Moving beyond the nightmares

FRANK HEYNICK SPECIAL TO THE JEWISH BULLETIN

The attacks of Sept.11 resulted in three to four thousand deaths, but few injuries - at least of the physical kind. Psychological traumas are another matter. Of the 20,000 or so people at the World Trade Centre and the Pentagon who were able to flee to safety, it is estimated that half have been plagued in varying degrees by nightmares in which the terror is relived - in extreme cases, night after night, for months on end. What do specialists know about such recurring post-traumatic nightmares, and how can they be treated?

Sigmund Freud, the Jewish Viennese psychiatrist, formulated the most influential dream theory of all time at the dawn of the 20th century. He hypothesized that dreams were wish-fulfilments, particularly relating to the gratification of instinctual needs. Occasionally this is obvious, as with dream of eating, drinking or sex. But Freud maintained that most dream wishes were of a taboo kind, particularly involving erotic oedipal fantasies stemming from early childhood which are banned from the adult's consciousness but which live on in the unconscious. At night, these find expression in camouflaged form by means of dream symbolism. An open representation would be too outrageous for our conscious to accept, even in sleep.

With this theory, Freud felt he had also explained the existence of bad dreams and nightmares. For, despite symbolism and camouflage, there can be emotion-laden conflicts between the wishes emerging from the unconscious and the forces trying to repress them.

But what about traumatic dreams? In the wake of the First World War, Freud was confronted with many cases of shell-shocked veterans who relived at night, again and again, the most traumatic experiences in the trenches. How were these to be explained?

Here, it's important to distinguish between the content and the function of dreams in Freud's theory. Freud saw dreams as serving as guardians of sleep. By giving hallucinatory gratification in symbolic form to the instinctual needs pressing for expression from the unconscious, they usually allow the sleeper to keep on sleeping. But dreams may protect sleep in other ways as well. The ringing of a telephone, the clanging of church bells, or the pain of a toothache can be incorporated into the dream rather than wakening the sleeper. Similarly, with the trauma that lives on in the psyche of the veterans and bursts forth at night. The dream does its best to tame it, though this is often unsuccessful so the sleeper is shocked into awakening.

Freud's dream theory steadily increased in influence among psychiatrists in the first half of the 20th century, but then it began to wane - in part due to new discoveries in laboratories about the physiology of sleeping and dreaming. But among many psychiatrists, the general Freudian concept remained influential - that the mind is made up of various conscious and unconscious agencies that are often, to a greater or less degree, in conflict, in both wakefulness and sleep.

The most prominent theoretician and researcher in the field of post-traumatic nightmares in the neo- and post-Freudian era is Ernest Hartmann, professor of psychiatry at the Tufts University School of Medicine in Boston. Hartmann studied Vietnam veterans who had experienced heavy combat in which fellow platoon members perished, and who were subsequently visited by post-traumatic nightmares. The results of this research apply as well to survivors of accidents, natural catastrophes and homicidal attacks, including terrorist acts.

Hartmann distinguished between post-traumatic nightmares, which are acute and more or less normal, and those which are chronic and pathological. The acute variety appears soon after the traumatic event. The first few times they may be virtual replays of the incident. But, in the course of time, they get mixed with other themes, especially new elements from daily life and old memories, including those of childhood. This is a good sign, for the post-traumatic nightmare increasingly comes to resemble common nightmares and eventually normal dreams.

Chronic-pathological nightmares, by contrast, may first begin a few weeks after the traumatic event or even quite a bit later (sometimes in the wake of a new emotional event, such as the breakup of a relationship). Characteristic of these dreams - which may plague the sleeper for years - is that they remain replays of the traumatic incident and don't evolve. Survivors who lost someone in the traumatic event with whom they closely identified are especially susceptible.

Hartmann views the chronic nightmare as a failure of the normal coping process. He recommends that survivors be encouraged to talk about their experiences in the days and weeks after the traumatic event - with a view towards letting their acute nightmare evolve into regular dreams. The chronic variety of the post-traumatic nightmare is far more refractory to treatment. Among the techniques that may be applied is lucid dreaming, in which the patient is trained to become actively conscious during the nightmare and able to influence its course.

A hundred years after Freud presented his theory, so much is still unknown about how or why anxiety dreams and recurrent post-traumatic nightmares come into being. Research into the dreams of the survivors of the horrific acts of Sept. 11 may yield new insights.

Dr. Frank Heynick's new book, Jews and Medicine: An Epic Saga, is published by KTAV.

^TOP