To the Editor: In a recent issue, Morton F. Reiser, M.D. (1), brought together sources from psychoanalysis and neuroscience to evaluate the role of the dream in current psychiatric thinking. I would like to add a contribution from psychopharmacology to the subject. Since the dream records first and foremost the current affect of the patient, it can—and, I believe, should—be used in the psychopharmacologic treatment of mental illness. Whether or not the dream is "the royal road to the unconscious"—and I believe it is—it is certainly the royal road to the affect. In my experience, the initial affect of the dream or sequence of dreams corresponds to the affect with which the patient awakens. I believe that the ultimate target symptom to be addressed in psychopharmacology is the patient’s affect, and it is for this reason that the dream provides a quick and efficient source of information—or, rather, supplementation to other clinical data—for the purpose of deciding which medication to prescribe and how to modify the dose. A description of a recent patient illustrates this concept.
Mr. A was a 24-year-old man with severe anorexia nervosa who had no improvement after 10 hospitalizations in programs for the treatment of eating disorders and the efforts of a number of psychopharmacologists. He had had many types of pharmacologic intervention, and when I first saw him, he was taking 40 mg/day of fluoxetine because his anorexia nervosa was complicated by severe obsessive-compulsive neurosis. However, I saw no depressive affect in Mr. A. On the contrary, the most recent dream he could recall was that he was in bed with a "very pretty girl." That did not sound like a depressive dream to me but, rather, a dream that indicated a euphoric mood. His appearance at consultation was also euphoric. There was no sexual activity in the dream; he had never experienced any sexual contact with a partner. However, he was very close to his mother, who was very sympathetic and indulgent, in contrast to his father, who was harsh and critical.
I reasoned that the anorexia nervosa might have been a self-destructive effort to counteract his "up" mood in the same way that self-defeating behavior on the part of patients with mania can be seen as a corrective attempt and often interpreted as punishment. Accordingly, I prescribed olanzapine, 10 mg/day, primarily as a depressive drug, although I was obviously taking advantage of its propensity for increasing Mr. A’s appetite. Within 3 days, for the first time in years, Mr. A began eating eagerly and with appetite. I gradually increased his dose of olanzapine to 20 mg/day, wondering whether I might not be pressing too hard. However, Mr. A came in delighted with his change in status and reported his weight gain to me daily.
We had been discussing Mr. A’s difficulty in finding appropriate women to date. One day he reported having a dream in which he was with two girls who told him that they heard him "farting," that he was "shitty," and that "they would not have anything to do" with him. He started to weep as he described the dream. Clearly, this was a change in affect and indicated a switch in mood to the depressive side, which I had anticipated. I reduced his dose of olanzapine to 15 mg/day and added 15/mg day of mirtazapine. He then recovered completely.
Thus, the dream can be used advantageously by psychopharmacologists. However, from a theoretical point of view, we may infer also that the dream primarily expresses affect directly and probably selects content from the store of memories associated with that affect. What Freud called "dream work" creates a story line of sorts that integrates the images and processes of the dream. It does not do nearly as well as waking consciousness does, but it does integrate the affects, images, and processes admitted to our waking consciousness.