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1.  Evaluation of Dream Content among Patients with Schizophrenia, their Siblings, Patients with Psychiatric Diagnoses other than Schizophrenia, and Healthy Control 
Iranian Journal of Psychiatry  2012;7(1):26-30.
Objective
Schizophrenia is a chronic psychotic disorder with unknown etiology that causes cognitive impairment, affecting thinking, behavior, social function, sleep and dream content. This study considered the dream content of patients with schizophrenia, siblings of patients with schizophrenia, patients with psychiatric diagnoses other than schizophrenia, and a group of healthy controls. The aim of this study was to compare the dream content of patients with schizophrenia with dream content of individuals with other mental disorders, first degree relatives of patients with schizophrenia, and community controls.
Method
Seventy-two patients were selected and placed in 4 groups. The first group consisted of 18 inpatients with schizophrenia whose medications were stable for at least four weeks; the second group consisted of 16 nonpsychotic mentally ill inpatients; the third group consisted of 18 individuals who were siblings of patients with schizophrenia; and the fourth group consisted of 20 healthy individuals in the community with no family history of mental or somatic disorders. The four groups were matched by age and gender. A 14-item dream content questionnaire was administered for all the participants, and the Positive and Negative Symptoms Scale (PANSS) was also administered for the two groups of hospitalized patients.
Results
Results showed that there were significant differences in dream content among groups included friends acquaintances, females and colorful components. No significant differences were found between the positive and negative subscales of PANSS and any of the dream questionnaire subscales.
Conclusion
Our results suggest that there were a few changes in the dream content of the patients with schizophrenia compare to other groups.
PMCID: PMC3395964  PMID: 23056114
Dream; Psychopathology; Schizophrenia
2.  Hallucinations and sleep disorders in PD 
Neurology  2010;75(20):1773-1779.
Objective:
To assess prospectively progression and relationship of hallucinations and sleep disorders over a 10-year longitudinal study of patients with Parkinson disease (PD).
Methods:
Eighty-nine patients with PD were recruited to fill cells of normal sleep without hallucinations (n = 20), sleep fragmentation only (n = 20), vivid dreams/nightmares (n = 20), hallucinations with insight (n = 20), and hallucinations without insight (n = 9). At baseline, 0.5, 1.5, 4, 6, and 10 years, sleep disorders and hallucinations were assessed by standardized scales with the longitudinal data analyzed by generalized estimating equations with assumptions of linearity in time.
Results:
At 10 years, we could account for all subjects (27 interviewed, 61 deceased, and 1 too ill for interview). Hallucination prevalence and severity increased over time (p < 0.0001, p = 0.0001). Acting out dreams also increased over time (p = 0.001). In contrast, presence of vivid dreams/nightmares or sleep fragmentation did not increase over time. For all visits, the prevalence of sleep fragmentation did not differ between subjects with vs without hallucinations (odds ratio [OR] = 1.50, p = 0.09). However, severe sleep fragmentation was associated with concurrent hallucinations (OR 2.01, p = 0.006). The presence of hallucinations was also highly associated with concurrent vivid dreams/nightmares (OR = 2.60, p < 0.0001) and with concurrent acting out dreams (OR = 2.38, p = 0.0004). Among the baseline nonhallucinators, no sleep abnormalities at study entry predicted future development of hallucinations.
Conclusions:
Hallucinations and sleep abnormalities follow very different patterns of progression in PD over 10 years. Whereas patients with hallucinations often have concurrent sleep aberrations, no sleep problem is predictive of future hallucinations.
GLOSSARY
= confidence interval;
= generalized estimating equation;
= Mini-Mental State Examination;
= odds ratio;
= Parkinson disease;
= Pittsburgh Sleep Quality Index;
= Unified Parkinson's Disease Rating Scale;
= motor section of the Unified Parkinson's Disease Rating Scale.
doi:10.1212/WNL.0b013e3181fd6158
PMCID: PMC2995381  PMID: 20962287
3.  The Dream 
The dream is a unique psychodynamically informative instrument for evaluating the subjective correlates of brain activity during REM sleep. These include feelings, percepts, memories, wishes, fantasies, impulses, conflicts, and defenses, as well as images of self and others. Dream analysis can be used in a variety of clinical settings to assist in diagnostic assessment, psychodynamic formulation, evaluation of clinical change, and the management of medically ill patients. Dreams may serve as the initial indicators of transference, resistance, impending crisis, acting-out, conflict resolution, and decision-making. A clinically functional categorization of dreams can facilitate an understanding of psychopathology, psychodynamics, personality structure, and various components of the psychotherapeutic process. Examples of different types of dreams are provided to illustrate their relevance and use in various clinical situations.
