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To provide a unique environment where folks who have experienced trauma can openly and safely talk. We strive to respect, validate, and learn from each other.


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Guidelines for Treating Dissociative Identity Disorder in Adults

Psychotropic medication is not a primary treatment for dissociative processes, and specific recommendations for pharmacotherapy of most dissociative symptoms await systematic research. However, most therapists treating DID report that their patients have received medication as one element of their treatment (Putnam&Loewenstein, 1993). Clinical and research reports support the use of various medications to treat co-morbid disorders such as PTSD (particularly hyperarousal and intrusive symptoms) and coexisting affective disorders, among others (Loewenstein, 1991b). Physicians and nurse specialists who prescribe medication should make patients aware, as part of the informed consent process for psychopharmacology, that medication protocols for DID are mostly empirical in nature and designed to target specific symptoms.

Alternate identities within the DID patient may report different responses to the same medication. This may be due largely to the different levels of activation in different identities and/or to their subjective experience of separateness, rather than actual, differential biological effects of the medications on the different alternate identities. In general, medications are more effective if the targeted symptoms are reported across “the whole human being,” rather than in only one or a few identities.

Medications in DID are usually best conceptualized as “shock absorbers,” rather than as curative interventions. Partial responses are the rule with DID patients as well as in similar complex PTSD patients with multiple co-morbidities and dysphoria and despair based on multiple adverse life experiences. The goal is to find the best medication or medications at a given time that most effectively moderate the patient’s symptoms. Not uncommonly, the DID patient will report that medications work for a while, and then stop doing so. Sometimes, these medi- 112 JOURNAL OF TRAUMA & DISSOCIATION medcations will work again if the patient is given them at a later time. Because of the potential for partial responses to many different medications, prescribers should be alert to the potentially negative effects of polypharmacy.

Nearly all classes of psychotropic medications have been used empirically with DID patients. Most often, antidepressant medications are used to treat depressive symptoms and/or PTSD symptoms. PTSD and Major Depressive Disorder are common outcomes of trauma. Accordingly, they are the most frequent co-morbidities diagnosed in DID patients. Currently, the most commonly used medications for these indications are the selective serotonin re-uptake inhibitor (SSRI) antidepressants.

Several of these (e.g., paroxetine [Paxil], sertraline [Zoloft]) have been found, in well-designed clinical trials, to be efficacious for patients with relatively uncomplicated PTSD. Fluoxetine (Prozac) has been reported to be helpful in treating mood and PTSD symptoms in patients with complex PTSD. Other SSRIs (e.g., citalopram [Celexa], escitalopram [Lexapro]), and non-SSRI antidepressants (e.g., venlafaxine [Effexor], bupropion [Wellbutrin]) have been found to be empirically effective in moderating depressive symptoms, PTSD symptoms, panic symptoms, and irritability in many DID patients. Antidepressants with anti-obsessive efficacy such as clomipramine (Anafranil) and fluvoxamine (Luvox) may be particularly helpful for the subgroup of DID patients with significant obsessive-compulsive symptomatology. Also, older antidepressant groups such as the monoamine oxidase inhibitors (MAOIs) and the tricyclic antidepressants (TCAs) are effective in some DID patients, but have largely been replaced by the SSRIs due to the SSRIs’ more favorable side effects profile and safety.

Anxiolytics may be used primarily on a short-term basis to treat anxiety, but the clinician must keep in mind that the commonly used benzodiazepine medications (BZDs; lorazepam [Ativan], clonazepam [Klonopin], diazepam [Valium], chlordiazepoxide [Librium] and others) have addictive potential and that some patients with DID are vulnerable to substance abuse. Patients with PTSD may be tolerant to seemingly quite high doses of BZDs. This is thought to be due to the severe chronic hyperarousal and putative alterations in benzodiazepine receptor binding in these patients. Some DID patients can successfully be maintained on a stable long-term BZD regimen. Others may require increased dosages to overcome tolerance to the beneficial effects of the medications. However, clinicians should be aware that increasingly higher dose regimens carry the potential of diminishing benefits and higher adverse effects. Usually, in these cases, the BZDs will eventually International Society for Study of Dissociation 113 have to be discontinued, by a careful taper to prevent a BZD discontinuation syndrome.

