The article "Sleep Medications to Get Stronger Label Warnings"
in the April 8 issue regarding what the FDA calls "complex sleep-related
behaviors" highlights a deficiency in DSM. These behaviors
include patients' "eating, driving, making phone calls, and having sex
while under the influence of sleep medications."
Fugue-like behavior secondary to an organic condition, such as the effects
of sleep medication, has no suitable category in the DSM
classification system. DSM's "dissociative fugue," for
example, 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)." In contrast, substance-induced disorders and
those due to a general medical condition, as well as delirium, do not include
as a central feature the apparently purposive and possibly complex or
elaborate behavior seen in the kinds of cases reported in the Psychiatric
News article on sleep medications and other reports over the years I have
I have previously proposed that DSM include a diagnostic category
for such cases of what could be called "organic dissociation" or"
dissociation secondary to a general medical or substance-induced
condition." Such a category would also help classify automatisms that
can be observed in conditions like temporal lobe epilepsy and
dissociative-like states due to other medical factors that presently have no
fitting DSM category. Not only would this category improve diagnostic
precision and permit possibly greater study of these states, but also it would
provide recognition of varying degrees of contribution from psychological,
general medical, substance-induced, and stress-related factors, as opposed to
requiring that the dissociative-like behaviors be "due to" either
an organic condition alone or have no organic contribution. The
dissociative-like behaviors seen in these states generally do not have an
either-or etiology but rather are the expression of several determinants.