Received: 1 March 2022 Revised: 28 March 2022 Accepted: 28 March 2022

DOI: 10.1111/jsr.13609

REVIEW ARTICLE

What about dreams? State of the art and open questions

Serena Scarpelli1 | Valentina Alfonsi1 | Maurizio Gorgoni1,2 |

Luigi De Gennaro1,2

1
Department of Psychology, Sapienza
University of Rome, Rome, Italy Summary
2
Body and Action Lab, IRCCS Fondazione Several studies have tried to identify the neurobiological bases of dream experiences,
Santa Lucia, Rome, Italy
nevertheless some questions are still at the centre of the debate. Here, we summarise
Correspondence the main open issues concerning the neuroscientific study of dreaming. After overcom-
Serena Scarpelli, Department of Psychology,
ing the rapid eye movement (REM) - non-REM (NREM) sleep dichotomy, investigations
Sapienza University of Rome, Via dei Marsi
78, 00185, Rome, Italy. have focussed on the specific functional or structural brain features predicting dream
Email: [email protected]
experience. On the one hand, some results underlined that specific trait-like factors are
associated with higher dream recall frequency. On the other hand, the electrophysio-
logical milieu preceding dream report upon awakening is a crucial state-like factor
influencing the subsequent recall. Furthermore, dreaming is strictly related to waking
experiences. Based on the continuity hypothesis, some findings reveal that dreaming
could be modulated through visual, olfactory, or somatosensory stimulations. Also, it
should be considered that the indirect access to dreaming remains an intrinsic limita-
tion. Recent findings have revealed a greater concordance between parasomnia-like
events and dream contents. This means that parasomnia episodes might be an expres-
sion of the ongoing mental sleep activity and could represent a viable direct access to
dream experience. Finally, we provide a picture on nightmares and emphasise the pos-
sible role of oneiric activity in psychotherapy. Overall, further efforts in dream science
are needed (a) to develop a uniform protocol to study dream experience, (b) to intro-
duce and integrate advanced techniques to better understand whether dreaming can
be manipulated, (c) to clarify the relationship between parasomnia events and dream-
ing, and (d) to determine the clinical valence of dreams.

KEYWORDS
activation hypothesis, continuity hypothesis, dream enacting behaviour, dream recall,
interindividual differences, nightmares

1 | I N T RO DU CT I O N The oneiric production is a form of mental sleep activity that appears

strictly related to memory processes and cognitive elaboration
Dreams have been extensively studied from many points of view, (Wamsley & Stickgold, 2010; Mangiaruga et al., 2018). In this respect,
focussing on different aspects of the phenomenon. Dreaming is a some investigations have highlighted that dream features mirror the
composite experience occurring during sleep that includes images, development of cognitive processes (Mangiaruga et al., 2018; Scarpell
sensations, thoughts, emotions, apparent speech, and motor activity. et al., 2019a).

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provided the original work is properly cited.
© 2022 The Authors. Journal of Sleep Research published by John Wiley & Sons Ltd on behalf of European Sleep Research Society.

