One More Dream…..

 

One More Dream…

The purpose of this post is an illustration of a strategy I use to improve my sleep.  I am currently an old man and have had sleep problems since I was a toddler. I had night terrors at an early age and still remember the hallucinations.  I wrote about them in a previous post.  Night terrors as a kid generally predicts sleep problems and risk for psychiatric difficulty as an adult. I also inherited obstructive sleep apnea and that contributes to poor sleep quality. For most of my career, I practiced in a high stress environment and with my personality factors that also lead to significant sleep disruption in situations where there was no clear solution to the problems I was trying to treat. A good example would be catatonic patients who were not eating, drinking, or responding to treatment. I would find myself laying in bed at night and reviewing the current treatment plan and that person’s medical status – sometimes for hours. Since retiring 2 years ago that type of nocturnal stress is gone – but your life is never completely stress free.

When I do fall asleep – I generally like dreaming. I tend to dream about medical centers and anxiety provoking situations. A common dream is being in residency and realizing that I just stopped going to biochemistry class as a first-year medical student. I never took the exams or confirmed whether I got a grade or not. Instead, I find myself near the end of residency and wondering if I am going to graduate.  I am not sure if there is a black mark against my name or not. At the same time, I am engaged with many doctors – doing what we did in residency training. I wake up somewhat anxious until I realize it is just a repetitive dream. I am always amazed at the content of the dream in terms of the architecture and landscape – all manufactured from incidental memory. None of the institutions in my dreams exist in real life. The same is true of most of the people in my dreams, but occasionally there is a friend, family member, or celebrity.

I try to practice the lucid dreaming that I discovered in childhood. If I am stressed or anxious in a dream, especially to the point of bodily sensations like feeling flushed, like my heart is pounding, or shortness of breath I try to wake myself up by rehearsing what to do ahead of time.  Those bodily sensations can be associated with strenuous activity in the dream like skating or biking – but not always.  I have tried a lot of the relaxation and CBT techniques for falling asleep but did not find them very effective. I also have not used any medications for sleep.  My primary care MD gave me 3 zolpidem tablets once.  They were moderately effective but he did not prescribe any more.  I take medication that is toxic and has drug interactions so I did not try other options that might affect cardiac conduction.

What I did come up with was a technique that I call “One more dream.”  Before I get into the details – let me emphasize that this is not an instruction manual or guide for people to use this technique.  It has not been shown to be effective in clinical trials and doubt it will ever be studied. This is just a technique that I personally have found to be effective and it is not medical advice for anyone else.  And like everything on this blog I am not promoting it to make money.  The discussion is strictly educational – nothing more.

Here is an outline of the basics beyond the typical sleep hygiene measures:

1: Recall the somatic sensations just before you fall asleep:  These sensations vary widely from person to person.  In my case, I get a feeling that I am sinking and I start to lose sensation in my arms and hands – they start to feel very light. I am also aware of any stiffness in the chest and abdominal wall.  I will typically do a few breathing exercises to get rid of that stiffness.  I actively try to recall that sequence of events and the actual feeling.  I have had several instances of general anesthesia in the past 5 years and recalling that state can also be helpful. 

2:  Recreate 'sleep reverie' transition state (usually just waiting for it is enough):  Sleep reverie is the transitional state from wakefulness to sleep. There is typically a period where conscious thoughts start to run together.  If you are good at mental imagery – an image might start out with a person walking down a stairway and change in an instant to a different person engaged in a different activity.  Noticing when this occurs is typically associated with transitional images. It is also a sign that sleep is rapidly approaching.  Focusing on those instances is helpful. 

3:  The conscious goal is one more dream:  I typically try to focus on an image of something that I want to dream about but having that dream is extremely rare. These images often dissolve in the sleep reverie stage. It is also a time to rehearse endings to problematic dreams. A common theme for me is strenuous physical activity. I am overexerting myself in a dream and wake up to rapid heartbeat, palpitations, rapid breathing, and sweating. If I can recognize that in a dream – my usual rehearsed ending is to wake up and start over.   

