BAGIAN/SMF ILMU KESEHATAN JIWA JURNAL

FAKULTAS KEDOKTERAN JUNI 2018

UNIVERSITAS HALU OLEO

PRINCIPLE AND PRACTICE OF SLEEP MEDICINE

CHAPTER 54 - DREAMING AS A MOOD-REGULATION SYSTEM

Oleh:
Dhiah Kurniati Ansar
K1A1 13 013

Pembimbing:
dr. Junuda RAF., M.Kes., Sp.KJ.

KEPANITRAAN KLINIK BAGIAN ILMU KESEHATAN JIWA

RUMAH SAKIT JIWA DR. SOEPARTO HARDJOHUSODO

FAKULTAS KEDOKTERAN

UNIVERSITAS HALU OLEO

KENDARI

2018
 Dreaming as a Mood-Regulation System

(Rosalind Cartwright)

Chapter 54

Abstract

Dream experience may be responsible for postsleep mood improvement in normal persons.
Research studies support the mood-regulation function of dreaming in healthy subjects.
Dysfunctions in overnight mood regulation are associated with short-term disrupted mood
states. Longer-term failures to regulate emotion occur in several sleep disorders. An example
of the latter is the reduced recall of dreams and lack of dream affect in severe major
depression with typically low, unregulated, morning mood and early onset of the first rapid
eye movement (REM) period. Other sleep disorders with a failure to improve morning mood
are the non-REM (NREM) parasomnias that abort the first REM episode and REM sleep
behavior disorder, idiopathic nightmares, and posttraumatic stress disorder, all of which are
associated with interruptions of REM sleep. These suggest that REM-associated dreaming
has an active role in emotional modulation, but that this role can be dysfunctional owing to
various inherent or acquired dysfunctions of sleep. Few studies have examined the content of
dreams for their contribution to mood regulation in patients with sleep disorders.

That we feel and function better after a night of a sufficient number of hours of sleep has
recently been supported in the Institute of Medicine report1 pointing out the negative impact
on health and behavior of reducing the hours of sleep. A major focus of sleep research is
investigating what it is about having 7 to 9 hours of sleep that restores physiologic and
psychological functions. This is puzzling in light of the amount and regularity of rapid eye
movement (REM) sleep—a complex state of high brain activation, motor inhibition,
shutdown of afferent input, and experience of hallucinations2—and that it is REM sleep that
is disproportionately reduced when total sleep hours are curtailed. This suggests that the loss
of sufficient REM sleep, and the accompanying dreams, may well be implicated in some
negative effects on health and behavior subsequent to widespread reduction in sleep hours.

The prevailing theory of dreaming at the time of the discovery of REM sleep was that
of Freud3 who stated that dreams were a mechanism for the expression of primitive
unacceptable drives, and that this display in sleep allowed these drives to be partially
gratified, preventing their intrusion into waking life. There were few research tests of the
validity of this theory. Foulkes4 undertook such a test by tracing the development of
dreaming in normal children studied in the laboratory. He describes his findings on preschool
aged children through to late adolescence, showing dreaming to be a cognitive skill parallel
to the waking level of cognitive development, and concluded that this failed to support a
unique drive-regulatory function of dreaming. Given that his method required a verbal report
of the experienced dream, a difficult task even for some adults, Foulkes left open the
possibility that REM sleep may perform this affect-modulating function before youngsters
have the cognitive skill to communicate this experience.

