LETrERS
with thyroid or pyridoxine merely a pharmacological without significant alteration of the basic pathophysiology? suspect that all patient populations are heterogeneous that several clinical syndromes will be found. Other
dens, such
as thyroiditis
be present,
may
greater. Clearly, ridoxine
and altered
making
the
magnesium
likelihood
a more systematic with altered thyroid
effect I and disor-
metabolism,
of heterogeneity
even
study of the interaction function is indicated.
of py-
REFERENCES 1. Brayshaw menstrual
ND, Brayshaw DD: Thyroid hypofunction in presyndrome (letter). N EngI J Mcd 1986; 315:1486-
1487 Casper
2.
RF,
prolactin menstrual
Patel-Chnistophcr
responses syndrome.
A,
Powell
A:
to thyrotropin-releasing J Clin Endocrinol
Thyrotropin
and
hormone Metab 1989;
in pre68:608-
612
3. Dakshinamurti hypothalamic 1986;
J: Hypothyroidism of rats. J Endocninol
109:345-349
4. Delitala (TSH)
G, Rovasio and prolactin
primary 1019-1022
P, Lotti
JW,
depressed
G:
(PRL)
Harrison
Suppression
release
J Clin
hypothyroidism.
Stewart
S.
K, Paulose CS, Vnicnd origin in pynidoxinc-deficient
by
Endocninol
W, Quitkin
outpatients.
Biol
of thyrotropin
pynidoxinc
in chronic
Metab
1977;
F, et al: Low
Psychiatry
1984;
45:
B6 levels
TO
THE
EDITOR
and a marked startle response to being unexpectedly touched. The state of dysphoria alternates with, and is ternporarily relieved by, the excitation of planning and executing substance-abusing (food) binge behavior. This provides, until the plan is fully executed, a sense of “high” or excited “rush.” A guilty, down period then follows, and a subsequent, well-learned cyclic pattern of relief (planning and cxecuting a binge) is repeated. This highly reinforcing pattern has been described in relation to combat-related PTSD (4, 5). Dr. Levy and associates reported responses to antidepressant medications, a high frequency of suicide attempts, depressionlike symptoms, and a tendency for depression to increase as bulimic behavior decreases. These findings and the lack of correlation with family history of affective disorder are also compatible with our hypothesis. We cannot yet estimate the frequency with which this cyclic pattern of reinforcement occurs as a subtype of eating disorders. We are certainly impressed that this type of history is commonly associated with binge-purge behavior; it cxplains some of the treatment-resistant quality of these disordens. The combination of trauma, avoidance of intimacy, and dysphonia relieved by recurring and highly reinforcing, powerful, excitatory periods should be addressed. We welcome comment by Dr. Levy and his colleagues and others on their clinical experience in this regard.
in
19:613-616
REFERENCES KENNETH
M.
LIPMAN, Martinez,
M.D. Calif.
1. Levy AB, Dixon KN, Stern SL: How arc depression related? Am J Psychiatry 1989; 146:162-169 2.
Fournier
Experiences Bulimia
Associated
With
Sexual
Trauma
extensive review, Alan B. Levy, M.D., and (1), investigating possible relationships between bulimia and depression, concluded that bulimia is not a vanant of depression. While this conclusion appears reasonable, SIR:
In
their
associates
it provides
no
guidance
for
further
investigation.
Part
of
the
difficulty One
may lie in their focusing on concurrent depression. wishes that the authors had distinguished between bulimia and bulimia associated with anorexia nervosa in their summarization of clinical evidence associating depression with these disorders. The authors quite correctly distinguished the two subsets of eating disorders in reporting the
work tion
of others. in
their
However, own
they
did not continue
conclusions.
It
appears
stress may
be
abuse,
Am
structure
disorder variable,
an
]
outcome
Psychiatry
often
(PTSD). but
The
associated
typically
there
of avoidance
147:3,
with
presence
the
March
of intimate
1990
Relationships
13-31499. R,
Master’s Howells
Between
Disorders:
Selected
University Abstracts
K, Palmer
Childhood
Microfilms International
R,
et
al:
Adverse
Num1987; sexual
experience in childhood and clinical eating disorders: a prclimmary description. J Psychiatr Res 1985; 19:2-3 4. Solursh LP: Combat addiction-PTSD re-explored. Psychiatr J Univ Ottawa 1988; 13:17-20 S. Solursh LP: Combat addiction: overview of implications in symptom maintenance and treatment planning. J Traumatic Stress (in press)
LIONEL P. SOLURSH, M.D., D.PSYCH. ANDREW D. BISSETf, M.D., PH.D. JOSEPH A.A. FOURNIER, R.N., M.S.W. Augusta, Ga.
