Dissociative Fugue: When People Forget Who They Are

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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.

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Episode Transcript

Linton (00:07):
Hey there you fantastic therapists.
I'm Dr Linton Hutchinson.
And guess what?
Today we're going to go overthe disassociative amnesia,
specifically with thedisassociative fugue specifier.
If you're wondering where Stacyis, well, today she's hanging
about 100 feet up in the airworking on a historic barn

(00:31):
somewhere in Minnesota no, notMinnesota, michigan.
What am I thinking?
Well, anyways, in the DSM-5-TRthis requires the inability to
recall importantautobiographical information.
That's inconsistent withordinary forgetting Definitely
not my words.

(00:51):
The amnesia causes significantdistress or impairment in
functioning and it's not due tosubstances or neurological
conditions.
The fugue specifier applies whenthere's purposeful travel or
bewildered wandering associatedwith amnesia for identity or

(01:12):
other autobiographicalinformation.
In other words, who am I, wheream I, what am I doing?
So the duration of thishappening really varies.
Some fugue states only last afew hours, while others will
last more than months.
The onset is typically sudden,often following severe

(01:36):
psychosocial stressors likecombat, exposure, natural
disasters or most likelypersonal crisis natural
disasters or most likelypersonal crisis.
You'll see complete memory lossof personal history during the
fugue state, though proceduralmemory and general knowledge
remains intact, the client mayassume a new identity and appear

(01:57):
to function normally inwhatever new environment that
they're in.
When the fugue ends, it'susually really abrupt and you'll
observe complete amnesia forall the events and situations
that occurred during the fugueperiod.
Okay, what's a clinicalpresentation.
What's that look like?
So when you encounterdisassociative fugue in therapy,

(02:20):
you'll see sudden unexpectedtravel away from home with
amnesia for their own personalidentity, of who they really are
.
Your client may be brought backto you by the police or family
after being found hundreds ofmiles away with typically no
memory of how they got there.
During the fugue state, you'llobserve organized, purposeful

(02:43):
behavior rather than feelingconfused.
They're not just wanderingaimlessly.
You'll notice selective amnesiaaffecting personal memories,
while just general knowledge ofthings stay intact.
Your client can still drive,use money and interact socially,
but won't remember real commonthings like their name or their

(03:06):
history.
The presentation often involvesthe assumption of a new
identity with differentcharacteristics and behaviors.
You've probably heard aboutsomeone who disappeared from
their life as an accountant andthen they were found weeks or
months later working at Publix,at the sushi department, under a
different name maybe Kai, whoknows?

(03:26):
So when the fugue ends, you'llsee significant distress and
confusion as your clientstruggles to understand what
happens.
So that's probably when you'regoing to see them in your office
.
So typical development beginswith an overwhelming
psychological stress thatexceeds your client's coping
capacity.

(03:46):
You often find histories ofprevious trauma or
disassociative experiences thatcreated vulnerability to the
fugue state.
The acute phase begins suddenly, lasting from, like I said
before, hours to months, with acomplete alteration of identity
during that period.

(04:07):
And just as it came on suddenly, recovery is usually also
abrupt.
Some clients experience sort ofa gradual return of memories
over days or weeks.
Post-fugue adjustment involvessignificant challenges for your
client because they've got toprocess what happened during
that lost time and they're alsogoing to have to deal with the

(04:28):
consequences of whatever theydid during the feud.
Something similar to thathappened with one of my students
.
I was working at Stone SoupSchool, which was a boarding
school, and one night John tookthe van and drove 300 miles over
the St Pete Beach and was onlydiscovered a couple days later
by the police and was returnedto the school.

(04:49):
So it does happen.
It seems to be rare, but itdoes happen, and you may have a
client such as that.
What are the associatedfeatures?
Well, when you have a client,you'll observe high rates of
childhood trauma.
Oh, talking about John, hisparents had just gotten a
divorce and he was really closeto them so I think that was the

(05:10):
precipitating factor with him.
But anyways, you'll observewith your clients a high rate of
childhood trauma, particularlyabuse or severe neglect.
That established disassociationas a coping mechanism.
Clients often show otherdisassociative symptoms like
depersonalization orderealization.

