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Nightmares and Bad Dreams in Patients with Borderline Personality Disorder: Fantasy As a Coping Skill?

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Nightmares and Bad Dreams in Patients with Borderline Personality Disorder: Fantasy As a Coping Skill? Eur. J. Psychiat. Vol. 24, N.° 1, (28-37) 2010 Keywords: Borderline Personality Disorder; Night- mares; Affect regulation; Fantasy. Nightmares and bad dreams in patients with borderline personality disorder: Fantasy as a coping skill? Peter Simor*,** Szilvia Csóka*** Róbert Bódizs***,**** * Implicit Laboratory Association, Budapest ** Department of Cognitive Sciences, Budapest University of Technology and Economics, Budapest *** Institute of Behavioural Sciences, Semmelweis University, Budapest **** HAS-BME Cognitive Science Research Group, Hungarian Academy of Sciences, Budapest HUNGARY ABSTRACT – Background and Objectives: Previous studies reported a high prevalence of nightmares and dream anxiety in Borderline Personality Disorder (BPD) and the sever- ity of dream disturbances correlated with daytime symptoms of psychopathology. Howev- er, the majority of these results are based on retrospective questionnaire-based study de- signs, and hence the effect of recall biases (characteristic for BPD), could not be controlled. Therefore our aim was to replicate these findings using dream logs. Moreover, we aimed to examine the level of dream disturbances in connection with measures of emo- tional instability, and to explore the protective factors against dream disturbances. Methods: 23 subjects diagnosed with BPD, and 23 age and gender matched healthy controls were assessed using the Dream Quality Questionnaire, the Van Dream Anxiety Scale, as well as the Neuroticism, Assertiveness and Fantasy scales of the NEO-PI-R ques- tionnaire. Additionally, subjects were asked to collect 5 dreams in the three-week study period and to rate the emotional and phenomenological qualities of the reported dreams using the categories of the Dream Quality Questionnaire. Results: Dream disturbances (nightmares, bad dreams, night terror-like symptoms, and dream anxiety) were more frequent in patients with BPD than in controls. Dream distur- bances correlated positively with Neuroticism, while Fantasy proved to be a negative cor- relate of dream disturbances. NIGHTMARES AND BAD DREAMS IN PATIENTS WITH BORDELINE PERSONALITY... 29 Conclusions: Our study provides further support for the association between dream distur- bances and BPD, links the presence of dream disturbances to the levels of emotional instabil- ity, and suggests that fantasy is a potential protective factor against dysfunctional dreaming. Received: 8 April 2009 Revised: 8 October 2009 Accepted: 20 October 2009 Introduction sign that examines the emotional character- istics of specific dream reports. Therefore our aim was to replicate the findings show- Sleep disorders are frequent, but relative- ing disturbed dreaming in BPD, and to clari- ly less emphasized in the diagnosis of Bor- fy if the negative emotional aspects of derline Personality Disorder (BPD). How- dreaming are present in the specific dream ever, patients diagnosed with BPD spend reports as well. Collecting dream reports can more time in REM sleep than healthy con- also be viewed as a retrospective method, trols1, their sleep is characterized by shorter since it is based on memory processes, how- REM latency, and increased REM density ever specific dream reports in form of dream especially in the first REM cycle2, they re- diaries are less susceptible to recall biases. port worse sleep quality than controls, and Cippoli and Poli11 demonstrated that the show depression-like sleep disturbances3. story-like organization of dreams does not Frequent nightmares and dream anxiety dis- differ between laboratory awakenings and rupting sleep and waking functioning are morning reports. This suggests that dream also reported in BPD, and disturbed sleep logs are valuable and authentic tools to ex- quality reflects the severity of psychopatho- amine the dream quality of the individuals11. logical symptoms, dissociative experiences Since nightmares are linked to a personality and childhood trauma found in patients with disposition characterized by emotional reac- BPD4,5. Moreover, dissociative symptoms tivity and vulnerability12 we wanted to ex- and suicidal behaviour (characteristic for amine the level of dream disturbances in BPD) are associated with recurrent night- connection with the severity of emotional mares in different populations6-9. Night- instability. Finally, we aimed to explore the mares disrupting sleep may deepen disso- protective factors against dream distur- ciative symptoms, since sleep loss elicits bances. Waking Fantasy and Assertiveness dissociative symptoms even in healthy vol- were focuses of our study, because the for- unteers according to a prospective study10. mer had been related to the phenomenologi- Except this study, the majority of the inves- cal qualities of dreaming13, and to an ability tigations were based on retrospective study to integrate the random dream images into a designs, using sleep-questionnaires. As pa- coherent plot14, while the latter is thought to tients with BPD are highly susceptible to re- be an important coping skill in stress-full call biases, it should be clarified if dream life situations, and its development is cru- disturbances can be observed in a study de- cial in the therapy of BPD patients15. 