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ORATION
Year : 2018  |  Volume : 19  |  Issue : 2  |  Page : 57-63

The mystery of the missing dream in psychiatry (DS Raju Memorial Oration at IPS-AP State Conference Kakinada)


President, Indian Psychiatric Society 2017-2018; President SAARC Psychiatric Federation 2017 -2019; President Association of Industrial Psychiatry of India 2018-2021; Board Member and Zone 16 Representative World Psychiatric Association 2017 -2020; Member World Psychiatric Association (Hon); International Distinguished Fellow American Psychiatric Association; Fellow International Institute of Organisational Psychological Medicine

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. M S. V. K. Raju
Brown Hill, A-18, Nyati Highland, Mohammadwadi, Pune - 411 060, Maharashtra

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMH.AMH_39_18

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How to cite this article:
Raju M S. The mystery of the missing dream in psychiatry (DS Raju Memorial Oration at IPS-AP State Conference Kakinada). Arch Ment Health 2018;19:57-63

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Raju M S. The mystery of the missing dream in psychiatry (DS Raju Memorial Oration at IPS-AP State Conference Kakinada). Arch Ment Health [serial online] 2018 [cited 2019 May 26];19:57-63. Available from: http://www.amhonline.org/text.asp?2018/19/2/57/248892




  Introduction Top


Honorable President and the office bearers of Indian Psychiatric Society, Andhra Pradesh branch, members of the council, distinguished guests, colleagues, ladies and gentlemen, I owe my deep sense of gratitude to you all for considering me eligible for the award of the prestigious Dr. D S Raju Oration. It gladdens me immensely to know that what little that I have been able to do over the years was considered worthy for recognition. Torn between mind and matter, the unique branch of medicine psychiatry is struggling through difficult times and seems to be going through an identity crisis yet again which to my mind appears rather unfortunate as the aphorism goes if one digs psychology, one finds biology. Dream became a casualty in this conflict. I thought it would be a fitting salute to the departed soul if I could speak on dreams which are poised to play an important role in psychiatry once again.

Dreams always have been a part of the warp and woof of human history for eons. While the regular nocturnal running shows, were dissected and interpreted as meaningful by some[1] others dismissed them outright as phenomena of no consequence.[2] But, dreams continue to fascinate humans of all hues as evidenced by the publication of more than 300 dictionaries and thousands of books on dreams.[3] In India, the Upanishads, Vedas, Classics, and Ayurveda texts have descriptions of dreams and dream omens.[4] The Pharoa's dream of seven fat cows and seven lean cows which Joseph had interpreted[5] is quite well known. Dream interpreters were reported to have been part of the entourage of ancient emperors in their campaigns and assaults were made at opportune times as per their prescriptions. Literature is replete with accounts of dreams, all alluding to their extra-human or divine origins.[6] Surprisingly, articles on dreams in psychiatry journals are hard to be found.[7] Apart from an article by Nathawat and Sethi in 1973,[8] there are no studies on dreams in Indian Journal of Psychiatry. Dreams found no mention in the monumental volume on psychiatry research in India brought out by the Indian Journal of Psychiatry in 2010.[9] Truly, dreams seem to have been buried alive for no particular cause or reason. This unceremonious burial indeed is a mystery as dreams after all are the products of the brain–mind system, which is the area of operations of every psychiatrist.

Dreams are defined in many ways, but may be succinctly defined as mental experiences in sleep which can be described in waking consciousness.[10] An average human being spends approximately a third of his/her life sleeping and at least a quarter of sleep time in dreaming. The chunk of dreaming time can roughly be worked out to be more than 50,000 h in an average life span of 70 years! The duration and form of sleep is assessed and monitored clinically as well as by gadgetry these days, but the content of sleep is disregarded and dismissed. No wonder that some consider dreams are an “endangered species”[11] in the landscape of psychiatry. The questions why human species have been dreaming since ancient times and for regularly so long in their individual lives, whether dreams have a meaning, and whether they serve any function can be answered with some confidence now.[1],[10]

From the pre-Freudian precognition to the Freudian and post-Freudian analysis and interpretation, from descriptive studies and content analysis to socio-biology, and from neurophysiological to neuroimaging investigations, so much has happened in oneirology that a psychiatrist cannot have the luxury of not knowing. We see an evolving integration of the knowledge into the knowledge base of psychiatry and psychiatric therapeutics. As we can see, the canvas is big and daunting. Within the allotted time, I shall make an endeavor to draw an outline for the interested clinician and investigator.