PMCID: PMC3330663  PMID: 11696648
Psychodynamic Psychotherapy; REM Sleep; Dreams
4.  Dream characteristics in a Brazilian sample: an online survey focusing on lucid dreaming 
During sleep, humans experience the offline images and sensations that we call dreams, which are typically emotional and lacking in rational judgment of their bizarreness. However, during lucid dreaming (LD), subjects know that they are dreaming, and may control oneiric content. Dreaming and LD features have been studied in North Americans, Europeans and Asians, but not among Brazilians, the largest population in Latin America. Here we investigated dreams and LD characteristics in a Brazilian sample (n = 3,427; median age = 25 years) through an online survey. The subjects reported recalling dreams at least once a week (76%), and that dreams typically depicted actions (93%), known people (92%), sounds/voices (78%), and colored images (76%). The oneiric content was associated with plans for the upcoming days (37%), memories of the previous day (13%), or unrelated to the dreamer (30%). Nightmares usually depicted anxiety/fear (65%), being stalked (48%), or other unpleasant sensations (47%). These data corroborate Freudian notion of day residue in dreams, and suggest that dreams and nightmares are simulations of life situations that are related to our psychobiological integrity. Regarding LD, we observed that 77% of the subjects experienced LD at least once in life (44% up to 10 episodes ever), and for 48% LD subjectively lasted less than 1 min. LD frequency correlated weakly with dream recall frequency (r = 0.20, p < 0.01), and LD control was rare (29%). LD occurrence was facilitated when subjects did not need to wake up early (38%), a situation that increases rapid eye movement sleep (REMS) duration, or when subjects were under stress (30%), which increases REMS transitions into waking. These results indicate that LD is relatively ubiquitous but rare, unstable, difficult to control, and facilitated by increases in REMS duration and transitions to wake state. Together with LD incidence in USA, Europe and Asia, our data from Latin America strengthen the notion that LD is a general phenomenon of the human species.
doi:10.3389/fnhum.2013.00836
PMCID: PMC3857923  PMID: 24368900
lucid dreaming; dreams; nightmares; REM sleep; dream features
5.  Risk of neuropsychiatric adverse events associated with varenicline: systematic review and meta-analysis 
Objective To determine the risk of neuropsychiatric adverse events associated with use of varenicline compared with placebo in randomised controlled trials.
Design Systematic review and meta-analysis comparing study effects using two summary estimates in fixed effects models, risk differences, and Peto odds ratios.
Data sources Medline, Embase, PsycINFO, the Cochrane Central Register of Controlled Trials (CENTRAL), and clinicaltrials.gov.
Eligibility criteria for selecting studies Randomised controlled trials with a placebo comparison group that reported on neuropsychiatric adverse events (depression, suicidal ideation, suicide attempt, suicide, insomnia, sleep disorders, abnormal dreams, somnolence, fatigue, anxiety) and death. Studies that did not involve human participants, did not use the maximum recommended dose of varenicline (1 mg twice daily), and were cross over trials were excluded.
Results In the 39 randomised controlled trials (10 761 participants), there was no evidence of an increased risk of suicide or attempted suicide (odds ratio 1.67, 95% confidence interval 0.33 to 8.57), suicidal ideation (0.58, 0.28 to 1.20), depression (0.96, 0.75 to 1.22), irritability (0.98, 0.81 to 1.17), aggression (0.91, 0.52 to 1.59), or death (1.05, 0.47 to 2.38) in the varenicline users compared with placebo users. Varenicline was associated with an increased risk of sleep disorders (1.63, 1.29 to 2.07), insomnia (1.56, 1.36 to 1.78), abnormal dreams (2.38, 2.05 to 2.77), and fatigue (1.28, 1.06 to 1.55) but a reduced risk of anxiety (0.75, 0.61 to 0.93). Similar findings were observed when risk differences were reported. There was no evidence for a variation in depression and suicidal ideation by age group, sex, ethnicity, smoking status, presence or absence of psychiatric illness, and type of study sponsor (that is, pharmaceutical industry or other).
Conclusions This meta-analysis found no evidence of an increased risk of suicide or attempted suicide, suicidal ideation, depression, or death with varenicline. These findings provide some reassurance for users and prescribers regarding the neuropsychiatric safety of varenicline. There was evidence that varenicline was associated with a higher risk of sleep problems such as insomnia and abnormal dreams. These side effects, however,are already well recognised.
Systematic review registration PROSPERO 2014:CRD42014009224.
doi:10.1136/bmj.h1109
PMCID: PMC4357491  PMID: 25767129
6.  Dreams of the Rarebit Fiend: food and diet as instigators of bizarre and disturbing dreams 
In the early 1900s, the Dream of the Rarebit Fiend comic strip conveyed how the spicy cheese dish Welsh rarebit leads to bizarre and disturbing dreams. Today, the perception that foods disturb dreaming persists. But apart from case studies, some exploratory surveys, and a few lab studies on how hunger affects dreaming, there is little empirical evidence addressing this topic. The present study examines three aspects of the food/dreaming relationship; it attempts to: (1) assess the prevalence of the perception of food-dependent dreaming and the types of foods most commonly blamed; (2) determine if perceived food-dependent dreaming is associated with dietary, sleep or motivational factors; and (3) explore whether these factors, independent of food/dreaming perceptions, are associated with reports of vivid and disturbing dreams. Three hundred and ninety six students completed questionnaires evaluating sleep, dreams, and dietary habits and motivations. Items queried whether they had noticed if foods produced bizarre or disturbing dreams and if eating late at night influenced their dreams. The perception of food-dependent dreaming had a prevalence of 17.8%; with dairy products being the most frequently blamed food category (39–44%). Those who perceived food-dependent dreaming differed from others by reporting more frequent and disturbing dreams, poorer sleep, higher coffee intake, and lower Intuitive Eating Scale scores. Reports of disturbing dreams were associated with a pathological constellation of measures that includes poorer sleep, binge-eating, and eating for emotional reasons. Reports of vivid dreams were associated with measures indicative of wellness: better sleep, a healthier diet, and longer times between meals (fasting). Results clarify the relationship between food and dreaming and suggest four explanations for the perception of food-dependent dreaming: (1) food specific effects; (2) food-induced distress; (3) folklore influences, and (4) causal misattributions. Research and clinical implications are discussed.
