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Dream content and intrusive thoughts in Obsessive-Compulsive Disorder

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Abstract

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.

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... However, another study (Stein, Chartier, & Walker, 1993) reports no difference on the risk of experiencing weekly nightmares between individuals suffering from a panic disorder and controls. Besides, in three studies ( Cavallotti et al., 2016;Kuelz, Stotz, Riemann, Schredl, & Voderholzer, 2010;Sauteraud, Menny, Philip, Peyré, & Bonnin, 2001), individuals suffering from an OCD and controls completed a dream diary for 1 week. Dream reports were self-rated or rated by independent evaluators. ...
... Individuals suffering from an OCD did not differ from controls on self-reported negative emotions or evaluator-rated negative emotions ( Kuelz et al., 2010). Moreover, there was no difference between the groups on the following evaluator-rated elements: anxiety in the dreamer, sadness in the dreamer, failure of the dreamer ( Sauteraud et al., 2001), and obsessions/compulsions ( Cavallotti et al., 2016;Kuelz et al., 2010;Sauteraud et al., 2001). ...
... In individuals suffering from a panic disorder, nightmare frequency is associated with the frequency of nocturnal panic attacks; however, it is not associated with the severity and frequency of panic disorder symptoms nor with the duration of illness ( Schredl et al., 2001). Furthermore, among individuals suffering from an OCD who completed a dream diary for 1 week, the number of evaluator-rated obsessive-compulsive themes in the dream reports was not associated with the severity of obsessive-compulsive symptoms in waking ( Cavallotti et al., 2016). Finally, among youth suffering from an OCD, children aged 8 -11 are at increased risk to experience nightmares compared with adolescents aged 12-17 ( Storch et al., 2008). ...
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... Meanwhile, the type of data used is theoretical data in questionnaires, monitoring, and the results of researchers' interviews with sources. Also, empirical data is obtained using methods or methods that can be observed by the human senses so that other people can also know and observe the methods or methods used (see BERNHARDT, 1983;Caldas-Coulthard & Coulthard, 1996;Cavallotti et al., 2016;Hu & Gao, 2017;Innes & Brookman, 2013;Larsson, 2017). ...
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Sleep related symptoms of depression include sleep fragmentation, early morning awakening, decreased rapid eye movement (REM) sleep latency, increased REM density, and more negative dream content. Most tricyclic antidepressants (ADs) increase total sleep time and decrease wake time after sleep onset, while many selective serotonin reuptake inhibitors (SSRIs) have an opposite effect. However, almost all ADs prolong REM sleep latency and reduce the amount of REM sleep. Case reports and research data indicate a strong effect of ADs on dream recall and dream content. We performed a systematic review (1950 to August 2010) about ADs impact on dreaming in depressive patients and healthy volunteers. Twenty-one clinical studies and 25 case reports were eligible for review and document a clear AD effect on dreaming. The major finding, both in depressed patients and in healthy volunteers, is a decrease of dream recall frequency (DRF) under ADs. This is a rather consistent effect in tricyclic ADs and phenelzine, less consistently documented also for SSRIs/serotonin norepinephrine reuptake inhibitors (SNRIs). Tricyclic ADs induce more positive dream emotions. Withdrawal from tricyclic ADs and from the monoamine oxidase inhibitors phenelzine and tranylcypromine may cause nightmares. Intake and even more withdrawal of SSRIs/SNRIs seem to intensify dreaming, which may be experienced in different ways; a potential to cause nightmares has to be taken into account. Though there are clear-cut pharmacological effects of ADs on DRF and dream content, publications have been surprisingly scarce during the past 60 years. There is evidence of a gap in neuropsychopharmacological research. AD effects on dreams should be recognized and may be used in treatment.
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A program for automatic sleep staging of whole nights polygraphic records of human subjects is described. The electronic system consists of an analog component, performing a first reduction of data, and a digital one, a small general purpose computer. The computer program assesses first the technical quality of the record, by recognition of artefacts, which may impair the diagnosis procedure. It performs second a two steps analysis, based upon electroencephalogram, muscle activity and eye movements. The first step of analysis is a recognition of elementary patterns on the tape and the second step is a calculation of a minute by minute sleep stage diagnosis, based upon these elementary patterns. This program has been tested by comparisons with human scoring of the same records, and has proved to have a good accuracy. This system is actually used as a clinical tool in the exploration of sleep disturbances.
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Very little is known about dreams in patients with obsessive compulsive disorder, especially regarding changes over the course of treatment with stimulus exposure and response prevention. By use of dream content analysis, 40 dreams of 9 obsessive compulsive (OC) inpatients were compared with 84 dreams of 10 matched OC outpatients and 63 dreams of 11 healthy control participants. Dream protocols of inpatients were collected at the beginning of treatment and after the first exposure exercises. Controls filled in dream protocols in respective intervals. Before treatment, dreams of patients showed significantly less positive contents than dreams of healthy controls. Under treatment with exposure, a significant reduction of OC themes was observed. The findings support the continuity hypothesis of dreaming by showing a link between day-time symptoms and OC symptoms in dreams. Contrary to expectations, however, exposure treatment does not intensify dreams.
