Bódizs R*, Simor P, Csóka Sz, Bérdi M, Kopp MS : Dreaming and health promotion: A theoretical proposal and some epidemiological establishments. European Journal of Mental Health 3: 35-62. 2008 – 1. Introduction

1. Introduction

1.1. Dreams and science

Does the investigation of dreaming belong to the field of science? This question is worth attention, since the common cultural context covering the phenomenon of dreaming cannot be characterised by a proper scientific background, with corresponding motivation and methodological requirements. Nevertheless, the mysteries of dreaming are often ‘immune’ to direct scientific investigations, and therefore it is difficult to differentiate between the scientifically justified facts, the scientific assumptions, based on these facts, and the conjectures that lack scientific evidence. Accordingly, our aim is to focus on the first and the second case, while we try to liberate the phenomenon of dreaming captured by the belief system full of mysteries that still surrounds it, in spite of all the scientific investigation that has been carried out. Notwithstanding the fact that the world of science can also be considered to be a kind of belief system. In the present paper we try to make this world more utilitarian, by conclusions that may help medical practice, and foster the scientific elaboration of the issue.

1.2. Why dreaming?

The apparently chaotic content and formal characteristics of dreams make it even more difficult to extract valuable information (from them) that can pass the filter of the criteria of clinical and experimental science. Using different approaches, some psychoanalytically oriented psychotherapists consider dreams to be a valuable tool for a deeper understanding of the feelings and attitudes of their patients, as well as a royal road to detect the subtle changes of the psychological state of the dreamer. However, it is difficult to extract these interpretations from the intersubjective context where they belong. Moreover, as a result of the disagreements among the psychoanalytic therapists, the questionable issues of the methods of dream interpretation became an even more debatable topic. Nevertheless, in our view these scientific circumstances do not necessarily mean that dreams would be only useless fragments of information. Hereinafter we review the evidence supporting the psychological relevance of dreams, contrasting the ‘neural noise theory’ according to which dreams are chaotic fragments of information, provoked only by autonomic physiological processes.

1.3. Dream images and brain function: Perception or imagination?

Dreams are hallucination-like experiences that are conceived as false perceptions by certain theories. For example, according to the activation-synthesis hypothesis, dreams result from the effects that the random-like discharges, originating from the brainstem, have on the cortex. Thus there is a meaningless random-like input, caused by physiological processes, and the cortex interprets this input in the light of the previously accumulated knowledge (HOBSON & McCARLEY 1977). The stimulation of the motor cortex provokes motion experiences, the stimulation of the visual cortex leads to the appearance of vivid dream images, the stimulation of the auditory cortex enriches the dream scenario with dreamt voices, etc. (HOBSON 1988). Accordingly, the activation is provided by the brainstem, while the synthesis is carried out by the cortex. In spite of the fact that this assumption is a typical example of the brain-mind isomorphism, there is a hidden higher-order and in some aspect a kind of mental element in it, namely the process of synthesis, that can potentially reflect the schemes and experiences of a synthesising structure, the cortex (BÓDIZS 2000a). Even so, the first drafts of the theory – in a radically reductionist manner – excluded the relevance of the higher organising principles from the mechanism of dreaming, that in the light of the new, forcing scientific evidence could only occupy their deserved role later in a kind of eclectic hybrid theory (HOBSON et al. 2000). According to the activationsynthesis hypothesis, dream images are fragments of perception, and as such, they come into existence by the route of perception.