doi:10.3389/fpsyg.2015.00047
PMCID: PMC4330685  PMID: 25741294
nightmares; dreaming; sleep; food; diet; fasting; internal awareness
7.  What I make up when I wake up: anti-experience views and narrative fabrication of dreams 
I propose a narrative fabrication thesis of dream reports, according to which dream reports are often not accurate representations of experiences that occur during sleep. I begin with an overview of anti-experience theses of Norman Malcolm and Daniel Dennett who reject the received view of dreams, that dreams are experiences we have during sleep which are reported upon waking. Although rejection of the first claim of the received view, that dreams are experiences that occur during sleep, is implausible, I evaluate in more detail the second assumption of the received view, that dream reports are generally accurate. I then propose a “narrative fabrication” view of dreams as an alternative to the received view. Dream reports are often confabulated or fabricated because of poor memory, bizarre dream content, and cognitive deficits. It is well documented that narratives can be altered between initial rapid eye movement sleep awakenings and subsequent reports. I argue that we have reason to suspect that initial reports are prone to inaccuracy. Experiments demonstrate that subjects rationalize strange elements in narratives, leaving out supernatural or bizarre components when reporting waking memories of stories. Inaccuracies in dream reports are exacerbated by rapid memory loss and bizarre dream content. Waking memory is a process of reconstruction and blending of elements, but unlike waking memory, we cannot reality-test for dream memories. Dream experiences involve imaginative elements, and dream content cannot be verified with external evidence. Some dreams may involve wake-like higher cognitive functions, such as lucid dreams. Such dreams are more likely to elicit accurate reports than cognitively deficient dreams. However, dream reports are generally less accurate than waking reports. I then propose methods which could verify the narrative fabrication view, and argue that although the theory cannot be tested with current methods, new techniques and technologies may be able to do so in the future.
doi:10.3389/fpsyg.2013.00514
PMCID: PMC3741533  PMID: 23964260
dreaming; fabrication; skepticism; philosophy; epistemology; memory
8.  Assessing the Dream-Lag Effect for REM and NREM Stage 2 Dreams 
PLoS ONE  2011;6(10):e26708.
This study investigates evidence, from dream reports, for memory consolidation during sleep. It is well-known that events and memories from waking life can be incorporated into dreams. These incorporations can be a literal replication of what occurred in waking life, or, more often, they can be partial or indirect. Two types of temporal relationship have been found to characterize the time of occurrence of a daytime event and the reappearance or incorporation of its features in a dream. These temporal relationships are referred to as the day-residue or immediate incorporation effect, where there is the reappearance of features from events occurring on the immediately preceding day, and the dream-lag effect, where there is the reappearance of features from events occurring 5–7 days prior to the dream. Previous work on the dream-lag effect has used spontaneous home recalled dream reports, which can be from Rapid Eye Movement Sleep (REM) and from non-Rapid Eye Movement Sleep (NREM). This study addresses whether the dream-lag effect occurs only for REM sleep dreams, or for both REM and NREM stage 2 (N2) dreams. 20 participants kept a daily diary for over a week before sleeping in the sleep laboratory for 2 nights. REM and N2 dreams collected in the laboratory were transcribed and each participant rated the level of correspondence between every dream report and every diary record. The dream-lag effect was found for REM but not N2 dreams. Further analysis indicated that this result was not due to N2 dream reports being shorter, in terms of number of words, than the REM dream reports. These results provide evidence for a 7-day sleep-dependent non-linear memory consolidation process that is specific to REM sleep, and accord with proposals for the importance of REM sleep to emotional memory consolidation.
doi:10.1371/journal.pone.0026708
PMCID: PMC3202556  PMID: 22046336
9.  Putative Dopamine Agonist (KB220Z) Attenuates Lucid Nightmares in PTSD Patients: Role of Enhanced Brain Reward Functional Connectivity and Homeostasis Redeeming Joy 
Journal of Behavioral Addictions  null;4(2):106-115.
Background
Lucid dreams are frequently pleasant and training techniques have been developed to teach dreamers to induce them. In addition, the induction of lucid dreams has also been used as a way to ameliorate nightmares. On the other hand, lucid dreams may be associated with psychiatric conditions, including Post-Traumatic Stress Disorder (PTSD) and Reward Deficiency Syndrome-associated diagnoses. In the latter conditions, lucid dreams can assume an unpleasant and frequently terrifying character.
Case Presentations
We present two cases of dramatic alleviation of terrifying lucid dreams in patients with PTSD. In the first case study, a 51-year-old, obese woman, diagnosed with PTSD and depression, had attempted suicide and experienced terrifying lucid nightmares linked to sexual/physical abuse from early childhood by family members including her alcoholic father. Her vivid “bad dreams” remained refractory in spite of 6 months of treatment with Dialectical Behavioral Therapy (DBT) and standard pharmaceutical agents which included prazosin, clonidie and Adderall. The second 39-year-old PTSD woman patient had also suffered from lucid nightmares.
