Case Report

Transitional Interpersonality Thunderclap Headache

Daniel E. Jacome, MD

Objective.—To report a patient with multiple personality disorder who experienced severe acute headaches
without warnings, solely during the transition between her host personality and her pain-prone personality.
Background.—The initial detailed description of headache in multiple personality disorder was made by
Packard and Brown and published in this journal 15 years ago.
Methods.—Clinical history, neurologic examination, electroencephalogram, and brain magnetic resonance
imaging.
Results.—A 54-year-old Holocaust survivor with an established diagnosis of multiple personality disorder had
recurrent, excruciating, acute (“thunderclap”) headaches only when switching between her domineering person-
ality and her pain-prone personality, who suffered from chronic back pain. None of her personalities otherwise
suffer from headaches. Electroencephalogram and brain magnetic resonance imaging were normal.
Conclusion.—This is an independent and current confirmation of the existence of transitional headaches in a
patient with multiple personality disorder. They may occur as an isolated event during the switch process and have
features of benign thunderclap headache.
Key words: migraine, stress, multiple personality disorder, thunderclap headache
Abbreviations: MPD multiple personality disorder, TCH thunderclap headache
(Headache 2001;41:317-320)

Headache is a common somatic complaint of pa-
tients with multiple personality disorder (MPD) and
is sometimes precipitated or aggravated by the switch
of personalities.1 Ludwig et al provided a limited de-
scription of a man with MPD and headache.2 He had
headache preceding “memory lapses,” during which
he exhibited multiple personalities; it is unclear from
their report if the patient had complex partial sei-
zures or confusional migraine with bizarre behavior,
since patients with MPD are normally aware of their
multiple selves. No imaging procedures were per-
formed on their patient. Packard and Brown gave the
first complete account of a young woman with MPD
and headache.3 Unfortunately, their original case did
From the Department of Medicine, Franklin Medical Center,
Greenfield, Mass and the Division of Neurology, Dartmouth-
Hitchcock Medical Center, Lebanon, NH.
Address all correspondence to Dr. Daniel E. Jacome, One
Burnham Street, Suite 2, Turners Falls, MA 01376.
Accepted for publication October 30, 2000.
not return for follow-up after her initial visit so imag-
ing procedures could be completed. Subsequently,
Packard reported two additional patients with head-
ache and MPD.4 Most of his patients’ personalities
reported chronic headaches. The electroencephalo-
grams (EEGs) on his initial patient and in case 2 of
his follow-up publication were normal.3,4 Computer-
ized tomography (CT) of the head was normal in case
2, but was not performed in the remaining two cases
(cases 1 and 3) of his series.3,4
Multiple personality disorder refers to a psychiat-
ric condition characterized by two or more distinct
personalities within an individual, each with their
own behavior and complex social interactions.5,6 A
controlling dominant personality is normally present
(the usual self or host personality). Multiple person-
ality disorder probably arises from child abuse and is
a disorder of identity classified among the dissocia-
tive disorders which include dissociative amnesia,
fugue, depersonalization, and dissociative disorder
not otherwise specified.7,8 The diagnostic validity of
MPD has been the subject of debate for years, with