(05:30):
Between fugue episodes,emotional numbing and avoiding
behaviors are common as yourclient tries to prevent
triggering another fugue state.
You may notice the identityconfusion persist even after the
fugue resolves, with yourclient questioning their sense
of self.
You also find that PTSDfrequently co-occurs, as the

(05:54):
same traumas that precipitatedfugue often meet the same
criteria for PTSD.
You'll see overlapping symptomslike avoidance, hypervigilance
and intrusive memories when yourclient isn't in the fugue state
.
And what's universal betweenthese two?
Depression.
Depression often follows afugue state as your client

(06:17):
grapples with feelings of shame,confusion and, of course, the
consequences of what they didwhen they disappeared, as well
as having to deal with theirfamily and friends when they do
come back.
Anxiety disorders, particularlypanic disorder, often develop
as your client fears losingcontrol or experience another

(06:39):
few episodes.
So what you need to know?
What are the evidence-basedtreatments?
Phase-oriented treatment hasthe strongest support.
You need to focus first onsafety and coping skills, then
gradually process traumaticmaterial as your client develops
tolerance for differentemotions.

(07:00):
Cognitive behavioral therapyhelps your client identify
triggers and develop alternativecoping strategies.
You work on challengingcatastrophic thoughts that make
disassociation seem like theonly coping mechanism that they
can use.
Emdr shows promise forprocessing traumatic memories

(07:21):
that precipitated the fugue,though you need to have
specialized training and havethe EMDR adapted for
disassociative clients.
Let's talk about specifictechniques now.
That's something you need toknow for your private practice
as well as for the licensingexam.
Three of them come to mind.

(07:41):
First is memory mapping.
It's a technique that involvescreating a visual timeline that
helps your client see theconnection between fragmented
memories and identify patternsin their disassociative
responses.
Then there's narrative exposure, and that'll help your client
tell their story withoutbecoming totally overwhelmed.
The idea is to guide them indeveloping multiple perspectives

(08:05):
on their experience, and ithelps them build a coherent
narrative of their identity.
And last, somatic resourceshelps build your client's
capacity to stay embodied whenprocessing different material.
With this technique, you focuson having them notice and
tolerate physical sensationsthat previously triggered their

(08:28):
disassociation.
Another thing that you need toknow are the different
assessment tools, determining ifthat's what they're exhibiting.
All three of them have the worddisassociative in them, so it's
going to be easy to identifywhich ones to use.
The first one is called theDisassociative Experiences Scale
and it screens fordisassociative symptoms.

(08:51):
The second is theDisassociative Disorders
Interview Schedule, which isbasically to assess for
differential diagnosis, toassess for differential
diagnosis.
And three and this is a longone the clinical administered
disassociative state scale.
Who comes up with these anyways?
But basically that tracks thesymptom changes over treatment.

(09:14):
So it's something that youwould administer at the
beginning, every couple weeks toobjectively measure your
client's progress.
So let's do a summarizationright now, okay.
Disassociative fugue representsan extreme psychological defense
.
It's really a defense mechanismwhere your client's mind

(09:37):
completely erases their identityto escape unbearable
circumstances.
Two, you need to recognize andunderstand the organized
behavior during fuguedistinguishes it from other
conditions.
Your client is not confused,they're not psychotic, they're

(09:58):
just functioning under adifferent identity.
They're not making it up,they're actually functioning as
a complete new person.
Your success treating thisclient will be dependent on you
actually respecting theprotective function of the fugue
while gradually building yourclient's capacity to face what

(10:20):
they couldn't tolerate before.
You're not trying to force anintegration, but you're trying
to facilitate it.
And the last, and probably mostimportant, is the
phase-oriented approach isnon-negotiable.
You always have to stabilizethe client before even trying to

(10:42):
attempt any trauma processing.
You can't skip ahead withoutrisking re-traumanization or
another fugue episode.
Well, that's it, and as wealways say, remember it's in
there.