| Burn
injuries, be they accidental or intentional, are
traumatic. Posttraumatic stress disorders (PTSD)
are well documented sequelae of many burn injuries
(Yu & Dimsdale, 1999). Equally well-documented
is the observation that medical/surgical treatment
of burns is at least, if not more, traumatic than
the initial burn itself (McFarlane & Girolamo,
1996). One of the most common symptoms of PTSD is
the recurrent nightmare. Clinical research indicates
that sleep disturbances, in particular, night terrors
and nightmares, are common following burns. According
to Stoddard, Chedekel & Shakun (1996): "A
progressive pattern of post-burn nightmares and
dreams is commonly seen in burned children. The
progression is from the more severe, at times organically-related,
sleep disturbances such as flashbacks and deliria
to nightmares and then to dreams that may facilitate
and reflect the psychological adaptation to changes
in body image."
Initial nightmares appear to follow a pattern in
which the dreams represent a realistic revisiting
of the burn trauma and its treatment. Over time,
however, the dreams change and often transform into
more metaphorical and symbolic representations of
burn-related events. The following case represents
an illustration of trauma dreams although they do
not progress all the way to adaptation to a new
body image. The purpose is simply to provide an
illustration of trauma dreamwork as it reflects
experiences that are forever embedded in memory.
The
Case
B.B. was four and a half years of age at the time
of psychological consultation. She was seen for
consultation at the request of her attorney to document
pain, suffering and to predict what, if any, psychological
difficulties she might have in the future. Although
a great deal of information was reviewed with regard
to her treatment and rehabilitation as well as from
my interviews with both parents and B.B., I will
condense the material to include only the salient
items related to her fears, fantasies and dreams.
B.B. was 15 months old when she accidentally sustained
1st, 2nd and 3rd degree scald injuries over 17%
of her body. Areas involved included chest, neck,
abdomen, arms and hands. Inpatient rehabilitation
lasted for 23 days; 22 of which were on the Burn
Intensive Care Unit (BICU).
The
Evaluation Process
B.B.'s father was interviewed first. When asked
to tell me about his daughter's burn injury, he
provided the following narrative. He, his wife and
daughter (B.B.) were visiting his wife's father
in the hospital. They decided to take a coffee break
and proceeded to the hospital cafeteria. The cafeteria
set-up was such that you waited in line, paid for
your coffee and then were given coffee cups that
you filled at an adjacent counter. He had been carrying
his daughter but set her down so that he could get
out his wallet. B.B.'s mother was already at the
serving counter with the cups. When set down, B.B.
immediately took off in the direction of her mother.
The next thing he recalls is hearing his daughter
screaming. She apparently grabbed at an already
poured cup of coffee on the lower counter and, holding
it with both hands, pulled it toward her spilling
it over herself. B.B.'s father immediately grabbed
her and placed her on an adjacent counter. He quickly
removed her clothing that was steaming from the
hot liquid. B.B. continued to scream. They ran with
her to the emergency room where she was given initial
treatment and then transferred to a local burn center.
He reported that "she was screaming so loud
because her skin was bubbling off." The father's
observations of his daughter both in hospital and
upon returning home was that she had a very difficult
time of it. Prior to the burn injury, she was a
precocious talker, walking a lot and a big eater.
After the injury, she had what appeared to be nightmares
and would not talk, walk or eat.
Upon returning home, B.B. continued to awaken frequently
at night, often screaming. The inference is that
she was experiencing either night terrors or nightmares.
He also remembered that she became very anxious
when around running water. According to the father,
B.B. began walking and talking toward the end of
her hospital stay. He expressed his concern that
B.B. does not yet know that "she is different"
and wonders how she will react when she becomes
more aware of her injuries. He did note that when
she is asked about her scars she states that she
does not know how she got them. The father explained
that the burn injury had made him a much more aware
and vigilant parent. He stated that he almost felt
paranoid in that he tended to be extremely overprotective,
ever vigilant, and anticipated the worse case scenarios
in terms of injuries.
Next the mother was interviewed and she told essentially
the same story regarding the accident. She remembered
watching her daughter in hospital and observed that
she just laid there and did not want to walk, talk,
eat or, in any way, interact with her mother. She
stated that she did not have a good time frame for
how long B.B.'s more regressive symptoms lasted
but noted that she had begun walking toward the
end of her hospital stay but had not resumed her
typical pattern of eating until she had been home
for approximately one month. When asked to characterize
her daughter's behavior now, she replied: "She's
a nervous wreck of a child, very hyperactive."
