Using volumetric brain analysis to differentiate a patient with 117 multiple personalities from schizophrenia: a case report and literature review

Abstract

gender, age, and even facial expressions that is entirely separate from their original, unique persona. In some instances, an aura has been reported to supersede an alter being pulled from the unconscious to the subconscious. 7 The memories that many of the alters elicit are often entirely different from what the original persona has experienced, so much so that it cannot yet be explained by dementia or any other medical condition. 8 DID and other psychiatric disorders such as schizophrenia have some diagnostic features in common that can often make it challenging to differentiate these comparable conditions. Schizophrenia and DID may both exhibit auditory hallucinations, negative symptoms, some degree of cortical atrophy, and are both often associated with comorbid substance abuse. In current literature, however, clinicians have found some differentiating ideas and evidence that suggest a number of key differences between these disorders. Of note is the finding that the auditory hallucination manifested in up to 80% of patients with DID often manifest at an early age, are experienced as internal in origin, and rarely responds to antipsychotic medication. 8 Conversely, patients with schizophrenia experience hallucinations as environmental, third person, external, or internal in origin and this is usually associated with negative symptoms such as flat affect, catatonia, associability, and anhedonia. Schizophrenia has also shown better response profiles to antipsychotic medication compared to DID. 9 Some patients diagnosed with schizophrenia have also reported higher delusion scores than DID. It is important to note that one of the major diagnostic differences between these disorders is the presence of amnesia or significant disparities in time. Some theories have suggested that DID patients engage in an autohypnotic phenomenon, as a defense mechanism, and have endured significant childhood trauma that is hypothesized to potentiate the onset of the disorder. 8 In contrast, childhood trauma does not seem to be directly related to the onset of schizophrenia and other psychiatric conditions. There is evidence that up to 90% of patients with DID also meet the diagnostic criteria for PTSD. This comorbidity is important to note when examining brain imaging. In addition, other conditions such as borderline personality disorder, bipolar disorder, anxiety disorders, dysfunctional early childhood attachment styles, and childhood neglect have all been implicated or associated with DID in literature. 10 Risk factors for DID include but are not limited to chronic childhood trauma, young age (onset from 28-34 years old), suicidal ideation with previous attempts, monozygotic twins, promiscuity, gender dysphoria, substance abuse, comorbid psychiatric conditions, and depersonalization. 8,10 Many psychiatric disorders are associated with significant changes in brain morphology at gross and molecular levels. The aim of our study is to explore the possibility of using volumetric analysis of specific brain regions to support the diagno...