strongest
posttraumatic
of intrusive is a history
The
and Eating
this distinc-
that
clinical evidence for concurrent depression cited by Dr. Levy and associates lies in studies reporting bulimia associated with anorexia nervosa. Our experience with anorexic patients (who may also have concurrent bulimia) suggests a possible avenue for further exploration. Fournier (2) found that women with histories of childhood sexual trauma had psychological profiles similar to those of anorexic patients. Oppenheimer et al. (3) similarly found that 50 of their 78 patients with eating disorders had had adverse sexual experiences (40 of them in childhood). We also have noted an apparently high incidence of convincing histories of early (usually childhood) sexual trauma. In this group at least, it appears that the outcome is not classical depression but, rather, a typical presentation of the personality
3.
ben ADG 26(2):276 Oppenheimer
JAA:
and bulimia
thoughts of
repeated
relationships,
ECT
as Prophylactic
Treatment
for
Bipolar
Disorder
SIR: In their excellent review of alternatives to lithium for preventive treatment of bipolar disorder (1), Robert F. Pnien, Ph.D., and Alan J. Gelenberg, M.D., omitted mention of the first treatment reported to be effective for this purpose: ECT. In a 1949 article presciently entitled “Prophylactic Electroshock,” Geoghegan and Stevenson (2) reported the results of an open clinical trial that showed no relapses over 3 years in 13 manic-depressive patients who received monthly treatments after a course of ECT, compared with frequent rclapses in 1 1 patients who refused such treatment. Two years later, the results were equally encouraging (3). To my knowledge, no attempt to replicate these results under controlled conditions has been reported. Nonetheless, a 1986 survey of practitioners of ECT (4) found that 59% of the respondents used maintenance ECT (for a median of three patients annually), and I have personally frequently
373
LETTERS
TO THE
observed
the
lected
EDITOR
effectiveness
bipolar
of
patients
who
such
therapy
continue
in carefully
to relapse
Se-
despite
in-
tensive attempts at pharmacological prophylaxis. I know that these observations are well-known to Drs. Pnien and Gelenberg, whose review was, after all, aimed at pharmacological methods of prophylaxis. But despite the often excellent results obtained with such maintenance drug
therapy,
there
continued
remains
residence
a hard
pendent on maintenance agree with Fink (5) that seriously, and of continuation academic and
core of bipolar
outside
of
ECT. “it
hospitals
One
patients seems
can,
whose
wholly
therefore,
de-
heartily
this option effort to assess this form ECT deserves greater
is timely
to
undertake a national therapy. Maintenance clinical attention.”
consider
REFERENCES 1. Pnien RF, Gelenberg treatment of bipolar 2.
848 Geoghegan Psychiatry
AJ: Alternatives to lithium for preventive disorder. Am J Psychiatry 1989; 146:840-
JJ, Stevenson 1949;
GH:
Prophylactic
electroshock.
Am J
105:494-495
3. Stevenson GH, Geoghegan JJ: Prophylactic electroshock: a fiveyear study. Am J Psychiatry 1951; 107:743-748 4. Kramer BA: Maintenance ECT: a survey of practice (1986). Convulsive Therapy 1987; 3:260-268 S. Fink M: Maintenance ECT and affective disorders (editorial). Convulsive Therapy 1987; 3:249-250 RICHARD
ABRAMS,
former group may well display REM sleep patterns that heretofore have not been described in depression. To predict that a particular constellation of REM sleep abnormalities might “mark” PTSD is not to imply that some evidence of REM sleep dysfunction cannot be seen in other psychiatric disorders.
