Drug Dreams: Clinical and Research Implications of Dreams about Drugs in Drug-addicted Patients

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"Drug dreams", or the dreams in which drug-dependent patients use or attempt to use the drugs that they are addicted to, are a well-documented clinical phenomenon in various forms of drug addiction. Authors have highlighted their clinical, prognostic and therapeutic usefulness, since they provide information about the patients' "drug craving", their ability to cope with it, and their motivation to stay clean and sober. However, the study of drug dreams also reveals several implications and inspiration for general dream research and theory, especially with respect to the recent neuropsychology of dreaming, the emotional adaptive theories of dream, and the classical Freudian theory of dreams.This book is aimed at providing a systematic and comprehensive discussion on drug dreams by considering the various perspectives involved (such as therapy in drug addiction, the neurobiology of drug craving, affective neuroscience, dream research) and, ideally, at suggesting future clinical applications for therapists (counsellors, psychoytherapists, clinicians) in charge of treating drug-addicted patients, as well as providing input for dream researchers. The book draws from the author's clinical and research experience on drug dreams among heroin-addicted patients, as well as from the scientific literature in this field. The book is composed of three parts: the phenomenology of drug dreams, their clinical and therapeutic aspects, and their implications for the dream research and theory.

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Chapter One - Drug Dreams: An Introduction

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Drug dreams: terms and definitions

Drug dreams are a ubiquitous phenomenon among drug-addicted patients. Indeed, these dreams do not appear in people who do not use drugs and/or alcohol and in individuals who, although they use or have occasionally used drugs, are not diagnosed as drug-addicted patients (see Box 1, below) (Colace et al. 2010; Johnson, B., 2011; Johnson, R. A., 2000; Keeley, 2004; Parker & Alford, 2009; Scott, 1968).

The term drug dreams appeared in 2001 in a paper by B. Johnson published in the Journal of the American Psychoanalytic Association. Johnson used this term in describing those dreams in the contents of which “…at least one person was getting high, or there was drug seeking or buying” (Johnson, 2001, p. 86). Other explicit terms appearing in the literature are, for example, “using dreams” (Flowers & Zweben, 1998), “dreams about drinking” (Choi, 1973), “drug-related dreams” (Christo & Franey, 1996; Herr, Montoya, & Preston, 1993), and “relapse dreams” (Washton, 1989) to refer to those dreams on drug/alcohol use or on activities related to drug use. Other authors have used the term “relapse pending dreams”, referring to a form of drug dreams that precedes a relapse (e.g., Brown, 1985; Flowers & Zweben, 1998).

 

Chapter Two - Drug Dreams: Prevalence and General Contents

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The prevalence of drug dreams among drug-addict patients

Studies show that drug dreams are a typical phenomenon among patients addicted to alcohol, heroin, crack cocaine, tobacco, LSD, amphetamine, and other drugs. In my experience, almost all heroin-addicted patients had drug dreams in the course of their past history of addiction or during the treatment.

A sizeable group of systematic studies provides specific data on the prevalence of drug dreams in the drug-addicted population: drug dreams are present on average in about 80% of patients, with the exception of tobacco smokers, who show less frequent drug dreams (33%) (Hajek & Belcher, 1991) (Table 2). A lower frequency of drug/ drinking dreams is found only in those studies that consider a very brief period of observation, such as two weeks or less (e.g., Araujo, Oliveira, Piccoloto, & Szupszynski, 2004; Colace et al. 2010; Parker & Alford, 2009).

One of the studies in which the sample is numerically greater is that of Christo and Franey (1996) on polydrug-addict patients (heroin, cocaine, methadone, tranquillisers). These authors, using a drug-related dream questionnaire (occurrence: yes/no), found that out of 101 patients, 84% reported having drug-related dreams during the first six weeks of abstinence. These results were also confirmed by a more reliable method of collection of drug dreams: Reid and Simeon (2001) asked crack cocaine addicts (n 57) to record their drug dreams daily, upon awakening, for a month, and found that, during the first month of abstinence, drug dreams were reported by 89.1% of patients.

 

Chapter Three - Drug Dreams and Drug Craving

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Drug craving: definitions and clinical aspects

Craving is defined by the Oxford Website Dictionary as a “powerful desire for something”; other possible synonyms are: wanting and compulsive wishing.

According to the United Nations International Drug Control Programme (UNDCP, 1992), “drug craving” is “the desire for the previously experienced effects of a psychoactive substance”. The main manifestation of drug craving is represented by a sort of tension and internal pressure to seek and consume the substance, and by the presence of obsessive drug-related thoughts. The presence of drug craving is considered one of the distinguishing signs of drug dependence.

Some authors have also described drug craving as a sort of new limbic drive produced by continued drug exposure (Robinson & Berridge, 1993). Indeed, drug-addicted patients experience the urge to obtain and take the drug in order to put an end to a state of inner tension, just as thirst or hunger drives can stimulate to seek food or water (Hutcheson, Everitt, Robbins, & Dickinson, 2001; Koob & Le Moal, 1997).

