Theme : Dreams
Changes in Dream Content After Drug Treatment
Nili T. Kirschner
University of California, Santa Cruz
NOTE: If you use this paper in research, please use the following citation,
as this on-line version is simply a reprint of the original article:
Kirschner, N. (1999). Changes in dream content after drug treatment. Dreaming,
9, 195-200.
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Abstract
This case study examines the effects of sertraline (Zoloft) on the dream
content of a young woman with generalized anxiety disorder and panic attacks.
The study uses the major categories of Hall and Van de Castle's (1966)
system of content analysis to compare dream reports before and after drug
treatment. Prior to diagnosis and treatment, the dreamer had high levels
of aggression and low levels of friendliness in her dreams. The post-medication
dreams more closely approximate the female norms. This pilot study suggests
a new direction for research on the effects of medication on dream content.
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Introduction
The purpose of this study is to present a case study of 33 pre-medication
and 40 post-medication dream reports from a young woman who entered outpatient
psychological treatment at age 18 and at age 20 was placed on sertraline,
an anti-depressant selective serotonin reuptake inhibitor. Since the study
involves only one subject and somewhat less than the 75-100 dream reports
for each condition that would be ideal in terms of sample size (Domhoff,
1996), it is best viewed as a pilot study. Nonetheless, it is the first
study on the influence of medication on dream content indicators to detect
any changes that may have occurred. The study is also worthy of note because
several of the changes in the dreams after medication are in the medium
to large range in terms of the magnitude of effect sizes (Domhoff, 1996,
1999).
Perhaps due to the great difficulties of carrying out systematic studies
on how drugs might effect dreams, the literature on this topic is not
large. Roth, Kramer, and Salis (1979) provide an excellent review and
critique of the nine studies that had been published up to the time of
their overview. They conclude that "some sedative-hypnotic and antidepressant
agents may effect the quality of dreams, but the precise nature of the
effect is yet to be determined" (Roth et al., p. 220). They further
note that "Few if any of the existing studies were more than pilot
studies," and that "there has been a failure to examine even
one drug in depth..." (Roth et al., p. 221). Moreover, it is their
conclusion that "the lack of standardization of methods of assessing
quality of dream content has resulted in isolated bits of information
that do not yet form a coherent picture" (Roth et al., p. 221).
There have been only two new studies since the critique of the literature
cited in the previous paragraph. The first does not deal directly with
dream content, but with self-ratings of the pleasantness of dream reports
by depressed outpatients at various stages in their treatment with trimipramine;
the patients reported after four weeks that their dreams had fewer negative
emotions (Riemann, Low, Schredl, Weigand, Dippel, & Berger, 1990).
The second study compares 27 pre-medication dream reports from a group
of patients suffering major, nonpsychotic depression with 32 dreams from
the same group after they began taking antidepressant medication, either
fluoxetine (Prozac) or nefazndone (Serzone). The study is described as
an "add-on to studies of the effects of antidepressants on sleep
physiology" (Armitage, Rochlen, Fitch, Trivedi, & Rush, 1995,
p. 191), so the dreams were obtained after a set time of awakening each
morning in the sleep laboratory. The major finding is the low level of
dream recall both before and during medication, with only 21 of 89 patients
reporting at least one dream from at least one of the two conditions.
The two small sets of dreams are rated on 0-5 scales for 19 dimensions
of dreams, such as vividness, active-passive participation, and presence
of others. The scales for emotionality, sexuality, violence, and success/failure
were adapted from Hall/Van de Castle categories (Armitage et al., 1995,
p. 192). Both sets of dream reports were "short, relatively bland
with little emotion" (Armitage et al., p. 193). There were only two
differences: "On treatment, when depression symptoms were improved,
dreams were less vivid with fewer scenes" (Armitage et al., p.196).
Given the tentative nature of most findings in this literature and the
sometimes inconsistent results (Armitage et al., 1995, p.196; Roth et
al., 1979, p. 219), perhaps this brief case study can suggest a new direction
for future studies.
Participant and Method
The dreamer is a female college student. She recorded the first series
of 33 dreams (pre-medication condition) as part of a psychotherapeutic
process when she was 18 and in her first year of college. At that time
she was suffering from anxiety and mild depression. After one year of
psychotherapy through her college health services, the patient terminated
her therapy because she felt that it was not helping her. One year after
ending psychotherapy, at age 20, the patient consulted a doctor about
heart palpitations and light-headedness and was referred to a psychiatrist
who diagnosed her with generalized anxiety disorder and panic attacks.
The psychiatrist prescribed sertraline (Zoloft), an antidepressant selective
serotonin reuptake inhibitor that is sometimes prescribed to ease panic
attacks and anxiety. The patient began taking 25 milligrams of sertraline
nightly, and gradually worked up to 100 milligrams before the panic attacks
stopped. One year later, at the age of 21 and still taking medication,
she recorded 40 more dreams (post-medication condition) for possible use
in a research project in conjunction with a college course in psychology,
but without any knowledge of the Hall/Van de Castle system.
