INTRODUCTION
The death of a person (spouse, family member, or close relative, in particular) is a stressful event in life (Holmes & Rahe, Reference Holmes and Rahe1967). Surveys of the bereaved have revealed that, although most people show recovery from their grief in an early stage, accepting the death of a loved one, others suffer from chronic grief and depression (Bonanno et al., Reference Bonanno, Wortman and Lehman2002; Maciejewski et al., Reference Maciejewski, Zhang and Block2007).
Bereavement, defined as “Other conditions that may be a focus of clinical attention” by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV-TR) of the American Psychiatric Association, from a medical viewpoint, is known to cause a variety of physical and mental disorders as well as increased mortality.
One study reported a 40% increase in mortality, of which 75% of cases were due to heart disease, among males aged 54 years or older who experienced a wife's death within 6 months (Parkes, Reference Parkes, Benjamin and Fitzgerald1969). Other studies have also demonstrated high mortality rates in those who experienced the death of a spouse (Lichtenstein et al., Reference Lichtenstein, Gatz and Berg1998; Manor & Eisenbach, Reference Manor and Eisenbach2003).
As for physical disorders, there have been reports of heart problems, high blood pressure, and changes in eating habits, which increase the risk of many different physical illnesses (Prigerson et al., Reference Prigerson, Bierhals and Kasl1997).
One survey found that the prevalence of depression in those who lost a loved one within 1, 7, and 13 months was 24%, 23%, and 16%, respectively (Zisook & Shuchter, Reference Zisook and Shuchter1991). An increased risk of suicide in those who lost a loved one within 1 year has also been reported (Kaprio et al., Reference Kaprio, Koskenvuo and Rita1987; Li, Reference Li1995; Erlangsen et al., Reference Erlangsen, Jeune and Bille-Brahe2004).
As already mentioned, if someone dies, people close to the deceased will become vulnerable to a variety of physical and psychological illnesses, and their mortality rate will increase. However, most patients do not tell physicians of their distress as a chief complaint, and the relationship between their experience and the illness is often overlooked (Piper et al., Reference Piper, Ogrodniczuk and Azim2001).
Dreaming is one of the most striking psychological phenomena of the bereavement period. Freud (Reference Freud1935) stated that the bereaved person experiences a series of dreams, and this seems to be important in the psychology of bereavement. A large number of persons questioned about such dreams said they had experienced them (Waller, Reference Waller1951). A feeling that the deceased has returned may be achieved through such dreams. The dream is called a bereavement dream (Parkes, Reference Parkes1972). Hadfield (Reference Hadfield1954) has spoken of dreaming as a form of problem-solving behavior, and it is no surprise to find that bereaved dreamers continue to go over in their minds the vivid mental images that preoccupy their waking and, out of them, create the action, setting, and cast of their dreams. However, some major depressive disorder (MDD) patients also experience dreams (Nejad et al., Reference Nejad, Sanatinia and Yousofi2004; Besiroglu et al., Reference Besiroglu, Agargun and Inci2005). The dream of the bereaved might be only a bereavement-related dream, yet the dream might be a symptom of MDD. These two types of dreams are sometimes difficult to differentiate. In this communication, we report one patient who had distressing dreams after the death of her mother.
METHODS
Case Report
A 63-year-old woman was referred by her internist for psychiatric consultation because of generalized fatigue and gradual onset of insomnia. At psychiatric referral, she showed a depressed mood most of the day, markedly diminished interest, insomnia, retardation, fatigue, loss of appetite, and indecisiveness nearly every day for 3 months.
Questioning her about recent events, she said that her mother had died of carcinoma of the colon at the age of 94, 5 months previously. The death of her mother was unexpected for the patient, even though the prognosis of her mother was poor, and the fact that she would die soon was explained to the family members often. Two months after the death, she suddenly started dreaming of her mother almost every night. In her dreams, her mother seemed to be in her later years and under medical treatment at home or at the hospital. She always got angry with the way her daughter (the patient) cared for her. For example, she complained about meals the patient prepared. This was similar to her mother's behavior when she was alive. The patient was adversely affected by the dreams. The contents of her dream caused much distress, making her afraid to fall asleep. She also thought that her mother might not be resting in peace. These dreams started coincidentally with the appearance of various physical and psychological symptoms.
