COONS
Psychophysiologic Aspects
of Multiple Personality Disorder
A Review
Philip M. Coons, M.D.
ABSTRACT
Multiple personality disorder has been associated with marked psychophysiologic alterations ever since careful clinical
observations have been made on this perplexing disorder. Physical symptoms known to be associated with multiple personality
include headaches, conversion symptoms, changes in voice, seizure-like activity, unexplained pain or insensitivity to pain, altera-
tions in handedness or handwriting style, palpitations, alterations in respiration, gastrointestinal disturbances including bulimia
and anorexia, menstrual irregularities, sexual dysfunction, and dermatological conditions including unusual allergic responses
and  differential responses to medication. Early scientific studies 
conducted by Prince in the early twentieth century. Since 1970 there has been a resurgence of interest in multiple personality
disorder including sophisticated studies of physical symptoms, brain-wave activity, visual evoked potential, regional cerebral blood
flow, visual refraction, muscle activity, cardiac and respiratory activity, galvanic skin response, and the switch process. In addition
to describing these studies, the etiology of multiple personality disorder and future directions in research will be discussed.
Marked psychophysiologic alterations are fre-
quently described in patients with multiple personality
disorder (MPD). The changes that occur across the
alternate personalities are most notable. These changes
have been reported almost from the beginning of the
literature on MPD. For example, in 1811 Mary Reynolds,
one of the earliest cases of multiple personality in the
United States, suffered from blindness and deafness in
her alter personality (Mitchell, 1888). In the French
literature; Despine patient, Estelle, appeared to suffer a
paralysis (Despine, 1840).
Dr. Morton Prince, a neurologist, was the first
scientist to study MPD beyond merely providing a good
clinical description. He and a psychiatrist colleague, Dr.
Frederick Peterson, were the first to study the galvanic
skin response in MPD (Prince Peterson, 1906). No
further studies were undertaken until Morselli (1953)
and Thigpen and Cleckley (1954) reported electro-
encephalographic differences between personalities in
separate cases of MPD. Not until 1972 did Ludwig,
Brandsma, Wilbur, Bendfeldt, and Jameson, perform a
comprehensive scientific study of a patient with MPD.
Their research included comprehensive electroencepha-
lography, visual evoked responses, galvanic skin re-
sponse, and numerous other psychophysiological tests.
In 1984 Putnam observed that the psychophysiol-ogic 
investigation of MPD was still in its infancy (1984a).
Now, thanks to the efforts of Putnam and others, the
scientific investigation of the various psyhophysiologicma
nifestations of MPD is enjoying a robust childhood.
To date, studies have been conducted to investigate
changes across personalities in virtually every organ
system of the body. A variety of sophisticated tech-
niques, including electroencephalography, visual
evoked responses, galvanic skin responses, electro-
myography, regional cerebral blood flow, voice spectral
analysis, brain electrical activity mapping, and electro-
cardiography have been used in the quest to better
characterize and further understand MPD. This paper
will attempt to summarize the major findings from these
studies, offer observations upon its etiology, and suggest
directions for future research. Major findings will be
grouped below according to organ system.
In an attempt to keep the reader abreast of the most
current developments in this rapidly changing scientific
field, the references cited include those which appear as
abstracts in conference proceedings. Some of the studies
cited here are admittedly anecdotal in nature and must
await further rigorous replication before their findings
may be regarded as established. In the interests of
comprehensiveness, all scientific source material avail-
able to the author as of the time of this writing has been
acknowledged.
NEUROMUSCULAR SYSTEM
Headaches
One of the most common physical symptoms in
MPD is severe headache. In studies reporting 20 (Coons
and Milstein, 1986), 70 (Bliss, 1984), and 100 (Putnam,
Cutoff, Silberman, Barban, Post, 1986) MPD patients,
headaches were reported to occur in 50-60 percent.
Recently Packard and Brown (1986) described a 24-year-
Dr. Coons is Associate Professor of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana.
