Ifa Referat

8/9/2019 Ifa Referat

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I. PENDAHULUAN

According to the text revision of the fourth edition of the Diagnostic and Statistical

Manual of Mental Disorders (DSMI!"#$% &'the essential feature of the dissociative

disorders is a disru)tion in the usuall* integrated functions of consciousness% +e+or*%

identit*% or )erce)tion of the environ+ent. "he distur,ance +a* ,e sudden or gradual%

transient or chronic.&' The DSM-IV-TR dissociative disorders are dissociative

identit* disorder% de)ersonali-ation disorder% dissociative a+nesia% dissociative fugue% and

dissociative disorder not otherise s)ecified (N/S$.

"he essential feature of dissociative fugue is descri,ed as sudden% unex)ected travel

aa* fro+ ho+e or one0s custo+ar* )lace of dail* activities% ith ina,ilit* to recall so+e

or all of one0s )ast. "his is acco+)anied ,* confusion a,out )ersonal identit* or even the

assu+)tion of a ne identit*. "he distur,ance does not occur exclusivel* during the course

of dissociative identit* disorder and is not due to the direct )h*siological effects of a

su,stance or a general +edical condition. "he s*+)to+s +ust cause clinicall* significant

distress or i+)air+ent in social% occu)ational% or other i+)ortant areas of functioning.

A+nesic )atients ho have an i+)ulse to ander are said to ,e in a fugue state. "he

+ain )heno+enon is sudden unex)ected travel aa* fro+ ho+e or a custo+ar* )lace of

or1. "here is also ina,ilit* to recall their )ersonal )ast histor*. So+eti+es a )artial or

co+)letel* ne identit* is assu+ed. "he +e+or* for so+e recent trau+atic or stressful

event +a* ,e lost% although these +atters are discovered hen other infor+ants ,eco+e

availa,le. In organic fugue states ,asic selfcare% such as eating or ashing% and si+)le

social activities% such as ,u*ing a tic1et% as1ing directions% or ordering a +eal% tend not to

,e )reserved% unli1e h*sterical fugues. In )ostictal states there is usuall* a histor* of

e)ile)s*% and often there is no i++ediatel* stressful event or current )ro,le+% hile the

travels of the )atient are less )ur)oseful and +ore frag+ented. 2oth I3D45 and DSMI!

offer si+ilar descri)tions and re6uire the exclusion of ,oth +ulti)le )ersonalit* disorderand organic +ental disorder. I3D45 also re6uires the exclusion of excessive fatigue and

intoxication.

Stengel found that 45 out of 78 )atients ith fugues had e)ile)s*% one had

schi-o)hrenia% and several others had de)ression. "rau+atic childhood ex)eriences and


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organic ,rain disease% )articularl* head in9ur*% have ,een found to ,e co++on in three

other series. S*+onds held that )atients ith h*sterical a+nesia and fugues had so+e

aareness of counterfeiting their s*+)to+s. /thers consider that the loss of aareness is

holl* genuine.

II. EPIDEMI/L/:I

"he disorder is thought to ,e +ore co++on during natural disasters% arti+e% or

ti+es of +a9or social dislocation and violence% although no s*ste+atic data exist on this

)oint. No ade6uate data exist to de+onstrate a gender ,ias to this disorder; hoever% +ost

cases descri,e +en% )ri+aril* in the +ilitar*. Dissociative fugue is usuall* descri,ed in

adults.

A recent general )o)ulation stud* found a )revalence of 5.7< for dissociative fugue.

"his disorder occurs )ri+aril* under conditions of ar% natural disaster% or intense )ersonal

crisis. =ugue +a* ,e +ore co++on in +ales. "here are no data on fa+ilial )atterns of

occurrence.

