dream content in complicated grief: a window into loss-related cognitive schemas

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This article was downloaded by: [The UC Irvine Libraries] On: 07 November 2014, At: 21:31 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Death Studies Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/udst20 Dream Content in Complicated Grief: A Window into Loss- Related Cognitive Schemas Anne Germain a , Katherine M. Shear b , Colleen Walsh a , Daniel J. Buysse a , Timothy H. Monk a , Charles F. Reynolds III a , Ellen Frank a & Russell Silowash a a Department of Psychiatry , University of Pittsburgh School of Medicine , Pittsburgh , Pennsylvania , USA b Columbia University School of Social Work , New York , New York , USA Accepted author version posted online: 11 Dec 2012.Published online: 18 Jan 2013. To cite this article: Anne Germain , Katherine M. Shear , Colleen Walsh , Daniel J. Buysse , Timothy H. Monk , Charles F. Reynolds III , Ellen Frank & Russell Silowash (2013) Dream Content in Complicated Grief: A Window into Loss-Related Cognitive Schemas, Death Studies, 37:3, 269-284, DOI: 10.1080/07481187.2011.641138 To link to this article: http://dx.doi.org/10.1080/07481187.2011.641138 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with

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Page 1: Dream Content in Complicated Grief: A Window into Loss-Related Cognitive Schemas

This article was downloaded by: [The UC Irvine Libraries]On: 07 November 2014, At: 21:31Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK

Death StudiesPublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/udst20

Dream Content in ComplicatedGrief: A Window into Loss-Related Cognitive SchemasAnne Germain a , Katherine M. Shear b , ColleenWalsh a , Daniel J. Buysse a , Timothy H. Monk a ,Charles F. Reynolds III a , Ellen Frank a & RussellSilowash aa Department of Psychiatry , University of PittsburghSchool of Medicine , Pittsburgh , Pennsylvania , USAb Columbia University School of Social Work , NewYork , New York , USAAccepted author version posted online: 11 Dec2012.Published online: 18 Jan 2013.

To cite this article: Anne Germain , Katherine M. Shear , Colleen Walsh , Daniel J.Buysse , Timothy H. Monk , Charles F. Reynolds III , Ellen Frank & Russell Silowash(2013) Dream Content in Complicated Grief: A Window into Loss-Related CognitiveSchemas, Death Studies, 37:3, 269-284, DOI: 10.1080/07481187.2011.641138

To link to this article: http://dx.doi.org/10.1080/07481187.2011.641138

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all theinformation (the “Content”) contained in the publications on our platform.However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness,or suitability for any purpose of the Content. Any opinions and viewsexpressed in this publication are the opinions and views of the authors, andare not the views of or endorsed by Taylor & Francis. The accuracy of theContent should not be relied upon and should be independently verified with

Page 2: Dream Content in Complicated Grief: A Window into Loss-Related Cognitive Schemas

primary sources of information. Taylor and Francis shall not be liable for anylosses, actions, claims, proceedings, demands, costs, expenses, damages,and other liabilities whatsoever or howsoever caused arising directly orindirectly in connection with, in relation to or arising out of the use of theContent.

This article may be used for research, teaching, and private study purposes.Any substantial or systematic reproduction, redistribution, reselling, loan,sub-licensing, systematic supply, or distribution in any form to anyone isexpressly forbidden. Terms & Conditions of access and use can be found athttp://www.tandfonline.com/page/terms-and-conditions

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Page 3: Dream Content in Complicated Grief: A Window into Loss-Related Cognitive Schemas

DREAM CONTENT IN COMPLICATED GRIEF:A WINDOW INTO LOSS-RELATED

COGNITIVE SCHEMAS

ANNE GERMAIN

Department of Psychiatry, University of Pittsburgh School of Medicine,Pittsburgh, Pennsylvania, USA

KATHERINE M. SHEAR

Columbia University School of Social Work, New York, New York, USA

COLLEEN WALSH, DANIEL J. BUYSSE, TIMOTHY H. MONK,CHARLES F. REYNOLDS III, ELLEN FRANK, and RUSSELL

SILOWASH

Department of Psychiatry, University of Pittsburgh School of Medicine,Pittsburgh, Pennsylvania, USA

Bereavement and its accompanying psychological response (grief) constitute potentexperiences that necessitate the reorganization of cognitive-affective representa-tions of lost significant attachment figures during both wakefulness and dream-ing. The goals of this preliminary study were to explore whether the dreamcontent of 77 adults with complicated grief (CG) differed from that of a norma-tive sample and whether CG patients who dream of the deceased differ from CGpatients who do not dream of the deceased on measures of daytime emotional dis-tress. CG dreams were characterized by more family and familiar charactersincluding the deceased (in women), and fewer social interactions and emotionscompared to norms. Increased representations of familiar characters in CGdreams may reflect attempts to reorganize relational cognitive schemas tocompensate for the loss.