Address reprint requests to: Philip M. Coons,M.D., Larue D. Carter Memorial Hospital, 1315 West 10th Street, Indianapolis,
Indiana 46202
DISSOCIATION 1:1, March 1988 47
PSYCHOPHYSIOLOGIC ASPECTS   
old woman whose seven personalities had a variety of
headache types. Most headaches in MPD are tension,
vascular, or a combination of both. These headaches
usually are worse during personality changes.
Voice
Changes in voice quality in MPD patients have
long been recognized (Bosse, 1892; Schreiber, 1973;
Coons, 1980). Studies to characterize these voice changes
further using voice spectral analysis are currently
underway (Putnam, 1984a).
Conversion
Conversion symptoms also occur quite commonly,
in about 40 percent of MPD patients in several large
series (Bliss, 1980, 1984; Coons & Milstein, 1986; Putnam
et al., 1986). These symptoms can be quite varied and
include blindness, deafness, aphonia, anaesthesia, and
paralysis (Taylor & Martin, 1944). Generally conversion
symptoms occur briefly in the course of illness during a
period of intense emotional distress. Personalities with
particular conversion symptoms are well known.
Vision
In addition to conversion symptoms, the eyes may
experience other changes both between personalities and
with integration. Shepard and Braun (1985) monitored
refraction, visual acuity, ocular tension, keratometry,
color vision, and visual fields in MPD patients and
found changes in these measures among patient's
personalities both before and after integration. Some of
these findings were replicated by Morgan, Hales and
Miller (1986) when they used a matched control group of
MPD simulators. Finally, a single patient with MPD was
reported to have microstrabismus which varied in its
frequency of occurrence among her three personalities
(Condon, Ogston, & Pacoe, 1969).
Pain
A number of early reports described insensitivity to
pain in alter personalities of MPD patients (Wilson, 1903;
Taylor & Martin, 1944). More recently Bliss (1984)
reported body anaesthesia in 32-38 percent of 70 MPD
patients while Putnam et al. (1986) reported a 25 percent
incidence of paresthesias and analgesias in a group of
100 MPD patients.
Seizure Disorders
Several studies have noted an association of MPD
with epilepsy (Mesulam, 1981; Schenk & Bear, 1981;
Drake, 1986; Bensen, Miller, & Signer, 1986). However,
the first two studies were seriously flawed because most
of the patients did not meet the DSM-III criteria for MPD
(Coons, 1984). Bensen, Miller and Signer (1986) de-
scribed two patients who exhibited personality changes
afer seizures with the preictal and postictal states
experiencing amnesia for each other, but neither patient
met the DSM-III criteria for MPD as non of the person-
alities were "complex and integrated" with their "own
unique behavior patterns and social relationships"
(American Psychiatric Association, 1980). Drake (1986)
described a series of 15 patients with MPD, five of whom
had seizure disorders. Four of these patients, however,
only had two "personalities," a preictal state and postic-
tal state, and like the Bensen patients probably do not
meet DSM-III criteria for MPD. It should be noted here
that most of the cases cited above also do not meet the
new DSM-III-R criteria for MPD (American Psychiatric
Association, 1987).
Coons, Bowman, and Milstein (1987) found a 14
percent incidence of psychogenic seizures and a 10
percent incidence of organic seizures in a series of 50
consecutive MPD patients (three patients had grand mal
epilepsy and two patients had temporal lobe epilepsy).
They concluded that dissociation in MPD is unlikely to
be a manifestation of chronic limbic epilepsy or an
interictal phenomenon of temporal lobe epilepsy as has
been suggested (Mesulam, 1981; Schenk & Bear, 1981).
Putnam (personal communication, 1987) confirms that
epilepsy does occur in a small percentage of MPD pa-
tients. It should be apparent from the foregoing discus-
sion that some rictal and interictal phenomena can
mimic dissociation and depersonalization seen in MPD.