Her psychiatric features fulfilled the DSM-IV-TR criteria for MDD, single episode. The death of her mother was considered to be one of the causes of MDD. She was administered 25 mg/day of sertraline hydrochloride, which was subsequently increased to 100 mg/day, in addition to psychotherapy. Two months later, she still dreamed of her mother frequently; however, her appetite and volition had recovered. Four months later, she dreamed of her mother less frequently, and her physical symptoms had almost disappeared. Five months later, the physical and psychiatric symptoms of MDD had completely resolved, and she achieved remission. At the same time, the distressing dreams of her mother also disappeared. Looking back upon losing her mother, she said it had been a bitter and distressful experience. One and a half years after remission, she was leading a normal life and not suffering from any distressing dreams of her mother. Furthermore, she sometimes had pleasant dreams about her mother, which seemed to be a bereavement dream.
Medical History
The patient was diagnosed with breast cancer three and a half years previously and had received a mastectomy followed by adjuvant chemotherapy and hormonal therapy. She had no signs of recurrence. The patient was a housewife and had no medical history of psychiatric illness or alcohol or drug abuse. She had a normally cooperative character and was kind to others.
DISCUSSION
We experienced a case of a woman suffering from distressing dreams after the death of her mother. Initially, her dreams were thought to be a reaction to the death of her mother because the dreams started after the death and the contents were related to her mother.
In this case, she was diagnosed with MDD. The symptoms of MDD and the distressing dreams were improved through antidepressant treatment as well as psychotherapy. Her symptoms of MDD and the distressing dreams about her mother who died of cancer appeared simultaneously and disappeared with the remission of MDD, suggesting that the two events did not incidentally appear at the same time, but were associated. Therefore, it may be appropriate to regard the dream as a symptom of MDD, rather than considering it simply as a bereavement dream. “Bereavement dreams” are described in a broad way as bereavement-related dreams. And, in a strict interpretation of “bereavement dreams,” it is not due to the direct physiological effects of substance (e.g., drug abuse), a general medical condition, or mental disease. Bereavement dreams are sometimes embellished by physiological effects and/or psychiatric disease. In this case, her distressing dreams might have been embellished with the symptoms of MDD, because they disappeared with antidepressant therapy. It was also reported that the frequency of distressing dreams in patients with MDD was reduced with antidepressant therapy (Kirschner, Reference Kirschner1999). And antidepressant therapy is also effective in bereavement-related depression (Reynolds, Reference Reynolds, Miller and Pasternak1999).
As a differential diagnosis, in this case, posttraumatic stress disorder (PTSD) was considered, because some patients with PTSD experience recurrent, distressing dreams (American Psychiatric Association, 2000). The criteria for the diagnosis of PTSD are exposure to a traumatic event and subsequent symptoms or conditions, including repeated intrusive thoughts of the traumatic event, persistent avoidance of stimuli associated with the trauma, reduced general responsiveness, and persistent symptoms of heightened arousal. Although she explained the actual death of her mother, she did not experience intense fear, helpless, or horror, which are characteristics of responses to the traumatic events.
Bereavement dreams are often observed in the bereaved. However, some MDD patients also experience dreams and suffer from them. Therefore, when the bereaved experience distressing dreams, it might be better to consider MDD as a differential diagnosis in addition to bereavement dream. If the dream is derived from a symptom of MDD, antidepressant treatment as well as psychotherapy might improve the condition. Antidepressant therapy is effective in bereavement-related depression (Reynolds, Reference Reynolds, Miller and Pasternak1999), and some of the symptoms may also disappear through treatment involving antidepressant therapy. Therefore, we should avoid viewing symptoms of MDD as reactions to bereavement.
ACKNOWLEDGMENTS
This study was supported by a grant-in-aid from the Ministry of Health, Labour and Welfare and the UNIVERS foundation.
