Dissociative Fugue: When People Forget Who They Are

Vanishing identities, sudden relocations, and complete memory loss—welcome to the fascinating world of dissociative amnesia with fugue. Ever wonder what happens when someone's mind creates the ultimate escape hatch from unbearable psychological pain?

Dissociative fugue represents an extraordinary psychological defense mechanism where individuals not only lose their autobiographical memories but may travel hundreds of miles away and assume entirely new identities. What makes this condition particularly intriguing is that while personal memories become inaccessible, practical skills remain intact. Someone might disappear from their life as an accountant only to be discovered weeks later working at a grocery store under a different name, with no awareness of their true identity.

We explore the clinical presentation, typical development, and evidence-based treatments for this complex condition. You'll learn about the strong connection between childhood trauma and dissociative disorders, and why a phase-oriented approach to treatment is absolutely essential. Through specialized techniques like memory mapping and narrative exposure, therapists can help clients build a coherent sense of identity while respecting the protective function the fugue served. From assessment tools to comorbid conditions, we provide a comprehensive understanding of this rare but fascinating psychological phenomenon.

Whether you're preparing for your licensing exam or looking to deepen your clinical knowledge, this episode offers valuable insights into one of psychology's most intriguing defense mechanisms. Subscribe to our podcast for more in-depth explorations of complex mental health topics that will enhance your therapeutic practice and understanding of the human mind.

If you need to study for your national licensing exam, try the free samplers at: LicensureExams


This podcast is not associated with the NBCC, AMFTRB, ASW, ANCC, NASP, NAADAC, CCMC, NCPG, CRCC, or any state or governmental agency responsible for licensure.

Chapters

• 0:00 Introduction to Dissociative Amnesia
• 1:42 Clinical Presentation and Symptoms
• 4:16 Development and Associated Features
• 6:51 Evidence-Based Treatment Approaches
• 8:42 Assessment Tools and Summary
• 10:53 Key Takeaways for Therapists

Transcript

Linton: 0:12

Hey there you fantastic therapists. I'm Dr Linton Hutchinson. And guess what? Today we're going to go over the disassociative amnesia, specifically with the disassociative fugue specifier. If you're wondering where Stacy is, well, today she's hanging about 100 feet up in the air working on a historic barn somewhere in Minnesota no, not Minnesota, michigan. What am I thinking? Well, anyways, in the DSM-5-TR this requires the inability to recall important autobiographical information. That's inconsistent with ordinary forgetting Definitely not my words. The amnesia causes significant distress or impairment in functioning and it's not due to substances or neurological conditions.

Linton: 1:06

The fugue specifier applies when there's purposeful travel or bewildered wandering associated with amnesia for identity or other autobiographical information. In other words, who am I, where am I, what am I doing? So the duration of this happening really varies. Some fugue states only last a few hours, while others will last more than months. The onset is typically sudden, often following severe psychosocial stressors like combat, exposure, natural disasters or most likely personal crisis natural disasters or most likely personal crisis. You'll see complete memory loss of personal history during the fugue state, though procedural memory and general knowledge remains intact, the client may assume a new identity and appear to function normally in whatever new environment that they're in. When the fugue ends, it's usually really abrupt and you'll observe complete amnesia for all the events and situations that occurred during the fugue period.

Linton: 2:18

Okay, what's a clinical presentation. What's that look like? So when you encounter disassociative fugue in therapy, you'll see sudden unexpected travel away from home with amnesia for their own personal identity, of who they really are. Your client may be brought back to you by the police or family after being found hundreds of miles away with typically no memory of how they got there. During the fugue state, you'll observe organized, purposeful behavior rather than feeling confused. They're not just wandering aimlessly. You'll notice selective amnesia affecting personal memories, while just general knowledge of things stay intact. Your client can still drive, use money and interact socially, but won't remember real common things like their name or their history. The presentation often involves the assumption of a new identity with different characteristics and behaviors. You've probably heard about someone who disappeared from their life as an accountant and then they were found weeks or months later working at Publix, at the sushi department, under a different name maybe Kai, who knows? So when the fugue ends, you'll see significant distress and confusion as your client struggles to understand what happens. So that's probably when you're going to see them in your office.

