While occasional nightmares are a common and normal responses to waking stress, more frequent disturbed dreams and nightmares may be indicative of underlying psychopathology. In the more benign case, the frequency and intensity of disturbing dreams may show a progression and resolution over time, whereas chronic nightmares are repetitive, persistent, and associated with lower psychological well-being, as well as histories of trauma or abuse.1 In fact, frequent and distressing nightmares, along with several other qualities of disturbed dreaming, such as changes in emotional intensity, increased bizarreness, or unusual character interactions, have been associated with specific psychological disorders, including depression, schizophrenia, and personality disorder.

Depression.

Perhaps unsurprisingly, depressed patients report dreams with more negative mood and emotion than control subjects, as well as more failures and misfortunes (compared to schizophrenics).2,13 Patients with depression also experience more frequent nightmares.4,14 Further, depressed patients with a history of suicidal thoughts or behaviors report more death themes in their dreams. However, one study found that depressed patients reported less negative, but more neutral affect in their dreams; the authors interpret this finding to be consistent with the affective flattening seen in depression. Further, one study of bipolar disorder, found that shifts from neutral or negative dream content (as in depression) towards more bizarre and unrealistic dreams can predict alterations between depressive and manic states.16 This suggests that shifts in affective content of dreaming may occur congruently with vacillations in waking mood in depression.

Besides affective content, depressed patients have been found to play a relatively passive role in their dreams, along with reporting less bizarre dreams, lower dream recall frequency, and less detailed dream reports.17,18 One study repeatedly awakened depressed patients 5 minutes into REM sleep episodes, a period that typically promotes high dream recall, and found that depressed patients were consistently unable to recall their dreams.19 These findings altogether are suggestive of a relative inhibition or flattening of dream content in depressed patients.

Schizophrenia.

Several studies have found the dreams of schizophrenic patients to contain heightened levels of anxiety and negative affect. For instance, they report higher frequencies of hostility in their dreams in comparison to controls, specifically increased hostility directed towards the dreamer.2,3 They also have more frequent nightmares than healthy subjects.4,5

When assessing the character involvement in the dreams of schizophrenics, several studies have found presence of more strangers, fewer familiar characters or friends, as well as an idiosyncratic finding that the patient is often not the main character of the dream.6-9 The combination of anxious and apprehensive dreams, and perceived hostility from strangers and unfamiliar characters is consistent with experiences of persecutory delusions in waking life.

Inconsistency in reports on bizarreness include results of at times more bizarreness and implausibility, but at other times, no differences in bizarreness of dreams of patients compared to controls.10-12 This inconsistency may be due to the methodology use for rating dream bizarreness; for instance, one study showed that schizophrenics self-rate their dreams as less bizarre than judges do (perhaps because they are so used to how bizarre their dreams are).8 On the contrary, waking daydreams are consistently found to be more bizarre in schizophrenic patients.

In general, the increased negative affect, higher frequency of nightmares, and unusual character profile of patients’ dreams is consistent with waking symptoms of schizophrenia.

Personality Disorder.

Patients with borderline personality disorder experience more negative dreams, as well as more distress within their dreams and after awakening from dreams.20,21 Further, personality disorder is consistently associated with higher-than-average nightmare frequency,20-22 and increasing nightmare frequency is associated with more severe symptoms in personality disorder.23 Some researchers suggest that these chronic nightmares may be related to childhood traumatic experiences, which are often implicated in the development of personality disorder.24

However, in another study, character interactions in the dreams of personality disordered patients were found to contain more friendliness and less aggressiveness, as well as less confusion than control subjects dreams.25 They also contained heightened levels of sensory vividness, including movement and auditory attributes. These findings seem somewhat contradictory to the prevalence of nightmares and anxious, distressing dreams, but could be indicative of a general intensification of dreaming processes that may at times result in nightmares, or at times in vivid non-nightmare dreams, depending on current levels of stress.

Clinical implications of disturbed dreaming in psychological disorders.

Patterns in disturbed dreaming may be useful as indicators of psychiatric progression. For instance, increasing reference to death in the dreams of depressed patients could reveal the presence of suicidal thoughts, and is thus a potent cue for clinicians, especially since nightmares themselves are associated with greater risk for suicide.22 On the other hand, shifts towards more positive themes may be indicative of successful treatment. As mentioned, in bipolar disorder, shifts from negative to bizarre dreams may reflect shifts from depressive to manic states, and can thus alert the patient/clinician to oncoming symptoms.16 The prevalence of nightmares in all three psychological disorders further suggests that treatments incorporating targeted nightmare reduction may be more successful than those that neglect nightmares. In general, assessment of dreams can serve as a useful barometer for changes in psychopathology and can thus be effectively used within treatment contexts.

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