Use of Dreams by Psychopharmacologists

Mr. A was a 24-year-old man with severe anorexia nervosa who had no improvement after 10 hospitalizations in programs for the treatment of eating disorders and the efforts of a number of psychopharmacologists. He had had many types of pharmacologic intervention, and when I first saw him, he was taking 40 mg/day of fluoxetine because his anorexia nervosa was complicated by severe obsessive-compulsive neurosis. However, I saw no depressive affect in Mr. A. On the contrary, the most recent dream he could recall was that he was in bed with a “very pretty girl.” That did not sound like a depressive dream to me but, rather, a dream that indicated a euphoric mood. His appearance at consultation was also euphoric. There was no sexual activity in the dream; he had never experienced any sexual contact with a partner. However, he was very close to his mother, who was very sympathetic and indulgent, in contrast to his father, who was harsh and critical.

I reasoned that the anorexia nervosa might have been a self-destructive effort to counteract his “up” mood in the same way that self-defeating behavior on the part of patients with mania can be seen as a corrective attempt and often interpreted as punishment. Accordingly, I prescribed olanzapine, 10 mg/day, primarily as a depressive drug, although I was obviously taking advantage of its propensity for increasing Mr. A’s appetite. Within 3 days, for the first time in years, Mr. A began eating eagerly and with appetite. I gradually increased his dose of olanzapine to 20 mg/day, wondering whether I might not be pressing too hard. However, Mr. A came in delighted with his change in status and reported his weight gain to me daily.

We had been discussing Mr. A’s difficulty in finding appropriate women to date. One day he reported having a dream in which he was with two girls who told him that they heard him “farting,” that he was “shitty,” and that “they would not have anything to do” with him. He started to weep as he described the dream. Clearly, this was a change in affect and indicated a switch in mood to the depressive side, which I had anticipated. I reduced his dose of olanzapine to 15 mg/day and added 15/mg day of mirtazapine. He then recovered completely.