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DREAMS AND PSYCHOPATHOLOGY
Dreams and hallucinations
Hartman (1975) suggested that dreams and
hallucinations lie upon a continuum. He proposed that an inhibitory factor
mediated by ascending cortical adrenergic system prevents hallucinations
and dreams from intruding into the waking state and that disruption of
this system results in hallucinations. Fishman (1983) proposed that
intrusion of PGO waves into the waking state might be responsible for
hallucinations and that a defective serotonergic gating mechanism is
probably responsible for emergence of such waves. Kavanau (2002) proposes
that mentation during sleep states originates in an activation of brain
circuits that encode inherited and experiential memories. He suggests that
the synaptic strengths get weakened with age and by exogenous influences
like radiation, and that infrequent activation of such old, incompetent
circuits in some waking conditions leads to false memories, delusions, or
hallucinations.
Organic brain disease
Kramer and Roth (1979) reported that there
is a decrease in dream reporting associated with increasing age and
dementia. Repetitive visual images awake and from sleep awakenings were
observed in cases of missile head injury by Askenasy et al (1986). Stern
et al (1990) reported that dreams can be effectively used in psychotherapy
with the head – injured who report an increase in threatening dreams and a
decrease in sexual dreams.
Substance abuse
Recent studies have shown that the ventral
tegmental pathway stimulates both dreaming and drug craving (Johnson,
2001). Drug dreams are seen ubiquitously in the treatment of various
addictions: cocaine (Jerry 1997), alcohol (Denzin 1988), opiate (Looney
1972) and nicotine (Persico, 1992). In a group of patients detoxifying
from drugs of abuse, dreaming about the drug was associated with an
increase in the likelihood of a return to drug use (Christo and Franey,
1996). Johnson (2001) suggests that intense and frequent dreaming in
patients in detoxification programs results from the upregulation of the
dopaminergic neurotransmission in the ventral tegmentum by the exposure to
addictive drugs. In detoxifying alcoholic patients “high cravers” dream
more about drinking than “low cravers” (Fiss, 1980). Cernovsky (1986)
found that alcoholic patients suffer from nightmares more often than
controls. In fact, 29% of a group of alcoholic patients reported further
drinking to alleviate nightmares (Hershon, 1977). Vivid and macabre
dreaming may be central to the delirium tremens (Hishikawa et al, 1981),
and a theory of DTs hallucinations emphasizing REM rebound and intrusion
of dreaming into wakefulness has been proposed (Feinberg, 1970).
Schizophrenia
Studies of patients with schizophrenia
have shown that their dreams are less coherent, less complex, and less
bizarre than those of normal persons. Dreams with color and unpleasant
emotions are more common in them. Family members appear more often in
dreams, and friends less often (Cancro and Lehmann, 2000). Kramer and Roth
(1979) showed in their review that schizophrenic patients are less
interested in their dreams and that their dreams are more primitive, more
direct, more sexual anxious and hostile. Hallucinations and dream contents
were relatable and the degrees of paranoia awake and in dreaming were
similar. Lesse (1974) found that with increasing anxiety, motion and
affect were increased in the dream, and that a decrease in the anxiety in
the dream was the first change seen with antipsychotic medication. Wilmer
(1982) reported that discussing dreams in a group decreased the insomnia
of schizophrenia patients and increased their self understanding.
Bipolar disorder
Bipolar patients report bizarre dreams
with death and injury themes before their shift to mania (Beauchemin and
Hays, 1995). Beauchemin and Hays (1996) found that dreams of bipolar
depressed patients have more anxiety than those of unipolar patients.
Dreams of bipolar patients, particularly those with rapid cycling, may
show evidence of the subsequent shift prior to noticeable affective and
behavioral changes (Frayn, 1991).
Depression
In depression there is a decrease in the
frequency and length of dream reports (Kramer, 2000). Beck (1967)
suggested that an increase in masochism in dreams is a trait
characteristic of the depressed patient. Kramer and Roth (1979) noted that
the depressed had in their dreams more friendly and fewer aggressive
interactions than schizophrenic patients, but more failure and
misfortunes. According to Hauri (1976) the dreams of the depressed patient
are focused on the past, this was confirmed by Cartwright et al (1984) who
pointed out that the past focus diminished with improvement in women
suffering from depression. An increased incidence of death themes have
been found in dreams of hospitalized depressed suicide attempters (Firth
et al, 1986). The content of the dreams in depressed patients may have
prognostic implications. Poorly organized dreams without people or the
dreamer correlate with a poor treatment response (Greenberg et al, 1990).
