with
measuring overall severity of psychiatric disturbance. Archives ofGeneral Psychiatry 33:766-771, 1976
6. McGlashan
TH:
low-up and study Psychiatry 7.
The Chestnut
study:
follow-up
sample. 41:573-585,
McGlashan
TH:
medium-,
and
schizophrenia. chiatry
Lodge
Predictors longer-term
American
143:50-55,
fol-
methodology
Archives 1984
of
9.
General
outcome
Journal
Multiple
four-month trial 60 mg per day, these symptoms,
360, 1988 Caton
other psychiatrist who would “do more than give me pills.” On presentation nine months postpartum, Mrs. A appeared anxious and tearful. She had not taken fluoxetine for three months. She complained of overwhelming anxiety, restlessness, crying spells, alcohol use, inability to sleep, and profound fear of sexually and physically harming her child. She reported that since childhood she had experienced periods of time for which she could later not give an account of her activities, and she claimed that these episodes had increased markedly since the birth of her child. She also described revivifications-that is, vivid lifelike perceptions of reenacting and reexperiencing past traumatic events. These took the form of brief episodes in which she “saw” herself harming her daughter and others harming toddlers. Persistent olfactory perceptions of feces accompanied these episodes. Mrs. A experienced auditory hallucinations consisting of conversations between several angry voices; these were especially intrusive at night and kept her awake. Also, during this period she described the emergence of what she called phobias. In particular, she found herself inexplicably unable to go into the basement and avoidant of concrete floors. She developed somatic cornplaints, such as an intolerable sore throat for which she was able to obtam antibiotics from an internist despite a negative laryngoscopic cx-
ci,
talization. in
of Psy-
10.
Gralnick length Hospital
A: A review
tal and Community 154, 1990
of issues
ofpsychiatric hospiand Community
Psychiatry 38:858-862, Kiesler CA: Predicting
tal stay forpsychiatric
1986
Case
schizoaffective dispersonality disorder, and unipolar affective disorder. Archives of General Psychiatry 45:35 3borderline
surrounding of shorter-,
8. Heinssen RK, McGlashan TH: Predicting hospital discharge status for patients
Unusual
schizophrenia,
order,
1987 length
inpatients. Psychiatry
of hospi-
Hospi41:149-
Report
Personality
Disorder Presenting as Postpartum Depression L. Sate!,
Sally
Frances
M.D. C. How!and,
M.D.
It is estimated that 1 percent of the population suffers from multiple personality disorder (1). Despite this prevalence, which is comparable to that of schizophrenia, an accurate diagnosis of the disorder is often difficult to make. The clinician’s task is complicated by the fact that patients with this disorder display numerous psychiatric symptoms and symptom constellations that suggest other psychiatnic conditions (1-4). On average, almost seven years elapse between a patient’s seeking help for symptoms related to multiple personality disorder and receiving the correct diagnosis (5). In this paper we describe a new mother with multiple personality disorder who was misdiagnosed as
suffering from postpartum depression. She had no knowledge of other personality states on ofthe pathological nature of her long-standing symptoms of amnesia and sense of lost time until several months after the birth of her first child. During this time, however, she began to cxpenience auditory hallucinations (voices arguing) and pronounced mood shifts. Both are common symptoms associated with multiple personality disorder, but, in this patient, they were attributed to postpartum depression with psychosis. This case illustrates a novel presentation ofmultipbe personality disorder and is, to our knowledge, the first report of the recognition of alternate personalities in the context of the discrete developmental event of motherhood.
of Medicine. Address corto Dr. Satel at West Haven Veterans Mfairs Medical Center, 950 Campbell Avenue, West Haven, Connecticut 06516.
Case report Mrs. A was a 37-year-old married white woman who sought treatment for what she believed to be postpartum depression. Her symptoms included fear ofhurting her child, tearfulness throughout the day, suicidal ideation, irritability, anhedonia, and difficulty sleeping. The symptoms began about five months after her daughter was born. Mrs. A had a
Hospital
December
Dr.
Sate!
psychiatry psychiatric partment
is assistant and Dr. consultant of medicine
professor Howland
in the deat Yale
School
respondence
and
Community
of is
Psychiatry
1992
Vol.
43
No.
12
of fluoxetine, up to with no change in and she sought an-
amination.
