Inclusion of Acupuncture as an Adjunct Therapy in the Management of a Patient With Schizophrenia and Dissociative Identity Disorder: A Case Report

Abstract

Objective

The purpose of this case report is to describe the inclusion of acupuncture in the management of a patient with schizophrenia and dissociative identity disorder (DID).

Clinical Features

A 68-year-old man presented with schizophrenia and DID, which had been diagnosed at age 25. The patient was currently under psychiatric care and prescribed antipsychotic medications and psychiatric counseling. His predominant symptoms were anxiety, paranoia, and irritability. In addition, 2 to 5 personas manifested over the years that he referred to as the “Others.” A Brief Psychiatric Rating Scale was 81 out of 126 on his first visit.

Intervention and Outcome

Traditional Chinese medicine–style acupuncture was administered. Over the year, the severity of the patient's symptoms was reduced according to the Brief Psychiatric Rating Scale to 56 and was maintained between 55 and 61 for 6 months.

Conclusion

Acupuncture included as an adjunct therapy to antipsychotic medication and psychiatric counseling may have reduced the severity of symptoms associated with schizophrenia and DID for this patient.

Introduction

Schizophrenia is a disabling mental disorder affecting 15.2 per 100 000 people worldwide.¹ The prevalence of schizophrenia in the United States is 0.94%, affecting 0.98 per 1000 people.² Research indicates that men have a greater tendency to develop this condition, and the age of onset is earlier in life.³ The symptoms of schizophrenia begin to manifest between the ages of 20 and 29 and are related to an impairment in perception and cognitive function, including symptoms such as delusions, hallucinations, and abnormal behaviors and speech.^4,5 Evidence signifies that people with schizophrenia have a shorter life expectancy of 15 to 25 years due to suicide and accidents, antipsychotic medication, lower quality of life, and various comorbidities such as cardiovascular disease, hypertension and diabetes, inadequate medical care, and premature aging.^6,7

Individuals with schizophrenia may develop dissociative identity disorder (DID).⁸ DID is potentially perpetuated by a significant acute or chronic stress that disrupts cognitive function altering the ability to identify oneself and their perceptions and memories.⁸ The predominant symptom of DID is the presence of 2 or more separate personalities.⁹ Each identity understands and relates to the world in a distinct pattern.⁹ There is typically 1 primary identity representing an individual's original personality state.⁹ However, this identity is often passive and dependent on the other personalities that have been created.⁹ The additional personalities may interfere with the perception of oneself or the world, modifying memories, cognitive function, or behaviors.⁹

The precipitating factor attributing to the development of DID is believed to occur during childhood due to sexual or physical abuse.¹⁰ During the abuse, the child experiences a mixture of extreme emotions related to the traumatic event, which results in the child rejecting reality.¹⁰ The resolution of the traumatic event in the child's mind could be the construction of an imaginary scenario in which another person was the victim of the incident.¹⁰ This is believed to initiate dissociation with the identity of self.¹⁰

The approach of conventional medicine for the management of schizophrenia and DID involves the administration of antipsychotic and mood-stabilizing medications with cognitive behavioral therapy (CBT) and psychotherapy.^{11, 12, 13} The pharmaceuticals used for treatment target dopamine and serotonin receptors.¹¹ The strategy for patients is to control their symptoms.¹¹ Although these medications diminish multiple symptoms associated with the condition, several symptoms persist, including social withdrawal, apathy, and other cognitive deficits, and individuals with chronic symptoms may not be compliant.^6,11 In addition, positive outcomes do not always occur with psychotherapy, and compliance with CBT is variable.^12,13

Acupuncture is a natural therapy that is safe for patients with schizophrenia.^{14, 15, 16} Several research articles have evaluated the efficacy of acupuncture for the treatment of schizophrenia, while the benefit of acupuncture for DID is not known. In these systemic reviews, the efficacy of acupuncture for the treatment of schizophrenia is conflicting. The trials reveal that using acupuncture can decrease some of the symptoms of the disease and can limit the number of adverse effects of medication.^{17, 18, 19, 20, 21} However, improvements tend to be mild.^{17, 18, 19, 20, 21} Although the evidence from large-scale studies is inconsistent, a few case reports have positive outcomes.^{22, 23, 24}

Currently, little is known about including acupuncture as an adjunct therapy to antipsychotic pharmaceuticals and psychotherapy to control the symptomatology of mental disorders. Therefore, the purpose of this case report is to describe the addition of acupuncture as an adjunct therapy to conventional medicine of an adult male patient with schizophrenia and DID.