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A new experimental paradigm called "Early-Night Serial Awakenings" (ENSA) was explored to find out its strengths and weaknesses for psychophysiological studies of NREM sleep dreaming. Five participants spent 20 experimental nights in the sleep laboratory, and were serially awakened with approximately 24-minute intervals during Stages 2 and 3 of NREM sleep. As a total, 164 awakenings were conducted during the sessions that lasted on average 193 min. Altogether, 30% of NREM sleep awakenings led to dream reports, 39% to reports of white dreaming, and 31% to reports of dreamless sleep. Results also show that sleep EEG spectral power, dream recall frequency as well as dream complexity remained stable throughout the serial awakening sessions. We conclude that, as ENSA dreams appeared to be static and very limited in content, the paradigm we identified could be used in future studies to reveal the psychophysiological mechanisms of relatively simple forms of early-night NREM sleep dreaming.
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Many clinical, laboratory and non-laboratory studies have examined dream content reported by patients with schizophrenia but findings have been variable and inconsistent. Using both questionnaire-based measures and laboratory REM sleep awakenings, we investigated dream content in 14 patients with schizophrenia (mean age=25.5+/-3.2 years) under atypical antipsychotic medication and 15 healthy controls (mean age=22.3+/-4.2 years). The relationship between eye movement density during REM sleep and dream content was also explored. Questionnaire data revealed that when compared to controls, patients with schizophrenia report experiencing a greater number of nightmares but no significant differences were found 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 patients 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 participant group. Patients with schizophrenia spontaneously rated their dream reports as being less bizarre than did controls, 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.
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Useful clinician-rated measures of OCD are now available. The Y-BOCS and NIMH Global OC both seem suitable for monitoring outcome in drug trials of OCD. These two scales seem relatively specific for symptoms of OCD and are sensitive to drug-induced changes in symptoms. Neither the Y-BOCS nor the NIMH Global OC confuse trait with state. There are ample data suggesting that the Y-BOCS is reliable and valid scale. Unlike some of the symptom inventories, such as the LOI and MOCI, final scores on the NIMH Global OC and Y-BOCS are not influenced directly by the type or number of obsessions and compulsions present. A computer-administered version of the Y-BOCS has been developed. Currently available patient-rated instruments suffer from serious shortcomings, including insensitivity to change and poor representation of patients with mono-symptomatic clinical pictures (e.g., hoarding alone). Some rating scales have been adapted for use in children with OCD. Several groups, including our own, have elected to use change scores on the 10-item Y-BOCS and a global measure of OCD, such as the NIMH Global OC or modified OGI, as the principal outcome variables in drug trials in patients with OCD. Several studies have selected a 35% decrease in Y-BOCS scores from baseline as indicative of clinically significant improvement. A limitation of all single-item global measures is that they cannot be resolved into smaller components. The more fine-grained analysis that is possible with the multi-item Y-BOCS makes it more desirable as a primary outcome measure, with a global scale as a secondary outcome measure.
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Jakes' critique fails to consider (i) the importance of appraisal of responsibility in initiating neutralising activity, and that (ii) obsessional patients negatively evaluate the occurrence as well as the content of intrusive thoughts. These factors are crucial because neutralising is presumed to be central to the development and maintenance of obsessional disorders. The current form of the hypothesis is outlined and recent data reviewed. Possible experimental investigations on the focus of therapeutic interventions are considered.
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The effect of a single, oral bedtime dose of the benzodiazepine hypnotics flunitrazepam (FR; 2 mg), flurazepam (FR; 30 mg), and triazolam (TR; 0.5 mg) on the sleep stages and the sleep EEG was investigated in eight healthy, young subjects. In comparison to the placebo night, all drugs reduced the percentage of stage 1 and REM sleep, increased stage 2, and decreased the number of stage shifts. For FN and FR, some of these changes persisted in the postdrug night. All-night spectral analysis of the EEG showed a reduction of low-frequency activity (0.25-10.0 Hz) in stages 2, 3 + 4 and REM sleep, changes that persisted for all three drugs in the post-drug night. In the drug nights, activity in the spindle frequency range (11-14 Hz) was enhanced particularly in stage 2 and 3 + 4, activity in the high frequency range (17-25 Hz) particularly in REM sleep and stage 1. In the first third of the drug night, the depression of low-frequency activity in stage 2 was either absent (FR) or less prominent (FN, TR) than in the following part of the night. The results demonstrate that benzodiazepine hypnotics induce specific changes in the EEG spectra which reflect the immediate and residual drug effects more sensitively than conventional sleep scores.