30 PETER SIMOR ET AL. Methods down the collected dreams in the morning after awakening, on a sheet of paper, and - Participants on the basis of the shortened version of the Dream Quality Questionnaire - they had to 23 patients (19 female and 4 male) meet- rate the emotional load, the bizarreness, the ing the DSM-IV diagnostic criteria of BPD vividness and the effect on waking mood of and 23 age- and gender-matched healthy vol- each reported dream. unteers participated in the study. The diagno- sis of BPD was confirmed by experienced clinicians, using the Hungarian version of the Instruments SCID-II16. Previous findings indicated that the Hungarian version of the SCID-II is char- The Van Dream Anxiety Scale (VDAS) acterized by excellent inter-rater reliability, provides the assessment of nightmare fre- and construct validity16. Subjects with other quency and dream anxiety caused by fright- Axis II co-diagnoses were not included and ening dreams. The items of the self-rating patients with PTSD and Substance Abuse scale are concerned with nightmare fre- could not enter the study. The former because quency and the maleficent effects of night- of the confounding factor of post-traumatic mares on daytime functioning Items are nightmares, the latter because of the influ- weighted on a 0-4 scale and summed to ence that drugs and alcohol exert on sleep ar- yield a global VDAS score of 0-42. Accord- chitecture17. 6 of the 23 BPD subjects were ing to our results based on a sample of 70 on their regular antidepressant (SSRI) med- patients diagnosed with adaptation disorder ication during the study. The BPD patients and 70 matched controls, the VDAS has were recruited from Hungarian psychiatric been shown to be a valid and reliable instru- institutes and outpatient clinics. Written in- ment to measure nightmare frequency and formed consent was obtained from the sub- dream anxiety (Cronbach’s a = 0.96). All jects, and the Local Ethics Committee ap- items are loading on one factor explaining proved the study protocol. 73% of the intersubject variance. The Dream Quality Questionnaire (DQQ) Procedure containing 11 dream-specific items, measu- res the clinically relevant aspects of dream- Participants were told that the purpose of ing, like the emotional load, the bizarreness, the study was to investigate their sleeping and the vividness of dreams, the tendency of and dreaming habits, and the relationship experiencing frequent non-recurrent and re- between dreaming and personality. Subjects current nightmares and night-terror-like were asked to fill in the Van Dream Anxiety symptoms, and the effects of dreams on Scale18, the Dream Quality Questionnaire19, daytime mood. The DQQ contains three as well as the Neuroticism, the Assertive- main factors, the positive, the negative and ness and the Fantasy scales of the Hungari- the neutral emotional aspects of habitual an version of the NEO-PI-R20. After com- dreaming. According to our results based on pleting the questionnaires subjects were the data of a large national sample consist- asked to keep a dream diary, recording 5 ing of 5009 individuals, the negative emo- “home dreams” within the three-week peri- tional aspects of dreaming was inversely re- od of the study. The subjects had to write lated to the levels of well-being, while the NIGHTMARES AND BAD DREAMS IN PATIENTS WITH BORDELINE PERSONALITY... 31 positive emotional aspects of dreaming was tive dream data. This way we examined the positively associated with well-being. To results of the completed questionnaires, and sum up DQQ proved to be a valid and reli- the ratings of a total of 209 dream reports. able psychometric instrument assessing the Some of the subjects (3 from the BPD and 4 emotional quality of dreaming19. from the control groups) provided less than 5 dreams. The mean frequency of reported The shortened version of the DQQ was dreams was 4.64 per subject (SD = 1.09). used to measure the quality of the reported Groups did not differ in their reported dream dreams. The 4 items measured the emotional frequency (t = - 0.04; p = 0.96). load, the bizarreness, the vividness and the ef- fect on waking mood of each reported dream. The emotional load of the reported dream was Habitual dream behaviour: asked to be rated by a 5-point scale (0 - ex- pressly oppressive, 1 - bad, 2 - neutral, 3 - retrospective results happy, 4 - expressly gratifying). The average The two groups differed significantly in of the ratings generated the DE (Dream Emo- several variables of the Dream Quality tion) score. The effect of the reported dream Questionnaire. 50% (SD = 0.51) of the BPD on daytime mood was also measured by a 5- group reported frequent nightmares that point scale. The average of the ratings gener- caused sudden awakenings, but only 9% ated the DI (Dream Influence) score. (SD = 0.29) of the control group reported The NEO-PIR-H1 was used to measure the same experience. This difference was the emotional instability of the subjects.
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