Reprinted from The Journal of Nervous and Mental Disease, Vol. 133, No. 6, December, 1961. Copyright 1962 by The Williams & Wilkins Co. Printed in U.S.A.
Whereas most theories of dreaming (8) touch on some aspects of the connection between dreaming and the sleeping state, only an occasional view has been advanced emphasizing the connection of the dream with arousal or alerting processes (4). Freud, recognizing the alerting aspects of dream consciousness, went on to develop the theory of the sleep-maintaining effect of dreaming, and, further, the idea of a specific function of the dream: to preserve sleep. The concepts of wish-fulfillment and disguise emerged as integral parts of the guardianship of sleep function. The experimental studies of Kleitman and his associates (1, 2, 5-7) call attention to the occurrence of repeated partial awakenings during the sleeping phase of the sleep-waking cycle. That these repetitive, abortive bouts of awakening have been found to be associated with dreaming suggests the possible relationship of dreaming to the vigilance needs of the sleeping organism. The applicability of the concept of vigilance to dreaming and other states of altered consciousness will be explored.
Liddell (10) emphasized the role of vigilance in his studies on induced neuroses in animals: "We know that even the simplest mammal, wild or domesticated, must at all times be asking both of our questions - "What is it" and "What happens next?" Vigilance and planning are, of necessity, dynamically inseparable." He makes the following interesting conjecture on the relation of unconscious processes to vigilance: "We may imagine that early in each person's life his stream of experience branches and the life of immediate awareness diverges from the life of unawareness. A dynamic barrier, as Freud suggested, now separates conscious from unconscious. Why is this? May it not be that the young child can freely communicate certain experiences, thoughts and fantasies, while others incite in him a state of primitive vigilance because of fear of punishment, of loss of love? These repressed materials of the unconscious may be thought of as detonators of wasteful visceral reaction and must, therefore, be cautiously dealt with by the organism. Conscious and unconscious then become matters of social communication - ease of communication or impossibility of communication."
The human organism shares with lower forms of life this need for vigilance. Unique in the human, however, are the manner and form of vigilance operations. Behavior, consciously directed in the waking state, is geared toward the maintenance of relatedness to the social environment. Potential threats arise out of the context of social existence, and the diffuse ramifications of the threat extend to experiences that expose the flaws, gaps, inadequacies and misconceptions of consciousness. Such threats now extend to any experience that challenges value systems, social status or psychologic mechanisms of defense. In the everyday experience of the human being, threats of this nature overshadow direct threats to physical existence. While he is awake, vigilance is tempered by adequate conceptualization, communication and behavior. In the neuroses and psychoses there are disturbances in all these areas. Vigilance operations are then attended by chronic anxiety states, autistic thought processes and organ pathology.
The problem of vigilance comes into focus more sharply in connection with the sleep-wakefulness cycle (14): "The necessities which confront the human organism in connection with sleep are of a twofold nature. With the inception of the sleeping state there arises the need to effect a radical transformation in the activity of the individual. Social orientation and relatedness to the external environment give way to a form of activity governed primarily by physiological needs and hence occurring at an involuntary level.
"Similarly, the transition from sleep to wakefulness in response to any stimulus of sufficient strength impinging upon the organism is characterized not simply by the process of awakening, but more significantly by the resumption of consciousness of one's social existence. In the human being these significant stimuli now include symbolic as well as direct sensory effects. The state of vigilance during sleep has shifted from one involving danger to the organism at an animal level, viz., in terms of physical attack, to one involving danger to the organism in its relatedness to society."