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Additionally, a growing number of studies have suggested that reports, several studies found that successful recall of a conscious
dream experience might be considered an expression of human experience can be frequently observed also after NREM awakenings,
wellbeing (Fränkl et al., 2021; Scarpelli et al., 2022) and has a pivotal role and in a minority of cases no dream experience was reported after
in emotional regulation, as suggested by some neurobiological findings REM awakenings (Foulkes, 1962; Nielsen, 2000). Moreover, dream
(Nielsen & Lara-Carrasco, 2007). For instance, dream recall and night- recall is still possible after lesions in brain regions involved in REM
mare frequency increase when subjects are exposed to adverse and trau- sleep generation, while the total disappearance of dream recall can be
matic events (e.g., Hartmann & Brezler, 2008; Nielsen et al., 2006; observed after focal forebrain lesions without an impact on REM sleep
Sandman et al., 2013; Tempesta et al., 2013). Also, the qualitative charac- (Solms, 2000). Also, dream experience is preserved after pharmacolog-
teristics of dream reports change in parallel with the emotional charge of ical suppression of REM sleep (Landolt et al., 2001; Oudiette
waking experiences (Schredl, 2006; Scarpelli et al., 2021). et al., 2012). Finally, dream recall has been recently associated with a
It should be highlighted that psychoanalysis had primacy in dream similar electrophysiological response after REM and NREM sleep
research until the discovery of the rapid eye movement (REM) sleep (D'Atri et al., 2019; Siclari et al., 2017). These results suggest that
stage (Aserinsky & Kleitman, 1953). The interpretation of oneiric con- (a) dream and REM sleep are controlled by distinct brain mechanisms,
tents was one of the main focusses of the Freudian theories positing (b) the postulate of a clear distinction between presence and absence
that dreaming allows access to the unconscious functions of the mind of dreaming respectively in REM and NREM has not a solid support,
in neurosis treatment (Freud, 1953). Aserinsky and Kleitman (1953) and therefore (c) dreams can occur in any sleep stage.
observed specific intervals with rapid and recurrent eye movement A dichotomy between NREM and REM sleep has been also hypo-
and bursts of alpha activity comparable to those that occur during thesised for the qualitative aspects of dreams. Indeed, it has been pro-
wakefulness. The enthusiasm linked to the discovery of REM sleep posed that REM and NREM sleep exhibit different kinds of mental
considerably influenced dreaming research in several ways, and the activity. According to this view, REM sleep is characterised by an
neuroscientific study of dreaming is relatively recent. Several studies emotional, vivid, and bizarre “dream-like” mentation (Antrobus, 1983;
have attempted to identify the neurobiological bases of dream experi- Casagrande et al., 1996; Foulkes, 1967; Foulkes & Schmidt, 1983;
ence through a neuropsychological approach (Solms, 1997, 2000), Waterman et al., 1993), while NREM mental activity would be
neuroimaging (Maquet et al., 1996) and electrophysiological tech- “thought-like”, with reduced emotional load, greater fragmentation,
niques (Marzano et al., 2011; Siclari et al., 2017). and contents more similar to waking thoughts (Foulkes, 1967;
Although several studies provide compelling evidence for the Rechtschaffen et al., 1963). Nevertheless, the existence of a clear-cut
existence of specific brain mechanisms predicting dream recall REM-NREM dichotomy has been questioned also in this case based
(e.g., Siclari et al., 2017), many questions are still at the centre of the on several findings: (a) “dream-like” reports have been observed also
debate. after NREM sleep (Monroe et al., 1965; Solms, 2000;
The present paper summarises the main open issues concerning Zimmerman, 1970) and (b) the qualitative differences between REM
the neuroscientific study of dream experience. Specifically, the review and NREM dream reports disappear when their length is equated
offers an overview about (a) the question related to the REM-non- (Antrobus, 1983; Cavallero et al., 1992; Foulkes & Schmidt, 1983).
REM (NREM) sleep dichotomy, (b) the state–trait-like problem, (c) the In light of these observations, the assumption that the presence/
relationship between waking and dreaming state and the manipulation absence and the phenomenological aspects of dream experiences
of dreaming, (d) the issue concerning the access to dream experience, strictly depend on the sleep stage per se is simplistic. It is worth not-
(e) the role of nightmares, and (f) the debate on dreamwork in ing that a precise definition of the time-coupling between the sleep
psychotherapy. stages and the actual occurrence of dream experience is difficult, as
the access to sleep mentation is possible only in an indirect way
through dream reports after the awakening (see the paragraph “What
1.1 | The REM-NREM sleep dichotomy about direct access to dream experience?”). At the same time, the
occurrence of dream experiences in both REM and NREM sleep, two
A classical view of the neurobiological basis of the oneiric activity pos- physiological stages characterised by distinct electrophysiological and
tulates the existence of a close relationship between dream experi- neurotransmitters patterns, appears paradoxical. Such considerations
ence and REM sleep (Hobson et al., 2000; Nielsen, 2000). This raised the question of what mechanisms facilitate/inhibit the recall of
hypothesis was based on early electroencephalographic (EEG) obser- a conscious experience at the awakening from different sleep stages,
vations showing that >70% of individuals awakened during REM sleep and what factors can explain intra- and inter-individual variability in
reported dreams, while dream recall at the awakening from other the phenomenology of the oneiric activity.
sleep stages was rare (Aserinsky & Kleitman, 1955). According to this
view, the wake-like high-frequency EEG pattern characterising REM
sleep would represent the ideal electrophysiological scenario for the 1.2 | State- and trait-like facets of dreams
occurrence of dream experiences, while the slow-frequency activity
characterising NREM sleep would be associated with the absence of Stable individual characteristics (trait-like factors) can impact dreams,
oneiric activity. However, using different criteria to collect dream explaining inter-individual variability. Sociodemographic factors like
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SCARPELLI ET AL. 3 of 12

