Journal of Psychiatry

Anxiety Dreams as a Predominant Feature of Prodrome

Rahul Saha^1*, Aastha Sharma² and Pankaj Verma^{1 1}Department of Psychiatry, VMMC and Safdarjung Hospital, New Delhi, India
²Department of Psychiatry, Child and Adolescent Psychiatrist, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
^*Correspondence: Rahul Saha, Department of Psychiatry, VMMC and Safdarjung Hospital, New Delhi, India, Email:

Received: 15-Nov-2023, Manuscript No. JOP-23-23915; Editor assigned: 18-Nov-2023, Pre QC No. JOP-23-23915 (PQ); Reviewed: 03-Dec-2023, QC No. JOP-23-23915; Revised: 01-Apr-2025, Manuscript No. JOP-23-23915 (R); Published: 08-Apr-2025, DOI: 10.35248/2378-5756.25.28.734

Introduction

Early psychiatry with its Freudian legacy routinely investigated dreams to understand and explore psychopathology [1]. Freud described dreams as a ‘royal road to the unconscious’ [2]. Carl Gustav Jung commented, “If we could imagine a dreamer walking around and acting his own dream as if he were awake, we would see the clinical picture of dementia praecox” [3]. However, contemporary psychiatry tends to focus more on categorical and ‘checklist’ methodology to aid diagnosis [4]. A common neuroanatomical and neurophysiological mechanism between REM sleep and psychotic illnesses led to the recent hypothesis of a dreaming brain as a biological model of psychosis, with dreaming considered as significant a source of content of thought as delusions expressed in waking state [5].

The cultural connotations to the content of nightmares are commonly understood, but overlooked in clinical practice. Anthropologists consider dreams as a reflector of culture and religion and categorize dreams by content and genres with special attention to “bad dreams” [6,7]. A study of culture specific variations of bad dreams in India were those that herald death e.g. Seeing a lamp go out, being swallowed by a fish, Yama myth [8]. The simplest way to study the amorphous dream work is to study the dream content and the relevance of the same to the person in his socio-cultural context [6].

Another perplexing and off-debated entity is the prodrome of illness. Prodrome is usually defined as the time between onset of unusual behaviour and frank psychotic symptoms [9,10]. Anxiety, anergia, suspiciousness and sleep disturbances feature among prominent prodromal presentations [11]. We report here a case that featured anxiety dreams as the predominant prodromal feature of a psychotic illness.

Case Presentation

A 26 years old Muslim female who was not formally educated and a homemaker, belonging to a nuclear family of lower socioeconomic status, presented to adult psychiatry OPD, VMMC and Safdarjung Hospital, New Delhi in June 2019 along with her husband, when they reported a change in her behaviour since the last 4 months.

Figure 1: Causes of anxiety dreams.

She started reporting a premonition of something going wrong in her environment since the last 4 months. The onset of this was preceded by a dream the patient had where she saw herself in an open meadow, performing odd acts like feeding breads to a cow, take a bath in a well whilst wearing a black coloured robe and saw this as her attempt to save herself from some predator in the vicinity. She also recalled seeing some cryptic figures speaking in a strange language, following her and chanting odd phrases. She would remember these dreams vividly when she would wake up and narrate them repeatedly to her family members. She would report a vague anxiety lasting throughout the day following this incident. Whenever she slept, she reported having similar dreams and for this reason, started staying up at night. She would be unable to concentrate on any household work, preoccupied with thoughts about the dream and trying to decode what it meant. She would also report of discrete episodes of palpitations, shortness of breath, dizziness and dryness of mouth at night when she woke up from these “nightmares”. For this, she was taken to a faith healer in the neighbourhood, who advised her to enact out her dreams to save herself from “wrath of the evil spirits”. She stayed back in this facility for approximately 2 months along with her mother and her daughter, where she would be encouraged to act out all her dreams with the help of the other members. Doing so apparently brought relief to the patient’s anxiety.

