Monday, March 07, 2016

Writing-Induced Fugue State

Who is this, wandering around the crowded street, afraid of everything, trusting no one?

“There must be something wrong, somewhere.”
But maybe I’m safer since I look disheveled.

Who are these people? Where is this place?
Did I write that? When did that happen? I don’t remember.

I can’t stop writing. I can’t stop walking, either, which is a problem because it’s hard to write and walk at the same time.

In the early 1940s, Austrian Psychiatrist Dr. Erwin Stengel wrote a pair of papers on fugue states, a type of dissociative disorder involving loss of personal identity and aimless wandering (Stengel, 1941):
THE peculiar condition designated “fugue state,” of which the main symptom is compulsive wandering, has puzzled psychiatrists since it was first described. Nothing is known of the aetiology of this well-defined condition. Fugue states occur in epileptics, hysterics, and certain psychopaths. Bleuler has described their occurrence in schizophrenia, and they have been recorded in cases of general paralysis and of altered personality due to brain tumour.  ...  Kraepelin recognized that it was impossible to distinguish between the states of compulsive wandering associated with various mental disorders. Janet tried to distinguish between hysterical and epileptic fugues by pointing out that short fugues are more likely to be epileptic than hysterical.  

He was disturbed by inaccurate use of the term, which was widespread (Stengel, 1943):
...the following conditions have been described as fugues: States of wandering, in accordance with the classical conception; states of double personality; all kinds of transitory abnormal behaviour of functional origin; hysterical loss of consciousness and of memory; twilight states; confusional states of hysterical nature; delirious states in schizophrenia. The tendency to call transient states of altered consciousness fugues, irrespective of the behaviour of the patient, is obvious. This is a most unsatisfactory state of affairs. 

Stengel presented dozens of cases in these papers and was obsessed with finding common etiological factors, no matter what the underlying medical condition (e.g., epilepsy, “hysteria”, schizophrenia):
The intimate similarity of fugue states associated with different mental disorders suggests that there must be aetiological factors common to all. However, no attempt has been made hitherto to ascertain such factors. I have been engaged in investigations concerning this problem for more than eight years...
...and (Stengel, 1943):
Clinical studies carried out over many years have convinced me that there is no justification in differentiating between hysterical and epileptic wandering states, as the behaviour of the patients and the majority of the etiological factors are fundamentally the same in all fugues with the impulse to wander (Stengel, 1939, 1941).

Since Stengel was trained as a psychoanalyst and considered Freud as a mentor, you might guess the common etiology:
This was a disturbance of the environment of child life. A serious disturbance in the child-parent relationship, usually of such a nature that the relationship to one or both parents was either completely lacking or only partially developed, had occurred in nearly every case.

Beyond the mommy/daddy issues, symptoms of severe depression (suicide attempts, failure to eat, lack of hygiene) and/or mania (elation, hypersexuality) were commonplace. Here's one especially tragic example:
CASE 9. M. E , female, born 1906. The patient was normal until her twenty first year. At that time she suddenly became unstable and wanted to live apart from her mother, with whom she had been happy hitherto. She went to Paris, where she found employment as a secretary, but after some months she returned home again. When she was 22 she experienced for the first time an urge to wander, which reappeared subsequently two or three times every year. For no adequate reason, sometimes after an insignificant quarrel, she left home and wandered about for some days. During these states she was not fully conscious, slept little, and neglected herself. When normal consciousness returned, after three or four days, she found herself in the country far away from home. These states were followed by profound depression, lasting for several weeks, when the patient indulged in self-reproaches, ate very little, lost weight, and could not work. ... The patient was a typical daydreamer. In her daydreams a fantasy of a man disappointed in love committing suicide often appeared. (Her father had committed suicide.) ... The patient, who was of unusual intelligence, suffered very much from her abnormal states, which appeared at intervals of four to five months, and were always followed by melancholic depression. In one of these depressions she committed suicide by poisoning.

Period Fugue

Stengel (1941) asserted that the majority of his female patients started their wandering premenstrually, but his definition of what this meant was kind of loose (and meaningless): “usually appear before menstruation”, “usually just before menstruation”, “usually commences shortly before her menstrual period”, “at the onset of menstruation”, “about the time of menstruation”.

He had no explanation for this, other than the implication that it's an unstable lady thing. One particularly fun case (Case 14) was a young woman with a previous bout of encephalitis lethargica. But it was determined that her menstrual period and an Oedipus Complex drove her to wander, not her illness.

The report for Case 35 (Miss May S. M, aged 18, member of the women's military service) was accompanied by a four page excerpt from her diary, which is illuminating for what it tells us about bipolar disorder (but fugue, not so much):
1940.  12.1: Had a drink, sang all the way home. 13.1: The matinee went off well. Feeling so horribly sad, a terribly empty feeling, felt like crying my heart out. Home is like the end of the world. 21.1: Tried to commit suicide. Instead wrote to G. telling him to give me some ideas how to get to America. Feeling just frightful, feel dead. 27.1: No feelings at all. 30.1: Have a mad desire to go really common, lipstick, scarlet nails and with as little clothes as possible.

Modern conceptions of fugue states (including dissociative amnesia) focus on trauma, memory systems, and underlying neurobiological causes, instead of dysfunctional child-parent relationships (MacDonald & MacDonald, 2009).

Who is this? How did I end up here?

You mean there’s a world outside my head, beyond the computer, exceeding all page limits and formatting errors?

Writing-Induced Fugue State

ADDENDUM (March 7 2016): I should clarify that in DSM-5, dissociative fugue no longer has its own category. Now it's a subtype of dissociative amnesia (DSM-5 diagnostic code 300.12):

Sub-Specifier: Dissociative Amnesia with dissociative fugue (300.13)

This occurs when an individual travels or wanders, either in a seemingly purposeful or bewildered fashion, without knowing who they are. Dissociative fugue involves amnesia of a person’s entire identity or for other important autobiographical information.

Another salient difference from Stengel's day is that the fugue state must not due to a general medical condition, like temporal lobe epilepsy.


Stengel, E. (1941). On the Aetiology of the Fugue States The British Journal of Psychiatry, 87 (369), 572-599 DOI: 10.1192/bjp.87.369.572

Stengel, E. (1943). Further Studies on Pathological Wandering (Fugues with the Impulse to Wander) The British Journal of Psychiatry, 89 (375), 224-241 DOI: 10.1192/bjp.89.375.224

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