 

Chapter Four - Drug Dreams and Abstinence from Drug Use

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Drug dreams as an effect of abstinence

It has been observed that drug dreams occur mostly after cessation of drug use or during early abstinence from drugs, rather than during regular drug use (e.g., Choi, 1973; Colace, 2004a; Fiss, 1980; Hajek & Belcher, 1991; Jerry, 1997; Jones, Krotick, Johnson, & Morrison, 2005; Persico, 1992; Stewart, 1999).

For example, Hajek and Belcher (1991), who studied the drug dream phenomenon in smokers, claim that drug dreams can be viewed as abstinence effects. In fact, these authors found that 97% of their sample subjects did not have drug dreams while they were still smoking. In my experience, when patients tell me about drug dreams reported in the past, investigations show that, in most cases, these appeared when they were not using heroin.

Drug dreams are frequent in the initial period of treatment, from the first or second week up to two/three months, in those patients who remain abstinent from drugs. For example, in tobacco smokers, “drug dreams” appeared during the first four weeks of abstinence (Hajek & Belcher, 1991) and in polydrug-addicted patients drug dreams occurred in the first six weeks of abstinence (Christo & Franey, 1996). Jerry (1997) found frequent drug dreams in a cocaine-addicted patient during the early months of treatment and abstinence. In heroin-addicted patients, drug dreams were observed in the first fifteen days of abstinence (Colace, 2004a). In alcoholics, too, “drinking dreams” occur frequently during their initial period of abstinence from alcohol (Alcoholics Anonymous, 1975; Denzin, 1988; Fiss, 1980; Makaric, 1979; Mooney, Eisenberg, & Eisenberg, 1992). For example, Choi (1973) reported that the first three months of abstinence were the ones where “drinking dreams” appeared with more frequency.

 

Chapter Five - Clinical and Psychological Functions of Drug Dreams

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Several authors have emphasised the clinical and therapeutic usefulness of drug dreams by suggesting that drug dreams can provide information about the patient's drug craving and his/her compliance with the treatment, allowing the clinician to establish appropriate therapeutic strategies (Araujo, Oliveira, Piccoloto, & Szupszynski, 2004; Beresford, Blow, Bower, & Maddahin, 1988; DeCicco & Higgins, 2009; Flowers & Zweben, 1996, 1997; Jerry, 1997; Keeley, 2004). For example, Flowers and Zweben (1996, 1998) suggested that the use of dreams might facilitate the work on addiction diseases at all stages of recovery. DeCicco and Higgins (2009) pointed out that drug dreams provide some helpful insight into the mood of alcohol-dependent patients during recovery. Drug dreams have also been a topic dealt with in the context of group therapy for drug/alcohol-addicted patients (Banys, 2002; Jorgensen & Salwen, 2000; Rawson, Obert, McCann, & Ling, 1993). However, drug dreams also have specific psychological functions with regard to the vicissitudes of personal drug craving and the development of a patient's ability to cope with it. Through drug dream reports, the patients have an opportunity to talk about their desire for drugs and their difficulties in trying to stay clean, which helps them to develop a greater awareness about their disease. This chapter deals with the specific clinical and psychological functions of drug dreams.

 

Chapter Six - Drug Dreams as Prognostic Indicator

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Authors have long attempted to establish whether drug dreams might have some prognostic value in the treatment of drug-addicted patients. However, nowadays, the results emerging from literature are conflicting in this regard (e.g., for a review, see Beaman, 2002; Christo & Franey, 1996; Steinig, Foraita, Happe, & Heinze, 2011) (see Table 9). Even recently, Steinig, Foraita, Happe, and Heinze (2011) have suggested that there is no clear guidance as to the prognostic value of these dreams, and for alcoholics they claim that:

more studies with larger samples are needed to further investigate the relationship between dreams of alcohol-dependent patients…to investigate whether dreaming of alcohol can indeed be seen as a good prognostic factor and prevent possible relapse. (p. 147)

The literature on the prognostic value of drug dreams

Some authors have noticed that drug-addicted patients who have drug dreams are more likely to remain abstinent than those who have no such dreams.

For example, Choi (1973) noted that the alcoholics who are able to satisfy their need to drink alcohol in dreams are able to stay abstinent for longer periods of time compared to alcoholics who do not have drinking dreams; thus, these dreams were considered as a good prognostic sign in the treatment of alcoholics.

