Archives of Psychiatry and Psychotherapy, 2013; 2 : 29–35

What links schizophrenia and dreaming? Common

phenomenological and neurobiological features of
schizophrenia and REM sleep

Dagna Skrzypińska, Barbara Szmigielska

Summary
Aim. The aim of this theoretical study is to present common phenomenological and neurobiological fea-
tures of schizophrenia and REM sleep.
Results. A review of professional literature was conducted in order to synthesize current findings about
associations between schizophrenia and REM sleep. Many researches reveal that both states share some
common phenomenological and neurobiological features. Autism, lack of insight and a loss of autonomy
in relation to mental content are just some of the characteristics that occur on a phenomenological level
in both dreams during REM sleep (lucid dreaming excluded) and schizophrenia. Data from experimental
conditions revealed that the waking mentation of patients suffering from schizophrenia has a similar de-
gree of formal cognitive bizarreness as dream narratives obtained from both non-clinical and clinical pop-
ulations. On the other hand, some common neurobiological features of the REM sleep stage and schiz-
ophrenia are: lack of central inhibitory processes, intracerebral disconnections, dysfunction of the dorso-
lateral prefrontal cortex or nucleus accumbens and disturbed responsiveness. Moreover, there is similar
activation of dopamine, acetylcholine, noradrenaline, serotonin and glutamate in both states.
Conclusions. Common phenomenological and neurobiological characteristics of these two states suggest
that data about REM sleep could help introduce a useful experimental model of schizophrenia.

schizophrenia / REM sleep / dreaming

Introduction turbances or instinctual behaviors [1], which re-

semble some features of schizophrenia.
Schizophrenia is one of the most severe men- Similarities between these two states – dream-
tal illnesses. Delusions, hallucinations, though ing and schizophrenia (or according to previ-
disturbances, as well as emotional and behavio- ous nomenclature and knowledge – psychosis,
ral changes are some of the most common symp- or even insanity) have been deliberated about
toms of this disease. Dreams that occur during by philosophers, neurophysiopathologist and
the REM (Rapid Eye Movement) sleep stage psychiatrists at least since the 17th century. Im-
have several formal characteristics, such as sen- manuel Kant claimed that “the madman is a
sory hallucinations, delusional beliefs, bizarre waking dreamer” [2], whereas Arthur Scho-
imagery, orientational instability, emotional dis- penhauer stated that “dreams are a short mad-
ness and madness a long dream” [3]. Wilhelm
Wundt in “Grundzüge der physiologischen Psy-
Dagna Skrzypińska, Barbara Szmigielska: Department of Psy-
chology, Jagiellonian Univesity. Correspondence address: upszmi-
chologie” wrote: „we ourselves, in fact, can ex-
[email protected] perience in dreams almost all the phenomena to
be met with in [an] insane asylums” [4]. Eugen
This study has not been aided by any grant. The authors had no
conflict of interests. Bleuler considered the secondary symptoms of
30 Dagna Skrzypińska, Barbara Szmigielska

