Open Trial of Clonazepam in the Treatment of Posttraumatic Stress Symptoms Inmpd

Few consistently helpful psychopharmacological interventions have been described in the treatment of multiple personality disorder. We report a successful open trial of clonazepam for posttraumatic stress symptoms in a group of patients with multiple personality disorder. Patients reported notable, sustained improvement in sleep, nightmares, flashbacks, panic attacks and other posttraumatic stress disorder symptoms while undergoing clonazepam treatment. The authors discuss the limitations of the current study and suggest a phenomenological framework for pharmacological interventions in multiple personality disorder. Patients with multiple personality disorder (MPD) frequently also meet diagnostic criteria for posttraumatic stress disorder (PTSD) and patients with PTSD are often described as having dissociative symptoms (American Psychiatric Association, 1987; Braun, 1986; Kluft, 1985,1988; Spiegel., 1984; van der Kolk , 1987). In multiple personality disorder, it is thought that dissociative defenses are used to protect the · child from the full psychological impact of severe traumausually extreme, repetitive child abuse (Braun, 1986; Kluft, 1984a, 1985a, 1988; Putnam et aI., 1986). Underthe pressure of a variety of developmental factors secondary structuring and personification by the child of the traumatically induced dissociated states of consciousness leads to development of multiple "personalities" (Kluft, 1984a). Once dissociative defenses are in place, they may be used preferentially to handle subsequent traumatic experiences as well as to cope with a variety of other developmental vicissitudes (Kluft" 1984a). Reports of several clinical series suggest that, in many cases, the symptoms of multiple personality disorder can be dramatically alleviated by appropriate treatment with intensive, dynamically-oriented psychotherapy, with adjunctive hypnotherapy in selected cases (Kluft, 1984b; Braun, 1986; Coons,1986). However, there is no known definitive pharmacotherapy for the "core" symptoms of multiple personality disorder (Kluft, 1984b). Adjunctive pharmacotherapy for affective, anxiety, and posttraumatic symptoms in multiple personality disorder has been tried primarily on an ad hoc basis (Barkin R., et aI., 1986; Kluft, 1984b). Sporadic success has been reported in individual cases with a variety of agents, including antidepressants, lithium, carbamazepine, major and minor tranquilizers, beta-blockers and others (Barkin et aI., 1986). No consistent pharmacological response pattern has been noted in MPD. There are no controlled, double-blind studies in the literature on pharmacotherapy for MPD (Barkin et aI., 1986). A few MPD patients have been studied in double-blind fashion for presumed treatment refractory affective disorders in medication trials at the NIMH. Trials of lithium, antidepressants, and carbamazepine failed to ameliorate symptoms in MPD patients in these trials (Putnam, unpublished data). Benzodiazepines frequently have been used in the treatment of MPD in an attempt to alleviate panic, anxiety and posttraumatic stress symptoms including poor concentration, hyperarousal, fragmented sleep with repetitive nightmares, anxiety and panic attacks triggered by situations which evoke traumata, and intrusive flashbacks of traumatic experiences. The authors' clinical experience with a large number of multiple personality disorder patients is that benzodiazapenes often have minimal impact on symptoms in multiple personality disorder, are often used in ever-increasing doses by the patient, and are commonly abused. Frequently, MPD patients have transient, subjective positive responses to psychopharmacological agents, only to relapse quickly to their baseline highly symptomatic state (Kluft, 1984). This paper describes an open, non-blind, clinical trial of clonazepam for post traumatic symptoms in multiple personality disorder patients. Clonezepam is a long-acting,