After spending 2 months in such a facility, she returned back home on the insistence of her husband, who personally was a non-believer in such practices and had only played along on the insistence of his in-laws. After returning home, her behavior turned stranger. She started suspecting her sister in law of poisoning the household water supply and food ration in her absence, citing a dream in which she had seen the same. She threw out all the food supply of the house in the drain and threw her sister-in-law out of the house. She suspected her inlaws of hatching a conspiracy to kill her and her daughter and get her husband remarried, as she had been unable to bear a male child. She reported having “witnessed” this in her dream state and was absolutely convinced of the veracity of the same. It was accompanied by disturbed and decreased sleep, multiple episodes of unprovoked aggression and deterioration in overall functioning with poor self-care. Patient attributed all of it to the dreams mirroring her reality and insisted on going back to the above mentioned facility. She was then brought to the hospital and admitted for further management. There was no significant past history but there was family history of an episode suggested of psychosis in the mother 9 years ago, that resolved without medication. The family had little belief in the medical system of healthcare and had only approached on the insistence of a few well-wishers. On admission, her vitals were stable and there were no significant medical abnormalities. Her mental status examination revealed blunt affect, hostility to interviewers, delusion of persecution and delusion of reference. Her Judgement was impaired and insight was absent. A diagnosis of other non-organic psychotic disorders (ICD-10, F28) was made. Investigations were within normal limits, except mild anemia. She was uncooperative for a detailed psychometric assessment.

The patient was admitted and started on T. Risperidone 2 mg, gradually increased to 6 mg. She also required injection Haloperidol (5 mg) and Promethazine (25 mg) on SOS basis on the first 2 days of ward stay. She was discharged in 10 days with 50% improvement in symptoms. Psych education and insight orientation was started on the patient and she was seen regularly on follow up. Interestingly, unlike most other patients, she was found complaining about how adequate and sound her sleep was on medications, as she was not having any dreams anymore. Irregular compliance was an issue on follow up and patient was started on depot antipsychotics from OPD.

Discussion

The term "prodrome" is derived from the Greek word prodromos meaning the forerunner of an event. In clinical medicine, a prodrome refers to the early symptoms and signs of an illness that precede the characteristic manifestations of the acute, fully developed illness [10]. Loebel et al. defined prodrome as the time interval from onset of unusual behavioral symptoms to onset of psychotic symptoms [12]. McGorry et al. Termed these vulnerable states as ARMS ‘At Risk Mental States’ [13]. Despite many studies emphasizing on the need of early identification and intervention, prodrome does not have a defined place in the current diagnostic nosology. The usual symptoms described in prodrome of schizophrenia include reduced attention and concentration, reduced motivation, depressed mood, sleep disturbances, anxiety, irritability, ssocial withdrawal, suspiciousness and deterioration in role functioning [14]. There are inherent problems in the reporting of psychosis prodrome. In most cases, retrospective reconstruction of events in an interview with patient and family members is conducted, which is laden with problems of recall bias. The best time to study prodrome is an in depth interview during prodrome or early course of psychosis. This patient presented us an opportunity to study the same at the fortunate time where recall bias could be eliminated to a major extent.

As early as in 1958, case reports predicted onset of psychosis by nightmares of death and patricide [15,16]. In the case mentioned above, a similar set of nightmares preceded the onset of full blown psychosis. The anxiety following them could be understood as the ‘trema’ phase of formation of a delusion, where she described “a strong gut feeling that something is not right, but being unable to put a finger on it”. D’Agustino et al. used mathematical correlates to suggest that at least some delusional contents recur within patients' dreams. Such an elaboration of the delusional content in dream was also noticed in this present case, where she continued to report witnessing the suspicious activities in her dreams.

Another perspective on this case could be the path elaborative influence of cultural beliefs on psychopathology of the illness. Wallace describes in detail the role of dreams in some cultures, where it was believed that dreams express a “desire of the soul”. It was believed that the desires must be met to prevent the soul from expressing vengeance upon the innocent dreamer. People in the 17^th century would travel long distances to acquire the manifest dream object and even villagers would embark on such journeys together to save the person’s soul. Illness was believed to be result from the failure of the dream to get fulfilled. In the index case as well, the visits to the faith healer inculcated the belief that acting out the dreams was necessary to ward off the evil spirits, and the patient resultantly rejected the medical model of illness and management. Interaction with the patient and family members revealed there were other members at that residential facility that had similar experiences and were given the same ‘treatment’. The current patient gave us an idea that this clinical presentation could be a culture bound unique manifestation of psychotic illness.

Conclusion

The case highlights the importance of anxiety dreams, as clinically most of these dreams are considered to be part of anxiety disorders. The indexed case highlights the progression of anxiety dreams to florid psychosis, and hence will help in recognizing similar cases in future and will help in proper management. It could also point to a possible pathoelaborative influence of cultural beliefs on psychopathology, as suggested by the advice from the faith healer facility and merits further study in this direction.

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