Case Report

A 68-year-old White man presented with a history of schizophrenia and DID. Multiple signs of schizophrenia and DID manifested over the years, yet his primary symptoms were feelings of irritation, tension, paranoia, and anxiety. He reported that as a child, he was physically and sexually abused for several years. He experienced social withdrawal from his peers and neglect from his parents. He was diagnosed with schizophrenia at age 25. However, he acknowledged he had symptoms of schizophrenia since his adolescence. In addition, he recalled the presence of 2 or 3 separate identities as a child that he referred to as the “Others,” but he was not diagnosed with DID until age 53. Since his diagnosis, he had been under the care of a psychiatrist and prescribed a pharmaceutical regimen that includes citalopram, risperidone, and trazodone daily. His psychiatrist provided psychotherapy and CBT. His psychiatrist was aware of and advocated for acupuncture as an adjunct to medication, psychotherapy, and CBT.

He reported that the number of Others ranged over the past 53 years. There were usually only 1 or 2 predominant Others at any time. There were as many as 5 Others at his initial appointment. However, the patient believed that one of the Others had the ability to mimic the voices of his coworkers and acquaintances. Consequently, the number of Others and additional personalities were difficult to determine as he perceived that the predominant Others was impersonating a coworker or an acquaintance.

In general, his interactions with the Others were negative. He stated that the Others berated him, inducing a catatonic, depressive state which lasted for several hours. One of the Others, termed “The Old One,” caused him to feel elderly, unmotivated, and disheartened. Another prominent persona named “Louis” insulted and degraded him. Additional personas that appeared were his “Higher Self” and “Little M.” His Higher Self had a protective role in difficult situations to soothe him. Little M reminded him of his past abuse and caused him to feel depressed and helpless.

He reported that The Old One and Louis generated thoughts that aggravated his paranoia and made him believe that the people around him heard his thoughts, judged him, or thought he was a bad person. These thoughts resulted in irritability, obsessive thinking, social withdrawal, and minimal social interactions. His Higher Self sometimes appeared and guided him through situations to reestablish a feeling of normalcy.

The Brief Psychiatric Rating Scale (BPRS) was used to assess the severity of his condition.²⁵ The BPRS is a clinical assessment tool that has been employed for over 40 years to evaluate the efficacy of treatment strategies for schizophrenia and psychotic disorders.²⁶ This tool is considered consistent and effective for accurately determining a clinical improvement in schizophrenia.²⁶ The form consists of 18 items rated on a scale from 0 to 7, with 0 being the least intense and 7 being the most intense. His initial score in October of 2018 was 81 out of 126. The scale indicated that his most prominent issues were related to his preoccupation with his physical health, worry and fear about the future, emotional withdrawal and self-isolation, conceptual disorganization with disorganized or confused thoughts, feeling guilty or shame for past events, feeling tense and physically nervous or anxious, feelings of hostility, irritability, and belligerence, being paranoid, suspicious, and mistrusting of others, hallucinatory behavior, and reduced emotional tone or flatness. The results of the BPRS are outlined in Table 1.

Table 1.