gender (Schredl & Reinhard, 2008; Settineri et al., 2019) and age et al., 2017; D'Atri et al., 2019; Scarpelli et al., 2017; Scarpelli
(Mangiaruga et al., 2018; Scarpelli et al., 2019a) can predict dream et al., 2020a; but see Wong et al., 2020). In particular, dream experi-
recall. Interest in dreams (Bealulieu-Prevost & Zadra, 2007), visual ence would be facilitated by a pattern of reduced slow-wave activity
imagery abilities (Cory & Ormiston, 1975), personality dimensions like (SWA), most steadily in posterior regions (Siclari et al., 2017, 2018).
openness to experience, absorption, psychological boundaries Interestingly, lucid dreams, phenomenon characterised by conscious
(Beaulieu-Prevost & Zadra, 2007), and predisposition to suppress neg- awareness during the oneiric experience, appear associated with
ative emotions and thoughts (Malinowski, 2015) appear related to greater EEG gamma activity (Baird et al., 2022; Voss et al., 2009). Fur-
individual differences in the oneiric activity. thermore, a transcranial current stimulation delivered in a lower
Crucially, neuroimaging studies provided evidence about the rela- gamma range during REM sleep can affect the ongoing electrophysio-
tionship between dream features and stable brain anatomical and logical activity and increase self-reflective awareness in dreams (Voss
functional characteristics. Qualitative facets of dreams have been et al., 2014). These observations are consistent with “activation” the-
associated with volumetric and structural measures of the amygdala- oretical models (Antrobus, 1991; Hobson & McCarley, 1977;
hippocampus complex in healthy subjects (De Gennaro et al., 2011) Koulack & Goodenough, 1976), which postulate that dream recall
and amygdala volume, dorsomedial prefrontal cortical thickness, and would be facilitated by a greater level of arousal during sleep, repre-
dopaminergic activity in patients with Parkinson's disease sented at an electrophysiological level by higher brain activation.
(De Gennaro et al., 2016). Moreover, compared to low dream Indeed, the frequency of dream recall increases in association with a
recallers, high dream recallers showed (a) greater medial prefrontal sleep pattern characterised by greater sleep fragmentation (van Wyk
cortex white-matter density (Vallat et al., 2018); (b) higher regional et al., 2019), faster spindles, especially in central and posterior cor-
cerebral blood flow in the temporo-parietal junction during wakeful- tical areas (Siclari et al., 2018), intra-sleep wakefulness
ness, Stage 3, and REM sleep and in medial prefrontal cortex during (De Gennaro et al., 2010; Eichenlaub et al., 2014b; Vallat
wakefulness and REM sleep (Eichenlaub et al., 2014a); (c) enhanced et al., 2017), and sleep arousal (Polini et al., 2017; Schredl, 2009).
functional connectivity within the default mode network (DMN) and Furthermore, a night of recovery sleep after a period of prolonged
between areas of the DMN and memory-related regions immediately wakefulness, usually characterised by reduced awakenings, almost
after the awakening (Vallat et al., 2020); and (d) larger event-related totally abolished dream recall after the final morning awakening
potentials to distracting sounds even during active listening, arguing (De Gennaro et al., 2010). The SWA represents a marker of sleep
for enhanced bottom-up processing of irrelevant sounds but also an intensity (Borbély & Achermann, 1999), likely subserving the fading
enhanced recruitment of top-down attention as suggested by larger of consciousness during sleep. Thus, the pattern of local SWA
contingent negative variation during target expectancy and P3b to reduction in association with dreaming activity may represent the
target sounds (Ruby et al., 2021). Taken together, these findings high- electrophysiological marker of the greater arousal level needed for
light that stable individual features of the brain structure and activa- a successful dream recall. Moreover, this evidence provides a reli-
tion patterns can explain inter-individual differences in dream able explanation for the apparently paradoxical occurrence of
experience. dreams in states of consciousness (i.e., REM and NREM sleep)
Beyond the influence of trait-like factors, a growing number of characterised by drastically different EEG patterns.
studies also point to the role of the physiological milieu associated Overall, these findings highlight the crucial role of the physiologi-
with the oneiric experience (state-like factors). In other words, the cal state preceding dream recall. However, several questions remain
specific regional features of the physiological background contingent open. First, the influence of circadian and homeostatic factors on the
with dreaming would facilitate or prevent dream recall, potentially oneiric experience and its electrophysiological pattern is not clear
explaining intra-individual differences in dream reports. This possibil- (Chellappa et al., 2011; D'Atri et al., 2019; Scarpelli et al., 2017;
ity has been investigated mainly by assessing the sleep EEG pattern Scarpelli et al., 2020a). Moreover, the impact of the regional distribu-
preceding dream recall. In this way, several studies found that a suc- tion of SWA on qualitative dream facets needs to be fully investi-
cessful dream recall was associated with greater frontal theta oscilla- gated, as empirical preliminary evidence has been provided only by
tions before the awakening from REM sleep (Marzano et al., 2011; Siclari et al. (2017). Finally, the possible interaction between state-
Scarpelli et al., 2015; Scarpelli et al., 2019b) and reduced parieto- and trait-like factors should be carefully considered.
occipital alpha activity before the awakening from NREM sleep
(Esposito et al., 2004; Marzano et al., 2011). As theta and alpha oscil-
lations are associated with memory processes during wakefulness 1.3 | Continuity between waking and dream
(Hsieh & Ranganath, 2014), these results suggest that wakefulness experience
and sleep share the same neurobiological mechanisms for the elabora-
tion of episodic memories (see the next paragraph). The above-mentioned “activation hypothesis” represents one of the
On the other hand, a growing number of within-subject investiga- main theoretical frameworks on dreaming, along with the so-called
tions (which allows overcoming the possible influence of stable trait- “continuity hypothesis” (Domhoff, 2017; Schredl & Hofmann, 2003).
like factors) show that a more desynchronised EEG pattern is associ- In the early 1970s, Bell and Hall (1971) firstly proposed that waking
ated with dream recall in both NREM and REM sleep (Siclari experiences may have continuity in sleep. The formulation of the
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4 of 12 SCARPELLI ET AL.

