The Impact of COVID-19 Lockdowns in a Sample of Outpatients in a Mental Health Department of a Metropolitan Hospital in Milan.

Background and Objectives: Italy was the first country in Europe to face the coronavirus 2019 (COVID-19) pandemic and its consequences, which led to two phases of severe restrictions for its population. This study aims to estimate the connections between the trauma of the COVID-19 emergency and the clinical features of a sample of outpatients in a Milan Community Mental Health setting, comparing the first (April 2020) and second lockdowns (November 2020). Materials and Methods: The sample included 116 consecutive outpatients recruited in April 2020 and 116 in November 2020. The subjects were evaluated with Clinical Global Impression Severity (CGI-S), Brief Psychiatric Rating Scale (BPRS-18), and Impact of Event Scale-Revised (IES-R). Results: The IES-R identified 47.4% participants in April and 50% in November with clinical scores over the cut-off. The network analysis of BPRS-18 and IES-R depicted the connection among different symptoms; in April, Unusual Thought Content, Anxiety, and Somatic Concern represented the most central items, and the strongest connections were found between Uncooperativeness and Hostility, Blunted Affect and Emotional Withdrawal, and IES-Intrusion and IES-Arousal. In the November group, the most central items were represented by Conceptual Disorganization and Emotional Withdrawal, whereas the strongest connections were found between IES-Arousal and IES-Intrusion, Excitement and Grandiosity, and Unusual Thought Content and Conceptual Disorganization. Conclusions: Our findings show continued high distress levels and increased psychological burdens during the second phase of restrictions; this could be described as "pandemic fatigue", a general psychological weariness due to pandemic-related restrictions, as well as a lack of motivation to comply with them. As mental health professionals, our mission during these difficult times has been to keep community psychiatry services accessible, with particular regard to vulnerable and marginalized populations.

Are delusional contents replayed during dreams?

The relationship between dream content and waking life experiences remains difficult to decipher. However, some neurobiological findings suggest that dreaming can, at least in part, be considered epiphenomenal to ongoing memory consolidation processes in sleep. Both abnormalities in sleep architecture and impairment in memory consolidation mechanisms are thought to be involved in the development of psychosis. The objective of this study was to assess the continuity between delusional contents and dreams in acutely psychotic patients. Ten patients with a single fixed and recurring delusional content were asked to report their dreams during an acute psychotic break. Sixteen judges with four different levels of acquaintance to the specific content of the patients' delusions were asked to group the dreams, expecting that fragments of the delusional thought would guide the task. A mathematical index (f,t) was developed in order to compare correct groupings between the four groups of judges. Most judges grouped the dreams slightly above chance level and no relevant differences could be found between the four groups [F(3,12)=1.297; p=n.s.]. Scoring of dreams for specific delusional themes suggested a continuity in terms of dream and waking mentation for two contents (Grandiosity and Religion). These findings seem to suggest that at least some delusional contents recur within patients' dreams. Future studies will need to determine whether such continuity reflects ongoing consolidation processes that are relevant to current theories of delusion formation and stabilization.

Challenging the myth of REM sleep behavior disorder: no evidence of heightened aggressiveness in dreams.

OBJECTIVES: Dreams are commonly described as violent, threatening, and aggressive in patients with REM behavior disorder (RBD), but very few studies have directly investigated dream content in this population. We systematically assessed dreams in subjects with a confirmed diagnosis of idiopathic RBD (iRBD) and explored psychological traits within the group with specific focus on aggressiveness. METHODS: A total of 129 dream reports was collected, of which 77 belonged to 12 iRBD patients and 52 belonged to 12 control subjects. Transcripts were analyzed with measures of both form and content. The Thematic Apperception Test was used to assess patients' personality traits and to yield information on formal aspects of waking thought processes. RESULTS: No statistically significant differences were found between the dreams of iRBD patients and those of normal controls in any of the applied measures. In wakefulness, passivity was found to differ between the two populations and was being higher in the iRBD group (F(9,14)=4.84, p<0.05). CONCLUSIONS: Our results do not support the anecdotal view that dreams of RBD patients contain more aggressive elements than those of the general population. However, over 80% of the patients were on treatment at the time of data collection. The "mild" waking temperament could be interpreted as an early subtle sign of the apathy that is commonly described in the context of neurodegenerative disorders.

