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A comparison of dream content in laboratory dream reports of schizophrenic and depressive patient groups
A Comparison of Dream Content in Laboratory Dream Reports of Schizophrenic and Depressive Patient Groups Milton
Kramer
and Thomas
Roth
W
E have been attracted to studying the dream for two different but interrelated reasons. In the usual clinical tradition, we have been drawn to study the dream for the insights it may provide into the personality of the dreamer. From a more theoretical point of view, we have been interested in the psychology of dreaming, especially in searching for evidence of a possible function that dreaming serves. We have pursued a series of studies of dream reports of schizophrenic and depressed patients both for the contribution they could make to our understanding of the personality of the dreamer and to elucidate possible functions of the dream. In a study of the spontaneously recalled dream reports of depressed, schizophrenic, and medical patients, we were able to distinguish among them based on the systematic analysis of the content of their dream reports.’ The content differences, such as the most frequent character in the depressed being a family member, in the schizophrenic a stranger, and in the medical patient a friend, did indeed provide potentially valuable insights into the personality of the dreamer. In our studies of collected dream reports (REM dreams from the laboratory) of schizophrenic2 and depressed patients” before treatment and after significant improvement, we were able to show content differences which suggested that the collected dream report was reflective of the current emotional state of the patient. This supports the possibility that the dream may play some adaptational role in the psychic economy of the patient. The current report, which compares the content of REM-dream reports of depressed and schizophrenic patients, addresses itself both to the clinical problem, i.e., the light that dream reports may shed on the personality of depressed and schizophrenic patients, and to the psychology of dreaming, i.e., the possible functional significance of the dream. METHOD In both groups of patients, after the onset of each REM
dream reports were collected from awakenings initiated five minutes period during the night. A standardized interview schedule was used.
From the Veteran’s Administration Hospital and the University of Cincinnati College of Medicine, Cincinnati, Ohio. Milton Kramer, M.D.: .4ssi.ptant ChieJl PsFchiatr,, Service. Veterans Administration Ho.cpital, Cincinnati. Ohio and Professor oJ Psychiatry. University of Cincinnati College OJ Medicine, Cincinnati. Ohio: Thomas Roth, Ph.D.: Research Psgchologisi. Veterans Administration Hospital, C‘incrnnati, Ohio and .4ssistant Professor OJ Psychology, Department of Psychiatry. University of Cincinnati College of Medicine,Cincinnati. Ohio. Supported by funds provided by the Veterans Administration. A version of this research was read at the Fifth World Congress of Psychiatry held in Me.xico City, December 1971. tz~1973 bv Crane & Stratton, Inc. Comprehenwe
Psychfatry.
Vol
14.
No
4 (July/Augusti.
1973
325
326
KRAMER AND ROTH
The five male and five female depressed patients were each run five nonconsecutive nights, while the 1 I male and two female patients were each run ix nonconsecutive nights. The dream reports were scored using the character, social interactions, emotional, environmental press and achievement outcome scales of the Hall-Van de Castle dream content scoring system.4 RESULTS
The depressed patients had 48 nights of REM awakening during which 177 awakenings were made yielding 91 dreams, a dream recall rate of 51%. The schizophrenic pat‘ients had 78 nights of REM awakenings during which 306 awakenings were made, yielding 217 dreams, a dream recall rate of 71%. The results of the present study are presented in the accompanying tables. The distribution of scored items in each category is expressed as a percent to facilitate presentation, although the statistical analysis was carried out using the actual frequency of the items in each case. In Table 1, it is clear that the distribution of characters: family, known, and strangers, is different for the schizophrenic and the depressed. The schizophrenics have strangers as their most frequent character, while the depressed have a family member as their most frequent character. Table 2 again reveals a difference between the depressed and schizophrenic patients’ dream reports in the ratio of male to female characters. The schizophrenic patients have more men than women in their dreams, while the ratio of males to females is about equal for the depressed. The increased ratio of males to females in the schizophrenic replicates the work of Hall in spontaneously reported dream reports.4 When individual characters are compared to groups of characters in the dream reports (see Table 3), again a difference between the depressed and schizophrenic groups is found. Both groups have more individual characters than groups, but this difference is greater for the depressed than schizophrenic patients. (Percentage)
Table 1. Characters-Identify Schzophrenlc
Depressed
Family
11
54
Known
18
22
Stranger
71
24
X2 test significant p < .Ol
Table 2.
Characters-Sex
(Percentage)
Schizophrenic
Depressed
Male
69
54
Female
31
46
X2 test significant p < .Ol
Table 3.