original concept has gone through several re-interpretations and reward system (Perogamvros & Schwartz, 2012). Notably, a recent
adjustments since then. simultaneous EEG-functional magnetic resonance imaging study dem-
Early cognitively-oriented studies focussed on the continuity onstrated the privileged re-emergence during sleep of patterns of
between dream contents and waking events, personal concerns, brain activity associated with a recent rewarding (compared to a non-
thoughts, behaviours, and emotions, suggesting that waking-life expe- rewarding) waking experience during sleep (Sterpenich et al., 2021).
riences are reflected into subsequent dreams (Nielsen & Powell, 1992; Starting from these findings, many researchers stated that dream
Schredl, 2006; Blagrove, 2011; Vallat et al., 2017). Compelling evi- activity might have a crucial role in processing emotional events expe-
dence also showed the key role of the personal and emotional rienced during wakefulness (see Scarpelli et al., 2019c). More in-
salience in mediating the preferential incorporation of waking-life depth, the theta (Nishida et al., 2009; Boyce et al., 2016; Sopp
aspects during mental sleep activity (Malinowski & Horton, 2014). et al., 2018) and gamma activities (Van Der Helm et al., 2011) were
Further, different time intervals between waking experiences and identified as the EEG markers of emotional memory processing. Selec-
related dream contents could represent “day-residue effect” or tive sleep deprivation protocols provided experimental evidence
“dream-lag effect” as a function of the elapsed period (i.e., 1–2 days about the lack of emotional memories consolidation in the absence of
and 5–7 days, respectively) (Eichenlaub et al., 2017). Specifically, the REM sleep stage (Spoormaker et al., 2014; Wagner et al., 2001),
delayed incorporation of waking life events (“dream-lag effect”) was supporting the notion that dreaming represents the privileged sce-
selectively observed during REM sleep and for personally significant nario for the offline reprocessing of waking emotional stimuli.
events (Van Rijn et al., 2015). Keeping in mind the unitary perspective across waking and sleep
A complementary field of study posits the continuity between state, several investigations aimed to overcome the boundaries
waking state and mental sleep activity from a neurophysiological per- between different states of consciousness directly influencing sleep
spective. Namely, a growing body of evidence suggests that brain mentation by different kinds of sensory stimuli administered pre- or
mechanisms underlying cognitive and emotional functioning remain during sleep. Pre-sleep stimulation methods have been used since the
the same across different states of consciousness (e.g., Marzano very beginning of dream research. The pioneering study by Dement
et al., 2011; Eichenalub et al., 2018). and Wolpert (1958) showed the relation between the 24-h fluid
The involvement of alpha (8–12 Hz) and theta (5–7 Hz) oscilla- restriction in participants and their subsequent REM dream content.
tions in memory-related neural processes during wakefulness are Sensory stimulation through pre-sleep visual stimuli affected dream
well-established, especially as regards episodic-declarative memory content by using stressful films (Goodenough et al., 1965) or visual
(Klimesch, 1999). In particular, the increase in the frontal theta activity inverting prisms (Corsi-Cabrera et al., 1986).
and the alpha power decrease during the encoding phase of episodic Concerning sensory stimulation delivered during REM or NREM
memories were found to play a pivotal role in the subsequent recall of sleep stages, early studies described the incorporation of meaning ver-
stored information (Hsieh & Ranganath, 2014; Klimesch, 1999). bal stimuli (Berger, 1963; Hoelscher et al., 1981). Also, somatosensory
Over the last two decades, several studies were conducted under stimulation (e.g., water on the skin, thermal stimulation, pressure cuff,
the assumption that dream encoding and recall could represent a electrical pulses) (Baldridge et al., 1965; Dement & Wolpert, 1958;
peculiar form of episodic memory (Fosse et al., 2003). As previously Koulack, 1969; Nielsen, 1993) or vestibular stimulation (Leslie &
mentioned, a successful dream recall has been linked to higher frontal Ogilvie, 1996) were found to affect dream content. As expected,
theta activity during REM sleep (Marzano et al., 2011; Scarpelli these types of stimulation increased vividness and bodily sensation in
