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Homoeopathic management of dissociative fugue: A case report
*Corresponding author: Dr. Vijaya Sanjay Patil, MD (Hom), Sparsh Homoeopathy and Child Care Centre, Navi Mumbai, Maharashtra, India. vijayassp@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Patil VS. Homoeopathic management of dissociative fugue: A case report. J Intgr Stand Homoeopathy 2021;4:80-5.
Abstract
A 14-year-old boy was brought to us with complaints of recurrent fleeing episodes with confusion, short-term amnesia and behavioural problems, including restlessness, obstinacy and temper tantrums. He was diagnosed with dissociative fugue based on the DSM IV criteria. He had undergone counselling with his school counsellor, without much benefits. His illness was affecting his academic performance and relationships with parents and friends. The case was explored from the point of psychosocial stresses and the child’s disposition with characteristic expressions. The homoeopathic remedy Cuprum Metallicum was selected using Kent’s approach, as predominant mental characteristics were available. The selected remedy brought changes at the level of the disease expression (fleeing episodes) as well as the deeper aspect of his sensitivity and behaviour. Improvements occurred in his academic performance, social relationships, behaviour at school as well as his relationship with his parents. This experience emphasises the role of homoeopathy in mental disorders, especially dissociative fugue and also demonstrates the importance of characteristic mental state and expressions when selecting a similimum using Kent’s approach.
Keywords
Homoeopathy
Dissociative fugue
Child psychiatry
Kent’s approach
Cuprum Metallicum
INTRODUCTION
Dissociative fugue is the least studied and most poorly understood of the dissociative disorders; it is especially rare in children and adolescents.[1] Although less understood, clinically, it is one of the most fascinating disorders in mental health. The symptoms are sudden unexpected travel away from home or one’s customary place of daily activities, with the inability to recall some or all of one’s recent past.[2]
According to the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition Text Revision, 2000 (DSM IV),[2] the diagnostic criteria for dissociative fugue are well defined [Table 1].
| A. | A predominant disturbance is sudden, unexpected travel away from home or one’s customary place of work, with inability to recall one’s past |
|---|---|
| B. | Confusion about personal identity or even the assumption of new identity (partial or complete) |
| C. | The disturbance does not occur exclusively during the course of dissociative identity disorder and is not due to direct physiological effects of a substance (e.g., a drug of abuse or medication) or a general medical condition (e.g., temporal lobe epilepsy) |
| D. | The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning |
Travel may range from brief trips to wandering over long periods. Once the individual returns to the pre-fugue state, there may be no memory for the event that occurred during the fugue state. The extent and duration of the fugue state may determine the degree of other problems such as loss of employment or severe disruption of personal and family relationships. The prevalence of this condition in the general population is only 0.2%. The onset is usually related to traumatic stressful or overwhelming life events.[2] Associated features can be depression, dysphoria, anxiety, grief, shame, guilt, conflict and suicidal or aggressive impulses.
Emotional turbulence such as fear, fright, anxiety and disappointment arising out of traumatic circumstances are thought to be the underlying cause, which leads to an altered state of consciousness with a wish to flee. Splitting is the underlying defence mechanism used by individual to cope with traumatic memories. These thoughts, emotions, sensations and/or memories are ‘split off’ from the integrated ego. The prevention of future episodes usually involves therapeutic resolution of the distressing situations and increasing the strength of personal coping mechanisms. For more difficult cases, hypnosis or the use of benzodiazepines (mild tranquilizers) is suggested.[3]
An unexpected finding in some cases was that associated criminal activity may allow the person with dissociative fugue to continue to function despite their loss of memory and original identity.[4] Individuals with dissociative amnesia with dissociative fugue can have psychotic symptoms, and it takes a longer time to recover from memory disturbances.[5]
Dissociative fugue can be associated with depressive disorder.[6]
Homoeopathy can be defined as a system of drug therapeutics based on the law of similars. The successful application of law of similars depends entirely on the concepts of individualisation and susceptible constitutions.[7]
Here, we discuss a case of dissociative fugue in a child.
CASE REPORT
Date of case definition: 27 July 2013
Mast R.S. was a 14-year-old boy studying in the 9th standard, living with his parents. His father was a bank employee and mother was a housewife.
The mother complained that till the 6th standard, his performance was very good (Grade A); it deteriorated later to Grade C. His behaviour at school was also changing. In the past 3 months, he had run away from school without telling anyone thrice.
The 1st time, he was outside the whole day. A passer-by noticed him and he was taken to the police station. There, he said that he was kidnapped. The school authorities were called and issue was resolved. The 2nd time, he took a rickshaw and roamed around aimlessly while parents were searching for him the whole day. The 3rd time as well, he managed to escape without anybody’s knowledge.
