Sleep-Related Dissociative Disorders.

In sleep-related dissociative disorders, phenomena of the psychiatrically defined dissociative disorders emerge during the sleep period. They occur during sustained wakefulness, either in the transition to sleep or following an awakening from sleep. Behaviors during episodes vary widely, and can result in injury to self or others. Daytime dissociative episodes and a background of trauma are almost always present; there is typically major co-existing psychopathology. Diagnosis is based on both clinical history and polysomnography; differential diagnosis primarily involves other parasomnias and nocturnal seizures. Information available about treatment is limited; in a few reported cases, psychological interventions have proven effective.

Sleep-related (psychogenic) dissociative disorders as parasomnias associated with a psychiatric disorder: update on reported cases.

STUDY OBJECTIVES: To update the literature on the diagnostic category of sleep-related dissociative disorders (SRDDs), involving psychogenic dissociation, since the time of their inclusion in the parasomnias section of the International Classification of Sleep Disorders, second edition, in 2005; to summarize the most salient clinical and video-polysomnographic (vPSG) findings and typical clinical profile from all reported cases; and to provide the rationale for the re-inclusion of the group of SRDDs in future editions of the International Classification of Sleep Disorders. METHODS: A systematic computerized literature search was conducted searching for SRDDs, nocturnal dissociative disorders, and nocturnal dissociation. RESULTS: Nine additional cases were identified, with sufficient clinical history and vPSG findings to justify the diagnosis of SRDDs, supplementing the 11 cases cited in the International Classification of Sleep Disorders, second edition, for a total of 20 cases. Twenty-six other cases with vPSG testing were found, with 18 cases reported in abstracts and 8 cases reported in a publication with compelling histories of SRDDs and 2 consecutive vPSG studies, but without the vPSG findings explicitly reported for any case. In more than half of all reported cases, there was objective diagnostic confirmation for SRDDs consisting of the hallmark finding of abnormal nocturnal behaviors arising from sustained electroencephalography wakefulness, or during wake-sleep transitions, without epileptiform activity. These nocturnal behaviors often replicated daytime psychogenic dissociative behaviors. A history of trauma (physical, sexual, emotional) was an almost universal finding, along with major psychopathology. All patients, except for one, had prominent histories of daytime dissociative disorders. Many of the patients were referred on account of a presumed parasomnia. CONCLUSIONS: Cases of SRDDs continue to be reported, often as a "parasomnia mimic," with psychogenic dissociation being clearly distinguished from physiologic sleep-wake dissociation as found in primary sleep disorders such as narcolepsy, rapid eye movement sleep behavior disorder, etc. Eleven reasons are provided for why the category of SRDDs should be re-included in future editions of the International Classification of Sleep Disorders, and in the parasomnias section.

Dream disorders and treatment.

Consensus does not exist regarding what should constitute a "dream disorder." Conditions with disordered dreaming may be thought of as primary (ie, arising from changes in dreaming per se) or secondary to extrinsic disorders that impinge on structures involved in dreaming. The major primary disorder of dreaming, nightmare disorder, is covered in depth in this article. Definition of nightmare, diagnostic criteria for nightmare disorder, and differential diagnosis are discussed. The value of a sleep-disorders perspective on nightmares, and the possible exacerbating effects of sleep disorders that cause arousals, are indicated. The importance of a perspective that appreciates nightmares as richly and personally meaningful, with links to complex psychological factors present and past, is emphasized. Two types of treatment approaches are discussed: approaches that target the symptom of nightmares in relative isolation, and approaches that aim at working out psychological issues viewed as causing nightmares and a variety of other interconnected symptoms and problems. The former type of treatment includes the cognitive-behavioral approach "imagery rehearsal therapy," and the medication prazosin. The latter approach entails exploratory or psychodynamic psychotherapies. The approaches are seen as so different in scope, aim, and conceptual framework as to defy ready comparison. I think that a thorough psychological/psychiatric evaluation is essential for informed consideration in conjunction with the patient's choice of treatment approach. Sleep terrors are discussed as a non-rapid eye movement sleep arousal disorder that at times may be linked to broader psychological issues warranting consideration of psychotherapy. Brief summaries are provided of dream disorders secondary to other sleep disorders, drug and alcohol effects, medical disorders, and organic brain damage.

Physiology and psychology of dreams.

The discovery of the close association between rapid eye movement (REM) sleep and dreaming and development of sleep laboratory techniques ushered in a new era in the study of dreams. For the first time, direct and systematic investigation could be made of such topics as the occurrence, qualities, recollection, and childhood development of dreaming. Experimental methodologies permitted investigation of the responsiveness of dreams to external stimulation and the effects of deprivation of REM sleep. Much effort was devoted to searching for parallels between physiological aspects of REM sleep and characteristics of associated dreams, with modest results. The leading theory of dreaming in the early decades of this research was the psychoanalytic, which views dreams as highly meaningful reflections of unconscious mental functioning. With developments in understanding of the neurophysiology of REM sleep, new theories of dreaming were proposed. The most prominent, the activation-synthesis hypothesis, derived its view of dreaming directly from the neurophysiology of REM sleep, in particular the role of the brain stem, and in its original form regarded dreams as not essentially meaningful. Further developments in neurobiological research, including lesion and brain imaging studies, have established a clearer view of the functional neuroanatomy of REM sleep and dreaming. To what degree, and in what way, implications can be drawn from these findings for the psychology of dreaming is controversial. Some more recent theories of dreaming emphasize an adaptive function related to emotion and a role in learning and memory consolidation.