“Dream Insertion”: A Case Report of a Novel Psychotic Symptom in a Male Inpatient With Treatment Resistant Schizophrenia

Background: Individuals with schizophrenia appear to experience differences in dreaming compared to control populations-the small amounts of research that does exist demonstrates abnormalities such as simpler dreams that are more bizarre and with greater negative content than those of controls. Dream-related psychopathology remains insufficiently described however-particularly experiences in which patients believe their dreams are externally generated or controlled. Such phenomena extend classically described first rank symptoms-such as thought insertion and passivity phenomena-into the domain of sleep mentation. This case presents a patient who describes a delusional belief that an external agent can directly infiltrate his nocturnal state to insert dreams themselves. Case Presentation: A 34-year-old male patient with schizophrenia was admitted to the inpatient unit for commencement of clozapine following poor response to multiple antipsychotic agents. While admitted, he described a new delusional belief that a Central Intelligence Agency (CIA) agent was infiltrating his dreams at night and inserting externally created dreams. This symptom did not respond to ongoing clozapine uptitration and community follow-up suggests an ongoing limited response. Conclusions: This patient describes a novel symptom not previously described in the literature to the best of the authors knowledge and neither appears consistent with other commonly described sleep related phenomenon nor first rank symptoms. As such, we use the term "dream insertion" to describe the phenomenon noted in the case report and suggest an expanded inquiry into the oneiric effects of schizophrenia to enhance understanding and management of such symptoms.