197 Dissociative Fugue (300.13)

Dissociative Fugue is characterized by sudden, unplanned trips from the home or workplace without the ability to remember some or all of the individual’s past. Some of these patients take on new characteristics or aspects not related to their original identity. They tend to be running away from something of which they are unaware. After a fugue episode resolves, patients are unable to remember the events of the state. Although moving occurs in other disorders, in fugue it is purposeful and it is not enacted in a confused or dazed state. In a typical case, the fugue is brief, with purposeful travel, and limited contact with others. About 0.2% of the general population is afflicted with this type of dissociative disorder. (American Psychiatric Association, 2000).

Mental Status

• The mental status exam varies widely.
• Patient may present alert and oriented only to oneself.
• Eye contact and relatedness are limited to fair at best.
• Psychomotor activity is characterized by normal activity.
• Thought processes are intact, although thought content may vary widely from preoccupations to preservations to obsessive fixations to none.
• Reasoning and judgment are lacking, and insight is poor.
• An increased finding of violent or homocidal ideation is present, but suicidal ideation is lacking.

The DSM-IV-TR criteria according to the American Psychiatric Association (2000) includes the following:

• A. “The predominant disturbance is sudden, unexpected travel away from home or one’s customary place of work, with inability to recall one’s past” (p. 526).
• B. “Confusion about personal identity or assumption of a new identity (partial or complete)” (p. 526).
• C. “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 (e.g.., temporal lobe epilepsy)” (p. 526).
• D. “The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning” (p. 526).

Associated features

Dissociative Fugue was formerly known as Psychogenic Fugue. It is comorbid with Bipolar Disorder, Major Depressive Disorder, and Schizophrenia, as well as PTSD, Substance Related disorders, Panic and Anxiety Disorders, Eating Disorders, and Somatoform Disorders. Note: Dissociative Fugue is often mistaken for malingering. This happens because the disorder enables people to escape their responsibilities or undesirable or dangerous situations; therefore it is seen as if a person is taking the ‘easy-way-out’. A person in the midst of a Dissociative Fugue episode may appear only slightly confused or they may appear to have no symptoms at all and attract no attention. Eventually, however, the person will begin to show significant signs of confusion or distress as they become aware of memory loss or confusion about their identity. This amnesia is characteristic of the disorder. When the fugue ends, the person may experience depression, grief, shame, guilt, dysphoria, psychological stress, conflict, and suicidal and aggressive impulses, and he may give approximate, though inaccurate, answers to questions. (American Psychiatric Association, 2000)

Child vs. adult presentation

Dissociative Fugue usually begins in adulthood. There is little information about the presentation of this disorder in children. When it does affect children, it is most commonly due to severe trauma such as sexual abuse, but even then it does not usually present until adulthood.

Gender and cultural differences in presentation

• Some research revealed that this condition most often occurs in females, but the reason is unknown. One source stated that females are at a rate six to nine times higher than males, and it increases as age increases. This pattern is most likely associated with the stresses on a woman to be both mother and a family provider and caretaker, in conjunction with the societal pressures and gender prejudices. Most studies however, believed that Dissociative Fugue is equally prevalent across genders.
• There is little information on the cultural differences in presentation of Dissociative Fugue. It is important to remember that what may be considered dissociative in one culture, may be seen as normal in another. Cultures prone to warfare are more likely to experience the distressing pressures of war, which is a common causal traumatic event of this disorder. Various cultures with defined “running” syndrome may have symptoms that meet diagnostic criteria for Dissociative Fugue, such as the amok in Western Pacific cultures.

Epidemiology

• This is a relatively rare disorder, actually the rarest of the dissociative disorders, affecting about only 2 in 1000 people in the United States. The prevalence rate is estimated at 0.2%. It is much more common however among people who have been in wars, accidents, natural disasters, or other highly traumatic or stressful events. (American Psychiatric Association, 2000)
• Single episodes are most commonly reported and vary in duration. Recovery is usually rapid, but Dissociative Amnesia may sometimes be present. (American Psychiatric Association, 2000)

Etiology

Episodes of Dissociative Fugue are usually triggered by traumatic, overwhelming, stressful events. Traumatic experiences such as war, natural disasters, accidents, and sexual abuse during childhood, often increase the incidence of the disorder. More personal types of stress, like the shocking death of a loved one or unbearable pressures at work or home, might also lead to the unplanned travel and amnesia that is characteristic of Dissociative Fugue. (American Psychiatric Association, 2000)