III. E"I/L/:I DAN PA"/:ENESIS

"rau+atic circu+stances (i.e.% co+,at% ra)e% recurrent childhood sexual a,use%

+assive social dislocations% natural disasters$% leading to an altered state of consciousness

do+inated ,* a ish to flee% are the underl*ing cause of +ost fugue e)isodes. In so+e

cases is seen a si+ilar antecedent histor*% although a )s*chological trau+a is not )resent at

the onset of the fugue e)isode. In these cases% instead of% or in addition to% external dangers

or trau+as% the )atients are usuall* struggling ith extre+e e+otions or i+)ulses (i.e.%

overhel+ing fear% guilt% sha+e% or intense incestuous% sexual% suicidal% or violent urges$

that are in conflict ith the )atient0s conscience or ego ideals.

Little is 1non a,out the etiolog* of dissociative fugue. Most fugues occur in the

context of overhel+ing life events or in individuals ith )rior histories of a,use or

trau+a. "he latter a+ounts to a dissociative diathesis. Ps*chod*na+ic theories e+)hasi-e

the )erson0s conflict over ishing to esca)e fro+ so+e circu+stance (eg% a terrif*ing ,attle

in arti+e$ and +oral )rohi,itions against flight (a fervent ,elief that arti+e coards


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should ,e shot$. "he a+nesia and loss of identit* satisf* the ish to flee as ell as the

)rohi,ition against it.

I!. >#I"E#IA DIA:N/S"I>

Table 20-5 DSM-IV-TR Diagnostic Criteria for Dissociative Fugue

A. "he )redo+inant distur,ance is sudden% unex)ected travel aa* fro+ ho+e or one0s

custo+ar* )lace of or1% ith ina,ilit* to recall one0s )ast.

2. 3onfusion a,out )ersonal identit* or assu+)tion of a ne identit* ()artial or

co+)lete$.

3. "he distur,ance does not occur exclusivel* during the course of dissociative identit*

disorder and is not due to the direct )h*siological effects of a su,stance (e.g.% a drug

of a,use% a +edication$ or a general +edical condition (e.g.% te+)oral lo,e e)ile)s*$.

D. "he s*+)to+s cause clinicall* significant distress or i+)air+ent in social%

occu)ational% or other i+)ortant areas of functioning.

(=ro+ A+erican Ps*chiatric Association. Diagnostic and Statistical Manual of

Mental Disorders. ?th ed. "ext rev. @ashington% D3 A+erican Ps*chiatric

Association; 7555% ith )er+ission.$

!. :AM2A#AN >LINIS

Dissociative fugues have ,een descri,ed to last fro+ +inutes to +onths. So+e

)atients re)ort +ulti)le fugues. In +ost cases in hich this as descri,ed% a +ore chronic

dissociative disorder% such as dissociative identit* disorder% as not ruled out.

In so+e extre+el* severe cases of P"SD% night+ares +a* ,e ter+inated ,* a a1ing fugue

in hich the )atient runs to another )art of the house or runs outside. 3hildren or


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adolescents +a* ,e +ore li+ited than adults in their a,ilit* to travel. "hus% fugues in this

)o)ulation +a* ,e ,rief and involve onl* short distances.

After the ter+ination of a fugue% the )atient +a* ex)erience )er)lexit*% confusion%

tranceli1e ,ehaviors% de)ersonali-ation% dereali-ation% and conversion s*+)to+s% in

addition to a+nesia. So+e )atients +a* ter+inate a fugue ith an e)isode of generali-ed

dissociative a+nesia.

As the )atient ith dissociative fugue ,egins to ,eco+e less dissociated% he or she

+a* dis)la* +ood disorder s*+)to+s% intense suicidal ideation% and P"SD or other anxiet*

disorder s*+)to+s. In the classic cases% an alter identit* is created under hose aus)ices

the )atient lives for a )eriod of ti+e. Man* of these latter cases are ,etter classified as

dissociative identit* disorder or dissociative disorder N/S ith features of dissociative

identit* disorder.

"he ord fugue is derived fro+ the Latin ver, fugere% hich +eans Bto flee.C

Dissociative fugue is characteri-ed ,* sudden% unex)ected BflightsC fro+ ho+e or

or1)lace ith an ina,ilit* to recall so+e or all of one0s )ast. So+e individuals assu+e a

ne identit* or ,eco+e confused a,out their identit* ("a,le 77$. It is as if the )atient is

running aa* fro+ so+ething ,ut is unaare of fleeing. @hen the e)isode resolves% +an*

individuals are una,le to re+e+,er events of the fugue state. Although a))arent

disorientation and )er)lexit* +a* occur% this disorder cannot ,e diagnosed in the )resence

of organic +ental disorder.

