Medications

It is generally agreed that medication does not influence the core psychopathology of MPD, but may palliate symptomatic distress or impact upon a co-existing drug-responsive condition or target symptom. Many MPD patients are treated successfully without medication. Kluft noted six patients with MPD and major depression, and found treating either disorder as primary failed to impact on the other. However, Coryell reported a single case in which de conceptualized MPD as an epiphenomenon of a depression. While most MPD patients manifest depression, anxiety, panic attacks, and phobias, and some show transient (hysterical) psychoses, the drug treatment of such symptoms may yield responses which are so rapid, transient, inconsistent across alters, and/or persistent despite the discontinuation of the medication, that the clinician cannot be sure an active drug intervention rather than a placebo-like response has occurred. It is known that alters within a single patient may show different responses to a single medication.

Hypnotic and sedative drugs are often prescribed for sleep disturbance. Many patients fail to respond initially or after transient success, and try to escape from dysphoria with surreptitious overdosage. Most MPD patients suffer sleep disruption when alters are in conflict and/or painful material is emerging, i.e., the problem may persist throughout treatment. Often one must adopt a compromise regimen which provides "a modicum of relief and a minimum of risk." Minor tranquilizers are useful, but tolerance can be expected, and occasional abuse is encountered. Often high doses become a necessary transient compromise if anxiety becomes disorganizing or incapacitating. In the absence of coexisting mania or agitation in affective disorder, or for transient use with severe headaches, major tranquilizers should be used with caution and generally avoided. A wealth of anecdotal reports describe serious adverse effects; no documented proof of their beneficial impact has been published. Their major use in MPD is for sedation when minor tranquilizers fail or abuse/tolerance has become problematic. Many MPD patients have depressive symptoms, and a trial of tricyclics may be warranted. In cases without classic depression, results are often equivocal. Prescription must be circumspect, since many patients may ingest prescribed medication in suicide attempts. Monoamine oxidose inhibitor (MAOI) drugs give the patient the opportunity for self-destructive abuse, but may help atypical depressions in reliable patients. Patients with coexistent bipolar disorders and MPD may have the former disorder relieved by lithium. Two recent articles suggested a connection between MPD and seizure disorders. Not with standing that the patients cited had, overall, equivocal responses to anticonvulsants, many clinicians have instituted such regimes. The author has now seen two dozen classic MPD patients others had placed on anticonvulsants, without observing a single unequivocal response.

Postfusion Therapy

Patients who leave treatment after achieving apparent unity usually relapse within two to twenty-four months. Further therapy is indicated to work through issues, prevent repression of traumatic memories, and facilitate the development of non-dissociative coping strategies and defenses. Patients often wish and are encouraged by concerned others to "put it all behind (them)," forgive and forget, and to make up for their time of compromise or incapacitation. In fact, a newly-integrated MPD patient is a vulnerable neophyte who has just achieved the unity with which most patients enter treatment. Moratoria about major life decisions are useful, as is anticipatory socialization in potentially problematic situations. The emergence of realistic goal-setting, accurate perception of others, increased anxiety tolerance, and gratifying sublimations augur well, as does a willingness to work through painful issues in the transference. Avoidance coping styles and defenses require confrontation. Since partial relapse or the discovery of other alters are both possible, the integration per se should not be regarded as sacrosanct. An integration's failure is no more than an indication that it's occurrence was premature, i.e., perhaps it was a flight into health or it was motivated by pressures to avoid further painful work in treatment.

Many patients remain in treatment nearly as long after integration as they required to achieve fusion.

Postfusion Therapy

Patients who leave treatment after achieving apparent unity usually relapse within two to twenty-four months. Further therapy is indicated to work through issues, prevent repression of traumatic memories, and facilitate the development of non-dissociative coping strategies and defenses. Patients often wish and are encouraged by concerned others to "put it all behind (them)," forgive and forget, and to make up for their time of compromise or incapacitation. In fact, a newly-integrated MPD patient is a vulnerable neophyte who has just achieved the unity with which most patients enter treatment. Moratoria about major life decisions are useful, as is anticipatory socialization in potentially problematic situations. The emergence of realistic goal-setting, accurate perception of others, increased anxiety tolerance, and gratifying sublimations augur well, as does a willingness to work through painful issues in the transference. Avoidance coping styles and defenses require confrontation. Since partial relapse or the discovery of other alters are both possible, the integration per se should not be regarded as sacrosanct. An integration's failure is no more than an indication that it's occurrence was premature, i.e., perhaps it was a flight into health or it was motivated by pressures to avoid further painful work in treatment.

Many patients remain in treatment nearly as long after integration as they required to achieve fusion.

Follow-up Studies

Case reports and a recent study of the natural history of MPD suggest that untreated MPD patients history of MPD suggest that untreated MPD patients do not enjoy spontaneous remission, but instead many (70-80%) appear to shift to a one-alter predominant mode with relatively infrequent or covert intrusions of others as they progress into middle age and senescence. Most case reports do not describe complete or successful therapies. Many of those which appear "successful" have no firm fusion criteria, unclear follow-up, and offer confusing conceptualizations, such as describing "integrations" in which other alters are still occasionally noted. Using operational fusion criteria defined above, Kluft has followed a cohort of intensively-treated MPD patients and periodically studied the stability of their unification. The 33 patients averaged 13.9 personalities (there was from 2 personalities to as many as 86) and 21.6 months from diagnosis to apparent integration. Reassessed after a minimum of 27 months after apparent fusion (two years after fulfilling fusion criteria), 31 (94%) had not relapsed into behavioral MPD and 25 (75.8%) showed neither residual nor recurrent dissociative phenomena. No genuine full relapse was noted. Of the two with MPD, one had feigned integration and the other had a brief reactivation of one of 32 previously integrated alters when her spouse was found to be terminally ill. Six had alters which had not assumed executive control, and were classified as intrapsychic. Of these, two had new entities: one formed upon a lover's death, the other upon the patient's return to college. Three patients showed layering phenomena, groups of preexisting alters which had been long-suppressed, but were beginning to emerge as other alters were solidly integrated. The other relapse events were partial relapses of previous alters under stress, but those alters remained intrapsychic. Object loss, rejection, or the threat of those experiences triggered 75% of the relapse events. Four of these eight patients were reintegrated and have been stable after another 27 months of follow-up. Three remain in treatment for the newly-discovered layers of alters, and all are approaching integration. One individual worked years to initiate a relapse autohypnotically, and only recently returned for treatment. In sum, the prognosis is excellent for those MPD patients who are offered intensive treatment and are motivated to accept it.

Summary

MPD appears to be quite responsive to intense psychotherapeutic interventions. Although its treatment may prove arduous and prolonged, results are often gratifying and stable. The most crucial aspects of treatment are an open-minded pragmatism and a solid therapeutic alliance.

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