Linton: 3:43

So typical development begins with an overwhelming psychological stress that exceeds your client's coping capacity. You often find histories of previous trauma or disassociative experiences that created vulnerability to the fugue state. The acute phase begins suddenly, lasting from, like I said before, hours to months, with a complete alteration of identity during that period. And just as it came on suddenly, recovery is usually also abrupt. Some clients experience sort of a gradual return of memories over days or weeks. Post-fugue adjustment involves significant challenges for your client because they've got to process what happened during that lost time and they're also going to have to deal with the consequences of whatever they did during the feud. Something similar to that happened with one of my students. I was working at Stone Soup School, which was a boarding school, and one night John took the van and drove 300 miles over the St Pete Beach and was only discovered a couple days later by the police and was returned to the school.

Linton: 4:54

So it does happen. It seems to be rare, but it does happen, and you may have a client such as that. What are the associated features? Well, when you have a client, you'll observe high rates of childhood trauma. Oh, talking about John, his parents had just gotten a divorce and he was really close to them so I think that was the precipitating factor with him. But anyways, you'll observe with your clients a high rate of childhood trauma, particularly abuse or severe neglect. That established disassociation as a coping mechanism. Clients often show other disassociative symptoms like depersonalization or derealization.

Linton: 5:35

Between fugue episodes, emotional numbing and avoiding behaviors are common as your client tries to prevent triggering another fugue state. You may notice the identity confusion persist even after the fugue resolves, with your client questioning their sense of self. You also find that PTSD frequently co-occurs, as the same traumas that precipitated fugue often meet the same criteria for PTSD. You'll see overlapping symptoms like avoidance, hypervigilance and intrusive memories when your client isn't in the fugue state. And what's universal between these two? Depression. Depression often follows a fugue state as your client grapples with feelings of shame, confusion and, of course, the consequences of what they did when they disappeared, as well as having to deal with their family and friends when they do come back. Anxiety disorders, particularly panic disorder, often develop as your client fears losing control or experience another few episodes.

Linton: 6:46

So what you need to know? What are the evidence-based treatments? Phase-oriented treatment has the strongest support. You need to focus first on safety and coping skills, then gradually process traumatic material as your client develops tolerance for different emotions. Cognitive behavioral therapy helps your client identify triggers and develop alternative coping strategies. You work on challenging catastrophic thoughts that make disassociation seem like the only coping mechanism that they can use. Emdr shows promise for processing traumatic memories that precipitated the fugue, though you need to have specialized training and have the EMDR adapted for disassociative clients.

Linton: 7:35

Let's talk about specific techniques now. That's something you need to know for your private practice as well as for the licensing exam. Three of them come to mind. First is memory mapping. It's a technique that involves creating a visual timeline that helps your client see the connection between fragmented memories and identify patterns in their disassociative responses. Then there's narrative exposure, and that'll help your client tell their story without becoming totally overwhelmed. The idea is to guide them in developing multiple perspectives on their experience, and it helps them build a coherent narrative of their identity. And last, somatic resources helps build your client's capacity to stay embodied when processing different material. With this technique, you focus on having them notice and tolerate physical sensations that previously triggered their disassociation.

Linton: 8:35

Another thing that you need to know are the different assessment tools, determining if that's what they're exhibiting. All three of them have the word disassociative in them, so it's going to be easy to identify which ones to use. The first one is called the Disassociative Experiences Scale and it screens for disassociative symptoms. The second is the Disassociative Disorders Interview Schedule, which is basically to assess for differential diagnosis, to assess for differential diagnosis. And three and this is a long one the clinical administered disassociative state scale. Who comes up with these anyways? But basically that tracks the symptom changes over treatment. So it's something that you would administer at the beginning, every couple weeks to objectively measure your client's progress. So let's do a summarization right now, okay.

Linton: 9:34

Disassociative fugue represents an extreme psychological defense. It's really a defense mechanism where your client's mind completely erases their identity to escape unbearable circumstances. Two, you need to recognize and understand the organized behavior during fugue distinguishes it from other conditions. Your client is not confused, they're not psychotic, they're just functioning under a different identity. They're not making it up, they're actually functioning as a complete new person. Your success treating this client will be dependent on you actually respecting the protective function of the fugue while gradually building your client's capacity to face what they couldn't tolerate before. You're not trying to force an integration, but you're trying to facilitate it. And the last, and probably most important, is the phase-oriented approach is non-negotiable. You always have to stabilize the client before even trying to attempt any trauma processing. You can't skip ahead without risking re-traumanization or another fugue episode. Well, that's it, and as we always say, remember it's in there.