Characters-Number
(Percentage)
Schlzophrenlc
Depressed
Individual
60
81
Group
40
19
X2 test significant p < .Ol
DREAM
327
CONTENT
Table
4.
Social
Interactions
(Percentage) Depressed
Schmphremc Friendly
17
48
Aggressm
66
52
Sexual
17
0
X2 test
significant Table
5.
p
< .Ol
Emotions
(Percentage)
Schlzophremc
Awry Sad Apprehenswe Confusion Happy X2 test
significant
p
<
Depressed
14
31
3
23
57
23
9
23
17
15
01
In Table 4, we report the distribution of social interactions, friendly, aggressive, and sexual, within each diagnostic group. The distribution of social interactions is different between the two patient groups. The schizophrenic patients have more aggressive social interactions than friendly or sexual ones. Table 5 describes the percentage of various emotions in the dream reports of the schizophrenic and depressed patients. The distribution of emotions is different in the two groups. The most frequent emotion in the schizophrenic patient group is apprehension, while the types of emotion are about equally represented in the depressed. The ratio of unpleasant to pleasant emotions is about 5:l in both groups. However, sadness is more frequent in the depressed patients than in the schizophrenic. The environmental press scale (Table 6), did not reveal differences between the two patient groups in the distribution of misfortune and good fortune. In the dream reports from both depressed and schizophrenic patients’ misfortune is much more frequent than good fortune. Table 7 gives the percentage distribution of the categories of the achievement outcome scale. Because of the small number of scoreable items in these categories in the dream reports, the differences in distribution were not statisticahy significant. Table
6.
Environmental
Press
Schmphrmc Good
fortune
M Isfortune X2 test Table
not 7.
significant
p
Achievement
(Percentage) Depressed
14
0
86
100.
> .lO Outcome
Schmphrmc
(Percentage) Depressed
Success
44
20
Failure
56
80
X2 test
not
significant
p
> .lO
328
KRAMER
AND
ROTH
DISCUSSION
The results of this study have replicated and extended the previous data from spontaneously collected dream reports on depressed and schizophrenic populations.’ The characters found in the two dream samples from the two patient groups were different. As in the spontaneously collected dream reports, the schizophrenics tended to report more strangers in their dreams, while the depressed reported largely family members. In addition, the characters in the depressive’s dream reports were relatively more likely to be individuals than groups of characters as compared to the schizophrenic’s dream reports. And finally, in regard to characters, the schizophrenic patients had a higher ratio of male to female characters. This result is not due to the greater number of male patients in the schizophrenic group. The other major content differences noted between the groups were that the schizophrenic population had (1) relatively more aggressive social interactions, and (2) showed more apprehensive emotions than the depressed population. Each of these differences in characters, social interactions, and emotions was significant with p being less than .O1, using a x’ analysis. We believe we have demonstrated that the content of the laboratory collected dream reports of depressed and schizophrenic patients can be differentiated one from the other at a statistically significant level. We think these results are germaine to a number of areas of concern. First, the dream report, whatever else it may be or whatever other properties it may have, is a form of verbal behavior. Traditionally, verbal behavior has been used to distinguish between depressed and schizophrenic patients and the diagnostic classification of patients into these two psychopathologic groups is to a large extent dependent on their verbal behavior. The dream report does indeed function like other verbal behavior and does serve or can be used to distinguish between schizophrenic and depressed patient groups. Second, if the dream report reflects the inner emotional state of the dreamer, the fact that the dream reports of depressed and schizophrenic patients differ, supports the idea that the subjective life of these two patient groups is different. Further, the content differences noted between the depressed and schizophrenic reflect in what specific areas the inner states do indeed differ and these differences, such as (1) the higher frequency of strangers in the dream reports of schizophrenics and family members in the dream reports of the depressed, (2) the higher ratio of male to female characters in dream reports of schizophrenics, (3) the lower incidence of groups of characters in the depressed, (4) the higher frequency of aggressive social interactions in schizophrenics, and (5) the differential distribution of emotions, all may provide clues to the psychological understanding of these patients. Third, the fact that dream reports are distinguishing between groups, clearly are suggests the continuity of mental life, i.e., the depressed and schizophrenic different while awake and different in what they report as their sleeping mental activity. The content of their dream reports may be similar to or different from their waking behavior, but it is consistent for each group. If the dream report reflects in some way the real life experiences of the dreamer, the differences between the two groups suggest that the prior or current life experiences of each
DREAM
329
CONTENT
