Dream content in chronically-treated persons with schizophrenia

Quantitative-Qualitative Assessment of Dream Reports in Schizophrenia and Their Correlations with Illness Severity

Positive symptoms of schizophrenia have been proposed to be an intrusion of dreaming in wakefulness; conversely, psychotic patients' abnormal cognitive and behavioral features could overflow into sleep, so that their dreams would differ from those of healthy people. Here we assess this hypothesis by comparing dream features of 46 patients affected by schizophrenic spectrum disorders to those of 28 healthy controls. In patients, we also investigated correlations of dream variables with symptom severity and verbal fluency. Overall, patients reported fewer and shorter dreams, with a general impoverishment of content (including characters, settings, interactions) and higher spatiotemporal bizarreness. The number of emotions, mainly negative ones, was lower in patients' reports and correlated inversely with symptom severity. Verbal fluency correlated positively with dream report length and negatively with perceptive bizarreness. In conclusion, our data show a significant impoverishment of dream reports in psychotic patients versus controls. Future research should investigate to what extent this profile of results depends on impaired verbal fluency or on impaired mechanisms of dream generation in this population. Moreover, in line with theories on the role of dreaming in emotion regulation, our data suggest that this function could be impaired in psychoses and related to symptom severity.

Examining the association between depersonalisation traits and the bodily self in waking and dreaming

Depersonalisation (DP) is characterized by fundamental alterations to the sense of self that include feelings of detachment and estrangement from one's body. We conducted an online study in healthy participants (n = 514) with DP traits to investigate and quantify the subjective experience of body and self during waking and dreaming, as the vast majority of previous studies focussed on waking experience only. Investigating dreams in people experiencing DP symptoms may help us understand whether the dream state is a 'spared space' where people can temporarily 'retrieve' their sense of self and sense of bodily presence. We found that higher DP traits-i.e. higher scores on the Cambridge Depersonalisation Scale (CDS)-were associated with more frequent dream experiences from an outside observer perspective (r = 0.28) and more frequent dream experiences of distinct bodily sensations (r = 0.23). We also found that people with higher CDS scores had more frequent dream experiences of altered bodily perception (r = 0.24), more frequent nightmares (r = 0.33) and higher dream recall (r = 0.17). CDS scores were negatively correlated with body boundary scores (r = - 0.31) in waking states and there was a negative association between CDS scores and the degree of trust in interoceptive signals (r = - 0.52). Our study elucidates the complex phenomenology of DP in relation to bodily selfhood during waking and dreaming and suggests avenues for potential therapeutic interventions in people with chronic depersonalisation (depersonalisation -derealisation disorder).

Nightmares in Patients with Major Depressive Disorder, Bipolar Disorder, and Psychotic Disorders: A Systematic Review

Chronic nightmares are very common in psychiatric disorders, affecting up to 70% of patients with personality or post-traumatic stress disorders. In other psychiatric disorders, the relationships with nightmares are poorly known. This review aimed to clarify the relationship between nightmares and both mood and psychotic disorders. We performed a systematic literature search using the PubMed, Cochrane Library and PsycINFO databases until December 2019, to identify studies of patients suffering from either a mood disorder or a psychotic disorder associated with nightmares. From the 1145 articles screened, 24 were retained, including 9 studies with patients with mood disorders, 11 studies with patients with psychotic disorders and 4 studies with either psychotic or mood disorders. Nightmares were more frequent in individuals with mood or psychotic disorders than in healthy controls (more than two-fold). Patients with frequent nightmares had higher suicidality scores and had more frequently a history of suicide attempt. The distress associated with nightmares, rather than the frequency of nightmares, was associated with the severity of the psychiatric disorder. Further studies assessing whether nightmare treatment not only improves patient-sleep perception but also improves underlying psychiatric diseases are needed. In conclusion, nightmares are overrepresented in mood and psychotic disorders, with the frequency associated with suicidal behaviors and the distress associated with the psychiatric disorder severity. These findings emphasize major clinical and therapeutic implications.

Troubles psychotiques et troubles du sommeil : revue de la littérature

Contexte La disparition de la nomenclature des troubles du sommeil dits primaires ou secondaires, rendue obsolète par le Manuel diagnostique et statistique des troubles mentaux (DSM-5), représente bien l’engouement académique actuel pour ce domaine de recherche. Il est de plus en plus reconnu que les troubles du sommeil sont plus que de simples conséquences d’un trouble psychiatrique et qu’ils peuvent persister malgré un traitement adéquat de la condition comorbide et même précéder ou exacerber cette dernière. Les troubles du sommeil dans les troubles psychotiques, très fréquents, sont donc devenus un sujet d’actualité, représentant une cible d’intervention jusqu’ici sous-estimée.

