Dissociative Fugue – Unearthing the Lost Memory with Lorazepam-assisted Interview

INTRODUCTION Dissociative fugue is characterized by sudden wandering away from the usual place linked with amnesia for the entire event.[1,2] Amnesia can be global or autobiographical; occasionally, semantic memory also gets affected.[3] As amnesia to personal identity is the cardinal feature of dissociative fugue, both the International Classification of Diseases 11th Revision and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition have included fugue as a qualifier to dissociative amnesia, rather than an individual entity.[4] Dissociation is a defense mechanism, which shakes the integrity of memory, consciousness, identity, or perception of the surroundings.[5,6] It is an innate attempt to protect oneself from intense psychological trauma. Even though dissociation has been reported as early as the 1940s in war victims, the overall prevalence of dissociative disorders is around 10% in the general population,[3,5,7] with fugue accounting for 0.2%.[1] A review of the literature shows a very few case reports of dissociative fugue.[8] The event of dissociation usually follows an intense stressful situation. Furthermore, the spectrum of dissociative disorders is strongly linked to childhood psychological trauma.[5] Identification of the underlying psychological distress aids in both diagnostic and therapeutic purpose. We present three case reports of dissociative fugue, who presented with varied symptomatology and the efficacy of lorazepam-assisted interview to retract the suppressed memory in them. CASE REPORTS Case 1 A 37-year-old married male was brought to the psychiatric outpatient department (OPD) with complaints of inability to remember anything that happened in the past 3 months. He was functioning well 3 months back, when he just disappeared from his work place, which was not usual of him. He had not taken any clothes or money with him. The patient was previously healthy, not on any medications, and there was no history of substance use or head injury. He was found about 275 km away from his place by a person of acquaintance. He was brought back to his family, and on returning, they noticed he was adequately kempt, was wearing new clothes, but he looked perplexed. He was unable to identify his mother and wife. On enquiring about his whereabouts, they came to know that he called himself by a new name, found a job at a local automobile workshop, and claimed that he was unmarried. He stayed in the workshop along with his coworkers. He lived under a different identity in the new place. After returning home, he isolated himself in a room and avoided interaction with anyone. After about 5 days, he suddenly recognized his mother and hugged her tearfully. However, he denied memory of any other details of his life. He was admitted and evaluated in detail. Routine blood investigations were normal. Electroencephalogram (EEG) and computed tomography brain were reported to be normal. There was no focal or generalized neurological deficits. There were no similar episodes reported in the past. On detailed evaluation, it was noted that the patient had a fight with his elder brother on property issues just one day prior to the event. The patient was started on sertraline and supportive psychotherapy therapy. The patient recovered no memory even after 2 weeks, and hence, a lorazepam-assisted interview was considered. After obtained informed written consent from the patient and the patient’s relatives, the interview was conducted. The patient felt sleepy after slow infusion of 2.5 mg of lorazepam. Gradually, the patient was questioned about the events he last remembered and progressed toward the core of memory deficit. He claimed that he just “felt like leaving” his house and did know how he chose a destination and his new identity. However, he was able to recollect information regarding his work and acquaintances in the new place. The owner of the workshop provided food and shelter in the early days and then he started working there. He expressed that the ongoing financial stressors and the conflict with his brother had significantly affected him. The session was uneventful. The following day, the patient reported some kind of unexplained relief. Case 2 A 55-year-old unemployed married male was brought to the psychiatric OPD with an alleged history of missing from home for about a period of 22 days. He returned home on his own, but appeared unusual, as he was wearing a shirt which did not fit him well, and his hair and nails were unkempt. He had multiple, colored threads tied to his wrist. On enquiring, he claimed that he was standing in a temple with unknown persons. He did not understand anything happening around him and got extremely frightened. He requested a random person nearby to call his wife, whose phone number he now remembered. He was brought back to his place, yet he continued to be frightened. He failed to remember the events during his missing days. He was sad and expressed suicidal ideations to his wife. He had a similar episode about 5 years back following his mother’s demise when he was brought back by his relative after about 3 days. He was hospitalized under high-risk protocol in view of suicidality. He was diagnosed with severe depression and was started on antidepressants and benzodiazepines. He had a patchy recovery of the memory for the missing days. He claimed that he went to three temples on his own, had food, and took shelter in the temples. However, he did not know the exact location of the temples. Routine physical examination and blood investigations were normal. The findings of EEG and magnetic resonance imaging of the brain were insignificant. A negative urine drug screening ruled out the use of psychoactive substances or other concurrent medications. There was no history of traumatic brain injury, infection, seizure, or acute confusion. A lorazepam-assisted interview was conducted with informed written consent from the patient and his wife. He required 3 mg of lorazepam (slow infusion) to get drowsy. The interview questions were framed with initial neutral topics followed by target stressors. He was able to recollect the series of events during the missing period. He claimed that prior to the fugue episode, someone in his neighborhood had told him about a temple about 150 km away. He had first gone to that temple, and from there, he hopped from one temple to another based on suggestions from bystanders. He made a friend on his travel and was traveling with him for 3 days whose details he was not able to remember. He said that before he went on his trip, he felt distressed about his daughter’s wedding, and when someone suggested that temple, he believed that his problems would be resolved if he visited that temple. The patient was questioned regarding hallucinations during the periods of wandering, but he denied hearing voices of that sort. No other significant psychotic symptoms were elicitable. The session was uneventful. In the following couple of days, his distress had reduced and he denied any active suicidal ideas. He was started on cognitive behavioral therapy. Case 3 A 65-year-old female was brought to the psychiatric OPD with a history of leaving her husband uninformed when traveling to a nearby village. She was waiting in a bus station with her husband and her husband was engaged in a conversation with a bystander. After a while, her