Mrs. A began treatment with one of us (FCH) at three hourly sessions a week. The working diagnosis was postpartum depression with psychotic features. The patient refused pharmacotherapy,
claiming
that
“it
did nothing for me before.” After one week Mrs. A had her first revivification experience in the therapist’s office. She claimed that she saw “the couch and the windows getting bigger.” Hen voice took on the quality of a small child’s. This experience, basting about 30 minutes, was baffling to Mrs. A. In the next (fourth)
1241
session an alternate personality appeared, and by the close ofthe second week, 12 distinct personality states had emerged. At this point, the sessions were increased to six days a week, and the patient’s diagnosis was changed to multiple personality disorder. Affective symptoms diminished rapidly during the two weeks after multiple personality disorder was diagnosed. The 1 2 alternates cornprised seven males and five females. Two of the males, Black and Guide, were not formal representations of specific people but served as states that contained memories and momtored their release. Among the female personalities were representations of Mrs. A’s grandmother, her mother, and a small girl. Four weeks elapsed between Mrs. A’s presentation for treatment and her recognition of alternate personalities. Subsequently, treatment focused on accessing graphic memories and “reliving” childhood traumas. As specific symptoms were linked to old traumas, the symptoms tended to remit. For example, the severe pain in Mrs. A’s throat resolved when one of her alternates relived a scene in which rosary beads were shoved into her mouth by a sadistic angry parent and her panicked grandmother retrieved them by plunging a hooked knitting needle down her throat. In another instance, one of the alternates reexpenienced being in her crib when Mrs. A was an infant and saw hen diapers and crib smeared with feces. After this revivification, Mrs. A stopped smelling the foul odor. Mrs. A was physically and sexualby abused by both parents between the ages of infancy and early adolescence. As an infant her mother left her unattended for up to 24 hours in her crib in soiled diapers. From age 1 2 to 1 5 sexual assaults often took place in the cold basement on the concrete floor. Once her father bed a group rape of the patient in public view of others at an annual family picnic. These incidents and others were corroborated by her older sister. Abuse ceased when Mrs. A left for boarding school at age 15. Before receiving fluoxetine, Mrs. A had not received psychiatric treat-
ment. She was medically healthy and worked in the health care field. When she initially presented hen histony, she denied memories of an abusive childhood. In the course of treatment over four years, Mrs. A’s strained relationship with her husband has improved. Tension diminished as the couple understood that amnestic periods, abrupt mood transitions, and other unexplained behavior such as excessive spending were manifestations of particularalternate personalities. Accordingly, certain strategies were agreed on; for example, credit cards were withheld. Child care is done more effectively as Mrs. A has albowed her husband to help care for their daughter. Permitting a babysitten access to the child represented a major step, as Mrs. A remains highly distrustful of strangers. Mrs. A attends alocal gym weekly but has a restricted social network. Overall, she and her husband report a more consistent and gentle motherdaughter interaction. She brings her daughter to therapy sessions once a month, and the child has become less vigilant and more engaging.
1242
December
Discussion This patient’s various personalities were essentially dormant in her awareness until the birth of her first child, an event that seemed to serve as a dynamic catalyst for the expression of symptoms associated with multiple personality disorder. Motherhood for the patient apparently stimulated especially powerful memones and affect states unconsciously paired with the severe physical and sexual abuse she suffered in her own infancy and childhood. Postpartum depressive psychosis is subsumed under the DSM-III-R umbrella of atypical psychosis. According to Harding (6), the postparturn period of psychiatric vulnenability begins within two weeks of delivery and lasts up to one year. The risk of postpartum depression, with or without psychotic features, is increased in women with a history of psychiatric illness. Mrs. A’s symptoms, initially attributed to postparturn psychopathology (obsessional thoughts ofharming the child, visual images
of abuse,
auditory
1992
Vol.
hallucina-
43
No.