High masochism scores in dreams of depressed women covary with a decreased
likelihood of improvement (Cartwright and Wood, 1993). Depressed divorcees
who incorporate the loss in their dreams have more intense dreams and
better outcomes (Cartwright, 1991). Cartwright and Lamberg (1992)
instructed depressed women to alter the plots in their dreams, and some of
them were successful in tilting their dream plots to happier endings. The
authors believe that these happier endings can carry over to affect waking
mood and thus have therapeutic value.
Anxiety
Hartmann (1991) reports that
anxious people have more anxious dreams, and that the application of
relaxation techniques reducing waking anxiety traits is accompanied by
improvements in the pleasantness of dreams. Systematic desensitization
applied to a phobic subject can induce the disappearance of the phobic
objects from dreams (Koulack et al, 1976). It have been shown that
patients with anxiety disorders suffer more often from nightmares than
healthy persons (Simmonds and Parraga, 1984), and that dream contents of
theses patients are characterized by intense fears and negative emotions (Kirschner,
1999).
Obsessive compulsive disorder
Sauteraud et al (2001) found that there is no evident link between
diurnal mental activity and the morning recollection of nocturnal dreams
regarding anxiety, failure, sadness, and obsessive-compulsive themes.
Post-traumatic stress disorder
Ross
et al (1989) saw the dream in PTSD as repetitive and stereotyped. They
characterized the dreams of PTSD patients as vivid, affect-laden,
disturbing, outside the realm of current waking experience and easy to
recall. They believe that the dream disturbance is relatively specific to
the disorder and that PTSD may fundamentally be a disturbance of REM sleep
mechanisms. But there has been repeated reports that the disturbing dream
in PTSD tends to occur early rather than late in the night (Burstein,
1984; Woodward, 1991). Kramer (1979) proposed that the disturbing dream is
more the hallmark of PTSD than the sleep disturbance. There are several
symptoms, such as increased awakenings, increased motoric activity (Melman
et al, 1995) and increased sweating (Wilmer, 1996) which are frequent
accompaniments of the disturbing dream experience. There is an extensive
literature describing the continuation or reactivation of disturbing
dreams 3 to 4 decades after the traumatic event and linking the current
trauma to earlier childhood traumas (Kramer, 2000). True et al (1993)
pointed out a genetic influence on liability for the reexperiencing
symptoms such as disturbing dreams in PTSD. Dream recall rates appear to
be lowered in PTSD and it has been suggested that this is related to
efforts to deal with memories of the trauma (Kramer and Kinney, 1988).
Cognitive behavioral therapy (Krakow et al, 2001), imagery rehearsal
therapy (Krakow et al, 2001b), phenelzine, imipramine (Kosten et al, 1991)
trazodone (Warner et al, 2001) nefazodone (Gillin et al, 1999) and
fluvoxamine (Neylan et al, 2001) appears effective for the treatment of
insomnia and nightmares associated with chronic PTSD.
Eating disorders
The content of the dreams of patients with eating disorders reflects a
preoccupation with food and oral activities (Brink and Allen, 1992).
Bulimic patients have more hostility in their dreams (Dippel et al, 1987),
whereas anorexic patients have less hostility (Hudson et al, 1978). Death
themes were found in the dreams of both anorexic and bulimic patients
(Jackson et al, 1993). Anorexic patients revealed in their dreams a fear
of getting fat (Wilson, 1982), and seemed more anxious in their dreams
than comparison groups (Frayn,1991).
Mental retardation
Mentally retarded patients dream of home, have simple dreams, and the
content of dreams and Thematic Apperception Test stories are similar.
Males who are mentally retarded have more aggressive dreams and dream more
about other males, sports, eating and family members, while females have
more colour in their dreams and dream more about falling and being chased
(Kramer and Roth, 1979). Voelm et al (1988) showed that one can use dreams
in therapy with these patients.
Alexithymia
Clinical reports show that the dreams of
alexithymic individuals are either undisguised or resemble waking thoughts
(Levitan et al, 1989; Taylor et al, 1997 ). Bauermann et al (1999) found
that the dreams of alexithymic individuals are less imaginative than the
dreams of nonalexithymic individuals, and that the REM density (total
number of eye movements divided by the number of REM periods) was 50% less
in the alexithymic individuals.
Dreams and Epilepsy
Recurrent dreams with ‘images’ similar to seizures are reported by
patients with complex partial seizures originating in the temporal lobe.
Reami et al (1991) describe two cases who experienced recurrent dreams
with content similar to that of the seizures they were experiencing during
day time. Both of them had visual hallucinations accompanied by affective
response as seizure phenomena. Epstein (1964) described 13 such cases.