schizophrenia to be similar with dreaming [4]. “impostor” [11]) which occurs in 15% of patients
His assistant, Carl Gustav Jung in his work “The [12] and Frègoli syndrome (conviction or belief
psychology of dementia praecox” noticed that that a familiar person or persons changed their
we should “let the dreamer walk about and act physical appearance while retaining their psy-
like one awakened and we [will] have the clini- chological identity [13]) that is less common, but
cal picture of dementia praecox” (schizophrenia) its prevalence is underdetermined in this popu-
[5]. More recently, Hughlings Jackson advised lation [14]. A change of characters by way of hy-
us: “find out about dreams and you will find out per- or hyporecognition occurs in approximate-
about insanity”; or Henri Ey – “it is obvious, it ly 1% of dreams [15].
cannot be but obvious that the dream and mad- The similarities with dream phenomenology
ness spurt from the same source” [6]. are most often exhibited by positive symptoms
Although historical considerations about simi- of schizophrenia, such as abnormal senso-per-
larities between dreaming and insanity are quite ceptual experiences or delusions, rather than the
common, only a handful of contemporary re- negative ones (i.e. withdrawal from the external
searchers have attempted to conduct a systemat- world) [16]. Although the dreamer experiences
ic study in this field. The main aim of this article a dream as any perceptual phenomenon, it is in
is to review the current state of knowledge about fact a hallucination [8]. Hallucinations are also
common phenomenological and neurobiological one of the very common symptoms of schizo-
features of schizophrenia and REM sleep stage. phrenia. However, in contrast with dreams
The evidence presented should serve to support where there is a predominance of visual over
the hypothesis that the dreaming brain resem- auditory imagery [17], in schizophrenia (espe-
bles one suffering from schizophrenia, and that cially in a paranoid type of the disease) auditory
a dreaming brain may be considered an experi- hallucinations are more frequent [18]. This dif-
mental model for this mental illness. ference has not yet been explained.
Once we exclude misidentifications delusions,
there are at least two other common kinds of
Common phenomenological features of schizo- false beliefs that can be found in both dreams
phrenia and dreaming and in schizophrenia. Firstly, persecution delu-
sions occur in approximately 58.3% of patients
The above presented quotes and definitions in- suffering from paranoid schizophrenia [19],
dicate the existence of phenomenological simi- while topics related to harassment and being
larities between these two states. One of the most chased are among the most frequent and typi-
fundamental common features of dreaming and cal dream contents [20]. Secondly, a belief that
schizophrenia is autism, defined by Eugen Bleul- one is younger than one actually is also appears
er as having no contact with the outside world in these two states [21]. A confusion regarding
and living in an inner world [7]. Both the dream- ones’ age affects about 35% of patients current-
er and a person suffering from schizophrenia are ly hospitalized or suffering from chronic schiz-
involved in internal, rather than external events. ophrenia. Approximately 25% of them express
Dreaming is a cognitive (thus internal) process a belief that they are five or more years young-
[8]. Similarly, it is common in schizophrenia to er, and about 9-12% that they are younger by
perceive internal events as being externally im- less than five years [22]. Since dreaming of the
posed (e.g. delusions of being controlled) [9]. A past is relatively common, it is possible that the
redirection of the locus of control suggests the confusion as to ones age may be associated with
existence of underlying abnormalities in moni- the memory of events occurring in dreams [15].
toring the source of stimulation and in an abil- Analysis of a long series of dream narratives re-
ity to differentiate other people in both schizo- vealed that events from the past that took place
phrenia and dreaming [10]. 8-21 years ago appeared in 15-40% of descrip-
Among the misidentification syndromes that tions [23].
may appear in the course of schizophrenia are: Once lucid dreaming is left out of the analysis
Capgras syndrome (a belief that a known per- we can see that what characterizes both states is
son has been replaced by a doppelganger or an not only a loss of autonomy in relation to mental
Archives of Psychiatry and Psychotherapy, 2013; 2 : 29–35
 What links schizophrenia and dreaming? 31

content, but also a lack of insight [7]. These are nia. On the other hand, in a study by Noreika,
some of the defining conditions of dreams [7]. Valli, Markkula, Seppäla and Revonsuo [30] the
Similarly a lack of awareness of one’s own ill- authors managed to only partially confirm this
ness is typical for 97% of persons suffering from relationship. It was found that the dream con-
schizophrenia in the first episode, and for 30% tent of persons suffering from schizophrenia is
of patients with chronic course of the disease more bizarre than of a non-clinical population.
[24]. What is more, Charles McCreery [7] also In addition, contrary to data obtained from the
distinguishes flattened or inappropriate affect, control group, judges had a greater difficulty in
as well as disorders of language and thought as discerning between dream narratives and wak-
common phenomenological features of psycho- ing thoughts when data was obtained from pa-
sis (schizophrenia) and dreams. tients with schizophrenia.
Persons suffering from schizophrenia exhib- The convergence of phenomenological aspects
it deficits in the theory of mind – a condition of mental organization of both schizophrenia
which in their case may be associated with oth- and dreaming is not sufficient to hypothesize
er aspects of cognitive impairment [25]. Approx- that a dreaming brain may be a model for this
imately 75% of patients experience significant disease. However, there are also neurobiological
cognitive impairment of, among others, mem- similarities between these two states which are
ory, attention and executive functions [26]. Fur- being investigated more rigorously.
thermore, persons with schizophrenia are char-
acterized by deficits in cognitive (emotion rec-
ognition) and affective (emotional reaction to Neurobiological similarities between schizophrenia
an emotional state of other) aspects of empathy and the REM sleep stage
[27]. Similarly, a dreamer usually exhibits little
empathy for other dream characters. The abili- In 1953 Eugene Aserinsky and Nathaniel
ty to empathically relate to others’ mental states, Kleitman discovered the REM sleep stage and
understanding their wishes and beliefs, and the revealed that in this phase dreams are longer,
ability to think about thinking, abstraction, ex- more vivid and bizarre, as well as containing
ecution control and reflectivity are also absent more elements connected with movement than
during dreaming [28]. in nREM sleep stage [1]. Several studies showed
In addition to the above described common that the neurobiological support of REM sleep
features of schizophrenia and dreaming, re- is necessary for the process of dreaming, even if
search on cognitive bizarreness conducted by not all of its criteria are “identified” [6]. For this
Scarone and colleagues [29] supports the hy- reason, most researchers restrict their investiga-
pothesis that due to similarities between these tions to the REM sleep stage.
two states, a dreaming brain may be a useful Evidence of common neurobiological charac-
model for this disease. The level of cognitive bi- teristics of schizophrenia and REM sleep come
zarreness, defined as discontinuity and incon- from electrophysiological studies, topographic
gruity of dream perception and cognition is com- approach, neurochemistry and pharmacology.
parable in both non-clinical subjects, and ones These kinds of analyses compare the activity of
suffering from schizophrenia. A comparison of the cerebral cortex, the blood flow and the se-
stories from the Thematic Apperception Test ob- cretion of neuromodulators and neurotransmit-
tained from both patients and non-clinical sub- ters in non-clinical sleeping subjects (during the
jects revealed that although the level of cognitive REM sleep stage) and awake patients suffering
bizarreness is significantly higher in the former from schizophrenia.
than in the latter, it still oscillates at a level sim- The results of electrophysiological stud-
ilar to that which occurs in dreams [29]. There- ies on the relationship between schizophrenia
fore, it seems that while bizarreness constitutes and REM sleep stage dreaming have been ex-
a kind of cognitive model for dreaming mental tensively presented by Claude Gottesmanna [6,
state (for both clinical and non-clinical popula- 31]. Main results indicate a lack of central inhib-
tions), it is still present as a characteristic feature itory processes in both schizophrenia and REM
of waking cognitive organization in schizophre- sleep stage. The negative component (N100) of
Archives of Psychiatry and Psychotherapy, 2013; 2 : 29–35
32 Dagna Skrzypińska, Barbara Szmigielska

