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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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