An Interview with Dr Mark Toh: The Effects of COVID-19 On Dreams
|Amrita Kaur, a journalist from the Straits times interviewed Dr Mark Toh, Consultant Clinical Psychologist about the effects of COVID-19 on dreams. Parts of the following interview was published in the Straits Times on 13 July 2020.|
Here’s the interview in full:
- Dr Deirde Barrett, assistant professor of psychology at Harvard Medical’s department of psychiatry, who has studied the dreams of survivors of the Sept 11 attacks, said people tend to have an increase of bizarre, emotional and vivid dreams after crises (such as Covid-19). Can you share your thoughts on why you think this happens?
- Some people dream about sanitisers, face masks and toilet paper. Why such particular items?
- What exactly is happening in our subconscious (when we sleep) during periods of stress? How does that manifest in our dreams?
- Will such dreams affect the quality of one’s sleep? Why or why not?
Nearly all trauma survivors experience some type of trouble sleeping such as insomnia. But for anywhere from half to three-quarters of people, it is vivid dreams that make it difficult to sleep soundly. Having flashbacks to traumatic events, also called re-experiencing, is a hallmark symptom of post-traumatic stress syndrome (PTSD). For half of PTSD patients, those flashbacks occur at night while sleeping. Some people have nightmares that are exact replays of the trauma that they experienced, and these are called “replicative nightmares.” Others have nightmares that are related to the trauma indirectly or symbolically. Trauma and stress can disrupt your sleep in many ways. It can set off your body’s fight-or-flight response, and ramp up production of neurotransmitters that keep you awake and vigilant when it is time to sleep.
The items sanitizers, face masks or toilet paper may be dreamt about because they represent perceived solutions to address the threat of being harmed by Covid-19. Our psyche (our human mind or soul where we deliberate consciously and unconsciously –judge, think, feel– in relation to our sense of self and our sense of reality) is highly concerned about safety and security and therefore, when a threat is perceived, we consciously and unconsciously move in search for items or avenues that promote and restore our sense of safety.
There are several theories about the role of dreams in our sleep. In the event of stress, it suggests that our unconscious is working overtime in search for safety or to be settled with what may be traumatic, distressing or are reasons for anxiety. Stress is a disruption to our equilibrium and is communicated as an emotional and physiological alert. Because our psyche does not like to be unsettled or be disturbed, we tend to work consciously and unconsciously to settle what may be threatening or disturbing towards safety.
Yes. Trauma and stress can disrupt your sleep in many ways. It can set off your body’s fight-or-flight response, and ramp up production of neurotransmitters that keep you awake and vigilant when it is time to sleep.
- Dr Rose Gibson, a research officer at the Sleep/Wake Research Centre at Massey University in New Zealand, said that while some dreams can be confusing or distressing, dreaming is normal and considered helpful in processing our waking situation. Can you comment on this?
Dr. Gibson is correct. Dreams are a normal part of our sleep. Dreams have been described as hallucinations (defined by Oxford as “an experience involving the apparent perception of something not present”) during certain stages of sleep. They are strongest during REM (rapid-eye-movement) sleep, one of the four stages of sleep. But dreams are thought to have other functions as well:
- Dreams are sometimes engaged in settling what is unsettling or disturbing as already mentioned,
- Since the psyche is particularly concerned about safety and security in the daytime, dreams can represent an unconscious search to address the threat in overtime when sleep is intended. One of the areas of the brain that is most active during dreaming is the amygdala. The amygdala is the part of the brain associated with the survival instinct and the fight-or-flight response. Because the logical part of the brain is less in play in contrast to the emotional during dreaming. Nightmares may reflect attempts to address our fears or to prepare to deal with anticipated threats in waking life.
- Dreaming may reflect our muse as it facilitates our creative tendencies. A person can be awakened by great ideas for a movie or song that has been deliberated on during awake hours. The awake period could also involve psychological defenses at play such as denial or suppression that prevent certain ideas from emerging. In dreaming, these filters are not as active so that suppressed ideas or fears often emerge then.
- Besides sorting through complicated and unresolved events or anticipated fears, dreams are also suspected in aiding the storage of important memories and getting rid of unimportant memories as a part of our need to process information triggered during the awake period. Learning new information and being able to sleep on it facilitates recall of lessons learned.
- Do you think extra sleep, or lack of sleep, might contribute to vivid dreams related to Covid-19?
Dreams can also be affected by certain health conditions that result in sleep deprivation. Sleeping issues that cause a lack of sleep, such as insomnia and narcolepsy, can increase one’s risk of experiencing vivid dreams. Changes to your sleep schedule, such as flying overseas (and going to sleep at a different time) or getting less sleep than usual, can also increase this risk. Those who are sleep-deprived can lead to parts of the brain being much more active so when they finally slip into REM sleep they are likely to have more vivid dreams. They are also more likely to recall their dreams too.
- It seems that people are having better memory of their dreams now (An ongoing study at the Lyon Neuroscience Research Center in France found that “the coronavirus pandemic has caused a 35 per cent increase in dream recall among participants, with respondents reporting 15 per cent more negative dreams than usual). Why are people having a better memory of their dreams?
