"Web Fugue": A new Transient Mental Illness.

"Web Fugue": A new Transient Mental Illness.

C. Cabrera-Abreu; Roumen V. Milev

Dr. Casimiro Cabrera-Abreu
Consultant Psychiatrist
Mental Health Clinic
2110 Hamilton St.
Regina S4P 2E3
Saskatchewan
Canada

Dr. Roumen V. Milev
Clinical Director, Mood Disorder Service
Providence Continuing Care Centre
Mental Health Services
752 King Street West
Kingston, On.
Canada
K7L 4X3

[otros artículos] [21/2/2002]



Introduction

“Falsehood flies and truth come limping after; so that when men come to be undeceived it is too late; the jest is over and the tale has had its effects. ”
Jonathan Swift (1667 – 1745)

In this presentation we intend to show the reader a two way process of manufacturing a relatively valid and new category of mental illness based in current diagnostic taxonomies. First, we familiarize the reader with the work of two Canadian scholars who have devoted some time and attention to this complex process (Hacking, 1998; Hacking, 2000; Shorter, 1992). Secondly, and on the basis of the current notion of “Ontological Incontinence” (McHugh, 2001) and a certain degree of taxonomic imperialism brought to the fore by the application of the diagnostic criteria of DSM, we meander through three case histories that illustrate the perils of “ready – to – use” diagnostic criteria on atheoretical grounds. The reader should be made aware of the “Swiftian” spirit inspiring this poster; we are also heavily indebted to a remarkably intelligent and ironic paper by Blashfield and Fuller (1996).

Finally, this poster would be unconceivable without the recent growth in the literature about Internet and Mental Illness. The papers by Black et al. (1999) and Shapira et al. (2000) are only starting to be quoted widely; sooner or later with predict that they will turn into true “Citation Classics” (see for example Garfield’s paper of 1989 or one of his most recent contributions, Garfield, 1999). A recent paper by Stein et al. (Stein et al. 2001) gives an interesting twist to our poster and should be compulsory reading after perusing this poster.

Conceptual material and methods

a. Pools. According to Shorter (1992), by definition psychogenic psychical symptoms arise in the mind; the surrounding culture provides our minds with templates, or models, of illness. All these templates, or different ways of presenting illness, constitute a “symptom pool” – the culture’s collective memory of how to behave when ill (p. 2). How does a culture of a given period decide which symptoms to select? It depends on representations of what is thought to be legitimate organic disease.

b. “Ecological niches” and vectors. For Ian Hacking (1998) we need to return to the debate on hysterical fugues of the beginning of the XXth Century. According to him what is applicable to the genesis of hysterical fugue then, would be applicable to the genesis of mental illnesses today; thus, it is applicable also to the new category we propose: Web Fugue. For Hacking, the main question is this: What made the diagnosis of hysterical fugue possible? His answer is: An ecological niche with four principal vectors to be named medical taxonomy, cultural polarity, observability and release (Hacking, 1998. p. 81). He adds: I mean nothing technical by the word vector. […] Here I use it as a metaphor. […] The metaphor fails for niches, because we nave no vector algebra to resolve forces. Yet the metaphor has the virtue of suggesting different kinds of phenomena, acting in different ways, but whose resultant may be a possible niche in which a mental illness may thrive.

c. Case Histories
Case 1. A true case of Transient Web Fugue?
Mrs. W. L. is a 42 y. o. Caucasian female, unhappily married, with two adolescent sons, who was brought to the attention of the Mental Health Clinic by her husband. The patient had met a man in a chat room. According to her husband an intense relationship ensued. W. L. confessed to her husband that she had had “Cyber-sex” with this other man. A few weeks after her painful confession the patient drove to the U. S. A. without letting her husband know. Four or five days after vanishing, she telephoned home to let her husband know of her whereabouts. Upon her arrival to Regina, Saskatchewan, her husband requested an urgent psychiatric assessment. On examination the patient was rather morose and uncommunicative; she argued that she had experienced a memory lapse and that she did not know where she had gone. The patient reported no head injury with loss of consciousness. At the end of a rather tortuous interview, W. L. told the interviewer that she had fragmentary memories of her “escapade. ” She had met with a man 18 years younger than her and had several fulfilling sexual liaisons. The patient had consulted the clinic previously for a rather dubious diagnosis of Pathological Gambling but never followed through the therapeutic program. There was no evidence of axis I disorders. The axis II diagnosis was deferred. The patient did not follow up her appointments and we have not heard of her since December of 1999.

