Abstract
DSM-IV acute stress disorder and posttraumatic stress disorder (PTSD) are known to be associated with dissociative symptomatology. Davidson et al. [1] suggested that dissociative symptoms tend not to recur repeatedly, despite PTSD persisting. The finding that dissociation in the face of trauma is a marker of long-term psychopathology [2, 3, 4, 5]] suggests that persisting dissociative symptoms in PTSD is an indicator of severity. Enduring dissociative responses to trauma sometimes include fugue states.
‘Fugue-like’ states have been noted in acute combat situations [6, 7, 8, 9]]. Kolb [10] observed clinically, that combat veterans returning from World War II continued to have dissociative symptoms to subsequent stressors. This observation is applicable to Vietnam veterans [2]. Indeed Spiegel [11] concluded that Vietnam veterans with PTSD may have more dissociative symptoms than other veterans. In combat veterans with PTSD and fugue states, Young [12] reported the assumption of a not necessarily new identity, but a prior, or different identity. He described a veteran who developed an alternate personality, assuming the identity of a friend who died in combat. McDougle and Southwick [13] reported a return of a prior combat personality during a fugue state of a Vietnam veteran.
Fugue states, when durable and prolonged, and associated with travel away from home or customary work locale tend to create distress for families and major management difficulties for police, rescue workers and mental health professionals. This is despite the known unlikely risk of sufferers harming themselves either deliberately or by neglect. This paper presents the case of a combat veteran with PTSD and recurrent fugue states whose management was aided by the use of an electronic locator device. This ensured his prompt discovery and rapid return to the care of his family.
Case history
Mr IB, now aged 50, served a tour of duty in Vietnam as an infantry man in the New Zealand Army, 1967/1968. He helplessly witnessed the fatal mutilation of his platoon leader by a mine, and the shooting of a Vietnamese boy-soldier. These events were aetiologically associated with the development of an acute and subsequently chronic PTSD. Initial acute posttraumatic symptomatology were masked by defensive suppression and heavy alcohol abuse. The following year, a 3-day dissociative fugue was precipitated by a minor disciplinary check and ensuing rage response.
Over the following two decades, several times a year, the subject disappeared for periods of hours, and on one occasion, for nearly 3 months. The police department recorded, that from 1983 to 1989, they committed staff to 93 working days searching for him; exhaustive searches rarely located him, despite reports of sightings. Usually he would emerge from a large coastal forest (similar in appearance to an area of active combat in which he served in Vietnam), hungry, thirsty, physically exhausted and acting as if in the role of a combat soldier. He was amnestic for the events of the missing hours/months.
When referred to this author in 1989, Mr IB was experiencing typical symptoms of chronic PTSD. Prominent posttraumatic symptoms included traumatic night terrors several times a week, and intrusive recollections cued, for example, by helicopter noise and by the smell of Asian cooking. Symptoms also included hyperarousal, exaggerated startle response, initial insomnia, irritability, poor concentration, hypervigilance. He avoided encounters with ex-military colleagues and did not attend reunions.
The patient did not actively avoid treatment. Rather, his trauma symptoms tended to be dismissed by his medical and psychological attendants. Since 1989, psychological interventions included: ventilation/catharsis, relaxation therapies, and self-hypnosis. Pharmacotherapeutic interventions comprised: prescriptions of clonidine, up to 300 μg t.d.s., substitution of a tricyclic antidepressant with an SSRI, and trials of the anticonvulsant medications carbamazepine, phenobarbitone, and vigabatrin. All of these medication modalities at least partially alleviated his symptomatology. However, fugue states continued to occur intermittently. They were precipitated by a range of stressors, from those which were clinically anticipated (e.g. attendance at a reunion, a passing helicopter) to the seemingly trivial (e.g. anger at stubbing his toe).
In 1991, Mr IB's wife saw a television program about fitting locator homing-devices to wild animals to track these for scientific research purposes. She suggested that such a device would enable tracking of her spouse during dissociative fugues. A matchbox-size, silent signal, transmitter was sealed and waterproofed, and attached to a neck chain which the patient wore, even when in Vietnam. A receiver was located at their home. The total cost, donated by an American Vietnam veteran, was NZ $2500.
Approximately 6 months later, Mr IB experienced a dissociative fugue state. Within a few hours he was located in the coastal forest, and was able to be persuaded home by his family. He had made no attempt to remove the neck chain. On several occasions over the next 5 years, this locator beacon proved helpful. Not only did the device dramatically ease the concerns and anxieties of Mr IB's family, but from a psychological perspective, it provided him with a sense of mastery over his fugue state. This was translated into other significant clinical gains.
In the past 4 years, there were no disappearances. Identification of environmental cues evoking fear, anger, and irritability (i.e. key emotional elements of the subjects’ ‘mental status') facilitated steady clinical improvement. Current medications are paroxetine 20 mg mane, clonidine 150 μg t.d.s., phenobarbitone 120 mg nocte and vigabatrin 500 mg b.d.
Discussion
Chronic PTSD complicated by dissociative symptoms poses difficult management problems. Fugue states are an unusual yet dramatic expression of dissociation, and a rare complication of severe PTSD. Anecdotal clinical descriptions of fugue, particularly in combat veterans, suggest a spectrum of intensity from brief episodes of ‘going bush’ to extended disappearances.
Loewenstein [14] considered the first task of treatment to be the restoration of safety and wellbeing, and establishment of a therapeutic working alliance. Fundamental issues in dissociative patients centre on tolerance and control of affects, and maintenance of trust and boundaries in relationships [15, 16]]. Immense anxiety is provoked in relatives and those involved in the community by the disappearance. A tracking device can ease safety concerns by facilitating control over the symptom. Removal of the device could have limited its usefulness. However, the subject did not remove his chain/locator during the fugues. This was most likely because he had habitually worn this chain since he had been on active combat duty.
A locator beacon is a novel, practical and cost-effective (to the Police and Rescue Services) therapeutic device. It augments existing multimodal therapies of PTSD, and is an innovative application of biotechnological advances to psychiatric practice. Further telecommunication developments should provide smaller, simpler and cheaper tracking devices. These could have clinical applicability to conditions other than fugue states, such as to the wandering, demented patient.