The essential feature of Dissociative Fugue is sudden, unexpected travel away from home or one’s customary place of daily activities, with inability to recall some or all of one’s past (Criterion A). This is accompanied by confusion about personal identity or even the assumption of a new identity (Criterion B). The disturbance does not occur exclusively during the course of Dissociative Identity Disorder and is not due to the direct physiological effects of a substance or a general medical condition (Criterion C). The symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion D).
Travel may range from brief trips over relatively short periods of time (i.e., hours or days) to complex, usually unobtrusive wandering over long time periods (e.g., weeks or months), with some individuals reportedly crossing numerous national borders and traveling thousands of miles. During a fugue, individuals may appear to be without psychopathology and generally do not attract attention. At some point, the individual is brought to clinical attention, usually because of amnesia for recent events or a lack of awareness of personal identity. Once the individual returns to the prefugue state, there may be no memory for the events that occurred during the fugue.
Most fugues do not involve the formation of a new identity. If a new identity is assumed during a fugue, it is usually characterized by more gregarious and uninhibited traits than characterized the former identity. The person may assume a new name, take up a new residence, and engage in complex social activities that are well integrated and that do not suggest the presence of a mental disorder.
Associated Features and Disorders
Associated descriptive features and mental disorders. After return to the prefugue state, amnesia for traumatic events in the person’s past may be noted (e.g., after termination of a long fugue, a soldier remains amnestic for wartime events that occurred several years previously in which the soldier’s closest friend was killed). Depression, dysphoria, anxiety, grief, shame, guilt, psychological stress, conflict, and suicidal and aggressive impulses may be present. The person may provide approximate inaccurate answers to questions (e.g., “2 plus 2 equals 5”) as in Ganser syndrome. The extent and duration of the fugue may determine the degree of other problems, such as loss of employment or severe disruption of personal or family relationships. Individuals with Dissociative Fugue may have a Mood Disorder, Posttraumatic Stress Disorder, or a Substance-Related Disorder.
Specific Culture Features
Individuals with various culturally defined “running” syndromes (e.g., pibloktoq among native peoples of the Arctic, grisi siknis among the Miskito of Honduras and Nicaragua, Navajo “frenzy” witchcraft, and some forms of amok in Western Pacific cultures) may have symptoms that meet diagnostic criteria for Dissociative Fugue. These are conditions characterized by a sudden onset of a high level of activity, a trancelike state, potentially dangerous behavior in the form of running or fleeing, and ensuing exhaustion, sleep, and amnesia for the episode.
A prevalence rate of 0.2% for Dissociative Fugue has been reported in the general population. The prevalence may increase during times of extremely stressful events such as wartime or natural disaster.
The onset of Dissociative Fugue is usually related to traumatic, stressful, or overwhelming life events. Most cases are described in adults. Single episodes are most commonly reported and may last from hours to months. Recovery is usually rapid, but refractory Dissociative Amnesia may persist in some cases.
Dissociative Fugue must be distinguished from symptoms that are judged to be the direct physiological consequence of a specific general medical condition (e.g., Head injury). This determination is based on history, laboratory findings, or physical examination. Individuals with complex partial seizures have been noted to exhibit wandering or semipurposeful behavior during seizures or during postictal states for which there is subsequent amnesia. However, an epileptic fugue can usually be recognized because the individual may have an aura, motor abnormalities, stereotyped behavior, perceptual alterations, a postictal state, and abnormal findings on serial EEGs. Dissociative symptoms that are judged to be the direct physiological consequence of a general medical condition should be diagnosed as Mental Disorder Not Otherwise Specified Due to a General Medical Condition. Dissociative Fugue must also be distinguished from symptoms caused by the direct physiological effects of a substance.
If the fugue symptoms only occur during the course of Dissociative Identity Disorder, Dissociative Fugue should not be diagnosed separately. Dissociative Amnesia and Depersonalization Disorder should not be diagnosed separately if the amnesia or depersonalization symptoms occur only during the course of a Dissociative Fugue. Wandering and purposeful travel that occur during a Manic Episode must be distinguished from Dissociative Fugue. As in Dissociative Fugue, individuals in a Manic Episode may report amnesia for some period of their life, particularly for behavior that occurs during euthymic or depressed states. However, in a Manic Episode, the travel is associated with grandiose ideas and other manic symptoms and such individuals often call attention to themselves by inappropriate behavior. Assumption of an alternate identity does not occur.
Peripatetic behavior may also occur in Schizophrenia. Memory for events during wandering episodes in individuals with Schizophrenia may be difficult to ascertain due to the individual’s disorganized speech. However, individuals with Dissociative Fugue generally do not demonstrate any of the psychopathology associated with Schizophrenia (e.g., delusions, negative symptoms).
Malingered fugue states may occur in individuals who are attempting to flee a situation involving legal, financial, or personal difficulties, as well as in soldiers who are attempting to avoid combat or unpleasant military duties (although true Dissociative Fugue may also be associated with such stressors). Malingering of dissociative symptoms can be maintained even during hypnotic or barbiturate-facilitated interviews. In the forensic context, the examiner should always give careful consideration to the diagnosis of malingering when fugue is claimed. Criminal conduct that is bizarre or with little actual gain may be more consistent with a true dissociative disturbance.
Diagnostic criteria for 300.13 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 to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a 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.