12
tions,
suicidal ideation, aSand somatic preoccupations) can also be interpreted as manifestations ofthe dissociated pensonality states. Specifically, visual scenes of abuse and other nevivifications represented the memories of certain alternate personalities; auditory hallucinations represented internab crosstalk between personalities; insomnia, suicidality, and depressed mood represented Mrs. A’s response to the inner experience of intrusive images and revivifications. The diagnosis of schizophrenia was unlikely as this patient was able to function in her career and family despite her distress. Reality testing was intact in all personalities. While it is possible for other axis I pathology, such as postpartum affective on psychotic states, to coexist with multipbe personality disorder, it seems more likely that multiple personality disorder was the patient’s exclusive diagnosis because symptoms of suscidality and profound dysphonia abated relatively rapidly without medication as the patient’s dissociative experiences were assigned meaning in treatment. Severe postpartum mental illness typically requires medication or electroconvulsive therapy for accelerated resolution of symptoms (7). Multiple personality disorder is considered an adaptation to severe psychic trauma. The various personalities can be conceptualized as split-off partial identifications with significant figures in the patient’s past (8). Within months after her child was born, Mrs. A became preoccupied with concerns about her own competence as a mother and a fear of sexually and physically molesting hen daughter. At this time she was not conscious of the fact that such acts had been perpetrated on herwhen she was a child. These anxieties and conflicts (certain alternate personalities wanted to hurt the baby, some wanted to protect it, and others wanted to block the memories of abuse) likely led to an increase in dissociative activity. Indeed, it is known that voices of alternate pensonalities argue when patients with multiple personality disorder undergo psychological conflict and that fective
Hospital
insomnia, lability,
and
Community
Psychiatry
switching from one personality to another occurs more frequently when these patients are under psychosocial stress or when meaningful environmental and social cues occur (9). Thus it is reasonable to assume that the defensive process ofdissociaiion, intrinsic to multiple personality disorder, is challenged in the face of developmental events charged with terrifying associations. Consequently, phenomena linked to multiple personality disorder, such as amnestic periods, internal conversations, and somatic experiences, may intensify. It is possible that the nelatively rapid emergence of alternate personalities within the treatment setting and the patient’s awareness of these discrete states were related to the discrete nature of the psychological stimulus-new motherhood. Finally, other associated features of new motherhood, such as endocrinologic and sleep disturbances, may have contributed to the emergencc ofdissociative states. Multiple personality disorder is three to nine times more likely to occur in women than in men and is now estimated to occur in 1 percent ofthe population (1). These statistics have implications for childrearing. One systematic study found that the majority of mothers with multiple personality disorder treated their children in either a grossly abusive on an impaired manner(10). Thus clinicians who treat women suffering from some form of penipartum psychiatnic syndrome should include multiple personality disorder in their differential diagnosis. In view of the fact that all patients with the disorden have sustained severe abuse at the hands of their primary caretakers, it is possible that motherhood-the onset of one’s own role as a caretaker-represents a psychologically disorganizing influence leading to the amplification of dissociative phenomena already present in vulnerable individuals.
2. Bliss EL: A symptom profile with multiple personalities, MMPI
results.
1. Kluft
RP:
The
American Psychiatry.
RE,
Yudofsky
American
Hospital
dissociative
Psychiatric Edited
Press,
Community
and
1259-1260,
1990 GuroffJJ, Silberman EK, et al: The clinical phenomenology of multiplepersonalitydisorder: 100 recent cases. Journal of Clinical Psychiatry 47:
5. Putnam
1W,
285-293, 1986 6. HardingJJ: Postpartum psychiatric cbsorders: a review. Comprehensive Psychi7.
atry 30:109-112, Bmckington
1989
IF, Winokur G, Dean C: Puerperal psychosis, in Motherhood and Mental Illness. Edited by Brockington IF, Kumar R. London, Academic Press, 1982
8. Coons P: Differentialdiagnosis pie personality. Psychiatric North
America
7:5 1-65,
of multiClinics of 1984
9. KIuft
R: The post-unification treatment of multiple personality disorder: first findings.
American
Journal
of Psycho-
therapy 42:212-228, 1985 10. Kluft R: The parental fitness of mothers with multiple personality disorder: preliminary study. Child Abuse and Neglect 11:273-280, 1987
Letters
Letters from readers are welcomed. They will be published at the discretion ofthe editoras space perm its andwill be subject to editing. They shouldbe a maximum of500 words with no more than five references and should be submitted in duplicate, typed double-spaced. Letters should be addressed toJohn A. Talbott, M.D., Editor, H&CP, Amencan Psychiatric Association, Washington, D.C. 20005. Writers should include their title and affiliation.
in Germany
1988
To the Editor: Isn’t it time for a presentation of the results of the treatment of schizophrenia in the United States versus the results of its treatment in another country, say Germany? How do the two countries
Psychiatry
December
disorders,
in
Textbook
Talbott JA, Washington,
by
SC.