317
318 March 2001

critics proposing that it is the result of fabrication by Personality Features

the psychotherapist. However, MPD is currently
back in the “fold of legitimacy.”9 Multiple personality Name Traits
has been described in patients with temporal lobe ep-
ilepsy and in a patient with Down syndrome.10,11 It is
Joni Out most of the time; host personality
probably underdiagnosed, and its incidence among Anna Holds most of the psychological trauma, back
the psychiatric population has been calculated to be pain, pain-prone but no chronic headache
Lizz Small child, does not communicate well
between 5% and 10%.8
Martha Bad mother
Thunderclap headache (TCH) refers to severe Paula Assertive and very angry
headaches of abrupt onset that could signify the pres- Carol Always sick; has asthma
Arlene Very smart; plays the piano and knows
ence of an intracranial aneurysm near to rupture computers
(“sentinel headache”).12 A benign form of TCH exists Milena Good mother
that develops spontaneously or after exertion, and Soldat Soldier; “not a nice person”
Gretel Stutters
can be accompanied by reversible multifocal vaso- Percy Playful girl
spasm of the intracranial arteries.13 Dottie Loves dancing and partying
Lettie Hard worker
A patient with MPD and recurrent, acute, excru- Karl and Karla Twins; he is very angry, she is mean
ciating, abrupt-onset headaches is reported to pro- Isabel Neutral
vide independent confirmation of Packard and Brown’s Maria Holds specific trauma
Peggy Neutral
detailed observation. She had only headaches during Baby boy 7 months old; does not communicate
the transition between her host personality and her Bertha Obsesses and analyzes
pain-prone personality, representing a clinical example
of true, transitional, benign, thunderclap interpersonal-
ity headache. hour or two. Her host personality was resistant to dis-
solution or replacement, and actively made efforts to
CASE HISTORY suppress the emergent personality. Her symptoms
A 54-year-old woman was referred for neuro- have lasted for many years, although she had no his-
logic consultation because of recurrent back pain, fa- tory of chronic headaches or headaches in other cir-
tigue, and headache. She had been diagnosed several cumstances. Headaches took place when “Joni” at-
years earlier with MPD following formal psychiatric tempted to suppress the emergence of “Anna” who
evaluation. She was followed by a psychotherapist held most of the psychological trauma and was prone
with interest in dissociative disorders for several to pain. She had no other neurologic symptoms with
years. She had a total of 19 active personalities (16 her headaches. She was of Jewish European ancestry
women and 3 men) at the time of her initial neuro- and was the subject of abuse both physical and psy-
logic evaluation. She had a domineering or host per- chological as a small child while living in her native
sonality (“Joni”) and an array of diverse personalities country, which was occupied by the Nazis early in the
including a child, a soldier, a baby, a musician, a pair Second World War. Her past medical history was sig-
of twins forming one personality, and an observing nificant for asthma (“Carol”) and chronic back pain
reflective personality (“Bertha”) that served as inter- (“Anna”). Eleven years earlier, she had a lumbar in-
nal analyst. “Anna” had chronic back pain and traspinal synovial cyst that was successfully resected
“Carol” had asthma. Additional details on her per- alleviating her host personality’s back pain but not
sonalities are given in the Table. She described expe- “Anna’s,” who suffered from chronic back pain. Her
riencing excruciating (“exploding”), abrupt, pressure two sisters had migraine but did not suffer from
headaches located over the forehead while switching MPD. There was no family history of intracranial an-
between specific personalities for several years. Her eurysms, subarachnoid hemorrhage, polycystic kid-
headaches could be brief or persist after the switch ney disease, or Marfan or Ehlers-Danlos syndrome.
for variable lengths of time, but not for more than an She was a widow with two older children in good
Headache
health and worked as a telephone operator. She com-
plained of chronic fatigue and numbness of her right