According to his parents, every episode had a reason, but the patient did not accept this. The 1st time, he had failed in history and science; the 2nd time, he was not prepared for examinations and the 3rd time, the teacher scolded him and kept his school calender. However, he did not accept that he was facing any stress. He said that he did not know why he was there at those places and how he reached there. He had no memory of what happened during that fleeing episode, but if he wanted to control the thought of escaping, he had headaches.
Excerpts from the patient’s interview
‘I don’t want to bow down anywhere. I don’t like to ask help from anybody. I will not ask for book if I want to complete the work. My mother says I should ask, people say I am egoistic, I don’t forget and forgive. If somebody pushes me, I will beat back and will not forget but no after effects of regrets. Nowadays, I have fear that I will lose control of my anger. I don’t want to do tit for tat.’ When asked about his hobbies and other interests, he said ‘I want to be in army. I like to do adventurous things. I like soldiers, guns, power and violence. I like rock climbing, dangerous things. I like to go out but to different places, foreign country. I like English movies – like comedy, army and adventurous. I feel that my parents don’t fulfil my wishes immediately. Sometimes, I feel that I am not able to understand math and cannot memorise. Sometimes, I am in my own world and do not understand what teacher is teaching and not able to concentrate.’
Excerpts from the mother interview
‘He is the only child. I am very strict with him but father is very friendly. I have to be strict with him as he is very adamant since childhood, will not comply. He gets very angry if his wish is not fulfilled. He will throw temper tantrum such as head banging, punching door and breaking things and he beats others. He is very impatient and has to get things fast. If somebody annoys him or teases him, he will immediately beat that person. One day, he wanted to keep his bag at particular place in the class. One boy was not allowing him to do that. He immediately hit that person and it was a big issue. He does tit for tat and does not forget. He does not get along with anybody and always complaining about others. Last week teacher scolded the whole class as food was spilled over benches, but he got very angry, came home and started abusing teacher.’
Observations
The patient was fidgety, constantly moving his leg, stretching his body. He was constantly running his fingers through his hair and appeared very confident.
Physical generals
Aversion: Milk
Fan seasonal, always requires covers when sleeping
Nail white spots +++
Medical history
Tendency to recurrent tonsillitis and loose motions.
Diagnosis: Dissociative fugue (DSM IV)
It was differentiated from malingering based on the following reasons:
There was a possibility of the patient benefiting from these fleeing episodes, but, as the patient said during interview, he could not control the thought of fleeing. If he tries to control his thoughts, he develops headaches. Moreover, he was unable to share details of the episodes even on extensive questioning. A malingering patient is fully aware of what he is doing and his gains. Our patient was also fully cooperative for treatment.
Characteristic and common symptoms
When we have too many symptoms at the level of mind, it becomes difficult to differentiate among similar remedies. It is, therefore, important that we differentiate between common and characteristic symptoms.
Case processing – Homoeopathic perspective
This case had many characteristics at the level of mind. Below, we list the characteristic mental symptom along with the most suitable Repertorial Rubric Reference for the same:
He likes adventures, army, rock climbing, guns, power and solders; he likes to be in army – Delusion he is a general
Fleeing episodes were with confusion, loss of memory for that period – Escape desire to be in delirium
He wants to be dictatorial like an army officer or commander and does not want to bow down in front of others – Egotism, haughty, dictatorial
He is obstinate and wants to do what he wants – Obstinate pertinacity
If not allowed, will do violence like striking others or self-injurious behaviour, abusive and revengeful – Rage leads to deeds of violence, malicious
He is always complaining about others – Discontented
Fear of losing control of self
He is impatient, restless, fidgety – Pulling hair, stretching body.
In this case, the most characteristic symptoms are
Delusion he is a general or officer
Escape attempts to in delirium (despite being a disease symptom, it is the most characteristic expression of the disease; very few remedies have this expression in proving)
Rage leading to violence
Obstinate-pertinacity
Pull hair desire to as expression of restlessness.
Common symptoms are
Haughty
Dictatorial
Malicious
Obstinate
Discontented
Fear of losing self-control
Restlessness in children, impatience
Desire to stretch in general.
At the physical level, the important symptoms are
Chilly thermal state
Aversion milk
Nail white discoloration.
All the fleeing episodes had probable causative factors: Sensitivity to reprimand, contradiction intolerant and ego sensitivity or fear of failure or punishment. However, the patient did not accept that his problem was related to these factors. Therefore, although important, these causations were not included in the totality, were taken as common precipitating cause of the disease as mentioned in the DSM IV.
Kent’s approach was used, as the totality of this case was based on the characteristic mental state and its expressions, followed by few physical symptoms. Dr. Kent was convinced that if a remedy was to help a patient to any extent, then it has to match closely the mental state that represents the core of the image, its outline being furnished by the physical generals.[7]
Totality with repertorisation done using the complete repertory [Figure 1].
- Repertorial sheet using Hompath classic software, Mind Technologies, Mumbai, India.
