in a relationship after she's had therapy.

What I want for Christmas: Please stop romanticizing head injury

Have you ever met an amnesia patient? If you have you know that amnesia is not exciting. Amnesia is not romantic. Amnesia is not relatively harmless. AIR syndrome seems to be all of these things, but in real life amnesia and other symptoms associated with severe head injury are a great personal tragedy for many families. They necessitate sometimes drastic life changes and cause a lot of emotional stress. Even mild brain injury symptoms may cause a lot of difficulty for the patients, and the situation is made worse by the general lack of knowledge about their subtle nature.

I hope authors writing about a head injured character would do more research. They spend a lot of time getting the historical facts right - why not try to check the medical ones as well? Please don't romanticize head injury and belittle the patients' problems. The nature of head injury symptoms is misunderstood and belittled often enough, to the disadvantage of the patients. I don’t claim that fiction writers are responsible for this but surely inaccurate depictions in fiction are not helpful either. (And I always whine about non-realistic descriptions.)

If the loss of identity is essential to the plot I guess there's no getting around AIR syndrome, but at least the stories could be made more realistic by having the head-injured character suffer from other head injury symptoms and acknowledging the emotional strain caused by amnesia. AIR patients are completely aware of their symptoms so they don’t even have the dubious comfort of deficient insight. An out-of- the-blue amnesia in an otherwise healthy, cognitively intact and psychologically stable person just doesn't work for me.

I have fewer problems with the AIR syndrome in fantasy settings because I assume that in a world where magic and time travel are possible medicine might be a different science as well.

Speaking of medicine; please don't make physicians say stupid things like "Just give her time, it'll all come back to her". Physicians shouldn't give false hope. They can't know for sure. Probably some problems will be alleviated in time but a severe head injury is likely to leave some residual difficulty. Another no-no is "Don't worry, there's nothing wrong with her." Nothing wrong with her? The patient has got severe amnesia, for heaven's sake! She needs a CT scan or a MRI to rule out hemorrhage, skull fractures and other complications, a complete neurological check-up, later a neuropsychological examination to determine the scope of her problems and probably a fair amount of rehabilitation.

Amnesia does not preclude romantic love and happy ever after but it definitely makes relationships more demanding for the other person, who might have to take on a caretaker role in addition to the lover and partner roles and adjust to the patient's other symptoms. I've never read a romance novel dealing with this theme, however. (I'd order it to all my friends too if someone wrote a good one, so keep this idea in mind.)

Synopsis: Passion's Savage Amnesia

A romance novel about a real life patient with severe amnesia could read something like this: Heroine gets hit by a car right after she's met the hero for the first time. Surprise, the romantic rescuer doesn't fall in love with her, as he's a paramedic who can stomach gruesome sights like blood and bruising without getting mushy. She's in coma for five days. When she wakes up she's aphasic and has decreased muscle strength on the right side of her body. She recovers from aphasia gradually with the aid of speech therapy but her right hand stays weaker than the left one. She needs anti-epileptic medication.

She's got severe retrograde amnesia: when asked she states that she's seventeen years younger than her actual age and that the current president of the USA is Jimmy Carter. She does not remember anything about the meeting with the hero. She's got anterograde amnesia as well, she has difficulty remembering the name of the hero who comes to visit her and she frequently forgets conversations and appointments. Gradually her condition improves and she gets to leave the hospital but they won't let her go home alone so she moves back to her parents who take care of all the practical matters as she has trouble concentrating and is too prone for errors to handle any complicated machinery or large amounts of money. Her temper becomes more irritable which is really hard for her parents and the hero.

She promises to leave on a romantic vacation with him, to fix their relationship up, but the plan falls through because she can't remember where they were supposed to meet each other. She goes to the wrong place at the wrong time, forgetting her passport, and can't ring his mobile because she does not remember the number. She wanders around confused, wants to go home, takes a cab and tells the driver the address where she used to live when she was nine years old.

In the meantime, the hero is angry for being stood up and figures she's too unreliable and probably doesn't even love him. Even though he got a brochure he's got difficulty understanding the problems in their relationship are mostly due to her head injury symptoms. Finally he decides that he wants a partner who can take care of him instead of the other way around. He goes to Barbados alone to lick his wounds and if he's lucky he could meet a pretty non- amnesiac pregnant virgin. We have to wait for the sequel to find out if the amnesic heroine ever finds true love. Fade to pink.

For more information see

  • Human Memory by Alan Baddeley
  • Human Cognitive Neuropsychology by Ellis and Young
  • Neuropsychiatry of Traumatic Brain Injury by Silver, Yudofsky & Hales

-- Maria K.

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