Bizarreness in dream reports and waking fantasies of psychotic schizophrenic and manic patients: empirical evidences and theoretical consequences.

Several overlapping features have frequently been described between psychosis and the subjective experience of dreaming from the neurobiological to the phenomenological level, but whether this similarity reflects the cognitive organization of schizophrenic thought or rather that of psychotic mentation independent of diagnostic categories is still unclear. In this study, 40 actively psychotic inpatients were equally divided in two age- and education-matched groups according to their diagnosis (Schizophrenia and Bipolar Disorder). Participants were asked to report their dreams upon awakening and the Thematic Apperception Test (TAT) was administered to elicit waking fantasies; the same procedure was used in a control group of 20 non-psychiatric subjects. Two highly trained judges scored the collected material according to a Dream Bizarreness scale. The same level of cognitive bizarreness was found in TAT and dream reports of schizophrenic and manic subjects but was almost completely absent in the TAT stories of the control group. Two-way analysis of variance for repeated measures assessed the effect of diagnosis and experimental conditions (TAT stories and dream reports) on bizarreness yielding a significant interaction. Cognitive bizarreness seems to be a shared feature of dreaming and psychotic mentation, beyond diagnostic categorizations. Although these findings must be considered preliminary, this experimental measure of the cognitive architecture of thought processes seems to support the view that dreaming could be a useful model for the psychoses.

The dreaming brain/mind, consciousness and psychosis.

Several independent lines of research in neurobiology seem to support the phenomenologically-grounded view of the dreaming brain/mind as a useful model for psychosis. Hallucinatory phenomena and thought disorders found in psychosis share several peculiarities with dreaming, where internally generated, vivid sensorimotor imagery along with often heightened and incongruous emotion are paired with a decrease in ego functions which ultimately leads to a severe impairment in reality testing. Contemporary conceptualizations of severe mental disorders view psychosis as one psychopathological dimension that may be found across several diagnostic categories. Some experimental data have shown cognitive bizarreness to be equally elevated in dreams and in the waking cognition of acutely psychotic subjects and in patients treated with pro-dopaminergic drugs, independent of the underlying disorder. Further studies into the neurofunctional underpinnings of both conditions will help to clarify the use and validity of this model.

Cognitive bizarreness in the dream and waking mentation of nonpsychotic patients with Parkinson's disease.

Cognitive bizarreness is a shared feature of the dream and waking mentation of acutely psychotic patients. The authors investigated this measure of the structural architecture of thought in the dream and waking mentation of 20 nonpsychotic patients with Parkinson's disease after treatment with prodopaminergic drugs. Statistically overlapping levels of cognitive bizarreness were found in the waking fantasy and dream reports of the Parkinson's disease population, whereas almost no bizarreness was found in the waking cognition of the comparison group, suggesting it may be an inherent quality of cognition in Parkinson's disease patients, possibly related to the cholinergic/dopaminergic imbalance underlying this complex disorder.

The dream as a model for psychosis: an experimental approach using bizarreness as a cognitive marker.

Many previous observers have reported some qualitative similarities between the normal mental state of dreaming and the abnormal mental state of psychosis. Recent psychological, tomographic, electrophysiological, and neurochemical data appear to confirm the functional similarities between these 2 states. In this study, the hypothesis of the dreaming brain as a neurobiological model for psychosis was tested by focusing on cognitive bizarreness, a distinctive property of the dreaming mental state defined by discontinuities and incongruities in the dream plot, thoughts, and feelings. Cognitive bizarreness was measured in written reports of dreams and in verbal reports of waking fantasies in 30 schizophrenics and 30 normal controls. Seven pictures of the Thematic Apperception Test (TAT) were administered as a stimulus to elicit waking fantasies, and all participating subjects were asked to record their dreams upon awakening. A total of 420 waking fantasies plus 244 dream reports were collected to quantify the bizarreness features in the dream and waking state of both subject groups. Two-way analysis of covariance for repeated measures showed that cognitive bizarreness was significantly lower in the TAT stories of normal subjects than in those of schizophrenics and in the dream reports of both groups. The differences between the 2 groups indicated that, under experimental conditions, the waking cognition of schizophrenic subjects shares a common degree of formal cognitive bizarreness with the dream reports of both normal controls and schizophrenics. Though very preliminary, these results support the hypothesis that the dreaming brain could be a useful experimental model for psychosis.