Dissociative Fugue - Diagnosis and Treatment

Dissociative fugue is characterized by sudden, unexpected travels from the home or workplace with an inability to recall some or all of one's past. Some of these patients assume a new identity or are confused about their own identity. They seem to be running away from something of which they are unaware.

After the 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 is not enacted in a confused or dazed state. In a typical case, the fugue is brief, with purposeful travel, and with limited contact with others. Approximately 0.2% of the general population has dissociative fugue.

Mental status

DSM-IV diagnostic criteria for fugue require that the predominant disturbance is sudden, unexpected travel away from home or one's workplace coupled with the inability to recall one's past. Also, the person has confusion about personal identity or assumes a new identity. The disturbance does not occur exclusively during the course of DID and is not due to the direct physiologic effects of a substance or medication. The symptoms also must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

An episode of fugue often starts in the context of psychological stress such as social dislocation or war. Usually, the fugue lasts for a few days; occasionally, it may last months, with a few extreme cases noted.

Differential diagnoses

Dissociative fugue includes other dissociative disorders, seizure disorder, amnestic disorder, schizophrenia, mania, dementia (often of the Alzheimer type), malingering, 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.

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 exists 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 is 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, of course, 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 care setting.

Treatment of Dissociative Fugue

Although patients with dissociative fugue often recover spontaneously, medical observation may serve the patient in providing insight and safety during the episode. Patients should be treated with psychotherapy with additional hypnosis and psychopharmacology in order to allow integration of feelings, anxieties associated with the fugue, and recovery techniques. Treatment addresses the many symptoms, ranging from schizophrenia to mania to seizure disorders. Medication and cognitive therapies in combination tend to provide the best overall treatment approach for fugue, allowing patients to understand their symptomology and the risks involved and to address their discomfort.

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Reviewed: 04/2006