Received 7 April 2011; accepted 18 October 2011.This research was supported by NIH grants MH60783, MH24652, MH30915, AG

020677, AG13396, MH71944, MH37869, the Fonds de la Recherche en Sante du Quebec,and the Canadian Institutes of Health Research.

Address correspondence to Anne Germain, Associate Professor of Psychiatry andPsychology, University of Pittsburgh School, 3811 O’Hara Street, Room E-1118, Pittsburgh,PA 15213. E-mail: [email protected]

Death Studies, 37: 269–284, 2013Copyright # Taylor & Francis Group, LLCISSN: 0748-1187 print=1091-7683 onlineDOI: 10.1080/07481187.2011.641138

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Dreaming is a universal human experience that has stimulatedmuch theoretical, clinical, and empirical debate. Psychodynamic,existentialist, and cognitive neuroscience models of the role andfunctions of dreams have been proposed (e.g., see Domhoff,2000; Hobson, Pace-Schott, & Stickgold, 2000; Pesant & Zadra,2006; Solms, 1997). Regardless of one’s theoretical approach tothe study of dreams, there is a general agreement that waking lifeexperiences, including specific events, related thoughts, memories,and emotional states, do influence dream content (e.g., Foulkes,1985; Freud, 1900; Hartmann, 1984; Hobson et al., 2000; Jung,1974; Nielsen, 2000; Maquet et al., 1996).

Bereavement and its accompanying psychological response(grief) constitute potent waking experiences that can influencedream content. Although not substantiated by empirical data, sev-eral anecdotal case reports are consistent with the widely heldbelief that dreaming of the deceased may be an important compo-nent in the recovery process (Garfield, 1996). This hypothesis pro-poses that dreaming about the deceased facilitates emotionalprocessing of the loss by ‘‘desensitizing the survivor to it, eventu-ally allowing him or her to bear the unbearable’’ (Garfield, 1996,p. 192). It is also possible that dreaming of the deceased is a com-pensatory process that operates by providing aspects of the wakinglife previously fulfilled by the deceased that are now missing.Either way, the notion that dreaming of the deceased facilitatescoping with the loss of a loved one suggests that such dreamswould be associated with reduced daytime emotional distress.However, we are not aware of empirical data that support thedreaming-as-coping hypothesis by showing that bereaved indivi-duals who dream of the deceased show reduced emotional distresscompared to bereaved individuals who do not report dreams of thedeceased.

Normative data in nonbereaved people indicate that dream-ing of a deceased person is a rare event, occurring in 1% of dreamsreported by women, and less than 1% of dreams reported by men(Hall & Van de Castle, 1966), and in 2% of college students (Barrett& Loeffler, 1992). If the hypothesis linking dreams of a lost lovedone with better coping is correct, bereaved people should report ahigher rate of dreaming about the deceased than that observed innormative dream content data. In addition, bereaved people who

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Page 5: Dream Content in Complicated Grief: A Window into Loss-Related Cognitive Schemas

report dreaming of the deceased should cope better than thosewho do not report dreaming of the deceased. Similarly, bereavedindividuals who are not coping well, such as those who have symp-toms of complicated grief, may experience more emotional distresswhen they report fewer dreams of the deceased.

Complicated grief (CG) is a disorder characterized by symptomsof prolonged acute grief persisting for more than 6 months after theloss of a loved one, and sometimes lasting for many years, andinclude intense, recurrent pangs of grief, and intrusive thoughtsabout the deceased individuals, which trigger and maintain avoid-ance of reminders of the deceased (Prigerson et al., 1996;Prigerson, Frank, et al., 1995). Recently, diagnostic criteria forcomplicated grief, or prolonged grief disorder, have been pro-posed for the 5th edition of the Diagnostic Statistical Manual ofMental Disorders (DSM-V) and the 11th edition of the Inter-national Classification of Disease (ICD-11) and include separationdistress (yearning), and a variety of cognitive, behavioral, andemotional symptoms that follow bereavement, persist for morethan 6 mo after the loss, and is associated with significantfunctional impairments (Prigerson et al., 2009).