Neurophysiologic Measures of Nerve and Muscle
Activity
Electroencephalography. Until just recently
electroencephalograms (EEGs) tracings of the brain's
electrical activity, of MPD patients only have been
reported on single cases. Instances of both normal
(Lipton, 1943; Thigpen & Cleckley, 1954; Ludwig, at al.,
1972; Larmore, Ludwig, & Cain, 1977; Bliss, 
Salama, 1980; Coryell, 1983) and abnormal (Horton &
Miller, 1972; Cutler & Reed, 1975; Pohl, 1977; Brende &
Rinsley, 1981; Coons, Milstein, & Marley, 1982; Braun,
1983b) EEGs have been reported.
A number of case reports and studies have com-
pared EEGs across personalities and have noted that
EEG differences occur predominately in alpha rhythm
(Thompson, Forbes, & Bolles, 1933; Thigpen & Cleckley,
1954; Ludwig et al, 1972; Larmore 1977; Cocores, Bender,
& McBride, 1984). Most of these investigators have
concluded that these differences in alpha rhythm
probably reflect the degree of arousal and tension across
different personality states. Except for muscle and
movement artefact, Coons, Milstein, and Marley (1982)
found no EEG differences across personalities in two
MPD patients and one simulating control. However,
frequency analysis revealed significant changes in the
relative EEG amplitudes at different frequencies for both
the MPD patients and control, with the control subject
showing more significant differences than the MPD
patients. These investigators proposed that these differ-
ences probably reflected changes in intensity of concen-
tration, mood, and degree of alertness.
Electromyography. Thus far, only one study
(Larmore et al., 1977) has been conducted using the
48  DISSOCIATION 1:1, March 1988
COONS
electromyogram (EMG), an instrument used to measure
the electrical activity of the muscle. Although the
investigators noted changes in EMG recordings among
personalities, they used no control subjects and were
unable to draw any definite conclusions.
Visual Evoked Potentials. Ludwig et al. (1972) were
the first to study visual evoked potentials (VERs), a
complex electrical measurement of the brain's response
to light stimulation. In their MPD patient two personali-
ties had prominent and similar VERs, a third personality
had none, and a fourth personality had only a small
potential. In similar studies Larmore, et al. (1977) and
Pitblado and Densen-Gerber (1986) reported differences
in VERs in their single MPD patients. Braun (1983a)
found differences in VERs in the personalities of two
MPD patients. After unification, the patients' post-
integration VERs were different from any of their pre-
integration VERs.
In the most comprehensive study of VERs in MPD
to date Putnam (1984a) found that the VER differences
among the personalities of 10 MPD patients were
significantly greater than the differences among the
simulated personalities of 10 normal matched controls.
Putnam holds that definitive interpretation of these VER
findings must await further research. The possibility
exists, however, that if these findings can be replicated
and understood, the VER might be used to distinguish
between MPD patients and non-MPD patients. This
might be especially useful in ruling out malingering or
factitious disorder.
Regional Cerebral Blood Flow. Several studies have
been conducted in MPD patients using regional cerebral
blood flow (TCBF) techniques (Lefkof et al., 1984; deVito,
Braun, Karesh, Henkin, & Caniga, 1985; Mathew, Jack, &
West, 1985). The rCBF is a research technique involving
the inhalation of Xenon-133 gas followed by the meas-
urement of its arrival and elimation through the use of
computerized radiation detectors. The change in
amount of radiation detected is proportional to rCBF
(Rosse, Owen, & Morihisa, 1987). Preliminary results
from the deVito et al. (1985) study indicate that rCBF
patterns among presenting personalities are abnormal
and that these patterns may vary among personalities in
the same individual. In the Mathew et al. (1985) study
rCBF was measured in two personalities of an MPD
patient and in three control subjects. Personality change
in the subject was accompanied by right temporal
hyperperfusion. Although it is tempting to make thein
terpretation that the activity in the Mathew et al. study
May be related to the resurgence of affect-laden memo-
ries, this would be premature. These results are based
on only a single measurement; any inferences drawn
must be regarded as speculative. These initial small
studies must be repeated with the use of more patients,
multiple trials, and the use of appropriate controlsubjects.