However, there is another theoretical trend that was preferred by FREUD (1999) already, at the so-called metapsychological level. This includes the ideas according to which dream images are not formed by the interpretation of meaningless inputs (the perception of meanings from meaningless stimuli), but by the imagination, visualisation of relevant thoughts and memories that already contain meaning. These ideas can be perfectly illustrated by the dream thoughts assumed by Freud: there is a thought whose meaning transforms into images, by a reverse path, that we can call today the route of imagination. This is an important difference, because the route of perception depicts the dreamer as the passive endurer of chaos. As HOBSON (1988) denotes, the dreaming mind is like a dream machine that constantly generates dream images, thus the dreamer is only a part and an endurer of an automatic – and in a certain aspect – independent process. In contrast with this view, according to the route of the imagination, it is actually the dre
amer who creates the chaos (naturally in the certain physiological state). So the dream – being an imagined idea – has meaning that contains information about the dreamer. According to the first theory we transform into dream machines and experience transient psychosis every night. In this context the psychosis is the metaphor of the loss of reality, but it also serves to explain the neurobiological aspects of dreaming (HOBSON 2004). According to this view, the qualitative aspects of the dream experience (that resemble psychosis) are the results of a general disinhibited state, where dopaminergic input is combined with the lack of serotonergic input (GOTTESMANN 1999). Others claim that the lack of self-reflective abilities in the dreaming mind, and the irrational, bizarre, illogical and discontinuous nature of dreams are caused by the selective deactivation of the dorsolateral prefrontal cortex, responsible for the functions of working memory, logical reasoning and goal-oriented behaviour (MUZUR et al. 2002). In turn, the theories jousting for the route of imagination emphasise that dreams reflect our thoughts, desires, attitudes, conflicts and feelings by using a sensorial, mainly visual language (SOLMS 1997; GREENBERG et al. 1992). Without negating the physiological bases of the dream process, these theories resemble the psychoanalytical theories that consider dreaming being a signal instead of noise (BÓDIZS 2003, 2005).

The route of perception and the route of imagination are two theoretical possibilities that do not necessarily exclude each other; nevertheless it is still worth examining which path constitutes the main compound of dream formation. It seems that the majority of dreams arise in the REM stage of sleep, or in phases that resemble the REM state in physiological terms (NIELSEN 2000). The analysis of REM sleep and the investigation of dream disturbances caused by brain lesions suggest that dreams principally arise from a ventral route of subcortical stimulation of the cortex. Since this network is independent of the route of perception, and primarily constitutes the neurological background of remembering and imagination, the majority of dreams probably come into existence by the route of imagination (BÓDIZS 2005). Furthermore, in some cases of brain damage in the parietal lobe that cause the cessation of dreaming, the waking visual imagination is also severely affected. For example, after the damage the patient cannot recall any dream, and at the same time is unable to imagine visually a well-known acquaintance or location. It is also noteworthy that in these cases the cessation of dreaming is not caused by memory deficits, because several patients who report the cessation of dreaming have intact memory functions (KAI-CHING YU 2006).

Apart from the neuropsychologically oriented research trends, (SOLMS 1997; KAI-CHING YU 2006) other dream researchers also emphasized the cognitive aspects of dreaming. In contrast with the reductionist theories this research tradition tried to avoid the old brain-mind problem by focusing principally on the mental phenomenon of dreaming (FOULKES 1999). At this level of explanation, dreaming is the manifestation of our mental activity that continues to function after we fall asleep, and thus reflects our self-reflective conscious representations of the outer and inner world (FOULKES 1999; OCCHIONERO 2004). A similar view is outlined by the continuity hypothesis according to which dreaming reflects waking thoughts, mainly the emotional concerns of the dreamer (SCHREDL 2003a; SCHREDL & HOFMANN 2003; DOMHOFF 2001). These phenomenological approaches suggest that dreaming is not a totally different function of our conscious mind, but rather the manifestation of the same conscious functioning, influenced by the altered neurobiological milieu of the sleeping brain. Thus, dreams are like thoughts, depicted in a visual, metaphorical language. If dream images are the fruits of imagination, then – according to the arguments

If dream images are the fruits of imagination, then – according to the arguments discussed above – the meaning, but at least the relevance of dreams is worth the attention of science. We do not exclude the possibility that dreams can also arise by the route of perception, but we propose that this does not constitute the principal mechanism in the case of dreams that we recall in natural circumstances (outside the sleep laboratory) (BÓDIZS 2005).

