Dissociative fugue
The behavior of patient with dissociative fugue is unusual and dramatic.The term fugue is used to reflect the fact that patients physically travel away from their customary homes or work situations and fail to remember important aspects of their previous identities (name, family, occupation). Such patients often, but not always, take on an entirely new identity is usually less complete than the alternate personalities in dissociative identity disorder,and the old and new identities do not alternate, as they do in dissociative identity disorder.
1. Epidemiology
Dissociative fugue is rare and, like dissociative amnesia, occurs most often during wartime, after natural disasters, and as a result of personal crisis with intense internal conflicts.According to DSM-IV–TR there is a prevalence rate of 0.2 percent in the general population.
2. Etiology
Although heavy alcohol abuse may predispose persons to dissociative fugue, the cause of the disorder is thought to be basically psychological. The essential motivating factor seems to be a desire to withdraw from emotionally painful experiences. Patients with mood disorders and certain personality disorders (e.g., borderline,histrionic,and schizoid personality disorders)are predisposed to develop dissociative fugue.
3. Diagnosis and Clinical Features
DSM-IV-TR Diagnostic Criteria for Dissociative Fugue
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.
B. Confusion about personal identity or assumption of a new identity(partial or complete).
C. The disturbance does not occur exclusively during the course of dissociative identity disorder and is not due the direct physiological effects of a substance (e.g., abuse of a drug, a medication) or general medical condition (e.g., temporal lobe epilepsy).
D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Dissociative fugue has several typical features. Patients wander a purposefulway, usually far from home and often for days at time.During this period, they have complete amnesia for their past lives and associations, but unlike patients with dissociative amnesia, they are generally unaware that they have forgotten anything.
Only when they suddenly return to their former selves do they recall the time antedating the on set of fugue, but then they remain amnesic for the period of fugue itself. Patients with dissociative fugue do not seem to others to be behaving in an extraordinary ways, nor do they give evidence of acting out any specific memory of a traumatic event.On the contrary, these patients lead quiet, prosaic, reclusive existence;work at simple occupations; live modestly; and, in general, do nothing to draw attention to them.
4. Differential Diagnosis
The differential diagnosis for dissociative fugue is similar to that for dissociative amnesia.The wandering that is seen in dementia or delirium is usually distinguished from the traveling of a patient with dissociative fugue by the aimlessness of the former and the absence of complex and socially adaptive behaviors’. Complex partial epilepsy maybe associated with episodes of travel, but the patient does not usually assume a new identity and the episodes are generally not precipitated by psychological stress. In dissociative amnesia, a loss of memory results from psychological stress,but without any episodes of purposeful travelora new identity. Malingering may bedifficult to distinguish from dissociative fugue; any evidence of a clear second arygain should raise the clinician’s suspicion.
5. Course and Prognosis
The fugue isusually brief-hours todays. Less commonly, a fugue lasts many months and involves extensive travel covering thousands of miles.Generally, recovery is spontaneous and rapid.Recurrence is possible.
6. Treatment
Treatment of dissociative fugue is similar to that of dissociative amnesia.Psychiatric interviewing,drug-assistedinter viewing,and hypnosis may help reveal to therapists and patients the psychological stressors that precipitated the fugue episode. Psychotherapy is indicated to help patients incorporate the precipitating stressors into their psyches in a healthy and integrated manner. The treatment of choice for dissociative fugue is expressive, supportive psycho dynamic psychotherapy.The most widely accepted technique requires a mixture of ab reaction of the past trauma and integrations of the trauma into a cohesive self that no longer requires fragmentation to deal with the trauma.