Brief Psychiatric Rating Scale Scores Over Time

Symptom	October 12, 2018	January 4, 2019	First Treatment Protocol Average	May 24, 2019	August 5, 2019	November 5, 2019	Second Treatment Protocol Average
Preoccupation with physical health, fear of physical illness, and hypochondria	5	3	4	3	4	3	3.33
Worry, fear, over-concern for present or future, uneasiness	5	5	5	3	4	4	3.66
Emotional withdrawal, lack of spontaneous interaction, isolating yourself from others	5	4	4.5	4	4	4	4
Conceptual disorganization, thought processes confused, disconnected, disorganized, and disrupted	5	6	5.5	4	4	4	4
Feeling guilty, self-blame, shame, remorse for past behavior	5	4	4.5	3	4	4	3.66
Tension, physical, and motor manifestations of nervousness and over-activation	5	4	4.5	3	3	3	3
Mannerisms and posturing, peculiar, bizarre, unnatural motor behavior	3	3	3	2	1	2	2.5
Grandiosity, exaggerated self-opinion, arrogance, conviction of unusual power or abilities	4	4	4	3	3	3.5	3.16
Depressive mood, sorrow, sadness, despondency, and pessimism	4	4	4	3	4	3	3.33
Hostility, animosity, contempt, belligerence, disdain for others	5	5	5	3	3	4	3.33
Suspiciousness, mistrust, belief others harbor malicious or discriminatory intent	5	5	5	3	3	4	3.33
Hallucinatory behavior perceptions without normal external stimulus correspondence	5	5	5	2	2	4	2.66
Motor retardation, slowed, weakened movements or speech, reduced body tone	4	5	4.5	4	2	3	3
Uncooperativeness, resistance, guardedness, rejection of authority	4	4	4	2	2	2	2
Unusual thought content, unusual, odd, strange, bizarre thought content	4	4	4	4	3	3.5	3.5
Blunted affect, reduced emotional tone, reduction in formal intensity of feeling, flatness	5	5	5	4	4	4	4
Excitement, heightened emotional tone, agitation, increased reactivity	4	5	4.5	3	3	4	3.33
Disorientation, confusion, or lack of proper association for person, place, or time	4	5	4.5	3	2	2	2.33
Total score	81	80	Average 80.5	56	55	61	Average 57.33

He had constipation, experiencing a bowel movement 1 time every 4 days. In addition, he regularly felt fatigued due to difficulty sleeping. Upon physical examination, his tongue was swollen with a slight purple hue in the middle. His pulse was wiry at the heart and liver positions and could not be felt at the kidney position. His pulse was deep and weak at the lung and spleen positions. According to traditional Chinese medicine (TCM) theory, he was diagnosed with heart fire with disturbance of the shen and kidney yin deficiency.

The treatment strategy using TCM theory based on historical context was to quench heart fire, foster the shen, and nourish kidney yin and essence. Manual acupuncture therapy was performed by interns on a 6-week rotation under the supervision of the head clinician using DBC Spring Singles (DongBang Corporation, Boryeong-si, Chungcheongnam-do, South Korea). The patient was treated 1 time a week for 20-minute sessions. Due to the sensitivity of the patient to the points, de qi was not sought.

The points utilized were UB13 (Feishu) bilaterally (B/L), UB15 (Xinshu) B/L, UB18 (Ganshu) B/L, UB20 (Pishu) B/L, UB23 (Shenshu) B/L, HT7 (Shenmen) on the right (R), PC6 (Neiguan) (R), and LU9 (Taiyuan) (R). The National Acupuncture Detoxification Association auricular acupuncture protocol was performed bilaterally, consisting of auricular shenmen, sympathetic, LR, KD, and LU. Upon the subsequent visit, Sishencong, KD 3 (Taixi) (R), and SP6 (Sanyinjiao) on the left (L) were added to the treatment protocol.

During the few months of treatment, the patient noted that he felt less paranoid, irritable, suspicious, and stressed for 3 to 4 days after treatment. In addition, the Others were not disrupting his life as much. After 4 weeks, the intern treating the patient was changed due to the normal rotation schedule. This caused the patient to become paranoid, agitated, and anxious. As a result, from October 2018 until January 2019, he attended the clinic sporadically and missed several appointments.

On January 4, 2019, a second BPRS scored 80, indicating marginal improvement. Due to the paranoia and irritability of the patient with new interns, the head clinician became the primary acupuncture provider for the patient on every visit to maintain continuity of care. In addition, his treatment strategy was altered. Using TCM theory based on historical context, manual acupuncture was performed on using GV20 (Baihui), Sishencong, SP6 (Sanyinjiao) R, auricular shenmen B/L, sympathetic B/L, LR B/L, KD B/L, and LU B/L, HT7 (Shenmen) R, PC6 (Neiguan) R, LU9 (Taiyuan) R, KD3 (Taixi) R, KD6 (Zhaohai) L, SP5 (Shangqiu) L, LR13 (Zhangmen) B/L, GB21 (Jianjing) B/L, CV17 (Shanzhong), and Yintang. LI4 (Hegu) was applied on the L side of the body and LR3 (Taichong) on the R to facilitate energy movement through the half-gate. The new treatment protocol was maintained until March 2020.