Although some symptoms of CG overlap with symptoms ofmajor depressive disorder (MDD; sadness, social withdrawal)and posttraumatic stress disorder (PTSD; intrusive thoughts andavoidance). CG, like MDD and PTSD, is also associated with sleepdisturbances (Germain, Caroff, Buysse, & Shear, 2005; Hardison,Neimeyer, & Lichstein, 2005; Monk et al., 2008), several psycho-metric studies have now shown symptoms of these three conditionsconstitute distinct clusters (e.g., Boelen & van den Bout, 2005;Golden & Dalgleish, 2010; Prigerson et al., 1996; Prigerson, Frank,et al., 1995), and that CG represents a distinct syndrome (Boelen,van den Bout, & de Keijser, 2003; Langner & Maercker, 2005).

In individuals with CG (as opposed to those experiencingnormal grief), it is possible that dreaming of the deceased may,paradoxically, be associated with more severe daytime symptomsof psychiatric distress, rather than less distress and better coping.In this instance, dreaming of the deceased may be a symptom ofCG related to increased daytime emotional distress, includingintrusive images about the deceased. This would be in a manneranalogous to that reported in trauma victims with acute and

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chronic stress reactions and would be consistent with thedreams-as-symptoms hypothesis. Trauma-exposed individualstypically experience trauma-related dreams (e.g., Esposito,Benitez, Barza, & Mellman, 1999; Germain et al., 2004; Hartmann,1984; Schreuder, van Egmond, Kleijn, & Visser, 1998), whichinclude intense fear and other negative emotions, and are associa-ted with increased daytime PTSD symptom severity (Krakow,et al., 2002). Others have reported a decreased frequency of dreamrecall in trauma-exposed adults (Kaminer & Lavie, 1991).

Dream content in MDD is characterized by fewer charactersand tends to be more mundane than dreams collected in nonde-pressed individuals (Agargun, Cilli, Kara, Tarhan, Kincir, & Oz,1998; Armitage, Rochlen, Fitch, Trivedi, & Rush, 1995; Barrett,& Loeffler, 1992; Cartwright, Lloyd, Knight, & Trenholme, 1984;Cartwright, Young, Mercer, & Bears, 1998). Increased nightmarefrequency and negative dream elements in MDD have been asso-ciated with increased severity of depressive symptoms and suicidalideations (Agargun & Cartwright, 2003; Agargun et al, 1998). Inboth PTSD and in MDD, intensified negative emotional valenceof dreams is considered an index of failure in restorative dreamfunction following a significant life event (Esposito et al., 1999;Rothbaum & Mellman, 2001; Hartmann, 1984; Cartwright et al.,1984; Cartwright et al., 1998). In a similar manner, increased fre-quency of negative dream elements and of dreams of the deceasedin individuals with CG may be an index of a similar failure toadapt to the loss of a loved one.

The first goal of this preliminary study was to compare dreamscollected from bereaved men and women with CG togender-matched dream content norms in an exploratory manner,using a reliable and standardized dream coding system (Hall &Van de Castle, 1966). Although exploratory, we expected thatCG dreams would be characterized by a greater frequency of nega-tive dream elements (i.e., negative emotions, aggression, failures,misfortunes), as well as more references to deceased characters,and fewer instances of positive dream elements (i.e., positive emo-tions, friendliness, success, and good fortunes) compared to dreamcontent norms. We also explored whether the severity of emotion-al distress differed in the group of CG patients who reporteddreaming of the deceased compared to the group of CG patientswho did not report such dreams.

