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Three quarters of patients suffering from a mental illness reported sleep complaints. Both the physiological and psychological aspects of sleep reflect changes in patients suffering from various types of emotional disorders. Having demonstrated at both the subjective and objective level that the sleep of anxious subjects is discriminable from the nonanxious, it was of interest to see if the degree of anxiety covaries with the degree of sleep disturbance in any of the sleep parameters, both subjective and objective. In a series of reports of the study of sleep and dream characteristics of a group of patients with chronic delayed post-traumatic stress disorder sufferers, it was found that their sleep and dreams were indeed altered. Changes in the sleep patterns, psychologically and physiologically, of the depressed occur with improvement in the depression. Of all the psychopathologies, schizophrenia has been the major enigma to sleep researchers. The psychobiology of schizophrenia, from the perspective of sleep, remains to be understood.

The “Dream Book” provides a subjectively extensive and humane approach to understanding dreams. The Talmudic dream is prophetic in nature so it is future oriented while the Freudian dream is past oriented toward childhood. In addition, there is the need to understand the dream experience. Dream meaning is not in the text but in the interpretation. The dream experience is over-determined. Word play is used by the Rabbis and modern interpreters. The Rabbis felt the dream experience reflected the psychology of the dreamer. Dreams of everyday men and women are presented, not just dreams of royalty. Good and bad dreams reflect the moral nature of the dreamer. And if it is a bad dream there is a method to prevent its fulfillment. Further, if one does not recall a dream, there is also a method for dealing with it in the daily prayers and asking the Lord to make it a good dream. Concern about false dream interpreters is expressed. Dreams with a sexual meaning are represented symbolically. Precursors of many of our modern views of dreaming are present in the “Dream Book”.

The dream exists as an experience extended in time which can be captured in the dream report as an excellent approximation of the experience. Dreams can be adequately collected and reliably measured. Dream reports are both stable and variable across time. Dream reports show meaningful content differences in group and individual situations, where psychological differences are known to exist. Dreams and waking life are linked and dreams are responsive to the immediate emotional concern of the dreamer. The dream is sufficiently orderly that the search for its meaning is justified. Methods exist to establish the meaning of the dream experience working with the dreamer through associations or amplification. A method “Dream Translation” is described in which the meaning of the dream report is explored using the associations of the translator rather than the dreamers. The translation approach could be used by the clinician to assess whether the patient has improved and to establish the immediate current emotional concern of the patient at the initial contact or at points of block in the therapy. Although the dream report has the necessary characteristics to establish a meaning from it and a method exists to establish the meaning, this does not address the possible functional significance of dreaming. We have explored the dream function question in a monograph on the subject (Moffitt et al., The functions of dreaming. Albany: State University of New York Press, 1993).

A number of behavioral, social, biological, and cultural factors are associated with suicide. However, the ability to predict an imminent suicide attempt remains problematic. Prior studies indicate that the manifest dream content of depressed, non-suicidal patients differs from that of depressed, suicidal patients. The dream imagery of depressed, suicidal patients contains themes of death, dying, violence, and departure. The dream imagery of depressed, non-suicidal patients contains themes of rejection, helplessness, hopelessness, humiliation, failure, and loss. In the present study, the dream reports of 52 depressed patients were collected and rated for various themes. Patients were divided into three groups: Depressed and non-suicidal; Depressed, with suicidal ideation; Depressed, with suicidal ideation and/or attempt(s). Themes of death and/or dying, and to a lesser extent, themes of violence, injury, and/or murder occurred with greater frequency in the dream reports of depressed patients with suicidal ideation and/or attempts, than in the dream reports of depressed patients without suicidal ideation or behavior. These observations correspond with the prevailing psychodynamic explanation of suicide; namely, that it is a murderous attack on the self that is identified with hated internalized objects.

The dream exists as an experience extended in time which can be captured in the dream report as an excellent approximation of the experience. Dreams can be adequately collected and reliably measured. Dream reports are both stable and variable across time. Dream reports show meaningful content differences in group and individual situations where psychological differences are known to exist. Dreams and waking life are linked and dreams are responsive to the immediate emotional concern of the dreamer. The dream is sufficiently orderly that the search for its meaning is justified. Methods exist to establish the meaning of the dream experience working with dreamer through associations or amplification. A method “Dream Translation” is described in which the meaning of the dream report is explored using the associations of the translator rather than of the dreamers. The translation approach could be used by the clinician to assess whether the patient has improved and to establish the immediate current emotional concern of the patient at initial contact or at points of block in the therapy. Although the dream report has the necessary characteristics to establish a meaning from it; this does not address the possible functional significance of dreaming. I describe here my selective, mood regulatory function of sleep and dreaming. We have explored this question more thoroughly in a monograph on dream function (Moffitt et al., The functions of dreaming, Albany, State University of New York Press, 1993)