1.4. Dream images and memories

Because of the highly selective and shallow reception and processing of external information during sleep (BÓDIZS & CSÓKA 2007), the role of memory systems start to dominate, and hence our existing knowledge and memories will be the building blocks of the dream scenario (BÓDIZS 2000b). The searching for memories in dreams has a long past in the history of dream research. FREUD (1999) noticed that in the majority of dreams there is an element that can be interpreted as a reference to the events of the preceding days. He called these elements day residues. The nature of day residues and their relations to other memories is still an important issue in current dream research. One of the main conclusions of the various investigations is that the recent memory elements found in the dream reports rarely reproduce the original context of the memory. The memories – with few exceptions – enter the dream scenario without their spatio-temporal context (NIELSEN & STENSTROM 2005). Dreams create new contexts and new narratives that are formed by the general, semantic knowledge of the dreamer. For example, if someone dreams about a birthday celebration, the dream will not portray a real birthday experienced in the past, but recreate a virtual birthday based on the memories, feelings, attitudes and factual knowledge of the notion birthday. Of course ‘real’ memory fragments can also appear in the dream, but a new narrative, a new context will provide the guideline for the dream. Neuroimaging studies (MAQUET et al. 2000) and phenomenological investigations of the content and structure of dreams (HARTMANN 1996; KAHN et al. 2002) suggest that in the hyperassociative quasi-chaos of dreaming, emotions can be the main organizers. Accordingly, the core emotional concerns of the dreamer, conscious and unconscious affective patterns, can be the deep structure of the dream (NIELSEN & STENSTROM 2005).

1.5. Dreams and emotional regulation

Neurophysiological evidence suggests that dreams are characterised by the interaction of memories and emotions (MAQUET et al. 2000). The synthesis of recent neuroimaging and psychological data have given birth to new theories according to which dreams facilitate the regulation of emotions. These assumptions are based on the neurobiological aspects of REM sleep, because the REM sleep-associated metabolism and blood flow of brain regions responsible for the processing of emotional memories and emotional behaviour exceeds the metabolism and blood flow and hence the activity associated with passive wakefulness (MAQUET et al. 2000). Therefore, it is rather surprising that in spite of the vivid and intense emotions, the dreamer is generally immune to any emotional turbulence. According to the physiological data, this should happen more frequently then we experience in everyday life. The typical example for the escalation of emotions is the nightmare that often awakens the dreamer. Patients with Posttraumatic Stress Disorder (PTSD) often report the presence of recurrent nightmares, and in some of these cases the dreamer re-experiences the traumatic event every night when he is falling asleep (GERMAIN & NIELSEN 2003). It is quite interesting that the intense emotional escalation is accompanied by the dysfunction of novel dream narrative formation because in contrast with the typical dreams, the nightmares of PTSD patients preserve the original spatio-temporal context of the frightening, traumatic event (STICKGOLD 2002). In this case, the dreaming mind ceases to create a new context and a new narrative for the trau
matic memory. Could that be the reason for the emotional escalation (NIELSEN & LEVIN 2007)?

Another example for the intense emotional graduation in dreaming is the nightmares and bad dreams of patients suffering from Borderline Personality Disorder (BPD). Patients with BPD often suffer from nightmares, while the presence of frightening dreams correlates with low fantasy scores, measured by psychological tests. Thus, the occurrence of nightmares was frequent for those subjects who were characterised by an unimaginative waking life. In turn, the nightmares were characterised by a frightening story, wedged into a narrow associative channel, lacking the hyperassociative processes, inner reflections and directed thoughts typical in dreams of the healthy population. Thus here again we can detect the tendency when the dysfunction of the creation of new context and narrative leads to the escalation of (negative) emotions. This also suggests that active imagination and creative skills can be a defending factor against the occurrence of nightmares (SIMOR 2007).

