Personality Disorder Chiefly Presenting with Chronic Dream Reality Confusion: A Case Report

The phenomenon of having difficulty differentiating experiences in sleep and wakefulness is called dream-reality confusion (DRC) and can cause significant functional impairment along with diagnostic challenges. Here, we present the first documented case of DRC from India, which for several years since early adolescence masqueraded as psychotic symptoms leading to poor treatment response. The case also underscores the importance of detailed history-taking and descriptive psychopathology in patients showing treatment resistance. Here, we also reiterate the commonly overlooked symptom of sleep disturbances in patients with a borderline personality trajectory with significant childhood trauma. Individuals with Cluster B personality traits are likely to experience DRC more, compared with normal individuals, due to their excessive dissociative tendencies, negative dream content, and fantasy proneness. Here, we describe the stepwise approach to reconceptualization and management of this patient, which led to a better outcome. The impact of childhood trauma on the sleep-wake cycle is further discussed. We also emphasize the common phenotypes seen in Cluster B personality, major mood disorders, and complex posttraumatic stress disorder that may cause diagnostic pitfalls.