The brain during sleep is involved in information processing where unnecessary information is eliminated and important short-term memories are moved into our long-term memories, and dreams occur during this process. As such, some people may recall dreams with a difference in their ability to memorize things in general. Also, memory is affected by recall. Memories that are repeated as perhaps a sign of preoccupation or paranoia are more accessible.
- Have you noticed any of your patients having problems with sleeping specifically related to Covid-19? For example, if they are worried about the number of community cases the next day and this worry keeps them up at night, they fear for their jobs, etc?
Difficulty sleeping because of Covid-19 concerns is not a common complaint among my patients. This may be suggested by them not feeling threatened by the risk of infection, or that they feel they are coping with this threat, or that they are not in jobs or situations that are being threatened by the pandemic.
- Have any of your patients experienced any dreams related to coronavirus and such fears? If so, can you share what some of such dreams are?
None of my patients have reported dreams related to the coronavirus to me. Those who are more likely to be reactive to the coronavirus are probably those who are vulnerable to anxiety such as those who are obsessive-compulsive in nature.
- According to National Geographic, Italian researchers found that people stuck in lockdown experienced nightmares that bear similarities with someone going through post-traumatic stress disorder. Can you comment on this?
The hallmark symptoms of PTSD are exposure to a traumatic event; re-experiencing the event or intrusive symptoms (flashbacks); avoidance of people, places, or things that serve as a reminder of the trauma; negative mood and thoughts associated with the trauma; and hyper-vigilance. Trauma is experienced when the perceived threat is overwhelming or life-threatening that leaves a victim feeling numb, helpless, disconnected and having difficulty trusting. Since this article in question is reported by researchers from a particular country (Italian), one has to question the scope of the study. Is the study about the traumatic response to the lockdown found across different countries or is it reported specific to a particular region or town in Italy? It is unclear if the reported trauma is in response to the lockdown itself (which is usually activated as a preventive measure to protect against infection), or that the attempt at lockdown is seen as inadequate because the infection rate is already at such high numbers so that the lockdown is perceived as irrelevant or ineffective. As such, there may be the existence of an extraneous variable to explain how those in lockdown could have experienced this action alone as traumatic. At the same time, once the specific group is defined in the study, the results of the study may be explained by a high and pre-existing inter-dependency on this community to cope together as the norm such that restricting communal support disrupts their coping. Subsequently, imposing personal isolation, which is otherwise highly unusual, is therefore experienced as traumatic. The people in this community feel cut off from a regular method of coping which relies on their dependence on each other.
- Is there anything people can do to try to control what they dream about? If so, what?
This depends on whether they view these dreams as distressing. If trauma is indicated or they could represent disturbing experiences in their past or their present, or difficulties at coping at their anticipated future, I would suggest they seek professional help from those familiar with psychodynamic psychotherapy. Dreams are problematic usually only if they are associated with nightmares or sleep disruption. To sleep better and avoid nightmares or sleep that is not restful, the above factors should be reviewed. In particular: (a) ensure that there is adequate sleep scheduled to avoid sleep deprivation, (b) observe their diet since some studies have found that meals high in sugar, spicy foods, or high in starch, too much alcohol, eating excessively and late are associated with higher reports of nightmares, (c) address reasons for anxiety, (d) address unsettled emotional issues such as trauma or abuse, and (e) develop good sleep hygiene practices. Additional steps can include practising mental relaxation before sleep, recording their anxieties somewhere so that they can resume the next day to avoid rumination of what is worrying when sleep is planned or plan for guidance or support to address the worrying on the next day so they can relax at present.
- There are some people who have difficulty sleeping due to anxiety about the economy, they worry about losing their jobs and the future. How common can this be, and what can people do to relax their mind before they sleep? Now that people are working from home, some are taking naps in the day. Should this be encouraged? Why or why not? Does this make it harder for them to sleep at night?
For those who tend to have difficulty sleeping because of worries about employment or their future, insomnia is a common occurrence. Some even have chronic insomnia. Various studies worldwide have shown the prevalence of insomnia in 10%–30% of the population, some even as high as 50%–60%. It is common in older adults, females, and people with medical and mental ill health. The consequences of insomnia are significant, such as depression, impaired work performance, work-related/motor vehicle accidents, and overall poor quality of life. The reasons behind insomnia are varied. If the problem of sleep is persistent, they should consult psychiatrists or clinical psychologists. If they are anxious, sleep disruption is a common symptom of poor coping. As such, they should see a mental health professional. But if the question is how to promote good sleep for the average person where the sleeping problem is only recent, consider developing good sleep hygiene practices as a start. The following practices are recommended by the Sleep Foundation:
- Limit daytime naps to 30 minutes.
- Avoid stimulants such as caffeine and nicotine close to bedtime.
- Exercise to promote good quality sleep.
- Steer clear of food that can be disruptive right before sleep.
- Ensure adequate exposure to natural light.
- Establish a regular relaxing bedtime routine.
- Make sure that the sleep environment is pleasant.
Since more people are working from home, they should limit their nap time. Their difficulty sleeping at night may be indicative that if they had naps during the day, their nap times may have become excessive. The objectives of those working at home should ensure that they maintain a healthy work-life balance. It is important at this time of disruption and uncertainty over a pandemic that we establish goals to maintain good physical and mental health consistent with building our resilience to cope with the unrelenting demands of living effectively in the present and in the future.