Case 2. Brief psychotic episode or Transient Web Fugue “Frustrée”?
Mrs. L. L. is a 39 y. o. Caucasian female who was seen at the Emergency Room of Regina General hospital at the beginning of fall of 2001. She works at one of the Crown Corporations based in Regina. Mrs. L. L. married when she was in her early twenties and she has two teenaged daughters. She became intensely drawn into a relationship with a man with whom she met at one of the Internet chats she frequented. The patient admits to a dull marriage and to a rather torrid Internet relationship with this other man. She believes that this man is relatively well known in the Show-world. She drove to Winnipeg to meet him. Her husband and her daughters did not know that she had left home. During her trip toWinnipeg (approximately a 6 hours drive) she had second thoughts and never met this man. She spent one night in Winnipeg. Upon her arrival the following day to Regina, the patient became increasingly anxious. She told her husband that their two daughter and him were under grave peril; apparently she thought that this other man had threatened to set fire to the house. The patient says that she cannot recall completely her thoughts during her trip to Winnipeg. Further, she vividly remembered not knowing where she was when she woke up the following day in a “strange room. ” The patient has an identical twin sister who believes that their alcoholic father sexually abused her during her childhood. Quite surprisingly her sister does not recall memories of these horrid events although she is “working” with her therapist towards that end. There is no previous psychiatric history and her medical history is unremarkable. The patient was treated empirically with a small amount of Risperdalâ. When she was last seen, at the end of October, she still could not remember what happened to her during her trip. No psychotic symptoms were elicited during her last visit. The final diagnosis under axis I remains an enigma although a few come to mind (from Brief Psychotic Episode to Dissociative Fugue). This would suggest possible comorbidity. The axis II diagnosis remains deferred.

Case 3. Borderline Personality Disorder or Transient Web Fugue?
Mrs. M. M. is a strongly built 34 y. o. female who married to her husband when she was 20. It was a “shotgun wedding” to her first and only boyfriend following her summer holidays in Regina. At that time she was visiting from Ontario. She consulted because she had expressed suicidal ideation to her counselor at the Mental Health Clinic. She stated that she wanted to crash her husband’s pick up truck against a wall. The patient gave a history of increasing unhappiness in her marriage. Mrs. M. M. argued that she had a very low self-esteem. Psychiatric assessment revealed mild depressive symptoms with no clear vegetative features. The patient had been engaged in an intense sentimental relationship with a man from the U. S. A. through Internet. Her suicidal thoughts seemed to be related to her ideas of profound guilt shortly after having “Cyber-sex” with this man. In this particular case it is important to mention that the patient had suffered a recent bereavement – the death of her brother in a car accident in March of 2001. Further, her mother had died 10 years ago and the patient held the unusual idea that in 10 years her two sons and her husband were going to die. The patient described the weeks before coming into the clinic to see a psychiatrist as “blurred. ” She did not seem to have amnesia for the period of time and for the circumstances leading to her episode of “Cyber-sex. ” A diagnosis of adjustment disorder was made under axis I. Her therapist – counselor – suggested a diagnosis of borderline personality disorder. The psychiatrist who assessed the patient believes that this diagnosis is unfounded.

Results (or how to apply Hacking’s and Shorter’s concepts to our patients)

Hacking defines a Transient Mental Illness as an illness that appears at a time, in a place, and later fades away. It may spread from a place to place and reappear from time to time. It may be selective for social class or gender. His metaphorical use of an “Ecological niche” represents, in our opinion, a further and sophisticated step over Shorter’s concept of “Pool. ” They both reflect the complexity and sheer size of the manifold of elements that makes a new type of diagnosis.