The executive function of the brain is at every moment contingent upon the arrival of an endless supply of orienting afferent stimuli. Consciousness is a measure of the capacity to integrate these stimuli and organize appropriate motor responses. In states of partial awakening, the functioning of the brain becomes radically altered. It mobilizes the current or residual experience of the individual in a manner that, in effect, makes the cumulative store of past as well as currently acting experience a source of afferent stimuli - afferent not to the higher centers, but to the reticular activating system in the service of eventual arousal (13). This provides a means (and the only means) whereby the human organism can participate in a process that has come about by forces beyond its control and foreign to the ego: the involuntary alterations in the depth of sleep, and the associated variations in the level of cortical activation. In sleep, concomitant with the alteration in afferent inflow, the content of consciousness becomes experiential in nature, concrete in form, and meaningful in terms of the vigilance needs of the individual. The person is unable to relate a stimulus, or the absence of an accustomed stimulus, to the appropriate environmental setting. Past memories are brought to bear in the situation, not haphazardly, but so organized as to relate to the currently disturbing stimulus, whether physical or psychologic. The resulting presentations have a potentiating or arousal effect upon the brain, alerting the individual in proportion to the strength of the stimulus and, in this sense, preparing him for the next higher order of consciousness, namely, waking consciousness (regardless of whether it occurs). It is in this light that the dream may be considered to be adaptive, functioning to regulate, within limits, the unstable equilibrium that exists during the transitional periods of consciousness. The effect is generally toward arousal, but, when arousal fails to materialize, the dream then reflects the return to sleep.
The concept of the sleep state as a release phenomenon is open to question. In sleep there is simply an alteration in the mechanism and the goal of the thought processes. Neither of these two differences, however, changes the basic social character of thought. By this I mean that thought, whether it be verbal, logical and referentially cued, or sensationally illogical and experientially based, still serves a social function and remains in its essence an active process of comprehension, leading to refinements in behavior and ultimately to mastery of the environment. Admittedly this is so in waking thought. It is also true of thought occurring during altered states of consciousness, although this may be more difficult to perceive. The main difference lies in the fact that, in the first instance, thought is directed toward external behavioral change, whereas in the second it may be considered to be directed toward inner change in the form of potentiating cortical processes in the service of vigilance. Waking thought is oriented to the changing pattern of current responses; dream thought cuts through the longitudinal history of the individual and, like a magnet, clusters about itself relevant historical data from different epochs in the life of the individual (12). In this manner, the full implications of a currently disturbing stimulus are both explored and stated in concrete terms. Depending upon the nature of the stimulus, the intactness of the psychologic defenses, and the need for sleep, full arousal may or may not result. The dream is a reflection of precisely the same struggle that characterizes waking consciousness - a struggle between the effects of a complicated and often unpredictable world, and the feeble efforts to bring order out of chaos by the symbolic interpretation and comprehension of the nature of the external world and the individual's relatedness to it. The essential difference is simply that, in the one case, the individual is developing his comprehension of current stimuli; in the second, he is struggling to arrive at that level of consciousness where this becomes possible. Neither wish fulfillment nor disguise is an important element in either circumstance.
Thus considered, dreaming becomes a form of orienting activity and not a disguising mechanism. It is the conscious orientation to the passively experienced movement into or out of the transitional states occurring during the course of sleep. It is an accurate reflection of the existing stimuli, including the psychologic, impinging upon the organism at the time - accurate not in the sense of logical, syntactic or reproductive felicity, but in the sense of assessing the strength of that stimulus at a given level in the sleep cycle. The dream, concerned as it is with the possible need for arousal as well as the need for continued sleep, may be said to subserve a function concerned with vigilance, rather than one concerned with the guardianship of sleep.
From a neurophysiologic point of view, sleep has been regarded as analogous to a state of relative de-afferentation (9). Hallucinatory and dreamlike effects have been noted in many other situations where there is interference with the effective reception and integration of sensory stimuli. Such interferences may operate peripherally - as in visual hallucinations associated with bilateral cataracts (3) - anywhere along the pathways transmitting afferent impulses (phantom limb), or at the cortical end-stations analyzing and integrating incoming sense data, as in the case of brain damage. These impulses are generally thought of in physical terms. The concept may also apply to stimuli ordinarily regarded as essentially psychologic in nature, such as thought processes. One such clear application at the psychologic level is illustrated by the schizoid maneuver defined by Silverberg (11) as "the attempt to deal with reality in terms of distorting or falsifying its perception or its meaning, so that a murderous enemy becomes a friendly dinner-companion, his gleaming sword a spoon or a silver bowl or the waters of a fountain." Other, more limited applications might include sensory disturbances brought about by post-hypnotic suggestion, or occurring as a conversion symptom in hysteria.
