Case Study: Elias Romero (DSM-5-TR: Dissociative Amnesia, With Dissociative Fugue Specifier)

Demographics

• Name: Elias Romero

• Age: 37

• Occupation: Accountant

• Marital/Family Status: Married, two children

• Background: First-generation college graduate; described as responsible but “highly anxious under pressure.”

Clinical Presentation

Course of Events

Two weeks ago, Elias disappeared after leaving work. His car and phone were found near a commuter rail station. Four days later, he was located 200 miles away in a coastal town, working at a diner under the name “Michael Rios.”

During this period:

• He had no memory of his prior life, family, or career.

• He created a new identity with a plausible backstory.

• He was functioning (oriented, able to converse and work) but emotionally flat when discussing his “past.”

When identified by authorities, Elias was bewildered, distressed, and initially resistant to accept his true identity. After returning home, he slowly regained memories of his life before the disappearance — but remains amnesic for the fugue interval itself.

DSM-5-TR Diagnostic Features

Dissociative Amnesia

• A. Inability to recall important autobiographical information, usually of a traumatic or stressful nature, inconsistent with ordinary forgetting.

  • Elias cannot recall details of his marriage, children, and career during the fugue episode.

• B. Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • His absence disrupted work, created marital strain, and caused distress to him and his family.

• C. Not attributable to substance use, a neurological or other medical condition.

  • Neurological exam, labs, and toxicology screen were negative.

• D. Not better explained by dissociative identity disorder, PTSD, acute stress disorder, somatic symptom disorder, or neurocognitive disorder.

  • Elias shows no evidence of distinct identity states (DID) or persistent trauma-related flashbacks (PTSD).

Specifier: With Dissociative Fugue

• Purposeful travel away from home with inability to recall one’s past.

• Possible assumption of a new identity.

  • Elias traveled 200 miles, worked under a new name, and presented as though starting a new life.

Precipitating Stressors

• Work stress: Accusations of mishandling client accounts (though no wrongdoing confirmed).

• Marital tension: Wife had recently threatened separation due to his long absences and emotional withdrawal.

• Psychological history: Childhood emotional neglect; dissociation in adolescence under stress (“zoning out”).

Differential Diagnosis (DSM-5-TR Guidance)

• Dissociative Identity Disorder: No recurrent identity states or amnesia for everyday events.

• Malingering/Factitious Disorder: No evidence of external gain; disappearance caused career harm.

• Neurological conditions: No seizure activity, TBI, or dementia; medical causes ruled out.

• Substance-induced amnesia: Negative toxicology screen.

Functional Impairment

• Elias expresses guilt, shame, and fear of recurrence.

• His wife is distrustful; children are anxious and withdrawn.

• Occupational reputation is damaged, requiring extended medical leave.

Treatment Considerations (DSM-5-TR informed)

• Psychotherapy: Supportive therapy focused on integrating recovered memories, processing stressors, and reducing avoidance.

• Trauma-informed care: Gentle retrieval techniques; avoid suggestive methods.

• Family therapy: To rebuild trust and address relational rupture.

• Stress management interventions: Relaxation training, mindfulness, cognitive restructuring.

• Monitoring: Risk of recurrence, especially during high stress.

Associated features

Dissociative Fugue was formerly known as Psychogenic Fugue, it is comorbid with Bipolar Disorder, Major Depressive Disorder, and Schizophrenia, as well as PTSD, Substance Related disorders, Panic and Anxiety Disorders, Eating Disorders, and Somatoform Disorders. Note: Dissociative Fugue is often mistaken for malingering. This happens because the disorder enables people to escape their responsibilities or undesirable or dangerous situations; therefore it is seen as if a person is taking the ‘easy-way-out’. A person in the midst of a Dissociative Fugue episode may appear only slightly confused or they may appear to have no symptoms at all and attract no attention. Eventually, however, the person will begin to show significant signs of confusion or distress as they become aware of memory loss or confusion about their identity. This amnesia is characteristic of the disorder. When the fugue ends, the person may experience depression, grief, shame, and suicidal impulses.

Child vs. adult presentation

Dissociative Fugue usually begins in adulthood. There is little information about the presentation of this disorder in children. When it does affect children, it is most commonly due to severe trauma such as sexual abuse, but even then it does not usually present until adulthood.

Gender and cultural differences in presentation

Some research revealed that this condition most often occurs in females, but the reason is unknown. One source stated that females are at a rate six to nine times higher than males, and it increases as age increases. This pattern is most likely associated with the stresses on a woman to be both mother and a family provider and caretaker, in conjunction with the societal pressures and gender prejudices. Most studies however, believed that Dissociative Fugue is equally prevalent across genders.
There is little information on the cultural differences in presentation of Dissociative Fugue. It is important to remember that what may be considered dissociative in one culture may be seen as normal in another. Cultures prone to warfare are more likely to experience the distressing pressures of war, which is a common causal traumatic event of this disorder. Various cultures with defined “running” syndrome may have symptoms that meet diagnostic criteria for Dissociative Fugue, such as the amok in Western Pacific cultures.

Epidemiology

This is a relatively rare disorder, actually the rarest of the dissociative disorders, affecting about only 2 in 1000 people in the United States. The prevalence rate is estimated at 0.2%. It is much more common however among people who have been in wars, accidents, natural disasters, or other highly traumatic or stressful events.

Etiology

Episodes of Dissociative Fugue are usually triggered by very stressful events. Traumatic experiences such as war, natural disasters, accidents, and sexual abuse during childhood, often increase the incidence of the disorder. More personal types of stress, like the shocking death of a loved one or unbearable pressures at work or home, might also lead to the unplanned travel and amnesia that is characteristic of Dissociative Fugue.

Empirically supported treatments

Most fugues last for only hours or days, and then often disappear on their own. The goal of treatment is to assist the person to come to terms with the trauma or stress that triggered the fugue in the first place. Another goal of treatment is to help develop new coping methods to prevent further fugue episodes. As with most disorders, the particular treatment approach depends on the individual and the severity of his or her symptoms. The most likely treatment however will include a combination of psychotherapy, cognitive therapy, medication, family therapy, creative therapy, and clinical hypnosis. Psychotherapy is the main treatment for dissociative disorders such as Dissociative Fugue. Such treatments aim to increase insight into problems. Cognitive therapy focuses on changing dysfunctional thinking patterns. Medication is useful when the person also suffers from depression or anxiety. Family therapy aims to teach the family more about the disorder and learn about the symptoms of recurrence. Creative therapies, such as music therapy and art therapy, let the person express themselves in safe manners. Clinical hypnosis uses intense relaxation, concentration, and focuses attention to achieve an altered state of awareness. This is risky however because of the risk of creating false memories. The prognosis for Dissociative Fugue is often very good because the episodes do not usually last longer than a few months and people generally recover quickly. Efforts to restore the memories of what happened during the fugue are usually unsuccessful or take a long time to be recovered.