Nightmare Utilization by Successful Artists: A Case Report Series

  

    
PTSD  
      
CRITERIA  
    
TRAUMA (1=NO RECALL – 5 = EXTREME)  
    
FUNCTIONAL  
      
IMPAIRMENT  
      
(1=NONE – 5 = HOSPITAL OR SUICIDE    ATTEMPT)  
    
CENTRAL IMAGE  
      
INTENSITY  
      
(1 = MINIMAL -5 = PRIMARY)  
    
NIGHTMARE  
      
LENGTH  
      
(1= IMAGE ONLY – 5 = LENTHLY FULL    STORY)  
    
ARTISTIC  
      
USE  
      
(1 = NONE – 5 = NM BASED)  
  
  

    
FULL  
      
(#7)  
    
4.5 (3-5)  
    
4.3 (4-5)  
    
2.27  
      
(1-5)  
    
3.1  
      
(1-5)  
    
3.4  
      
(1-5)  
  
  

    
PARTIAL  
      
(#4)  
    
4.0 (3-5)  
    
3.0 (2-5)  
    
3.5  
      
(2-5)  
    
3.75  
      
(2-5)  
    
3.75  
      
(2-5)  
  
  

    
NONE (#3)  
    
1.4 (1-2)  
    
1.0  
    
3.0  
      
(2-5)  
    
3.3  
      
(1-5)  
    
4.3  
      
(3-5)  
  

Table 1: Comparisons between PTSD groups of trauma severity; functional impairment; and nightmare content including Central Image (CI) intensity, narrative length;
and nightmare (NM) incorporation into best work (artistic use) [means (range).

The classic nightmare almost always occurs in REMS except in individuals diagnosed with PTSD [9]. Distressing and recurrent nightmares are the most commonly reported symptom of PTSD, a waxing and waning chronic illness occurring after the experience of major physical or psychological trauma that can affect both waking and sleep into extreme old age [10,11]. Cognitive-behavioral therapies and medications can help some patients with the distress associated with PTSD [12]. Medications or behavioral approaches such as imagery or lucid control can reduce the intrusion of nightmares, hopefully reducing the destructive personal and social effects of PTSD [13]. However, many individuals who experience the irreconcilable physical or psychological trauma producing PTSD will continue to have symptoms throughout their lives. Many individuals with PTSD will never return to the level of functioning that they achieved before their experience of trauma [14]. Years after trauma, PTSD persists as a major risk factor for attempted and completed suicides [15,16]. A much higher risk of suicide post-trauma is present even in individuals with sub-threshold symptoms for PTSD [17]. In the short-term treatment of PTSD, reported nightmare frequency is the easiest to evaluate treatment outcome measure [11]. The therapeutic success of current medication and cognitive-behavioral psychological therapies is most often addressed as based on their ability to suppress and decrease the frequency and distress of the associated nightmares [18].

Freud suggested that the psychological origin of creativity is based in trauma [19]. Freud suggested that the creative process could be therapeutic. The artist; “possesses the mysterious power of shaping some particular material until it becomes a faithful image of his phantasy.” So that the traumatized artist can potentially achieve; “…honour, power, and the love of women.” [20]. Ernest Hartmann noted that the only personality characteristic clearly associated with a higher incidence of nightmares is the characteristic of “thin-borders.” Individuals with thin borders are more likely to invest themselves in the creative experience, to produce creative products, and to lead creative roles in society with those reporting frequent nightmares testing as unusually imaginative [21]. In creative writing classes, those students with the most bizarre and fantastic dreams are the most likely to produce superior work [22].

Methodology

This project was presented in part at the 2010 Faulkner Society’s Words and Music meeting, in 2011 and 2013 at the International Society for the Study of Dreams, and in 2012 at Creativity and Madness (Santa Fe). The artists included in this project came based on personal contacts (primarily through the Sundance Film Labs), attendees at the above programs who volunteered after the presentation, and referrals from other interviewees involved in this project. All are successful artists who have, at some point, derived primary income based on their artistic role. All, even those past retirement age, were currently working in their field at the time of interview (2010- 2015) except for one who is currently active duty military. The interviews were conducted by a physician Board certified in Sleep and Behavioral Sleep Medicine, and were transcribed and returned to each interviewee for correction and signed release. Three of the interviewees chose to submit their interview under a pseudonym. Art works were submitted by eight of the participants. Examples of that work have been published in a previous article [23].