"he +oving a,out that is )art of dissociative fugue is )ur)oseful% in contrast to the

confused% da-ed activit* that +a* ,e seen in acute DA. In a t*)ical case% the fugue consists

of ,rief% )ur)oseful 9ourne*ing during hich contacts ith other )eo)le are +ini+al. "he

individual in a fugue usuall* does not attract attention. "he ne identit* that is )roduced is

fre6uentl* 6uite li+ited in its develo)+ent. In rare cases% the assu+ed identit* is 6uite

ela,orate% and the individual +a* ta1e a ne na+e and residence and engage in co+)lex

inter)ersonal relations or occu)ational activities so that the )resence of a +ental disorder is

not sus)ected. @hen a ne% co+)lex identit* is esta,lished% it is often characteri-ed ,*

+ore gregarious and uninhi,ited social ,ehavior than as the )atient0s )revious st*le.


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!I. DI==E#ENSIAL DIA:N/SIS

Individuals ith dissociative a+nesia +a* engage in confused andering during an

a+nesia e)isode. In dissociative fugue% hoever% there is )ur)oseful travel aa* fro+ the

individual0s ho+e or custo+ar* )lace of dail* activities% usuall* ith the individual

)reoccu)ied ,* a single idea that is acco+)anied ,* a ish to run aa*.

Patients ith dissociative identit* disorder +a* have s*+)to+s of dissociative fugue%

usuall* recurrentl* throughout their lives. Patients ith dissociative identit* disorder have

+ulti)le for+s of co+)lex a+nesias and% usuall*% +ulti)le alter identities that develo)%

starting in childhood.

In co+)lex )artial sei-ures% )atients have ,een noted to exhi,it andering or

se+i)ur)oseful ,ehavior% or ,oth% during sei-ures or in )ostictal states% for hich

su,se6uent a+nesia occurs. Sei-ure )atients in an e)ile)tic fugue often exhi,it a,nor+al

,ehavior% hoever% including confusion% )erseveration% and a,nor+al or re)etitive

+ove+ents. /ther features of sei-ures are t*)icall* re)orted in the clinical histor*% such as

an aura% +otor a,nor+alities% stereot*)ed ,ehavior% )erce)tual alterations% incontinence%

and a )ostictal state. Serial or tele+etric EE:s% or ,oth% usuall* sho a,nor+alities

associated ith ,ehavioral )atholog*.

@andering ,ehavior during a variet* of general +edical conditions% toxic and

su,stancerelated disorders% deliriu+% de+entia% and organic a+nestic s*ndro+es could

theoreticall* ,e confused ith dissociative fugue. In +ost cases% hoever% the so+atic%

toxic% neurological% or su,stancerelated disorder can ,e ruled in ,* the histor*% )h*sical

exa+ination% la,orator* tests% or toxicological and drug screening. Use of alcohol or

su,stances +a* ,e involved in )reci)itating an e)isode of dissociative fugue.

@andering and )ur)oseful travel can occur during the +anic )hase of ,i)olar disorder

or schi-oaffective disorder. Patients ho are +anic +a* not recall ,ehavior that occurred in

the euth*+ic or de)ressed state and vice versa. In )ur)oseful travel oing to +ania%hoever% the )atient is usuall* )reoccu)ied ith grandiose ideas and often calls attention to

hi+self or herself ,ecause of ina))ro)riate ,ehavior. Assu+)tion of an alternate identit*

does not occur.

Si+ilarl*% )eri)atetic ,ehavior can occur in so+e )atients ith schi-o)hrenia.

Me+or* for events during andering e)isodes in such )atients +a* ,e difficult to ascertain


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oing to the )atient0s thought disorder. Patients ith dissociative fugue% hoever% do not

de+onstrate a )s*chotic thought disorder or other s*+)to+s of )s*chosis.