The dreams were coded separately by the author and Adam Schneider using
Hall and Van de Castle's (1966) major content categories. The percentage
of perfect agreement was above 90 percent for each category. When the
codings differed, the codings by Schneider were used. The individual codings
were entered into DreamSAT, which calculated a subset of the Hall/Van
de Castle indicators along with significance levels and effect sizes (Domhoff,
1996, 1999; Schneider & Domhoff, 1999).
Results
The post-medication dreams differed significantly from the pre-medication
dreams in several of the content categories (see Table 1). The effect
sizes were often above .40, which is considered large for dream content
studies (Domhoff, 1996). The most dramatic effect is the post-medication
decrease in the A/C Index, the ratio of aggressive acts to characters
(h = -.82, p < .001). The aggression/friendliness percent also decreased
(h = -.48, p < .003).
In addition to the decrease in aggression, there was a corresponding
increase in friends and friendliness. The ratio of friendliness to characters
(F/C Index) increased (h = +.41, p < .003), along with the number of
characters who were friends of the dreamer (h = +.44, p < .003).
Another positive effect was the dreamer's increase in good fortune (h
= +.58, p < .013). Finally, the number of elements from the dreamer's
past decreased dramatically (h = -.71, p < .01), as did familiar settings
(h = -.75, p < .002).
Table 1. Pre-Medication vs. Post-Medication Content Category Percentages
Pre-med Post-med h p
Characters
Animal percent 11% 06% -.20 .135
Male/Female percent 54% 60% +.10 .545
Familiarity percent 76% 75% -.02 .913
Friends percent° 42% 64% +.44 .003b
Group percent 29% 27% -.03 .820
Social interaction ratios
A/C index° .78 .39 -.82 .000b
F/C index° .18 .35 +.41 .003b
Aggression/Friendliness percent° 75% 52% -.48 .003b
Befriender percent 80% 63% -.39 .197
Aggressor percent° 53% 41% -.23 .330
Physical aggression percent° 26% 13% -.35 .054
Other content categories
Indoor setting percent 53% 59% +.13 .544
Familiar setting percent 88% 55% -.75 .002b
Negative emotions percent° 92% 84% -.28 .111
Dreamer-involved success percent° 18% 23% +.14 .714
Bodily misfortunes percent° 32% 18% -.33 .241
Percentage of dream reports with at least one:
Aggression 65% 50% -.30 .201
Friendliness 38% 45% +.14 .556
Sexuality 06% 10% +.15 .510
Good fortune 03% 20% +.58 .013a
Misfortune° 56% 48% -.17 .472
Success 09% 08% -.05 .836
Failure 32% 20% -.28 .225
Elements from past 43% 13% +.71 .010b
NOTE: Categories followed by ° are possible indicators of psychopathology.
a Significant at the .05 level.
b Significant at the .01 level.
Most of the changes in the post-medication dream content brought the
dreamer closer to the female norms established by Hall and Van de Castle
(see Figure 1). In the cases where she moved further from the norms, such
as friendliness and good fortune, it was on dream content that can be
considered positive in nature.
Figure 1. h-profile of pre-medication and post-medication dreams compared
to female norms.
Discussion
The large effects in this study could be due to the passage of time, but
research on age and dream content shows that there is very little change
in dream content beyond young adulthood (Domhoff, 1996). The change also
may be due in part to psychotherapy, but one unpublished study by Hall
showed no effect of psychotherapy on dream content (Domhoff, 1993). It
is therefore most likely that the changes in dream content are related
to the medication or the reduction of anxiety that ensued.
One possible explanation for the disparity in findings between this study
and previous studies is that the latter tended to focus on the dreams
of depressed patients. Several researchers have found the dreams of depressives
to be short, bland, and lacking in detail (Armitage et al., 1995; Barrett
& Loeffler, 1992, Riemann et al., 1990). It may be harder to detect
changes in content in less detailed dreams.
Domhoff (1996) has suggested that several of the Hall and Van de Castle
content categories may be useful in predicting psychological disturbances.
Before the dreamer was diagnosed and treated, she showed many of the potential
indicators of psychopathology: high percentages of aggression, misfortune,
and negative emotions, and low percentages of known characters, friendly
interactions, and dreamer-involved success.
The dreamer's pre-medication scores are consistent with the previous
findings that the dreams of anxious patients are low in friendly interactions
(Gentil & Lader, 1978), and that patient populations tend to have
more negative emotions in their dreams (Bollea, Carbonetti, Donini, Marrucci,
& Vella, 1978). Her post-medication dreams more closely approximate
the female norms in most categories, including those that might reflect
psychological disturbance. In categories that are not indicators of psychopathology
(such as the percentage of characters that are individuals or groups,
the male/female percent, and the dream setting), the dreamer showed more
consistency - even when she differed from the female norms - between the
pre- and post-medication dreams. The changes in the pertinent categories
suggest that the drug treatment did indeed affect dream content.
