When major depression accompanies MPD, response to tricyclic antidepressants can be gratifying. When symptoms are less straightforward, results are inconsistent. A trial of antidepressants is often indicated, but its outcome cannot be predicted. Ingestion and overdosage are common problems.

MAOI drugs are prone to abuse as one alter ingests forbidden substances to harm another, but can help patients with intercurrent atypical depression or hysteroid dysphoria. Lithium has proven useful in concomitant bipolar affective disorders, but has had no consistent impact on dissociation per se.

The author has seen a number of patients placed on anticonvulsants by clinicians familiar with articles suggesting a connection between MPD and seizure disorders. ^14,15 None were helped definitively: most responded to hypnotherapy instead. Two clinicians reported transient control of rapid fluctuation on Tegretol, yet over a dozen said it had no impact on their patients.

The Hospital Treatment Of Multiple Personality

Most admissions of known MPD patients occur in connection with 1) suicidal behaviors or impulses; 2) severe anxiety or depression related to de-repression, emergence of upsetting alters, or failure of a fusion; 3) fugue behaviors; 4) inappropriate behaviors of alters (including involuntary commitments for violence); 5) in connection with procedures or events in therapy during which a structured and protected environment is desirable; and 6) when logistic factors preclude outpatient care.

Very brief hospitalizations for crisis interventions rarely raise major problems. However, once the patient is on a unit for a while, certain problems begin to emerge unless one strong and socially-adapted alter is firmly in control.

On the part of the patients, alters may emerge who are afraid, angry, or perplexed at being in the hospital. Protectors begin to question procedures, protest regulations, and make complaints. Sensitive alters begin to pick up on staff's attitudes toward MPD; they try to seek out those who are accepting, and avoid those who are skeptical or rejecting. These lead to the patient's wishing to evade certain people and activities. Consequently, their participation in the milieu and cooperation with the staff as a whole may diminish. Rapidly, their protective style makes them group deviants and exerts polarize them, and the second toward protecting staff group cohesion from the patient. The patient experiences the latter phenomenon as rejection. Some alters are too specialized, young, inchoate, or inflexible to comprehend the unit accurately or conform their behavior within reasonable limits. They may view medication, rules, schedules, and restrictions as assaults, and/or repetitions of past traumata, and perceive to encapsulate the admission as a traumatic event, or to provide an alter which is compliant or pseudocompliant with treatment.

Other patients may be upset or fascinated by them. Some may feign MPD to evade their own problems, or scapegoat these individuals. MPD patients' switching can hurt those who try to befriend them. Some cannot help but resent that the MPD patient requires a great deal of staff time and attention. They may believe such patients can evade the accountability and responsibilities they cannot escape. A more common problem is more subtle. MPD patients openly manifest conflicts most patients are trying to repress. They threaten others' equilibria and are resented.

It is difficult to treat such patients without staff support. As noted, the patients are keenly perceptive of any hint of rejection. They openly fret over incidents with the therapist, staff, and other patients. Hence, they are seen as manipulative and divisive. This engenders antagonisms which can undermine therapeutic goals.

Also, such patients can threaten a milieu's sense of competence. The [patient becomes resented for the helplessness with the psychiatrist who, they feel, has inflicted an overwhelming burden upon them by admitting the patient.

The psychiatrist must try to protect patient, other patients, and staff from a chaotic situation. MPD patients do best in private rooms, where they retreat if overwhelmed. This is preferable to their felling cornered and exposing a roommate and milieu to mobilized protector phenomena. The staff must be helped to move from a position of impotence, futility, and exasperation to one of increasing mastery. Usually this requires considerable discussion, education, and reasonable expectations. The patients can be genuinely overwhelming. The staff should be helped in matter-of-fact problem solving vis-a-vis that particular patient. Concrete advice should precede general discussions of MPD, hypnosis, or whatever. Staff is with the patient 24 hours a day, and may be unsympathetic with the goals of a psychiatrist who appears to leave them to work out their own procedures, and then finds fault with what has occurred.