Many pothesis
of Dr. Reynolds’s suggestions for pursuing the hythat aberrant REM sleep mechanisms underlie fit squarely with our own. It is important to extend
PTSD questionnaire and sleep diary studies to other patient groups, so that the question of the specificity of the recurrent, stereotyped anxiety dream can be addressed directly. We agree that awakening studies, in which REM sleep and non-REM sleep mentation can be compared in PTSD subjects, are potentially useful. Long-term polysomnographic investigations over the course of treatment might establish correlations between REM sleep measures and dream intensity. As Dr. Reynolds asserted, the pivotal question is whether the sleep disturbance of PTSD is central to the pathogenesis of this disorder or is an epiphenomenon; experimental strategies using naturalistic and pharmacological probes of the REM sleep system should help to provide an answer. We believe that support for the concept of a core REM sleep dysfunction in PTSD already emerges from the theoretical linkage between REM sleep mechanisms and some of the characteristic waking symptoms of the disorder (1). Thus, investigating the nature of startle and flashback behavior in PTSD, as we have begun to do (6), can provide indirect evidence that ultimately may prove compelling.
M.D.
Chicago,
Ill.
REFERENCES
1. Reynolds Sleep
Disturbance
in Posttraumatic
Stress
SIR: In his editorial (1) accompanying our article “Sleep Disturbance as the Hallmark of Posttraumatic Stress Disonden” (2), Charles F. Reynolds III, M.D., offered a thoughtful commentary on our hypothesis that posttraumatic stress disorder (PTSD) may be fundamentally a disorder of REM sleep mechanisms. Citing Cantwnight’s finding (3) that, among a group of women undergoing divorce, those who were depressed showed a shortened REM sleep latency and a disruption of the normal REM sequence, he appeared to suggest
that a “major Consequently,
mood-disturbing PTSD would
event” can disturb dreaming. not be unique in its association
with the repetitive, stereotyped anxiety dream. However, this reasoning does not fully take account of other observations from the same study. “Anxiety dreams” were no more frequent in the depressed women than in a control group of euthymic married women (4). Furthermore, the dreams of the depressed women had a low “dreamlike quality” and
avoided
the
subject
of divorce
(5).
They
stand
Sleep
disturbance
2.
Ross
RJ,
hallmark 1989;
Ball
WA,
Sullivan
in posttraumatic
KA,
of posttraumatic
stress
(editorial). et al:
stress
Sleep
disturbance
disorder.
disor-
Am J Psychi-
Am
as the
J Psychiatry
146:697-707
3. Cartwnight RD: Rapid eye movement sleep characteristics duning and after mood-disturbing events. Arch Gen Psychiatry 4.
1983; 40:197-201 Trenholme I, Cartwnight
RD,
Greenberg
G:
Dream
dimension
differences during a life change. Psychiatry Rcs 1984; 12:35-45 S. Cantwnight RD, Lloyd S, Knight 5, et al: Broken dreams: a study of the effects of divorce and depression on dream content. Psy6.
chiatry 1984; Ross RJ, Ball
47:251-259 WA, Cohen
reflex
in posttraumatic
Clinical
Neurosciences
ME,
stress
et al: Habituation
disorder.
of the
J Neuropsychiatry
startle
and
(in press)
RICHARD
J. ROSS,
M.D.,
PH.D.
WILL1AM
A. BALL,
M.D.,
PH.D.
KENNETH A. SULLIVAN, PH.D. STANLEY N. CAROFF, M.D. Philadelphia, Pa.
in marked
contrast to the vivid dreams of PTSD, which often recapitulate the trauma. Dr. Reynolds emphasized that the depressed women in Cartwnight’s study, who did not have PTSD, nonetheless had polysomnognaphic evidence of heightened “REM sleep pressure,” which has also been identified in endogenous depression. Thus, if an abbreviated REM sleep latency or an altered REM sequence were to be demonstrated in PTSD, the question of specificity would inevitably be raised. However, while it may not be feasible to control adequately for concurrent depression in PTSD patients (most of whom are on have been depressed), it should be possible to compare the sleep of PTSD subjects and depressed subjects without PTSD. The
374
CF:
den: pathogenetic or cpiphenomcnal? atry 1989; 146:695-696
Disorder
SIR: Some recent observations that I have made on the structure of the manifest dream in troubled patients might shed some light on the problems described by Richard J. Ross, M.D., Ph.D., and associates in their article and by Charles F. Reynolds III, M.D., in his editorial on sleep disturbance in posttraumatic stress disorder. I find that in the dreams of patients with depression, schizophrenia, or bordenline personality disorder, one can often identify alternation of two tendencies-one constructive, hopeful, and associated with good feeling, and the other destructive, discounaging, and dysphonic. These two tendencies usually alternate in the dreams of these patients in a full dream se-
Am
J
Psychiatry
1 47:3,
March
1990
with thyroid or pyridoxine merely a pharmacological without significant alteration of the basic pathophysiology? suspect that all patient populations are heterogeneous that several clinical syndromes will be found. Other
dens, such
as thyroiditis
be present,
may
greater. Clearly, ridoxine
and altered
making
the
magnesium
likelihood
a more systematic with altered thyroid
effect I and disor-
metabolism,
of heterogeneity
even
study of the interaction function is indicated.
of py-
REFERENCES 1. Brayshaw menstrual
ND, Brayshaw DD: Thyroid hypofunction in presyndrome (letter). N EngI J Mcd 1986; 315:1486-
1487 Casper
2.