It is noteworthy that 43 percent of the pre-medication dreams contained
elements from the dreamer's past, while only 13 percent of the post-medication
dreams contained such references. This may be related to the large decrease
in familiar settings in the post-medication dreams. Although Domhoff (1996)
does not list a high percentage of elements from the past as an indicator
of psychopathology, he does mention that people suffering post-traumatic
stress disorder (PTSD), a type of anxiety disorder, tend to have dreams
in which distressing events are relived again and again. It may be that
other anxiety disorders invoke a similar response in which the dreamer
has a tendency to dwell on past events. This possibility merits further
research.
A final observation is that the results of this study provide support
for Hartmann's (1984) biological model of the effects of drugs on dreams.
An early study which focused mainly on long-term sleep patterns found
little change in dream content associated with psychotropic drug administration
(Hartmann & Cravens, 1974), but a later study conducted in Hartmann's
laboratory indicated that increased levels of dopamine resulted in more
vivid, nightmarish dreams (Hartmann, Russ, Oldfield, Falke, & Skoff,
1980). Based on his own research and the literature on drugs and nightmares,
Hartmann (1984) proposed that drugs that increase the neurotransmitters
dopamine or acetylcholine, or decrease norepinephrine or serotonin, produce
nightmares and more vivid bizarre dreams. Drugs that have the opposite
effects would decrease the incidence of disturbing dreams. The dreamer
in this study was taking a serotonin reuptake inhibitor, which served
to increase the effects of serotonin. According to the biological model,
with the onset of medication the dreamer should have experienced a decrease
in nightmares, or, in Hall and Van de Castle's terms, lower aggression,
negative emotions, and other unpleasant factors. This was, in fact, the
case.
Conclusion
This study would have benefited from several additions, most notably a
larger sample of dreams from both conditions. It is possible that the
dramatic effects in this study would have diminished or even disappeared
in a larger sample of dreams. Although these data are from a small case
study, they nonetheless point toward a new area of dream research. If
dream reports could be obtained from a wide range of patients before and
after undergoing drug treatment for psychological disturbances, it might
be possible to assess the effects of medication on dream content in a
systematic way.
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References
Armitage, R., Rochlen, A., Fitch, T., Trivedi, M., & Rush, A. J.
(1995). Dream recall and major depression: A preliminary report. Dreaming,
5 (3), 189-198.
Barrett, D., & Loeffler, M. (1992). Comparison of dream content of
depressed vs nondepressed dreamers. Psychological Reports, 70, 403-406.
Bollea, E., Carbonetti, P., Donini, G., Marrucci, M., & Vella, G.
(1978). Dream activities of depressives. Archivo de Psicologia, Neurologia
e Psichiatria, 39, 473-501.
Domhoff, G. W. (1993). The repetition of dreams and dream elements: A
possible clue to a function of dreams. In A. Moffitt, M. Kramer, &
R. Hoffman (Eds.), The Functions of Dreams (pp. 293-320). Albany, NY:
State University of New York Press.
Domhoff, G. W. (1996). Finding Meaning in Dreams: A Quantitative Approach.
NY: Plenum Press.
Domhoff, G. W. (1999). New directions in the study of dream content using
the Hall/Van de Castle coding system. Dreaming, 9, in press.
Gentil, M., & Lader, M. (1978). Dream content and daytime attitudes
in anxious and calm women. Psychological Medicine, 8, 297-304.
Hall, C. S. & Van de Castle, R. (1966). The Content Analysis of Dreams.
NY: Appleton-Century-Crofts.
Hartmann, E. (1984). The nightmare: The psychology and biology of terrifying
dreams. NY: Basic Books, Inc.
Hartmann, E. & Cravens, J. (1974). Long-term psychotropic drug administration:
Effects on dream content and on REM density. Sleep Research, 3, 119.
Hartmann, E., Russ, D., Oldfield, M., Falke, R., & Skoff, B. (1980).
Dream content: Effects of L-Dopa. Sleep Research, 9, 153.
Riemann, D., Low, H., Schredl, M., Weigand, M., Dippel, B., & Berger,
M. (1990). Investigations of morning and laboratory dream recall and content
in depressive patients during baseline conditions and under antidepressive
treatment with trimipramine. Psychiatric Journal of the University of
Ottawa, 15, 93-99.
Roth, T., Kramer, M., & Salis, P. J. (1979). Drugs, REM sleep, and
dreams. In B.B. Wolfman (Ed.), Handbook of Dreams (pp. 203-225). NY: Van
Nostrand Reinhold Co.
Schneider, A., & Domhoff, G. W. (1999). The quantitative study of
dream content. Available: http://www.dreamresearch.net
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