Objectif Cet article vise à présenter l’état des connaissances actuelles sur la relation entre les troubles du sommeil et les troubles psychotiques ainsi que sur l’utilisation de la thérapie cognitivo-comportementale (TCC) pour traiter les troubles du sommeil dans ce contexte.

Méthode L’article fait une recension narrative de la littérature pour décrire la relation bidirectionnelle entre la psychose et les troubles du sommeil, les corrélations cliniques et les traitements ciblant l’insomnie chez les patients psychotiques.

Résultats Malgré la présence d’une relation entre les troubles du sommeil et les troubles psychotiques, les mécanismes neuronaux, hormonaux et socioculturels régissant cette relation demeurent encore incertains. Bien que l’association reliant les troubles du sommeil et les troubles psychotiques demeure à clarifier, les études démontrent qu’elle serait bidirectionnelle et peut engendrer un cercle vicieux où ces deux composantes s’aggravent mutuellement. Dans ce contexte de comorbidités, les modèles unifiés en TCC deviennent un traitement de choix, à condition d’adapter les protocoles de TCC pour insomnie (TCC-i) à une population avec trouble psychotique (TCC-ip).

Conclusion Malgré la complexité de la relation entre les troubles psychotiques et ceux du sommeil, la TCC-i a été démontrée efficace pour traiter les troubles du sommeil dans une population psychotique et pourrait, dans certains cas, permettre d’alléger la symptomatologie psychotique. De futures études sur ce domaine pourraient permettre le développement de protocoles de thérapie cognitivo-comportementale pour les troubles du sommeil mieux adaptés à la population avec troubles psychotiques.

Dreams, Sleep, and Psychotropic Drugs

Over the past 60 years, the impact of psychotropic drugs on dream recall and content has been scarcely explored. A review of the few existing experimental results on the topic leads us to the following conclusions. For antidepressant drugs, in the great majority, they reduce dream recall frequency (DRF), and the improvement of depressive symptoms is associated with an increase of positive emotion in dream content. For sedative psychotropic drugs, their improvement of sleep quality is associated with a reduction of DRF, but the effect on dream content is less clear. Few occurrences of nightmare frequency increase have been reported, with intake of molecules disturbing sleep or with the withdrawal of some psychotropic drugs. Importantly, the impact of psychotropic drugs on rapid eye movement (REM) sleep does not explain DRF modulations. The reduction of intra-sleep awakenings seems to be the parameter explaining best the modulation of DRF by psychotropic drugs. Indeed, molecules that improve sleep continuity by reducing intra-sleep awakenings also reduce the frequency of dream recall, which is coherent with the “arousal-retrieval model” stating that nighttime awakenings enable dreams to be encoded into long-term memory and therefore facilitate dream recall. DRF is nonetheless influenced by several other factors (e.g., interest in dreams, the method of awakening, and personality traits), which may explain a large part of the variability of results observed and cited in this article.

Successful treatment of nightmares may reduce psychotic symptoms in schizophrenia

Nightmares occur more frequently in patients with schizophrenia than they do in the general population. Nightmares are profoundly distressing and may exacerbate daytime psychotic symptoms and undermine day-to-day function. Clinicians do not often ask about nightmares in the context of psychotic illness and patients may underreport them or, if nightmares are reported, they may be disregarded; it may be assumed that they will disappear with antipsychotic medication and that they do not, therefore, require separate intervention. This is a missed opportunity because Image Rehearsal Therapy, among other psychological and pharmacological interventions, has proven effective for nightmares in non-schizophrenia populations and should be considered at an early stage of psychotic illness as an important adjunct to standard treatment. There is active ongoing research in this field, which will undoubtedly benefit patients with schizophrenia in the future.