The potential shortage of psychiatrists over the next 5 - 10 years has focused attention on the need to recruit more IMGs to fill the needs rather than use nurse practitioners or physician assistants. IMGs make up about 1/3 of first year psychiatry residents. These individuals have been found to provide services to the poor, the elderly and the psychotic. The quality of their medical work has been found to be satisfactory. The training needs of these physicians require an understanding on the part of their teachers that they come from cultures with different values that we have. The extended families of these primarily Asian residents clash with our strong commitment to individualism. It leads to a We-self rather than our I-Self. This difference coupled with the stress of leaving to come to a new culture is a great stress. Their exposure to psychiatry has been limited. They request and need more interview demonstration and practice, ore feedback and examinations. They should have help in accent reduction. They should be exposed to the working of the hospital by sitting on departmental and hospital committees. The faculty should extend their social opportunities and work as mentors on joint projects. Courses on the history of American culture should be taught. Psychotherapy for them should be encouraged as well as teaching medical ethics. They must become the major educational concern for the department that they are in.

The values of American culture have changed and this has led since 1970 to a competition with traditional medical values. The social forces that have stirred a reconsideration of core medical values come from 1. economic, 2. institutional and 3. life style sources and is related to efforts by non-service providers to gain profits from medical services and the attempts by both governmental and non-governmental sources to control the cost of medical care. The actions of physicians will be assessed based on how well their behavior conforms to the ethical precepts of the profession. Being instructed in what the ethical precepts are and in how they were derived should contribute to establishing the expectations for what is expected of the physician. In order to delineate medical professionalism for the practitioner and the student we will explore: 1) the sources from which medical professionalism were derived, 2) the attempts to define medical professionalism, 3) conceptual approaches to medical professionalism, 4) the process of change in the scope of medical professionalism in the 20 th century, and 5) attempts to teach medical professionalism.

The initial and last manifest dream reports (MDRs) of 30 patients who had either successfully terminated, or continued to make satisfactory progress at an advanced stage of psychodynamic psychotherapy and combined psychotherapy/pharmacotherapy, were rated according to the following variables: Affect and Affect Valence; Affect Valence of Associations and Direction of Association Themes; Dream Narrative; Psychodynamic Formulation; Transference; and Dream Theme. Similar to previous studies, the initial MDRs contained more negative than positive affect. Conversely, the last MDRs contained more positive than negative affect. Associations to initial MDRs contained more negative affect; on the other hand, associations to last MDRs contained more positive affect. Direction of association themes were more negative in initial MDRs and more positive in last MDRs. Dream narratives were more negative in initial MDRs and more positive in last MDRs. Psychodynamic formulations were more negative in initial MDRs and more positive in last MDRs. Transference was more negative in initial MDRs and more positive in last MDRs. Relational and injury dream themes occurred more frequently than others in both initial and last MDRs. Initial MDRs contained more injury dream themes than last MDRs. The findings of this study demonstrate that there is a correlation between MDR variables and clinical improvement during treatment. The patients in this study were selected by MG, the treating therapist, on the basis of satisfactory progress. The MDRs of patients who failed to progress or did poorly were not discussed in this report. The findings, therefore, must be taken as preliminary and indicate the need for further research on manifest dreams during psychotherapy and combined psychotherapy/pharmacotherapy.

The authors collected the initial dreams of treatment from 63 patients and independently evaluated the manifest dream report (MDR). Variables included: Affect and Valence of Affect; Associations; Psychodynamic Theme; Psychodynamic Theme as Predictor of Core Psychodynamic Issues; Transference; Gender; Psychodynamic Theme Categories; Clinical Progress in relation to Psychodynamic Theme Categories and Transference. The initial MDR invariably contains Affect that is frequently Negative. The Psychodynamic Themes of MDRs are dependable predictors of Core Psychodynamic Issues that emerge during treatment. Transference is evident in a significant number of MDRs and is often Negative. Gender of the majority of MDRs is predictable. The most frequent Psychodynamic Themes of initial MDRs fall into Relational and Injury Categories. Relational and Injury Themes, as well as Positive and Negative Transference, are associated with clinical progress. This study confirms that the initial MDR of treatment provides a significant amount of clinical and predictive information.

