Dissociative Fugue

Causes and Symptoms:

According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV):

The essential feature of Dissociative Fugue is sudden, unexpected travel away from home or one's customary place of daily activities, with inability to recall some or all of one's past (Criterion A).
This is accompanied by confusion about personal identity or even the assumption of a new identity, partial or complete (Criterion B).
The disturbance does not occur exclusively during the course of Dissociative Identity Disorder and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (temporal lobe epilepsy) (Criterion C).
The symptoms must cause clinically significant distress of impairment in social, occupational, or other important areas of functioning (Criterion D).

Dissociative Fugue, formerly called Psychogenic Fugue, is one of four Dissociative Disorders that are found in the DSM-IV. The other three disorders include: Dissociative Amnesia, Depersonalization Disorder, and Dissociative Identity Disorder. There is a fifth category for Dissociative Disorder that does not meet criteria for any of the other four.

Fugue is more often a unique Dissociative phenomenon. However, it may occasionally occur in other conditions; i.e. undirected wandering seen in neurological disorders, particularly complex partial seizures (temporal lobe epilepsy). Travel may range from brief trips over relatively short periods to complex, usually unobtrusive wandering over long periods, (i.e. hours or days). There have been instances where the individual has crossed numerous national borders and traveled thousands of miles.

During a fugue episode, the individual involved generally appears to be without pathology and does not attract attention. The person in a fugue state may function normally until questioning about their identity produces confusion. At this time, the individual is usually brought to clinical attention. Other than identity confusion, orientation and global mental functioning may be intact. Once the individual returns to the prefugue state, there may be no memories of the events that occurred during the fugue. In contrast, individuals with Alzheimer's or other forms of dementia often wander, but this wandering is classified as part of their dementia because of their intellectual deficits.

Fugue is a state of alteration of consciousness combined with an impulse to wander. It occurs in hysteria (it should be noted here that "hysteria" is no longer a part of the DSM-IV diagnostic vocabulary), depression, epilepsy, schizophrenia, organic cerebral disease and psychopathy. If the amnesia of fugue occurs without the unexpected travel, Dissociative Amnesia is usually diagnosed.

In addition, as stated in the DSM-IV, most fugues do not involve the formation of a new identity. If a new identity is assumed during a fugue, it is usually characterized by more gregarious and uninhibited traits than those of the former identity. The person may assume a new name, take up a residence, and engage in complex social activities that are well integrated and that do not suggest the presence of a mental disorder.

It should be noted that there is a prevalence rate of 0.2% for Dissociative Fugue in the general public. It is a rare disorder that is usually found in men. The prevalence may increase during times of extremely stressful events such as wartime or natural disaster.

This disorder is usually triggered by traumatic events, such as wartime battles, abuse, rape, accidents, natural disasters, and extreme violence. However, the fugue state may not occur immediately.

After the individual returns to the prefugue state, amnesia of traumatic events in the person's past may be noted. Depression, dysphoria, grief, shame, guilt, psychological stress, conflict, suicidal and aggressive impulses may be present. The person may also answer questions inaccurately, i.e. two plus two equals five as in Ganser Syndrome. (Ganser Syndrome was first described by Sigbert Ganser in 1898 while studying three prisoners, and was sometimes termed prison psychosis by early clinicians. It is sometimes referred to as "the syndrome of approximate answers," since individuals with Ganser's usually reply to questions by giving an answer that is slightly off.)

Some specific cultural features, defined as "running" syndromes may have symptoms that meet diagnostic criteria for Dissociative Fugue. These would include:

pibloktoq - found among native peoples of the Arctic
grisi siknis - found among the Miskito of Honduras and Nicaraqua
Navajo "frenzy" witchcraft
Some forms of "amok" in Western Pacific cultures.

These are conditions that are characterized by a sudden onset of a high level activity, a trancelike state, potentially dangerous behavior in the form of running or fleeing, and ensuing exhaustion, sleep and amnesia for the episode. These usually fall under Dissociative Trance disorder.

Diagnosis

Patients who experience fugue states should undergo a thorough physical examination and patient history to rule out an organic cause for the illness (i.e., epilepsy or other seizure disorder). If no organic cause is found, a psychologist or other mental healthcare professional will conduct a patient interview and administer one or more psychological assessments. These assessments are also called clinical evaluations, scales or tests. They may include the Dissociative Experiences Scale (DES or DES-II), Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D), and the Dissociative Disorders Interview Schedule (DDIS).

Dissociative Fugue must be distinguished from the symptoms of several other conditions that may include:

Head injuries - this determination is based on history, laboratory findings, or physical examination.
Individuals with complex partial seizures - individuals with complex partial seizures have been noted to exhibit wandering or semi- purposeful behavior during seizures or during postical states in which there is subsequent amnesia. However, the epileptic fugue can be recognized by motor abnormalities, stereotyped behavior, a postical state, and abnormal findings on serial EEGs.
Direct physiological effects of a substance - the use and abuse of certain medications and illegal drugs can also prompt fugue-like episodes. For example, alcohol induced "blackouts" that mimic the memory loss of the fugue state and sometimes involve unplanned travel.
Manic Episodes - in a manic episode, the travel is associated with grandiose ideas and other manic symptoms and such individuals often call attention to themselves by inappropriate behavior. Assumption of an alternate identity does not occur.
Schizophrenic Episodes - this psychopathology is usually accompanied by delusions, and negative symptoms that are not present in the Dissociative Fugue Disorder.
Malingered fugue states - this is the pretending of symptoms in order to avoid situations involving legal, financial, personal difficulties, as well as soldiers who are attempting to avoid combat or unpleasant military duties. However, true Dissociative Fugue may be associated with such stressors. Malingering of Dissociative Fugue can be maintained even during hypnotic or barbiturate facilitated interviews. Therefore, the examiner should always consider the diagnosis of malingering when the patient is claiming fugue.

Treatment:

Treatment for Dissociative Fugue focuses on helping the patient come to terms with the traumatic event or stressor that caused the disorder. Various kinds of interactive therapies that explore the trauma and work on building the patient's coping mechanisms to prevent further recurrence are often used. Some therapists use cognitive therapy, which focuses on changing maladaptive thought patterns, based on the principal that maladaptive behavior (the fugue episode) is triggered by inappropriate or irrational thinking patterns. A cognitive therapist will attempt to change these thought patterns by examining the rationality and validity of the assumptions behind them, with the patient.

In the case of a dissociative fugue brought on by abuse, therapeutic work that uncovers and invalidates negative self-concepts the patient has about him/herself may be used.

Hypnotherapy, or hypnosis, can often help the patient recover lost memories of trauma. Creative therapies (i.e. art therapy, music therapy) are also constructive, as they allow the patient to explore thought and emotions in "safe" ways. Self-discovery and a sense of control are encouraged, as this empowers the patient.

Medication in the form of antidepressants or anti-anxiety medications may be prescribed and used as an adjunct or a complementary treatment for some of the symptoms that the patient is experiencing.

Group therapy can be helpful, as it provides an on-going support system. The patient is thereby able to gain self-confidence and learns to interact with peers in a positive way.

Family therapy sessions may also be part of the treatment regime. Family therapy is used not only to explore the trauma that caused the fugue episode, but also to educate the rest of the family about the dissociative disorder and the causes behind it.

**This report is for educational purposes only, and should not be used to self-diagnose. Any symptoms of a personality disorder should be reported to one's healthcare provider in order to receive proper diagnosis, care and treatment.