Friday, 3 August 2012

Schizophrenia and Dreaming

There has been a substantial volume of scholarly investigation into the dream patterns and content of schizophrenic subjects.  The fact that many schizophrenics suffer from waking hallucinations means that the psychological disorder and its effect on dreaming is of significant interest to dream scientists.  In Dixon, An Extension of Freud and Jung’s Theory of the Relation of Dream States to Schizophrenia (2005) the theories of Freud and Jung were combined to explain various dream states in relation to schizophrenia. Dixon argues that schizophrenics generally have a lack of emotional reactivity, which is thought to be a vital factor of dreaming, which reflects emotional activity.  Dixon theorises that the schizophrenic may be ‘defending’ themselves (inadvertently, by mental processes) from emotional trauma or unpleasant memories and this will have a ‘flattening effect’ on the dream state. Jung (1958) held similar views to Dixon, arguing that speech, judgment and lack of willpower contribute to exceptional inward violence for the schizophrenic subject because of – and as a cause of – the flattening effect on dream states. The schizophrenic is under emotional stress which impacts on their ability to differentiate between fantasy and reality when in a delusional state.  Dixon argues that this emotional stress can have a substantial effect upon the schizophrenic’s determination of objects which are purely fantasised and those existing in reality, because of primary process thinking.  Freud’s concept of ‘primary process thinking’ refers to undirected attempts at immediate satisfaction of wishes and desires. If not governed by logic, such attempts may contain contradictory, yet co-existent impulses. It is the subject’s primary subjective reality at the subconscious level. Dixon asserts that schizophrenics use symbols to explain certain subconscious emotions and frustrations they are experiencing and therefore, manifest dream states whilst fully conscious. 

Cameron (1938) states that there is an imprecision and incongruency between acts and words, and therefore schizophrenics have difficulty in comprehending and managing their emotional disorders and therefore enter waking dream states. This suggests that they may also have distorted postulation systems which prevent them from determining whether something is real and present or not.  Jung argues that non-schizophrenics dream in a way which reflects persons/objects represented in their external environments, whereas in schizophrenics, random objects may be perceived which appear to be fragmentary, absurd and illogical.

In the study, Sleep Disturbance in Schizophrenia, Wulff (2006) explored subjects’ abnormal sleep patterns which may interrupt their daily routine. Schizophrenics were found to have a shorter dream recall than non-schizophrenics, along with less personal involvement in the dreams and exhibited anxiety as a result of sleep disturbance.  One male subject (27 years) had a urine sample collected every 48 hours, which revealed abnormal levels of melatonin production, enabling a prediction of how much sleep the subject was getting. The study also used actigraphy – a wristwatch-sized, portable unit worn on the least dominant arm, using accelerometer sensors to detect light waves, both inside and outside the home.  The subject then had to record their daily sleeping and other routines in a diary. The urine samples also showed a progressive delay in sleep and disturbance in the subject’s biological clock, which by the final week of the experiment, had been completely reversed. He was unable to sleep during the hours of darkness, and sometimes slept all day. It was concluded that light may cause a schizophrenic subject to have delayed sleep activity, although sleep patterns may be significantly affected by any medication the subject has taken.  Wulff stated that a non-institutionalised schizophrenic subject may suffer even more delayed and disturbed sleep cycles as a result of lack of medical intervention and assistance.

In The Neurochemistry of Waking and Sleeping Mental Activity: The Disinhibition-Dopamine Hypothesis, Gottesmann (2002) attempted to explain the neurochemistry of dream states in schizophrenic subjects and the disinihibition-dopamine hypothesis. He argued that, generally, dreams are fragmentary and disorderly, similar to the waking experience of a schizophrenic subjects when suffering from a delusional episode. Schopenhauer & Maury have claimed that dreams are a form of temporary madness or delusion. Dreams are thought to ‘occur’ mainly in the cerebral cortex structure of the brain, in particular, the dorsolateral prefrontal cortex. Deactivation of the cerebral cortex during sleep explains why reasoning and logic is often absent in the dream state. This decrease in reasoning and logic – as indicated by levels of brain activity – is most prominent during REM sleep – where dreaming occurs. Non-schizophrenics have increased levels of dopamine in the cortex while asleep – this increase in brain activity accounting for visual images during dreaming. Gottesmann found that the opposite is true in schizophrenics, who exhibit a decrease in dopamine activity during REM sleep, allowing the dorsolateral prefrontal cortex (DLPFC) to deactivate during the dream state. Dream content is non-reactive in schizophrenics, because the DLPFC is unable to produce visual images or the dream state is very fragmented. Further, an increase in dopamine levels during waking states accounts for waking hallucinations and delusions. Gottesmann argues that in non-schizophrenics, dream content is largely visual, yet in schizophrenics, there is a tendency for auditory hallucinations. Gottesmann’s research demonstrates a relationship between dopamine dysfunction and psychosis. There was also a correlation between dopamine production and REM sleep, accounting for schizophrenic’s evidence that their dreams are often not vivid.