et al., 2015) and lower alpha activity over the temporo-parietal region the dream contents.
during NREM (Esposito et al., 2004; Marzano et al., 2011; Takeuchi Recent studies using olfactory stimulation during sleep showed
et al., 2003). Moreover, the topographical distribution of the above- the influence on the emotional content of dreams as a function of the
mentioned frequency bands resembles brain regions involved in hedonic characteristic of stimuli (Schredl et al., 2009) and the reac-
encoding and retrieval mechanisms during wakefulness. tivation of the odour-associated images (Schredl et al., 2014). The
A large body of experimental studies have also shown the conti- strong effect of olfactory stimulation on dream emotional aspects is
nuity between dreaming and emotional processing (for a review, see interpreted in terms of direct connections to the limbic system
Scarpelli et al., 2019c). First of all, as described in the previous para- (Smith & Shepherd, 2003).
graph, neuroimaging studies showed the relationship between qualita- In the last few years, a promising field of research explored the
tive and quantitative stable aspects of dream experience and shared neural circuits between wake and sleep mentation by directly
structural parameters of limbic areas (De Gennaro et al., 2011). Con- manipulating dream activity via transcranial electrical stimulation tech-
sistently, subjects reporting higher levels of fear in their dreams niques. Some studies showed that interfering with cortical areas that
showed a concomitant higher activation of the medial prefrontal cor- are notably involved in a specific function during wakefulness
tex, responsible for reduced activation of the amygdala, insula, and influenced the dream content accordingly (Jakobson et al., 2012;
midcingulate cortex both during sleep and wakefulness (Phelps Noreika et al., 2020).
et al., 2004; Sterpenich et al., 2020). Further, the main brain circuits Taken together, these results strengthen the hypothesis of shared
involved in emotional processing during wake are highly activated mechanisms between the awake and sleeping brain from both psycho-
during REM sleep, such as the limbic system (Nir & Tononi, 2010) and logical and neurobiological perspectives and through experimental
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manipulations. However, the intrinsic restraint due to the impossibility the body movements, verbal or emotional expressions during sleep
of directly investigating the dream content represents a common limi- and the subsequent components of dream recall (Arkin et al., 1970;
tation of these studies. Leclair-Visonneau et al., 2010; Oudiette et al., 2009; Rocha &
Arnulf, 2020).
Assessing REMs in patients with RBD, Leclair-Visonneau
1.4 | What about direct access to dream et al. (2010) found a concordance between limbs, head, and eye
experience? movements during the REM behaviour episode. The authors
suggested that REMs may imitate the scanning of the dream scenario
The issue concerning dream access is definitively the most complex to according to the so-called “scanning hypothesis” (Arnulf, 2011;
address. Indeed, the real object of study in the abovementioned inves- Leclair-Visonneau et al., 2010). Moreover, Oudiette et al. (2009) rev-
tigations (e.g., Chellappa et al., 2011; Marzano et al., 2011; Scarpelli ealed that during sleepwalking or sleep terror episodes, subjects show
et al., 2015, 2017; Scarpelli et al., 2020a; Scarpelli et al., 2019b; Siclari complex motor behaviours strictly related to their oneiric scenes. The
et al., 2017) is “dream recall” and not the dream experience itself. In same group has demonstrated that sleepwalkers are able to replay the
other words, dreaming is not directly observable, and researchers are recently trained behaviour during the parasomnia episode, supporting
able to obtain information about the oneiric activity just requiring a the idea that dream enactment may have a pivotal role in memory
dream report to the individual when he is awake. Also, we have processing during sleep (Oudiette et al., 2011).
already discussed that detecting the exact moment in which the More recently, Rivera-García et al. (2019) investigated the activa-
dreams are produced during sleep is very difficult. tion of facial muscles during REM sleep among healthy women. They
From a methodological point of view, three approaches to collect considered facial expressions during sleep on a par with DEBs and an