Snyder5 extended the age group covered by Foulkes’s study by analyzing the content
of the dreams of healthy young adults. His study provided two findings that contributed to the
hypothesized mood-regulation function of dreams. The first was the presence in dreams of
the dreamer as the main character in 95% of the reports from REM awakenings.5 The second
was the direct expression of “unpleasant” emotion more than twice as often as pleasant
emotion; fear and anxiety was the most common category, and anger was the next most
common category.5 A common thread in current views of dream function is that dreams
reflect recent emotion-related experience and connect this to the organized system of
memories that define the self-concept. The recurrence of content patterns within the dreams
of a night and between nights over time suggests that activation of dream images is not
random. Globus proposed that “the periodic disturbances of REM … moves the [memory]
networks towards … self consistency.”6, p. 134 Kramer7 tested this assertion using the Clyde
Mood Scales8 before and after sleep and found that mood changed through the night and that
dreaming seemed to be a problem-solving method that, when successful, resulted in increased
happiness scores.7 Foulkes9 stated that “activation spreads according to preexisting patterns
in symbolic memory” and “significant emotional life experiences may appear later in dreams
when they serve as mnemonic references to those meaningful experiences organized by
emotion.”9, p. 151 Thus there is some consensus that dreaming supports an identity-
preserving function by downregulating affect that is disturbing to the organized self-system.

MOOD-REGULATION FUNCTION OF DREAMING IN NORMAL PERSONS

That dream function improves postsleep mood has been supported by using four types of
studies: home dreams recalled spontaneously, laboratory dreams collected by awakenings
from REM periods, dreams reported during psychotherapy, and brain-imaging studies
distinguishing areas that are activated and deactivated during REM sleep, NREM sleep, and
waking. None of these data sources alone yields sufficient proof of the mood-regulating
function of dreams, but the cumulative evidence across these independent sources does
support this conclusion.

Evidence of Mood Regulation from Self Reported Home Dreams

Some dreams are sufficiently unpleasant to abort sleep and awaken the sleeper prematurely
with vivid recall of frightening content. This is the usual definition of a nightmare.
Nightmares are common, affecting 2% to 6% of the overall population; are more frequent in
children, women, and psychiatric patients; and have a negative relation to measures of mental
health.10,11 Nightmare frequency compared between patients with and without laboratory-
diagnosed insomnia found nightmares were more frequent in the insomnia group, but
frequency was lower in those with reduced REM sleep.11 On a continuum of more unpleasant
to more pleasant content, nightmares are at one extreme, bad dreams that do not wake the
sleeper are at a mid point, and neutral or more pleasant dreams are at the opposite end. The
frequency of the two types of unpleasant dreams correlate negatively with a self-report
measure of well-being.12

Dreams recalled spontaneously by adults often have a negative affective tone. This
contributes to their ability to be recalled. Individual differences in recall rates have been
noted to be related to various personality traits and to specific states, although few of these
correlations have stood up to replication. Dream recall has been noted to be higher in women
and associated with a trait of their higher interest in their inner life. Recall has also been
associated with a state of anxiety, which is linked to light sleep, higher rates of NREM
dreams,13 and REM dreams with more intense negative affect. When these disturbing dreams
exceed the capacity of sleep to contain them, a premature awakening from REM results in a
failure of within-night mood regulation. However, failure to regulate negative mood on one
night does not necessarily invalidate the mood-regulatory function. It might take more than
one night to regulate a highly disturbing mood. Other possibilities are that the recall of
negative dreams is an artifact of the method used to collect them. Researchers generally use
questionnaires that ask for retrospective reports. A comparison of home dream reports to
laboratory-collected dream reports show that home dream reports have more disturbing
content.14
 Because most sleep does not result in a premature REM awakening in fear, it is
possible that dreaming is for the most part successful in regulating affect within the night or
that the presleep affect might not require nightly regulating in healthy sleepers. In either case,
waking without a change in mood when the mood was not elevated before sleep onset, or
waking in a more positive mood when the presleep mood was only moderately elevated, was
predicted in an early model of the relations of presleep mood, dream characteristics, and
postsleep affect level.15 This model proposes:

• Morning mood varies systematically with the degree and kind of presleep emotional state
and the quality and quantity of sleep that follows.

• When the mood before sleep is elevated and moderately negative, dream affect will show a
progressive reduction within a normal night of sleep in healthy persons, resulting in a
reduction in the negativity of morning mood from the presleep level.

 When the degree of presleep affect is either highly elevated and negative in type or is not
elevated in intensity above that person’s baseline and is neutral in type, the within-sleep
dream affect sequence will be random from REM to REM and the morning mood will be
unchanged.

