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Cataplexy and the switch process of multiple personality disorder
PSYCHIATRY RESEARCH ELSEVIER
PsychiatryResearch63 (1996)231-232
Case Report
Cataplexy and the switch process of multiple personality disorder Maria C. La Via, Timothy Institute of Psychiatry,
D. Brewerton*
Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 294250742,
Received31 July
1995;
USA
accepted10February 1996
Abstract
A case history is presented of an l&year-old male with dissociative disorder and polysubstance abuse. The patient was observed to switch between three personalities, and the personality changes were often associated with symptoms of cataplexy. Both dissociative episodes and cataplexy are associated with strong affective stimuli. Similar reports in the literature are briefly reviewed. Keywords: Dissociative identity disorder; Muscular weakness; Substance abuse
1. Introduction Multiple personality disorder (MPD), now called dissociative identity disorder, is a posttraumatic psychiatric disorder in which the individual’s consciousness is organized into a set of discrete dissociative states, each with its own statedependent affects, body images, thoughts, memories, and behaviors. Transitions between these states are abrupt and discontinuous compared with the smoother transitions between normal states of consciousness. Cataplexy is a neurologic condition in which the patient abruptly loses muscle tone and often falls, usually in response to some emotionally provoking l Corresponding author,Tel: 7924042.
+1 803 7924092;
0165-1781/96/$15.00 0 1996 Elsevier PII SOl65-1781(96)02887-9
Fax: +1 803
ScienceIrelandLtd. All rights
stimulus. Mild episodes may show a drooping of the jaw, head nodding, or a sense of weakness obliging the patient to sit down or lean against a wall. The patient typically remains fully alert and aware of his surroundings. Attacks are of short duration, usually lasting several seconds and rarely more than a minute. Precipitation by emotional stimuli, particularly laughter, is usually strikingly evident in the history, but any strong emotion may bring on an attack. We here report a case in which cataplectic attacks appeared to be associated with the switch process in a patient with MPD. 2. Case description Mr. H. is an l&year-old male with a history of dissociative disorder and polysubstance abuse who reserved
232
M.C. La Via, T.D. Brewerton/ Psychiatry Research 63 (19%)
presented with complaints of increasing frequency of disturbing traumatic images, dissociative episodes, and ‘voices’. During the course of this hospitalization, he was found to meet DSM-III-R criteria (American Psychiatric Association, 1987) for MPD, including the existence of an alter personality, T. Mr. H. was observed to switch between three personalities a number of times, and these switches were usually noted to be associated with head dropping. On several occasions, Mr. H. experienced episodes in which he lost muscle tone and fell to the ground, maintaining consciousness throughout. These episodes were also noted to be associated with switching. On one occasion when discussing a particular episode before a family meeting, Mr. H. reported extreme anxiety before the meeting and attributed this attack to his anxiety, he indicated that similar episodes had happened in the past. Family members confirmed this history in separate interviews. 3. Comment The switch process in MPD can be divided into experiential psychological and observable-physical changes. Switching often occurs in response to environmental stress and/or internal psychological triggers, usually evoking traumatic memories. In many cases, the strongest indication that a switch has occurred will be a sudden, otherwise inexplicable shift in the person’s affect and psychomotoric function. These phenomena suggest important temporo-limbic circuits. On reviewing the literature on MPD, we found that the temporal lobes have been suggested as neurophysiological mediators of MPD phenom-
231-232
enology, although there is as yet no definitive data supporting this hypothesis. In an MPD patient who was studied with single photon emission computed tomography, major changes in blood flow to the temporal lobes were reported during the switch process (Saxe et al., 1992). Another case report described cataplexy in a 30-year-old man secondary to a left midtemporal lymphoma (Onofrj et al., 1992). Other case reports describe cataplexy secondary to hypothalamic, brainstem, frontal lobe, and parietal lobe lesions (Anderson and Salmon, 1977; Stahl et al., 1980; Schwartz et al., 1984). Interestingly, strong affective stimuli are associated with both MPD and cataplexy. In the patient described above, these processes appear to occur simultaneously and suggest common neuropsychophysiological mechanisms. References American Psychiatric Association. (1987) DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders. 3rd rev. edn. American Psychiatric Press, Washington, DC. Anderson, A. and Salmon, M.V. (1977) Symptomatic cataplexy. J Neurol Neurosurg Psychiatry 40, 186-191. Onofrj, M., Curatola, L., Ferracci, F. and Fulgente, T. (1992) Narcolepsy associated with primary temporal lobe B-cell lymphoma in an HLA DR2 negative subject. J Neurol Neurosurg Psychiatry 55, 852-853. Saxe, G.N., Vasile, R.G., Hill, T.C., Bloomingdale, K. and Van Der Kolk, B.A. (1992) SPECT imaging and multiple personality disorder. J Nerv Menr Dis 180, 662-663. Schwartz, W.J., Stakes, J.W. and Hobson, J.A. (1984) Transient cataplexy after removal of a craniopharyngioma. Neurology 34, 1372-1375. Stahl, S.M., Layzer, R.B., Aminoff, M.J., Townsend, J.J. and Feldon, S. (1980) Continuous cataplexy in a patient with a midbrain tumor: the limp man syndrome. Neurology 30, 1115-1118.