dreaming are well-known: (a) retrospective, (b) prospective, and index of emotional dreams. Consistently, the previous literature
(c) provoked awakenings with subsequent dream reports. While the shows that DEBs are more frequent during intense emotional dreams,
retrospective method allows researchers to collect dreaming through such as nightmares (Nielsen et al., 2009). Indeed, the authors revealed
interviews or questionnaires in large samples quickly, the prospective that the activation of corrugator and zygomatic muscles are highly
protocol (i.e., dream diaries; longitudinal dream report collection) is associated with dreams featured by negative affect (Rivera-García
less prone to memory biases (Robert & Zadra, 2008). These two strat- et al. (2019)).
egies allow classifying people in high and low recallers, helping to Also, sleep talking could be considered an additional non-
investigate the neurobiological trait-like features of dreamers pathological parasomnia-like event related to dreaming (Alfonsi
(e.g., Eichenlaub et al., 2014b; Eichenlaub et al., 2014a; Ruby et al., 2019; Mangiaruga et al., 2021). During sleep, the audible ver-
et al., 2021; van Wyk et al., 2019). However, the most accurate balisations may represent access to oneiric contents (Arkin
approach is represented by the provoked awakenings associated with et al., 1970; Alfonsi et al., 2019). In this regard, some studies showed
the polysomnography (PSG) of one or more sleep nights in a labora- different degrees of correspondence between sleep talking and
tory. Generally, participants are awakened to explore the presence of dreaming (Arkin et al., 1970; Rechtschaffen et al., 1962). Arkin
a dream report and to compare the recall and non-recall condition et al. (1970) reported different orders of concordance between sleep
(Scarpelli et al., 2017; Scarpelli et al., 2020a; Siclari et al., 2017) or the speech and later dream reports. Some authors investigated the pres-
report's qualitative features (Scarpelli et al., 2020b), correlating them ence of dialogical components within the dream reports proposing an
with the specific EEG patterns preceding the awakening. It is worth overlapping between the neural mechanisms underlying linguistic pro-
noting that the narration of dream contents could be influenced by duction in dreams and those responsible for language during waking
many biases after awakenings, such as the experimental setting state (Shimizu & Inoue, 1986; Hong et al., 1996; Siclari et al., 2017).
(Schredl, 2008), the physiological background of waking-life and by Specifically, Hong et al. (1996) found a reduction of the alpha activity
individual variables, such as personality, cognitive functions, censure/ focussed on Broca's and Wernicke's language regions, proportional to
omissions and socio-cultural features (Nir & Tononi, 2010), making the amount of expressive and receptive language reported in dreams
dream reports not always completely reliable. (Hong et al., 1996; Shimizu & Inoue, 1986). In addition, Noreika
How can we overcome this obstacle? In this regard, recent studies et al. (2015) demonstrated a decrement in the theta and alpha activity
have suggested that viable access to mental sleep activity is represen- in a single-case study associated with linguistic hypnagogic hallucina-
ted by dream-enacting behaviours (DEBs; Baltzan et al., 2020). Any tion. Consistently, a recent study revealed that similar EEG patterns
acting out of a dream during sleep characterised by motor, emotional predict intelligible verbalisations during sleep (Mangiaruga
or verbal components may be considered a direct observation of et al., 2022).
dream experience while the subject is asleep (Nielsen et al., 2009). In Overall, both findings in subjects suffering from parasomnias
this view, the study of parasomnias or parasomnia-like events, and those related to “benign” phenomena (e.g., facial expressions,
i.e., REM behaviour disorder (RBD), sleep walking, nightmares, and sleep talking), suggest that parasomnia-like episodes may open a
sleep talking, may provide new insights about dreaming. Interestingly, new frontier in dream research making the oneiric production more
some investigations highlighted a strong level of congruence between accessible.
 13652869, 2022, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsr.13609 by Indian Institute Of Technology Mandi, Wiley Online Library on [18/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
6 of 12 SCARPELLI ET AL.