thigh. Her reported visual acuity was different for dif-
ferent personalities, some of which did not require
reading glasses. Different personalities used different
glasses with different powers of refraction for read-
ing. Her general physical examination was normal ex-
cept for high arches of the feet. Neurologic examina-
tions were performed on “Joni” since no personality
switching was provoked by the neurologist on her
various visits in order to avoid regressive or cata-
strophic reactions. Her examination of language, at-
tention, short- and long-term memory, mood and af-
fect, cranial nerves, cerebellar, muscle strength, muscle
tone, sensory, and gait were normal. Deep tendon re-
flexes were symmetric, and she had no pathologic re-
flexes. Testing included a normal EEG and brain mag-
netic resonance imaging (MRI). Electromyogram and
nerve conduction velocities of her right leg were nor-
mal. Her lumbar spinal MRI showed no recurrent
synovial cysts but an extraforaminal L3 disk hernia-
tion. Conservative management was offered with an-
algesics, muscle relaxants, and physical therapy. She
was eventually referred back to her psychologist for
continuous psychotherapy as desired by the patient.
In 3-year follow-up, she reported no additional neuro-
logic or psychiatric symptoms. Her level of anxiety has
improved with continuous psychotherapy.
COMMENTS
Distinct psychophysiologic states perhaps reflect-
ing different levels of consciousness are identifiable
in individuals with MPD. Coons et al found different
background EEG frequencies in different personali-
ties in two patients.14 Hughes et al performed brain
EEG mapping in a case of multiple personality. Maps
obtained from the basic personality were compared
with 3 of 10 alternate personalities; 4 had significant
differences in the beta and theta band in their studies
completed 2 months apart.15 Mathew et al demon-
strated right temporal lobe hyperperfusion in a pa-
tient with multiple personality undergoing cerebral
blood flow studies.16 Increased uptake over the left
temporal lobe was reported in a patient with MPD
detected by means of single photon emission comput-
erized tomography performed on each of her four
319
ego states.17 Although MPD has been associated with
temporal lobe epilepsy, this patient’s EEG showed
no paroxysmal activity, she had no history of seizures,
and her brain MRI revealed no structural abnormali-
ties that suggested that her symptoms were partial
seizures. Miller et al documented optical differences
in MPD.18 These authors collected data from 20 pa-
tients and compared their data with the data obtained
from 20 controls. They encountered a significant in-
crease in variability of results among different per-
sonalities in the patient group when testing visual
acuity, refraction, eye muscle balance, and peripheral
vision. Average visual evoked responses recorded at
the vertex also exhibited substantial differences among
different personalities.19 These differences in visual
function found between personalities’ states were
corroborated more recently.20 It is of interest that the
subject of this report needed different glasses of dif-
ferent refraction power for some of her personalities,
while others did not require glasses at all, indicating
significant differences in visual acuity among person-
alities. Pain perception differences were reported by
McFadden and Woitalla, employing a visual analog
scale and the McGill Pain Questionnaire in a patient
with MPD.21 The latter patient also exhibited differ-
ences in muscle tension that was measured by fore-
head EMG in two separate testing sessions, reflecting
psychophysiologic differences.21 Finally, Putnam et al
described distinct changes in arousal responses among
different personalities in 9 patients with MPD.22 These
authors measured heart rate, respiration, reaction times,
and skin conductance variability in their subjects, con-
firming the presence of diverse autonomic nervous sys-
tem levels of activity.22
Transition between personalities (“switching”),
which normally occurs very quickly and dramatically in
these patients, constitutes a stage of vulnerability, simi-
lar to other psychiatric disorders in which abrupt behav-
ioral changes are associated to striking psychophysio-