Those are the basic steps and the mile high view. They are not completely original since there are elements of lucid dreaming and dream/imagery rehearsal – both of which have been studied, tested and used clinically (1). In clinical practice I have had good results advising people about sleep hygiene; the pharmacology of caffeine, alcohol, and addictive drugs; whether their dreams were interpretable; and how to stop unpleasant dreams or nightmares using dream rehearsal. The decision to use these techniques generally depends on the amount of autonomic arousal the person is experiencing.  For example, people with high levels of anxiety all day long who experience associated nightmares and nocturnal arousal including panic attacks, rapid heartbeat, palpitations, sweating, and ongoing sleep deprivation are much more likely to need pharmacotherapy in addition to the above measures.  Standard insomnia therapies may be useful, but more specific therapy targeting heightened adrenergic output is more likely to work, especially in the case of post traumatic nightmares.

The biology of sleep transitions remains at the theoretical stage at this point with several interesting classical and newer hypotheses (2,3).  While the hypotheses are interesting and becoming more sophisticated it is also apparent that pluralistic interventions are effective including the measures described in this post.  In other words, astute clinicians have been able to design self-help, structured, and psychotherapeutic interventions that can reduce or eliminate both primary and trauma-based nightmares and improve sleep quality and general health.  Like many other interventions in psychiatry - they work irrespective of whether a biological mechanism of action is known or not. They also do not depend on a prescribed medication or medical test. They are dependent on a skilled sleep assessment and training in these techniques.

 

George Dawson, MD, DFAPA

 

References:

1:  Yücel, D. E., van Emmerik, A. A. P., Souama, C., & Lancee, J. (2020). Comparative efficacy of imagery rehearsal therapy and prazosin in the treatment of trauma-related nightmares in adults: A meta-analysis of randomized controlled trials. Sleep Medicine Reviews, 50, https://doi.org/10.1016/j.smrv.2019.101248

2:  Saper CB, Fuller PM, Pedersen NP, Lu J, Scammell TE. Sleep state switching. Neuron. 2010 Dec 22;68(6):1023-42. doi: 10.1016/j.neuron.2010.11.032. PMID: 21172606; PMCID: PMC3026325.

3:  Osorio-Forero A, Cardis R, Vantomme G, Guillaume-Gentil A, Katsioudi G, Devenoges C, Fernandez LMJ, Lüthi A. Noradrenergic circuit control of non-REM sleep substates. Curr Biol. 2021 Nov 22;31(22):5009-5023.e7. doi: 10.1016/j.cub.2021.09.041. Epub 2021 Oct 13. PMID: 34648731.

 

A New Perspective on Dreaming

From: Reference 1 with permission.

A friend of mine insists on telling me his dream.  He knows I am interested:

"So I am in this old house.  I have the feeling it is my Grandmother's house, but it is really a house I have never been in before.  There is a gathering on the main floor and there are two people there.  I know that one of them is supposed to be my grandmother but it doesn't look at all like her.  There is a guy there who is apparently dating my grandmother.  I know that he is supposed to be a handyman that my brother introduced to my Grandmother but I have never seen him either.  They look like they are in their 70s.  But in reality as you know - my grandmother has been dead for over 20 years."

"Suddenly I am no longer at the party.  I am in the house and I am in an upstairs bedroom.  For some reason, I think it is my grandmother's bedroom.  I don't know why I'm there but all of a sudden this guy comes down the hallway.  He is one of the commentators from TMZ that Hollywood gossip show (let's call him Bob).  I look to the floor next to the wall to my right and there are two small bowls of M&Ms - a bowl of green M&Ms closer to him and a bowl of red M&Ms closer to me.  They are in those Anchor Hocking glass bowls without the blue plastic lids.  Anyway - I grab a small handful and start eating them.  They are dark chocolate M&Ms.  I look at Bob and say: "That's what they're there for" and he starts eating a few."  He asks why I am there and I say: "I heard there was a mouse in here and I need to kill it."

"A mouse runs between me and Bob and I tell him to kill it.  He misses it and it runs at me and I kick at it and knock it into the corner.  Bob is still reluctant to kill it.  The mouse runs at me again but this time it is as big as a rat.  I kick it into the corner of the room again.  This time it runs back out at me and it not longer looks like a rat - it is as big as an otter.  I kick it again - but this time I am shaken awake by my wife.  She asks me if I was having a bad dream.  She said I was kicking my legs like I was running and punching my arms in the air for a few seconds.  My heart was pounding like I was really in a fight with this thing.  What was all of that?  What  does it mean?"