RF,
prolactin menstrual
Patel-Chnistophcr
responses syndrome.
A,
Powell
A:
to thyrotropin-releasing J Clin Endocrinol
Thyrotropin
and
hormone Metab 1989;
in pre68:608-
612
3. Dakshinamurti hypothalamic 1986;
J: Hypothyroidism of rats. J Endocninol
109:345-349
4. Delitala (TSH)
G, Rovasio and prolactin
primary 1019-1022
P, Lotti
JW,
depressed
G:
(PRL)
Harrison
Suppression
release
J Clin
hypothyroidism.
Stewart
S.
K, Paulose CS, Vnicnd origin in pynidoxinc-deficient
by
Endocninol
W, Quitkin
outpatients.
Biol
of thyrotropin
pynidoxinc
in chronic
Metab
1977;
F, et al: Low
Psychiatry
1984;
45:
B6 levels
TO
THE
EDITOR
and a marked startle response to being unexpectedly touched. The state of dysphoria alternates with, and is ternporarily relieved by, the excitation of planning and executing substance-abusing (food) binge behavior. This provides, until the plan is fully executed, a sense of “high” or excited “rush.” A guilty, down period then follows, and a subsequent, well-learned cyclic pattern of relief (planning and cxecuting a binge) is repeated. This highly reinforcing pattern has been described in relation to combat-related PTSD (4, 5). Dr. Levy and associates reported responses to antidepressant medications, a high frequency of suicide attempts, depressionlike symptoms, and a tendency for depression to increase as bulimic behavior decreases. These findings and the lack of correlation with family history of affective disorder are also compatible with our hypothesis. We cannot yet estimate the frequency with which this cyclic pattern of reinforcement occurs as a subtype of eating disorders. We are certainly impressed that this type of history is commonly associated with binge-purge behavior; it cxplains some of the treatment-resistant quality of these disordens. The combination of trauma, avoidance of intimacy, and dysphonia relieved by recurring and highly reinforcing, powerful, excitatory periods should be addressed. We welcome comment by Dr. Levy and his colleagues and others on their clinical experience in this regard.
in
19:613-616
REFERENCES KENNETH
M.
LIPMAN, Martinez,
M.D. Calif.
1. Levy AB, Dixon KN, Stern SL: How arc depression related? Am J Psychiatry 1989; 146:162-169 2.
Fournier
Experiences Bulimia
Associated
With
Sexual
Trauma
extensive review, Alan B. Levy, M.D., and (1), investigating possible relationships between bulimia and depression, concluded that bulimia is not a vanant of depression. While this conclusion appears reasonable, SIR:
In
their
associates
it provides
no
guidance
for
further
investigation.
Part
of
the
difficulty One
may lie in their focusing on concurrent depression. wishes that the authors had distinguished between bulimia and bulimia associated with anorexia nervosa in their summarization of clinical evidence associating depression with these disorders. The authors quite correctly distinguished the two subsets of eating disorders in reporting the
work tion
of others. in
their
However, own
they
did not continue
conclusions.
It
appears
stress may
be
abuse,
Am
structure
disorder variable,
an
]
outcome
Psychiatry
often
(PTSD). but
The
associated
typically
there
of avoidance
147:3,
with
presence
the
March
of intimate
1990
Relationships
13-31499. R,
Master’s Howells
Between
Disorders:
Selected
University Abstracts
K, Palmer
Childhood
Microfilms International
R,
et
al:
Adverse
Num1987; sexual
experience in childhood and clinical eating disorders: a prclimmary description. J Psychiatr Res 1985; 19:2-3 4. Solursh LP: Combat addiction-PTSD re-explored. Psychiatr J Univ Ottawa 1988; 13:17-20 S. Solursh LP: Combat addiction: overview of implications in symptom maintenance and treatment planning. J Traumatic Stress (in press)
LIONEL P. SOLURSH, M.D., D.PSYCH. ANDREW D. BISSETf, M.D., PH.D. JOSEPH A.A. FOURNIER, R.N., M.S.W. Augusta, Ga.