A review of studies when presleep affect level is expected to be elevated in intensity

and negative in type have been examined for their findings relevant to these proposals.
Following the 1989 San Francisco earthquake, frequency of nightmares was reported to
increase to 40% among persons who were living in the area but not in a control group living
remotely in Arizona, where the rate was 5%.16 A traumatic event plus helplessness to cope
with it were the conditions implicated in the persistence of nightmares over 4 or more years
in children who had been kidnapped and buried in an abandoned quarry for 2 days.17 The
author suggests that the long delay in dream adaptation was a function of the children’s
having had no previous solutions to such an event stored in their long-term memory, which
were necessary to provide helpful dream images to defuse their fear. Children who witnessed
the 9/11 New York City Twin Towers attack, some from their preschool across the street,
were studied by interviewing the parents, the teachers, and the children over 4 years. Those
who continued to have disturbed dreaming had a higher rate of a previous personal trauma—
tonsillectomy, car accident, or dog bite—than did exposed children who did not have
nightmares. The authors suggested that those with previous traumas had been “sensitized” to
attend to frightening events.18 Among adults surveyed by Internet for nightmare frequency
following 9/11, only men reported a significant increase.10

Nightmares are more frequent in young children and gradually reduce with age. The
elderly have the lowest rate, suggesting nightmares relate negatively to the presence of
learned coping behavior, which tends to increase with age. These naturalistic studies support
a general trend for disturbing events to be followed by disturbed dreaming but do not provide
sufficient data to be more than suggestive.

Dreams Collected in the Sleep Laboratory

DREAMS IN SUBJECTS UNDERGOING SURGERY

Dream content reports were collected in the laboratory by Breger and colleagues19 before and
after a planned stressful event: elective surgery. Although the dreams demonstrated the
impact of surgery on the dreamers’ sense of personal integrity, this varied according to the
meaning of this event to the person: whether it was anticipated to correct a problem or was a
dreaded experience. This meaning was not directly represented in the dreams but was
displayed metaphorically. This is one of the complications of dream research; the images are
not realistic snapshots of waking events. They are more often compounds of new and old
associated images and so require some unwrapping of their personal meaning. This poses
problems for the reliability of scoring dream content. Winget and Kramer20 have provided a
resource for this work in a book devoted to instruments for measuring dream content along
with the reliability data available for each scale.

DREAMS IN DEPRESSED SUBJECTS

Sleep disorder clinicians have rarely applied sleep monitoring methods to study the dreams of
patients presenting with various sleep disorders. Notable exceptions are work with major
depression and nightmare patients. The finding that the classic timing of REM sleep is shifted
to occur earlier in the sleep of those suffering a major mood disorder was noted by early sleep
investigators.21,22 This was modeled as a phase advance of REM sleep by Wehr and
coworkers23 and as a response to increased waking affect.24 There are other abnormalities of
sleep in the depressed including an increased fragmentation of sleep, particularly of the REM
periods. The percentage of rapid eye movements themselves is a good indicator of the general
emotional or motivational turmoil in schizophrenics and in depressed patients.25 The density
of rapid eye movements in REM episodes is more variable in the depressed subjects than in
controls. These patients show periods when the eye movements are very sparse and periods
of eye movement storms.

These abnormalities suggest an explanation for the why depressed subjects have
difficulty developing or reporting coherent dreams and consequently fail to regulate morning
mood. Dream recall in depressed subjects is poor, even when they are awakened from REM.
Most common are reports of no recall or a short report describing a single image with flat
affect.26-28 This poverty of dreaming may be due to the observed disturbances—the frequent
interruptions of REM sleep and the dysregulation of the release of rapid eye movements,
allowing too few to supply the images or too many to allow time for the associations
necessary to construct a dream scenario. Nofzinger and colleagues29 reported that patients in
remission from depression show a reduction in eye movement density. Other aspects of sleep
in depressed subjects prove to be more stable. Two of these, the poor quality of sleep and
early onset of REM, typically remain after remission.30,31 The most robust of the markers, the
reduced latency to the first REM, appears to represent a genetic vulnerability to depression in
family members.32