husband noticed that she was missing, and he enquired to the bystanders who reported to have noticed her board a bus on her own which was plying on the opposite route. After 7 days, the husband received a call from a police station informing him that his wife had picked up a fight with a person and they had kept her in their custody. When her husband went to pick her up, she did not recognize him. She was wearing the same clothes but claimed that she had taken a bath and washed her clothes. On further inquiry, it was found that she had travelled to two random places without money. However, she did not remember the names of the places and the purpose of the visit. She remembered her husband and family members after 2 days. She claimed that she left because her husband assaulted her. She gave different versions of the missing period every time she was questioned. She had left the house uninformed, similarly, 2 months back for 3 days when she was found in the neighboring village, to which family members did not give much attention. On hospitalization, she was evaluated for organic brain disorders, which was negative. Urine screening for drug use was negative. She did not have memory disturbances before the episode. She was subjected to a lorazepam-assisted interview with informed consent from the patient and her husband. She, however, was agitated when initiating the interview and that led to the premature termination of the procedure. Evaluation for marital discord was made, which was significant and was believed to be the trigger for the recurrent fugue episodes. She was started on selective serotonin reuptake inhibitor and supportive psychotherapy; however, she did not co-operate for psychotherapy. She had residual patchy memory loss, but further probing was not preferred. DISCUSSION Dissociation was found to occur mostly in the second to fourth decades of life, which could be attributed to the higher age-related stress exposure.[9,10] However, one of our patients falls in the seventh decade of life, which is very unusual. There has not been significant gender predisposition.[2,5] They also tend to occur in higher frequency in certain special populations like war victims and substance abusers. The episodes can be recurrent.[11] The amnesia associated with fugue is usually retrograde or episodic autobiographical amnesia.[2,10,12] Dissociation has a strong association with exposure to childhood psychological trauma, with sexual abuse accounting for the majority (up to 90%). Emotional and physical abuse had more than 50% association.[5] But, we were not able to elicit any childhood exposure to psychological trauma in any of our patients. The lack of reliable attenders to give childhood history should be considered before ruling out the possibility. Coons found a relationship between dissociation and criminality which he proposed to enable normal functioning despite amnesia of their identity. However, our patients had no criminal records.[9] A detailed account of a patient with dissociative fugue was given by Howley and Ross, who unwound the memory strings of the patient starting with the memory farthest from the stressful event and gradually progressing toward the ones closest. This gradual desensitization helps prevent anxiety-triggering memories from flooding back into the conscious state. They also found that the clearing of fugue amnesia reveals a depressive background.[7] Depression has a close correlation with dissociation disorder.[1,7,13] The association with depression has been found in all the three cases in our study. One of the possible reasons for them to develop postfugue depression can be the sudden dramatic loss of autobiographical memory, leading to a greater degree of despair. It is noteworthy that the premorbid stressors still play a role. A significantly higher association of dissociation to suicidality has been reported in various epidemiological studies.[5,14] This phenomenon is observed in one of our patients, who consistently expressed suicidal thoughts in the postfugue recovery period. It is, however, to be noticed that he never expressed death wishes or suicidal ideas prior to the fugue. This gives a clue that dissociation blocks the distressful thoughts of self-injurious ideas. Hence, it is essential to be cautious about these high-risk events after the subconscious barricade of dissociation is removed. During the postfugue period, patients give different versions of the events that happened during the period of amnesia without substantial evidence.[3] This was found in one of our patients, 65-year-old female (Case 3), which highlighted the possibility of age-related cognitive deficits. However, the fact that there were no prefugue memory deficits and a normal finding in the cognitive examination, excluding memory, and normal neuroimaging helped in ruling out organic brain disorders. Differential diagnoses for dissociative amnesia can include neurocognitive disorders and other neurological diseases, substance-induced amnesia, psychotic disorders, and factitious disorders.[3] The use of drug-assisted interviews has proven to be both diagnostic and therapeutic.[15,16] It unplugs the subconscious pressure, which triggers the defense mechanism of dissociation. The establishment of adequate rapport and gaining the patient’s confidence is an essential feature of a successful drug-assisted interview.[16] It marks the importance of spending adequate time with the patient before experimenting with drug-assisted interviews. It was historically called an Amytal interview before amobarbital was stopped using due to the side effect profile. Currently, lorazepam is the preferred drug.[6] Highly anxiety-provoking questions must be avoided when framing the interview questions. Each session lasts from 30 to 60 min after which the interview has to be terminated. In literature, single session of interview has been shown to adequately tap the memory reservoir;[6] however, few patients may require multiple graded sessions with short intervals of 1 week to 10 days,[17,18] depending on the suggestibility of the patient. There is no definite pharmacotherapy for the management of dissociative fugue disorder except for symptomatic management.[3,6,12] Psychotherapy plays a vital role in the psychological uncoupling of the mind–body framework. The course of illness can range from spontaneous complete recovery to chronic debilitation.[12] In a report by Helmes et al., the patient showed no recovery of memory on an 11-year follow-up.[19] The finding in our patient is in line with this, as all the three cases had varying outcome. Legal implications secondary to fugue should always be kept in mind.[3] The propensity to travel without documents, bizarre or suspicious presence of the person, and high-risk behavior during fugue can attract legal action against them.[8,20] CONCLUSION Dissociative fugue is a rare, but interesting clinical disorder. The association with childhood psychological trauma indicates the deep-rooted psychological underpinning of the disorder. A detailed analysis of the clinical presentation, triggering factors, comorbidities, and premorbid personality may be useful in predicting the outcome of the illness. The lack of adequate studies on the pathophysiological attributes of dissociation provides scope for further research. Declaration of patient consent The authors certify they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.