User:Brett Lukshis/sandbox

Charcot-Wibrand Syndrome (CWS) describes dream loss following focal brain damage specifically characterized by visual agnosia and loss of ability to revisualize images. The name of this condition dates back to the case study work of Jean-Martin Charcot and Hermann Wilbrand, and was first described by Otto Potzl as “mind blindness with disturbance of optic imagination” MacDonald Critchley, former president of the World Federation of Neurology, summarizes CWS as “a patient loses the power to conjure up visual images or memories, and furthermore, ceases to dream during his sleeping hours”. This condition is quite rare and further study could help illustrate the brain pathway for dream formation.

Jean-Martin Charcot
In 1883 Jean-Martin Charcot  encountered a patient who was most likely suffering from posterior cerebral artery thrombosis (not confirmed with autopsy) and lost the ability to consciously reproduce images from his dreams while awake. While this patient still reported dreams of words, the loss of imagery, termed visual irreminiscence, became the center of Charcot's case study. His resulting contribution to the formulation of the syndrome lies on the lack of ability to re-visualize dream imagery and does not imply their complete absence but a general state of visual amnesia.

Hermann Wilbrand
In 1887 Hermann Wilbrand was studying an elderly female subject with bilateral posterior cerebral artery thrombosis. This subject displayed a complete inability to dream coupled with an inability to recognize familiar places, a condition known in modern times as topographic agnosia. Additionally a condition known as prosopagnosia, or the inability to recognize familiar faces was also noted in the patient. Wilbrand's contribution revolves around complete dream loss with agnosias as possible side conditions.

Traditional Classification
Combing early studies, the traditional symptoms of CWS centered around visual irreminiscence, prosopagnosia, and topographic agnsoia. However due to the different circumstances of the patients, this syndrome bridged the entire loss of dreaming whether it be due to the isolated inability of the brain to produce images while asleep as Charcot had dictated, or the complete loss of dreaming all together as with Wilbrand. This has lead to the terming of Charcot and Wilbrand variants, which corresponded to either loss of dream imagery or the inability to dream outright often coupled with agnosia.

Modern Classification
There is new focus on the type of injury and analysis of REM sleep pertaining to CWS. A more current definition lists CWS as “the association of loss of the ability to conjure up visual images or memories and the loss of dreaming”. A 2004 case-evaluation of a 74 year-old woman who had experienced an acute, bilateral occipital artery infarction which rendered her dreamless for a 3 month period was to perform polysomnography testing in combination with patient dream reporting to determine both her sleep architecture and subsequent dream recollection. Such techniques allow for associations between the physiological timetable of dreaming during REM sleep and the patient's ability to revisualize to be compared closely.

Physiological Causes
The loss of visual imagery during sleep can be the outcome of a variety of pathologies. Specifically pathologies of acute onset such as thrombosis, hemorrhage, trauma, and carbon monoxide poisoning in particular have been indicated as possible motivators for CWS. Additionally patient's with abnormal cell growth or neoplasm, Alzheimer’s disease, Dysgenesis of the corpus callosum, and Turner’s syndrome have also described having CWS. In terms of localization, the lesion is most often localized to the lateral occipitotemporal or mesial occipitotemporal regions, and typically appears bilaterally, however the exact localization has not come to light and can best be summarized as "a lesion in an acute phase affecting the posterior regions”.

In patients with complete loss or suppression of dreaming there is typically an association with focal, acute-onset cerebral lesions like hemorrhage, thrombosis, or trauma. Early attempts to locate the lesion site responsible for the cessation of dreaming on a universal scale lead to the parietal lobe with no lateralization bias, and unilateral lesions of either hemisphere commonplace. Recent case studies of dream loss have found evidence suggesting that damage to the parietal is not necessary for CWS. Additionally in some of the cases of parietal lobe lesions, the lesion continued into the occipitotemporal regions, further blurring the localization of global dream loss. In almost all cases, dreaming returned within 12 months and therefore implies diaschetic effects that would further complicate localization.

Relation to REM Sleep
Rapid eye movement sleep or REM sleep is traditionally when the majority of dream activity has been documented. Following the Activation Synthesis Hypothesis, sensory systems such as the visual systems (activated by PGO waves activity), and vestibular systems are activated. Feedback from the nerves controlling movement influence dream experience despite the inhibition of motor output following brain stem muscle atonia systems, and mismatch of this data might create specific dream experiences such as floating or flying. Emotional behavior and memory formation centers like the amygdala and hippocampus are reactivated during sleep and are believe to generate the emotional content of dreams. In patients with CWS, REM sleep is not necessarily impaired but the sensory systems responsible are most likely damaged from lesions and do not contribute to the synthesis of dreams. In particular damage to the occipitotemporal may alter the activation normally produced by PGO waves leading to an absence of dreams. Additionally under activation due to lesions may produce the lack of revisualization experienced by patients.