Indrusky and Rotenberg33 studied patients who had major depression and found mood
change based on the patients’ self-report of their morning mood as worse, the same, or better
than before sleep. When morning mood was “better,” the eye movement density was low in
the first REM period and increased across the night to be highest in the last REM period. This
is similar to the eye movement distribution pattern of healthy subjects. In contrast, those
whose mood either did not change or worsened overnight had high eye movement density in
the first REM and a slow decrease from REM to REM, the opposite to that of control
sleepers. Thus depressed patients whose within-night sequence of rapid eye movement
density resembles that of healthy subjects are more likely to feel an improvement of mood on
awakening next morning. This is consistent with the findings of mood improvement with this
pattern reported by others.30,34

DREAMS IN DIVORCING SUBJECTS

Marital separation or divorce is another disturbing life event that has been studied in the sleep
laboratory for its impact on sleep and dreams and on overnight mood regulation.

Divorce has a lengthy time course allowing longitudinal study of changes in mood
and adaptation to an identity change. There is a wide variance in emotional response to this
event, from a relatively rapid adjustment to one that is long delayed and has serious
emotional consequences.

Clinical depression is common and has a strong effect on both sleep and dreaming. In
one study of this series24,30,35-37 equal numbers of male and female subjects, 40 with
untreated clinical depression secondary to the divorce and 30 nondepressed controls, were
studied in the laboratory, with REM dreams collected at intake and, for 22 of 30 controls and
39 of 40 depressed subjects, 1 year later. Subjects rated their dream affect as pleasant,
unpleasant, or neutral and whether the dream was unemotional, mildly emotional, or strongly
emotional. The number of unpleasant dreams was significantly higher in the depressed group.
Depressed subjects who dreamed of the ex-spouse were not more depressed than those who
did not but had higher dream affect scores and no longer met depression criteria at the 1-year
reassessment. Those who dreamed of the former partner with expressed emotion on the first
REM collection night showed a within-the-night dream affect change from negative to
positive. The difference in percentage of positive and negative affect ratings in the dream
reports of the first half night and those in the second are seen in Figure 54-1. The
discriminant function analysis testing whether the order of dream affect predicted remission
from depression was highly significant. This withinsleep change in dream affect correctly
classified the remission status of 72% of those initially depressed.

This study was followed with a second study testing mood-regulation in a

nondivorcing sample38 using the Profile of Mood States (POMS)39 and a current concerns
questionnaire.40 Sixty high-functioning adults, with no present symptoms or history of
depression, had dreams collected from each REM period and rated for affect. The group was
stratified by presleep POMS Depression scale into two groups by intensity of mood: no
elevation of depressed mood (N = 50) and mild elevation of depressed mood (N = 10). The
no elevation group had more positive than negative dreams, with a flat distribution across the
night, and those with mild elevation had a higher percentage of negative dreams in the first
half of the night and a reduction of these and increase in the percentage of positive dreams in
the last two dreams collected (Fig. 54-2). This supports that there is a within-night mood
regulation process in normal persons. The reduction in POMS morning score suggests that
within night dream affect change helps to reduce the level of the negative morning mood
when the intensity of the mood is modestly elevated before sleep.
 The third study in this series,40-42 enrolled 30 divorcing volunteers with equal
numbers of men and women. Twenty depressed subjects and 10 controls were tested for
changes in mood regulation in relation to remission from depression after 5 months. The
POMS before and after each night of laboratory sleep yielded 12 data points, showing
successful mood regulation for those remitting and failure to change in those who did not
remit. The contribution of dream content to remission was significant. The degree of the
presleep waking concern about the former spouse from the current concerns test40 and the
total number of dreams of the ex-spouse in REM reports, the degree and type of affect
expressed in the ex-spouse dreams, and the presence of older memory images in those dream
reports were predicted to contribute to remission without treatment. The number of ex-spouse
dreams was associated with successful regulation of disturbed morning mood, but only when
these dreams included the expression of negative affect and older associated memories (Box
54-1).43,44

DREAMS FOLLOWING PRESLEEP STRESS

Breger, Reiman, and Lauer43 manipulated presleep stress levels in the laboratory to induce an
increased negative state in healthy and depressed volunteers to investigate changes in sleep
and dreams collected from the first and last REM period. Stress levels were measured by
mood ratings; blood samples to measure cortisol, human growth hormone, and prolactin
levels; and heart rate while the subjects watched a stressful movie and a neutral movie.