Each subject voluntarily provided sufficient information to determine whether they met criteria for PTSD based on the current DSM-V criteria: 1) A traumatic exposure must result from one or more of the following scenarios, in which the individual directly experiences the traumatic event, witnesses the traumatic event in person, learns that the traumatic event occurred to a close family member or close friend, or experiences first-hand repeated or extreme exposure to aversive details of the traumatic event; 2) The disturbance, regardless of its trigger, causes clinically significant distress or impairment in the individual’s social interactions, capacity to work or other important areas of functioning. It is not the physiological result of another medical condition, medication, drugs or alcohol; and 3) The experience includes the following diagnostic clusters: a) re-experiencing spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks or other intense or prolonged psychological distress, b) avoidance of distressing memories, thoughts, feelings or external reminders of the event, c) negative cognitions and mood including myriad feelings, from a persistent and distorted sense of blame of self or others, to estrangement from others or markedly diminished interest in activities, to an inability to remember key aspects of the event, and d) arousal including aggressive, reckless or self-destructive behavior, sleep disturbances, hyper- vigilance or related problems [24]. Using these criteria participants were divided into three groups: 1) nightmare disorder without a history of major trauma and without symptoms of PTSD [25]; 2) partial criteria for PTSD; and 3) full criteria for PTSD.

For analysis, categories of assessment were developed in the attempt to rate artistic use of nightmares, trauma severity, reported functional impairment, and the incorporation in art of contextual imagery. Artistic use of nightmares was rated from 1 = none to 5 = primary artistic focus. Trauma severity was rated from 1 = no clear recall of trauma through 5 = reported extreme trauma. Functional impairment was rated from 1 = none to 5 = volunteered history of associated suicide attempt or psychiatric hospitalization. Contextual imagery was rated from 1 = minimal through 5 = intense (the predominate characteristic of the reported nightmare). The length of nightmare report was also assessed varying from 1 = image with no reported story through 5 = lengthy report developed fully into a three act story.

Results

While the age of those interviewed varied markedly (18-90) for the age of nightmare onset, the mean age at the time of interview was almost identical (61.3). Ten subjects were visual artists (painters, photographers, and/or videographers) and four were writers. All of those interviewed were not currently taking psychotropic medication or using nightmare-suppressive cognitive or behavioral therapies. Reasons given included cost, drug side effects interfere with clarity and rapidity of thought or diminish their levels of enthusiasm, emotion and energy. Artistic use of nightmares was high for all the age groups.

As based on trauma exposure and symptoms of PTSD, the artists could be divided into three groups: (1) Nightmare disorder: No other symptoms of PTSD and no clear history of a major traumatic event and reporting recurrent nightmares since they were very young (#3) (21%); (2) PTSD meeting full criteria - a history of major trauma, definite and persistent functional impairments, as well as symptoms in all the diagnostic clusters (#7) (50%); and group (3) – PTSD partial criteria, individuals who after their experience of major trauma, developed and continue to experience some, but not all, of the diagnostic cluster of symptoms associated with PTSD (#4) (29%) (Table 1).

Approximately 80% (11/14) of these successful artists using nightmares in their creative work had experienced major trauma and had at least some symptoms associated with PTSD. The rest (3/14) fit better into the diagnostic category referred to as nightmare disorder: individuals without a clear history of major trauma with frequent nightmares present since childhood that can lead to disrupted sleep and sometimes negative effects on next day mood and behavior. No significant difference in repot length or extent of narrative development was evident based on PTSD symptom category.

The majority of the interviewees in this project (8/14 – 57%) described extreme traumatic experiences. These individuals were more likely than others interviewed to clearly have PTSD (6/8 – currently met full diagnostic criteria). This group had clearly experienced great distress as a result of their trauma. Six described suicidal ideation and two volunteered descriptions of suicide attempts during their interviews.

Nine of the interviews were with females and five with males. The mean age of trauma experience and nightmare onset was younger for the women respondents (20. 8 years of age) than for the men (31.2 years of age). The mean age of nightmare onset for the women interviewed (#4) who had experienced the most severe documented trauma was only 7.5 years of age (range 3-11) where as for men the mean age of onset was 28.5 (range 18-50). The type of trauma was different as well. Three of the four women experienced the loss of a parent or sibling. Two of the three severely traumatized men experienced their trauma during war-associated combat. For those included in this project that had experienced lesser traumas, the gender based age difference was not nearly as profound: a mean of 27.5 for the women (range 4-60) and 32 for the men (range 6-50).

