A Little History

Figure 1. Those who have fallen asleep in class or on the bus have likely experienced those “micro-dreams” – that moment or two where reality kind of blends in with your dreams. For a long time, scientists thought dissociative disorders were simply this confusion of waking and dreaming states. [Image: kooklanekookla, https://goo.gl/Cn3xul, CC BY 2.0, https://goo.gl/BRvSA7]

Researchers (Watson, 2001) have proposed that dissociative symptoms, such as absorption, derealization, and depersonalization originate from sleep. This idea is not entirely new. In the 19th century, double consciousness (or dédoublement), the historical precursor of dissociative identity disorder (DID; formerly known as multiple personality disorder), was often described as “somnambulism,” which refers to a state of sleepwalking. Patients suffering from this disorder were referred to as “somnambules” (Hacking, 1995). Many 19th-century scholars believed that these patients were switching between a “normal state” and a “somnambulistic state.” Hughlings Jackson, a well-known English neurologist from this era, viewed dissociation as the uncoupling of normal consciousness, which would result in what he termed “the dreamy state” (Meares, 1999). Interestingly, a century later, Levitan (1967) hypothesized that “depersonalization is a compromise state between dreaming and waking” (p.157). Arlow (1966) observed that the dissociation between the “experiencing self” and the “observing self” serves as the basis of depersonalized states, emphasizing its occurrence, especially in dreams. Likewise, Franklin (1990) considered dreamlike thoughts, the amnesia one usually has for dreams, and the lack of orientation of time, place, and person during dreams to be strikingly similar to the amnesia DID patients often report for their traumas. Related, Barrett (1994, 1995) described the similarity between dream characters and “alter personalities” in DID, with respect to cognitive and sensory abilities, movement, amnesia, and continuity with normal waking. The many similarities between dreaming states and dissociative symptoms are also a recurrent theme in the more recent clinical literature (e.g., Bob, 2004).

Sleep Problems and Dissociative Disorders

Anecdotal evidence supports the idea that sleep disruptions are linked to dissociation. For example, in patients with depersonalization, symptoms are worst when they are tired (Simeon & Abugel, 2006). Interestingly, among participants who report memories of childhood sexual abuse, experiences of sleep paralysis typically are accompanied by raised levels of dissociative symptoms (McNally & Clancy, 2005; Abrams, Mulligan, Carleton, & Asmundson, 2008).

Patients with mood disorders, anxiety disorders, schizophrenia, and borderline personality disorder—conditions with relatively high levels of dissociative symptoms—as a rule exhibit sleep abnormalities. Recent research points to fairly specific relationships between certain sleep complaints (e.g., insomnia, nightmares) and certain forms of psychopathology (e.g., depression, PTSD) (Koffel & Watson, 2009).

Studying the relationship between dissociation and sleep

In the general population, both dissociative symptoms and sleep problems are highly prevalent. For example, 29% of American adults report sleep problems (National Sleep Foundation, 2005). Thus researchers study the relationship between dissociation and sleep not only in patients, but also in the general population. In a pioneering study, Watson (2001) showed that dissociative symptoms—measured by the Dissociative Experiences Scale (DES)—are linked to self-reports of vivid dreams, nightmares, recurrent dreams, and other unusual sleep phenomena. This relationship has been studied extensively ever since, leading to three important statements.

First, Watson’s (2001) basic findings have been reproduced time and again. This means that the same results (namely that dissociation and sleep problems are related) have been found in lots of different studies, using different groups, and different materials. All lead to the conclusion that unusual sleep experiences and dissociative symptoms are linked.

Second, the connection between sleep and dissociation is specific. It seems that unusual sleep phenomena that are difficult to control, including nightmares and waking dreams, are related to dissociative symptoms, but lucid dreaming—dreams that are controllable—are only weakly related to dissociative symptoms. For example, dream recall frequency was related to dissociation (Suszek & Kopera, 2005). Individuals who reported three or more nightmares over a three-week period showed higher levels of dissociation compared to individuals reporting two nightmares or less (Levin & Fireman, 2002), and a relation was found between dream intensity and dissociation (Yu et al., 2010).