Brain Electrical ActivityliSpkig. Studies using
brain electrical activity mapping (BEAM), a research
technique in which computerized topographic maps are
made of brain electrical activity (Duffy, F.H., Burchfiel,
J.L., & Lombrosco, C.T., 1979) are in progress (Lefkof et
al., 1984; Putnam, 1984) but none have been published.
Switch Process
The switching from one personality to another in
MPD usually occurs rapidly in about five seconds
(Putnam, 1985; Coons et al., 1987), and may be accompa-
nied by eyelid fluttering, and/or twitching of facial
muscles or other body parts such as the extremities. In
one patient observed by the author, the presenting
personality perspired heavily in a rather warm room,
but an alter personality was insensitive to heat and did
not. A small number of multiples switch almost instan-
taneously and an equally small number take an inordi-
nately long period of time (minutes to hours) to switch.
Sometimes the patient is immobile, as if in a trance-like
state, during the switch process. Putnam (1985) has
recently monitored the switch process using slow-
motion video tape technique while recording GSR,
pulse, respiration, and skin temperature. Quite recently
Putnam (1988) has offered a scholarly review of the
switch process, with particular emphasis upon its
importance in MPD.
Changes in Handedness and Handwriting
Changes in handwriting between personalities
have been noted for decades (Taylor & Martin, 1944;
Thigpen & Clecklery, 1954). Coons (1980) reported one
patient who had at least 10 different handwriting scripts
among her 24 personalities. Change in handedness has
likewise been reported (Taylor & Martin, 1944; Smith &
Sager, 1971). Putnam et al. (1986) reported this change to
occur in at least 37 percent of 100 MPD patients.
CARDIOVASCULAR SYSTEM
Palpitations and Heartrate
Heart palpitations related to anxiety were found in
30 percent (Putnam et al., 1986) of EXI MPD patients.
Bahnson and Smith (1985) reported that their patient
showed both bradycardia and tachycardia during the
switching process.
Blood Pressure
Larmore et al. (1977) reported slight and probably
insignificant changes in blood pressure among person-
alities in an MPD patient.
RESPIRATORY SYSTEM
Thus far, Bahnson and Smith (1975) have been the
only investigators to monitor respiration in MPD. They
found that dramatic respiratory pauses of up to two
minutes duration accompanied switching of personali-
DISSOCIATION 1:1, March 1988   49
PSYCHOPHYSIOLOGIC ASPECTS
ties in an MPD patient. The author has never witnessed
this phenomenon, but he has observed a quickening of
respiratory rate in certain alters when those alters are
talking about affect-laden material.
GASTROINTESTINAL SYSTEM
Bliss (1980) reported the occurrence of a number of
gastrointestinal symptoms in 14 WO patients. These
included stomach upsets (91%), severe nausea without
pregnancy (73%), abdominal pain (91%), and severe
constipation (73%). Putnam et al (1986), reported a
somewhat lower incidence of gastrointestinal symptoms
in a series of 100 MPD patients, including gastrointesti-
nal disturbances (35 percent) and nausea and vomiting
(30%). Recently Torem (1986) found several patients
with eating disorders whose binging/purging/starving
behavior was carried out by other dissociated ego states.
Putnam et al. (1986) found anorexic symptoms (25%)
and bulimic symptoms (15%) in their group of 100 MPD
patients.
GENITOURINARY SYSTEM
Bliss (1980) found a wide variety of genitourinary
symptoms in his series of 14 MPD patients, including
burning genital pain (55%), urinary retention (27%),
painful (36%) or irregular (64%) menses, sexual dis-
pleasure (55%), and dyspareunia (18%). Of these symp-
toms the burning genital pain, irregular menses, and
sexual displeasure were the only symptoms which were
found significantly more commonly among MPD
patients than within the control group. Coons and
Milstein (1986) found symptoms of psychosexual
dysfunction in 55 percent of 20 patients with MPD.