  Dreamless Sleep Top


The scientific investigation into dreams started with Freud's interpretation of his own dream on July 24, 1895,[1] culminating in the publication of his acknowledged masterpiece “The interpretation of Dreams” at the turn of the 20th century.[12] Freud said, “When I enquired about symptoms people came up with dreams.”[6] But, the prevailing clinical ambience in these parts of the world is different. People do not report dreams spontaneously because of the singular fact that they were not asked about them. Second, the notion that dreams disturb sleep and signify weakness of mind seems to be entrenched in the minds of people here. Gentle coaxing is required to extract dreams and utilize them for the benefit of patients.

The first thing I tell my patients is that everybody dreams every night and important work happens for us in the dreams when our minds talk to us! An example of what Freud calls as “Imperative somatic dream”[6] may make things easier. For example, say in the unearthly hours of a particular night you dream that your spouse is delivering painful nudges and telling you to get up and stop the running tap in the wash room. You are in no mood to oblige until the nudges become increasingly insistent and unbearable. You shake yourself up and get up only to note that your bladder was on the verge of bursting and your wife was a sleeping beauty as she always was! The point to note is that the dream is allowing you to sleep as long as possible. In the present example, perhaps, you would have continued to sleep if the nudges were little tender! Sleep and dreams are required for health. Our minds talk to us in symbols. There is much knowledge and pleasure in unraveling the seemingly meaningless symbols. If it is not for this fact, Picasso and Dali of the world would not have been the celebrities that they are.


  Dream Dynamics Top


Freud was a medical scientist who brought the spirit of science to bear on the hitherto mysterious phenomenon of dream. He did not have the wherewithal that we can boast of now to study the brain–mind system. In his introductory lectures, he unfolds his concepts of the mechanisms of dream formation and the method of dream interpretation drawing from his rich knowledge of literature, basic sciences, medicine, and his ruthless dissection of his own dreams and those of others. He introduces the concept “disturbed” and “disturbing” elements in the “currently unconscious” by exploring the “sense” of parapraxis where the object of interest is just one element. He proceeds to guide you skillfully toward the “sense” of dreams which consists of several elements.[6] In a significant departure, he rejects the idea of precognition and posits that dream has a function and purpose. He postulated that the unconscious wishes which are not acceptable to the ego find expression in disguised fashion as dreams. The dream censor in the preconscious creates this disguise giving an opportunity to the undischarged wish to gain conscious perception and partial satisfaction of the wish as a compromise and pragmatic solution to restore homeostasis in the mind. Fundamentally, dreams are wish fulfilling in nature. Dream is a compromise like a neurotic symptom.[6],[12] What is reported is the manifest dream and the inexpressible unconscious wish is the latent dream. The latent content is often our early childhood preverbal conflicts which seek to express out. As the content is disguised, the disjointed manifest dream appears un-understandable. The therapist unravels the mystery by de-disguising the dream to bring out the naked threatening wish by applying the clinical method of free association to each element of the dream. Let me give an example:

Example 1: A person lay spread eagled on the bed with an intravenous line and leads on his chest leading to a monitor. His back ached badly because of lying in the same position for hours, he was feeling hungry, his tongue craved for a few drops of water and he badly wanted to kill the monitor which let out ping-ping sounds with monotonous regularity. In his fitful sleep he dreamt of two huge yellow boulders perched on a hill slope. Two small boys, their bodies silhouetted against the cut surface of the boulders were running down the slope. In the dream he thought they were about to plunge into a pond. The long chain of associations revealed that actually there was a hill where as a young boy he would frolic around with his cousin. One day the cousin relieved him of great pain by pulling out a big thorn that pierced his foot. The boulders were also there in reality. But the yellow boulders were in fact potatoes in a particular curry which he liked. They would run down the slope and somersault into the nearby pond almost daily. It was all great fun.

