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Exploring causes of sleep difficulty and dreaming problems

Ingardena 6, 30-060 Krakow, Poland, lp. The use, distribution or reproduction in other forums is permitted, provided the original author s or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice.

No use, distribution or reproduction is permitted which does not comply with these terms. This article has been cited by other articles in PMC. Abstract This paper presents an analysis of dream-reality confusion DRC in relation to the characteristics of borderline personality disorder BPDbased on research findings and theoretical considerations.

It is hypothesized that people with BPD are more likely to experience DRC compared to people in non-clinical population. Several variables related to this hypothesis were identified through a theoretical analysis of the scientific literature. People with BPD have nightmares more often than other people Semiz et al.

Many BPD patients experience various cognitive disturbances, including problems with reality testing Fiqueierdo, 2006 ; Mosquera et al. People with thin boundaries are more prone to DRC than people with thick boundaries, and people with BPD tend to have thin boundaries Hartmann, 2011. The theoretical analysis on the basis of these findings suggests that people who suffer from BPD may be more susceptible to confusing dream content with actual waking events.

Although, only few studies on DRC in non-clinical populations have been conducted e. Research has found that there is a relationship between DRC and psychotic symptoms e. BPD is a pervasive pattern of instability of interpersonal relationships, self-image and affect, and marked impulsivity that begins by early adulthood and is present in a variety of contexts DSM-V; American Psychiatric Association, 2013p.

To qualify for this diagnosis, the person should, among other symptoms, make a frantic effort to avoid real or imaginary abandonment, experience a chronic feeling of emptiness or stress-related temporary paranoid symptoms, or exhibit severe dissociative symptoms.

Dream-reality confusion in borderline personality disorder: a theoretical analysis

Moreover, persons with BPD often engage in self-destructive behaviors and are at significant risk of suicide. Borderline personality disorder affects between 1 and 5. Due to the complex psychopathology of BPD, numerous studies have examined different areas of functioning in individuals with this disorder. The present theoretical analysis addresses the question of whether individuals with certain features of BPD may have difficulty distinguishing between dreams and reality.

This hypothesis is supported by the underlying assumption that there are groups of interrelated variables that are present in both DRC and BPD. These variables, which we identified through an analysis of the scientific literature, can be divided into the following categories: This division was made on the basis of theoretical considerations; no factor analyzes have been conducted yet. Each of these five variables is presented separately below.

Such sleep problems are very common among individuals with BPD Hafizi, 2013. Though there is little epidemiological data on sleep disorders among persons diagnosed with BPD, cross-sectional studies show that sleep disorders are prevalent in 15—95. Compared to a non-clinical group, individuals with BPD take more time to fall asleep, sleep for shorter times, have lower sleep efficiency, and have frequent sleep disturbances Semiz et al. Patients with BPD also have more night awakenings than persons from a non-clinical population Battaglia et al.

Labile sleep—wake cycles are another example of sleep disturbances. Labile sleep—wake cycles may promote the intrusion of dreamlike experiences into waking consciousness that can lead to DRC and foster the feeling of depersonalization, which is a dissociative symptom. They also have an adverse effect on memory, thus favoring the creation of false memories van der Kloet et al.

Individuals who report sleep disturbances score high on dissociative scales, fantasy proneness a tendency for deep and long-standing involvement in fantasy and imagination; Lynn and Rhue, 1988p.

Taken together, the above relationships appear to support our hypothesis that BPD patients are likely to experience DRC. Persons diagnosed with BPD have a stronger tendency toward dissociative symptoms than non-clinical population and individuals who suffer from depression or schizophrenia Merckelbach et al.

The occurrence of dissociative symptoms during the course of BPD may be associated with childhood traumatic events. According to one of the theories of the etiology of BPD, this personality disorder develops in individuals who report that traumatic events were a characteristic of their early lives, mainly physical abuse and emotional neglect. A study of 139 patients with BPD found that those who had high scores on the Dissociative Experience Scale DESwhich measures the frequency of dissociative symptoms, such as autobiographical amnesia, derealization, depersonalization, absorption, and identity alteration Bernstein and Putnam, 1986experienced significantly more severe emotional and physical neglect and emotional and physical abuse but not sexual abuse during childhood than those who had low scores on the DES Watson et al.