She then went on to offer rather insightfully: "I
project that." She explained that, similar
to her
husband, she had many fears of her daughter being
re-injured. Parenthetically, the mother reported
that B.B. talks about her dreams every morning,
often reporting them in great detail. The mother
believes that her daughter no longer has nightmares,
just "hyperactivity."
Finally, B.B. was interviewed. It is important to
note that she was given the option of having either
or both parents present during the interview but
she opted to do it herself. I will not present my
entire report but will only abstract what I think
germane to this presentation. It is just a lucky
circumstance that I happen to have in my waiting
room a poster print from the New School for Social
Research that depicts a cartoon version of three
characters from the Wizard of Oz; notably the cowardly
lion, the tin man, and the straw man. The caption
reads: "For a heart, courage or a brain."
B.B. began talking even before she was seated stating
that the Wizard of Oz was her favorite movie and
that she had her own copy of the film. She went
on with great enthusiasm and effervescence about
the plot and demanded to know why my picture did
not include Dorothy and Toto. She certainly has
regained her language skills. In addition to being
very verbal, she was quite expressive with her hands,
making many gestures as she talked. She does display
signs of a mild hyperactivity as is frequently seen
in individuals after trauma.
Using an open-ended interview style, it soon became
apparent that, although B.B. has no conscious or
accessible memories of her trauma, its effects lie
just below the surface of consciousness and will
no doubt break through one day. When this happens,
I would anticipate either a reactivation of PTSD-like
symptoms or a generalized anxiety. The basis for
this speculation is to be found in the following
clinical material. When asked what she thought she
might like to do when she grows up, she replied:
"I want to be a fire girl when I grow up."
When asked how she knew about fire girls, she stated
that she had seen them on TV and she went on to
elaborate about a "little kid trapped in a
building with fire, the little kid got killed. A
fire girl would have saved the little kid."
Asked about good and bad dreams, she replied that
she has both good and bad dreams about the Wizard
of Oz. Asked specifically about bad dreams, she
replied that she has dreams in which "bad guys
tie me up." She went on to spontaneously elaborate
"the bad guys are the doctors in the hospital."
When asked about other scary dreams, she replied
that she had dreams about "witches, bad guys
and hospitals that try to tie me." Remember
that B.B. is being interviewed by herself at this
juncture. At this point it seemed that I had uncovered
enough conscious and unconscious signs of trauma
to offer that traumatic sequelae continued to have
both an overt and covert role in her development
and I decided to end the interview. Almost as an
afterthought, remembering what her father had said
about running water, I asked rather casually: "B.B.,
are you afraid of running water?" At that point
she looked me dead in the eye and stated rather
emphatically: "I think I want my mommy in the
room now."
Conclusions
Although I omitted much of my report from this presentation,
it appears clear that trauma dreams continue to
be a significant aspect of her dreamlife. Many of
these "bad dreams" involve mental representations
that are hardly symbolically veiled indicators of
what she has experienced. Her many references to
fire, water and being "tied up" suggest
that the anxious fears related to her burn trauma,
be they repressed or dissociated, are very near
awareness. What remains unclear is whether her veiled
trauma dreams represent a gradual transformation
of manifest content as Stoddard, Chedekel and Shakun
(1996) suggest, or rather a barely disguised representation
of the burn trauma that reflects her developmental
level at the time of injury.
References
McFarlane, A. C., & Girolamo, G. (1996). The
nature of traumatic stressors and the epidemiology
of posttraumatic reactions. In B. A. van der Kolk,
A. C. McFarlane, and L.
Weisaeth (Eds.), Traumatic stress: The effects
of overwhelming experience on mind, body, and
society. New York: Guilford, pp. 129-154.
Stoddard, F. J., Chedekel, D. S., & Shakun,
L. (1996). Dreams and nightmares of burned children.
In D. Barrett (Ed.), Trauma and dreams. Cambridge:
Harvard University Press, pp. 25-45.
Yu, B., and Dimsdale, J. E. (1999). Posttraumatic
stress disorder in patients with burn injuries.
Journal of Burn Care & Rehabilitation, Sept/Oct.,
426-433.
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