Exploring the neural correlates of dream phenomenology and altered states of consciousness during sleep

The science of dreaming constitutes a relevant topic in modern-day neuroscientific research and provides major insights into the study of human consciousness. Linking specific, universal, and regularly occurring stages of sleep with dreaming encourages the direct and systematic investigation of a topic that has fascinated humankind for centuries. In this review, we explore to what extent individuals dream during periods of rapid eye movement and non-rapid eye movement sleep, and we introduce research on lucid dreaming. We then discuss how dreaming during different stages of sleep varies in terms of phenomenological characteristics, and to what extent individuals are conscious throughout the sleep cycle. Finally, we provide a synopsis of the previous literature on brain activity during sleep, and we aim to clarify how the neurofunctional changes observed throughout sleep may lead to changes in phenomenological aspects of dreams, and in the domain of consciousness.

Dream content and intrusive thoughts in Obsessive-Compulsive Disorder

Although central to any exhaustive theory of human subjectivity, the relationship between dream and waking consciousness remains uncertain. Some findings suggest that dream consciousness can be influenced by severe disorders of thought content. The suppression of unwanted thoughts has been shown to influence dream content in healthy individuals. In order to better define this phenomenon, we evaluated the persistence of obsessive/compulsive themes across the dream and waking cognition of OCD patients and in a control group of healthy subjects. Participants were administered a shortened version of the Thematic Apperception Test to produce a waking fantasy narration, and were trained to keep a dream diary. Dream and waking narrative contents were analyzed in order to recognize obsessive/compulsive themes, and to calculate Mean Dream Obsession/Compulsion (MDO, MDC) and Mean TAT Obsession/Compulsion (MTO, MTC) parameters. No differences were found between the two populations in terms of MDO, MDC, MTO, nor MTC. Density of obsessive and compulsive themes were significantly higher in dream reports than in waking narratives for both groups. No correlation was observed between MDO/MDC scores and Y-BOCS obsession/compulsion scores in the OCD group. These findings strengthen the discontinuity hypothesis, suggesting that ruminative aspects of cognition are somehow interrupted during dream activity.

Free Energy and Virtual Reality in Neuroscience and Psychoanalysis: A Complexity Theory of Dreaming and Mental Disorder

The main concepts of the free energy (FE) neuroscience developed by Karl Friston and colleagues parallel those of Freud's Project for a Scientific Psychology. In Hobson et al. (2014) these include an innate virtual reality generator that produces the fictive prior beliefs that Freud described as the primary process. This enables Friston's account to encompass a unified treatment-a complexity theory-of the role of virtual reality in both dreaming and mental disorder. In both accounts the brain operates to minimize FE aroused by sensory impingements-including interoceptive impingements that report compliance with biological imperatives-and constructs a representation/model of the causes of impingement that enables this minimization. In Friston's account (variational) FE equals complexity minus accuracy, and is minimized by increasing accuracy and decreasing complexity. Roughly the brain (or model) increases accuracy together with complexity in waking. This is mediated by consciousness-creating active inference-by which it explains sensory impingements in terms of perceptual experiences of their causes. In sleep it reduces complexity by processes that include both synaptic pruning and consciousness/virtual reality/dreaming in REM. The consciousness-creating active inference that effects complexity-reduction in REM dreaming must operate on FE-arousing data distinct from sensory impingement. The most relevant source is remembered arousals of emotion, both recent and remote, as processed in SWS and REM on "active systems" accounts of memory consolidation/reconsolidation. Freud describes these remembered arousals as condensed in the dreamwork for use in the conscious contents of dreams, and similar condensation can be seen in symptoms. Complexity partly reflects emotional conflict and trauma. This indicates that dreams and symptoms are both produced to reduce complexity in the form of potentially adverse (traumatic or conflicting) arousals of amygdala-related emotions. Mental disorder is thus caused by computational complexity together with mechanisms like synaptic pruning that have evolved for complexity-reduction; and important features of disorder can be understood in these terms. Details of the consilience among Freudian, systems consolidation, and complexity-reduction accounts appear clearly in the analysis of a single fragment of a dream, indicating also how complexity reduction proceeds by a process resembling Bayesian model selection.

A unified 3D default space consciousness model combining neurological and physiological processes that underlie conscious experience

The Global Workspace Theory and Information Integration Theory are two of the most currently accepted consciousness models; however, these models do not address many aspects of conscious experience. We compare these models to our previously proposed consciousness model in which the thalamus fills-in processed sensory information from corticothalamic feedback loops within a proposed 3D default space, resulting in the recreation of the internal and external worlds within the mind. This 3D default space is composed of all cells of the body, which communicate via gap junctions and electrical potentials to create this unified space. We use 3D illustrations to explain how both visual and non-visual sensory information may be filled-in within this dynamic space, creating a unified seamless conscious experience. This neural sensory memory space is likely generated by baseline neural oscillatory activity from the default mode network, other salient networks, brainstem, and reticular activating system.