Zarcone (1965) in his study Rorschach Responses Subsequent to REM Deprivation in Schizophrenic and Non-schizophrenic Patients, tested REM deprivation using both schizophrenic and non-schizophrenic subjects. He hypothesised that schizophrenics have a lack of dream content and REM sleep, leading to behavioural disorder. All subjects in the study were deprived of 75% of their REM sleep. Each night before sleep, and in the morning upon waking, the subjects were required to complete a Rorschach test to gauge their responses and, during the night, EEG, EOG and EMG were used to monitor their brain activity i.e. the electric pulses of the brain. The Rorschach test would determine adaptiveness and maladaptiveness, by how well the subjects responded to each of the cards. At first, the responses given did not reveal significant differences between the two sets of subjects, but on second analysis, a difference was found in levels of adaptive aggression, showing that the schizophrenics had – according to the rating scale of the controversial Rorschach test – more difficulty controlling their responses as a result of lack of REM sleep. 

Cartwright (1971) conducted a further study into schizophrenia and REM sleep, Sleep Fantasy in Normal and Schizophrenic Persons, which compared ‘sleep fantasy’ between schizophrenics and non-schizophrenics. In this study, three groups were tested. Cartwright hypothesised that the three groups would differ in (a) levels of sleep fantasy; and (b) that dream content would be less vivid in schizophrenic subjects. An EEG monitor was used on the subjects and for four consecutive nights the subjects were assessed in a psychiatric hospital, where dream content was analysed by use of MMPI. Cartwright was able to make links between disturbed periods of REM sleep in schizophrenics and hallucinatory images in waking life and indeed, dreams were much less vivid for the schizophrenic subjects tested.

In his paper, Dream Content of Schizophrenic, Nonschizophrenic Mentally Ill, and Community Control Adolescents, Hadjez (2003) measured the dream content of three groups – non-schizophrenic, mentally ill adolescents; schizophrenic adolescents; and community control adolescents. He predicted that schizophrenics subjects’ dreams are more likely to be incoherent or inplausible and would be typically characterised by less anxiety and less personal and emotional involvement/expression. In addition, schizophrenic subjects are more likely to have significantly less effective dream recall, if any at all. Hadjez used Freud’s Interpretation of Dreams (1900) and the psychoanalytic theory in his study, a paradigmic approach which suggests that all dreams are functional in resolving conflicts and unacceptable urges/impulses in a safer way than would be possible in waking life, given that civilised society forbids certain behaviours. He used the Formal Dream Content Rating Scale (FDCRS) which rates levels of anxiety; cognitive disturbance; implausibility; involvement; primitivity; emotional expression; and dream duration. All subjects were interviewed upon waking so that there was the best chance of dream recall, and the interviews were recorded and analysed independently. There was found to be no significant difference in all three groups with respect to dream content, although there was markedly less personal and emotional involvement /expression recorded for the schizophrenic subjects and their dreams appeared to be more symbolic in nature. The schizophrenic subjects did not exhibit significantly more disturbance than the non-schizophrenic adolescents with other mental disorders. However, the community control adolescents had substantially more vivid dreams and better dream recall than the other two groups, where mental health was a factor. 

