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CASE REPORTS

The Use of Carbamazepine for Episodic Violence in Multiple Personality Disorder and Dissociative Disorder Not Otherwise Specified: Two Additional Cases Philip M. Coons

Introduction Although there are several reviews of the psychopharrnacological treatment of multiple personality disorder (MPD), this literature remains largely anecdotal (Barkin et al 1986; Putnam 1989; Loewenstein 1991). Two single case reports have appeared concerning the use of antidepressants to treat depression (Coryell 1983) and the use of carbamazepine to treat episodic violence (Fichtner et al 1990) in patients with MPD. In the only well-designed open trial, clonazepam decreased intrusive posttraumatic symptoms in a group of five patients with MPD and posttranmatic stress disorder (PTSD) (Loewenstein et al 1988). ' ~ e use of such a variety of psychophannacologic agents has been justified because MPD ts a polysymptomatic disorder which often has several coexisting diagnoses such as affective disorders, somatoform disorders, borderline personality disorder, and anxiety disorders including PTSD (Coons et al 1988). Carbamazepine has been reported to reduce both intrusive symptornatology (Lipper et al 1986) and aggressive outbursts (Wolf et al 1988) in male combat veterans with PTSD. Neither Barkin et al (1986) nor Putnam (1989) found carbamazepine useful in the treatment of MPD, although they did not make clear which target symptoms they were treating. In a recent review (Fichtner et al 1990), carbamazepine was found to be useful in treating violent episodes in a wide variety of clinical conditions including bipolar disorder, schizophrenia, borderline personality disorder, PTSD, and intermittent explosive disorder. Carbamazepine has recently been suggested as a way to decrease episodic violence and increase control of dissociation in MPD (Fichtner et al 1990). The following two cases illustrate the usefulness of carbamazepine in reducing episodic violence in MPD and dissociative disorder not otherwise specified (DDNOS).

From the Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, Address reprint requests to Philip M. Coons, M.D., Lame D. Carter Memorial Hospital, 1...15 West 10th Street, Indianapolis, Indiana 46202. Received January 3, 1992; revised June 25, 1992. © 1992 Society of Biological Psychiatry

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Case Reports Case 1 A 32-year-old woman was hospitalized for a variety of dissociative and affective symptoms. Dissociative symptoms included marked depersonalization, derealization, infrequent amnesia, and identity alteration among 14 poorly defined and quite fluid ego states which did not always assume executive control. Just as in MPD, there was a history of childhood physical and sexual abuse. Although affective symptoms had been present for many years, there was a marked worsening with the birth of her first child 4 years previously. The affective symptoms consisted of lengthy periods of depression and intermittent suici~lality alternating with brief periods (hours to a few days) of elation, decreased sleep, and flight of ideas. The hypomanic symptoms were first noted when her depression was treated with tricyclic antidepressants. Three electroencephalograms (EF,Gs) were normal. Her diagnoses included DDNOS, bipolar disorder NOS, and borderline personality disorder. Previous successive single dose trials (some of which were adequate in dose and duration and some were not) of imipramine (150 rag/day), fluoxetine (20 mgMay), phenelzine (45 mg/day), clorazepate dipotassium (75 mgMay), alprazolam (10 mgMay), and haloperidol (10 mg/day) had been ineffective in treating both her affective and anxiety symptoms. Her 13-month hospitalization was characterized overall by profound regression with occasional periods of improvement. When decompensated she was depressed, suicidal, self-mutilating, and dissociated frequently. Most distressing were her violent outbursts towards people and property which she attributed to an ego state labeled "anger." The treatment team reasoned that these violent outbursts might be related to affective dysregulation. Treatment gith perphenazine (20 mg/day) and lithium carbonate (1200 mg/day) was ineffective despite adequate serum lithium levels (1.2 meqlL). Treatment with clonazepam (1 rag/day) worsened her dissociation and violence. Finally, a trial of carbamazepine (200 mg BID) was initiated, but severe nausea and vomiting forced its discontinuation. Although she continued to dissociate into various parts, including "anger," her violent episodes stopped dramatically when the carbamazepine was restarted but resumed promptly with its discontinuation due to more nausea and vomiting. Subsequently, she was restexted at 100 mg/day, but this lower dosage was not tolerated either. She was finally able to tolerate a dose of 50 mgMay which was raised at 50-mg increments at weekly intervals to a final dosage of 300 mglday, following which no further violent episodes occurred. Prior to use of carbamazepine, she exhibited 58 episodes of violence on 44 separate days which required 106 his of restraint.