strongest
posttraumatic
of intrusive is a history
The
and Eating
this distinc-
that
clinical evidence for concurrent depression cited by Dr. Levy and associates lies in studies reporting bulimia associated with anorexia nervosa. Our experience with anorexic patients (who may also have concurrent bulimia) suggests a possible avenue for further exploration. Fournier (2) found that women with histories of childhood sexual trauma had psychological profiles similar to those of anorexic patients. Oppenheimer et al. (3) similarly found that 50 of their 78 patients with eating disorders had had adverse sexual experiences (40 of them in childhood). We also have noted an apparently high incidence of convincing histories of early (usually childhood) sexual trauma. In this group at least, it appears that the outcome is not classical depression but, rather, a typical presentation of the personality
3.
ben ADG 26(2):276 Oppenheimer
JAA:
and bulimia
thoughts of
repeated
relationships,
ECT
as Prophylactic
Treatment
for
Bipolar
Disorder
SIR: In their excellent review of alternatives to lithium for preventive treatment of bipolar disorder (1), Robert F. Pnien, Ph.D., and Alan J. Gelenberg, M.D., omitted mention of the first treatment reported to be effective for this purpose: ECT. In a 1949 article presciently entitled “Prophylactic Electroshock,” Geoghegan and Stevenson (2) reported the results of an open clinical trial that showed no relapses over 3 years in 13 manic-depressive patients who received monthly treatments after a course of ECT, compared with frequent rclapses in 1 1 patients who refused such treatment. Two years later, the results were equally encouraging (3). To my knowledge, no attempt to replicate these results under controlled conditions has been reported. Nonetheless, a 1986 survey of practitioners of ECT (4) found that 59% of the respondents used maintenance ECT (for a median of three patients annually), and I have personally frequently
373
LETTERS
TO THE
observed
the
lected
EDITOR
effectiveness
bipolar
of
patients
who
such
therapy
continue
in carefully
to relapse
Se-
despite
in-
tensive attempts at pharmacological prophylaxis. I know that these observations are well-known to Drs. Pnien and Gelenberg, whose review was, after all, aimed at pharmacological methods of prophylaxis. But despite the often excellent results obtained with such maintenance drug
therapy,
there
continued
remains
residence
a hard
pendent on maintenance agree with Fink (5) that seriously, and of continuation academic and
core of bipolar
outside
of
ECT. “it
hospitals
One
patients seems
can,
whose
wholly
therefore,
de-
heartily
this option effort to assess this form ECT deserves greater
is timely
to
undertake a national therapy. Maintenance clinical attention.”
consider
REFERENCES 1. Pnien RF, Gelenberg treatment of bipolar 2.
848 Geoghegan Psychiatry
AJ: Alternatives to lithium for preventive disorder. Am J Psychiatry 1989; 146:840-
JJ, Stevenson 1949;
GH:
Prophylactic
electroshock.
Am J
105:494-495
3. Stevenson GH, Geoghegan JJ: Prophylactic electroshock: a fiveyear study. Am J Psychiatry 1951; 107:743-748 4. Kramer BA: Maintenance ECT: a survey of practice (1986). Convulsive Therapy 1987; 3:260-268 S. Fink M: Maintenance ECT and affective disorders (editorial). Convulsive Therapy 1987; 3:249-250 RICHARD
ABRAMS,
former group may well display REM sleep patterns that heretofore have not been described in depression. To predict that a particular constellation of REM sleep abnormalities might “mark” PTSD is not to imply that some evidence of REM sleep dysfunction cannot be seen in other psychiatric disorders.