In each instance referred to above the individual is simply forced to use different aspects of his experience, expressed in a different mode and toward different goals. He is not aware, or not clearly aware, of all - or of a certain segment - of experience. The true explanation either is not available or is overshadowed by the felt reactions, and a confabulated explanation presents itself, arising out of experiential sources and directed toward the maintenance of a unified feeling of self. The alterations in the form and content of consciousness that characterize dreaming may be taken as the prototype for the disturbances in consciousness which follow in the wake of the varied conditions referred to above.
The work on denial of illness in patients with organic brain disease brings into focus some interesting adaptive capacities of the human organism (15). Brain-damaged patients present, in varying measure, disturbance in their capacity to orient themselves accurately to their illness, as well as to aspects of their reality situation. What emerges in the form of partial or marked objective disorientation is the paradoxic resultant of the individual's effort to maintain an orientation in the face of his disability. This may become manifest in a variety of ways, but all form part of an experiential pattern of thought, rather than a referential one. It might be described as a situation in which the individual confronts himself, as well as others, with an autistically created environmental response at precisely those points where effective sensory integration and appropriate motor participation are no longer possible.
A 50-year-old Italian-born female, hospitalized following an embolus to her right middle cerebral hemisphere, was seen one week after admission, at which time she had a residual left hemiparesis. In addition to the motor deficit, she had a left hemisensory syndrome and left hemanopsia. The electroencephalogram was reported as showing diffuse abnormality. When asked where she was, the patient confabulated, naming another hospital and saying that the hospital was located around the corner from where she lived. When asked what was wrong, she denied that she was ill. Pressed further, she stated that her doctor had told her to come in for an operation on her heart. (She had rheumatic heart disease. An operation had been advised several months earlier but had been refused.) Asked if she could move her left arm, she said she could. When asked to do so, she raised her right arm. When the examiner pointed out that her left arm did not move, she said it was not her arm but her husband's, and that he liked to caress her. At this point she raised her left arm by means of her right hand and began stroking her breast. When she was reminded that her husband was dead, she said that he liked to come back and caress her because he liked her so much.
By the following day the picture had changed somewhat: the same type of disorientation was present, but the patient now admitted that the left arm was hers, referring to it in the third person and saying that it wouldn't listen to her. She insisted that her dead husband was lying in the next bed.
Several days later the sexual theme was elaborated in a different way. Her dead husband was no longer in the scene, but the nurses were doing things with the other patients. Some of the patients were really men. The nurses would put screens around the beds, slip their hands under the sheets, and play with the men for hours on end. The patient reacted with fear, and called the ward a "jungle," because it frightened her just as if it were inhabited by wild animals.
To recapitulate some of the denial mechanisms shown by this patient:
1) Confabulation. She fabricated data about the hospital and the circumstances of her admission.
2) Spatial disorientation. At different times she spoke of her home as being around the corner, upstairs, and so on.
3) Temporal disorientation. The passage of time was confused at two points - in relation to her dead husband, and in relation to the operation.
4) Explicit verbal denial. The occurrence and aftermath of the stroke were denied in toto.
5) Hemispatial inattention. The patient persistently looked away from the affected side.
What can be learned from this sequence of events - so similar to ordinary dream sequences, but occurring in the waking state - that may shed further light on dream mechanisms? The events occurring in the wake of the stroke might be reconstructed as: A sudden deflection of the afferent inflow is followed by the fragmented integration of stimuli from the environment, the greatest defect centering about the recognition, meaning and impact of the illness itself. The patient states: "The arm isn't mine; it belongs to my dead husband." How is this symbolism arrived at? By virtue of both sensory and motor loss, the arm is experienced as unconnected with the self, external to the self, and incapable of movement. In short, it is experienced as dead. Yet, it can be held and manipulated with the right hand, and the range of motion results in sensually tinged contact with the breasts. Death reduces a human being to the status of being a dead object. The dead husband is then equated with the dead arm, linked by the element of sensual contact as well as by the feeling of apartness from her own body. When she touches herself with the paralyzed arm it feels the same as when her husband touched her. Both are dead - both are equal to each other. The tables are turned on fate and a catastrophe becomes a triumph. The rest of the picture then falls into line. The confabulation, denial of illness, the spatial and temporal disorientation follow logically once the arm-husband substitution is made. As the patient is forced to surrender this fantasy by the recovery process itself, the husband fades from the scene but the sexual fantasy is maintained vicariously. An experiential core has filled the gap in much the same way as in the dream. This combination of events - the sudden loss on the one hand, and the experiential replacement on the other - then acts as a deterrent to the reception and integration of environmental influences that might alter or change the experiential adaptation that has occurred.