The results suggest that individuals exposed to severe traumatic events during childhood are more likely to develop dissociative symptoms. Traumatic experiences also often interfere with the integration of mental functions, thus, leading to their dysfunction Vermetten exploring causes of sleep difficulty and dreaming problems Spiegel, 2014.

Moreover, dissociative symptoms involve automatic avoidance strategies that defend consciousness from traumatic memories Briere, 2002. It is noteworthy that dissociative symptoms are one of the correlates of DRC Rassin et al.

Levitan 1967p. It seems that frequent experiences of dissociative symptoms or their intensification may produce frequent intrusions of dreams into experiences during the waking state. Dissociative symptoms and proneness to fantasy — characteristics linked to DRC — are correlated, and it appears this correlation can be mediated by experiences during sleep Giesbrecht and Merckelbach, 2006.

High fantasy-prone students report more dissociative symptoms than their friends who score low or medium on fantasy-proneness Rauschenberger and Lynn, 1995 ; Waldo and Merritt, 2000.

Furthermore, individuals who find it difficult to discriminate between dreams and reality score higher on scales that measure dissociative symptoms and fantasy proneness than individuals who do not confuse dream content with experiences during the waking state Rassin et al. A study of 51 women from the general population found that fantasy proneness is linked to both dissociative symptoms and everyday cognitive failures Merckelbach et al. Moreover, dissociative symptoms, fantasy proneness, cognitive failures, and sleep disturbances are correlated van Heugten — van der Kloet et al.

Later in the current paper, we present data indicating that disturbances in cognitive functioning are among the variables that increase proneness to DRC. The relationship exploring causes of sleep difficulty and dreaming problems dissociative symptoms and fantasy proneness also has been observed in clinical populations. In addition, Steiger et al. To summarize, the above findings support our hypothesis that individuals with diagnosed BPD are more likely to experience DRC because of their tendency to experience dissociative symptoms and related phenomena, such as fantasy proneness, sleep disturbances, and cognitive problems.

Negative Dream Content Individuals suffering from BPD experience more negative life events than other individuals — even those with other personality disorders Pagano et al. The quantitative analysis of a group of 27 individuals diagnosed with BPD and a non-clinical group of 20 individuals showed that the BPD group had dreams with more negative affect than those in the non-clinical group.

Generally, individuals suffering from BPD experience negative dreams, including nightmares, more often than individuals who do not have any of the characteristic symptoms of this personality disorder Schredl et al. Nightmares are sleep disturbances that are related to sleep disorders.

They are defined as vivid dreams, charged with negative emotions that awaken the dreamer from sleep DSM-V; American Psychiatric Association, 2013. The higher frequency of nightmares among BPD patients compared to the non-clinical population is related to greater emotional instability and heightened neuroticism in this clinical group Simor et al.

The intensity of BPD symptoms is positively correlated with the frequency of nightmares Semiz et al. To try to explain the prevalence of nightmares in persons with BPD, we present two theories: Levin and Nielsen 2007 proposed a theory to explain the occurrence of dysphoric dreaming, which is based on two major assumptions: The first, cross-state continuity, assumes that some structures and processes implicated in nightmare production are also engaged during the expression of pathological signs and symptoms such as dissociative symptoms during the waking state Levin and Nielsen, 2007p.

The second, the multilevel explanation, refers to the idea that nightmare formation can be explained at two different levels: At the cognitive—emotional level, there are imagery processes that represent emotional dream imagery, whereas the neuronal level contains a network of brain regions responsible for imagistic and emotional processes.

This model was created to explain the occurrence of nightmares in the course of posttraumatic stress disorder PTSD ; however, it may also be used in an attempt to describe experiences related both to nightmares and cross-state continuity in patients diagnosed with BPD.

We will not discuss the concept of neuronal correlates of DRC and BPD, as this is beyond the scope of the present article. Instead, we will focus on the notion of cross-state continuity with reference to BPD. Other factors include high degrees of physiological and psychological reactivity, maladaptive coping, fantasy proneness, imagery vividness, and thin boundaries.