Psychiatric
and
Press
of Nervous
Mental Disease 172:197-202, 1984 3. KIuft R: First-ranked symptoms as a diagnostic clue to multiple personality disorder. AmericanJournal of Psychiatry 144:293-298, 1987 4. Nakdimen KA: Differential diagnosis of multiple personality disorder (ltr). American Journal of Psychiatry 147:
Schizophrenia References
Journal
of patients including
of
Hales DC,
1992
Vol.
43
No.
12
compare in the number of days of hospitalization for each psychotic break, and how does length of stay seem to influence patients’ ability to stay on their medication? What percentage of the schizophrenic population end up homeless on the streets ofthe major cities, and what percentage end up in jail? What is the effect of those outcomes on the rate of suicide? What is the difference in the mcdication of choice to treat the initial psychotic break, and what are the dosages? How do programs for the care of schizophrenic patients after discharge from the hospital compare? The problem of schizophrenia does not exist in the United States alone. Certainly much can be learned from how this mental illness is treated in other countries. I wonder if we dare face such comparisons. ABRAHAM M. FUCHS
Mr. Fuchs, a member of the National Alliance for the Mentally Ill, lives in Ambler, Pennsylvania. Editor’s note: Mr. Fuchs raises some intriguing questions. We forwarded his ktter to Professor Uwe Hennik Peters, president of the German Association of Psychiatry and Neurology; Professor Peters referred the letter to Professor Heinz Hafner, aprominent German psychiatnic epidemiologist, for reply. We welcome other letters presenting cross-country comparisons of patient populations and service systems. In Reply: Hospital treatment of schizophrenia can be assumed not to differ between Germany and the United States. The intensive cornmunication on neuroleptic medication at international conferences has led to similar standards. Although efforts to reform inpatient psychiatnc care started with a considerable delay compared with the U.S., today many psychiatric units and hospitals in Germany offer comprehensive measures according to the needs of their patients, including social skills training, cognitive training, and counseling.
1243
measuring overall severity of psychiatric disturbance. Archives ofGeneral Psychiatry 33:766-771, 1976
6. McGlashan
TH:
low-up and study Psychiatry 7.
The Chestnut
study:
follow-up
sample. 41:573-585,
McGlashan
TH:
medium-,
and
schizophrenia. chiatry
Lodge
Predictors longer-term
American
143:50-55,
fol-
methodology
Archives 1984
of
9.
General
outcome
Journal
Multiple
four-month trial 60 mg per day, these symptoms,
360, 1988 Caton
other psychiatrist who would “do more than give me pills.” On presentation nine months postpartum, Mrs. A appeared anxious and tearful. She had not taken fluoxetine for three months. She complained of overwhelming anxiety, restlessness, crying spells, alcohol use, inability to sleep, and profound fear of sexually and physically harming her child. She reported that since childhood she had experienced periods of time for which she could later not give an account of her activities, and she claimed that these episodes had increased markedly since the birth of her child. She also described revivifications-that is, vivid lifelike perceptions of reenacting and reexperiencing past traumatic events. These took the form of brief episodes in which she “saw” herself harming her daughter and others harming toddlers. Persistent olfactory perceptions of feces accompanied these episodes. Mrs. A experienced auditory hallucinations consisting of conversations between several angry voices; these were especially intrusive at night and kept her awake. Also, during this period she described the emergence of what she called phobias. In particular, she found herself inexplicably unable to go into the basement and avoidant of concrete floors. She developed somatic cornplaints, such as an intolerable sore throat for which she was able to obtam antibiotics from an internist despite a negative laryngoscopic cx-
ci,
talization. in
of Psy-
10.
Gralnick length Hospital
A: A review
tal and Community 154, 1990
of issues
ofpsychiatric hospiand Community
Psychiatry 38:858-862, Kiesler CA: Predicting
tal stay forpsychiatric
1986
Case
schizoaffective dispersonality disorder, and unipolar affective disorder. Archives of General Psychiatry 45:35 3borderline
surrounding of shorter-,
8. Heinssen RK, McGlashan TH: Predicting hospital discharge status for patients
Unusual
schizophrenia,
order,
1987 length
inpatients. Psychiatry
of hospi-
Hospi41:149-
Report
Personality
Disorder Presenting as Postpartum Depression L. Sate!,
Sally
Frances
M.D. C. How!and,
M.D.
