Dissociative Fugue

Dissociative fugue is a disorder in which one or more episodes of sudden, unexpected, and purposeful travel from home (fugue) occur, during which a person cannot remember some or all of his past life.

Dissociative fugue affects about 2 of 1,000 people in the United States. It is much more common in people who have been in wars, accidents, or natural disasters.

Causes

The causes of dissociative fugue are similar to those of dissociative amnesia. Dissociative fugue is often mistaken for malingering, because both conditions may occur under circumstances that a person might understandably wish to evade. However, dissociative fugue occurs spontaneously and is not faked. Malingering is a state in which a person feigns illness because it removes him from accountability for his actions, gives him an excuse to avoid responsibilities, or reduces his exposure to a known hazard, such as a dangerous job assignment. Many fugues seem to represent a disguised wish fulfillment (for example, an escape from overwhelming stresses, such as divorce or financial ruin). Other fugues are related to feelings of rejection or separation, or they may protect the person from suicidal or homicidal impulses.

When dissociative fugue recurs more than a few times, the person usually has an underlying dissociative identity disorder.

Symptoms and Diagnosis

A fugue may last from hours to weeks or months, or occasionally even longer. A person in a fugue state, having lost his customary identity, usually disappears from his usual haunts, leaving his family and job. If the fugue is brief, the person may appear simply to have missed some work or come home late or, if confused, may come to the attention of medical or legal authorities. If the fugue lasts several days or longer, the person may travel far from home and begin a new job with a new identity, unaware of any change in his life. During the fugue, the person may appear normal and attract no attention. However, at some point, the person may become aware of the memory loss (amnesia) or confused about his identity.

Often the person has no symptoms or is only mildly confused during the fugue. However, when the fugue ends, the person may experience depression, discomfort, grief, shame, intense conflict, and suicidal or aggressive impulses.

A doctor may suspect dissociative fugue when a person seems confused about his identity or is puzzled about his past, or when confrontations challenge the person's new identity or absence of one. The doctor makes the diagnosis by carefully reviewing the person's symptoms and performing a physical examination to exclude physical disorders that might be contributing to or causing memory loss. A psychologic examination is also performed.

Sometimes dissociative fugue cannot be diagnosed until the person abruptly returns to his pre-fugue identity and is distressed to find himself in unfamiliar circumstances. The diagnosis is usually made retroactively by a doctor reviewing the person's history and collecting information that documents the circumstances before the person left home, the travel itself, and the establishment of an alternate life.

Treatment and Prognosis

Most fugues last for hours or days and disappear on their own. Dissociative fugue is treated much the same as dissociative amnesia, and treatment may include the use of hypnosis or drug-facilitated interviews (see Section 7, Chapter 106). However, efforts to restore memories of the fugue period usually are unsuccessful. A therapist may help the person to explore his patterns of handling the types of situations, conflicts, and moods that triggered (precipitated) the fugue episode to prevent subsequent fugue behavior.