Third, the sleep-dissociation link is apparent not only in general population groups—people such as you and me—but also in patient groups. Accordingly, one group of researchers reported nightmare disorder in 17 out of 30 DID patients (Agargun et al., 2003). They also found a 27.5% prevalence of nocturnal dissociative episodes in patients with dissociative disorders (Agargun et al., 2001). Another study investigated a group of borderline personality disorder patients and found that 49% of them suffered from nightmare disorder. Moreover, the patients with nightmare disorder displayed higher levels of dissociation than patients not suffering from nightmare disorder (Semiz, Basoglu, Ebrinc, & Cetin, 2008). Additionally, Ross (2011) found that patients suffering from DID reported higher rates of sleepwalking compared to a group of psychiatric outpatients and a sample from the general population.

To sum up, there seems to be a strong relationship between dissociative symptoms and unusual sleep experiences that is evident in a range of phenomena, including waking dreams, nightmares, and sleepwalking.

Inducing and Reducing Sleep Problems

Sleep problems can be induced in healthy participants by keeping them awake for a long duration of time. The result is called sleep deprivation. If dissociative symptoms are fueled by a labile sleep-wake cycle, then sleep loss would be expected to intensify dissociative symptoms. Some evidence that this expectation might be true was already found in 2001, when soldiers who underwent a U.S. Army survival training, which included sleep deprivation, showed increases in dissociative symptoms (Morgan et al., 2001). Other researchers conducted a study that tracked 25 healthy volunteers during one day and one night of sleep loss. They found that dissociative symptoms increased substantially after one night of sleep loss (Giesbrecht, Smeets, Leppink, Jelicic, & Merckelbach, 2007).

To further examine the causal link between dissociative experiences and sleep, a group of researchers (van der Kloet, Giesbrecht, Lynn, Merckelbach, & de Zutter, 2011) investigated the relationship between unusual sleep experiences and dissociation in a patient group at a private clinic. They completed questionnaires upon arrival at the clinic and again when they departed eight weeks later. During their stay, they followed a strict program designed to improve sleep problems. And it worked! In most patients, sleep quality was improved after eight weeks. The researchers found a robust link between sleep experiences and dissociative symptoms and determined that sleep normalization was accompanied by a reduction in dissociative symptoms.

Figure 2. No longer are dissociative disorders untreatable illnesses. With the new methods developed by researchers, there is hope for curing or at least improving the lives of those with this debilitating disorder. [Image: CC0 Public Domain, https://goo.gl/m25gce]

An exciting interpretation of the link between dissociative symptoms and unusual sleep phenomena (see also, Watson, 2001) may be this: a disturbed sleep-wake cycle may lead to dissociative symptoms. However, we should be cautious. Although studies support a causal arrow leading from sleep disruption to dissociative symptoms, the associations between sleep and dissociation may be more complex. For example, causal links may be bi-directional, such that dissociative symptoms may lead to sleep problems and vice versa, and other psychopathology may interfere in the link between sleep and dissociative symptoms (van der Kloet et al., 2011).

Implications and Conclusions

The sleep-dissociation model offers a fresh and exciting perspective on dissociative symptoms. This model may seem remote from the PTM. However, both models can be integrated into a single conceptual scheme in which traumatic childhood experiences may lead to disturbed sleep patterns, which may be the final common pathway to dissociative symptoms. Accordingly, the sleep-dissociation model may explain both (a) how traumatic experiences disrupt the sleep–wake cycle and increase vulnerability to dissociative symptoms and (b) why dissociation, trauma, fantasy proneness, and cognitive failures overlap.

Future studies can also discern which characteristic sleep disruptions in the sleep-wake cycle are most reliably related to dissociative disorders, and then establish training programs, including medication regimens, to address these problems. This would constitute an entirely novel and exciting approach to the treatment of dissociative symptoms.

In closing, the sleep-dissociation model can serve as a framework for studies that address a wide range of fascinating questions about dissociative symptoms and disorders. We now have good reason to be confident that research on sleep and dissociative symptoms will inform psychiatry, clinical science, and psychotherapeutic practice in meaningful ways in the years to come.