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Methods

Participants

Data were collected from a sample of 25 men (M age¼ 49.8,SD¼ 13.6 years old) and 103 women (M age¼ 47.0, SD¼ 12.7years old) who enrolled in a larger study of the treatment of CG.Written, informed consent was obtained from all participants. Part-icipants, design, and treatment procedures have been reported indetail elsewhere (Shear, Frank, Houck, & Reynolds, 2005). Briefly,participants were included if they were at least 6 months postlossand if they endorsed symptoms generating a score greater thanor equal to 30 on the Inventory of Complicated Grief (ICG; Priger-son, Maciejewski, et al., 1995). The ICG is a self-reported 19-itemscale that assesses symptoms of complicated grief, and has anexcellent internal consistency (Cronbach’s alpha¼ .94) andtest-retest reliability (r¼ .80). A score of 25 or higher is associatedwith significant functional impairments (Prigerson, Maciejewski,et al., 1995). ICG scores in this sample ranged from 31 to 76.Participants included in the present study all provided a dreamnarrative of their most recent dream prior to initiating treatmentin the main study.

Psychiatric Symptom Measures

Prior to treatment, the Hamilton Rating Scale for Depression(HRSD; Hamilton, 1960), and the Structured Interview Guidefor the Hamilton Anxiety Rating Scale (SIGH-A; Shear, VanderBilt, et al., 2001a; Hamilton, 1959) were administered to allparticipants by a trained clinical assessor.

Dream Measures

Participants completed the Most Recent Dream Form (Domhoff,1996). This form is a validated and reliable method developedfor the collections of dreams in large samples by asking peopleto report the most recent dream that they can remember(Domhoff, 1996, 2000). This method has been shown providerepresentative samples of dream narratives (Domhoff, 1996).

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The Hall and Van de Castle dream content scoring system(H=V; Hall & Van de Castle, 1966) was used to code dream nar-ratives reported by participants. The H=V system, derived fromqualitative and quantitative content analysis of over 500 dreamreports collected from men (n¼ 100) and women (n¼ 100)between the ages of 18 and 25 years old. All were EuropeanAmerican college students, and each provided 12 to 18 dreams,of which five were randomly selected for analysis (Hall & Vande Castle, 1966). The H=V dream coding system has been shownto be a valid and reliable method of coding dream elements (Hall& Van de Castle, 1966, Domhoff, 1996). Multiple studies haveshown that dream content norms remain stable within Americansamples across age, socioeconomic, racial, and ethnic groups(reviewed in Domhoff, 1996), with the exception of a generaldecrease in the frequency of reported aggressive interactions inolder men and women compared to younger adults (Hall &Domhoff, 1963; Winget, Kramer, & Whitman, 1972). Cohorteffects also appear to be negligible (Hall, Domhoff, Blick, &Weesner, 1982).

The H=V scale produces a score comprising the total numberof explicit occurrences of items on each of 10 operationally defineddream subscales. In this study we used six subscales that pertainedto our a priori hypotheses: (a) characters (including deceased char-acters), (b) social interactions (aggression, friendliness), (c) success,(d) failure, (e) fortune and misfortunes, and (f) emotions (positive,negative). Other subscales (i.e., activities, settings, objects, anddescriptive elements) were not coded because they did not directlyrelate to the study hypotheses. Explicit operational coding rules areused to score each subscale, and the scale has been shown to pro-duce high interrater reliability (Domhoff, 1996). We confirmedinterrater reliability among our raters. Two raters were first trainedon 30 dreams from the original H=V dream sets. Discrepanciesamong raters were reviewed and discussed. Thirty additionaldreams were randomly selected from the online DreamBank(Schneider & Domhoff, 2004, http://www.dreamresearch.net) forcomputing interrater reliability. Interrater reliability, computedas ratio of the number of agreements over the number of agree-ments and disagreements, was satisfactory (kappa> 0.85 for allthe scales).

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Statistics

To compare the proportion of the H=V categories in CG patientsto published norms, we first computed the frequency ratio of num-ber of instance of a subscale (e.g., number of aggressive interac-tions) divided by to the total number of all interactions (e.g.,total number aggression þfriendly interactions) in the dream sam-ple. This ratio is used to normalize the contribution of each indi-vidual in the sample, and bypasses the effects of dream reportlength (Domhoff, 1996). Normative dream content differs by gen-der (Domhoff, 1996; Hall & Van de Castle, 1966). Therefore, weexamined dream content separately for men and women in ourstudy. The magnitude of the differences for each scale ratios forthe CG samples of women and men and gender-specific normswas then computed using the h effect size statistics (Cohen,1977), which allows for assessing the significance of the magnitudeof the difference between two independent proportions. Toexplore the relationship between dreams of the deceased and psy-chiatric symptoms, we compared scores on the ICG, HRSD, andSIGH-A in participants with and without the presence or absenceof a deceased character in the dream narrative, using anindependent means t-test.