Results
The medication visit notes reveal changes in the frequency, intensity and nature of these dreams after the complex putative dopamine agonist KB220Z was added to the first patient’s regimen. The patient reported her first experience of an extended period of happy dreams. The second PTSD patient, who had suffered from lucid nightmares, was administered KB220Z to attenuate methadone withdrawal symptoms and incidentally reported dreams full of happiness and laughter.
Conclusions
These cases are discussed with reference to the known effects of KB220Z including enhanced dopamine homeostasis and functional connectivity of brain reward circuitry in rodents and humans. Their understanding awaits intensive investigation involving large-population, double-blinded studies.
doi:10.1556/2006.4.2015.008
PMCID: PMC4500891  PMID: 26132915
putative complex dopamine agonist; KB220Z; parasomnia; functional brain connectivity; lucid nightmares; Post-Traumatic Stress Disorder (PTSD)
10.  Reporting dream experience: Why (not) to be skeptical about dream reports 
Are dreams subjective experiences during sleep? Is it like something to dream, or is it only like something to remember dreams after awakening? Specifically, can dream reports be trusted to reveal what it is like to dream, and should they count as evidence for saying that dreams are conscious experiences at all? The goal of this article is to investigate the relationship between dreaming, dream reporting and subjective experience during sleep. I discuss different variants of philosophical skepticism about dream reporting and argue that they all fail. Consequently, skeptical doubts about the trustworthiness of dream reports are misguided, and for systematic reasons. I suggest an alternative, anti-skeptical account of the trustworthiness of dream reports. On this view, dream reports, when gathered under ideal reporting conditions and according to the principle of temporal proximity, are trustworthy (or transparent) with respect to conscious experience during sleep. The transparency assumption has the status of a methodologically necessary default assumption and is theoretically justified because it provides the best explanation of dream reporting. At the same time, it inherits important insights from the discussed variants of skepticism about dream reporting, suggesting that the careful consideration of these skeptical arguments ultimately leads to a positive account of why and under which conditions dream reports can and should be trusted. In this way, moderate distrust can be fruitfully combined with anti-skepticism about dream reporting. Several perspectives for future dream research and for the comparative study of dreaming and waking experience are suggested.
doi:10.3389/fnhum.2013.00708
PMCID: PMC3819526  PMID: 24223542
dreaming; subjective experience; dream reports; first-person reports; philosophy of mind; scientific dream research; skepticism; inference to the best explanation
11.  Polysomnographic Findings in Dementia With Lewy Bodies 
The neurologist  2013;19(1):1-6.
Introduction
The clinical features of dementia with Lewy bodies (DLB) during wakefulness are well known. Other than REM sleep behavior disorder (RBD), only limited data exists on other sleep disturbances and disorders in DLB. We sought to characterize the polysomnographic (PSG) findings in a series of DLB patients with sleep-related complaints.
Methods
Retrospective study of patients with DLB who underwent clinical PSG at Mayo Clinic Rochester or Mayo Clinic Jacksonville over an almost 11 year span for evaluation of dream enactment behavior, excessive nocturnal movements, sleep apnea, hypersomnolence, or insomnia. The following variables were analyzed: respiratory disturbance index (RDI) in disordered breathing events/hour, periodic limb movement arousal index (PLMAI), arousals for no apparent reason (AFNAR), total arousal index (TAI), presence of REM sleep without atonia (RSWA), and percent sleep efficiency (SE).
Results
Data on 78 patients (71M, 7F) were analyzed. The mean age was 71 ± 8 years. Seventy-five (96%) patients had histories of recurrent dream enactment during sleep with 83% showing confirmation of RSWA +/- dream enactment during PSG. Mean RDI = 11.9 ± 5.8, PLMAI = 5.9 ± 8.5, AFNARI = 10.7 ± 12.0, and TAI = 26.6 ± 17.4. SE was <80% in 72% of the sample, <70% in 49%, and <60% in 24%. In patients who did not show evidence of significant disordered breathing (23 with RDI<5), 62% of arousals were AFNARs. In those patients who had significant disordered breathing (55 with RDI ≥ 5), 36% of arousals were AFNARs. Six patients underwent evaluations with PSG plus MSLT. Two patients had mean initial sleep latencies less than five minutes, and both had RDI<5. No patient had any sleep onset rapid eye movement periods. Nineteen patients have undergone neuropathologic examination, and 18 have had limbic- or neocortical-predominant Lewy body pathology. One had progressive supranuclear palsy, but no REM sleep was recorded in prior PSG.
Conclusions
In patients with DLB and sleep-related complaints, several sleep disturbances in addition to RBD are frequently present. In this sample, about three quarters had a significant number of arousals not accounted for by a movement or breathing disturbance, and the primary sleep disorders do not appear to entirely account for the poor sleep efficiency in DLB, especially in those without a significant breathing disorder. Further studies are warranted to better understand the relationship between disturbed sleep, arousal and DLB; such characterization may provide insights into potential avenues of treatment of symptoms which could impact quality of life.
doi:10.1097/NRL.0b013e31827c6bdd
PMCID: PMC3587292  PMID: 23269098
Sleep disorders; REM sleep behavior disorder; dementia with Lewy bodies; synucleinopathy
12.  Parasomnias: An Updated Review 
Neurotherapeutics  2012;9(4):753-775.