In April of 2019, his symptoms of paranoia, irritability, and stress receded for 5 to 6 days after treatment. He described himself as feeling “Like a new person.” His employer started to give him more responsibilities at work, which gave him a feeling of accomplishment. He reported that he felt less overwhelmed and that his Higher Self was present at a greater frequency. He expressed that Louis and The Old One were not as active and berated him less often. On May 24, 2019, his symptom score for BPRS was 56, showing improvements in almost every treatment category. His improvement was sustained over the next 6 months, with his highest symptom score in November with BPRS at 61. His BPRS results are provided in Table 1. A comparison between the 2 treatment protocols is available in Table 1. An outline of his symptoms of DID is provided in Table 2. Throughout the treatment period, the dosages of his medications did not change, and no adverse effects were observed. The patient consented to include his information in this case report.

Table 2.

DID Symptoms From June 2019 to February 2020

Date	Reported DID Symptoms
June and July 2019	•Paranoia, irritability, and stress were maintained at a mild to moderate level. •“Little M” appeared and was vocal about his abuse as a child causing a depressed state. •His “Higher Self” helped him understand that “Little M” stemmed from a memory of abuse and cruelty experienced as a child. •After 2 weeks, “Little M” faded and did not reappear. •“Louis was present and would make him feel insignificant and worthless. •His “Higher Self” supported him during these situations. •“The Old One” was in the background and was not a factor.
August and September 2019	•Paranoia, irritability, and stress were minimal to mild. •“Louis” was acting as the primary antagonist during this time. •“The Old One” made appearances on occasion and made him feel elderly and slow. •His “Higher Self” comforted him and helped him cope with “Louis” and “The Old One.” •The patient attended a local gym to exercise and participate in yoga, which were activities he had not participated in for several years. •When he participated in these activities, he felt normal.
October and November 2019	•Paranoia, irritability, and stress were minimal to mild. •A new “Other” known as the “Still Quiet Voice” emerged. •The “Still Quiet Voice” was an ally to his “Higher Self.” •The “Still Quiet Voice” spoke the truth about a situation to help calm him down, bring him back to reality, and prevent him from feeling overwhelmed. •The “Still Quiet Voice” infused him with confidence and diminished his self-doubt. •“Little M” reappeared after a yoga session and tried to berate him. •His “Higher Self” and “Still Quiet Voice” protected him and helped him regain control of his emotions.
December 2019 and January and February 2020	•Paranoia, irritability, and stress were generally mild until the holidays. •The holidays exacerbated his paranoia, irritability, and stress, which he described as moderate to severe. •His “Higher Self” and the “Still Quiet Voice” were not as present during the holidays. •“Little M” reappeared and induced a depressed state on several occasions. •“Louis” was more vocal, indignant, and agitated during this time. •He stopped going to the gym and participating in yoga. •After the holidays, “Little M” disappeared, and “Louis” was less active. •His “Higher Self” and “Still Quiet Voice” regained control and were the predominant “Others” for the next several weeks. •“Louis” would become more vocal during times of stress but was otherwise unobtrusive.

DID, dissociative identity disorder.

Discussion

In this case, inclusion of acupuncture in addition to regular care appeared to diminish the patient's symptoms of schizophrenia, according to a BPRS, and DID. During the first phase of treatment, acupuncture mildly alleviated some symptoms associated with schizophrenia when used in conjunction with antipsychotic medication.^{17, 18, 19,21} However, with the new treatment strategy and consistency of care provided by a single practitioner, more pronounced benefits were observed as indicated by an improvement in the BPRS that resembled outcomes from other case reports.^{22, 23, 24}

Previously published case reports utilized acupuncture for a 42-year-old man, 44-year-old woman, and 63-year-old woman with schizophrenia. Similar to this case, those patients still experienced symptoms of schizophrenia even with medication, and the addition of acupuncture improved psychological symptoms.^{22, 23, 24} The case by Bosch et al aligned with this case as an immediate mitigation of symptoms did not occur.²² However, after 12 weeks, daily improvements in schizophrenic symptoms were observed and maintained.²² In this case, marginal short-term improvements were observed early on, but symptoms did not begin to abate until continuity of care was established.

Traditional Chinese Medicine Theory

According to TCM theory, excessive fear damages kidney essence, creating an imbalance between kidney yin and kidney yang energy.²⁷ This allows the yang energy to rise unrestricted to the mind and disrupt mental function and maturation, resulting in delusions, impaired development and cognitive function, and the development of additional personas. The treatment strategy of quenching heart fire, which generates yang energy that disrupts the mind, fostering the shen to calm the mind, and nourishing kidney yin and essence, may have reestablished the balance between kidney yin and could have resulted in the attenuation of his symptoms of his schizophrenia and DID.