It is estimated that 1 percent of the population suffers from multiple personality disorder (1). Despite this prevalence, which is comparable to that of schizophrenia, an accurate diagnosis of the disorder is often difficult to make. The clinician’s task is complicated by the fact that patients with this disorder display numerous psychiatric symptoms and symptom constellations that suggest other psychiatnic conditions (1-4). On average, almost seven years elapse between a patient’s seeking help for symptoms related to multiple personality disorder and receiving the correct diagnosis (5). In this paper we describe a new mother with multiple personality disorder who was misdiagnosed as
suffering from postpartum depression. She had no knowledge of other personality states on ofthe pathological nature of her long-standing symptoms of amnesia and sense of lost time until several months after the birth of her first child. During this time, however, she began to cxpenience auditory hallucinations (voices arguing) and pronounced mood shifts. Both are common symptoms associated with multiple personality disorder, but, in this patient, they were attributed to postpartum depression with psychosis. This case illustrates a novel presentation ofmultipbe personality disorder and is, to our knowledge, the first report of the recognition of alternate personalities in the context of the discrete developmental event of motherhood.
of Medicine. Address corto Dr. Satel at West Haven Veterans Mfairs Medical Center, 950 Campbell Avenue, West Haven, Connecticut 06516.
Case report Mrs. A was a 37-year-old married white woman who sought treatment for what she believed to be postpartum depression. Her symptoms included fear ofhurting her child, tearfulness throughout the day, suicidal ideation, irritability, anhedonia, and difficulty sleeping. The symptoms began about five months after her daughter was born. Mrs. A had a
Hospital
December
Dr.
Sate!
psychiatry psychiatric partment
is assistant and Dr. consultant of medicine
professor Howland
in the deat Yale
School
respondence
and
Community
of is
Psychiatry
1992
Vol.
43
No.
12
of fluoxetine, up to with no change in and she sought an-
amination.
Mrs. A began treatment with one of us (FCH) at three hourly sessions a week. The working diagnosis was postpartum depression with psychotic features. The patient refused pharmacotherapy,
claiming
that
“it
did nothing for me before.” After one week Mrs. A had her first revivification experience in the therapist’s office. She claimed that she saw “the couch and the windows getting bigger.” Hen voice took on the quality of a small child’s. This experience, basting about 30 minutes, was baffling to Mrs. A. In the next (fourth)
1241
session an alternate personality appeared, and by the close ofthe second week, 12 distinct personality states had emerged. At this point, the sessions were increased to six days a week, and the patient’s diagnosis was changed to multiple personality disorder. Affective symptoms diminished rapidly during the two weeks after multiple personality disorder was diagnosed. The 1 2 alternates cornprised seven males and five females. Two of the males, Black and Guide, were not formal representations of specific people but served as states that contained memories and momtored their release. Among the female personalities were representations of Mrs. A’s grandmother, her mother, and a small girl. Four weeks elapsed between Mrs. A’s presentation for treatment and her recognition of alternate personalities. Subsequently, treatment focused on accessing graphic memories and “reliving” childhood traumas. As specific symptoms were linked to old traumas, the symptoms tended to remit. For example, the severe pain in Mrs. A’s throat resolved when one of her alternates relived a scene in which rosary beads were shoved into her mouth by a sadistic angry parent and her panicked grandmother retrieved them by plunging a hooked knitting needle down her throat. In another instance, one of the alternates reexpenienced being in her crib when Mrs. A was an infant and saw hen diapers and crib smeared with feces. After this revivification, Mrs. A stopped smelling the foul odor. Mrs. A was physically and sexualby abused by both parents between the ages of infancy and early adolescence. As an infant her mother left her unattended for up to 24 hours in her crib in soiled diapers. From age 1 2 to 1 5 sexual assaults often took place in the cold basement on the concrete floor. Once her father bed a group rape of the patient in public view of others at an annual family picnic. These incidents and others were corroborated by her older sister. Abuse ceased when Mrs. A left for boarding school at age 15. Before receiving fluoxetine, Mrs. A had not received psychiatric treat-
ment. She was medically healthy and worked in the health care field. When she initially presented hen histony, she denied memories of an abusive childhood. In the course of treatment over four years, Mrs. A’s strained relationship with her husband has improved. Tension diminished as the couple understood that amnestic periods, abrupt mood transitions, and other unexplained behavior such as excessive spending were manifestations of particularalternate personalities. Accordingly, certain strategies were agreed on; for example, credit cards were withheld. Child care is done more effectively as Mrs. A has albowed her husband to help care for their daughter. Permitting a babysitten access to the child represented a major step, as Mrs. A remains highly distrustful of strangers. Mrs. A attends alocal gym weekly but has a restricted social network. Overall, she and her husband report a more consistent and gentle motherdaughter interaction. She brings her daughter to therapy sessions once a month, and the child has become less vigilant and more engaging.