PsychiatryResearch63 (1996)231-232
Case Report
Cataplexy and the switch process of multiple personality disorder Maria C. La Via, Timothy Institute of Psychiatry,
D. Brewerton*
Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 294250742,
Received31 July
1995;
USA
accepted10February 1996
Abstract
A case history is presented of an l&year-old male with dissociative disorder and polysubstance abuse. The patient was observed to switch between three personalities, and the personality changes were often associated with symptoms of cataplexy. Both dissociative episodes and cataplexy are associated with strong affective stimuli. Similar reports in the literature are briefly reviewed. Keywords: Dissociative identity disorder; Muscular weakness; Substance abuse
1. Introduction Multiple personality disorder (MPD), now called dissociative identity disorder, is a posttraumatic psychiatric disorder in which the individual’s consciousness is organized into a set of discrete dissociative states, each with its own statedependent affects, body images, thoughts, memories, and behaviors. Transitions between these states are abrupt and discontinuous compared with the smoother transitions between normal states of consciousness. Cataplexy is a neurologic condition in which the patient abruptly loses muscle tone and often falls, usually in response to some emotionally provoking l Corresponding author,Tel: 7924042.
+1 803 7924092;
0165-1781/96/$15.00 0 1996 Elsevier PII SOl65-1781(96)02887-9
Fax: +1 803
ScienceIrelandLtd. All rights
stimulus. Mild episodes may show a drooping of the jaw, head nodding, or a sense of weakness obliging the patient to sit down or lean against a wall. The patient typically remains fully alert and aware of his surroundings. Attacks are of short duration, usually lasting several seconds and rarely more than a minute. Precipitation by emotional stimuli, particularly laughter, is usually strikingly evident in the history, but any strong emotion may bring on an attack. We here report a case in which cataplectic attacks appeared to be associated with the switch process in a patient with MPD. 2. Case description Mr. H. is an l&year-old male with a history of dissociative disorder and polysubstance abuse who reserved
232
M.C. La Via, T.D. Brewerton/ Psychiatry Research 63 (19%)
presented with complaints of increasing frequency of disturbing traumatic images, dissociative episodes, and ‘voices’. During the course of this hospitalization, he was found to meet DSM-III-R criteria (American Psychiatric Association, 1987) for MPD, including the existence of an alter personality, T. Mr. H. was observed to switch between three personalities a number of times, and these switches were usually noted to be associated with head dropping. On several occasions, Mr. H. experienced episodes in which he lost muscle tone and fell to the ground, maintaining consciousness throughout. These episodes were also noted to be associated with switching. On one occasion when discussing a particular episode before a family meeting, Mr. H. reported extreme anxiety before the meeting and attributed this attack to his anxiety, he indicated that similar episodes had happened in the past. Family members confirmed this history in separate interviews. 3. Comment The switch process in MPD can be divided into experiential psychological and observable-physical changes. Switching often occurs in response to environmental stress and/or internal psychological triggers, usually evoking traumatic memories. In many cases, the strongest indication that a switch has occurred will be a sudden, otherwise inexplicable shift in the person’s affect and psychomotoric function. These phenomena suggest important temporo-limbic circuits. On reviewing the literature on MPD, we found that the temporal lobes have been suggested as neurophysiological mediators of MPD phenom-
231-232
enology, although there is as yet no definitive data supporting this hypothesis. In an MPD patient who was studied with single photon emission computed tomography, major changes in blood flow to the temporal lobes were reported during the switch process (Saxe et al., 1992). Another case report described cataplexy in a 30-year-old man secondary to a left midtemporal lymphoma (Onofrj et al., 1992). Other case reports describe cataplexy secondary to hypothalamic, brainstem, frontal lobe, and parietal lobe lesions (Anderson and Salmon, 1977; Stahl et al., 1980; Schwartz et al., 1984). Interestingly, strong affective stimuli are associated with both MPD and cataplexy. In the patient described above, these processes appear to occur simultaneously and suggest common neuropsychophysiological mechanisms. References American Psychiatric Association. (1987) DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders. 3rd rev. edn. American Psychiatric Press, Washington, DC. Anderson, A. and Salmon, M.V. (1977) Symptomatic cataplexy. J Neurol Neurosurg Psychiatry 40, 186-191. Onofrj, M., Curatola, L., Ferracci, F. and Fulgente, T. (1992) Narcolepsy associated with primary temporal lobe B-cell lymphoma in an HLA DR2 negative subject. J Neurol Neurosurg Psychiatry 55, 852-853. Saxe, G.N., Vasile, R.G., Hill, T.C., Bloomingdale, K. and Van Der Kolk, B.A. (1992) SPECT imaging and multiple personality disorder. J Nerv Menr Dis 180, 662-663. Schwartz, W.J., Stakes, J.W. and Hobson, J.A. (1984) Transient cataplexy after removal of a craniopharyngioma. Neurology 34, 1372-1375. Stahl, S.M., Layzer, R.B., Aminoff, M.J., Townsend, J.J. and Feldon, S. (1980) Continuous cataplexy in a patient with a midbrain tumor: the limp man syndrome. Neurology 30, 1115-1118.