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The dynamics of EEG slow wave activity during sleep were investigated in two subjects recorded for 14 consecutive nights, and in 14 subjects recorded for one night after placebo administration. In addition, records were obtained after a single bedtime dose of the benzodiazepine hypnotics flurazepam (30 mg), flunitrazepam (2 mg), triazolam (0.5 mg) and midazolam (15 mg). Mean slow wave activity (i.e. spectral power density in the 0.75-4.5 Hz band) invariably declined from the first to the third nonREM sleep episode. Within episodes, slow wave activity showed initially a gradual buildup over a period of offroximately 35 min, and in the end a rapid decline. Both the rise rates and fall rates decreased over the first three nonREM sleep episodes. The benzodiazepines typically attenuated mean slow wave activity within episodes as well as the rise and fall rates. For three compounds, residual effects were demonstrated in the drug-free post-drug night. We conclude that a homeostatically regulated sleep process determines the buildup rate of slow wave activity within nonREM sleep episodes.
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In this preliminary and exploratory study, we collected the dream reports and mood ratings of 6 outpatients with bipolar disorder over a 6-month period to compare the relationship between dream themes and mood states. We found that neutral mood states were associated with mundane, routine or uneventful dreams while manic states featured bizarre and improbable dream themes. Neither depressed nor mixed states showed a consistent trend in dream themes. By categorizing the dreams that preceded mood shifts, we were able to identify a particular type of dream that seemed to precede a mood shift, particularly in the direction of mania. Shifts to mania were heralded by dreams of death and bodily injury. Forthcoming depression was more clearly associated with a decrease in overall number of dreams reported. The significance of dreaming in relation to mood is discussed in terms of these preliminary findings and our bipolar dream scale is offered for the convenience of subsequent investigators.
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Rapid eye movement (REM) sleep is a behavioral state characterized by cerebral cortical activation with dreaming as an associated behavior. The brainstem mechanisms involved in the generation of REM sleep are well-known, but the forebrain mechanisms that might distinguish it from waking are not well understood. We report here a positron emission tomography (PET) study of regional cerebral glucose utilization in the human forebrain during REM sleep in comparison to waking in six healthy adult females using the 18F-deoxyglucose method. In REM sleep, there is relative activation, shown by increased glucose utilization, in phylogenetically old limbic and paralimbic regions which include the lateral hypothalamic area, amygdaloid complex, septal-ventral striatal areas, and infralimbic, prelimbic, orbitofrontal, cingulate, entorhinal and insular cortices. The largest area of activation is a bilateral, confluent paramedian zone which extends from the septal area into ventral striatum, infralimbic, prelimbic, orbitofrontal and anterior cingulate cortex. There are only small and scattered areas of apparent deactivation. These data suggest that an important function of REM sleep is the integration of neocortical function with basal forebrain-hypothalamic motivational and reward mechanisms. This is in accordance with views that alterations in REM sleep in psychiatric disorders, such as depression, may reflect dysregulation in limbic and paralimbic structures.
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To test the hypothesis that REM sleep and/or dreams contribute to overnight mood regulation, 61 subjects were tested on the Beck Depression Inventory (BDI), and for 3 nights of monitored sleep on two occasions, once close to, and 1 year after, a marital separation. Forty-nine percent of the variance in the follow-up BDI could be accounted for by the initial BDI score, and three sleep and dream variables associated with the mood regulatory hypothesis: eye movement density in the first REM, strength of the affect in the first dream and total number of negative dreams recalled from REM awakenings. Among the 39 who met BDI depression criteria initially, 71.8% could be classified correctly as remitted or not remitted at follow-up by discriminant function analysis based on the presence of negative dreams the first vs. second half of the night. Subjects reporting more negative dreams at the beginning and fewer at the night's end were more likely to be in remission 1 year later than were those with fewer negative dreams at the beginning and more at the end of the night. Early negative dreams may reflect a within-sleep mood regulation process taking place, while those that occur later may indicate a failure in the completion of this process.
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Controversy surrounds the function of the anterior cingulate cortex. Recent discussions about its role in behavioural control have centred on three main issues: its involvement in motor control, its proposed role in cognition and its relationship with the arousal/drive state of the organism. I argue that the overlap of these three domains is key to distinguishing the anterior cingulate cortex from other frontal regions, placing it in a unique position to translate intentions to actions.