Parasomnias are abnormal behaviors emanating from or associated with sleep. Sleepwalking and related disorders result from an incomplete dissociation of wakefulness from nonrapid eye movement (NREM) sleep. Conditions that provoke repeated cortical arousals, or promote sleep inertia lead to NREM parasomnias by impairing normal arousal mechanisms. Changes in the cyclic alternating pattern, a biomarker of arousal instability in NREM sleep, are noted in sleepwalking disorders. Sleep-related eating disorder (SRED) is characterized by a disruption of the nocturnal fast with episodes of feeding after an arousal from sleep. SRED is often associated with the use of sedative-hypnotic medications; in particular, the widely prescribed benzodiazepine receptor agonists. Recently, compelling evidence suggests that nocturnal eating may in some cases be a nonmotor manifestation of Restless Legs Syndrome (RLS). rapid eye movement (REM) Sleep Behavior Disorder (RBD) is characterized by a loss of REM paralysis leading to potentially injurious dream enactment. The loss of atonia in RBD often predates the development of Parkinson’s disease and other disorders of synuclein pathology. Parasomnia behaviors are related to an activation (in NREM parasomnias) or a disinhibition (in RBD) of central pattern generators (CPGs). Initial management should focus on decreasing the potential for sleep-related injury followed by treating comorbid sleep disorders. Clonazepam and melatonin appear to be effective therapies in RBD, whereas paroxetine has been reported effective in some cases of sleep terrors. At this point, pharmacotherapy for other parasomnias is less certain, and further investigations are necessary.
Electronic supplementary material
The online version of this article (doi:10.1007/s13311-012-0143-8) contains supplementary material, which is available to authorized users.
doi:10.1007/s13311-012-0143-8
PMCID: PMC3480572  PMID: 22965264
Parasomnia; Sleepwalking; Sleep terrors; REM sleep behavior disorder; Restless legs syndrome
13.  Sleep Disturbances in Parkinson’s Disease 
Sleep disturbances are very common in patients with PD and are associated with a variety of negative outcomes. The evaluation of sleep disturbances in these patients is complex, as sleep may be affected by a host of primary sleep disorders, other primary medical or psychiatric conditions, reactions to medications, aging or the neuropathophysiology of PD itself. In this article we review the evaluation of the common disturbances of sleep seen in PD. This includes the primary sleep disorders, the interaction of depression and insomnia, the impact that medications for PD have on sleep, as well as the role of factors such as nocturia, pain, dystonia, akinesia, difficulty turning in bed and vivid dreaming. The treatment of sleep disturbances in PD is largely unstudied but recommendations based on clinical experience in PD and research studies in other geriatric populations can be made. Important principles include, diagnosis, treating the specific sleep disorder or co-occurring disorder, and control of the motor aspects of PD.
doi:10.1002/mds.22788
PMCID: PMC2840057  PMID: 20187236
14.  Correlation of Sleep Disturbance and Cognitive Impairment in Patients with Parkinson’s Disease 
Journal of Movement Disorders  2014;7(1):13-18.
Objective
Cognitive impairment is a common nonmotor symptom of Parkinson’s disease (PD) and is associated with high mortality, caregiver distress, and nursing home placement. The risk factors for cognitive decline in PD patients include advanced age, longer disease duration, rapid eye movement sleep behavior disorder, hallucinations, excessive daytime sleepiness, and nontremor symptoms including bradykinesia, rigidity, postural instability, and gait disturbance. We conducted a cross-sectional study to determine which types of sleep disturbances are related to cognitive function in PD patients.
Methods
A total of 71 PD patients (29 males, mean age 66.46 ± 8.87 years) were recruited. All patients underwent the Mini- Mental State Examination (MMSE) and the Korean Version of the Montreal Cognitive Assessments (MoCA-K) to assess global cognitive function. Sleep disorders were evaluated with the Stanford Sleepiness Scale, Epworth Sleepiness Scale, Insomnia Severity Index (ISI), Pittsburg Sleep Quality Index, and Parkinson’s Disease Sleep Scale in Korea (PDSS).
Results
The ISI was correlated with the MMSE, and total PDSS scores were correlated with the MMSE and the MoCA-K. In each item of the PDSS, nocturnal restlessness, vivid dreams, hallucinations, and nocturnal motor symptoms were positively correlated with the MMSE, and nocturnal restlessness and vivid dreams were significantly related to the MoCA-K. Vivid dreams and nocturnal restlessness are considered the most powerful correlation factors with global cognitive function, because they commonly had significant correlation to cognition assessed with both the MMSE and the MoCA-K.
Conclusions
We found a correlation between global cognitive function and sleep disturbances, including vivid dreams and nocturnal restlessness, in PD patients.
doi:10.14802/jmd.14003
PMCID: PMC4051722  PMID: 24926405
Cognitive impairment; Parkinson’s disease; Sleep disturbance
15.  REM Sleep Behavior Disorder: Updated Review of the Core Features, the RBD-Neurodegenerative Disease Association, Evolving Concepts, Controversies, and Future Directions 
Rapid eye movement (REM) sleep behavior disorder (RBD) is a parasomnia manifested by vivid, often frightening dreams associated with simple or complex motor behavior during REM sleep. Patients appear to “act out their dreams,” in which the exhibited behaviors mirror the content of the dreams, and the dream content often involves a chasing or attacking theme. The polysomnographic features of RBD include increased electromyographic tone +/- dream enactment behavior during REM sleep. Management with counseling and pharmacologic measures is usually straight-forward and effective.