Results

Dream Recall Rates

Thirty-nine of the 103 women (38%), and 12 of the 25 men (48%)did not provide written dream narratives on the MRD form.Dream recallers (13 men, 64 women) were significantly youngerthan nonrecallers (12 men, 39 women), t(126)¼ 3.18, p< .01. Thispattern held in both women and men. Because of the preliminarynature of this study, the small sample of dreams collected frommen was included in subsequent comparisons. Mean grief inten-sity scores on the ICG for dream nonrecallers, M¼ 44.79,SD¼ 11.11, and dream recallers, M¼ 47.75, SD¼ 9.50, did notsignificantly differ, t(105)¼�1.47, p¼ .14. Depression severityin nonrecallers, M¼ 20.62, SD, 8.16, and dream recallers,M¼ 21.64, SD¼ 7.10, did not differ between the two groups,

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t(106)¼�.69, p¼ .50. Neither did mean levels of anxiety(M¼ 21.40, SD¼ 9.12 in nonrecallers, and M¼ 21.68, SD¼ 7.00in recallers), t(106)¼�.18, p¼ .86. Time since the index loss inrecallers, M¼ 5.33 years, SD¼ 7.21 years, did not differ from timesince index loss in nonrecallers, M¼ 4.07 years, SD¼ 5.24 years,t(126)¼�1.07, ns. The distribution of participants with a comor-bid diagnosis of current MDD did not differ in the 77 dreamrecallers (n¼ 50) and the 51 nonrecallers (31 with MDD),v2¼ .19, df¼ 1, ns. Similarly, the distribution of participants witha comorbid diagnosis on current PTSD was comparable inrecallers (n¼ 26) and nonrecallers (n¼ 28), v2¼ 1.11, df¼ 1, ns.

Dream Content Analyses

Table 1 shows the proportions of dreams containing coded H=Vdream elements in CG men and women in comparison to pub-lished norms for men and women separately. Dreams involvingdeceased characters were more frequent in women with CG com-pared to norms, but this was not the case for men with CG. Com-pared to gender-specific norms, both women and men with CG

TABLE 1 Proportion of Dreams Containing Occurrences of Selected H=VSubscale in CG Patients and Dream Norms

Women Men

% of dreams CG % Norm % h CG % Norm % h

Familiarity 61 58 .06 83 35 .83��

Family 45 19 .57�� 42 12 .70��

Deceased characters 4 1 .20� 0 0 �.12Aggression 13 44 �.71�� 7 47 �.97��

Friendliness 21 42 �.46�� 29 38 �.20Success 1 8 �.31� 0 15 �.80��

Failure 13 10 .11 7 15 �.27Good fortune 3 6 �.13 21 6 .47Misfortune 18 33 �.36�� 0 36 �1.29��

Positive emotion 3 20 �.58�� 29 20 .21Negative emotion 21 80 �1.29�� 8 80 �1.64��

Note. H=V¼Hall and Van de Castle dream content scoring system; CG¼ complicatedgrief; h¼ h effect size statistics.

�p< .05. ��p< .01.

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reported more instances of family characters, and fewer instancesof aggression, success, misfortunes, and negative emotions.Women with CG also reported more instances of family charac-ters, and fewer instances of friendliness and of positive emotionscompared to women’s dream norms. Men with CG reportedmore instances of familiar characters (nonfamily characters) thanis reported in men’s norms. There was no difference from norma-tive data for the rate of positive emotions, failures, or goodfortunes.

Relationship Between Dreaming of the Deceasedand Psychiatric Distress

Of the 77 dream recallers, 14 individuals (18%; all women) reporteda dream that included at least one deceased character, whereas theremaining 63 (82%; all 13 men and 50 women) did not. Mean griefintensity scores did not differ between the group who did not dreamof the deceased,M¼ 48.57, SD¼ 9.40, and the groupwho did reportsuch dreams,M¼ 44.17, SD¼ 9.49; t(63)¼ 1.46, p¼ .15. Depressionseverity was not significantly different between who did not report adream of the deceased, M¼ 22.04, SD¼ 7.25, and the group whodid report such a dream, M¼ 19.83, SD¼ 6.12; t(63)¼ 1.46,p¼ .33. Similarly, anxiety severity did not differ between the twogroups: M¼ 21.65, SD¼ 7.20 for the group without dreaming ofthe deceased, andM¼ 21.83, SD¼ 6.25 for the groupwith dreamingof the deceased; t(64)¼�.82, p¼ .94.