Their predictions of differences in first and last dream reports following the two
conditions and morning mood change were supported only in the healthy group, who showed
a presleep physiologic and psychological stress reaction to the stressful movie. They had first
dreams following the stress movie that were more anxious and aggressive, with higher self-
participation than in their first dreams following the neutral movie. The dreams from the last
REM showed improved mood in both conditions and a marked improvement in morning
mood scores. The depressed group had few scorable dreams, although their self-reports of
mood at each REM awakening were poorer from first to last experimental awakening.

The authors conclude that the dreams of healthy subjects show within- night coping
with stress leading to positive mood regulation, but dreams of depressed persons may actually
promote depression. The small samples and the failure of the depressed group to report
dreams are limitations of the study.
 Results

Results from these various negative life event studies support the proposition that dreaming
is generally responsive to new emotion-evoking situations requiring adaptation; however,
there are individual differences. Those with “thin boundaries” are more likely to have high
recall and increased dream intensity to levels that disrupt sleep,44 whereas others, like the
depressed subjects, have low dream recall with dampened dream affect and lesselaborate
dream construction. Both extremes, those with high and low affect in waking, display less
mood regulation following sleep. It is those with moderate presleep mood disturbance who
show the predicted dream response with progressive downregulation of mood. It is only in
studies where dreams are retrieved in the laboratory that these within-the-night affect changes
can be tested. If negative dream affect is not progressively reduced, and the content does not
link present disturbing experiences to similar past events, mood regulation may require a
therapeutic intervention.

Mood Regulation in Office Dreams in Psychotherapy

Psychotherapists who encourage patients to report dreams expect this will further their
treatment goals. The assumption is that dreams give the therapist access to information about
the emotional life that patients are unable or unwilling to verbalize directly; dreams are a
short-cut to the affective or cognitive organizational patterns underlying the irrational
anxieties and poor behavior choices that have brought patients to seek help. Here the
emphasis is on how dreams reveal the way the patient’s past affective learning history
influences their present behavior in a detrimental manner.
Box 54-1 Examples of Dreams of Ex-spouse in Remitting and Nonremitting Depressed
Subjects

Example 1 This dream is from a depressed woman who did not remit: “I was dreaming about
my husband dating this girl that he works with and him taking her out. That’s all I can
remember.” (Question: Anything else?) “He was just taking her out, meeting her at our
house. I was just sitting in my house, in my living room, and he was going out the door with
this girl.” Comment: The spouse is present but no affect is expressed. There is only a single
image without story development or any older memories.

Example 2 This dream is from a depressed woman who was in remission at month 5: “I was
fleeing from something with my daughter and son on a dark street in a suburban area, an
Indian or Asian community with barbed wire around the fence. My son needed to use the
bathroom and my daughter needed water for her dog. We knocked on the door of this house
and an old woman answered and I asked her for help but a man came to the door and said
“No.” I asked him “Why not?” and he said “You would have to be my wife.” I didn’t know
what to do. Then we were backtracking through a field and there were shots being fired all
around. Then we were in a room where a dance was being planned. I was telling my ex-
husband that I would only be staying for 5 minutes and he said “Fine,” like he didn’t care. I
knew that his new girlfriend would be there and they would be dancing. I felt resentful. I
didn’t want to see that.” Comment: Here the spouse is present and the dreamer’s negative
affect “resentful” is expressed. The historical elements are the setting of her former South
African home where she is rejected as a nonwife when in danger and asking for help. This
past is linked to a present image of the ex-husband who doesn’t care. Her changing role as
now the primary caregiver in the family is linked to present marital dissolution.
 Schredl’s group45 surveyed psychotherapists on their use of dreams in treatment. Both
psychoanalytic and humanistic therapists report they work on dreams in 28% of their
sessions. Seventy percent of those believed this work to be beneficial to their patients. With
few exceptions,46,47 evidence from hypothesis-driven research of a direct benefit from
therapeutic work with dreams is lacking. Support of this practice rests on abundant case
reports illustrating dream interpretation furthers the insight of the therapist into their patient’s
inner life. Evidence that this promotes better use of therapy hours, is instrumental in changing
dysfunctional dreaming, and is responsible for subsequent changes. in waking emotional
adaptation is at present correlational.