These included inhibited sexual desire (N=6), promiscu-
ity (N=5), functional dyspareunia (N=2), and inhibited
female orgasm (N=2). Symptoms of psychosexual
dysfunction were found more commonly among
patients with MPD than among a matched control
group. In addition, a positive association was found
between prior sexual abuse and subsequent psychosex-
ual disturbance, but fell short of achieving statistical
significance. Labott, Leavitt, and Braun (1986) have
studied sexual experiences in MPD using a sexual
experiences inventory.
SKIN
Dermatological Conditions and Stigmata
Shelly (1981) was the first to report on dermatological
manifestations of MPD. In his 28-year-old female patient
an alter personality induced a factitial dermatitis on her
arm with poison ivy. In one of his patients Braun (1983b)
noted a factitial dermatitis which was induced by the
scratching of an alter personality. Another of his pa-
tients developed a puritic rash on her face and hands
which was associated with discussing sexual abuse by
her mother. A third patient developed an outbreak of
red dots on her skin when discussing being tortured
with burning cigarettes.
Densen-Gerber (1986) reported on two patients
who exhibited dermatological stigmata similar to
Braun's third patient. The first patient would develop
symbolic needle track marks when she would switch to
a drug-addicted personality. The second would develop
welts and marks on his back and legs when undergoing
flashbacks of physical beatings.
Self-mutilation
Although self-mutilation is not a psychophysiological
symptom, it will be discussed here because it may be
confused with the aforementioned dermatological
conditions. Bliss (1980) was among the first to report on
self-mutilation in MPD. Of 14 female patients, three had
alters who engaged in self-mutilation without experi-
encing pain. The first patient had cut herself and broken
bones in acting out her angry impulses towards her
stepfather and another personality. The second patient
had an alter who hit herself with her fist producing
bruises which were mistakenly thought to be due to
autoerythrocyte sensitization. The third patient tried to
self-induce an abortion with a sharp stick, resulting in
profuse bleeding.
Coons, Bowman and Milstein (1987) reported that
34 percent of 50 MPD patients engaged in self-mutila-
tion. In a somewhat larger study of 65 patients with
MPD and other dissociative disorders Coons and Jani
(1987) reported tbat 39 percent of MPD patients engaged
in self-mutilation. Examples of self-mutilation included
the cutting of extremities or genitals with sharp instru-
ments, bruising with fists or other objects, and burning
with cigarettes or lighters. In most of these patients the
self-mutilation was accompanied by an absence of pain.
Galvanic Skin Resoonse
Although the galvanic skin response (GSR) is under the
control of the autonomic nervous system, it is being
reported here because it is a measurement of skin
electrical conductivity. As previously mentioned, Prince
and Peterson (1908) were the first to measure GSR in
MPD. They measured GSR in response to emotion-laden
words across three personalities in their patients,
obtained different reactions among the personalities and
concluded that the reactions of their patient confirmed
that their patient's amnesia was not only genuinely
based on unconscious processes, but was directional in
nature. In a similar study 64 years later Ludwig et al.
(1972) found personality-specific GSR responses for
emotion-laden words in an MPD patient. Bahnson and
Smith (1975) demonstrated a drop in skin potential
during the transition between personalities in their
patient. Larmore et al. (1977) reported GSR changes in
their patient,which they attributed to habituation to a
change in room temperature. Finally Brende (1984)
noted changes in skin conductance during transitions
between personality states in his patient. These changes
50  DISSOCIATION 1:1, March 1988
COONS
in skin conductance were sometimes unilateral, and
sometimes accompanied affect-laden material. In other
words, alterations in skin conductances occurred both
with personality switches and sometimes even with
presentation of affect-laden material when no personal-
ity switching had occurred.