To further explore whether measures of psychiatric distressrelate to dream elements other than dreaming of the deceased,we conducted exploratory Spearman’s correlations in the samplesof women and men separately. In women, anxiety scores werenegatively and significantly correlated with the number of aggress-ive dream interactions, q¼�.30, p¼ .02, as well as with the num-ber friendly dream interactions, q¼�.43, p< .001. The griefintensity and depression scores were also negatively and signifi-cantly correlated with friendly dream interaction, q¼�.48,p< .001, and q¼�.51, p< .001, respectively. No significant corre-lations between dream elements and distress scores were found formen, although the small sample of men compromises the robust-ness of these correlations.

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Discussion

Complicated grief is a prolonged grief disorder that can be reliablyidentified, has a chronic impairing course, and is not responsive tostandard treatments for depression (Reynolds et al., 1999; Shear,Frank, et al., 2001b). In this exploratory study, men and womenwith CG provided their most recent dreams, which differed in con-tent from normative dream content data in some unexpected ways.Both men and women with this debilitating prolonged grief dis-order reported more family characters compared to norms, andfewer instances of aggression, misfortunes, and negative emotions,as well as fewer instances of success. Thus, the dreams were moreextensively populated, yet both positive and negative dream ele-ments were greatly attenuated in this sample of adults (mainlywomen) with CG. There were gender differences in some of theways CG dreams differed from norms. Dreams of women withCG contained more instances of deceased characters, and fewerinstances of friendliness and positive emotions, whereas dreamsof men with CG contained more familiar characters who werenot family members. However, the reliability of the latter observa-tions is uncertain, given the very small sample of dreams availablefrom men in this pilot study. Among all CG participants, dreamingof the deceased was not associated with either reduced or increasedseverity of CG, depression, or anxiety. In women, exploratory cor-relation analyses indicated that fewer occurrences of friendlinesswere correlated with increased anxiety, depression, and grief. Inaddition, less aggression correlated with more anxiety. The lattertentatively suggests that dream content and emotional distressmay be related in women. These relationships were not observedin the small sample of men with CG, but the small sample does notallow for a definitive conclusion. Thus, our findings failed to pro-vide conclusive support both the dreams-as-coping hypothesisand=or the dreams-as-symptom observations from studies of PTSDand MDD. Nevertheless, these preliminary findings provide strongsupport that detectable changes in dream content can be capturedin adults with CG, and suggest that dreams in CG may reflect areorganization of cognitive-affective representations of lost signifi-cant attachment figures.

Contrary to our expectation, both positive and negativedream elements were significantly attenuated in CG dreams

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relative to normative dream content. The lack of significantrelationship between dreaming of the deceased and severity ofCG, depression, and anxiety in CG patients is also contrary toour initial expectation. In summary, dream content results for thisCG sample show a distinct dream pattern characterized by anincreased number of characters, accompanied by fewer positiveelements as well as fewer negative emotions, aggression, and mis-fortunes. This pattern suggests possible marked differencesbetween dream content in CG, from previously reported dreamcharacteristics in PTSD and MDD samples. Direct comparisonsof dream content in these three clinical samples may provideadditional insights into the relationship between dream featuresand daytime emotional distress, and may provide novel evidencethat CG is a distinct clinical entity and is not simply a subtype ofPTSD or MDD.