Paroxysmal EEG abnormalities characterized by spikes over anterotemporal
areas have been found. The right temporal lobe has been described as the
site of origin of these seizures. Polysomnographic studies in such
patients have shown electrographic seizures characterized by temporal
spikes during REM phase of sleep occurring simultaneously with the dreams.
It has been stated that REM sleep can activate complex partial seizures
with temporal focus. Some authors have suggested that recurrent dreams
with affective phenomena may be epileptic in origin.
Schredl and Engelhardt (2000) found that
it is not the diagnostic classification, but the severity of the specific
symptoms that is primarily related to the dream content. Hazelton (2002)
reminds that even though psychiatrists don’t often ask about dreams, the
patients love to tell us about them and that they are worth our attention.
Sadock (2000) includes information about the patient’s prominent dreams
and nightmares in his outline of the psychiatric report.
DREAMS AND PSYCHOPHARMACOLOGY
Numerous classes of drugs, including catecholaminergic agents (e.g.,
reserpine, thioridazine), beta blockers and some antidepressants trigger
bizarre dreams and night mares (Nielsen and Zadra, 2000). It has been
shown that dopaminergic agents like L-DOPA leads to an increase in the
frequency and vividness of dreams, and that this increase can be
controlled by anti-psychotics (Sacks, 1991).TCAs, MAOIs (Vogel et al, 1990), and SSRIs (Nicholson and Pascoe, 1988)
reduce REM sleep. Bupropion leads to more vivid dreams and nightmares than
do other antidepressants (Balon, 1996). Bedtime administration of
tricyclic and neuroleptic agents leads to a higher recall of frightening
dreams than when these are taken in twice daily doses (Strayhorn and Nash,
1978). Neuroleptic and tricyclic drugs appear to render dream affect more
dysphoric, rather than to recall dream recall per se (Nielsen and Zadra,
2000). Barbiturates and benzodiazepines suppress deep SWS and either
suppress or delay REM onset (Declerck and Wauquier, 1990). Adams and
Oswald (1989) found a five-fold increase in bad dreams accompanying REM
rebound after withdrawal from triazolam. Kales and Jacobson (1967) showed
that barbiturate withdrawal is accompanied by negative dream experiences.
However, REM rebound following cessation of TCAs and low potency
phenothiazines is not consistently accompanied by negative dream
experiences (Kales and Vgontzas, 1995). The neuropharmacological basis of
drug-induced or withdrawal-associated disturbed dreaming remains unclear.
There may be an imbalance among various neurotransmitter systems such that
nightmares are produced by reduced brain norepinephrine and serotonin or
increased dopamine and acetylcholine, or a combination of these (Hartmann,
1984).
COGNITIVE NEUROPSYCHOLOGY OF DREAM
BIZARRENESS
Schwartz and Maquet (2002) propose that some bizarre features in normal
dreaming imply an underlying pattern of regional brain activity not unlike
the one imposed by lesions in specific neuropsychological syndromes.
Fregoli syndrome is reported more commonly than Capgras’ in dreams. In
addition reduplicative paramnesia is also reported.
Fregoli Syndrome
Fregoli like phenomena in dreams indicate that neuronal processes during
sleep can simultaneously and independently engage (a) unimodal visual
areas underlying the internal generation of a perceptual representation of
an individual’s face and (b) distinct multimodal associative areas in the
temporal lobe responsible for triggering the retrieval of a familiar
individual’s identity (O’Craven and Kanwisher, 2000; Ellis and Young,
1990). The absence of supervisory control functions normally exerted by
the frontal lobe (markedly hypoactive during REM sleep) would then prevent
the detection and verification of this mismatch between face identity and
face appearance, hence favoring the delusive quality of Fregoli like
representations in dreams, usually accepted without much surprise by the
dreamer.
Reduplicative Paramnesia
This
is likely to result from abnormal integration of environmental cues and
semantic information about place identity as a result of poor correlation
in activity between prefrontal cortex and temporal lobe (Hakim et al.,
1988).
Other Visual Distortions
Deficits in spatiotemporal integration leading to the multiplication of a
visual percept in time (palinopsia) or in space (polyopia) are observed in
patients with lesions in visual associative areas (Michel and Troost,
1980). Similarly ‘macropsia’ and ‘micropsia’ can occur after right
occipital damage. Dreams with such instances suggest a regionally specific
hypoactivation within visual areas. A defect in working memory could
aggravate the symptoms by disturbing spatio-temporal integration (Mesulam,
1998). Heterogeneous activation in visual cortices during sleep is further
suggested by the frequent loss of colour saturation or achromatopsia, in
dream imagery. Schwartz and Maquet (2002) propose that activation of area
V4 will be lower in scans that are followed by dream reports containing
achromatopsia.