There are a few things about this dream that are striking.  The first is the amount of detail recalled right down to what appear to be the product placements.  Most people telling me about their dreams rarely recall this level of detail.  Often they recall only the emotional tone of the dream and the vague idea that something happened.  The second is the overall content of the dream.  By the dreamer's report it is illogical - none of the events really happened or are likely to happen.  With the exception of the TV celebrity, none of the people in the dream were really who they were supposed to be.  Strangers were supposed to be his grandmother and his grandmother's boyfriend but in reality - there was no such relationship.  There is the movement.  The dreamer is thrashing about the bed until his wife wakes him up.  A final consideration that I like to think about is the processing power necessary to create this experience either de novo or from existing elements.

Dream interpretation is still alive and well in psychiatry - at least the way I practice it.  It is not quite the detailed analysis of all of the elements that Freud thought were important but a combination of a look at the predominate affects and what might be called a synthesis of what is supposed to happen in dreams.  It is also not quite where we need it to be from a neuroscientific perspective.  For example, for the most part we are still operating on a model that suggests more dream activity occurs in REM (rapid eye movement) sleep and that NREM (non-rapid eye movement) sleep contains very little.  We know from dream studies that is not completely correct because both REM and NREM sleep have EEG correlates and we can wake research subjects up during dreams and determine if they are dreaming or not.  Based on those studies there is a rough correlation - but there are still dreams occurring during NREM sleep and REM sleepers without dreams.  Various theories have been advanced about why that occurs, but there is no comprehensive theory.  The other issue is that dream content needs a better explanation.  The simplified explanation is that illogical impossible dreams like the one described here are REM dreams and that NREM dreams are more like plausible events.  Finally - movement during REM dreams is not possible suggesting that the dreamer in the above example was not in REM sleep or he has a neurological problem to account for the dissociation between his motor activity and the fact that he should be paralyzed in REM sleep.  These thoughts about REM and NREM sleep are so pervasive in our society that I routinely interview patients who tell me why they think they are (or are not) getting enough "REM sleep".

I was lucky to have found a recent paper (1) on the subject that if correct may prove to be a landmark study about the neural basis of dreaming and possibly consciousness.  One of the advantages of this paper is that is it written from the perspective of consciousness researchers with an interest in the neural correlates of consciousness.  In this study the authors ran three experiments looking at the question of dream reports and high density (256 channel) EEG.  They used a serial wakening model in which subjects were awakened and asked to report if they were dreaming and could recall some of it (DE = dreaming experience) or if they experienced something but could not recall (DEWR=dreaming without recall of content).  A third option was no experience of dreaming (NE = no experience).  They were asked to characterize any content further according to protocol.  There were two groups of research subjects.  The first was a group of 32 subjects who underwent few awakenings - 233 total.  The second was a smaller group of 7 subjects who had many (815) awakenings.  In a third experiment 7 subjects were studied with 84 awakenings to see if the results of the first two experiments could be predicted.

The initial section of the paper reports on the results of DE versus NE experience in the low frequency (1-4 Hz) power spectrum.  The authors were able to identify what they describe as a posterior cortical hot zone (bilateral parieto-occipital area including the occipital lobe extending to the precuneus and posterior cingulate gyrus superiorly p. 873).  DE occurred when there was decreased low frequency power in this region.  That condition occurred in  both REM and non-REM states.  This finding across distinct sleep stages appears to be highly significant.

The next section of the paper reports on DE versus NE in the high frequency power spectrum (20-50 Hz) that corresponds with high rates of neuronal firing.  Some of the results are summarized in Figure 3 at the top of this post.  In the DE experience condition increased high frequency power was noted in the same parieto-occipital regions that were associated with decreased low frequency power but it was more extensive. DE with recall of content was associated with more widespread extension of the high frequency map than DEWR (no recall of content).  Additional observations were made of the high frequency maps with regard to specific recalled dream content.  The results here are extremely interesting in terms of the specifics of content.  The authors comment on the "perception versus thought" content of dreams.  Some recalled content is an isolated thought or emotion and other content is very vivid imagery including full conversations like the example at the top of this post.  In their experiments, the authors note that there appears to be an anterior -> posterior gradient for high frequency activity with thought content mapping out over frontal cortex and perceptual content mapping out over posterior cortical regions.  They looked at dream content involving facial recognition and noted an increase in high frequency activity over the right fusiform gyrus - a structure noted to be involved in facial recognition during wakefulness.  Dream content that involved spatial imagery was correlated with increased high-frequency activity in the right posterior parietal cortex and area with that expected function during wakefulness.  Additional correlations were noted with movement and speech.