The 5 Element Theory can provide another possible explanation of the cause of these disorders. According to the 5 Element Theory, the kidney represents the water element.²⁷ The water element is responsible for controlling the fire element.²⁷ The fire element is related to the heart.²⁷ A kidney deficiency from prolonged abuse would fail to contain heart fire. Uninhibited fire energy becomes excessive, damaging the shen, which is the mind/spirit contained within the heart.²⁷ Consequently, the excessive fire energy can disrupt the function of the shen, resulting in mental instability.

The set of points selected for the treatment of the patient had various applications according to TCM theory. The primary functions of the points chosen were to calm the spirit, nourish yin energy, and balance yin and yang. Other points were utilized to augment the activity of specific yin and yang organs to diminish his symptoms. The functions of the points are included in the supplemental file.^{28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40}

Possible Mechanisms for Outcomes

There may be several possible mechanisms responsible for the improvement observed in this case. One of the mechanisms is the regulation of dopamine. Hyperactivity of tyrosine hydroxylase excessively producing dopamine causes cognitive impairment in people with schizophrenia.⁴¹ The administration of acupuncture suppressed gene expression of tyrosine hydroxylase, lowering dopamine levels.^42,43 Data also indicates that dopamine agonists can ameliorate paranoia.⁴⁴ Research found that acupuncture potentiated the synthesis and discharge of dopamine into the vasculature, increasing its bioavailability in the synapse.^42,45 Inhibiting tyrosine hydroxylase or modulating dopamine may explain the abatement of his symptoms in this case.

A second mechanism may have been abnormalities of the GABAergic system, resulting in a suppression of GABA release. Lower levels of GABA are positively correlated with schizophrenia and heightened states of anxiety and paranoia.^43,46,47 Acupuncture can increase GABA release, producing a calming effect, which could have improved his symptoms of schizophrenia, especially anxiety and paranoia.⁴⁸

Cortisol is often elevated in individuals with schizophrenia.⁴⁹ The overactivation of the hypothalamic-pituitary-adrenal axis leading to elevated levels of cortisol has been observed during anxious and irritable states. Acupuncture can reduce the release of adrenocorticotropic hormone, diminishing cortisol secretion, which could account for the improvement in this case.^42,50

Dysfunction of the glutamate system may be implicated in the manifestation of the symptoms of the patient. The activation of N-methyl-D-aspartate (NMDA) receptors enhances the transport of cations through the cell membrane.¹⁵ However, the hyperactivity of NMDA receptors causes a disproportionate concentration of cations to accumulate in the neuron, contributing to the deterioration and possible apoptosis of the cell.¹⁵ Acupuncture can decrease the excessive expression of NMDA receptors, preventing neurodegeneration.¹⁵

Another effect of acupuncture relating to the glutamate system is the down-regulation of α-amino-3-hydroxy-5-methyl-4-isoxazoleproprionic acid (AMPA) receptor activity.¹⁵ AMPA receptors regulate fast synaptic transmission for the central nervous system, which controls the excitability of neurons.¹⁵ Individuals with schizophrenia may experience alterations of AMPA receptor activity affecting synaptic strength.¹⁵ Acupuncture can modulate this activity, dampening excitation of the neurons with the potential to alleviate symptoms of schizophrenia.¹⁵

Limitations

This was a single case; thus, other patients may not respond as well. A limitation was that acupuncture was only offered once a week. Unfortunately, this was unavoidable as the clinic was only open once a week. The patient may have shown greater improvements with more frequent care. In addition, the rotation of the interns caused the patient to become paranoid, irritable, and anxious, resulting in missed appointments interfering with the consistency of care. Another limitation was that the assessment tool was not given at regular intervals. However, this was due to the patient missing appointments on occasion. Another limitation was an absence of an assessment tool for DID; thus, the recorded improvements were subjective. Lastly, follow-up was not performed due to the prolonged clinic closure and loss of contact with the patient in 2020.

Conclusion

Acupuncture included as an adjunct therapy to antipsychotic medication and psychiatric counseling may have reduced the severity of symptoms associated with schizophrenia and DID for this patient.