DISORDERS OF DREAMING
Nightmares
The widely accepted definition is that a nightmare is a frightening dream
that awakens the sleeper, those that do not awaken the dreamer should be
labeled “bad dreams” (Halliday, 1987). Although the idiopathic nightmare
is the most prevalent form of dream disturbance, its cause and
psychopathology remain largely unstudied (Nielsen and Zadra, 2000).
Lifetime prevalence for a nightmare experience in the general population
is unknown but may well approach 100%. Nightmares are both more prevalent
and more frequent in childhood. Approximately 24% of nonpsychotic patients
seen in psychiatric emergency services report nightmares, but with an
unknown frequency (Brylowsky, 1990). Although many studies suggest weak to
moderate relationships between nightmare frequency and measures of
psychopathology (Berquier and Ashton, 1992; Levin and Hurvich, 1995),
others do not (Belicki, 1992; Wood and Bootzin, 1990). Nightmare frequency
is only moderately related to nightmare distress, and it is the distress
factor that is significantly related to psychopathology (Belicki, 1992).
Although psychotherapy aimed at conflict resolution has traditionally been
the treatment of choice for nightmares (Jones, 1951), it lacks empirical
support (Nielsen and Zadra, 2000). Systematic desensitization and
relaxation techniques (Miller and DiPilato, 1983), imagery rehearsal
(Krakow et al, 1995), lucid dreaming (Zadra and Pihl, 1997), eye movement
desensitization and reprocessing (Marquis, 1991) and hypnosis (Kingsbury,
1993) are the treatments for nightmares that have some empirical support.
REM sleep behavior disorder
The
diagnostic criteria of REM sleep behavior disorder (American Sleep
Disorder Association, 1990) is as follows: (1) polysomnographic
abnormality during REM sleep: elevated submental electromyographic tone
and /or limb electromyographic twitching. (2) Documentation of abnormal
REM sleep behaviors during polysomnographic studies, or a history of
injurious or disruptive sleep behaviours. (3) Absence of EEG epileptiform
activity during REM sleep. Tricyclic antidepressants, MAO inhibitors,
SSRIs, and venlafaxine can induce or aggravate REM sleep behaviour
disorder. Clonazepam is remarkably effective in controlling both the
behavioral and the dream-disordered components of REM sleep behavior
disorder (Schenck and Mahowald, 2000).
Dream-interruption insomnia
Greenberg (1967) suggested this subcategory of insomnia, where patients
report a period of intense nightmares just before onset of their insomnia.
The pattern suggested that the awakenings might be a means of defending
against anxious dream content. Cartwright (1994) reported that
psychotherapy focusing on the content of patient’s dreams and nightmares
is successful in alleviating their insomnia.
Existential (grief) dreams
These are characterized by distressing emotions, salient bodily feelings
(e.g., ineffectuality of action, paralysis) and failures in goal
attainment (Kuiken and Sikora, 1993). There is also separation and loss,
the appearance of deceased family figures, and an increased sensory
vividness that may culminate in an intensely real ending – often with an
awakening. The clinical importance of existential dreams is their
appearance during bereavement. Patients report gaining both personal and
spiritual insight from existential dreams (Kuiken, 1995).
Epic dreaming
In this condition patients feel that they dream all night and complain of
marked daytime fatigue (Schenck and Mahowald, 1995). Their dreams
typically involve constant, trivial, or banal physical activity such as
repetitive household work. Emotional arousal is absent from epic dreams.
The neuropsychological evidence points to involvement of the anterior
limbic system and suggests that further clues to its cause may be found in
associated emotional disturbances (e.g., alexithymia, dysthymia) in these
patients. Treatments for epic dreaming (cognitive, hypnosis, relaxation,
medications) have proved largely ineffective.
Terrifying hypnagogic hallucinations (THHs)
THHs are terrifying dreams which arise from sleep-onset REM periods
(Nielson and Zadra, 2000). They may be aggravated by withdrawal from
REM-suppressant medications, chronic sleep deprivation, sleep
fragmentation and narcolepsy. Other sleep and medical disorders may
accompany the condition. THHs are perhaps more anxiety-provoking than most
nightmares because of a vivid sense of reality related to their close
proximity to wakefulness and the frequently accompanying feelings of
paralysis.