While discussing the study of dreams, it is essential to be clear on what does and what does not constitute a dream. This is true for whatever one studies; the object of study must be delineated, or confusion and contradiction will be the inevitable consequence. This question was raised by the author in the symposium entitled ‘‘Dreams, dream content and their psychophysiologic correlates’’ at the First International Congress of the Association for the Psycho-physiological Study of Sleep in 1972. The importance of the definition of the term dream was rejected in the discussion but recognized by the chair as a recurrent theme that remained unresolved. More recently, under the direction of the editor of this issue, James Pagel, MD, an effort has been undertaken to provide a definition for dream, but it resulted in the conclusion that there was no single definition possible. After reviewing about 20 definitions of dreaming, it was concluded that definitions of dreaming have 3 characteristics: (1) an association with wake/sleep states, (2) recall, and (3) content. It is not apparent what is meant when one says one is studying the dream. There is little agreement on what is encompassed and what is excluded in the concept ‘‘the dream.’’ Nagera provides Freud’s most concise definition of the dream: ‘‘a dream is the (disguised) fulfillment of a (repressed)

International medical graduate (IMG) physicians are vital to the physician workforce in the United States, and over the past few decades have become especially important in the provision of psychiatric care in this country. IMG physicians have assumed crucial roles in caring for the underserved, and they have had greater opportunities in public psychiatry than in other areas of the field. In this chapter, key historical patterns in medical training in the United States are outlined. Medical training in India is described to illustrate issues experienced by medical graduates not born in the United States. It is suggested that IMG physicians are collaborators who bring wisdom, expertise, effort, and valuable traditions, and yet IMG physicians have often faced prejudice and obstacles to their professional advancement. It is hoped that IMG physicians in the future will be more respectfully embraced and will have robust professional opportunities in the health system of the United States and other economically established countries.

The heterogeneity in the cultural, linguistic, and medical educational background of international medical graduate (IMG) physicians in psychiatry poses significant challenges in assessing their training needs. This chapter addresses the complex determination of training needs and their recommended solutions. To that end, inter-group differences within the IMG physician spectrum are discussed, with an emphasis on the imperatives within each culture. The recent literature on training needs for IMG physicians was reviewed and the following needs were identified as most relevant (in descending order): communication and language skills, medical/pharmacologic knowledge, dealing with social isolation, other acculturation issues, adequacy of supervision, psychosocial/patient management focus, cultural diversity training, understanding the health care systems, understanding the hospital culture, and medical documentation. This chapter highlights the role of psychotherapy training as an acculturative experience, along with the importance of a program development paradigm for needs evaluation and training implementation. Specific recommendations will be listed to assist training directors and IMG physicians in this crucial training area.

Positive airway pressure (PAP) devices are used to treat patients with sleep related breathing disorders (SRBD) including obstructive sleep apnea (OSA). Currently, PAP devices come in three forms: (1) continuous positive airway pressure (CPAP), (2) bilevel positive airway pressure (BPAP), and (3) automatic self-adjusting positive airway pressure (APAP). After a patient is diagnosed with OSA, the current standard of practice involves performing full, attended polysomnography during which positive pressure is adjusted to determine optimal pressure for maintaining airway patency. This titration is used to find a fixed single pressure for subsequent nightly usage. A task force of the Standards of Practice Committee of the American Academy of Sleep Medicine reviewed the available literature. Based on this review, the Standards of Practice Committee developed these practice parameters as a guideline for using CPAP and BPAP appropriately (an earlier review and practice parameters for APAP was published in 2002). Major conclusions and current recommendations are as follows: 1) A diagnosis of OSA must be established by an acceptable method. 2) CPAP is effective for treating OSA. 3) Full-night, attended studies performed in the laboratory are the preferred approach for titration to determine optimal pressure; however, split-night, diagnostic-titration studies are usually adequate. 4) CPAP usage should be monitored objectively to help assure utilization. 5) Initial CPAP follow-up is recommended during the first few weeks to establish utilization pattern and provide remediation if needed. 6) Longer-term follow-up is recommended yearly or as needed to address mask, machine, or usage problems. 7) Heated humidification and a systematic educational program are recommended to improve CPAP utilization. 8) Some functional outcomes such as subjective sleepiness improve with positive pressure treatment in patients with OSA. 9) CPAP and BPAP therapy are safe; side effects and adverse events are mainly minor and reversible. 10) BPAP may be useful in treating some forms of restrictive lung disease or hypoventilation syndromes associated with hypercapnia.

