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Dissociative Fugue

by Daphne Simeon, MD

Dissociative fugue is one or more episodes of amnesia in which patients cannot recall some or all of their past and either lose their identity or form a new identity. The episodes, called fugues, result from trauma or stress. Dissociative fugue often manifests as sudden, unexpected, purposeful travel away from home. Diagnosis is based on history, after ruling out other causes of amnesia. Treatment consists of psychotherapy, sometimes combined with hypnosis or drug-facilitated interviews.

The incidence of dissociative fugue has been estimated at 0.2%, but the rate increases in connection with wars, accidents, and natural disasters.

Etiology

Causes are similar to those of dissociative amnesia (see Dissociative Amnesia), with some additional factors (eg, prolonged and escalating subacute stress, extreme intrapsychic conflict, intense struggle between a wish to escape from one’s life as is and a very harsh superego).

Fugues are often mistaken for malingering because like malingering, fugues may absolve people of accountability for their actions or of certain responsibilities or remove them from hazardous situations. However, unlike malingering, fugues are spontaneous, unplanned, and not faked. Many fugues appear to represent disguised wish fulfillment, the only permissible means of escape from severe distress, especially for people with a rigid conscience. For example, a financially distressed executive leaves a hectic life and lives as a farm hand in the country. A fugue may also remove the person from an embarrassing situation or intolerable stress or may be related to issues of rejection or separation. For example, the fugue may say, in effect, “I am not the man who found his wife to be unfaithful.” Some fugues may be an alternative response to suicidal or homicidal impulses.

About half of people have only one dissociative fugue, and the others have a few episodes over their lifetime. When dissociative fugue recurs more than a few times, people usually have an underlying dissociative identity disorder.

Symptoms and Signs

The length of a fugue may range from hours to months, occasionally longer. During the fugue, people may appear and act normal or be only mildly confused. They may assume a new name and identity and engage in complex social interactions. However, at some point, confusion about the new identity or a return of the original identity may make them aware of amnesia or cause distress. When the fugue ends, shame, discomfort, grief, depression, intense conflict, and suicidal or aggressive impulses may appear—people must deal with what they left behind. Failure to remember events that occurred during the fugue may cause confusion, distress, or even terror. When the fugue ends, many people recall their past identity and life up to fugue onset; however, for some, recalling is a lengthier and more gradual process, and some aspects of their autobiographic past may never be recalled. A very few people remember nothing or almost nothing about their past indefinitely.

Diagnosis

  • Clinical evaluation (usually a disorder is diagnosed retrospectively)

A fugue in progress is rarely recognized. It may be suspected when people seem confused about their identity, puzzled about their past, or confrontational when their new identity is challenged. Often, the fugue is not diagnosed until people abruptly return to their pre-fugue identity and are distressed to find themselves in unfamiliar circumstances.

The diagnosis is usually made retrospectively, based on documentation of the circumstances before travel, the travel itself, and the establishment of an alternate life. When clinicians suspect that a fugue is faked, cross-checking information from multiple sources may reveal inconsistencies that preclude the diagnosis.

Prognosis

Most fugues are brief and self-limited. Impairment after the fugue ends is usually mild and short-lived. However, if the fugue was prolonged and complications due to behavior before or during the fugue are significant, people may have considerable difficulties trying to return to their pre-fugue identity—eg, a soldier who returns after a fugue may be charged with desertion, or a person who marries during a fugue may have inadvertently become a bigamist.

Treatment

  • During fugue, restoring missing information

  • After fugue ends, psychotherapy

Rarely, people are identified while still in a fugue. In such cases, the following are important:

  • Recovering information (possibly with help from law enforcement and social services personnel) about their true identity

  • Figuring out why it was abandoned

  • Facilitating its restoration

Treatment after the fugue ends involves psychotherapy, sometimes combined with hypnosis or drug-facilitated (barbiturate or benzodiazepine) interviews. However, efforts to restore memory of the fugue period are often unsuccessful. Regardless, a psychiatrist can help people explore how they handle the types of situations, conflicts, and affects that precipitated the fugue and thus foster better future adaptations and solutions and help prevent fugue recurrences.

* This is a professional Version *