Why dreaming can be an important guide to a patient's mental health status

Although dreams may seem unimportant, they can be a gateway into understanding the mental and physical state of a patient.

According to the National Institute for Neurological Disorders and Stroke (NINDS), poor waking habits can prevent people from entering rapid eye movement (REM), a stage in the sleep cycle where most dreams occur. Sleep apnea or insomnia also inhibit this sleeping stage—two sleep disorders that can signal health problems.^[]

Freud as a baseline

Deciphering dreams and what they mean has been a topic of psychological interest since Sigmund Freud’s The Interpretation of Dreams in 1899. In this polarizing book, Freud attempted to pioneer the legitimacy of a “correct” way to interpret a dream. To prove this, he analyzed the dreams of several patients, trying to connect nonsensical events to trauma or health issues within their lives.

Although some of Freud’s patients resonated with his interpretations, his work was grounded in presumption. Despite ongoing research, psychologists have yet to create concrete rules defining what certain motifs or events may mean in someone’s dream. For example, falling off a cliff is commonly interpreted as losing control of some aspect of your life, while being chased may mean you’re running from a larger life problem.^[]

Despite the controversy in Freud's interpretations, there is still a strong place for dream psychoanalysis with some niches of therapists.

Freud’s book presented an imperative idea about interpreting dreams that some psychologists still use today. He believed all dream material is derived from experience, even if we cannot remember it. This material can stem from childhood memories, arbitrary events from the recent past, and so on.

These memories, known as latent dream thoughts, serve as the basis for dream construction.

Ultimately, many sleep experts believe we dream to process emotions, express personal desires, and gain practice confronting potential dangers.^[]

The importance of REM

Most dreams occur during REM because it is the deepest stage of sleep. Thus, not experiencing this stage can inhibit the above-mentioned emotional processing functions, according to the NINDS.

A 2018 study in Frontiers in Psychology found that REM dreams incorporate more emotional and instructive memories than non-REM dreams.^[]

However, sleep disorders make it difficult to achieve REM. As reported by NINDS, selective serotonin reuptake inhibitors like Prozac or Zoloft, which are used to treat anxiety and depression, can also block the REM stage.

Being aware of patients’ struggles with sleep difficulties can in turn identify if they are missing out on this cathartic stage of sleep, whereby providers can better understand their mental health.

When dreams go bad

In an article by the Viva Center, Jacky Casumbal, LICSW, noted that nightmares can be identified as “dreams that are often connected to unresolved anxiety and trauma that our brain has not fully worked through.”

Patients who experience regular nightmares may need more psychiatric attention. For example, a study by the University of Pittsburgh Medical School found that 80% of patients with PTSD suffer from recurring nightmares compared with 5% of the general population.^[]

Oftentimes, nightmares will be metaphorical reflections of trauma or stressors rather than literal ones. Like regular dreams, popular nightmare motifs cannot be assigned a concrete meaning, but frightening events like car accidents, death, and violence may point to the same, general concern for a troubled mental state.

In addition, some medications cite nightmares as a side effect, and there are also concerns for nightmares during withdrawal from substances like alcohol or barbiturates. Since these substances suppress REM, detoxing may result in REM rebound, which typically yields a compensatory increase in dreams.^[]

Getting more sleep

Educating patients on healthy sleep habits can also foster a healthier mental state. Here are some tips for getting a good night's sleep:

• Set a schedule—go to bed and wake up at the same time each day.

• Exercise 20 to 30 minutes a day, but no later than a few hours before going to bed.

• Avoid caffeine and nicotine late in the day and alcoholic drinks before bed.

• Relax before bed—try a warm bath, reading, or another relaxing routine.

• Create a room for sleep – avoid bright lights and loud sounds, keep the room at a comfortable temperature, and don’t watch TV or have a computer in your bedroom.

• Don’t lie in bed awake. If you can’t get to sleep, do something else, like reading or listening to music, until you feel tired.

• See a doctor if you have a problem sleeping or if you feel unusually tired during the day. Most sleep disorders can be treated effectively.^[] 

For patients with recurring nightmares, Casumbal also recommended breathing exercises before bed. What she describes as “deep, diaphragmatic breathing”—inhaling for four counts, holding it for seven, and exhaling slowly for eight.

She said exercises like this stimulate the vagus nerve, which is associated with the parasympathetic nervous system, the body's "calming" system. According to NINDS, tracking your sleep with a smartwatch may also be helpful.