| 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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