the evoked potential achieves the same increase modulators (dopamine and noradrenaline) and
in the amplitude of the REM sleep in both non- neurotransmitters (glutamate and acetylcholine).
clinical and clinical subjects, which indicates a While playing an essential role in the differen-
disinhibition process present in this state [6]. tiation between states of dreaming and waking,
Central inhibition is not observed in non-clinical they also play a fundamental part in schizophre-
subjects during dreaming, it is however present nia. The importance of their role is shown by
in waking states. In persons with schizophrenia several hypotheses regarding the relationships
it appears neither in REM sleep stage nor in ac- between the activity of various neuromodula-
tive waking [31]. As a consequence, it seems that tors and neurotransmitters and the etiology of
due to the distortion of cortical function, menta- the disease. The most general assumption con-
tion present in REM sleep stage is similar to psy- cerning the comparison of REM sleep stage and
chotic thinking. schizophrenia in terms of secretion and activity
Additionally, electrophysiological data re- of neuromodulators and neurotransmitters sug-
vealed that the gamma rhythm is synchronized gests that their level during REM sleep in non-
in the cortical regions during wakefulness, clinical subjects is similar to their levels in pa-
whereas it is suppressed between visual areas, tients being awake.
the frontal cortex and the prefrontal cortex [32] The dopamine
�����������������������������������
hypotheses have a signifi-
as well as between the hippocampus and the cer- cant impact on explaining the neurobiological
ebral cortex during REM sleep [33]. The discon- causes of schizophrenia [38]. On the most ba-
nection of the gamma rhythm between central sic level, they assume diverse activity of differ-
structures of the brain in REM sleep in non-clin- ent dopamine receptors in various brain regions.
ical individuals corresponds to the disturbanc- Negative symptoms of schizophrenia are associ-
es in cortical connectivity typical for schizophre- ated with decreased dopaminergic activity par-
nia [6]. ticularly in the prefrontal cortex, while the pos-
Similarities between REM sleep and schizo- itive ones - with increased activity in the mid-
phrenia are also indicated by data from the tom- brain region (mainly the nucleus accumbens)
ographic study of the cerebral blood flow. Some [19]. Dopamine is active during waking, slow
structures involved in mentation are active not wave sleep and REM sleep. What is important
only during waking, but also during REM sleep, is that dopaminergic neurons are the only re-
whereas in the latter state some structures are lease monoamines during REM sleep [31]. The
deactivated [34]. For example, the dorsolateral release of dopamine in the nucleus accumbens
prefrontal cortex is not active during REM sleep during REM sleep state is slightly greater than in
[35]. Dysfunctions of the same area are also ob- the waking state. On the other hand, dopamine
served in schizophrenia [36]. Deactivation of this release in the prefrontal cortex is significant-
area may explain the disturbances in mentation, ly smaller during REM sleep stage than when
especially a reduction in control associated with awake. These trends in dopamine release ob-
self-reflectiveness. Furthermore, the results ob- served during REM sleep stage show the same
tained from the CT scans allowed formulating tendency as the one postulated for schizophre-
a hypothesis about the formation of hallucina- nia [6]. Thus, the maximal release of dopamine
tions in schizophrenia. It is assumed that halluci- in nucleus accumbens during REM sleep stage
nations could be under-constrained perceptions could be associated with hallucinatory activity of
which occur when the impact of sensory input dreaming, whereas in schizophrenia – with delu-
on activation of thalamacortical circuits and syn- sions and bizarre thought content. What is more,
chronization of thalamacortical gamma rhythm in schizophrenia the reduced level of dopamine
are reduced [37]. A similar phenomenon is ob- in prefrontal cortex is partially connected with
served during REM sleep [31], therefore it could cognitive impairment, while in REM stage –
at least partially explain the hallucinatory char- with decrease of the critical faculty. A reduction
acteristic of dreaming. of dopamine in prefrontal cortex beyond optimal
A very important group of evidence of simi- level can also explain the decrease or loss of re-
larities between schizophrenia and REM sleep flectiveness, characteristic for both schizophre-
stage dreaming relates to the activation of neuro- nia and REM sleep stage dreaming [6, 31].
Archives of Psychiatry and Psychotherapy, 2013; 2 : 29–35
 What links schizophrenia and dreaming? 33