In this review, the terminology, clinical and polysomnographic features, demographic and epidemiologic features, diagnostic criteria, differential diagnosis, and management strategies are discussed. Recent data on the suspected pathophysiologic mechanisms of RBD are also reviewed. The literature and our institutional experience on RBD are next discussed, with an emphasis on the RBD-neurodegenerative disease association and particularly the RBD-synucleinopathy association. Several issues relating to evolving concepts, controversies, and future directions are then reviewed, with an emphasis on idiopathic RBD representing an early feature of a neurodegenerative disease and particularly an evolving synucleinopathy. Planning for future therapies that impact patients with idiopathic RBD is reviewed in detail.
doi:10.1111/j.1749-6632.2009.05115.x
PMCID: PMC2902006  PMID: 20146689
REM sleep behavior disorder; parasomnia; synucleinopathy; neurodegenerative disease
16.  Negative Emotions in Migraineurs Dreams: The Increased Prevalence of Oneiric Fear and Anguish, Unrelated to Mood Disorders 
Behavioural Neurology  2014;2014:919627.
Background. Migraineurs brain has shown some functional peculiarities that reflect not only in phonophobia, and photophobia, but also in mood and sleep. Dreaming is a universal mental state characterized by hallucinatory features in which imagery, emotion, motor skills, and memory are created de novo. We evaluated dream contents and associated emotions in migraineurs. Materials and Methods. 412 subjects: 219 controls; and 148 migraineurs (66 with aura, MA; 82 without aura, MO), and 45 tension type headache patients (TTH). A semistructured retrospective self-reported questionnaire was used to evaluate dreams. The Generalized Anxiety Disorder Questionnaire (GAD-7), and the Patient Health Questionnaire (PHQ-9) were administered to evaluate anxiety and depression. Results. Migraineurs showed increased levels of anxiety (P = 0.0002 for MA versus controls, P = 0.004 for MO versus controls). Fear and anguish during dreaming were more frequently reported by migraine patients compared to controls, independently by anxiety and depression scores. Discussion. The brain of migraineurs seems to dream with some peculiar features, all with a negative connotation, as fear and anguish. It may be due to the recorded negative sensations induced by recurrent migraine pain, but it may just reflect a peculiar attitude of the mesolimbic structures of migraineurs brain, activated in both dreaming and migraine attacks.
doi:10.1155/2014/919627
PMCID: PMC4094847  PMID: 25049452
17.  Sleep from an Islamic perspective 
Annals of Thoracic Medicine  2011;6(4):187-192.
Sleep medicine is a relatively new scientific specialty. Sleep is an important topic in Islamic literature, and the Quran and Hadith discuss types of sleep, the importance of sleep, and good sleep practices. Islam considers sleep as one of the signs of the greatness of Allνh (God) and encourages followers to explore this important sign. The Quran describes different types of sleep, and these correspond with sleep stages identified by modern science. The Quran discusses the beneficial effects of sleep and emphasizes the importance of maintaining a pattern of light and darkness. A mid-day nap is an important practice for Muslims, and the Prophet Muhammad peace be upon him (pbuh) promoted naps as beneficial. In accordance with the practice and instructions of Muhammad (pbuh), Muslims have certain sleep habits and these sleep habits correspond to some of the sleep hygiene rules identified by modern science. Details during sleep include sleep position, like encouraging sleep on the right side and discouraging sleep in the prone position. Dream interpretation is an established science in the Islamic literature and Islamic scholars have made significant contributions to theories of dream interpretation. We suggest that sleep scientists examine religious literature in general and Islamic literature in particular, to understand the views, behaviors, and practices of ancient people about the sleep and sleep disorders. Such studies may help to answer some unresolved questions in sleep science or lead to new areas of inquiry.
doi:10.4103/1817-1737.84771
PMCID: PMC3183634  PMID: 21977062
Circadian rhythm; dreams; Islam; Quran; sleep
18.  Sleep and Impulsivity in Parkinson’s Disease 
Parkinsonism & related disorders  2013;19(11):10.1016/j.parkreldis.2013.06.018.
Background
Impulsive behavior and poor sleep are important non-motor features of Parkinson’s disease (PD) that negatively impact the quality of life of patients and their families. Previous research suggests a higher level of sleep complaints in PD patients who demonstrate impulsive behaviors, but the nature of the sleep disturbances has yet to be comprehensively tested.
Methods
Consecutive idiopathic PD patients (N=143) completed the Minnesota Impulse Disorder Interview and a sleep questionnaire that assessed sleep efficiency, excessive daytime sleepiness, restless legs symptoms, snoring, dreams/nightmares, and nocturia. Patients were also given a Unified Parkinson’s Disease Rating Scale motor examination and they completed cognitive testing.
Results
Impulsive PD patients endorsed more sleep complaints than non-impulsive PD patients. The group difference was primarily attributable to poor sleep efficiency (e.g., greater nocturnal awakenings), p < .01, and greater daytime sleepiness, p < .01, in the impulsive PD patients. Interestingly, restless legs symptoms were also greater in the impulsive PD patients, p < .05. The results could not be explained by medications or disease severity.