The point to note here is that the dream is wish fulfilling: relief from pain, pleasure of eating, and pleasure of moving around. The dream also gives a visual form to a wish and that the dream wish need not be traced to the preverbal early life. And, this dream also tells us loudly that nature of all dreams is not always sex. There was also no conflict involving sex or aggression here. But, it is to be noted if he had ran out to loosen his limbs and seek food he would have imperiled his life. We only find conflict and wish fulfillment of nonsexual and nonaggressive nature here: relief from pain, pleasure of food, and pleasure of movement. You unwrap the dream layer by layer as far as possible and as far as practicable because if you are so anankastic and want to go to the root of everything, you may have to undertake the long journey to the Big Bang which is the original cause of everything!

A dream element may stand as a symbol for many things. Say for example, if you see stray dogs in your dream, it may stand as a signal symbolizing forbidden sexual excitement as we find dogs doing it openly in our streets, it may mean your love for stray dogs or the pet dog you lost, or it may mean sympathy to the parents of the boy who got killed by stray dogs in this city recently or it may reflect your remorse at hitting a stray mercilessly in younger days, and so on. Like an encrypted message, each image may have layers that you may have to unwrap like the layers we unwrapped in the yellow boulders. A substantial number of dreams have meanings which are individual specific.

Example 2: A man dreamed that his father left for an unknown place and returned after some time with a large consignment of onion saplings. For some reason he was not able to tell anyone to plant them. The person felt bad that the saplings were getting wasted. He instructed his laborers to plant them in the field.

This individual was a farmer from Nasik region known for its onions. He lost his father some time ago. After his father's death, he planted banana in his farm instead of onion. On one fine day, a stray whirlwind flattened out the fruit-laden banana plants right in front of his eyes. Had he planted onion like his father, he would not have had to suffer the trauma of crop loss– gales bring down trees not grass! As the associations rolled out, he cried. Unwittingly, I might have saved a life in these days of farmer suicides! We see here once again a wish and remorse with roots in the recent past. I must mention here that in Freudian terms departure symbolizes death.[6]

Example 3: A middle-aged doctor would see repeatedly black mangoes in his dreams which baffled him. Analysis revealed that the trigger for this was sexual excitement after seeing a bit of the exposed breast of his colleague's teen-aged daughter which he associated with the experience of touching the breast of an obliging dark girl in his youth and his studies as a college student under mango trees laden with fruit which he was not allowed to pluck by the watchman and the finding in the farm house of the mango orchard a vagrant couple who he thought were indulging in clandestine sexual activity.

We can see clearly here the day's residue, condensation, and displacement at work. The single image of a black mango captured so many images, symbolic of a common theme, in an apparent attempt at psychic economy. The sexual conflict is also evident here. It can be seen that dream interpretation can be done to ascertain current conflicts and wishes without going too far into childhood. Some go to the extent to say that even face-to-face interaction with persons is not needed to understand the meaning of dreams. They hold the view that the current concerns and the character of the dreamer can be discerned simply by meticulous documentation and analysis of their dream reports.


  Quantitative Studies of Dreams Top


Calvin Hall and Robert Van de Castle developed a method of finding meaning of dreams through the quantitative study of dream content.[13] Essentially, the method converts content of dream reports into letters and numbers so that they can be statistically analyzed and effect sizes can be determined by comparing with norms to determine significance. Normative data are available for American college students which were found to be suitable for comparison purposes. This system does not utilize free association, amplification, or any information provided by dreamer other than the dream report. Domhoff believes that if one has one hundred dream reports of a person, one can fairly know the personality of a person and his current concerns without resorting to interpretation of putative unconscious drives and further goes on to the extent of saying that analysis of a thousand dream reports collected over a few decades will give a very accurate description of a person's personality much akin to a fingerprint.[14]