Narcolepsy
During their nocturnal sleep episodes, people with narcolepsy may
experience frequent dreams that are intense, vivid and bizarre (APA,
1994). Compared with those suffering from insomnia, patients with
narcolepsy report more frightening, recurrent dreams (Lee et al, 1993).
The cause of disturbed dreaming in narcolepsy has more to do with the
fragmentation of REM sleep than it does with increases in the intensity of
REM sleep phasic activity (Montplaisir et al, 1978). Dreaming that a
presence has entered the premises is closely associated with sleep
paralysis and persons with severe narcolepsy may experience such horrors
almost daily (Nielson and Zadra, 2000).
Dream-reality confusions
Intensification and vivification of dreaming to the point of confusion
with reality has been described as characteristic of a small subgroup of
neurologic patients (Solms, 1997). There is some evidence with the
hypothesis that dream-reality confusions are due to localized anterior
limbic lesions. Dream-reality confusions are also known to occur in sleep
paralysis, narcolepsy, psychosis and in normal persons (reality dreaming)
(Nielson, 1991).
Prodromal dreaming and symptom incorporation
Many dreams – referred to as prodromal- are disturbed by ongoing or
anticipated medical conditions (Garfield, 1991). For e.g., patients with
peripheral or central vestibular diseases reported a selective increase in
fearful vestibular imagery in their dreams following onset of the illness
(Doneshka and Kehaiyov, 1978). Such themes may often appear in dreams
before any overt symptomatology, a phenomenon that has been exploited (and
often misunderstood) since the earliest days of medical science (Gallop,
1990).
LUCID DREAMING
Lucid
dreams are the ones during which the dreamer possesses clear cognizance
that he/she is dreaming. During such “lucid” dreams, one can reason
clearly, remember the conditions of waking life, and act upon reflection
or in accordance with plans decided upon before sleep (LaBerge, 2000).
LaBerge et al (1981) in a polysomnographic study confirmed voluntary
prearranged eye-movements in REM sleep during uninterrupted lucid dreams.
Zadra and Pihl (1997) have utilized lucid dreaming in the treatment of
recurrent nightmares by asking the patients to undergo relaxation,
rehearse the dreams in detail and carry out mental tasks at salient point
in the dream to modify its course. During such rehearsal the patient keeps
telling himself that he/she is dreaming. Later, during an actual dream,
this action will cue that the experience is a dream whereupon the patient
can alter the course of dream by carrying out the task at indicated point.
This study found that over a follow up for 6 months to 2 years the
frequency of nightmares decreased and ultimately disappeared.
CULTURE AND DREAMS
Striking cross-cultural variations occur in beliefs about the nature of
dreams and the importance attributed to them. In western society rarely do
people believe the events in the dreams. However in Australian aborigines
dreaming is the focal point of their traditional aboriginal existence and
simultaneously determines their way of life, their culture and their
relationship to the physical and spiritual environment. In the New Guinea,
Arapesh people are held responsible for their dream actions, eg. an erotic
dream about some one may be viewed as the equivalent of an adulterous act.
In some cultures dreams are seen as window into the spiritual world or
into the future. In some ethnic groups like the Senoi of Malaysia gather
in groups every morning to discuss and analyze their dreams from the
previous night. Shared systems for interpreting the dream content also
vary from one society to another eg. among the Toraja of Indonesia a dream
of objects being thrown at dreamer is interpreted as ‘rain will fall’
(Weiten, 1995).
RELIABILITY IN DREAM RESEARCH
A
study by Schredl et al (2001) found that dream recall and dream length are
quite stable. Good internal consistency and retest reliability were found
for these variables. However dream characteristics such as bizarreness,
emotional tone and occurrence of interactions underlie large
intraindividual fluctuations. The reliability issue has to be taken into
consideration if dream content measures are related to trait variables of
waking life, eg. personality dimensions. It is recommended that one should
obtain as many dreams as possible (about 20) in a very short time period
(one week).
CONCLUSION
Does the dream have a
place in contemporary psychiatry? A satisfactory answer to this needs to be
more complex and multifaceted than a simple “yes” or “no”. The important
place of the dream in the 1950s was a reflection of an interest that was
centered- in fact, anchored- in the psychoanalytic psychology of the dream
and the dream process (Reiser, 2001). But the question must now be
reframed because our information base has become so much larger and more
complex, as is evident from the literature cited in this article, and it
encompasses a wide range of sectors (eg. clinical, theoretical,
therapeutic, and research), each with its subspecialties and programmatic
interests. The relative importance of the dream varies according to the
specific issues under consideration and the context in which the question
is considered.
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