The Practical Psychopharmcology Of MPD

Kline and Angst tersely state pharmacological treatment of MPD is not indicated. ¹¹ There is general consensus 1) that drugs do not affect the core psychopathology of MPD; and 2) that, nonetheless, it is sometimes necessary to attempt to palliate intense dysphoria and/or to try to relieve target symptoms experienced by one, some, or all personalities. At this point in time treatment is empirical and informed by anecdotal experience rather than controlled studies.

Different personalities may present with symptom profiles which seem to invite the use of medication, yet the symptom profile of one may be so much at variance with another's as to suggest different regimens. A given drug may affect personalities differently. Alters who experience no effect, exaggerated effects, paradoxical reactions, appropriate responses, and various side effects may be noted in a single individual. Allergic responses in some but not all alters has been reported and reviewed. ¹² The possible permutations in a complex case are staggering.

It is tempting to avoid such a quagmire by declining to prescribe. However, distressing drug-responsive target symptoms and disorders may coexist with MPD. A failure to address them may leave the MPD inaccessible. The author has reported cross-over experiences on six MPD patients with major depression. ^4,1,3 He found if dissociation alone was treated, results were unstable due to mood problems. Relapse was predictable if medication was omitted. Medication alone sometimes reduced chaotic fluctuations which were chemically triggered, but did not treat the dissociation. An example is a depressed MPD woman who repeatedly relapsed on therapy alone. Placed on imipramine, she became euthymic but continued to dissociate. Therapy abated dissociation. With medication withdrawn, she relapsed in both depression and dissociation. Imipramine was reinstituted and fusion was achieved with hypnosis. On maintenance imipramine she has been asymptomatic in both dimensions for four years.

A psychiatrist's empathic capacities may be sorely tested

Depression, anxiety, panic attacks, agoraphobia, and hysteroid dysphoria may coexist with MPD and appear medication-responsive. However, response may be so rapid, transient, inconsistent across alters, and/or persist despite withdrawal of drugs, as to cause question. There may be no impact at all. The same holds for the insomnia, headaches, and pain syndromes which can accompany MPD. The author's experience is that, in retrospect, placeboid responses to the actual medications are more common than clear-cut "active drug" interventions.

Neither automatically denying nor readily acceding to the patient's requests for relief is reasonable. Several questions must be raises: 1)Is the distress part of a medication-responsive syndrome? 2)If the answer to 1) is yes, is it of sufficient clinical importance to outweigh possible adverse impacts of prescription? If the answer to 1) is no, whom would the drug treat (the physician's need to "do something." an anxious third party, etc.)? 3) Is there a non-pharmacological intervention which might prove effective instead? 4) Does the overall management require an intervention which the psychiatrist patient's "track record" in response to interventions similar to the one which is planned? 6) Weighing all considerations, do the potential benefits outweigh the potential risks? Medication abuse and ingestions with prescribed drugs are common risks.

Hypnotic and sedative drugs are frequently prescribed for sleep deprivation and disturbances. Initial failure or failure after transient success is the rule, and escape from emotional pain into mild overdose is common. Sleep disruption is likely to be a long-standing problem. Socializing the patient to accept this, shifting any other medication to bed-time (if appropriate), and helping the patient accept a regimen which provides a modicum of relief and a minimum of risk is a reasonable compromise.

Minor tranquilizers are useful as transient palliatives. When used more steadily, some tolerance should be expected. Increasing doses may be a necessary compromise if anxiety without the drug is disorganizing to the point of incapacitating the patient or forcing hospitalization. The author's major use of these drugs is for outpatients in crisis, inpatients, and for post-fusion cases which as yet have not developed good non-dissociative defenses.

...alters may emerge who are afraid, angry, or perplexed at being in the hospital.

Major tranquilizers must be used cautiously. There are ample anecdotal accounts of adverse effects, including rapid tardive dyskinesia, weakening of protectors, and patients' experiencing the drug's impact as an assault, leading to more splitting. Those rare MPD patients with bipolar trends may find these drugs helpful in blunting mania or agitation; those with hysterical dysphoria or severe headaches may be helped. Their major use has been for sedation when minor tranquilizers failed and/or tolerance has become an issue. Sometimes supervised sedation is preferable to hospitalization.