In Kelly (1998), Defective Inhibition of Dream Event Memory Formation: A Hypothesized Mechanism in the Onset and Progression of Symptoms of Schizophrenia, the author states that the average non-schizophrenic person experiences approximately 90 minutes to two hours of dreaming per night. It is argued in the paper that schizophrenic delusions initially arise because system which normally inhibits the formation of memories of dream events is defective. Therefore, memories of dream events or fragments would be occasionally made and placed in the normal memory store. The only reason that we really know anything happened to us in the past is that we have a memory of it, and having a memory of an event is sufficient to really believe it. Therefore, the schizophrenic would believe that the dream events actually happened. It is proposed that this is the basis of primary delusions. Because memories are represented by strengthened neural connections there will be an accumulation of connections that do not correspond to reality. This accumulation may account for other symptoms of schizophrenia such as thought disorder, loosening of associations, and hallucinations. The brain trying to draw conclusions from several memories may be the basis of secondary delusions. Evidence is presented for the ideas that primary delusions are due to memories of dream events, that a substance, with vasotocin-like bioactivity, is released in the brain during dreaming and inhibits memory formation, that the lateral habenula is a brain area involved in vasotocin actions and is affected by neuroleptics, and that brain mechanisms involved in vasotocin actions show pathological alterations in schizophrenia.

The Human Givens Institute published discourse on the relationship between schizophrenia and REM sleep, Griffin & Tyrell, A New Approach to Emotional Health and Clear Thinking (2006) who state the brain is organised to keep waking life and dream content separate and draw similarities between hypnotic states and REM sleep, both of which are characterised by muscle paralysis, dissociation, imperviousness to pain, and amnesia for the event after ‘waking’. Starting from the premise that a psychotic breakdown is generally preceded by an overload of stress and depression, the authors argue that persons suffering from a psychotic or schizophrenic episode are ‘trapped’ within an REM state – a state of wakeful dreaming – a waking reality processed through the dreaming brain. To illustrate their point, they suggest that many schizophrenic behaviour patterns match those common in REM states – such as strange bodily sensations (such as paralysis, feeling as if one’s limbs do not belong to them  or the sensation that their physical self is dissolving) or resistance to considerable pain, due to a decrease in sensory perception. Therefore there is correlation in schizophrenics subjects, hypnotised subjects and normal subjects in an REM state in that bodily relationships can become distorted and pain can be unperceivable  - the latter of course being proven in the use of hypnosis during surgery.

The authors state that psychotic patients may also talk about hearing voices and this too can be traced to an abnormality in REM cycles. In the dream state, which is the province of the right hemisphere of the brain, people are not usually capable of independent thought, the province of the left hemisphere, because the mind is ‘locked’ into the metaphorical script of the dream. But if an individual is trapped in a waking REM state, with waking reality happening around them, there is still likely to be activity in the left hemisphere of the brain and it is claimed that, due to the fact that dreams operate through metaphor, the only way the schizophrenic subject’s brain is able to make sense of these ‘independent left brain thoughts’ is to ‘create’ a metaphor or ascribe them some meaning – hearing voices/feeling as if one is being watched – leading to paranoid states. Many schizophrenics speak of hearing voices commenting on and criticising their every move – something which is also commonly experienced during dreams of non-schizophrenics.  Visual delusions or hallucinations associated with schizophrenia are also characteristic of normal dreams, where a hallucinatory ‘reality’ is created, which we (often) unquestioningly believe in for the duration of the dream. Rapid eye movements are often seen in psychotic individuals – the defining feature of the REM state and thoughts are quickly converted into sensory experience with the result that schizophrenic subjects can experience sudden bouts of intense emotion and sometimes, a transporting back to the memory of a traumatic event. The authors argue that this phenomenon is another characteristic of the dream state, when arousals from the emotional brain trigger a thought pattern in the cortex, which is immediately converted into a sensory metaphor — the dream. Their evidence is that schizophrenic subjects often talk in ‘metaphors’ and are actually living them out – explaining bizarre speech and behaviour patterns. Their paradigm of the REM state is essentially of a ‘reality generator’ which creates illusory perceptions which we experience in our dreams.  Indeed, when schizophrenic subjects are experiencing delusions, they are often highly aware that they are in a ‘dream-like’ state, removed from reality. This could be due to past experience and a developed understanding of their disorder and patterns of thought.  The authors perceive the metaphorical language and behaviour of schizophrenic subjects as representing how emotional needs are not being satisfied; or as attempts to express what it feels like to process waking reality directly through the distorting REM state. Largely, this theory – part of the HGI’s new school of psychological theory and therapeutic approach - corresponds in many ways with the earlier discourse on REM patterns in schizophrenic subjects and the empirical data from those studies. It also tends to sway towards the Freudian perspective of dreaming in the assertion that the actions of the schizophrenic subject, trapped in the REM state represent an attempt to satisfy an unfulfilled need or impulse. Similar theories have been propounded by researchers subscribing to the Expectation Fulfilment theory of dreaming – which is largely based on Freudian psychoanalysis (Freud referred to ‘wish fulfilment’).