group are more like each other than they are like that of the other pagroup. This would be peripheral support for a psychogenetic understanding of these patients. However, even if the dream report does reflect the current or prior life experiences of the dreamer, the dream report as such may be only the result of a reflective process. This would not argue for or against the functional role of the dream in the mental economy of the dreamer. Fourth, the implications of these studies for a functional theory of the dream, e.g., problem solving, is moderately positive. We would grant that the clinical state could and indeed probably often does alter without a change in the basic problem of the patient. However, the clinical state is unable to change, in our opinion, without a change in the manner in which the patient attempts to solve his basic emotional problem. We would predict, therefore, that if dreams are attempts to solve problems, a clinical change would lead to an alteration in how the patient was attempting to solve his problem in the dream. This change in the problem-solving method would be reflected in a change in the content of his dream report. We did indeed find, in previous studies, that the dream content of depressed patients changed with a change in clinical state,” and a suggestion (an increase in active relative to passive activities and a decrease in negatives)’ that the dream content of schizophrenics did also. The systematic examination of the content of dream reports may well serve to shed further light on (1) the verbal behavior of the dreamer; (2) an understanding of the dreamer’s subjective life; (3) relate the dream report to other aspects of the patient’s waking mental life; and (4) help us to clarify the role of the dream experience in the mental life of the dreamer, i.e., the possible function of the dream. patient
tient
REFERENCES 1. Kramer M, Baldridge BJ, Whitman RM, Ornstein PH. Smith PC: An exploration of the manifest dream in schizophrenic and depressed patients. Dis Nerv Sys, GWAN Supp 30:126130, 1969 2. Kramer M, Trinder JA: A content analysis of the dream reports of male paranoid schizophrenic patients. Can J Psychiat (in press) 3. Kramer M, Whitman RM, Baldridge BJ, Omstein PH: Drugs and dreams III: The effects
of imipramine on the dreams of the depressed. Amer J Psychiat, 124:1385~1392. 1968 4. Hall CS, Van de Castle RL: The content analysis of dreams. Appleton-Century-Crofts, New York, 1966 5. Hall CS: A comparison of the dreams of four groups of hospitalized mental patients with each other and with a normal population. J Nerv Ment Dis 143:1355139. 1966 6. Kramer M, Clark M, Day N: Dreaming in schizophrenia. Slovak Acad Sci (in press)
Kramer
and Thomas
Roth
W
E have been attracted to studying the dream for two different but interrelated reasons. In the usual clinical tradition, we have been drawn to study the dream for the insights it may provide into the personality of the dreamer. From a more theoretical point of view, we have been interested in the psychology of dreaming, especially in searching for evidence of a possible function that dreaming serves. We have pursued a series of studies of dream reports of schizophrenic and depressed patients both for the contribution they could make to our understanding of the personality of the dreamer and to elucidate possible functions of the dream. In a study of the spontaneously recalled dream reports of depressed, schizophrenic, and medical patients, we were able to distinguish among them based on the systematic analysis of the content of their dream reports.’ The content differences, such as the most frequent character in the depressed being a family member, in the schizophrenic a stranger, and in the medical patient a friend, did indeed provide potentially valuable insights into the personality of the dreamer. In our studies of collected dream reports (REM dreams from the laboratory) of schizophrenic2 and depressed patients” before treatment and after significant improvement, we were able to show content differences which suggested that the collected dream report was reflective of the current emotional state of the patient. This supports the possibility that the dream may play some adaptational role in the psychic economy of the patient. The current report, which compares the content of REM-dream reports of depressed and schizophrenic patients, addresses itself both to the clinical problem, i.e., the light that dream reports may shed on the personality of depressed and schizophrenic patients, and to the psychology of dreaming, i.e., the possible functional significance of the dream. METHOD In both groups of patients, after the onset of each REM
dream reports were collected from awakenings initiated five minutes period during the night. A standardized interview schedule was used.
From the Veteran’s Administration Hospital and the University of Cincinnati College of Medicine, Cincinnati, Ohio. Milton Kramer, M.D.: .4ssi.ptant ChieJl PsFchiatr,, Service. Veterans Administration Ho.cpital, Cincinnati. Ohio and Professor oJ Psychiatry. University of Cincinnati College OJ Medicine, Cincinnati. Ohio: Thomas Roth, Ph.D.: Research Psgchologisi. Veterans Administration Hospital, C‘incrnnati, Ohio and .4ssistant Professor OJ Psychology, Department of Psychiatry. University of Cincinnati College of Medicine,Cincinnati. Ohio. Supported by funds provided by the Veterans Administration. A version of this research was read at the Fifth World Congress of Psychiatry held in Me.xico City, December 1971. tz~1973 bv Crane & Stratton, Inc. Comprehenwe
Psychfatry.