1242
December
Discussion This patient’s various personalities were essentially dormant in her awareness until the birth of her first child, an event that seemed to serve as a dynamic catalyst for the expression of symptoms associated with multiple personality disorder. Motherhood for the patient apparently stimulated especially powerful memones and affect states unconsciously paired with the severe physical and sexual abuse she suffered in her own infancy and childhood. Postpartum depressive psychosis is subsumed under the DSM-III-R umbrella of atypical psychosis. According to Harding (6), the postparturn period of psychiatric vulnenability begins within two weeks of delivery and lasts up to one year. The risk of postpartum depression, with or without psychotic features, is increased in women with a history of psychiatric illness. Mrs. A’s symptoms, initially attributed to postparturn psychopathology (obsessional thoughts ofharming the child, visual images
of abuse,
auditory
1992
Vol.
hallucina-
43
No.
12
tions,
suicidal ideation, aSand somatic preoccupations) can also be interpreted as manifestations ofthe dissociated pensonality states. Specifically, visual scenes of abuse and other nevivifications represented the memories of certain alternate personalities; auditory hallucinations represented internab crosstalk between personalities; insomnia, suicidality, and depressed mood represented Mrs. A’s response to the inner experience of intrusive images and revivifications. The diagnosis of schizophrenia was unlikely as this patient was able to function in her career and family despite her distress. Reality testing was intact in all personalities. While it is possible for other axis I pathology, such as postpartum affective on psychotic states, to coexist with multipbe personality disorder, it seems more likely that multiple personality disorder was the patient’s exclusive diagnosis because symptoms of suscidality and profound dysphonia abated relatively rapidly without medication as the patient’s dissociative experiences were assigned meaning in treatment. Severe postpartum mental illness typically requires medication or electroconvulsive therapy for accelerated resolution of symptoms (7). Multiple personality disorder is considered an adaptation to severe psychic trauma. The various personalities can be conceptualized as split-off partial identifications with significant figures in the patient’s past (8). Within months after her child was born, Mrs. A became preoccupied with concerns about her own competence as a mother and a fear of sexually and physically molesting hen daughter. At this time she was not conscious of the fact that such acts had been perpetrated on herwhen she was a child. These anxieties and conflicts (certain alternate personalities wanted to hurt the baby, some wanted to protect it, and others wanted to block the memories of abuse) likely led to an increase in dissociative activity. Indeed, it is known that voices of alternate pensonalities argue when patients with multiple personality disorder undergo psychological conflict and that fective
Hospital
insomnia, lability,
and
Community
Psychiatry
switching from one personality to another occurs more frequently when these patients are under psychosocial stress or when meaningful environmental and social cues occur (9). Thus it is reasonable to assume that the defensive process ofdissociaiion, intrinsic to multiple personality disorder, is challenged in the face of developmental events charged with terrifying associations. Consequently, phenomena linked to multiple personality disorder, such as amnestic periods, internal conversations, and somatic experiences, may intensify. It is possible that the nelatively rapid emergence of alternate personalities within the treatment setting and the patient’s awareness of these discrete states were related to the discrete nature of the psychological stimulus-new motherhood. Finally, other associated features of new motherhood, such as endocrinologic and sleep disturbances, may have contributed to the emergencc ofdissociative states. Multiple personality disorder is three to nine times more likely to occur in women than in men and is now estimated to occur in 1 percent ofthe population (1). These statistics have implications for childrearing. One systematic study found that the majority of mothers with multiple personality disorder treated their children in either a grossly abusive on an impaired manner(10). Thus clinicians who treat women suffering from some form of penipartum psychiatnic syndrome should include multiple personality disorder in their differential diagnosis. In view of the fact that all patients with the disorden have sustained severe abuse at the hands of their primary caretakers, it is possible that motherhood-the onset of one’s own role as a caretaker-represents a psychologically disorganizing influence leading to the amplification of dissociative phenomena already present in vulnerable individuals.