A person's narration of the dream that she or he had is called a “Dream Report.” Two or more dream reports from the same person are called “Dream Series.” A dream series of more than 75 dream reports is considered “long.” Dream reports from a certain type of persons (doctors, men, schizophrenic patients, etc.) or certain types of dreams (falling, flying, loss of teeth, etc.) are called “Dream Sets.” The Hall and Van de Castle system converts the content of dreams into ten categories. They are character, social interaction, strivings, misfortunes/good fortunes, emotionality, physical surroundings, descriptive elements, food and eating, and elements from the past. Each category is further divided into two or more subcategories. For example, the character is subgrouped into people, animals, and mythical figures, each of which can be further divided into individual and group categories. Three additional characters can be given to people and mythical figures – gender, identity, and age. Content analysis revealed that dreams of a person are “consistent” in the sense that are remarkably similar over time. The Consisteny Theory is buttressed by dream series of Dorothea, Jason, and a person with the nickname of Engineman, which gave dream reports extending over years. The study of Krammer and Roth of 820 dream reports in the laboratory also supported the Consistency theory.[14]

There are three studies of Content analysis from India: Grey and Kelsched[15] from Allahabad and that of Bose and Pramila[16] and Prasad[17] from Andhra University. There were many similarities with American population, but Indians saw more familiar characters, family members, food, and nature and witnessed (not participated) aggression. Domhoff also believes that that there is a continuity between dream and waking life (Continuity Hypothesis). People dream about positive or negative personal concerns and interests. Recurrent dreams (repetition dimension) reflect the unfinished business of mind. Intensity of preoccupation can be inferred from the frequency with which they appear.[14] The repetition dimension is also evident in typical dreams.


  Typical Dreams Top


Each dream reflects a particular conflict or a wish that seeks expression albeit in a disguised fashion. According to Freud, there are certain dreams which almost everyone dreams alike.[6],[12] Typical dreams are shared by many, presumably arising out of common childhood experiences such as losing teeth, finding money, flying, and falling. Griffith and Miyagi Oand Tag[18] devised a Typical Dream Questionnaire (TDQ) with 32 items to capture typical dreams in population. Nielsen et al. (2001)[19] administered modified TDQ with 55 items to 1348 to students of three universities in Canada and found that being chased by someone without physical injury (81.5%) and having sexual experience (76.5%) are the most common typical dreams. In a first study of this kind, in this country, we further modified Nielsen's TDQ and administered it to 100 each of medical interns, psychiatric patients, and healthy persons.[20] The results of the study will be published elsewhere, but dreams depicting snakes, insects and worms, classroom and failure in examinations, and repetitive dreams are quite common unlike Canadian sample where being chased and having sexual experience are quit common. Responses to each of the 59 items of our questionnaire can studied as dream set and normative information can be obtained. Dream sets in individual categories of mental disorders have also been investigated by some investigators.


  Dreams in Mental Disorders Top


Dreams in schizophrenia have been studied by many workers: Kant;[21] Noble;[22] Okuma et al.;[23] Stompe et al., 2003;[24] Domhoff, 2005;[25] Michels et al.;[26] Skrzypinska and Szmigielska;[27] and Mota et al., 2016.[28] Schizophrenic patients do not have vivid dreams. They reported more control over lucid dreams than normals and had less emotional reaction to delusions and hallucinations, more nightmares, shorter dreams, more family members, and less friends. Abnormalities in dreams sometimes antedated manifestation of clinical psychosis.

Tharp et al. reported that more ambitious dreams predicted manic shift.[29] Baucchemin and Hays reported more anxiety dreams in bipolar depression patients than unipolar depression patients.[30] Beck and Hurvich reported more masochistic content in the dreams of depressed patients.[31] Krammer et al. reported depressive themes in depression.[32] Agargun et al. reported repetitive frightening dreams in suicidal patients.[33] Miller (1969)[34] reported that dreams are bland in the beginning in depressed patients, but as they improve, they become more troubled. An interesting study by Kron (2003)[35] found that pregnant women who had unpleasant dreams did not develop postpartum depression. Bellici et al., 2002,[36] found more dream anxiety in melancholic depression. Marinova et al., 2014,[37] observed that nightmares indicated suicidal risk in depressed patients. Agargun et al., 2016,[38] found higher masochism in melancholic depression. Nadorff et al., 2014,[39] reported that unpleasant dreams in anxiety disorders improve with treatment with CBT. Steinig et al., 2011,[40] found alcohol-dependent patients dreamed more of alcohol, and Choi, 1973,[41] found that dreaming of alcohol is a good prognostic sign in alcohol-dependent patients. Psychotropic drugs were also found to have varied effect on dreams.[42]