Buckner, a cognitive neuroscientist, states the complex symptoms of schizophrenia could arise from a disruption in the brain’s control system resulting in an overactive (or inappropriately active) default network. The normally strongly defined boundary between perceptions arising from imagined scenarios and those from the external world might become blurry, including the boundary between self and other. In a non-schizophrenic default network, there is a dividing line between internally generated thoughts, sensations, emotions and external perceptions of reality. Therefore, when most people wake up, the prefrontal cortex wakes up from standby mode (it needs deactivation during  because of the amount of processing it carries out during wakefulness), re-connects itself to the rest of the default network, and installs the boundary between internal perceptions and external perceptions. For schizophrenics, this boundary is disrupted and Kaufman (2009) argues that abnormal default network connectivity in people with schizophrenia is related to the ability to perform a task that requires concentration on the external environment as well as auditory hallucinations, paranoid and bizarre delusions, and disorganised speech (some of the most common ‘positive’ symptoms of schizophrenia). The common theme here is ‘altered perceptions of reality’.

In Dream Content in Chronically-treated Persons with Schizophrenia, Lusignan et al (2009) found that the schizophrenic subjects experienced a greater number of nightmares but no significant differences on other measures, including overall dream recall; presence of recurrent dreams;  and frequency of specific emotions. 39 dream reports were collected from each group following awakenings from REM sleep. Laboratory dream narratives from the schizophrenic subjects were shorter and, after controlling for report length, most significant differences in dream content between the two groups disappeared with the exception of a greater proportion of unknown characters in the non-schizophrenic group. Schizophrenic subjects spontaneously rated their dream reports as being less bizarre than did controls (non-schizophrenic subjects), despite a similar density of bizarre elements as scored by external judges. Finally, both groups had a comparable density of rapid eye movements during REM sleep but a significant positive correlation between eye-movement density and dream content variables was only found in controls. Taken together, the findings suggest that dream content characteristics in schizophrenia may reflect neurocognitive processes, including emotional processing, specific to this disorder. A study by Stompe et al (2003), Anxiety and Hostility in the Manifest Dreams of Schizophrenic Patients, involved an experiment where schizophrenic and non-schizophrenic subjects were analysed over an 8 week period. Cluster analysis showed general similarity in the organisation of dream affects between the two groups, there was significant different with regard to dream content, in particular the presence of hostile or anxiety-provoking elements in dream content. As with persecution delusions, the schizophrenic subjects tended to be more likely to perceive an outside hostility, which corresponded with greater levels of threat anxiety (focusing on death/mutilation). The study found that value anxiety (separation, guilt) tended to occur less in the dreams of schizophrenic subjects. 

In Dreams and Schizophrenia, Carrington (1972) conducted a study into the dream content of schizophrenic subjects. Recalled night-time dreams of 30 schizophrenic and 30 non-schizophrenic women were compared on parameters theoretically related to schizophrenia. Ten hypotheses concerning the reflection of the schizophrenic process in dreams were tested and 19 additional variables which qualified these hypotheses were compared. The study as a whole tested the general assumption that dream content is consistent with waking psychopathology or normalcy. Nine of the hypotheses were confirmed at high levels of significance. Qualitative categories also showed differences. Schizophrenic subjects thus displayed personality traits commonly associated with schizophrenia more often in their dreams than did non-schizophrenic subjects. In general, schizophrenic dreams gave the impression of an acute state of emergency or stress. Control dreams, depicting every day, practical concerns, were far less traumatic.