Palombo48 proposed a mechanism to explain how dream interpretation helps to

“restore and renew the incomplete self” by the analyst’s work interpreting the patient’s
dreams, which leads the patient to have a “corrective” dream. This stimulates the same dream
memory network, which incorporates the interpreted changes and produces a corrective
dream that is now ready to respond more positively to a similar new emotion-evoking
experience. This could be tested, but there has been no study published.

A formal test of the idea that becoming aware of what one is dreaming is helpful to
the process of initiating change in emotionally dysfunctional patients was conducted by
Cartwright, Tipton, and Wicklund.46 Dream access was provided by 2 weeks of laboratory
sleep with REM awakenings and by prompting dream recall next morning before treatment
began for an experimental group of 12 patients. The effects of this intervention were
compared to those of two control groups: One was awakened only in NREM sleep the same
number of times as the experimental group at same time of night, and the other group went
directly into treatment. All 36 subjects were selected by the intake worker as being poor risks
for successful treatment based on their low score on a counseling readiness scale49 and
judgment that they were not insightful, with poor skills for self-understanding. These subjects
were predicted to drop out of treatment before receiving any benefit. The benefit criteria were
remaining in treatment for at least 10 sessions and engaging in therapy-appropriate behavior
such as discussing their feelings. The results of the research supported that increasing the
patient’s access to their dreams and practice in recalling and discussing these was related to
the patients staying in treatment and engaging in productive psychotherapy. Two
unanticipated findings were that some in the experimental group failed to recall dreams even
with REM awakenings, similar to patients with major depression, and a few in the NREM
control group produced reports that were judged by blind raters to be dreams. These patients
derived the same benefits from treatment that were expected only for the experimental group.
Those who were able to access their emotional issues through dream retrieval, whether from
REM or NREM awakenings, progressed well in treatment. The dreams provided focus on an
issue they explored in their treatment.

Hill and colleagues have developed and tested a short treatment program focused on
dreams called the Hill Cognitive-Experiential Dream Model.47,50,51 This is a threestage
approach: exploration, insight, and action. The method is designed to elicit feelings in
relation to the dream images by retelling a recalled home dream using the present tense as if
it were being experienced in the hour and, with the therapist’s help, to explore how the
images relate to their waking experience. Limitations of these types of studies include the
experience level of the therapists, often students in training, and the clients themselves, who
are also often student volunteers rather than real patients. Also the therapy is limited to one or
only a few sessions of work on a single dream. Not having the opportunity to see the recalled
dream in the context of the series of dreams occurring the same night limits the applicability
of this method to the question of a within-sleep progressive mood regulation. Despite this, the
model has potential for formalizing dream work and testing the effectiveness of practice in
dream recall on improving waking mood regulation.

A few treatment studies of nightmare sufferers using imagery rehearsal and

desensitization techniques52,53 have reported positive results in reducing the frequency of
nightmares. However, these rely on the patients’ reports and do not document changes in the
experienced dreams.