OTHER PSYCHOPHYSIOLOGIC REACTIONS
Allergies
Braun (1983b) reported two patients who experi-
enced allergic responses to citrus juice and cats respec-
tively in some personalities but not others. A third
patient sensitivity to smoke resolved after she had
worked through the issues surrounding abuse by her
father, a heavy smoker. Putnam et al. (1986) found that
26 percent of 100 MPD patients exhibited a differential
allergic response across personality states.
Differential response to medication
Numerous clinicians have made anecdotal reports
of differential response to medication across different
personalities (Putnam, 1984a; Kluft, 1984; Barkin, Braun,
and Kluft, 1986; Kluft, 1987). These medications include
anxiolytics, sedative-hypnotics, antidepressants, antip-
sychotics, and narcotic pain medication. This same phe-
nomenon has been seen with alcohol and other sub-
stances of abuse. Putnam et al. (1986) found that 46
percent of 100 MPD patients responded differentially to
medication and 35 percent responded differentially to
food. Thus far, no studies have investigated this phe-
nomenon across personalities in a cohort of MPD
patients in a rigorous and controlled matter.
DISCUSSION
This review of the psychophysiologic aspects of
MPD provides further confirmation of the polysympto-
matic nature of MPD (Bliss, 1980; Putnam et al., 1986:
Kluft, 1987). The existence of a polysymptomatic picture
or the occurrence of changing psychophysiologic
symptoms and measures over time in a undiagnosed
patient should suggest to the clinician the possibility of
MPD as a diagnosis.
This review also suggests some possible mecha-
nisms underlying the occurrence of a wide variety of
functions underlying learning and memory.
markedly differing psychophysiologuic responses in
MD. Bliss (1980). Kluft (1982), and Braun (1983b) have
commented about the similarities of many aspects of
MPD to the phenomena of hypnosis. Braun suggests
that the psychophysiologic phenomena seen in MPD
have also been observed in patients without MPD, both
with and without hypnosis. Many of these psy-
chophyiologic phenomena such as anaesthesia, paraly-
sis, pain, seizure-like activity, and alterations in vision,
hearing and voice have been observed in patients with
conversion disorder. Bliss (1980) feels that MPD is
actually a form of self-hypnosis. Other phenomena such
as palpitations, respiratory changes, gastrointestinal
upsets, menstrual irregularities, etc. are manifestations
of anxiety. Thus, it appears that MPD is not only a
polysymptomatic disorder, but that a wide variety of
defense mechanisms may underlie the production of
these symptoms. These include conversion, somatiza-
tion, hypochondriasis, and acting-out as well as denial,
repression, regression, dissociation, identification, and
fantasy (Bliss, 1980; Coons, 1980; Berman, 1981). It has
already been well-established that these defensive
reactions occur in response to overwhelming childhood
trauma, particularly child abuse (Putnam et al., 1986;
Kluft, 1987; Coons et al., 1987).
Putnam (1984a, b) has already made numerous
suggestions about future directions for research. There
is a need for more studies with matched control groups
to distinguish differences across personalities from dif-
ferences due to changes in arousal, tension, or artefact.
These control groups could include normals, patients
with other mental disorders, simulators, and those
under hypnotic trance. Furthermore it would be advis-
able to include control groups with different degrees of
hypnotizability, to enable distinctions to be drawn
between the phenomena of high hypnotizability per se
and those of MPD (Kluft, personal communication,
December 27, 1987). In addition, study designs are
necessary that can make use of multiple psychophysiol-
ogical measurements in multiple trials. Furthermore, the
use of polycenter approaches will enable investigators to
study enough MPD patients to generate sufficient data
to permit the application of sophisticated statistical
methodologies. Research into the phenomena of MPD
may illuminate far more than the mechanisms underly-
ing dissociation. They may offer insights that clarify the
mechanisms underlying functional somatic illnesses,
and provide new understandings of the processes and
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