  Neuroscience of Dreams Top


Dreams obviously are the productions of the brain–mind system. The foundations for the biological investigation of dreams were laid by Eugene Aserinsky in a dingy basement room of Daniel Kletman's laboratory in Chicago. Aserinsky recorded the brainwaves of his son Armond and noted that the brain was becoming very active at intervals of 90 min which coincided with rapid movements of the eyes. He called this rapid eye movement (REM) sleep and published a paper with his mentor Kleitman as a co-author in 1953.[10] Dement took up the investigations further. He woke up persons going through REM sleep in his laboratory and asked what was going on at that time in their minds. More than 75% reported that they were dreaming in their REM sleep. Seizing the opportunity, Hobson and his resident McCarley placed microelectrodes into neurons to study electrical activity and contended that a dream generator in pons sent random signals to the cortex. The cortex just supplied the images to the random signals emerging from pons, the result of which was the dream. They contended that there was nothing to interpret in the dream and there was no meaning in the dream.[2] The activation-synthesis theory of Hobson and McCarley[2] could be questioned as David found earlier on 1965 that dreams were also produced in non-REM sleep.[43] The psychoanalyst Solms[44] investigated patients with bilateral prefrontal lesions and found that dreams were abolished in these patients though they were having REM sleep. He found that the reward circuits and dopamine were involved in dream production, which was quite contrary to the findings of Hobson andMcCarley.[2] Since reward circuits were involved in motivation, Solms' view supported dynamic motivational concept of dreams. Hobson revised his theory later on (2012),[45] but never accepted that any dream had anything to interpret. Boag, 2016,[46] after an extensive review contended that Freud's view was in the right direction as recurrent dreams should not occur if one takes Hobson's view of random brain stem neuronal firing causing dreams.

Berlin, 2011,[47] and Mancia, 2005,[48] reviewed the neuroscience of the dynamic unconscious and dreams. The elegant experiments of Marcel (1980) and Nakamura et al. (2007) on subliminal perception and cognition of Westen (1998), Tsuchiya, and Adolph (2007) on unconscious feelings of Barg and Chatrand (1999) and Pessiglione on unconscious motivation objectively proved the existence of unconscious mental processes. The homophobe experiments of Adams et al. (1996) and the Continuos Flash Supression experiment of Tsuchiya et al. (2006) proved repression. Wilson's elegant experiment on rats strongly suggested day's residue besides memory consolidation.[49] Wegner et al. in a novel study found that when a thought is suppressed, it emerged in dream more frequently than the other thoughts.[50] Anderson et al.[51] further extended the study by means of functional magnetic resonance imaging investigation. They found that dorsolateral prefrontal cortex became overactive and HC became underactive when the individuals suppressed thoughts, which is opposite to that of what happens in REM sleep when most dreams occur, thereby lending credence to the concept of repressed material emerging in dreams.


  Dreams in Psychotherapy Top


Dream analysis and interpretation is done in various types of psychotherapy.[1] Keller et al., 1995,[52] reported that 57% of therapists worked on dreams occasionally and only 4% worked on dreams always. Raju, 2006,[53] found that several images may be embedded in a recurrent dream image of trauma which can be effectively removed by eye movement desensitization and reprocessing. Schredl et al.,[54] investigated the use of dream work in psychiatric practice. Interestingly, they found that therapists seldom stimulated dream recall in patients and 68% of dream work was initiated by the patients! Therapists who work on their own dreams took more interest in dream work with patients. Freudian and Jungian methods were more frequent. Therapists reported that working on dreams contributed considerably to treatment success. Men and women in our study[20] reported dreams, wherein they had intercourse with strangers, and different types of relations. It would have been interesting to explore their dreams in psychotherapy, but as strict anonymity was maintained while eliciting responses, the exploration would not have been possible. Future researchers would have to find a way to overcome the anonymity problem. Hill and Knox, 2010,[55] reviewed empirical research about how dreams are used in psychotherapy and suggested that dream work should be incorporated in psychotherapy because of its potential effectiveness.


