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Volume 14 No. 09
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Accepted Papers

Letters to the Editor

Obstructive Sleep Apnea Severity in Dissociative Identity Disorder can Vary Significantly Depending Upon the Autonomic Activation Status of the Personality That Has Executive Control

Madhulika A. Gupta, MD, MSc, FAASM, RST; Daiana R. Pur, BMSc
Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada

Gandotra and colleagues1 have presented an interesting case of a woman with dissociative identity disorder (DID) (previously multiple personality disorder), and mild obstructive sleep apnea (OSA) treated with continuous positive airway pressure (CPAP) where adherence to CPAP was dependent upon certain personalities that decided her CPAP use. The authors report daily CPAP data and the dominant personalities, observed prospectively over 7 months. “Mrs. B” (present 88% of time, treatment-adherent personality) and “Mrs. C” (present 4% of time, treatment nonadherent personality) were the dominant personalities with the remaining 4 personalities present 8% of the time in total.1 The summary of usage (h/night) and apneahypopnea index (AHI) (events/h) by personality indicated the following: as expected, the mean ± standard deviation (SD) usage by “Mrs. B” of 4.92 ± 1.6 h/night was significantly (P < .000001, Figure 21) greater than the mean ± SD usage of 0.96 ± 2.15 h/night by “Mrs. C”. However the mean ± SD AHI of 1.07 ± 0.7 events/h associated with “Mrs. B” who was CPAP-adherent was not significantly different (P = .15, Figure 21) from the mean ± SD AHI of 0.67 ± 0.9 events/h associated with “Mrs. C” who was CPAP nonadherent.

The prevalence of DID in the United States is about 1.5%.2 The core feature of DID is the presence of two or more distinct personality states that exchange executive control over the behavior of the individual.2,3 The different personalities in DID that embody complex dissociated states of consciousness also demonstrate physiological differences1 including different levels of autonomic nervous system (ANS) reactivity and arousal.3,4 The varying levels of ANS arousal embodied by the different personalities in DID can theoretically affect the AHI wherein higher levels of arousal can lead to greater ventilatory instability5 and a higher AHI. “Mrs. B” was significantly (P < .000001, Figure 21) more adherent to CPAP than “Mrs. C”, although the AHI values were not significantly different (P = .15, Figure21) between the two personalities, suggesting perhaps that the baseline AHI (not reported1 for the individual personalities) for “Mrs. C” may have been much lower than for “Mrs. B.” Even though physically both “Mrs. B” and “Mrs. C” shared the same body, differences in their levels of autonomic activation could have contributed to variations in their AHI, a factor that has important implications in the management of OSA in DID.


All authors have seen and approved the manuscript. The authors report no conflicts of interest.


Gupta MA, Pur DR. Obstructive sleep apnea severity in dissociative identity disorder can vary significantly depending upon the autonomic activation status of the personality that has executive control. J Clin Sleep Med. 2018;14(9):1633.



Gandotra K, Golish J, Rosenberg C, Strohl K. Dissociative identity disorder CPAP adherence: an uncommon factor in obstructive sleep apnea. J Clin Sleep Med. 2018;14(4):693–695. [PubMed]


American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.


Putnam FW, Zahn TP, Post RM. Differential autonomic nervous system activity in multiple personality disorder. Psychiatry Res. 1990;31(3):251–260. [PubMed]


Reinders AA, Willemsen AT, Vos HP, den Boer JA, Nijenhuis ER. Fact or factitious? A psychobiological study of authentic and simulated dissociative identity states. PLoS One. 2012;7(6):e39279[PubMed Central][PubMed]


Eckert DJ, White DP, Jordan AS, Malhotra A, Wellman A. Defining phenotypic causes of obstructive sleep apnea. Identification of novel therapeutic targets. Am J Respr Crit Care Med. 2013;188(8):996–1004