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Dissociative fugue is an acute episode of severe and overt dissociative amnesia that is characterized by sudden memory loss with the leaving of one’s surroundings and unexpected travel away from one’s home or place of work. The episode is usually acute and is characterized by temporary autobiographical memory loss and the inability to recall essential information, such as identity. Patients may wander long distances, even thousands of miles, during a fugue. The duration of the fugue may be a couple of days to several weeks or months. When patients recover their pre-dissociative state, they can’t remember the events that happened during the fugue.
Epidemiology of Dissociative Fugue
Dissociative fugue occurs rarely. The estimated prevalence of overt dissociative amnesia or fugue is 0.2% in the general population. These patients usually have a history of significant social or life trauma. Additionally, a fugue is usually more common in times of wars, natural disasters, and accidents. The onset of the disease is sudden, and recovery is also sudden and often complete. Onset in adolescence or early adulthood usually is associated with a history of child abuse and current severe distress.
Patients who have fugue are later found to have more complex forms of dissociative amnesia in most cases.
The risk of fugue seems to be higher in certain populations, such as drug addicts, women who work in prostitution, and strippers or exotic dancers. This can be related to the lifestyle of these individuals, who are more likely to suffer from emotional or psychological trauma (e.g., the rape of a woman who works in prostitution might lead to a fugue state).
Clinical Presentation of Dissociative Fugue
A person in a dissociative fugue episode may have no psychiatric symptoms at all. He or she appears normal and cannot be differentiated from the crowd. He or she might show signs of confusion and distress upon realizing that part of the memory is unavailable during the fugue.
Patients who develop fugue are usually brought to the emergency department to exclude alcohol intoxication or drug overdose, two common causes of bizarre and abnormal behavior.
History taking is an essential tool in establishing the diagnosis of fugue because the diagnostic criteria per DSM-5 are largely based on the clinical features of the disorder.
Patients are usually confused and have amnesia. Amnesia can be associated with the creation of a new identity.
Fugue differs from dissociative amnesia in that patients with fugue usually travel suddenly, away from their home, and are unable to recall recent past events in their lives. Patients with dissociative amnesia do not show this kind of behavior. Therefore, cases of severe amnesia without unexpected travel are diagnosed as overt dissociative amnesia rather than fugue. Suicidal risk should be assessed in any patient with fugue.
Diagnostic Criteria for Dissociative Fugue
For the diagnosis of dissociative fugue to be made, the patient needs to show an apparently purposeful travel, or wandering, in addition to amnesia for identity and other autobiographical information. Uncertainty and confusion about one’s identity can be obvious with the adoption of a new identity. It should be differentiated from substance abuse and physical illness. The episode must cause remarkable alteration of the functioning of the patient in society, at work, or at home.
Patients with dissociative amnesia might also have a generalized amnesia for identity and life history, but they usually have selective amnesia of a certain traumatic or stressful event in their lives.
For the diagnosis of fugue to be made, the symptoms need to be severe enough to cause significant social, occupational, or other functional impairment in life. Accurate assessment of the case can be made after the fugue is over, and the patient calls for help.The diagnosis is made on the basis of personal history and reconstruction of past events before, during, and after the episode of fugue.
Alcohol use, drug abuse, or the use of medication need to be excluded. Additionally, medical conditions such as seizure disorder, transient generalized amnesia, traumatic brain injury, or Alzheimer disease should be excluded.
It is important to differentiate between fugue and other disorders, such as post-traumatic stress disorder, acute stress disorder, somatization, or malingering.
Brain Imaging in Dissociative Fugue
Neuroimaging studies can shed more light on the differences between healthy individuals and those with psychiatric disorders such as dissociative fugue. The current status of neuroimaging applications in patients with dissociative fugue makes such modalities only research-based and not clinically oriented.
Positron emission tomography (PET) scans of patients with fugue showed two important differences compared to healthy subjects.
First, while healthy subjects showed right frontotemporal activation in response to viewing of familiar objects and items from the patient’s past, patients with fugue showed left frontotemporal activation. This finding supports the notion that psychiatric disorders are related to impaired neuronal circuits rather than gross brain pathology.
The other important finding, which was also obtained from PET scans, showed decreased glucose intake (i.e., hypometabolism) in the right frontotemporal regions in patients with fugue.
While these results are not helpful clinically speaking (i.e., they cannot alter the management plan in our current practice), they have huge implications for the future care of such patients. If we understand which neuronal circuits are impaired in these patients, we will have a better understanding of the pathology and perhaps develop better therapeutics one day.
Treatment of Dissociative Fugue
Most patients with dissociative fugue will go back to normal state without significant sequelae, but the risk of recurrent episodes of fugue is high.
The most important aspect of the treatment of fugue is to help the patient to identify the traumatic events or stressors that lead to this state in the first place. Unfortunately, because of the rarity of this disorder, most forms of psychotherapy and cognitive therapy in dissociative disorder are based on individual work with small numbers of patients and not on randomized clinical trials.
Cognitive therapy might be successful in these patients because some psychologists believe that dissociative fugue is a response mechanism to irrational thinking patterns.
Patients who undergo extreme physical, sexual, or emotional abuse might develop dissociative fugue. Such patients might have some misconceptions, such as thinking that they are bad people and they brought this on themselves. Consequently, their mind can make them develop amnesia, and they can later create a new identity, which is commonly seen in severe cases of fugue. It is important to address this with the patient, and he or she should be educated to face and deal with such stressful experiences. Recalling the events in the episode of fugue might trigger grief, depression, fear, anger, or other psychological states that should be handled with psychotherapy.
Hypnosis has been tested in a few cases of dissociative fugue with good results. Again, it is important to remember that most of these treatments are not evidence-based.
Family therapy is also indicated because it is important for the victim and the family to understand the traumatic events that might have led to this state. Additionally, it is important to educate the family about the patient’s condition and teach them how to deal with the patient. Group therapy, which is helpful in patients with traumatic stress disorder and other types of anxiety disorder, has been shown to be effective in dissociative amnesia and fugue.
Finally, antidepressants or anti-anxiety medications also have been used in the management of fugue with good results. Benzodiazepines might help with anxiety, which can be severe due to the traumatic event. Additionally, benzodiazepines can be used with barbiturates for a medicated interview. A medicated interview might provide new insights into the traumatic events that the patient has suppressed.