  Dream Imponderables Top


In spite of the impressive advances in dream research clinically and experimentally, the phenomena of dreams yet times remain inexplicable. Vedfelt narrates some really strange and inexplicable dreams: Abraham Lincoln narrated the dream of the scene of his own assassination a few days before the happening to his biographer Ward Hill Lamon. Robert van de Castle gave an example of the curious case Lt Col H R P Dickson, a British Officer stationed in Kuwait in 1937. One day, a violent sand storm made a hole near the palm tree in his compound. He dreamed at night that a beautiful maiden came out of the hole. He consulted a popular Bedouin woman dream interpreter to find out the meaning. She told him it meant that there were riches in the sands of Kuwait. Col Dickson got a British drilling crew who were drilling for water there without success for 2 years to dig. At his insistence, they kept digging and found Oil in May 1938! Oil was undoubtedly riches of the dessert.[56] I wish I had a dream of the latter kind but had this many years ago:

I am on a motor cycle driving on a mud track along a sweeping curve on the hillside strewn with broken tiles. On the right side of the road ran a pipeline of large black pipes. Oil was leaking at the seams of the pipe.

When I settled down to analyze the dream, I found that I wished to drive a bike always since childhood; I could identify the mud track with the one near my village on which I would often gallop on bare feet as a child; I could identify the broken tiles as those near the old town hall of Visakhapatnam beach where I used to go every evening 60 years ago after reading Chandamama stories in the district central library which was then on the way to town hall from the main street. The beach would excite me like the surge of surf and unfailingly fill me with thrill every day. All the elements of the dream obviously were sources of great pleasure. But, I could not place the pipeline of the dream in spite of my best efforts till I went to a place near Bombay a few years ago where I saw huge black pipes that ran along the road leaking oil at the seams!

I can only say that today's mystery is tomorrow's science. Prudence demands we pursue the inexplicable in a spirit of enquiry and scientific equanimity. What is surreal today may be found to be as yet another kind of reality tomorrow!


  Conclusion Top


By discarding dreams, we are leaving a very large portion of the mental life of our patients unexamined. Making sense of dreams imparts meaning to the clinical interaction. The experience of being understood forges a powerful empathic bond between the physician and the patient. Investigating dreams is not all about unraveling shadowy and reprehensible sexual and aggressive desires as we have seen in the few examples. One does come to know some of the current concerns of the patient which for the time being were not in the foreground of consciousness. We also have seen these concerns could be layered and as you peel the layers, you may come to know more about the person who is before you and most importantly the person would come to know more about you as a skillful, sensitive, and empathic professional being. We know much about dreams now than ever before. Domhoff observes very rightly that the biology of dreaming does not tell us the psychological meaning of dreams. Attributing all kinds of mental disorders solely to disturbed neurotransmitters anthropomorphizes molecules and impoverishes psychiatry and may in fact imperil its very existence as a unique branch of medicine, dealing with the subjective minds and objective brains of persons with disorders and distress. Mercifully, the warring dynamists and diehard biologists appear to be reaching at a rapprochement. One can see salutary spinoffs in this development, but it remains to be seen how much of this diffuses into clinical practice. Well, dreams offer the potential onierophile, to coin a word, a vast area of study, and the mysteries that the dreams hold will only be revealed when they are studied.

Ladies and gentlemen, it has been awfully kind of you to give me a patient hearing. I will consider our labors have served a purpose if a few among us got interested in the topic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  In this article
  Introduction
  Dreamless Sleep
  Dream Dynamics
   Quantitative Stu...
  Typical Dreams
   Dreams in Mental...
   Neuroscience of ...
   Dreams in Psycho...
  Dream Imponderables
  Conclusion
   References

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