Differential diagnosis

Dissociative fugue includes other dissociative disorders, seizure disorder, amnestic disorder, schizophrenia, mania, dementia (often of the Alzheimer type), malingering, frontal lobe disorders, head trauma and injury, and factitious disorder. Fugue differs from other mental disorders in that the flight behavior is organized and purposeful. Patients with seizure disorder do not assume a new identity and usually have an altered state of conscious with abnormal findings on electroencephalogram testing. (American Psychiatric Association, 2000)

Indications for hospitalization

In making a primary diagnosis, observing the patient in a controlled setting is often necessary. Patients reveal their level of need through interactions with others, inappropriate behavior without remorse, or by verbalizing their symptoms when they are aware of their suffering. In general, hospitalization is indicated when medical or surgical treatment is required, when the diagnosis is unclear, when no safe alternative exist for housing the patient, or as a means of stopping the ongoing abuse. Additionally, any time a patient experiences severe confusion regarding his or her identity or chronic amnesia regarding the total fugue episode, hospitalization if indicated. Hospitalization is also a tool for assessing and administering social services and medication, developing behavior, and ensuring that a patient will respond to medication under the safety and care of medical professionals. And, hospitalization provides containment. Most patients with dissociative fugue symptoms receive acute treatment in general hospital settings and psychiatric departments because they have a tendency to be brought in during an episode. In this way, the hospital provides the safety and treatment mechanism needed for a disorder that, without intervention, remains undiagnosed. Hospitalization most often occurs in order to provide emergency crisis treatment that is best provided in an acute are setting.

Empirically supported treatments

• Most fugues last for only hours or days, and then often disappear on their own. The goal of treatment is to assist the person to come to terms with the trauma or stress that triggered the fugue in the first place. Another goal of treatment is to help develop new coping methods to prevent further fugue episodes. As with most disorders, the particular treatment approach depends on the individual and the severity of his or her symptoms. The most likely treatment however will include a combination of psychotherapy, cognitive therapy, medication, family therapy, creative therapy, and clinical hypnosis.
• Psychotherapy
  • is the main treatment for dissociative disorders such as Dissociative Fugue. Such treatments aim to increase insight into problems.
• Cognitive therapy
  • focuses on changing dysfunctional thinking patterns.
• Medication
  • is useful when the person also suffers from depression or anxiety.
• Family therapy
  • aims to teach the family more about the disorder and learn about the symptoms of recurrence.
• Creative therapies
  • such as music therapy and art therapy, let the person express themselves in safe manners.
• Clinical hypnosis
  • uses intense relaxation, concentration, and focuses attention to achieve an altered state of awareness. This is risky however because of the risk of creating false memories. The prognosis for Dissociative Fugue is often very good because the episodes do not usually last longer than a few months and people generally recover quickly. Efforts to restore the memories of what happened during the fugue are usually unsuccessful, or take a long time to be recovered.

Illustrative case

A case study was reported in Psychology Today (Drawing a Blank, October 2007) and was also reported in Maclean’s Magazine (The Man Who Lost Himself, May 2007) about a man named Jeff Ingram. A short summary of this case goes as follows: Ingram, 40, is a former mill worker in Olympia, Washington. He left his home one morning headed for Alberta to visit a terminally ill friend. A few days later he woke up on a street in Denver with no idea of who he was. Ingram became confused, angry, and worried when he was being questioned by the hospital’s receptionist because he had no knowledge of his identity. Even months after being reunited with his family, Ingram still had no pre-fugue memories, including that of his three year relationship with then-fiancée. In order to prevent such confusion in the future, Ingram ordered GPS shoes and had his identity information tattooed on him. He also wears a zip disk with medical information around his neck. It is believed that the possible trigger of Ingram’s fugue episode was the stress of his friend’s battle of cancer. A more detailed article can be found in Maclean’s magazine (May 2007). Here is a news video clip on this case.

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Proposed Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V)

Dissociative Fugue subtype:

• 1. Amnesia includes lack of control over how much of a person’s past they can recall, confusion about their individual identity, or assumption of a new identity (partial or complete)
• 2. Sudden, unplanned journey away from home or a job.