Conclusions
Poor sleep efficiency, restless legs symptoms, and increased daytime sleepiness are associated with impulsivity in PD. Longitudinal studies are needed to determine whether sleep disturbances precede impulsivity in PD.
doi:10.1016/j.parkreldis.2013.06.018
PMCID: PMC3878049  PMID: 23880026
Parkinson s disease; sleep; impulse control disorder; excessive daytime sleepiness
19.  Autobiographical memory and hyperassociativity in the dreaming brain: implications for memory consolidation in sleep 
In this paper we argue that autobiographical memory (AM) activity across sleep and wake can provide insight into the nature of dreaming, and vice versa. Activated memories within the sleeping brain reflect one’s personal life history (autobiography). They can appear in largely fragmentary forms and differ from conventional manifestations of episodic memory. Autobiographical memories in dreams can be sampled from non-REM as well as REM periods, which contain fewer episodic references and become more bizarre across the night. Salient fragmented memory features are activated in sleep and re-bound with fragments not necessarily emerging from the same memory, thus de-contextualizing those memories and manifesting as experiences that differ from waking conceptions. The constructive nature of autobiographical recall further encourages synthesis of these hyper-associated images into an episode via recalling and reporting dreams. We use a model of AM to account for the activation of memories in dreams as a reflection of sleep-dependent memory consolidation processes. We focus in particular on the hyperassociative nature of AM during sleep.
doi:10.3389/fpsyg.2015.00874
PMCID: PMC4488598  PMID: 26191010
autobiographical memory; dreaming; memory consolidation; sleep; continuity hypothesis; hyperassociativity
20.  Resting Brain Activity Varies with Dream Recall Frequency Between Subjects 
Neuropsychopharmacology  2014;39(7):1594-1602.
Dreaming is still poorly understood. Notably, its cerebral underpinning remains unclear. Neuropsychological studies have shown that lesions in the temporoparietal junction (TPJ) and/or the white matter of the medial prefrontal cortex (MPFC) lead to the global cessation of dream reports, suggesting that these regions of the default mode network have key roles in the dreaming process (forebrain ‘dream-on' hypothesis). To test this hypothesis, we measured regional cerebral blood flow (rCBF) using [15O]H2O positron emission tomography in healthy subjects with high and low dream recall frequencies (DRFs) during wakefulness (rest) and sleep (rapid eye movement (REM) sleep, N2, and N3). Compared with Low recallers (0.5±0.3 dream recall per week in average), High recallers (5.2±1.4) showed higher rCBF in the TPJ during REM sleep, N3, and wakefulness, and in the MPFC during REM sleep and wakefulness. We demonstrate that the resting states of High recallers and Low recallers differ during sleep and wakefulness. It coheres with previous ERP results and confirms that a high/low DRF is associated with a specific functional organization of the brain. These results support the forebrain ‘dream-on' hypothesis and suggest that TPJ and MPFC are not only involved in dream recall during wakefulness but also have a role in dreaming during sleep (production and/or encoding). Increased activity in the TPJ and MPFC might promote the mental imagery and/or memory encoding of dreams. Notably, increased activity in TPJ might facilitate attention orienting toward external stimuli and promote intrasleep wakefulness, facilitating the encoding of the dreams in memory.
doi:10.1038/npp.2014.6
PMCID: PMC4023156  PMID: 24549103
chronobiology; sleep; cognition; default mode network; dreaming; imaging; clinical or preclinical; neurophysiology; positron emission tomography; resting state; temporo-parietal junction; sleep; dreaming; default mode network; positron emission tomography; resting state; self
21.  Experimental Research on Dreaming: State of the Art and Neuropsychoanalytic Perspectives 
Dreaming is still a mystery of human cognition, although it has been studied experimentally for more than a century. Experimental psychology first investigated dream content and frequency. The neuroscientific approach to dreaming arose at the end of the 1950s and soon proposed a physiological substrate of dreaming: rapid eye movement sleep. Fifty years later, this hypothesis was challenged because it could not explain all of the characteristics of dream reports. Therefore, the neurophysiological correlates of dreaming are still unclear, and many questions remain unresolved. Do the representations that constitute the dream emerge randomly from the brain, or do they surface according to certain parameters? Is the organization of the dream’s representations chaotic or is it determined by rules? Does dreaming have a meaning? What is/are the function(s) of dreaming? Psychoanalysis provides hypotheses to address these questions. Until now, these hypotheses have received minimal attention in cognitive neuroscience, but the recent development of neuropsychoanalysis brings new hopes of interaction between the two fields. Considering the psychoanalytical perspective in cognitive neuroscience would provide new directions and leads for dream research and would help to achieve a comprehensive understanding of dreaming. Notably, several subjective issues at the core of the psychoanalytic approach, such as the concept of personal meaning, the concept of unconscious episodic memory and the subject’s history, are not addressed or considered in cognitive neuroscience. This paper argues that the focus on singularity and personal meaning in psychoanalysis is needed to successfully address these issues in cognitive neuroscience and to progress in the understanding of dreaming and the psyche.