The content of the trauma-associated nightmares was reported as a replay of the actual event by two of the fourteen interviewees. Each of these individuals had nightmares that included metaphoric memories and associated emotional intrusions, closely parodying the actual experience of trauma. For the other individuals whose nightmares begin after the experience of major trauma, 5/9 or 55% had specific content elements from their experience of trauma that were apparent in their nightmares. Those reporting the most severe trauma were able to describe only minimal nightmare content during their interviews. Among the interviewees, 4/14 or 29% reported an overwhelming Central Image (CI) of a tidal wave as the primary image in their nightmare [26]. Other dream CI’s included falling (2), spinning vortex (2), live burial, drowning, significant loss (2), and body alteration (1). For each PTSD grouping (full/partial/none) the intensity of central image, the extent of narrative content (dream length), as well as the severity of experienced trauma and the degree to which nightmares are incorporated into their art are compared in (Table 1).

Among the most successful group of interviewees (the 9/14 who had achieved awarded preeminence in their chosen fields), four meet full diagnostic criteria for PTSD, three meet partial criteria, and two met no criteria. Among those who are somewhat less successful (#5), three met full, one partial, and one no criteria. The two interviewees whose nightmares were replays of their traumatic experience demonstrated the least capacity for an ability to integrate their experience into their art. Of the 11/14 with subjects with symptoms of PTSD, in 10 of 11 cases their most acclaimed work was accomplished after the experience of trauma.

Discussion

In our previous studies, questionnaire responses indicated an association between reported nightmare frequency and artistic / creative interest. The question arose as to whether some of those successful artists surveyed might have frequent nightmares as a symptom of experienced trauma and PTSD. This proposition, while consistent with Freudian theory, was to some degree counterintuitive since some individuals with PTSD function poorly in their work and social roles [7]. This study indicates, however, that some creative individuals can successfully function and produce art of highest quality after the experience of significant trauma. In this small series, most, but not all, of this group of successful artists met criteria for the diagnosis of PTSD.

These interviews collaborate the PTSD literature in finding that the greater the severity of the trauma, the greater the likelihood for an individual to develop symptoms of PTSD and the functional impairment associated with that diagnosis (this finding is consistent with the PTSD literature) [7,14,15].

Successful artists with nightmares, including both those with PTSD and those without, were successful at the incorporation of their nightmares into the creation of some of their best work. As to specific nightmare content, CI’s were commonly reported with tidal waves as primary content in 4 of 14 nightmares. Among those with the most intense central imagery, there was a tendency to report less narrative. There was the suggestion that individuals who had nightmares that are close replays of the actual traumatic event were less artistically successful.

Those interviewed with PTSD symptoms had been treated at some point with behavioral therapies or medications, prescribed to reduce their PTSD symptoms and improve their waking function. Most had used techniques (extinction therapy, imagery therapy, and/ or lucid dream control) designed to suppress their nightmares? The painter Edvard Munch, hospitalized more than once in psychiatric hospitals, illustrates this point: “A German once said to me: ‘But you could rid yourselves of your troubles.’ To which I replied: ‘They are part of me and my art. They are indistinguishable from me, and it would destroy my art. I want to keep those sufferings” [27]. While none of these artists report that they are currently using any of the medications or the varieties of cognitive – behavioral therapy designed to suppress nightmares, three reported the periodic use of hypnotics, and antidepressants, as well as continued involvement in insight-based psychotherapy.

Many individuals being treated for PTSD discontinue their therapies and medications [28]. Some individuals, particularly those who have experienced less severe levels of trauma, can return to their normal level of functioning pre-trauma, but it is not currently clear as to which form of medication or therapy is most likely to help any particular individual achieve normal functioning [18]. In some cases the discontinuation of medication and/or therapy may reflect a cure, but such was not apparent among this group. Al of the groupings in this study with a history of significant trauma continued to have at least some symptoms of PTSD many years after the precipitating event. Many individuals with diagnosed PTSD will periodically achieve higher levels of function until episodic life-stressors, or new trauma induces a return of significant PTSD symptoms and produces a decline in function and quality of life [14] (Figure 1C). For those interviewed in this study, this pattern was commonly reported. Other PTSD affected individuals will learn to accept a level of functioning and quality of life post-trauma that is different, and less rich in quality of experience than the life they had lived before their trauma (Figure 1D). Others never recover physically and/or mentally from their experience of trauma (Figure 1E).

    

    

    Figure 1:  Function and quality of life effects induced by major physical and
psychological trauma and potential outcomes [2].