Many pothesis
of Dr. Reynolds’s suggestions for pursuing the hythat aberrant REM sleep mechanisms underlie fit squarely with our own. It is important to extend
PTSD questionnaire and sleep diary studies to other patient groups, so that the question of the specificity of the recurrent, stereotyped anxiety dream can be addressed directly. We agree that awakening studies, in which REM sleep and non-REM sleep mentation can be compared in PTSD subjects, are potentially useful. Long-term polysomnographic investigations over the course of treatment might establish correlations between REM sleep measures and dream intensity. As Dr. Reynolds asserted, the pivotal question is whether the sleep disturbance of PTSD is central to the pathogenesis of this disorder or is an epiphenomenon; experimental strategies using naturalistic and pharmacological probes of the REM sleep system should help to provide an answer. We believe that support for the concept of a core REM sleep dysfunction in PTSD already emerges from the theoretical linkage between REM sleep mechanisms and some of the characteristic waking symptoms of the disorder (1). Thus, investigating the nature of startle and flashback behavior in PTSD, as we have begun to do (6), can provide indirect evidence that ultimately may prove compelling.
M.D.
Chicago,
Ill.
REFERENCES
1. Reynolds Sleep
Disturbance
in Posttraumatic
Stress
SIR: In his editorial (1) accompanying our article “Sleep Disturbance as the Hallmark of Posttraumatic Stress Disonden” (2), Charles F. Reynolds III, M.D., offered a thoughtful commentary on our hypothesis that posttraumatic stress disorder (PTSD) may be fundamentally a disorder of REM sleep mechanisms. Citing Cantwnight’s finding (3) that, among a group of women undergoing divorce, those who were depressed showed a shortened REM sleep latency and a disruption of the normal REM sequence, he appeared to suggest
that a “major Consequently,
mood-disturbing PTSD would
event” can disturb dreaming. not be unique in its association
with the repetitive, stereotyped anxiety dream. However, this reasoning does not fully take account of other observations from the same study. “Anxiety dreams” were no more frequent in the depressed women than in a control group of euthymic married women (4). Furthermore, the dreams of the depressed women had a low “dreamlike quality” and
avoided
the
subject
of divorce
(5).
They
stand
Sleep
disturbance
2.
Ross
RJ,
hallmark 1989;
Ball
WA,
Sullivan
in posttraumatic
KA,
of posttraumatic
stress
(editorial). et al:
stress
Sleep
disturbance
disorder.
disor-
Am J Psychi-
Am
as the
J Psychiatry
146:697-707
3. Cartwnight RD: Rapid eye movement sleep characteristics duning and after mood-disturbing events. Arch Gen Psychiatry 4.
1983; 40:197-201 Trenholme I, Cartwnight
RD,
Greenberg
G:
Dream
dimension
differences during a life change. Psychiatry Rcs 1984; 12:35-45 S. Cantwnight RD, Lloyd S, Knight 5, et al: Broken dreams: a study of the effects of divorce and depression on dream content. Psy6.
chiatry 1984; Ross RJ, Ball
47:251-259 WA, Cohen
reflex
in posttraumatic
Clinical
Neurosciences
ME,
stress
et al: Habituation
disorder.
of the
J Neuropsychiatry
startle
and
(in press)
RICHARD
J. ROSS,
M.D.,
PH.D.
WILL1AM
A. BALL,
M.D.,
PH.D.
KENNETH A. SULLIVAN, PH.D. STANLEY N. CAROFF, M.D. Philadelphia, Pa.
in marked
contrast to the vivid dreams of PTSD, which often recapitulate the trauma. Dr. Reynolds emphasized that the depressed women in Cartwnight’s study, who did not have PTSD, nonetheless had polysomnognaphic evidence of heightened “REM sleep pressure,” which has also been identified in endogenous depression. Thus, if an abbreviated REM sleep latency or an altered REM sequence were to be demonstrated in PTSD, the question of specificity would inevitably be raised. However, while it may not be feasible to control adequately for concurrent depression in PTSD patients (most of whom are on have been depressed), it should be possible to compare the sleep of PTSD subjects and depressed subjects without PTSD. The
374
CF:
den: pathogenetic or cpiphenomcnal? atry 1989; 146:695-696
Disorder
SIR: Some recent observations that I have made on the structure of the manifest dream in troubled patients might shed some light on the problems described by Richard J. Ross, M.D., Ph.D., and associates in their article and by Charles F. Reynolds III, M.D., in his editorial on sleep disturbance in posttraumatic stress disorder. I find that in the dreams of patients with depression, schizophrenia, or bordenline personality disorder, one can often identify alternation of two tendencies-one constructive, hopeful, and associated with good feeling, and the other destructive, discounaging, and dysphonic. These two tendencies usually alternate in the dreams of these patients in a full dream se-
Am
J
Psychiatry
1 47:3,
March
1990