1.4.1 | Nightmares Neidhardt et al., 1992). This technique consists of modifying the plot
of the recurring nightmare during the wakefulness by an imaginal
Nightmares are disturbing mental sleep activity characterised by nega- rehearsal of a new dream without disturbing items (Kellner
tive emotions and often considered a clinical symptom causing signifi- et al., 1992). The nightmare sufferers learn to change the nightmares
cant distress. They are frequently associated with a high level of scenes by creating a less unpleasant ending and including mastery ele-
arousal and somatic manifestations that are capable to awake the ments in the new dream scenario (Germain et al., 2004).
dreamer from REM sleep. The repeated occurrence of this event is Interestingly, lucid dreaming induction could represent a useful
categorised as parasomnia, i.e., “nightmare disorder”, according to the intervention to reduce nightmares (Zadra & Pihl, 1997; Spoormaker &
Diagnostic and Statistical Manual of Mental Disorders, fifth edition Van Den Bout, 2006; Rak et al., 2015). It has been hypothesised that
(DSM-5; American Psychiatric Association, 2013). lucid dreaming could be a sort of coping strategy to face unpleasant
On the one hand, this disturbance is frequently related to post- stimuli during a dream experience (Schiappa et al., 2018). Actually,
traumatic stress disorder (PTSD; Germain, 2013), but it could also be a lucid dream therapy is a cognitive technique that allows patients to
reaction to stress conditions (Scarpelli et al., 2022). On the other hand, learn to be aware of and modify their mental sleep activity during
also idiopathic nightmares, i.e., without a known cause, should be con- their nightmares through daily exercises (Spoormaker & Van Den
sidered. For instance, this kind of mental sleep activity is quite com- Bout, 2006; Zadra & Pihl, 1997).
mon in children tending to disappear during adulthood, and it is more More recently, eye movement desensitisation and reprocessing
frequent among females (Nielsen & Levin, 2007). (EMDR; Shapiro, 1989) has been employed for nightmares treatment
From a neurobiological perspective, a recent investigation shows in PTSD. Starting from the view that nightmares are the manifesta-
that the activation of the autonomic nervous system may be linked to tions of adverse events registered in a dysfunctional form, this tech-
nightmares (Paul et al., 2019). Some studies revealed REM-specific nique aimed to promote the recall of distressing images while
alterations in nightmare sufferers such as longer REM latency, activating one type of bilateral sensory input (e.g., hand tapping or
increased skipping of early REM periods and cycle length, and more side-to-side eye movement). The protocol allows subjects to identify
frequent REM periods (Nielsen et al., 2010). Furthermore, some EEG and reprocess the targeted disturbing memories and experiences in
findings highlighted the presence of slow frontal and central theta order to formulate insight and adaptive behaviour.
activity during REM sleep in a group of nightmare recallers (Marquis In conclusion, it should be underlined that studies on PSG abnor-
et al., 2017). Further studies reported evidence for reduced slow- malities and specific macro- and micro-structural features correlated
wave sleep and greater intra-sleep wakefulness (Simor et al., 2012), to nightmares are still missing. Further, efficacy studies on nightmare
increased alpha power during REM sleep, and higher levels of EEG treatment (i.e., IRT, lucid dream therapy, EMDR) are scarce and frag-
desynchronisation in NREM sleep of students with frequent night- mentary. Future research should be conducted to fill this gap and
mares (Simor et al., 2013). In other words, as already mentioned for explore the effectiveness of the above-mentioned interventions for
dream recall, a higher autonomic and electrophysiological activation nightmare disorders.
may provide the physiological background to the nightmare occur-
rence (Fisher et al., 1970; Nielsen & Zadra, 2005). This is consistent
with the self-reported experience of greater emotional and physical 1.4.2 | What role for dreamwork in modern
activations during the nightmare occurrence. psychotherapy?
Fear is the predominant emotion included in nightmares (Zadra
et al., 2006), suggesting that nightmares could be linked to fear- An interesting open issue concerns the possible usefulness of the
dysfunction disturbances, i.e., phobias, generalised or social anxiety oneiric experience as a tool in clinical practice, also in light of the neu-
(Nielsen & Levin, 2007; Walker, 2010). In other words, nightmares roscientific knowledge on dreams.
could be related to the dysfunction in the hippocampal–amygdala pre- Classically, Freud (1953) proposed two main functions of dreams:
frontal system that controls fear memory formation and extinction the expression of repressed infantile wishes and the protection of
(Marquis et al., 2017; Nielsen & Levin, 2007). Nevertheless, the func- sleep. The antimoral nature of such wishes implies the need of a dis-
tional role of nightmares is still debated. Considering the early theo- tortion through the dream censor to be acceptable, allowing their par-
ries of dream function emphasising roles for REM sleep and dreaming tial expression while protecting the continuity of sleep. Freud
in promoting adaptation to stress, nightmares could be interpreted as distinguished the manifest and the latent content of dream, the latter
a failure of this process (Wright & Koulack, 1987). containing the true meaning of the dream. Free associations would
Along this vein, some authors proposed that a certain degree of represent the “royal road” to uncover the latent dream content, and
awareness of our dream contents and the possibility of altering them the analyst provide his/her dream interpretation on the basis of the
may be beneficial for nightmares sufferers (Kellner et al., 1992; patient's dynamics.
Krakow et al., 2001; Neidhardt et al., 1992). In particular, compelling The role of dream interpretation in modern psychoanalytic
evidence highlighted that imagery rehearsal therapy (IRT) is very models has been significantly redefined compared to the initial Freud-
effective in reducing chronic nightmares within 6–12 weeks of ther- ian conceptualisation (Pesant & Zadra, 2004). Crucially, several
apy (Germain et al., 2004; Kellner et al., 1992; Krakow et al., 2001; authors focussed their attention to the intrinsic validity of the
 13652869, 2022, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsr.13609 by Indian Institute Of Technology Mandi, Wiley Online Library on [18/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
SCARPELLI ET AL. 7 of 12

