Trauma Dreams in a Pre-Schooler Scaled as a Toddler: A Clinical Illustration

Roy C. Grzesiak, Ph.D. & Gary S. Stocco, M.P.H.


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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