CPA Bulletin: February 2003 Clinical Report - Treatment of Nightmares by Abreaction

Abstract: This paper describes the successful treatment of a 46-year-old man with a 30-year history of horrific nightmares. The pathological dreams began before his 16th birthday, shortly after he had witnessed his brother’s suicide. Orthodox psychiatric treatment, including electroconvulsive therapy (ECT), had failed to bring about any improvement. Abreaction was induced by the oral administration of sodium amytal and methylphenidate. The patient was interviewed repeatedly while he was under the influence of these drugs. After 27 sessions, the nightmares ceased, and normal sleep was restored. Six months after his discharge from the hospital, there had been no recurrence. Drug-induced abreaction is a valuable technique in particular cases. By using the oral route, its hazards and inconveniences can be eliminated.

Résumé : Le traitement des cauchemars par abréaction Cet article décrit le traitement réussi d’un homme de 46 ans ayant des antécédents de 30-ans d’affreux cauchemars. Les rêves pathologiques ont débuté avant son 16e anniversaire de naissance, peu après qu’il a été témoin du suicide de son frère. Le traitement psychiatrique orthodoxe, incluant les électrochocs, n’avait apporté aucune amélioration. L’abréaction a été provoquée par l’administration orale de sodium amytal et de méthylphénidate. Le patient a été interviewé à maintes reprises tandis qu’il était sous l’effet de ces médicaments. Après 27 séances, les cauchemars ont cessé et le sommeil normal est revenu. Six mois après son congé de l’hôpital, il n’y avait pas eu de récurrence. L’abréaction provoquée par des médicaments est une technique valable dans des cas particuliers. En utilisant la voie orale, les dangers et les inconvénients qu’elle comporte peuvent être écartés.

Key Words: Posttraumatic stress disorder, nightmares, abreaction, amytal interviews

The condition of many victims of shell shock after the First World War showed that the sequelae of extreme psychological trauma sometimes included recurrent horrific dreams (1). In the case we are describing the precipitating events occurred in civilian life, but the symptoms were of equivalent severity and severely disabling. Showing no tendency to resolve spontaneously, these symptoms persisted for 30 years with undiminished malignancy and only brief remissions. Because conventional methods failed to produce any improvement, the disorder was treated successfully with serial abreactions, a form of therapy that is currently out of fashion and is considered by some authorities to be obsolete (2).

The patient, a 46-year-old unemployed addiction counsellor, informed us on admission that the persistence of his nightmares and his failure to gain any relief from previous psychiatric interventions had brought him to the verge of suicide. The records showed that he had been hospitalized on eight occasions, always with the same complaint, and that his nocturnal distress had not responded to antidepressants, neuroleptics, anxiolytics, soporifics or ECT.

The patient’s nightmares began before his 16th birthday when, within a period of six months, he had witnessed three horrifying incidents. His older brother, who had a criminal record and was depressed by the drowning death of a friend, blew his head off with a rifle while the patient was standing in front of him. On the day after his brother’s funeral, the patient saw a transport truck run over and crush a drunken pregnant woman. Some five months later, he and his friend heard a scream while walking in town at night. Entering the house from which it came, they were confronted with the remains of three young children who had been killed by a sexual predator.

In his dreams, the patient saw a faceless figure in black who held the controls of a slide projector; he referred to him as the “clicker man.” Night after night, he had to watch reproductions of the three incidents and to listen to the associated sounds. From time to time, the clicker man would say, “I don’t think you are getting it.” The projector would click again, and he would see the slides in what seemed to be slow motion.

In the final phase of the nightmare, which he described as a night terror, he seemed to be wrestling with the clicker man and struggling to wake up. At such times, he made frightening feral noises, which had been heard by the nursing staff during his periods of hospitalization. On several occasions, he had hurt himself while struggling, and the self-inflicted injuries included a broken nose, a dislocated shoulder and a ruptured hamstring tendon. He had an ongoing fear that anyone who might try to wake him up during a night terror would be attacked and seriously harmed.

He married at age 23, but as a result of the nightmares his wife refused to sleep in the same room. She would not let him hold their infant son, thinking that he might fall asleep and inflict some injury. He rebelled against these restrictions, and this led to early separation and divorce.