Some research has focused on the potential therapeutic and healing values of exploring dream content with schizophrenic subjects. Wilmer (1982a) in Vietnam and Madness: Dreams of Schizophrenic Veterans, the author assessed the possibility of therapeutic healing for Vietnam veterans suffering from post-traumatic shock and delayed-stress disorders, using group sessions and individual analytical psychology to work through the subjects’ dreams.  The author states that the subjects’ dreams record an unconscious history of Vietnam, uncontaminated by the waking ego’s conscious motivations of distortions. Combat dreams of some veterans, which remained identical in form/content for periods of six years, were found to change and evolve as a result of therapeutic work. Wilmer (1982b) subsequently published a secondary report, Dream Seminar for Chronic Schizophrenic Patients which describes the innovative approaches of an inpatient milieu treatment unit for chronic schizophrenic patients at a Veterans’ Hospital. The purpose was to help patients understand and appreciate their dreams in a special group setting. It was hypothesised that the Dream Seminar would diminish insomnia and night fears; that the examination of dream experiences, no matter how bizarre or frightening, would be potentially healing; and that patients' attitudes toward dreams as well as delusions and hallucinations might change. It was also predicted that by limiting the focus of the Dream Seminar to the manifest dream content, the images and internal sequences of the dream (and by not allowing free association), the connective unconscious of the group would be brought into the open and balance the more conventional therapies of the rest of the programme. 

Lucid dreaming – when you are aware you are asleep and dreaming – is a hybrid state between sleeping and conscious wakefulness. Research has discovered that lucid dreaming creates distinct patterns of electrical activity in the brain which have similarities to the patterns made by psychotic conditions such as schizophrenia. Confirming links between lucid dreaming and psychotic conditions offers potential for new therapeutic routes based on how healthy dreaming differs from the unstable states associated with neurological and psychiatric disorders. New data from the European Science Foundation workshop affirms the connection by showing that while dreaming lucidly the brain is in a dissociated state. Dissociation involves losing conscious control over mental processes, such as logical thinking or emotional reaction. In some psychiatric conditions this state is also known to occur while people are awake. In the field of psychiatry, analysis dreams has progressively fallen out of both clinical practice and research, but the new data appears to show that we may be able to make comparisons between lucid dreaming and some psychiatric conditions that involve an abnormal dissociation of consciousness while awake, such as psychosis, depersonalisation and pseudoseizures. Meanwhile, the previously discredited idea of treating some conditions with dream therapy has attracted interest from clinicians. An example is people suffering from nightmares can sometimes be treated by training them to dream lucidly so they can consciously wake up.

This means that basic dream researchers could now apply their knowledge to psychiatric patients with the aim of building a useful tool for psychiatry, reviving interest in patients' dreams; and neuroscientists could possibly explore how to extend their work to psychiatric conditions, using approaches from sleep research to interpret data from acute psychotic and dissociated states of the brain-mind.

The existence of such psychotic conditions may be rooted in the evolutionary role of dreams, where dreaming is thought to have emerged to enable early humans to rehearse responses to the many dangerous events they faced in real life. Developed by Revonsuo, Threat Simulation Theory argues that it may have origins even further back in evolution, given that other mammals such as dogs also exhibit the characteristic electrical activity of dreaming. Researchers from the ESF workshop also looked at the idea that paranoid delusions and other hallucinatory phenomena occur when the dissociative dreaming state involving replay of threatening situations is carried through into wakefulness. Exposure to real threatening events supposedly activates the dream system, so that it produces simulations that are realistic rehearsals of threatening events in terms of perception and behaviour. Threat Simulation theory works on the basis that the environment in which the human brain evolved included frequent dangerous events that posed threats to human reproduction. These would have been a serious selection pressure on ancestral human populations and would have fully activated the threat simulation mechanisms. However, dreaming is unlikely to have evolved purely to recreate threats. It may also have a role in the learning process, according Hobson, a psychiatrist and dream researcher. Contents are added while you are awake and integrated with the automatic program of dream consciousness during sleep. This works with observations that daytime learning is consolidated by night-time sleeping, leading to the phenomenon where people remember facts better the day after they have learnt them than at the time.

I will update this article with further material shortly.

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