2. Bliss EL: A symptom profile with multiple personalities, MMPI
results.
1. Kluft
RP:
The
American Psychiatry.
RE,
Yudofsky
American
Hospital
dissociative
Psychiatric Edited
Press,
Community
and
1259-1260,
1990 GuroffJJ, Silberman EK, et al: The clinical phenomenology of multiplepersonalitydisorder: 100 recent cases. Journal of Clinical Psychiatry 47:
5. Putnam
1W,
285-293, 1986 6. HardingJJ: Postpartum psychiatric cbsorders: a review. Comprehensive Psychi7.
atry 30:109-112, Bmckington
1989
IF, Winokur G, Dean C: Puerperal psychosis, in Motherhood and Mental Illness. Edited by Brockington IF, Kumar R. London, Academic Press, 1982
8. Coons P: Differentialdiagnosis pie personality. Psychiatric North
America
7:5 1-65,
of multiClinics of 1984
9. KIuft
R: The post-unification treatment of multiple personality disorder: first findings.
American
Journal
of Psycho-
therapy 42:212-228, 1985 10. Kluft R: The parental fitness of mothers with multiple personality disorder: preliminary study. Child Abuse and Neglect 11:273-280, 1987
Letters
Letters from readers are welcomed. They will be published at the discretion ofthe editoras space perm its andwill be subject to editing. They shouldbe a maximum of500 words with no more than five references and should be submitted in duplicate, typed double-spaced. Letters should be addressed toJohn A. Talbott, M.D., Editor, H&CP, Amencan Psychiatric Association, Washington, D.C. 20005. Writers should include their title and affiliation.
in Germany
1988
To the Editor: Isn’t it time for a presentation of the results of the treatment of schizophrenia in the United States versus the results of its treatment in another country, say Germany? How do the two countries
Psychiatry
December
disorders,
in
Textbook
Talbott JA, Washington,
by
SC.
Psychiatric
and
Press
of Nervous
Mental Disease 172:197-202, 1984 3. KIuft R: First-ranked symptoms as a diagnostic clue to multiple personality disorder. AmericanJournal of Psychiatry 144:293-298, 1987 4. Nakdimen KA: Differential diagnosis of multiple personality disorder (ltr). American Journal of Psychiatry 147:
Schizophrenia References
Journal
of patients including
of
Hales DC,
1992
Vol.
43
No.
12
compare in the number of days of hospitalization for each psychotic break, and how does length of stay seem to influence patients’ ability to stay on their medication? What percentage of the schizophrenic population end up homeless on the streets ofthe major cities, and what percentage end up in jail? What is the effect of those outcomes on the rate of suicide? What is the difference in the mcdication of choice to treat the initial psychotic break, and what are the dosages? How do programs for the care of schizophrenic patients after discharge from the hospital compare? The problem of schizophrenia does not exist in the United States alone. Certainly much can be learned from how this mental illness is treated in other countries. I wonder if we dare face such comparisons. ABRAHAM M. FUCHS
Mr. Fuchs, a member of the National Alliance for the Mentally Ill, lives in Ambler, Pennsylvania. Editor’s note: Mr. Fuchs raises some intriguing questions. We forwarded his ktter to Professor Uwe Hennik Peters, president of the German Association of Psychiatry and Neurology; Professor Peters referred the letter to Professor Heinz Hafner, aprominent German psychiatnic epidemiologist, for reply. We welcome other letters presenting cross-country comparisons of patient populations and service systems. In Reply: Hospital treatment of schizophrenia can be assumed not to differ between Germany and the United States. The intensive cornmunication on neuroleptic medication at international conferences has led to similar standards. Although efforts to reform inpatient psychiatnc care started with a considerable delay compared with the U.S., today many psychiatric units and hospitals in Germany offer comprehensive measures according to the needs of their patients, including social skills training, cognitive training, and counseling.
1243