The dreams of CG patients pertained mostly to mentalrepresentations of familiar people. Interestingly, although thesedream characters were increased relative to normative data, thereappeared to be a restriction in both positive and negative emotionas well as positive and negative content related to these images.Loss of a loved one creates a need for reorganization of thecognitive-affective mental representation of the deceased, and wehave proposed elsewhere that the failure to achieve this reorgani-zation is associated with CG (Shear & Shair, 2005). We further sug-gested that failure to engage in satisfying ongoing life activities andfeel connected to others, impedes the grief process. If these ideasare correct, increase in dream characters could be related to effortsto revise mental representations. If so, the reduced frequency ofboth positive and negatively toned emotions and events and thelack of a relationship between reported dream characters andreduced intensity of grief severity, depression, and anxiety couldindicate failure to reconstruct effective forms of such representa-tions. The finding that grief intensity, anxiety, and depression cor-related with less coding of friendliness in dreams of women withCG is consistent with the possibility that dream alterations arerelated to the onset and=or maintenance of CG. The absence ofthis finding for men may be due to our small sample of men,but also raises the possibility that the relationship between dreamelements and symptoms may differ in bereaved women and menwith CG.

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Of note, neuroimaging findings suggest that the failedreorganization of cognitive-affective representations of attachmentin CG may be related to changes in brain responses to cues of thedeceased figure. Specifically, CG has been associated with alteredbrain activation patterns in response to photographs of thedeceased (O’Connor et al., 2008). In this study, increased acti-vation of the nucleus accumbens (NA; a central component ofthe brain reward system) in response to photographs of a deceasedloved one has been reported in adult women with CG compared tobereaved women who did not suffer from CG. Rather, womenwho did not suffer from CG exhibited decreased activation ofthe NA in response to photographs of the deceased one. Inaddition, increased activation of the NA was positively correlatedwith yearning symptoms of CG. The dream content characteristicsobserved in this study in the women with CG may arise from simi-lar underlying neurobiological substrates, but sleep neuroimagingstudies combined with prospective dream sampling are necessaryto test this possibility.

There are several limitations of this study, which include theabsence of a bereaved group without CG and of a nonbereaved,age- and gender-matched comparison group, the use of the retro-spective MRD form, small samples of men and of dreams of thedeceased, and the cross-sectional design of this ancillary study.In the absence of comparison groups of bereaved individuals with-out CG and nonbereaved age- and gender-matched adults, it is notpossible to determine whether the observed dream characteristicsare specific to CG, more generally reflect bereavement, andwhether age- or cohort specific effects may have influenced thefindings. Although studies to date have found that age, and ethnicand racial backgrounds have limited impact on dream content, theinclusion of such comparison groups will be critical in future stu-dies. However, the present findings nevertheless suggest thatbereavement with CG is associated with detectable changes indream content relative to well-established norms. Gender differ-ences observed in this preliminary and exploratory study arehighly tentative given the very small sample of dreams that werecollected from men and available for analysis. Larger samplesare necessary to obtain a sufficient number of dreams frombereaved men (with and without CG) to more definitely study gen-der differences in dream content and their emotional correlates.

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Longitudinal collection of nightly dream reports by using dreamdiaries may reveal different content patterns in CG patients com-pared to standard normative data. Longitudinal studies thatinclude individuals across the spectrum of the grief responses arealso necessary to determine how dreams related to waking lifeexperiences of bereavement and grief. Dream patterns early afterthe loss may be an important indicator of bereavement-relatedpsychological outcomes. However, given our sample onlyincluded CG patients, and given the cross-sectional nature of thisstudy, we could not examine the possibility that dreaming of thedeceased may be related to emotional well-being in the normalbereavement process, or that dreaming of the deceased may beassociated with adaptive reconfiguration of mental representationsamong individuals who do not develop CG following bereavement(Field, Gao, & Paderna, 2005). Future studies are required tofurther explore these hypotheses. Finally, the addition oflaboratory-based dream collection concurrent with polysomno-graphic (sleep) studies could further the understanding of thepotential impacts of bereavement and CG on mental representa-tions across the sleep-wake cycle. Objective sleep measuresderived from polysomnographic studies have been shown inbereaved individuals with CG and depression (McDermott et al,1997). Identifying objective sleep parameters that relate to dis-turbed dreaming and daytime emotional distress in bereavementand=or CG could provide new objective indices to identifybereaved individuals at risk to develop CG.

Despite these limitations, findings from this exploratory studysuggest that investigating the effect of bereavement and CG ondream content may provide valuable insights into the psychologi-cal mechanisms that characterize this prolonged grief syndromeduring wakefulness, sleep, and dreaming. Investigating the effectsof CG treatments on dream content may also provide new insightsinto the reorganization of cognitive-affective representations of lostsignificant attachment figures.

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