In the final phase of the experiments, the authors sought to find out if the markers identified in the initial sections of the paper could be used to predict where or not a person was dreaming just based on their EEG data.  They were able to accurately predict dreams 80.7 to 91.6% of the time (87% accurate across all states).  

I consider this to be a potentially critical paper to any psychiatrist interested in sleep or dreaming.  If replicated it illustrates that there is a posterior cortical hot zone that correlates with dreaming across REM and NREM sleep stages.  That in itself explains the lack of tight correlation of dreams with REM and NREM sleep.  From a theoretical standpoint they point out the the low delta activity (1-4 Hz) that correlates with dreaming also corresponds to alternations in neuronal depolarization and hyperpolarization that causes a breakdown in cortical communication.  High delta activity  corresponds to states of diminished consciousness including some forms of delirium and loss of consciousness.  They suggest that posterior cortical activation should be studied in patients with disorders of consciousness to see if there may be consciousness without responsiveness based on activity in this area. They also discuss the broader implications of dreaming as a model for the study of consciousness.

That is a good point to end this post.  I will continue to monitor the work of these authors and have been following some of them for some time.  Dr. Tonini for example is probably one of the top experts (and theorists) on consciousness and the only psychiatrist who I am aware of who is doing this work.        


George Dawson, MD, DFAPA


References:

1:  Siclari F, Baird B, Perogamvros L, Bernardi G, LaRocque JJ, Riedner B, Boly M,Postle BR, Tononi G. The neural correlates of dreaming. Nat Neurosci. 2017 Jun;20(6):872-878. doi: 10.1038/nn.4545. Epub 2017 Apr 10. PubMed PMID: 28394322; PubMed Central PMCID: PMC5462120



Attribution:

Figure 3 at the top used with permission from Nature Publishing Group - License Number 4154981341951.  The figure is from reference 1.



Supplementary:

As I have previously posted - I have experience with standard array quantitative EEG (QEEG) and its limitations.  I am a little skeptical of being able to determine the EEG spectrum in the fusiform gyrus by standard surface electrodes in what I imagine is a cap array.  But time will tell.

Dreaming of the EHR

The Dream:

I am at the APA convention.

It is in a crummy hotel attached to a mall. I am going down to the street level in an elevator and it stops at a level where there is a big cinema complex. An 8 year old boy runs excitedly into the elevator and jams in to my left. The elevator is crowded. He looks at my name badge and says: "What would George Dawson say if the Watson computer said he wasn't doing a good job?"

I glance down at him and say: "George Dawson would not care."

The kid says: "That's not good" and laughs intensely.......


It is all a dream. I had that dream early Saturday morning. It doesn't require detailed analysis. That last thing I did on Friday was try to review a 22-page paper record that was generated by a modern electronic health record (EHR) system. With the exception of a few paragraphs it was largely unintelligible. It contained bits and pieces of information. I was looking for imaging (CT, MRI, ultrasound reports) and ECG data, but instead could find only a few lines that summarized fewer results. There were no dates - no hospital admission or discharge date.  Although the hospitalization was longer than a week - there was no medication administration record or MAR - showing the specific dates when medications were changed.  There were no comprehensive reports that I am used to seeing for the past 30 years from Radiologists. There was no discharge summary. The documentation was basically unacceptable as a source of clinical information and yet it was created by a very high end, enterprise wide EHR system. It brought back a memory of a mandatory meeting I had with a "coding specialist" about 10 years ago. That person let me know that I had "passed" the documentation review in that I had ticked off the necessary "bullet points" so that documentation specialists would approve my EHR note for the day and the associated billing document that had to be submitted with each note.  She showed me how I could do things faster by ticking off a series of check boxes and electronically signing the note.  She was shocked when I told her that I really could not sign my name to that document because there was no sign that an intelligent human being had seen the patient.  For all of these reasons, very poor documentation in the EHR is always on my mind.