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We sought to investigate the content of the dreams of obsessive-compulsive outpatients in the light of the following postulate: if dreams play a role in the processing of information and mental storage of events of the day, the dream recollections of obsessive-compulsive disorder (OCD) patients should present evidence of diurnal obsessive or ritual themes. On seven successive mornings, immediately after awakening in their home environment, 10 nondepressed OCD patients and 11 controls recorded their recollections of the night's dreams on an audiotape. After randomization of dreams, two judges were asked to carry out a blind evaluation of the emotional characteristics perceptible in these dreams and the presence of obsessive or ritual themes. 47 dreams were collected in the OCD group and 55 in the control group. No differences were found between the two groups regarding anxiety, sadness, the theme of failure, or the presence of obsessive or ritual themes. About 60% of OCD patients and 73% of the control group recounted dreams expressing anxiety, sadness, or failure. Most surprisingly, in the control group as well as in the OCD group, about one-third of subjects presented obsessive or ritual themes in their dreams. These data suggest that there is no evident link between diurnal mental activity and the morning recollection of nocturnal dreams regarding anxiety, failure, sadness, and obsessive-compulsive themes.
Article
Recent neurobiological models of obsessive-compulsive disorder (OCD) posit that a dysfunction in orbitofrontal-subcortical circuitry underlies the etiology of this disorder. Much of the empirical support for these theories comes from studies using neuroimaging techniques to compare brain activity in OCD patients with that in non-OCD controls. Qualitative reviews of this literature implicate the orbitofrontal cortex, caudate nuclei, and thalamus. In this study, a meta-analysis was conducted to summarize the results of studies using positron emission tomography (PET) and single photon emission computed tomography (SPECT) to investigate brain activity in OCD. Results suggest that differences in radiotracer uptake between patients with OCD and healthy controls have been found consistently in the orbital gyrus and the head of the caudate nucleus. No other significant differences were found. The implications of these results for theories regarding the etiology of OCD are discussed.
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Depressed patients often report sleep problems, which usually include difficulties with initiation and maintenance of sleep, as well as poor subjective quality of sleep. Such reports are confirmed by objective analysis of depressed patients' sleep through polysomnography, although there is no exact correspondence between subjective and objective measurements. In the present paper, we discuss some methodological problems related to the subjective estimates of sleep. Further, we review the differential effects of the various classes of antidepressants on subjective sleep parameters, as well as on sleep onset latency, continuity of sleep, sleep efficiency and rapid eye movement (REM) sleep verified with sleep recordings. Finally, we discuss the attempts to use these and other indices, such as delta sleep ratio (DSR), as signposts of the course of the illness, and predictors of response to treatment.
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Insomnia is a significant public health concern that has prompted substantial efforts to develop treatment and management strategies. A significant proportion of complaints of insomnia are related to psychiatric conditions such as anxiety disorders and depression, and treatments for these disorders are known to exert both direct and indirect benefits on sleep as well as some negative effects on sleep and sleep physiology. Insomnia is also a prominent symptom of a number of other psychiatric disorders, including schizophrenia and bipolar disorder. The observed impact of a variety of psychiatric medications on insomnia has prompted an empirically derived practice of treating non-psychiatric disorder-related insomnia with psychiatric medications by clinicians searching for alternatives to established medication treatments for primary insomnia. This article aims to review the evidence of the impact of psychiatric medications on sleep physiology, sleep disorders in psychiatric conditions, and on primary sleep disorders. The potential for exploiting the relevant pharmacological mechanisms of action in drug development for primary insomnia will be addressed as well.
Article
Sleep studies in patients with obsessive compulsive disorder (OCD) are sparse and results inconsistent. Moreover, in 3 out of 4 published studies up to 50% of patients suffered from secondary major depression. In this study, 10 inpatients with a DSM-IV diagnosis of OCD without comorbid major depression (Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score >15; Hamilton Depression Rating Scale (HAMD)-21 total score <17) and 10 healthy matched controls were included. Polysomnography of patients (7 males, 3 females, 34.5+/-12.7 years, Y-BOCS: 27.8+/-4.6, HAMD-21: 13.3+/-1.9) and controls (7 males, 3 females, 34.4+/-12.8 years) was recorded, following an adaptation night. Sleep variables did not significantly differ in both groups except that stage 4 sleep was reduced in patients. Three of the patients with OCD, however, exhibited sleep onset REM periods (SOREMPs), i.e. rapid-eye-movement (REM) latencies <10 min. Obsessive compulsive symptoms were significantly (P<0.05) more severe in these patients (Y-BOCS: 32+/-2.0) compared to those without SOREMPs (Y-BOCS 26+/-4.2). This is, to our knowledge, the first report of sleep onset REM periods in OCD.
Diagnostic and Statistical Manual of Mental Disorders
American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Publishing, Arlington, VA.
A meta-analysis of functional neuroimaging in obsessive-compulsive disorder
  • S P Whiteside
  • J D Port
  • J S Abramovitz
Whiteside, S.P., Port, J.D., Abramovitz, J.S., 2004. A meta-analysis of functional neuroimaging in obsessive-compulsive disorder. Psychiatry Res. 132, 69-79.