Affect is central to our understanding of many processes, including dreams. The question has been raised as to whether it is the affective or narrative aspect of dreaming that is central to its development. The purpose of the study is to assess the frequency and valence of affect in the manifest content of dream reports of patients in analytic therapy and if affect is absent to assess the frequency and valence of affect in the associations to the dream reports without affect [MK1]. The presence and valence of affect was evaluated in the first and last manifest dream report of 24 patients who had completed psychoanalytic treatment. If no affect was found, the dream associations were examined for affect and valence. Affect was found in 58.3% of dream reports. The valence of affect in dream reports became more positive during the course of treatment from 19.2% in the first manifest dream report to 53.3% in the last. The associations to the dream reports without affect had affect 94.1% of the time. Affect was present in either the dream report or the associations to it 97.9% of the time. The positive change in affect is most likely the result of psychotherapeutic treatment, although the psychotropic medication 46% of the patients were on at the time of the last dream report and the passage of time may also be factors. The centrality of affect in dream formation and interpretation is supported if the view of the dream experience includes the associations to the dream report.

Characterization of excessive sleepiness is an important task for the sleep clinician, and assessment requires a thorough history and in many cases, objective assessment in the sleep laboratory. These practice parameters were developed to guide the sleep clinician on appropriate clinical use of the Multiple Sleep Latency Test (MSLT), and the Maintenance of Wakefulness Test (MWT). These recommendations replace those published in 1992 in a position paper produced by the American Sleep Disorders Association. A Task Force of content experts was appointed by the American Academy of Sleep Medicine to perform a comprehensive review of the scientific literature and grade the evidence regarding the clinical use of the MSLT and the MWT. Practice parameters were developed based on this review and in most cases evidence based methods were used to support recommendations. When data were insufficient or inconclusive, the collective opinion of experts was used to support recommendations. These recommendations were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. The MSLT is indicated as part of the evaluation of patients with suspected narcolepsy and may be useful in the evaluation of patients with suspected idiopathic hypersomnia. The MSLT is not routinely indicated in the initial evaluation and diagnosis of obstructive sleep apnea syndrome, or in assessment of change following treatment with nasal continuous positive airway pressure (CPAP). The MSLT is not routinely indicated for evaluation of sleepiness in medical and neurological disorders (other than narcolepsy), insomnia, or circadian rhythm disorders. The MWT may be indicated in assessment of individuals in whom the inability to remain awake constitutes a safety issue, or in patients with narcolepsy or idiopathic hypersomnia to assess response to treatment with medications. There is little evidence linking mean sleep latency on the MWT with risk of accidents in real world circumstances. For this reason, the sleep clinician should not rely solely on mean sleep latency as a single indicator of impairment or risk for accidents, but should also rely on clinical judgment. Assessment should involve integration of findings from the clinical history, compliance with treatment, and, in some cases, objective testing using the MWT. These practice parameters also include recommendations for the MSLT and MWT protocols, a discussion of the normative data available for both tests, and a description of issues that need further study.

This article describes several studies that examine the relationship between the manifest content of selected dreams reported by patients and their clinical progress during psychoanalytic and psychodynamically oriented treatment. There are a number of elements that dreaming and psychotherapy have in common: affect regulation; conflict resolution; problem-solving; self-awareness; mastery and adaptation. Four different studies examined the relationship between the manifest content of selected dreams and clinical progress during treatment. In each study, the ratings of manifest content and clinical progress by independent observers were rank-ordered and compared. In three of the four studies there was a significant correlation between the rankings of manifest content and the rankings of clinical progress. This finding suggests that the manifest content of dreams can be used as an independent variable to assess clinical progress during psychoanalytic and psychodynamically oriented treatment.