My attempt to read the last report may have been enough of a reason for the dream, but I also spent time on Thursday with a colleague who really dislikes the EHR for additional reasons. We regaled our spouses with tales of incomprehensible reports.  In addition, his reports require a synthesis of many imaging, lab, and clinical reports.  He previously used a system where all of the reports showed up in a queue and he could go down that list in chronological order to dictate the report.  In the new system, he has to go to tabs to find all of the reports he is looking for.  Some of these tabs are hyperlinked and the reports don't load very well.  In the end, he and his colleagues end up printing out all of the reports on paper so they can dictate then more efficiently without having to search for what they need in real time in the EHR.  That reminded me of an experiment I did about 8 years ago with the same EHR.  I went in and read all of the clinical notes looking for chronic diagnoses that were not addressed.  I came up with an additional 8 diagnoses from 340 clinical notes buried in the EHR. There is generally no good way for physicians to mine data on their own patients to make sure that they have done the most thorough assessment of their problems.  On the other hand administrators can get detailed numbers of mouse clicks by nurses in primary care clinics and rate their productivity in terms of mouse clicks, screen views, or tasks completed.  My colleague's theory was that the current EHR is selected for the administrative capabilities like monitoring doctors or nurses rather than any inherent advantage for medical staff.  The major evidence for that is that many EHR vendors have permanent staff in the hospital and they are making constant modifications to the EHR.  In many cases there are meetings of all the physicians in a particular department about these modifications.  The hospitals and clinics purchasing these systems are purchasing incomplete products that require what seems like constant revisions.

It has been about 15 years since the blight of the EHR hit physicians.  It was originally called the electronic medical record (EMR) but I suppose some business type decided that they could really solidify the corporate stranglehold on medicine by eliminating the word "medical" from another phrase.  Corporate psychology also dictates that they give the impression that they are maintaining health rather than treating medical problems.  That is another good reason for eliminating the word medical from the corporate lexicon.

The marketing of the EHR has been masterful.  The political hype promised untold savings.  National candidates seemed to suggest that we could actually "save" enough with the EHR that it would cover a substantial part of American health care inflation.  Any physician involved in the implementation phase of enterprise EHRs knew that was a bold faced lie.  There is no way that annual multimillion dollar a year licensing fees as far as the eye can see are going to save anybody any money.  In fact, I am certain that many clinics and hospitals have had to cut staff and services just to bankroll the EHR. Nobody has ever followed the money on the EHR debacle as far as I know.  Congress is well known to invent businesses and turn people into billionaires overnight.  All it takes is a few Congressional mandates about the need to use an EHR and electronic prescribing.  There is no mandate to keep things cost effective of make sure that independent practitioners can afford it.  There are mandates to implement EHRs and electronic prescribing and the White House brags about it.  The following graphic and text are from a White House document on the EHR entitled: More than Half of Doctors Now Use Electronic Health Records Thanks to Administration Policies.

The problem with the White House statement is that despite spending about $3 billion dollars a year and in some cases $44,000 per physician,  the value of the EHR for the reasons already stated remains in question.  It is very handy to be able to pull up lab results and x-rays on a computer screen.  It is also very handy to be able to send electronic prescriptions to any pharmacy in the country.  On the other hand, it is reasonable to expect that a multimillion dollar piece of software will write a report that any hundred dollar database software from the 1990s could write.  That same software should be capable of allowing physicians to search their own patient results for quality and report writing purposes.  In the end we are left with very expensive, high maintenance systems, and massive amounts of information that is either buried in storage because it is not easily accessible or because it is worthless and generated primarily for justifying a billing document.

That is one of the many real costs of having a health care system run by bureaucrats and politicians.  


George Dawson, MD, DFAPA


Attribution:

Photo at the top of this blog is by Paco Burrola on Flickr and is used courtesy of this Creative Commons license.

Dream recall endophenotypes?