Detection Methods
While scientific dream analysis has been avoided in the past given the difficulty in quantifying and qualifying the experience of patients, emerging technology has made it easier to chart brain activity and target physiological areas responsible for dream function.

Polysomnography
A Polysomnography test(PSG) records the biophysical changes during sleep through monitoring the brain (Electroencephalography), eye movement (Electrooculography), heart rhythm (Electrocardiogram), and muscle activity (Electromyography). Typically a PSG requires a minimum of 12 channels and 22 wire attachments and produces a “score” or report. Sleep stages are identifiable through comparison of the EEG, EOG and EMG channels with stages 1 and 2 being light sleep, 3 being slow wave sleep and 4 being REM sleep. Additionally a PSG can reveal “arousals” or sudden shifts in brain wave activity. . Analyzing the resulting amount of REM sleep in combination with patient reported dream experience has been the method of choice for recent dream studies. In particular researchers can wake the patient mid-REM sleep and ask for dream experience, which in normal patients would enhance their recollection and dream count. Absence of dream experience suggests the presence of CWS and this test method can also help to illustrate whether the patient is suffering from an inability to revisualize or global dream loss.

fMRI
Functional magnetic resonance imaging or functional MRI (fMRI) is the specific MRI procedure associated with measuring brain activity. It does so by detecting changes in blood flow (hemodynamic response) related to the energy utilization by the brain using a specific blood-oxygen-level-dependant contrast. Recently fMRI has come to the forefront of dream research because it does not require the use of dyes or isotopes and allows for brain blood flow and related activity to be monitored during sleep. Specifically durring dreaming studies have reported increase blood flow/oxygen utilization in a network consisting of the pontine tegmentum, thalamus,amygdala, basal ganglia and anterior cingulate and occipital cortex. Specifically in CWS activation of the occipital cortex is of great interest and it can monitored through fMRI and combined with patient dream reporting to determine dream formation. Additionally during sleep there is a significant decrease in the activity of the prefrontal cortex which likely accounts for the decrease in time perception, insight, and remembrance of dreams. This can be analyzed in patients to help better differentiate between global dream loss and a lack of revisualization. The specific mechanism for deactivation of the prefrontal cortex is unclear due to cholinergic projections not only reaching this cortex but a variety of other cortical areas.

Dream Journals
Dream journals are an effective tool for patients to quantify their dreaming experience. By recording the frequency of dreams and the level of detail, dream journals can be combined with other physiological data to arrive at the best picture of dream synthesis. Additionally dream journal data can help to organize the bizarre features of existing dreams such as discontinuities, incongruities, and uncertainties which are useful to the dreamer.

Medical Significance
Until recently CWS was considered rare and is now recognized as a more common acute phase of focal brain damage. While CWS patients do not suffer from any serious effects, dreaming does provide some relatively important functions to the human mind. It is hypothesized that a Reverse Learning Mechanism occurs while dreaming that facilitate the unlearning of unfavorable pathways to the organism. Complete failure of such as system has been postulated to lead to a state of almost perpetual obsession coupled with hallucinatory associations. In addition it has been postulated that dreams account for emotional preservation with the emotions one feels during nightmares and joyful dreams solidifying and checking the successful ability of the organism to express them. Lastly Freudian Dream Content Analysis, although lacking in credibility in the modern scientific community, once held that dreams hold the key to understanding and emancipating the subconscious.

Refining the Dream Pathway
Since CWS patients have limited to nonexistent symptoms other than dream loss, studying these cases can give great insight into the physiological basis of dreams. The regions of damage and condition affecting them can be compared to the severity of the dream-loss to help create a map of importance when it comes to synthesizing and remembering dream images.

Post Traumatic Stress Disorder
The diagnosis criteria for PTSD involves hyper-arousal, disturbed sleeping, and traumatic nightmares with numerous REM-related sub-symptoms. CWS on the other hand marks little to no dreaming, decreased REM dream linkage, and visual irreminiscence. The specific physiological changes that take place in CWS patients might help to isolate the dream formation pathways that are hyperactive in PTSD patients.

Depression
Major depression which is believed to be modified by acetylcholine systems, is a functional disorder pertaining to the same neuronal structures that regulate dreaming. CWS may unlock the means to understand the stimulation of these structures better leading to enhanced treatment for sufferers of chronic depression.