International medical graduates (IMGs) currently make up about 25% of physicians practicing in the US. IMGs and U.S. medical school graduates (USMGs) have a great deal in common. The quality of the medical skills of more recent IMGs has improved as measured by the scores they obtain on the clinical skills assessment examination and has begun to approach that of USMGs, 89% compared to 80% (Whelan, Gary, Kostis, Boulet, & Hallock, 2002). In clinical practice, IMGs provide services comparable in effectiveness to USMGs (Norcini et al., 2010). However, the specific educational needs of IMGs must be recognized by training programs. IMGs face a series of concurrent issues having to do with immigration (Akhtar, 1999), which may result in loneliness and social isolation, a decrease in social status with diminishment of self-esteem, concerns related to the family left behind, and the impact of migration on the family they may have brought with them. Some IMGs are also concerned about the vagaries of their visa status. Group and individual resident social interaction with faculty is enormously valuable in reducing the sense of isolation. The central role of language and culture lies at the heart of the challenges that IMGs face in psychiatric training in the American context, particularly in learning psychological theory and therapy. Without mastery of the dominant language, both formal and informal (i.e., slang and idioms), IMGs may have difficulty understanding and being understood by their patients and teachers. In some settings, IMG psychiatric residents have asked for more intensive training including more demonstrations of interviewing, opportunities for oral presentations, and examinations and feedback. Fully 41% of psychiatric residents in the US are from Asia (Gangure, 2002) and their values and conceptions of personhood may be different from those

Dream interpretative efforts appear unconstrained by methodological standards. An examination of the re-interpretations of Freud's dream of “Irma's Injection,” the dream specimen of psychoanalysis, illustrates the undisciplined nature of dream interpretation. Reading “in” from presumed day residues or infantile experiences rather than “out” from the dream report per se lies at the heart of the problem. The failure to spell out inferences, to link inferences to the dream text, to explain and maintain the relationships in the dream report, and to offer a substitute text for the entire dream text all contribute to the inadequacies of dream interpreatation.

Background Psychiatric patients often have residual intractable insomnia as a serious problem. Method Forty-eight psychiatrically ill patients (DSM-IV diagnoses) who had failed to respond to medicinal treatment for chronic insomnia were referred for and completed behavioral therapy as an adjunct to the pharmacologic treatment of their insomnia. The behavioral treatments included structured sleep hygiene, progressive muscle relaxation, stimulus control, and sleep restriction. The treatment program was accomplished in 6 sessions over 2 months. Follow-up evaluations were completed at 2, 6, and 12 months from the beginning of the treatment program. The outcome of the treatment program was evaluated in terms of the change in (1) self-reported specific sleep parameters, (2) self-ratings of sleep-related day-time state, (3) self-rating of quality of sleep, (4) the use of sleep medication, and (5) the therapist's global rating of improvement. Results There was a statistically significant change from the baseline in all self-reported specific sleep parameters after 2 months that was sustained after 6 and 12 months. Sleep-related characteristics of daytime state showed statistically significant changes after 2 and 6 months that were maintained after 12 months. Sleep quality had a statistically significant change after 2 months, continued to improve statistically after 6 months, and was maximum after 12 months. Over half the patients (52.7%; 20 of 38) either reduced their sleep medication by half or stopped it completely. The therapist's global rating showed an improvement in 29.2% (N = 14) of patients after 2 months, 56.2% (N = 27) after 6 months, and 68.7% (N = 33) after 12 months. Conclusion The use of concomitant behavioral and pharmacologic treatment of chronic insomnia in psychiatrically ill patients results in improving sleep and sleep-related state and reduces the risk of return of insomnia for 10 months after finishing active treatment.

Although subjective evidence suggests that patients with burns are deprived of sleep, previous clinical studies have been limited to observational data and have not to date included electroencephalographic or polysomnographic recordings. The purpose of this study was to characterize the sleep pattern of patients suffering from thermal injury. Biweekly 24-hour polysomnographic measurements (electromyography, electrooculography, and electroencephalography) were performed with 12 leads. This measuring permitted continuous recording of intrinsic electrical activity in skeletal muscles via chin electrodes, eye movement via outer canthal electrodes, and brain wave activity with the other bipolar electrodes. Determinations were obtained on 11 patients with thermal injuries for a total of 43 24-hour periods. The patients had a mean age of 8.31 +/- 1.5 years (range 1.4 to 16 years), a mean total body surface area burn of 55.1% +/- 16.5% (range 17.5% to 90.5%), and a mean full-thickness burn of 48.5% +/- 8.1% (range 10.5% to 90.5%). Although mean total sleep time was seemingly adequate (625.1 +/- 31.6 min/patient/24 hrs), large aberrations in sleep stage distribution were noted. Significant decreases in stage 3 + 4 and in rapid eye movement (deep sleep) and increases in stages 1 and 2 (light sleep) were noted, suggesting a cycling back to stages 1 or 2 after disruption of sleep. Overall, in 43 runs 40% of the subjects were completely lacking stage 3 + 4, and 19% were missing rapid eye movement during an entire 24-hour run.(ABSTRACT TRUNCATED AT 250 WORDS)