- Medical taxonomy refers, in our three cases, to the use and misuse of the DSM-IV. As in the case of Hacking’s mad travelers, it invites a controversy: into which part of the established taxonomy should Web Fugue be fitted? Either as a Dissociative Disorder or as an Impulse Control Disorder not otherwise specified (as it has been suggested by Shapira et al. , 2000)?

- Cultural polarity refers to two social phenomena that loom very large in contemporary culture: the stability of married life and the instability of mercenary sex, one virtuous, one vicious. This is clearly illustrated in our three vignettes. At least two of the patients confessed to “Cyber-sex” One of our patients insisted that it demonstrated the truth of the adage that ninety per cent of sex takes place in the mind (it is rather surprising that this patient coincided with Sherry Turkle who mentions an identical phenomena in her book “Life on the screen. ”).

- Observability refers to the following phenomena: in order for a form of behaviour to be deemed a mental disorder, it must be strange, disturbing and noticed. In one case, it was the husband who brought the patient to the Mental Health Clinic directly from the U. S. A. (case 1, Mrs. W. D. ).

- Release refers to a space in which women, on the edge of freedom (via Internet) yet trapped, could escape from what they perceive as a sordid existence.

Discussion and Conclusions

Trying to test strict scientific hypotheses against a changing culture is akin to measuring a developing weather front with a stepladder and a yardstick (Farrell, 1998). It can be argued that suggesting a new mental disorder for a future edition of the DSM is a tall order not unlike the above. We submit that our clinical experience with real patients, in the context of a constantly changing “Cyber-culture”, demands shunning the old DSM-IV category of Dissociative Fugue and incorporating our sleek new set of criteria under the name of Web Fugue.

DSM-IV diagnostic criteria for dissociative fugue (APA, 1994).

A. The 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 assumption of a new identity (partial or complete).

C. The disturbance does not occur exclusively during the course of dissociative identity disorder and is not due to the direct physiological effects of a substance (e. g. , a drug of abuse, a 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.

DSM-V diagnostic criteria for web fugue (Cabrera-Abreu & Milev, 2001)

A. The 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 of assumption of a new identity (partial or complete) following an excessive amount of time in “Chat-rooms” of the Internet.

C. The disturbance does not occur exclusively during the course of dissociative identity disorder and is not due to the direct physiological effects of a substance (e. g. , a drug of abuse, a 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.

References

1. Black DW, Belsare G, Schlosser S. Clinical features, psychiatric comorbidity, and health-related quality of life in persons reporting compulsive computer use behavior. J Clin Psychiatry 1999; Dec 60:839-44.

2. Blashfield RK, Fuller AK. Predicting the DSM-V. J Nerv Ment Dis 1996; Jan 184:4-7.

3. Farrell K. Post-traumatic Culture. Injury and Interpretation in the Nineties. Baltimore and London. The Johns Hopkins University Press; 1998.

4. Garfield E. A tribute to Eli & Lee Robins – Citation superstars: A citationist perspective on biological psychiatry. Current Contents 1989; 12(46):321-29.

5. Garfield E. Journal impact factor: a brief review. CMAJ 1999; Oct 161:979-80.

6. Hacking I. Mad Travelers. Reflections on the Reality of Transient Mental Illnesses. Virginia. The University Press of Virginia; 1998.

7. Hacking I. The Social Construction of What? Cambridge, Massachusetts / London, England. Harvard University Press; 2000.

8. McHugh PR. Book review. N Engl J Med 2001; 354:299-300.

9. Shapira NA, Goldsmith TD, Keck PE, Khosla UM, McElroy SL. Psychiatric features of individuals with problematic Internet use. J Affect Disord 2000; 57:267-72.

10. Shorter E. From Paralysis to Fatigue. A History of Psychosomatic Illness in the Modern Era. New York. The Free Press; 1992.

11. Stein DJ, Black DW, Shapira NA, Spitzer RL. Hypersexual Disorder and Preoccupation with Internet Pornography. Am J Psychiatry 2001; Oct 158(10):1590-94.

12. Turkle S. Life on the Screen. Identity in the Age of the Internet. New York. Touchstone; 1995.