Dream Function Studied with Brain Imaging

Brain-imaging studies are another source for understanding the function of dreaming from
investigating where in the brain REM dreams are formed.54-59 Winson54 states that “dreams
are a window on the neural processes whereby, from early childhood on, strategies of
behavior are being set down, modified or consulted.”54, p. 204 Imaging has mapped the areas
in which there is increased brain activation and deactivation occurring during REM sleep.
The consensus of this work is that there is increased activation in the integrative visual cortex
and the limbic and paralimbic systems and decreased activation in the dorsolateral prefrontal
and parietal cortices, in comparison to the patterns during waking and in NREM sleep. This
supports that REM dreaming displays emotional concerns in visual terms in a nonlogical
structure.
 Solms56 has tracked the correlation between the sites of brain damage and changes in
the dream experience reported by patients. He finds an intact dopaminergic tract to be basic
to normal dreaming. This work has added to our knowledge base of how dreams are made but
not why. A recent PET imaging study of depressed and control subjects indicates that patients
show different patterns of glucose metabolic changes in the limbic and paralimbic systems in
waking than they show in their first REM period.60 The lack of an increase in activation of
the anterior cingulate in depressed persons was interpreted as perhaps related to the blunted
responsive of these patients to emotionally salient information.

MOOD REGULATION FUNCTION OF DREAMING IN PATIENTS WITH

PARASOMNIAS

The research in support of a mood-regulatory function of dreaming is strongest from the

laboratory studies comparing normal sleepers to those with major depression. Although the
dreaming patterns in other clinical disorders have not been studied in the same detail, there
are indications of support also from the disturbed dreams acted out by patients with REM
sleep behavior disorder (RBD).61 These patients explain their aggressive behavior as a
response to their perceived need to defend themselves or to attack others on the basis of an
ongoing threatening dream scenario. Similarly, NREM parasomnia patients might attack in a
behavioral arousal that occurs in slowwave sleep prior to REM.62,63 This suggests that some
waking experience with an affective charge continues into NREM sleep. Presumably this
would stimulate a relevant memory network and initiate a mood-regulatory process, if REM
sleep had not been aborted by the prior behavioral arousal.

Although many NREM parasomnia events are benign, these may become dangerous
to the patient or others. Sleep terrors are models of overwhelming fear. In neither
sleepwalking nor sleep terrors are dream images being connected to a network of older
memories that might diffuse the affect. Rather this is expressed in the arousal behavior.
NREM parasomnias are more likely to occur in those genetically vulnerable to slow-wave
sleep arousals when their presleep stress levels are high. Then the consequent sleep
deprivation increases the pressure for more delta sleep, but the genetic flaw in controlling
movement during deep sleep leads to partial arousals with motor behavior.64,65 The single
photon emission computed tomography (SPECT) study by Bassetti and colleagues 66 of a
sleepwalker in action shows increased blood flow into the posterior cingulate cortex and
decreases in the frontoparietal cortices.
 The nightmares in PTSD are another example of nonprogressive affect reduction.
These vivid dreams are often repetitive and refer to some earlier life trauma that has left
powerful images in long-term memory. These are associated to a current problem as if it, too,
is life threatening.67 Sleep disorders that interrupt sleep such as REM sleep behavior disorder
and NREM parasomnias prevent mood regulation. The effect of shortened total sleep, which
does not allow time for end-of-night dreaming to complete the modulation of disturbed affect,
may also be implicated in failures to improve morning mood.

CLINICAL APPLICATIONS

Sleep medicine clinicians rarely investigate their patients’ dreams for their contribution to the
sleep complaint. Collecting dreams in the laboratory is costly and not usually covered by
insurance. This makes systems for recording dreams in the home an option.68 The relevance
of dream health to waking physical and mental health has been pointed out in a recent
study.69 This topic has been given increased credence through recent studies of sleep-related
learning and memory and by brain imaging. These studies have anchored the psychology of
70,71
dreaming in science by supporting the contribution of REM sleep to enhanced learning
and identifying the brain sites damaged in head-injury patients with subsequent distortions of
dream experience. Future studies of patients should note if REM is misplaced in the sleep
cycle, occurring too early or too late; if the eye movements are too sparse or too frequent; if
the dreams are well or poorly constructed; and if the dreams fragment REM sleep or end the
night too early. We also need to study the effects these REM and dream variables have on the
waking emotional state that follows. The more we bring objective measurement to the
question of dream function, the better will be the science base for applying this information to
patient care.

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