Vol
14.
No
4 (July/Augusti.
1973
325
326
KRAMER AND ROTH
The five male and five female depressed patients were each run five nonconsecutive nights, while the 1 I male and two female patients were each run ix nonconsecutive nights. The dream reports were scored using the character, social interactions, emotional, environmental press and achievement outcome scales of the Hall-Van de Castle dream content scoring system.4 RESULTS
The depressed patients had 48 nights of REM awakening during which 177 awakenings were made yielding 91 dreams, a dream recall rate of 51%. The schizophrenic pat‘ients had 78 nights of REM awakenings during which 306 awakenings were made, yielding 217 dreams, a dream recall rate of 71%. The results of the present study are presented in the accompanying tables. The distribution of scored items in each category is expressed as a percent to facilitate presentation, although the statistical analysis was carried out using the actual frequency of the items in each case. In Table 1, it is clear that the distribution of characters: family, known, and strangers, is different for the schizophrenic and the depressed. The schizophrenics have strangers as their most frequent character, while the depressed have a family member as their most frequent character. Table 2 again reveals a difference between the depressed and schizophrenic patients’ dream reports in the ratio of male to female characters. The schizophrenic patients have more men than women in their dreams, while the ratio of males to females is about equal for the depressed. The increased ratio of males to females in the schizophrenic replicates the work of Hall in spontaneously reported dream reports.4 When individual characters are compared to groups of characters in the dream reports (see Table 3), again a difference between the depressed and schizophrenic groups is found. Both groups have more individual characters than groups, but this difference is greater for the depressed than schizophrenic patients. (Percentage)
Table 1. Characters-Identify Schzophrenlc
Depressed
Family
11
54
Known
18
22
Stranger
71
24
X2 test significant p < .Ol
Table 2.
Characters-Sex
(Percentage)
Schizophrenic
Depressed
Male
69
54
Female
31
46
X2 test significant p < .Ol
Table 3.
Characters-Number
(Percentage)
Schlzophrenlc
Depressed
Individual
60
81
Group
40
19
X2 test significant p < .Ol
DREAM
327
CONTENT
Table
4.
Social
Interactions
(Percentage) Depressed
Schmphremc Friendly
17
48
Aggressm
66
52
Sexual
17
0
X2 test
significant Table
5.
p
< .Ol
Emotions
(Percentage)
Schlzophremc
Awry Sad Apprehenswe Confusion Happy X2 test
significant
p
<
Depressed
14
31
3
23
57
23
9
23
17
15
01
In Table 4, we report the distribution of social interactions, friendly, aggressive, and sexual, within each diagnostic group. The distribution of social interactions is different between the two patient groups. The schizophrenic patients have more aggressive social interactions than friendly or sexual ones. Table 5 describes the percentage of various emotions in the dream reports of the schizophrenic and depressed patients. The distribution of emotions is different in the two groups. The most frequent emotion in the schizophrenic patient group is apprehension, while the types of emotion are about equally represented in the depressed. The ratio of unpleasant to pleasant emotions is about 5:l in both groups. However, sadness is more frequent in the depressed patients than in the schizophrenic. The environmental press scale (Table 6), did not reveal differences between the two patient groups in the distribution of misfortune and good fortune. In the dream reports from both depressed and schizophrenic patients’ misfortune is much more frequent than good fortune. Table 7 gives the percentage distribution of the categories of the achievement outcome scale. Because of the small number of scoreable items in these categories in the dream reports, the differences in distribution were not statisticahy significant. Table
6.
Environmental
Press
Schmphrmc Good
fortune
M Isfortune X2 test Table
not 7.
significant
p
Achievement
(Percentage) Depressed
14
0
86
100.