Numerous studies suggest that almost all of these factors are usually present during the course of BPD, however more recent studies indicate that there is no heightened physiological reactivity in BPD e. In addition, BPD entails affective instability and a low level of emotion recognition Cole et al.

Studies confirm that BPD patients display a negative distortion in the identification of their own emotional states and the emotional states of other persons e. The inability to accurately recognize emotional states may intensify negative affect, emotional instability, and emotional reactivity in everyday life.

  1. To qualify for this diagnosis, the person should, among other symptoms, make a frantic effort to avoid real or imaginary abandonment, experience a chronic feeling of emptiness or stress-related temporary paranoid symptoms, or exhibit severe dissociative symptoms.
  2. Sleep patterns in borderline personality disorder.
  3. The theoretical analysis presented above is exploratory in nature and is intended to serve as a starting point for further, more advanced analyses, and to provide a theoretical basis for planning empirical studies.

Disorders of emotional processes in patients with BPD seem to occur not only in the waking state, but also during dreaming, as in the case of nightmares Simor et al. The effects of nightmares and other bad dreams, apart from the fear they produce, can involve deficits in appropriate emotion-regulation skills, and decrease ability to cope with distress during the subsequent day, according to the ECM.

Patients with BPD experience emotional cascades during the waking state, and this negative affect induces rumination — repetitive thoughts with mainly negative content. Ruminations increase negative affect, which, in turn, intensify ruminations. These processes result in increased cognitive activity during sleep that favors the appearance of nightmares and maladaptive behaviors during the waking state that are intended to cope with negative emotions.

It seems that frequent nightmares in persons with BPD may influence the occurrence of negative life events Selby et al. Generally, a simplified model of emotional cascades assumes the subsequent occurrence of: Elevated cognitive arousal during sleep may cause awakenings or semi-awakenings, which consequently may lead to difficulty distinguishing between dreaming and waking experiences Trajanovic et al.

In addition, the inability to cope effectively with stressful situations may enhance the tendency toward dissociative states Mosquera et al. Moreover, a study by Rassin et al. Taken together, the findings suggest that frequent unpleasant dream content in BPD may be a factor that increases proneness to DRC.

Dreams: Why do we dream?

Cognitive Disturbances Patients with BPD can experience a number of different cognitive disturbances. Usually, executive functions, such as working memory and response inhibition, also are disturbed in BPD Hagenhoff et al. Moreover, BPD is characterized by deficits in feedback processing, altered social inference, and poor decision-making skills Trivedi, 2006 ; Mak and Lam, 2013.

Generally, four types of cognitive disturbances are distinguished in BPD: A detailed description of cognitive problems in BPD, however, remains beyond the scope of the present paper. What is important is that problems with reality testing may occur in patients with BPD Fiqueierdo, 2006.

Reality monitoring, which is related to reality testing, seems to play a significant role in the process of distinguishing dream content from waking experiences. Reality monitoring, a type of source monitoring, is defined as the ability to discriminate between memories of actual events, and memories of dreamed events, imagination, or exploring causes of sleep difficulty and dreaming problems. Reality monitoring consists of two decision-making processes: Memory source is distinguished on the basis of its characteristics: Dreams are classified as internally generated events, which are difficult to distinguish from similar, external events because they are created without conscious cognitive operations Johnson et al.

In the case of dreams, conscious cognition, which is the most important cue that would help differentiate between internally generated memories and those generated externally is not present. These conclusions indicate that DRC may be associated with difficulty with reality monitoring. The temporary suspension of the source monitoring process, along with reduced ability to respond to a sensory stimulus and reduced attention, is one of the common features of both dreaming and waking fantasy.

These processes may make it more difficult to distinguish between the content generated during dreaming and waking fantasy. Both waking fantasy and dreams play an integral role in mood regulation, adaptive information processing, and maintenance of self-cohesion by providing working templates for future goal-directed behavior and the development and maintenance of self-schemas Levin and Young, 2002.

BPD patients exhibit certain cognitive disturbances that make them more prone to problems related to reality testing, and waking fantasy may also disturb the processes involved in correct source monitoring.