The remedies that came up after repertorisation [Figure 1]
Cuprum Met 12/16
Arsenic 11/15
Sulphur 10/14
Nux vomica 10/15
Merc sol 9/17
Materia Medica differentiation
Arsenic Alb, covers the totality, but the most important delusion as well as important expression escape desire to in delirium is not covered by Arsenic Alb. Moreover, the core features of Arsenic Alb: Fears, anxiety, insecurity and mistrust were missing in the case
Sulphur was not considered because of the patient’s thermal state; the characteristic delusion was also not covered by Sulphur.
Nux vomica comes very close, but it does not cover the delusion, fleeing expression and nail white discoloration
Merc sol: The first remedy selected was Merc sol, it showed similarity at the general level, with the common symptoms such as dictatorial, rage, haughty, malicious, obstinate and restlessness fear of losing self-control. However, the characteristic mental state of delusion he is a general; other characteristics such as obstinate pertinacity or pull hair desire to as qualified expression of restlessness; and white discoloration of nail, as a characteristic physical expression were not covered by Merc sol.
Only one of the remedies – Cuprum Met – covers the most important core mental state of delusion he is a general.[8] The characteristic expression was escape with confusion and short-term amnesia, restlessness with pull hair desire to, discoloration on nail, white. As all these symptoms are covered by Cuprum Met,[8] we studied the remedy from various Materia Medica texts.[9,10]
While Cuprum Met was selected on the basis of delusion, he is a general, which is a single remedy rubric, it covered all other common as well as characteristic mental symptoms and physical generals. The totality matched the characteristic mental state, disposition, expressions and physical generals. Hence, Cuprum Met is a complete similimum in this case [Figure 2].
- Study of Cuprum Met.
Prescription
From 27 July 2013 to 1 October 2013, Merc sol 200C was administered for 2 months (six doses). However, it did not help and the fleeing episodes continued, with no change in his behaviour. Therefore, the totality was reviewed.
On 1 October 2013 – Cuprum Met was administered. As the susceptibility was deemed to be high, 200C potency was selected [Table 2].
| Date | Fleeing | Anger temper | Fidgety pulling hair | Concentration | Rx |
|---|---|---|---|---|---|
| 1 October 2013 | Cup met 200C weekly 1 powder. |
||||
| 17 October 2013 | None | Better | Fidgety> Pulling hair> |
SQ | Placebo |
| 23 January 2014 | None | >> | >> | > | Placebo |
| 20 February 2014 | None | >> | >> >> |
>>Since 3 days had coryza cough, mild fever, with thirst less, thermal chilly |
Pulsatilla 200C TDS for 3 days Followed by Cup met 200C weekly one dose. weekly |
| 15 March 2014 | None | >> | >> >> |
>> | Placebo |
>Mild better, >>Much better, SQ: Same
The patient was under our treatment for nearly 4 years. His academic performance gradually improved, and the complaints from the school reduced. His parents were happy with his behaviour and performance. After completing school and college, he opted for the engineering field.
DISCUSSION
Dissociative fugue is a rarely reported diagnostic entity.[1] As the individual loses his/her episodic memory and is often in a confused state, it is extremely important to handle this disorder more consciously. If not treated in time, this condition may lead to disturbances at the level of occupation as well as social and family relationships. This may give rise to other psychological disorders such as anxiety or depression. Dissociative symptoms can persist in some rare cases. Case has to be enquired in great details to understand the disposition, psychosocial stresses, coping mechanisms with characteristic expressions as well as work performance of the individual. This knowledge will help us to define the therapeutic problem definition (the diagnosis, stresses, morbid expressions, difficulty at social relations and academic or occupational performance) and hence problem resolution (homoeopathic medicines with counselling). As the individual loses his episodic memory or is often in confusion, it becomes difficult to collect data of the fleeing episodes and its probable causative factors. This difficulty has to be overcome by gathering information from related people such as parents, caretakers, friends, teachers and colleagues. In this case, detailed information and observation were available from the parents which helped the physician to individualise the case and arrive at the similimum. Cases need to be followed up for longer periods as the state may relapse depending on stressful triggers.
CONCLUSION
The case report highlights the difficulties faced by a homoeopathic physician when too many mental symptoms are present. Here, classifying the symptoms into common and characteristics will guide the physician to differentiate similar remedies and to select the similimum. The case study also shows that the selected remedy could bring, change at the level of disease expressions (fleeing episodes); as well as the deeper aspect of his sensitivity and behaviour as was evident through his academic performance, his social relations, behaviour at school and his relationship with his parents. We can conclude that homoeopathic remedies, if correctly selected using the similimum principle, can play a major role in the treatment of dissociative fugue.
Acknowledgments
I am thankful to Dr. M. L. Dhawale Memorial Trust for giving me the opportunity to present my experience in the journal and Dr. Nikunj Jani for his guidance while preparing this case report.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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