Other sedating medications (e.g., trazodone [Desyrel], diphenhydramine [Benadryl], mirtazapine [Remeron], low dose tricyclic antidepressants, etc.) have been used for anxiety and especially for insomnia in this population. Unfortunately, DID patients commonly suffer from a complex sleep disorder including PTSD nightmares and flashbacks, sleep problems related to affective disorders, triggered fear reactions at night due to recall of reported nocturnal abuse, and the activities of the alternate identities (some of whom are nocturnal). Accordingly, sleep problems in DID are usually best addressed in the overall framework of the treatment using symptom management strategies for fearful alternate identities, negotiating sleep for the nocturnal identities, and cognitive behavioral strategies to decrease PTSD reactivity at night, along with judicious use of medications. In general, barbiturates, chloral hydrate, and similar medications should be avoided in DID patients due to their addictive qualities and lethal potential in overdose. Neuroleptic or antipsychotic medications, particularly the newer atypical agents (e.g., risperidone [Risperdal], quetiapine [Seroquel], olanzapine [Zyprexa], ziprasidone [Geodon]), have been used to treat successfully the overactivation, thought disorganization, intrusive PTSD symptoms as well as the chronic anxiety, insomnia and irritability experienced by many DID patients. Although antipsychotic medications have also been used to treat the inner auditory hallucinatory experiences in DID, usually these “hallucinations” are unaffected by even high dose neuroleptics. In a few cases, they may be decreased or somewhat quieted; but they do not disappear. In rare cases individuals with DID have true comorbid psychotic symptoms that are responsive to antipsychotic medication (for example, the patient can distinguish the “inside voices” of the alternate identities that are medication non-responsive from the “outside” psychotic voices that do respond to neuroleptics). Neuroleptics have many side effects, most prominently significant weight gain has been reported in several of the newer agents (e.g., olanzapine [Zyprexa]). Weight gain is often very problematic for DID patients and can cause glucose intolerance and other significant metabolic side effects.

Accordingly, careful monitoring by the psychiatrist, often including metabolic testing, is mandatory if the patient is receiving these medicines. Some extremely ill DID patients have responded well to clozapine (Clozaril) for severe PTSD symptoms and chronic thought disturbance. The latter manifests itself with refractory, often bizarre or severely concrete, cognitive distortions. Other atypical symptoms, more characteristic of chronically psychotic patients, like mistrust bordering on true paranoia, may be found in these patients as well. The patient on clozapine must be able to obtain weekly blood tests to monitor the blood count for agranulocytosis (disappearance of the body’s white blood cells). Mood stabilizers are medications that specifically target mood swings in bipolar patients. Many mood stabilizers are anticonvulsants that have also been used in open label studies in PTSD. Because many DID patients suffer from rapid mood swings, psychiatrists frequently diagnose them with rapid-cycling bipolar disorder or Type II bipolar disorder.

However, a careful history usually shows that the mood swings are actually due to PTSD intrusions and/or the switching of alternate identities or interference by alternate identities. There is no evidence that bipolar disorder is more common among DID patients than in the general population. Accordingly, only a small minority of DID patients derive benefit for mood swings from these medications. However, some patients describe a moderation in PTSD symptoms, anxiety and mood instability on anticonvulsant mood stabilizers such as valproate (Depakote), lamotrigine (Lamictal), carbamazepine (Tegretol), oxcarbazepine (Trileptal), gabapentin (Neurontin), or topiramate (Topomax). To be sure, DID patients with true intercurrent bipolar disorder often will receive benefit from appropriate mood stabilizing medications. Other medications used to treat DID patients include naltrexone, an opiate antagonist that may have some efficacy in decreasing the pressure for self-mutilation or other self-destructive and self stimulatory behaviors, especially if the patient reports a “high” from self harm. Some patients have responded to centrally active beta blockers such as propranolol (Inderal) for PTSD hyperarousal and panic. Clonidine (Catapres), a centrally acting alpha agonist whose primary indication is as an antihypertensive medication, has been used to treat PTSD and may be effective for hyperarousal and intrusive PTSD symptoms including nightmares in some DID patients. Prazosin (Minipress), another antihypertensive medication, has been reported to be helpful for PTSD nightmares in a study of combat veterans. Hospitalized DID patients experiencing acute anxiety, agitation, intrusive PTSD symptoms, chaotic switching and/or urges to harm themselves or others may respond to “prn” (as needed) oral or intramuscular benzodiazepines (primarily lorazepam) and/or oral or intramuscular neuroleptics. Either typical or atypical neuroleptics may be given for this indication. Typical neuroleptics used for acute agitation in inpatient DID patients include haloperidol (Haldol), fluphenazine (Prolixin), and International Society for Study of Dissociation 115 others. Intramuscular ziprasidone (Geodon) and sublingual olanzapine (Zyprexa) may also be useful for this indication. Administration of ziprasidone should not be commenced without a screening electrocardiogram (ECG) to rule out a prolonged QT interval that may predispose to lethal arrhythmias that can occur when ziprasidone is administered. Droperidol (Inapsine) is also useful for acute agitation in hospitalized DID patients. However, it can only be given with cardiac monitoring due to reports of fatal arrhythmias with its administration. Thus, it is usually impractical to use droperidol routinely any longer in most inpatient settings.

Unfortunately, systematic research on medications for DID does not exist and most studies of pharmacotherapy for PTSD have not been performed on female survivors of repeated childhood maltreatment and adversity. Until that time, the pharmacological treatment for DID will remain almost entirely empirical and based on clinical experience.

Article taken from International Society for Study of Dissociation - http://www.isst-d.org/