Case 2 This 17-year-old woman who w~ 6 months pregnant was transferred from a state hospital where she had resided since age I.L Her initial hospitalization was prompted by a number of severe behavior problems including running away, multiple suicide attempts, recurrent self-mutilation, and assaultive behavior involving serious physical injury to hospital staff. She had a history of physical abuse by both parents since childhood and sexual abuse by her father since age 14. She was subsequently removed from the home by welfare authorities and placed in over 20 foster homes over the next 3 years. Although dissociative

Carbamazepine for Episodic Violence in MPD and DDNOS

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symptoms including depersonalization, amnesia, and "inner voices" were discovered by a consultant during this hospitalization, these symptoms were not addressed by the treatment team who chose instead to treat her borderline personality disorder with a multilevel behavioral program. A single EEG was normal. Following childbirth, treatment with a variety of medications (some of which were of adequate dose and duration and some were not) including sodium amytal (250 mg IM pro), nortriptyline (150 mg/day), lithium carbonate (1200 mg/day), thiothixene (10 mg/day), chlorpromazine (200 rag/day), and propanolol (40 mg/day) were ineffective in controlling her violent outbursts which consisted of 5~ episodes on 54 separate days requiring 163 hrs of restraint. Seclusion was prescribed in her behavioral program for violent episodes, but only seemed to make her aggression worse. After 11 months, she was transferred to another state hospital for longer-term care. Immediately upon admission she was started on carbamazepine in addition to her lithium and chlorpromazine. Thereafter, she experienced no further violent episodes and only occasional episodes of self-mutilation. However, her dissociation and suicidal ideation continued undiminished. MPD was diagnosed after at least four other personality states were observed. The patient attributed her violent episodes to an angry alter. An administrative psychiatrist ordered her carbamazepine stopped and her violent episodes promptly resumed. Her violence stopped again when the carbamazepine was restarted. Discussion In addition to the Fichtner et al (1990) case, these two additional cases provide further evidence that carbamazepine is useful in controlling violent episodes in patients with severe dissociative disorders such as MPD or DDNOS. It shou!~lbe pointed out, however, that all three patients had other diagnoses including borderline personality disorder, PTSD, and affective disorder which have also been reported to respond to carbamazepine with decreased violent episodes. The carbamazepine may be merely treating the affective dysregulation in these patients. Unlike the Fichtner et al patient, who was found to have a decre~me in rapid and uncontrolled switching, neither of the two patients reported here responded to carbamazepine with decreased dissociative symptoms. Also, unlike the Fichtner et al patient, these patients did not have decreased auditory hallucinations while on antipsychotic medication. Finally, unlike the Fichtner et al patient who demonstrated a rhythmic midtemporal lobe EEG discharge, neither patient reported there had abnormal EEGs. Previous research on EEGs in MPD patients has demonstrated a higher than average occurrence of EEG abnormalities (16%) and seizure histories (10%) than in other psychiatric patients (Coons et al 1988). At least four other studies (reviev,ed in Coons 1986; Fichtner et al 1990) have noted an association of dissociative symptoms including MPD with temporal lobe epilepsy. These findings have caused clinicians and researchers to reflect upon the neurobiology of MPD. At this time there is little data to suggest that temporal lobe or other gross EEG findings bear an etiological relationship to MPD in most patients. However, the use of more sophisticated EEG or other brain imaging techniques may further clarify the neurobiology of MPD. In summary, the use of carbamazepine for treatment of aggressive episodes in severe dissociative disorders such as MPD and DDNOS appears promising. Further systematic and controlled studies are indicated to study the exact nature of this response.

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References Barkin R, Braun BG, Kluft RP (1986): The dilemma of drug therapy for multiple personality disorder. In B.raun BG (ed), Treatment of Multiple Personality Disorder. Wasl~mgton, DC: American Psychiatric Press, pp 107-132. Coons PM (1988): Psychophysiologic aspects of multiple personality disorder: A review. Dissociation 1(1):47-53. Coons PM, Bowman ES, Milstein V (1988): Multiple personality disorder: A clinical investigation of 50 cases. J Nerv Ment Dis 176:519-527. Coryell W (1983): Multiple personality and primary affective disorder. J Nerv Ment Dis 171:388390. Fichtner CG, Kuhlman DT, Gmenfeld MJ. Hughes JR (1990): Decrea~.,d episodic violence and increased control of dissociation in a carbamazepine-treated case of multiple personality. Biol Psychiatry 27:1045-1052. Lipper S, Davidson JRT, Grady TA, et al (1986): Preliminary study of carbamazepine in posttraumatic stress disorder. Psychosomatics 27:849-853. Loewenstein RJ (1991): Rational psychopharmacology in the treatment of multiple personality disorder. Psychiatr Clin North Am 14:721-740. Loewenstein IU, Homstein N, Farber B (1988): Open trial of clonazepam in the treatment of posttranmatic symptoms in multiple personality disorder. Dissociation 1(3):3-12. Putnam FW (1989): The Diagnosis and Treatment of Multiple Personality Disorder. New York: Guilford Press, pp 253-259. Wolf ME, Atavi A, Mosnain AD (1988): Posttraumatic stress disorder in Vietnam veterans: Clinical and EEG findings, possible therapeutic effects of cmbamazepine. Biol Psychimry 23:642-644.

The use of carbamazepine for episodic violence in multiple personality disorder and dissociative disorder not otherwise specified: two additional cases.

BIOL PSYCHIATRY 1992;32:717-72o 717 CASE REPORTS The Use of Carbamazepine for Episodic Violence in Multiple Personality Disorder and Dissociative D...
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