His attempts to obtain a university degree were frustrated by his inability to profit from restful sleep. He was frequently able to find work, but he usually resigned out of general dissatisfaction or was dismissed because of his poor performance. Although he was physically strong and healthy, he was in reduced circumstances, living alone in a house that had belonged to his parents and supported by a disability pension. He had placed his mattress directly on the floor of the bedroom, from which all glassware and other potentially dangerous objects had been removed.

During childhood, he had been repeatedly beaten by his father, and as a gesture of defiance, he had decided that he would never permit himself to cry. This enhanced self-control was evident when attempts were made to treat the disorder with interpersonal psychotherapy. He gave an emotionless account of his life history, including the three traumatic incidents. One therapist had compared his performance with a reading of the television news.

Treatment

On the assumption that the emotion engendered by the traumata was being suppressed and that its release would be therapeutic, the disorder was treated with serial abreactions. To induce the abreactive state, the patient was given 300 milligrams of sodium amytal and 80 milligrams of methylphenidate by mouth; these quantities have been found to be effective in other cases of posttraumatic stress disorder (3). The interviews began 30 minutes after the drugs were ingested. Abreactions took place three times weekly, and a single session lasted from two to three hours. Apart from two occasions when medical students participated, only the patient and the writer were present in the interview room.

While he was under the influence of the two drugs, the patient talked freely about the salient features of his life, expressing anger, sorrow, guilt, remorse and fear, clenching his fists, pounding the table and weeping profusely. He recalled the deaths of friends and acquaintances, for some of which he believed himself to be responsible. He revealed that, between the ages of eight and twelve, he had been subjected to extreme physical and sexual abuse his father and his father’s male and female friends.

The patient remained in hospital for 92 days, and the course of treatment was terminated after 27 sessions. At that point, he stated that he had talked about every significant feature of his personal history. Furthermore, he had become desensitized and even when he was under the influence of the two drugs he was able to discuss the most harrowing aspects of his life without experiencing painful emotion. He reported that the nightmares, having gradually become less disturbing, had now totally ceased.

When he was seen for follow-up six months after discharge, he stated that he had experienced only two bad dreams since leaving the hospital. The clicker man had not returned. He was going to bed with confidence and averaging five hours of restful sleep.

Discussion

Drug-facilitated interviewing attained peak popularity in the early 1940s and Dysken (4), who reviewed the North American literature, cited 52 studies in which the procedure was found to be useful for either diagnosis or treatment. Tilkin, its most enthusiastic advocate, stated in 1949, “The future of narcosynthesis is infinite and the possibilities endless”(5). Since then, interest in the technique has waned, and if we may generalize from the results of a recent British survey, there is a strong possibility that abreaction may be entirely abandoned (6).

The reasons for the rejection of drug-facilitated interviewing may be found in the way in which the procedure is usually carried out, which involves intravenous injection of sodium amytal or a similar substance. Psychiatrists are uncomfortable with parenteral administration, and they do not feel competent to cope with laryngospasm or respiratory depression, which may occur if the injection is too rapid or the quantity of barbiturate excessive. These difficulties are entirely overcome if the drugs, in moderate amounts, are given by mouth.

It has been claimed that abreaction as a treatment for posttraumatic stress disorder has been superseded by the development of neuroleptics and other recent additions to the pharmacopedia, but the case described here shows that even the latest drugs have their limitations. Abreaction was successful where other methods had failed. We agree with Naples and Hackett when they state that the amytal interview may be of extraordinary value in particular cases and that it is a technique that should be made available to every clinical psychiatrist (7).

References

1. Howorth P. The treatment of shell shock. Psychiatr Bull 2000;24:225–7.

2. Brandon S, Boakes J, Glaser D, Green R. Recovered memories of childhood sexual abuse. Br J Psychiatry 1998;172:296–307.

3. Denson R. Abreaction. Psychiatr Bull 2002;26:276.

4. Dysken MW, Chang SS, Casper RC, Davis JM. Barbiturate-facilitated interviewing. Biol Psychiatry 1979;14:421–32.

5. Tilkin L. The present state of narcosynthesis using sodium pentothal and sodium amytal. Dis Nerv Syst 1949;110:215–8.

6. Wilson S. Survey of the use of abreaction by consultant psychiatrists. Psychiatr Bull 2002;26:58–60.

7. Naples M. Hackett TP. The amytal interview: history and current uses. Psychosomatics 1978;19:98–105.