> .lO Outcome
Schmphrmc
(Percentage) Depressed
Success
44
20
Failure
56
80
X2 test
not
significant
p
> .lO
328
KRAMER
AND
ROTH
DISCUSSION
The results of this study have replicated and extended the previous data from spontaneously collected dream reports on depressed and schizophrenic populations.’ The characters found in the two dream samples from the two patient groups were different. As in the spontaneously collected dream reports, the schizophrenics tended to report more strangers in their dreams, while the depressed reported largely family members. In addition, the characters in the depressive’s dream reports were relatively more likely to be individuals than groups of characters as compared to the schizophrenic’s dream reports. And finally, in regard to characters, the schizophrenic patients had a higher ratio of male to female characters. This result is not due to the greater number of male patients in the schizophrenic group. The other major content differences noted between the groups were that the schizophrenic population had (1) relatively more aggressive social interactions, and (2) showed more apprehensive emotions than the depressed population. Each of these differences in characters, social interactions, and emotions was significant with p being less than .O1, using a x’ analysis. We believe we have demonstrated that the content of the laboratory collected dream reports of depressed and schizophrenic patients can be differentiated one from the other at a statistically significant level. We think these results are germaine to a number of areas of concern. First, the dream report, whatever else it may be or whatever other properties it may have, is a form of verbal behavior. Traditionally, verbal behavior has been used to distinguish between depressed and schizophrenic patients and the diagnostic classification of patients into these two psychopathologic groups is to a large extent dependent on their verbal behavior. The dream report does indeed function like other verbal behavior and does serve or can be used to distinguish between schizophrenic and depressed patient groups. Second, if the dream report reflects the inner emotional state of the dreamer, the fact that the dream reports of depressed and schizophrenic patients differ, supports the idea that the subjective life of these two patient groups is different. Further, the content differences noted between the depressed and schizophrenic reflect in what specific areas the inner states do indeed differ and these differences, such as (1) the higher frequency of strangers in the dream reports of schizophrenics and family members in the dream reports of the depressed, (2) the higher ratio of male to female characters in dream reports of schizophrenics, (3) the lower incidence of groups of characters in the depressed, (4) the higher frequency of aggressive social interactions in schizophrenics, and (5) the differential distribution of emotions, all may provide clues to the psychological understanding of these patients. Third, the fact that dream reports are distinguishing between groups, clearly are suggests the continuity of mental life, i.e., the depressed and schizophrenic different while awake and different in what they report as their sleeping mental activity. The content of their dream reports may be similar to or different from their waking behavior, but it is consistent for each group. If the dream report reflects in some way the real life experiences of the dreamer, the differences between the two groups suggest that the prior or current life experiences of each
DREAM
329
CONTENT
group are more like each other than they are like that of the other pagroup. This would be peripheral support for a psychogenetic understanding of these patients. However, even if the dream report does reflect the current or prior life experiences of the dreamer, the dream report as such may be only the result of a reflective process. This would not argue for or against the functional role of the dream in the mental economy of the dreamer. Fourth, the implications of these studies for a functional theory of the dream, e.g., problem solving, is moderately positive. We would grant that the clinical state could and indeed probably often does alter without a change in the basic problem of the patient. However, the clinical state is unable to change, in our opinion, without a change in the manner in which the patient attempts to solve his basic emotional problem. We would predict, therefore, that if dreams are attempts to solve problems, a clinical change would lead to an alteration in how the patient was attempting to solve his problem in the dream. This change in the problem-solving method would be reflected in a change in the content of his dream report. We did indeed find, in previous studies, that the dream content of depressed patients changed with a change in clinical state,” and a suggestion (an increase in active relative to passive activities and a decrease in negatives)’ that the dream content of schizophrenics did also. The systematic examination of the content of dream reports may well serve to shed further light on (1) the verbal behavior of the dreamer; (2) an understanding of the dreamer’s subjective life; (3) relate the dream report to other aspects of the patient’s waking mental life; and (4) help us to clarify the role of the dream experience in the mental life of the dreamer, i.e., the possible function of the dream. patient
tient
REFERENCES 1. Kramer M, Baldridge BJ, Whitman RM, Ornstein PH. Smith PC: An exploration of the manifest dream in schizophrenic and depressed patients. Dis Nerv Sys, GWAN Supp 30:126130, 1969 2. Kramer M, Trinder JA: A content analysis of the dream reports of male paranoid schizophrenic patients. Can J Psychiat (in press) 3. Kramer M, Whitman RM, Baldridge BJ, Omstein PH: Drugs and dreams III: The effects
of imipramine on the dreams of the depressed. Amer J Psychiat, 124:1385~1392. 1968 4. Hall CS, Van de Castle RL: The content analysis of dreams. Appleton-Century-Crofts, New York, 1966 5. Hall CS: A comparison of the dreams of four groups of hospitalized mental patients with each other and with a normal population. J Nerv Ment Dis 143:1355139. 1966 6. Kramer M, Clark M, Day N: Dreaming in schizophrenia. Slovak Acad Sci (in press)