Malingering of dissociative fugue can occur in individuals ho are atte+)ting to flee

a situation involving legal% financial% or )ersonal difficulties% as ell as in soldiers ho are

atte+)ting to avoid co+,at or un)leasant +ilitar* duties. No test% ,atter* of tests% or set of

)rocedures exist that invaria,l* distinguish true dissociative s*+)to+s fro+ those that are

+alingered. Malingering of dissociative s*+)to+s% such as re)orts of a+nesia for

)ur)oseful travel during an e)isode of antisocial ,ehavior% can ,e +aintained even during

h*)notic or )har+acologicall* facilitated intervies. Man* +alingerers confess

s)ontaneousl* or hen confronted. In the forensic context% the exa+iner should ala*s

carefull* consider the diagnosis of +alingering hen fugue is clai+ed.

!II. "reat+ent Prognosis

Dissociative fugue is usuall* treated ith an eclectic% )s*chod*na+icall* oriented

)s*chothera)* that focuses on hel)ing the )atient recover +e+or* for identit* and recent

ex)erience. H*)nothera)* and )har+acologicall* facilitated intervies are fre6uentl*

necessar* ad9unctive techni6ues to assist ith +e+or* recover*. Patients +a* need

+edical treat+ent for in9uries sustained during the fugue% food% and slee).

3linicians should ,e )re)ared for the e+ergence of suicidal ideation or self

destructive ideas and i+)ulses as the trau+atic or stressful )refugue circu+stances are

revealed. Ps*chiatric hos)itali-ation +a* ,e indicated if the )atient is an out)atient.

=a+il*% sexual% occu)ational% or legal )ro,le+s that ere )art of the original +atrix that

generated the fugue e)isode +a* ,e su,stantiall* exacer,ated ,* the ti+e the )atient0s

original identit* and life situation are detected. "hus% fa+il* treat+ent and social service

interventions +a* ,e necessar* to hel) resolve such co+)lex difficulties.

@hen dissociative fugue involves assu+)tion of a ne identit*% it is useful to

conce)tuali-e this entit* as )s*chologicall* vital to )rotecting the )erson. "rau+atic

ex)eriences% +e+ories% cognitions% identifications% e+otions% strivings% or self)erce)tions%

or a co+,ination of these% have ,eco+e so conflicting and% *et% so )ere+)tor* that the

)erson can resolve the+ onl* ,* e+,od*ing the+ in an alter identit*. "he thera)eutic goal

in such cases is neither su))ression of the ne identit* nor fascinated ex)lication of all its


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attri,utes. As in dissociative identit* disorder% the clinician should a))reciate the

i+)ortance of the )s*chod*na+ic infor+ation contained ithin the alter )ersonalit* state

and the intensit* of the )s*chological forces that necessitated its creation. In these cases%

the +ost desira,le thera)eutic outco+e is fusion of the identities% ith the )erson or1ing

through and integrating the +e+ories of the ex)eriences that )reci)itated the fugue.

Most fugues are relativel* ,rief% lasting fro+ hours to da*s. Most individuals a))ear

to recover% although refractor* dissociative a+nesia +a* )ersist in rare cases. So+e studies

have descri,ed recurrent fugues in +ost individuals )resenting ith an e)isode of

dissociative fugue. No s*ste+atic +odern data exist that atte+)t to differentiate

dissociative fugue fro+ dissociative identit* disorder ith recurrent fugues.

Most fugue )atients receive acute treat+ent in general hos)itals and )s*chiatric

facilities. So+e fugues resolve co+)letel*% although there is fre6uentl* so+e residual

a+nesia for all or )art of the fugue. Ps*chothera)* ith ad9unctive h*)nothera)* andFor

)har+acologicall* facilitated intervies +a* hel) overco+e the DA associated ith the

ter+ination of a fugue. So+e )atients sho )ersistent a+nesia and ill undergo a

)rolonged )s*chothera)* ith ad9unctive )s*cho)har+acological and h*)nothera)eutic

interventions.

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