Glutamate hypothesis assumes that hypofunc- brain during REM sleep could be a useful ex-
tion of the NMDA receptor may contribute to perimental model for schizophrenia [6, 16, 29,
the patophysiology of schizophrenia [38]. There 31]. While dreaming may be a condition advan-
is also a dysfunction in glutamate level in REM tageous to a better understanding of schizophre-
sleep stage. When compared with wakefulness nia, it is important to remember that these states
and slow wave sleep stage, nucleus accumbens are not identical.
shows the lowest concentration of glutamate The evidence presented in this article does not
during REM sleep. This is connected with the re- exhaust all the concepts regarding links between
lease of glutamate in the hippocampus, amygda- schizophrenia and dreaming or REM sleep. There
la and prefrontal cortex. In schizophrenia, as in are some theories that need to be mentioned. Sue
the REM sleep state, decreased release of gluta- Llewellyn [40] formulated a hypothesis about a
mate from the ventral part of the hippocampus possible etiology of schizophrenia. According
prevents the activity of glutamate released in the to the evidence based on the activity of neuro-
prefrontal cortex. As a consequence, the amy- transmitters and neuromodulators, the chaos the-
gdala becomes particularly active [6]. An in- ory, creativity, as well as the membrane theory
creased activity of this structure results in prob- of schizophrenia, the disease is a state of mind/
lems with perceiving and experiencing emotions brain “trapped” between waking and dream-
in both schizophrenia and REM sleep. ing. Professional literature provides reports on
Another neuromodulator affecting the nucleus convergence between dreaming, schizophrenia
accumbens and prefrontal cortex is noradrena- and a drug induced hallucinogenic state. In this
line. Noradrenergic neurons are the most active case, the hallucinogenic mental state induced by
in both structures during waking, whereas dur- drugs has been considered a model of psycho-
ing REM sleep stage their activity decreases sig- sis [41]. A broader view concerning psychosis as
nificantly. More importantly, in this state a lack not confined to schizophrenia has been consid-
of serotonergic neuron activity can also be ob- ered by Charles McCreery [7]. He proposes that
served. Similarly, both noradrenaline and serot- this state is based on a link between sleep and
onin deficits occur in schizophrenia [6]. Acetyl- hyperarousal. On the other hand, due to the na-
choline, being of great importance to the proc- ture of hallucination, intensity of emotions and
ess of thinking, maintains high levels in the cer- cognitive deficits such as confusion, memory im-
ebral cortex both in waking and REM sleep, but pairment or tendency to confabulate, Allan Hob-
at REM stage its concentration is lower [6]. In son [42] compares dreaming to psychosis simi-
schizophrenia, there is also a decreased acetyl- lar not with schizophrenia but with delirium tre-
choline activity, which may be associated with mens. Regardless of the type of psychosis, pros-
the development of hallucinations [40]. pecting similarities of this state and REM sleep
Data indicates that some characteristic features stage dreaming is a very promising direction for
of REM sleep stage dreaming, resulting to some further research allowing for a better understand-
extend from the neurobiological processes in the ing of not only the mental illness, but also of the
brain, resemble some of the symptoms of schiz- process of dreaming.
ophrenia. However, despite significant similari-
ties, there are still differences between these two
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