Working with dissociative fugue in a general psychotherapy practice: A cautionary tale

American Journal of Clinical Hypnosis,  Apr 2003  by Jasper, Frank J

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Dissociative Fugue is a somewhat rare condition that therapists may see only once or twice over the course of a professional career. A brief review of the uses of hypnosis in the treatment of Dissociative Fugue is followed by a presentation of the case of a 51 -year-old man who presented with the clinical picture of Dissociative Fugue State and who experienced complete amnesia for the time prior to the fugue state. This article focuses on the pitfalls that the psychotherapist in a general practice may face when working with such a patient and offers specific recommendations and scripts that may be useful in proceeding with treatment.

Keywords: Consultant, Dissociative Identity Disorder (DID), dissociation, ethics, education, fugue, hypnosis, pitfalls, training

Introduction

"Joe" went to work at his usual time of 4:30 a.m. on Monday morning. On the following Tuesday evening at 10:00 p.m., he wandered into a K-Mart 150 miles from home and said, "Could you please help me? I don't know who I am or how I got here. Would you call the police for me?"

The police took his truck keys and located his truck. They discovered his identity took him to the emergency room, and called his hometown where his wife had reported him missing. When he returned, he did not recognize his home, his wife, or his children.

Dissociative Fugue is a "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" (American Psychiatric Association, 1994, p. 481). The most common hypothesis is that acute traumatic experiences are linked with this kind of dissociation (Frankel, 1996; Coons, 2000; Steinberg, 2000). Reports of childhood trauma, particularly physical and sexual abuse, reach a prevalence of up to 90% in dissociative disorders and especially Dissociative Identity Disorder (Spiegel, 1993; Coons & Milstein, 1986; Coons, 2000; Frischholz, 1985; Putnam et al., 1986; Kluft, 1993). There is only one recent empirical study of the fugue state. Coons (1999) reported on five consecutive cases that presented themselves to his dissociative clinic over a period of ten years.

A prevalence rate for Dissociative Fugue is estimated at 0.2% of the general population (American Psychiatric Association, 1994). Coons (1999) reported that Dissociative Fugue accounted for 1.6% of all dissociative disorders at his dissociative disorders clinic. Since this disorder is so rare, it is unlikely that clinicians will encounter more than a single case in their entire career, unless they specialize in dissociative disorders.

Discussions of psychogenic fugue in standard psychiatric references offer suggestions of sodium amobarbital interviews or hypnosis (Ford, 1989; Linn, 1989; Wilbur & Kluft, 1989; Putnam & Loewenstein, 2000; Gilmore & Kaufman, 1996/97; Nemiah, 1985). These references give little guidance as to how to conduct these interviews. However, all indicated that it was critical to address the initial stressors so that the experience would not be repeated.

Hypnotizability itself may be a diathesis for dissociative symptomology, especially when combined with acute traumatic stress (Butler, Duran, Jasiukaitis, Koopman, & Spiegel, 1996). Spiegel (1997, p. 1161) thought that hypnosis could be helpful in the treatment of Dissociative Fugue "by accessing otherwise unavailable components of memory and identity." The structure of hypnotic induction may elicit dissociative phenomena, and the patient in a Dissociative Fugue is usually capable of entering a deep level of hypnosis. Age regression can be used as the framework for accessing information available from a previous time (Spiegel, 1997).

There is relatively little information about how to proceed with hypnosis in therapeutic interventions for fugue states. Much of the material on hypnosis and dissociation focuses on Dissociative Identity Disorder which is more common (Kluft, 1982; Wilbur & Kluft, 1989; Spiegel, 1997; Butler et al., 1996). Kluft (1995) has described 22 specific ways to utilize hypnosis with Dissociative Identity Disorder. Loewenstein (1995) recommended using hypnosis for ego strengthening and to promote the integration of repressed material.

In the management of this case, I immediately encountered the pitfalls that awaited someone not familiar with treatment of dissociative disorders. I present some of these pitfalls and offer some recommendations that may help the general practitioner to engage in a clinically beneficial manner should encounters with this rather rare disorder arise in his/ her practice. I also offer some practical suggestions and actual scripts.

Clinical Material Continued: Background and History

Joe was hospitalized and had a thorough evaluation by an internist, a neurologist, and a psychiatrist. After an extensive diagnostic work up that included x-rays, blood work, CAT scan, MRI, spinal tap, and thyroid function tests, the only abnormality found was a slight amount of protein in Joe's cerebral spinal fluid. Joe's internist pronounced him "the healthiest 50-year-old he had ever seen." Thus, the physicians eliminated organic causes for the fugue, which is an essential step in the diagnosis (Coons, 1998; Loewenstein, 1993).