 

Chapter Seven - Drug Dreams and the Classic Psycho-Physiological Dream Research and Theory

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It is widely known that for a long time the study of the role of motivations in dreaming processes has received, with rare exceptions, very little attention in the classic psycho-physiological dream research and theory (see, on this topic, Antrobus, 2001; Colace, 2010a; Smith et al., 2004). For example, in 1977, McCarley and Hobson suggested that REM sleep and dreaming are due to an automatic and cyclical brainstem neural mechanism and that, therefore, the underlying causal mechanism of dreaming is “motivationally neutral” (p. 1219). Later, in the 1980s, the psychological cognitive approach put great emphasis on the description of dream generation processes, by assuming that the issues of dream meaning and dream motivation could be temporarily omitted (e.g., Foulkes, 1985). This trend has reversed only recently, due to the results of functional neuroimaging and neuropsychological studies of dreaming that have shown how the forebrain areas, including the frontal and limbic structures involved in the individual's basic emotions and motivations, play a key role in dreams (Braun et al., 1997; Maquet et al., 1996; Nofzinger, Mintun, Wiseman, Kupfer, & Moore, 1997; Solms, 1997, 2000). However, many years before these results, several authors found the clear effects of biological drive frustration on dreams (i.e., “the biological drive frustration paradigm”), by emphasising the role of motivations in instigating the dream (i.e., Baldridge, 1966 and Baldridge, Whitman, Kramer, Ornstein, & Lansky, 1965; Bokert, 1968; for review, see Arkin & Antrobus, 1991; Colace, 2009b), but, unfortunately, these studies received little attention from the scientific community. This chapter highlights the ways in which drug dreams can offer a good methodological and conceptual dream framework for the study of the motivational determinants of dreaming and in support of the studies on the effects of biological drive frustration on dreams.

 

Chapter Eight - Drug Dreams and Freud's Dream Theory

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Clinical observations and systematically collected data show that drug-addicted patients seem to gratify in their dreams, or attempt to do so, their frustrated craving for the drug. From this perspective, several authors have explained drug dreams as a form of wish-fulfilment, with direct reference to Freud's dream theory (Choi, 1973; Colace, 2000b, 2004a; Denzin, 1988, Fiss, 1980; Peters, 2000). Actually, the implications arising from the study of drug dreams with a view to Freud's theory of dreams cover different areas, such as the concepts of drive and desire, the role of desire in triggering dreams, and the issue of the empirical testability of Freud's dream model.

Drug craving and the concept of drive and desire in Freud

The concept of drug craving has been equated to the Freudian concept of drive (Freud, 1915c). This is probably very true for the definition of unconscious drug craving. In Johnson's words: “drives are an endogenous force of nature pushing from within that only secondarily come into interaction with the external world” (Johnson, B., 2003b, p. 33). Once the drug craving is established, it will push people to search for drugs, not necessarily with awareness of their desire for such drugs. Shevrin (1997, 2001) suggested that drug craving, as compared to the concept developed by Berridge and Robinson (1995, 1998), has an equivalent in powerful drives in Freud's sense, that is, drives are unconscious and independent from the conscious affective experience and are manifested through “drive derivates”. Indeed, in Berridge and Robinson's description (1998), drug craving constitutes an internal pressure or an urgent appetite for drugs that operates unconsciously, including when drugs are unavailable.

 

Chapter Nine - Drug Dreams and the Neuropsychoanalytic Model of Dreams

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Drug dreams and the neuropsychoanalytic model of dreams

Neuropsychoanalysis analyses the “…internal psychological structure of the various changes in personality, motivations and complex emotions that occur following a damage to different cerebral structures” (Kaplan-Solms & Solms, 2000, p. 62) (see also Solms & Turnbull, 2002; 2011). One of the most important applications of this approach is the study of the dreaming process (Solms, 1997). In this chapter, I shall describe how the study of drug dreams might contribute to prove the validity of neuropsychoanalytic findings concerning the dreaming process. In fact, drug dreams represent a real exemplification and, at the same time, a clinical support to Solms's neuropsychological model.

The neuropsychoanalytic model of dream

Neuropsychological studies on dreaming are based on the observation of subjects who, due to a lesion in a specific brain area, have changed their way of dreaming. These studies suggest which brain structures are involved in the ordinary process of dreaming, that is, the cerebral organisation of dreaming (Solms, 1995, 1997, 2000, 2011).

 

Chapter Ten - Conclusion and Research Agenda

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The study of drug dreams has shown important implications for both the clinics and therapy of addiction rather than for general dream research and theory. It is, therefore, advisable to continue investigating this phenomenon.

At present, although the number of systematic studies on the topic is not yet sufficient and even seems to be imbalanced in favour of certain drugs rather than others, the results obtained make it possible to sketch a first overview of this phenomenon with some firm points.

Drug dreams are a phenomenon typical and exclusive of drug-addicted patients who, typically, show a craving for drugs. They do not occur in people who do not use substances and in those who use drugs occasionally. These dreams are a significant expression of drug craving, or, better said, of a high degree of drug craving. This is the reason why drug dreams appear mainly during periods of abstinence from drugs, when the intensity of the drug craving increases, and are much less present during the periods when patients use drugs regularly.

 

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