Nightmares in Patients With Psychosis: The Relation With Sleep, Psychotic, Affective, and Cognitive Symptoms

OBJECTIVE

To examine the prevalence of nightmares in people with psychosis and to describe the link between nightmares and sleep quality, psychotic, affective, and cognitive symptoms.

METHODS

Forty participants with psychotic symptoms completed an assessment of nightmares, sleep quality, positive symptoms of psychosis, affect, posttraumatic stress, social functioning, and working memory.

RESULTS

Among the patients, 55% reported weekly distressing nightmares. Experience of more frequent nightmares was related to poorer sleep quality and sleep efficiency. More distressing nightmares were positively associated with greater delusional severity, depression, anxiety, stress, and difficulties with working memory.

CONCLUSIONS

Nightmares might be common in those with psychosis and are associated with increased day- and nighttime impairment. Future research should investigate treatments for nightmares, for people presenting with psychotic symptoms.

What do we really know about blunted vocal affect and alogia? A meta-analysis of objective assessments

Deficits in nonverbal vocal expression (e.g., blunted vocal affect, alogia) are a hallmark of schizophrenia and are a focus of the Research Domain Criteria initiative from the National Institute of Mental Health. Results from studies using symptom rating scales suggest that these deficits are profound; on the order of four to six standard deviations. To complement this endeavor, we conducted a meta-analysis of studies employing objective analysis of natural speech in patients with schizophrenia and nonpsychiatric controls. Thirteen studies, collectively including 480 patients with schizophrenia and 326 nonpsychiatric controls, were identified. There was considerable variability across studies in which aspects of vocal communication were examined and in the magnitudes of deficit. Overall, speech production (reflecting alogia) was impaired at a large effects size level (d=-.80; k=13), whereas speech variability (reflecting blunted affect) was much more modest (d=-.36; k=2). Regarding the former, this was largely driven by measures of pause behavior, as opposed to other aspects of speech (e.g., number of words/utterances). On the other hand, ratings of negative symptoms across these studies suggested profound group differences (d=3.54; k=4). These data suggest that only certain aspects of vocal expression are affected in schizophrenia, and highlight major discrepancies between symptom rating and objective-based measures. The discussion centers on advancing objective analysis for understanding vocal expression in schizophrenia and for identifying and defining more homogenous patient subsets for study.

Neural correlates of insight in dreaming and psychosis

The idea that dreaming can serve as a model for psychosis has a long and honourable tradition, however it is notoriously speculative. Here we demonstrate that recent research on the phenomenon of lucid dreaming sheds new light on the debate. Lucid dreaming is a rare state of sleep in which the dreamer gains insight into his state of mind during dreaming. Recent electroencephalogram (EEG) and functional magnetic resonance imaging (fMRI) data for the first time allow very specific hypotheses about the dream-psychosis relationship: if dreaming is a reasonable model for psychosis, then insight into the dreaming state and insight into the psychotic state should share similar neural correlates. This indeed seems to be the case: cortical areas activated during lucid dreaming show striking overlap with brain regions that are impaired in psychotic patients who lack insight into their pathological state. This parallel allows for new therapeutic approaches and ways to test antipsychotic medication.

Thematic and content analysis of idiopathic nightmares and bad dreams

STUDY OBJECTIVES

To conduct a comprehensive and comparative study of prospectively collected bad dream and nightmare reports using a broad range of dream content variables.

DESIGN

Correlational and descriptive.

SETTING

Participants' homes.

PARTICIPANTS

Three hundred thirty-one adult volunteers (55 men, 275 women, 1 not specified; mean age = 32.4 ± 14.8 y).

INTERVENTIONS

N/A.

MEASUREMENT AND RESULTS

Five hundred seventy-two participants kept a written record of all of their remembered dreams in a log for 2 to 5 consecutive weeks. A total of 9,796 dream reports were collected and the content of 253 nightmares and 431 bad dreams reported by 331 participants was investigated. Physical aggression was the most frequently reported theme in nightmares, whereas interpersonal conflicts predominated in bad dreams. Nightmares were rated by participants as being substantially more emotionally intense than were bad dreams. Thirty-five percent of nightmares and 55% of bad dreams contained primary emotions other than fear. When compared to bad dreams, nightmares were more bizarre and contained substantially more aggressions, failures, and unfortunate endings.