It seems that the creation of a new narrative and new context is important for the emotional regulation in dreaming. According to the neurocognitive model of LEVIN & NIELSEN (2007) the new dreamt contexts of intense emotional memories can serve the role of fear-extinction, while others emphasise that the associative enriching and the integration of the emotional memories into a broader self-centered, semantic network is the ‘royal road’ for emotional regulation (HARTMANN 1996; CARTWRIGHT et al. 2006; STICKGOLD 2002; SIMOR 2007). Whichever mechanism is responsible for the emotional regulation, possibly both, research based evidences suggest that creating new contexts for frightening dreams may facilitate the improvement of waking affect. In the course of the Imagery Rehearsal Therapy the patients suffering from nightmares are told to recall their frightening dreams in a relaxed waking state, and to imagine a positive outcome for their suffocating dream narrative. Afterwards they are told to imagine the new dream narrative again and again. This method not only diminishes the frequency of nightmares but also improves the general mental state of the patients (KRAKOW & ZADRA 2006). This suggests that dreams could have a general role in emotional regulation that can influence the waking affect. Neurobiological data support that the use of imagination, and the integration of rich associations and diverse memory elements into the dream narrative can facilitate coping with the adverse life events and stress caused by emotional conflicts (NIELSEN & LEVIN 2007). For example, bicultural subjects dispose of a richer repertoire of emotional expressions than persons owning only one cultural heritage. If biculturally competent subjects experience a significant loss, they not only use direct and aesthetic-artistic self-reflection more frequently, but they also experience more feeling-change in their dreams, which does not directly ensue from the dream narratives. This is not characteristic of monocultural subjects (ENG et al. 2005). Once again we find that the more expressive the subject is in waking, the more diverse their dream life is, and that in the light of the above mentioned results we consider this favourable for the regulation of emotions. Finally, we should mention the mood restorative effect of REM sleep (CARTWRIGHT et al. 1998) being probably the beneficial effect that the emotional regulation in dreaming exerts on waking functioning. However, in certain pathological conditions, such as depression, the mood restorative effect of sleep and dreaming fails to prevail, and accordingly sleep and dream disturbances are one of the more characteristic symptoms of depression (FLEMING 1994; GOTTESMANN & GOTTESMANN 2007; CARTWRIGHT et al. 2006). Furthermore, in a recent study, CARTWRIGHT et al. (2006) have shown that the dreams of a non-remittent depressed patient group differed from the dreams of depressed patients in remission. The dreams of the remitted patients were more elaborated and richer in associations, while the not remitted group failed to experience emotions in their dreams, and failed to connect their waking concerns to older memories, and to integrate their emotions in a broader network of associated self-relevant emotional memories. The failure of the emotional information processing mechanism was associated with a low morning mood.

1.6. Dreams and modern health conception

In sum we can conclude that dreams reflect the psychological balance of the dreamer. The dysfunctions of emotional regulation suggest that depressing dreams and recurrent nightmares indicate problems of adaptation. Considering the interaction between environment and personality, according to converging evidence environmental stress enhances the frequency of nightmares, primarily in those who are characterised by emotional instability (SCHREDL 2003b; NIELSEN & LEVIN 2007). The frequency of nightmares and even more the distress caused by nightmares and disturbing dreams are prevalent in several psychopathologic states (MIRÓ & MARTÍNEZ 2005; LEVIN & NIELSEN 2007). In a longitudinal study NIELSEN and colleagues (2000) found that the prevalence of disturbing dreams is also frequent in adolescents with trait anxiety symptoms. The association between trait anxiety and the recall of disturbing dreams was demonstrable at ages 13 and three years later in the same subjects, the girls showing a bit worsening and the boys a certain improvement. Thus, the emotional charge of dreams provides information about the successes or failures of psychological adaptation. Therefore, dreams provide information about the environmental influence, the individual sensitivity and levels of coping of the dreamer. This information is more precise than the environmental impacts because it is not distorted by individual sensitivity and reactivity. At the same time it seems a potentially more reliable source of information than the queries concerning the psychological balance directly, because the latter can be much more biased by the individual expectations than dream mentation. Dreams are told from an outer perspective, and if we inquire about the emotional aspect instead of the content of dreams, we do not intrude into the subjective space that people may consider too intimate. If we ask someone how he felt yesterday at a family reunion or we ask how he felt yesterday in his dream, we can imagine that the former could provoke a much more partial answer. In contrast, the latter exempts the subject from the burden of the direct communication of the problem, but in some cases even the sole confession of the problem can cause difficulties. Exploring dream content may be even more useful in those individuals who are unable or unwilling to talk about their psychological state (PESANT & ZADRA 2006). In dreaming everyone can feel free without offending any interest.

1.7. Dreams and health in the light of the epidemiological investigations

We aimed to explore the interrelations between dreams and health indicators by analysing data from a national epidemiological investigation. Along with the questions concerning health and disease, subjects were asked about their dreams. The questions about dreaming were based on our clinical and research experience. These questions form the Dream Quality Questionnaire. Here we report our first experiences with this questionnaire, by performing a factor analysis and by using some relevant items in a health psychological survey and research. We aimed to find out whether we could establish the general state of health of the subjects, by exploring the usual dream recall frequency, the emotional load of dreams, the presence of frequent recurrent and nonrecurrent nightmares and the bizarreness of dreams. Questions were foregrounded that concerned the change of the state of health (improved, without change, worsened), because these directly indicate the disharmony of psychobiological balance. Moreover, we examined the number of days spent
in hospital in the last year, which we considered more or less objective indicators of high practical relevance.