manifest facets of dreams and their relationship with the diurnal expe- 2 | CONC LU SIONS
rience. According to different approaches, the role of dream has been
conceptualised in terms of reorganisation of the experience From the discovery of REM sleep to the present day, empirical investi-
(Fosshage, 2002), adaptation to reality (Gazzillo et al., 2020), and co- gations have considerably increased our understanding of neural
construction of the intersubjective reality (Jiménez, 2012). mechanisms underlying dream recall.
Although several authors underline a “marginalisation” of dream Although compelling evidence converges in providing support to
in modern clinical psychological practice (Leonard & Dawson, 2018), it the so-called activation hypothesis and continuity hypothesis, consid-
is worth noting that dreams have become an object of study also in erable efforts are still needed to fully understand the neurobiological
clinical paradigms different from the psychoanalytical models bases of oneiric processes.
(Pesant & Zadra, 2004; Velotti & Zavattini, 2019). Among the others, Overall, we believe that (a) some results are still heterogeneous
the evolution of the debate about dreaming in the cognitivist frame- due to the application of different protocols, so a more consistent
work (Rosner et al., 2004) represents an interesting example of the approach is needed; (b) the use of advanced techniques such as
redefinition of dreamwork in psychotherapy based on novel experi- high-density EEG or source localisation methods should be encour-
mental data, theoretical models, and clinical observations. Beck (1971) aged to better understand the relationship between specific oscilla-
proposed that dreams reflect the individual conception (and biases) tions and dream features; (c) further studies on experimental
about the self, the world, and the future, and may represent and indi- manipulation of dreaming should be carried out, also considering the
cator of changes in the emotional status. Nevertheless, the initial need implementation of brain stimulation techniques to promote dream
to move away from the psychoanalytical framework and the pressure recall or its specific characteristics; and (d) DEBs could be used as a
to adopt an empirically verifiable clinical model led to a common dis- model to observe dream contents overcoming the problem regarding
use of oneiric activity in cognitive-behavioural psychotherapy. Dreams the correspondence between specific time/stage of sleep and dream
were mainly considered as psychologically meaningless epiphenomena production, offering new insights about the neural correlate of
of sleep, useless for the dreamer and in turn for the therapeutic pro- dreaming.
cess. More recently, the progress in the scientific understanding of Lastly, it is worth noting that recent pandemic studies have “elec-
dreams has led to the reintegration of dreams among the object of ted” dream activity (and nightmares) as a reliable index of our emo-
interest from different epistemological paradigms in the cognitivist tional and psychological health (Fränkl et al., 2021; Scarpelli
framework. From a rationalist perspective, starting from the hypothe- et al., 2022). Considering this, we underline that a translational view is
sis that dreams are subjected to the same cognitive distortions that needed to systematically explore the potential role of neurobiological
characterise the waking experience, it has been proposed that and experiential facets of dreaming in a clinical context.
dreamwork can help to detect cognitive biases and maladaptive
thought patterns (Barrett, 2002; Freeman & White, 2002; Hill, 1996, AUTHOR CONTRIBU TIONS
2003) and promote cognitive reconstructing. On the other hand, the All the authors contributed equally.
constructivist paradigm moved the focus on the narrative facets of
dreams and the co-construction of meaning between patient and AC KNOW LEDG EME NT S
therapist (Bara, 2012; Rezzonico & Bani, 2015; Rosner et al., 2004), Open Access Funding provided by Universita degli Studi di Roma La
with the aim to promote the emergence of relevant aspects of the Sapienza within the CRUI-CARE Agreement. [Correction added on 26
personal meaning and increase the level of awareness of the patient. May 2022, after first online publication: CRUI funding statement has
The interest in the clinical use of dreams led to the development been added.]
of different articulated models of dreamwork in psychotherapy, like
the Description, Memory Sources, and Reformulation (DMR) model CONFLIC T OF INT ER E ST
(Montangero, 2009) and the cognitive-experiential model (Hill, 1996, All authors report no conflict of interest.
2003). Overall, Eudell-Simmons and Hilsenroth (2005) identify four
main functions of dreams in psychotherapy: (a) facilitate the therapeu- DATA AVAILABILITY STAT EMEN T
tic process, (b) increase patient insight and self-awareness, (c) provide N/A
clinical information relevant for the therapist, and (d) provide a mea-
sure of therapeutic change. OR CID
Clearly, a further research effort is needed to provide support for Serena Scarpelli https://orcid.org/0000-0002-9260-7111
the objective and efficacy of dreamwork in psychotherapy. Neverthe- Valentina Alfonsi https://orcid.org/0000-0002-9929-0399
less, the ongoing debate on this topic has led to several models of the Maurizio Gorgoni https://orcid.org/0000-0002-5544-5483
clinical valence of dreams that appear consistent with experimental Luigi De Gennaro https://orcid.org/0000-0003-3613-6631
findings on oneiric activity, mainly moving from standardised symbolic
interpretations of dreams to approaches based on the relationship of RE FE RE NCE S
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