logic alterations (ie, panic attacks). These abrupt
changes facilitate the appearance of somatic symp-
toms and are usually accompanied by a great degree
of tension. In support of this notion is the unique case
of cataplexy induced by switching reported by La Via
and Brewerton in an 18-year-old man with history of
polysubstance abuse.23 The severe, bitemporal, pound-
320
ing headache experienced by the patient of Packard
and Brown was aggravated by the transition between
an adolescent alter personality and her host personal-
ity.3 Her headache paradoxically followed 2 minutes
of napping. The pathogenesis of headache in MPD is
uncertain; it is legitimate to speculate that the stress
associated with the transitional state precipitates the
abrupt appearance of symptoms. Of additional inter-
est was this patient’s benign TCH which, to my
knowledge, has not been previously reported as a
transitional phenomenon in MPD.
REFERENCES
1. Bliss EL. Multiple personalities. A report of 14 cases
with implications for schizophrenia and hysteria.
Arch Gen Psychiatry. 1980;37:1388-1397.
2. Ludwig AM, Brandsma JM, Wilbur CB, Bendfeldt
F, Jameson DH. The objective study of a multiple
personality. Or, are four heads better than one?
Arch Gen Psychiatry. 1972;26:298-310.
3. Packard RC, Brown F. Multiple headaches in a case
of multiple personality disorder. Headache. 1986;26:
99-102.
4. Packard RC. Multiple headaches in multiple person-
ality disorder. In: Adler CS, Adler S, Packard RC,
eds. Psychiatric Aspects of Headache. Baltimore,
Md: Williams & Wilkins; 1986.
5. Putnam FW, Guroff JJ, Silberman EK, Barban L,
Post RM. The clinical phenomenology of multiple
personality disorder: review of 100 recent cases. J Clin
Psychiatry. 1986;47:285-293.
6. Putnam FW. Recent research on multiple personality
disorder. Psychiatr Clin North Am. 1991;14:489-502.
7. Lewis DO, Yeager CA, Swica Y, Pincus JH, Lewis
M. Objective documentation of child abuse and dis-
sociation in 12 murderers with dissociative identity
disorder. Am J Psychiatry. 1997;154:1703-1710.
8. Coons PM. The dissociative disorders. Rarely con-
sidered and underdiagnosed. Psychiatr Clin North
Am. 1998;21:637-648.
9. Brenner I. Deconstructing DID. Am J Psychother.
1999;53:344-360.
March 2001
10. Schenk L, Bear D. Multiple personality and related
dissociative phenomena in patients with temporal
lobe epilepsy. Am J Psychiatry. 1981;138:1311-1316.
11. Fotheringham JB, Thompson F. Case report of a
person with Down’s syndrome and multiple person-
ality disorder. Can J Psychiatry. 1994;39:116-119.
12. Day JW, Raskin NH. Thunderclap headache: symp-
tom of unruptured cerebral aneurysm. Lancet. 1986;
2:1247-1248.
13. Dodick DW, Brown RD Jr, Britton JW, Huston J
III. Nonaneurysmal thunderclap headache with dif-
fuse, multifocal, segmental, and reversible vaso-
spasm. Cephalalgia. 1999;19:118-123.
14. Coons PM, Milstein V, Marley C. EEG studies of
two multiple personalities and a control. Arch Gen
Psychiatry. 1982;39:823-825.
15. Hughes JR, Kuhlman DT, Fichtner CG, Gruenfeld
MJ. Brain mapping in a case of multiple personality.
Clin Electroencephalogr. 1990;21:200-209.
16. Mathew RJ, Jack RA, West WS. Regional cerebral
blood flow in a patient with multiple personality.
Am J Psychiatry. 1985;142:504-505.
17. Saxe GN, Vasile RG, Hill TC, Bloomingdale K, Van
Der Kolk BA. SPECT imaging and multiple person-
ality disorder. J Nerv Ment Dis. 1992;180:662-663.
18. Miller SD, Blackburn T, Scholes G, White GL, Ma-
malis N. Optical differences in multiple personality
disorder. A second look. J Nerv Ment Dis. 1991;179:
132-135.
19. Larmore K, Ludwig AM, Cain RL. Multiple person-
ality—an objective case study. Br J Psychiatry. 1977;
131:35-40.
20. Birnbaum MH, Thomann K. Visual function in mul-
tiple personality disorder. J Am Optom Assoc. 1996;
67:327-334.
21. McFadden IJ, Woitalla VF. Differing reports of pain
perception by different personalities in a patient
with chronic pain and multiple personality disorder.
Pain. 1993;55:379-382.
22. Putnam FW, Zahn TP, Post RM. Differential auto-
nomic nervous system activity in multiple personal-
ity disorder. Psychiatry Res. 1990;31:251-260.
23. La Via MC, Brewerton TD. Cataplexy and the
switch process of multiple personality disorder. Psy-
chiatry Res. 1996;63:231-232.