Dreams are important part of psychiatric practice.  A discussion of dreams comes up in a number of contexts ranging from diagnoses like Post Traumatic Stress Disorder to primary sleep problems like Nightmare Disorder.   Dreams can be affected by substance abuse and medications.  Some people are still interested in what a dream might mean or they have their own interpretation that they want to discuss.  Sleep is often a source of stress to people who come in to see psychiatrists and questions about dreams frequently come up in discussion about too much sleep or too little sleep.  As a result, I have done a lot of reading and study about sleep and dreams.  I have the last 5 editions of Kryger, Roth and Dement's Principles and Practice of Sleep Medicine and additional texts and journals.  Since I worked in a residential settings, I see people who have their sleep observed and can tell me if they have apneic episodes or behavioral problems associated with sleep and refer them for polysomnography.  Whenever I ask about sleep there are a significant number of people who tell me: "I never dream."

Is it possible that a person is not dreaming at night?  Since the discovery of REM sleep it is well known that this biological process and dreaming are inextricably linked.  Dream researchers have determined that dream recall is influenced by a number of factors including the setting, whether a person is awakened slowly or rapidly and the sleep stage that they are awakened from.  For example, awakenings form REM sleep can result in 4 or 5 dream narratives per night.  Writing dreams recalled the next morning is not likely to produce that amount of content.

When an article suggesting a marker for differences in dream recall showed up on my Facebook feed I was naturally interested.  The authors in this case had a pool of 1,000 people who completed questionnaires indicating an interest in the study.  They were contacted by phone and asked the question: "on the average, how many mornings in the week do you wake up with a dream in mind?"  That is an important distinction from the people I talk with because they usually say: "I dream a lot." or "I don't dream at all."  For the purpose of this study the authors defined high recallers (HR) as those who recalled dream narratives or images on three mornings per week(4.42 ± 0.25 SEM dream recalls/week).  Low recallers (LR) recalled narratives or images per month (0.25  ± 0.02).   The subjects underwent standard polysomnography and an experimental paradigm that involved presenting a recorded voice saying first names through headphones in the alert and REM state.  Event related potentials (ERPs) and alpha frequency (8-12 Hz) responses to the auditory hallucinations were recorded.        

The authors summarize their data using the above graphics.  The top graphic is a little confusing at first if you are used to seeing similar graphics from QEEG analysis.  It is only alpha spectrum and the white lines represent occurrences of the auditory stimulus.  The bottom row shows the HR - LR power and the significant difference at the Pz electrode.  The black and white graphics at the bottom show ERPs and alpha power in response to first names for HR, LR, and HR-LR.  In general the alpha power decreases during wakefulness and increases during  REM sleep on all graphics.  The HR group had a more sustained decrease in alpha power to first names at 1000 to 1200 ms during wakefulness.

The authors go on to discuss the implications of these findings including the theory that increased alpha power during REM sleep could imply microarousals without awakenings.  A second hypothesis is that increased alpha power during REM sleep implies cortical deactivation rather than microarousal that would lead to decreased processing and less likelihood of awakening.  The authors interpret the greater reactivity in ERPs and alpha activation in the HR state as indicating that alpha is associated with activation in sleep.  They point out that the increased intrasleep wakefulness being great in HR is consistent with that observation.  They go on to point out that this trait may be central to a personality organization and cognitive substrate within the brain.  They pose a larger question about moving from one phenotype to the other.  They make the important observation that a hippocampus needs to be in the loop for dream recall and that there may be a point where functional imaging will be able to provide that level of detail.

I could not help but wonder if dream recall is a possible endophenotype.  What would happen if families were studied on their ability to recall dreams?  Would there be characteristic findings on polysomnography?  What would the pattern of heritability be and what would lead to transitions between phenotypes?  Sleep medicine is one of the areas of psychiatry where there are clear and valid biomarkers and it would be interesting to look at those differences.  In the meantime, it appears that what I have been saying to people about possible REM related dreams seems to be true based on this study.  Microarousals - probably from a number of possible etiologies will probably increase dream recall of characteristic REM type dreams and you may not actually experience interrupted sleep.  There is also the interesting consideration of dreaming without the hippocampus being engaged and have no dream recall on that basis.

George Dawson, MD, DFAPA

Ruby PM, Blochet C, Eichenlaub J-B, Bertrand O, Morlet D, Bidet-Caulet A (2013) Alpha reactivity to first names differs in subjects with high and low dream recall frequency. Frontiers in Psychology 4.

All of the figures in this post are from the above reference and are produced here via Creative Commons license.  Please see the original article for all of the details.