CONCLUSIONS

The results have important implications on how nightmares are conceptualized and defined and support the view that when compared to bad dreams, nightmares represent a somewhat rarer-and more severe-expression of the same basic phenomenon.

Are delusional contents replayed during dreams?

The relationship between dream content and waking life experiences remains difficult to decipher. However, some neurobiological findings suggest that dreaming can, at least in part, be considered epiphenomenal to ongoing memory consolidation processes in sleep. Both abnormalities in sleep architecture and impairment in memory consolidation mechanisms are thought to be involved in the development of psychosis. The objective of this study was to assess the continuity between delusional contents and dreams in acutely psychotic patients. Ten patients with a single fixed and recurring delusional content were asked to report their dreams during an acute psychotic break. Sixteen judges with four different levels of acquaintance to the specific content of the patients' delusions were asked to group the dreams, expecting that fragments of the delusional thought would guide the task. A mathematical index (f,t) was developed in order to compare correct groupings between the four groups of judges. Most judges grouped the dreams slightly above chance level and no relevant differences could be found between the four groups [F(3,12)=1.297; p=n.s.]. Scoring of dreams for specific delusional themes suggested a continuity in terms of dream and waking mentation for two contents (Grandiosity and Religion). These findings seem to suggest that at least some delusional contents recur within patients' dreams. Future studies will need to determine whether such continuity reflects ongoing consolidation processes that are relevant to current theories of delusion formation and stabilization.

Bizarreness in dream reports and waking fantasies of psychotic schizophrenic and manic patients: empirical evidences and theoretical consequences

Several overlapping features have frequently been described between psychosis and the subjective experience of dreaming from the neurobiological to the phenomenological level, but whether this similarity reflects the cognitive organization of schizophrenic thought or rather that of psychotic mentation independent of diagnostic categories is still unclear. In this study, 40 actively psychotic inpatients were equally divided in two age- and education-matched groups according to their diagnosis (Schizophrenia and Bipolar Disorder). Participants were asked to report their dreams upon awakening and the Thematic Apperception Test (TAT) was administered to elicit waking fantasies; the same procedure was used in a control group of 20 non-psychiatric subjects. Two highly trained judges scored the collected material according to a Dream Bizarreness scale. The same level of cognitive bizarreness was found in TAT and dream reports of schizophrenic and manic subjects but was almost completely absent in the TAT stories of the control group. Two-way analysis of variance for repeated measures assessed the effect of diagnosis and experimental conditions (TAT stories and dream reports) on bizarreness yielding a significant interaction. Cognitive bizarreness seems to be a shared feature of dreaming and psychotic mentation, beyond diagnostic categorizations. Although these findings must be considered preliminary, this experimental measure of the cognitive architecture of thought processes seems to support the view that dreaming could be a useful model for the psychoses.

Characteristics and contents of dreams

Dreams have been studied from different perspectives: psychoanalysis, academic psychology, and neurosciences. After presenting the definition of dreaming and the methodological tools of dream research, the major findings regarding the phenomenology of dreaming and the factors influencing dream content are briefly reviewed. The so-called continuity hypothesis stating that dreams reflect waking-life experiences is supported by studies investigating the dreams of psychiatric patients and patients with sleep disorders, i.e., their daytime symptoms and problems are reflected in their dreams. Dreams also have an effect on subsequent waking life, e.g., on daytime mood and creativity. The question about the functions of dreaming is still unanswered and open to future research.

The dreaming brain/mind, consciousness and psychosis

Several independent lines of research in neurobiology seem to support the phenomenologically-grounded view of the dreaming brain/mind as a useful model for psychosis. Hallucinatory phenomena and thought disorders found in psychosis share several peculiarities with dreaming, where internally generated, vivid sensorimotor imagery along with often heightened and incongruous emotion are paired with a decrease in ego functions which ultimately leads to a severe impairment in reality testing. Contemporary conceptualizations of severe mental disorders view psychosis as one psychopathological dimension that may be found across several diagnostic categories. Some experimental data have shown cognitive bizarreness to be equally elevated in dreams and in the waking cognition of acutely psychotic subjects and in patients treated with pro-dopaminergic drugs, independent of the underlying disorder. Further studies into the neurofunctional underpinnings of both conditions will help to clarify the use and validity of this model.