doi:10.3389/fpsyg.2011.00286
PMCID: PMC3220269  PMID: 22121353
dream; neurophysiological correlates of dreaming; dream functions; unconscious; personal meaning; neuroimaging; psychoanalysis
22.  Dreaming and the brain: from phenomenology to neurophysiology 
Dreams are a most remarkable experiment in psychology and neuroscience, conducted every night in every sleeping person. They show that our brain, disconnected from the environment, can generate by itself an entire world of conscious experiences. Content analysis and developmental studies have furthered our understanding of dream phenomenology. In parallel, brain lesion studies, functional imaging, and neurophysiology have advanced our knowledge of the neural basis of dreaming. It is now possible to start integrating these two strands of research in order to address some fundamental questions that dreams pose for cognitive neuroscience: how conscious experiences in sleep relate to underlying brain activity; why the dreamer is largely disconnected from the environment; and whether dreaming is more closely related to mental imagery or to perception.
doi:10.1016/j.tics.2009.12.001
PMCID: PMC2814941  PMID: 20079677
23.  Dreaming and insight 
This paper addresses claims that dreams can be a source of personal insight. Whereas there has been anecdotal backing for such claims, there is now tangential support from findings of the facilitative effect of sleep on cognitive insight, and of REM sleep in particular on emotional memory consolidation. Furthermore, the presence in dreams of metaphorical representations of waking life indicates the possibility of novel insight as an emergent feature of such metaphorical mappings. In order to assess whether personal insight can occur as a result of the consideration of dream content, 11 dream group discussion sessions were conducted which followed the Ullman Dream Appreciation technique, one session for each of 11 participants (10 females, 1 male; mean age = 19.2 years). Self-ratings of deepened self-perception and personal gains from participation in the group sessions showed that the Ullman technique is an effective procedure for establishing connections between dream content and recent waking life experiences, although wake life sources were found for only 14% of dream report text. The mean Exploration-Insight score on the Gains from Dream Interpretation questionnaire was very high and comparable to outcomes from the well-established Hill (1996) therapist-led dream interpretation method. This score was associated between-subjects with pre-group positive Attitude Toward Dreams (ATD). The need to distinguish “aha” experiences as a result of discovering a waking life source for part of a dream, from “aha” experiences of personal insight as a result of considering dream content, is discussed. Difficulties are described in designing a control condition to which the dream report condition can be compared.
doi:10.3389/fpsyg.2013.00979
PMCID: PMC3872037  PMID: 24550849
Dream; sleep; REM sleep; insight; psychotherapy
24.  Phasic Muscle Activity in Sleep and Clinical Features of Parkinson Disease 
Annals of neurology  2010;68(3):353-359.
Objective
The absence of atonia during rapid eye movement (REM) sleep and dream-enactment behavior (REM sleep behavior disorder [RBD]) are common features of sleep in the alpha-synucleinopathies. This study examined this phenomenon quantitatively, using the phasic electromyographic metric (PEM), in relation to clinical features of idiopathic Parkinson disease (PD). Based on previous studies suggesting that RBD may be prognostic for the development of later parkinsonism, we hypothesized that clinical indicators of disease severity and more rapid progression would be related to PEM.
Methods
A cross-sectional convenience sample of 55 idiopathic PD patients from a movement disorders clinic in a tertiary care medical center underwent overnight polysomnography. PEM, the percentage of 2.5-second intervals containing phasic muscle activity, was quantified separately for REM and non-REM (NREM) sleep from 5 different electrode sites.
Results
Higher PEM rates were seen in patients with symmetric disease, as well as in akinetic-rigid versus tremor-predominant patients. Men had higher PEM relative to women. Results occurred in all muscle groups in both REM and NREM sleep.
Interpretation
Although our data were cross-sectional, phasic muscle activity during sleep suggests disinhibition of descending motor projections in PD broadly reflective of more advanced and/or progressive disease. Elevated PEM during sleep may represent a functional window into brainstem modulation of spinal cord activity and is broadly consistent with the early pathologic involvement of non-nigral brainstem regions in PD, as described by Braak.
doi:10.1002/ana.22076
PMCID: PMC3666956  PMID: 20626046
25.  A Neurodegenerative Disease Sleep Questionnaire: Principal Components Analysis in Parkinson’s Disease 
Sleep disturbances are common in many neurodegenerative diseases and may include altered sleep duration, fragmented sleep, nocturia, excessive daytime sleepiness, and vivid dreaming experiences, with occasional parasomnias. Although representing the “gold standard,” polysomnography is not always cost-effective or available for measuring sleep disturbance, particularly for screening. Although numerous sleep-related questionnaires exist, many focus on a specific sleep disturbance (e.g., restless legs, REM Behavior Disorder) and do not capture efficiently the variety of sleep issues experienced by such patients. We developed and administered the 12-item Neurodegenerative Disease Sleep Questionnaire (NDSQ) and the Epworth Sleepiness Scale to 145 idiopathic Parkinson’s disease patients. Principal component analysis using eigenvalues greater than 1 suggested five separate components: sleep quality (e.g., sleep fragmentation), nocturia, vivid dreams/nightmares, restless legs symptoms, and sleep-disordered breathing. These results demonstrate construct validity of our sleep questionnaire and suggest the NDSQ may be a useful screening tool for sleep disturbances in at least some types of neurodegenerative disorders.
doi:10.1016/j.jns.2013.09.009
PMCID: PMC3947083  PMID: 24074551
sleep questionnaire; principal components analysis; nocturia; sleep disordered breathing; dreaming; restless legs syndrome; neurodegenerative disease; Parkinson’s disease

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