In this patient, wish fulfillment is not the key to the initial clinical productions. What she says is not based on the wish that her dead husband were there caressing her. This bit of confabulation arises out of her own past experience of lying in close physical proximity to a bodily appendage not an organic part of her own body (her husband's arm). The experience of the stroke is interpreted at a concrete sensational level. What appears subsequently as the continued denial of illness is the result in part of the relative impotence of reality factors to alter the felt explanation experienced by the patient, and in part of an active wish to maintain the status quo. To say that the arm belongs to her dead husband and that the arm is paralyzed is to offer two explanations for the same event. The incorrect - but experientially correct - interpretation dominates the scene. As the patient gets better, the other comes to the fore. The factor of wish fulfillment and the capacity for self-deception are more often features of clear waking consciousness than of altered states of consciousness.
The brain-damaged person is in a less tenable position than the dreamer, or the healthy person in the waking state. He must rely on transparent subterfuges. But these subterfuges exist for the very good reason that he has been the object of a catastrophic experience and has had to account for the experience in terms of his own personal past, without any reference to the real factors at work. Further, he has had to defend the fruits of his labors (i.e., the confabulated explanation) against an incredulous social environment. The dreamer's task is easier. He does not have to prove that his dream is real. He experiences it in its totality as real. And when awake, he is the first to recognize it as a dream.
In the dream there usually is no given concordant external event about which to structure the symbolism. The elements in the dream generally arise from endogenous sources in connection with affective traces derived from recent experience. A distant rumble not attended to during the day is set in motion; it develops in a setting where it is not perceived clearly or appreciated in a fully conscious manner. Then comes sleep, and a state of relative de-afferentation. What are activated during periods of arousal are felt reactions connected with aspects of past and current experience, never adequately conceptualized, but always relating to perceptual experience of importance to the individual. In the normal course of events in the waking state, the proper relations between internality and externality would be arrived at in the process of transforming sensory experiences into conceptual constructs. In states of altered consciousness, however, this does not occur, as the entire experience is re-experienced without the guiding influence of an afferent stream originating in the external world. The fragmentary percept is developed but remains at a perceptual level and, as such, is experienced in its externality. The various elements are endowed with spatial attributes, as in the case of any other sense data. In both situations, the executive function of the brain is lacking or impaired. What appears in its place is the creation of vicarious internal afferents. At a physiologic level these afferents exert a potentiating influence on the cortical processes taking place. At a subjective level they represent the effort to make an unknown and, in some instances, unknowable occurrence more familiar and known. In the absence of the appropriate explanation, a mythical or confabulated explanation evolves providing an egosyntonic account of events that cannot be accurately conceptualized. The elements entering into the confabulated explanation may be unrelated in spatial and temporal terms, but all are connected in their relevance to the current problem. The reactions at both levels represent the effort to become oriented to a drastically altered internal environment.
In both the brain-damaged patient and the dream, the alterations in the reception and integration of afferent impulses set the stage. The vigilance needs provide the motivation and direction for what ensues. The fragments of life experience related to the current problem provide the costume, the scenery, and the actors themselves. A play is produced that either is successful and gets an ovation loud enough to bring down the house (awakening, in the case of the dream, or loss of the delusional responses, in the brain-damaged), or is unsuccessful, the audience remaining quiescent (continued sleep, in the one case, or continued clouding of consciousness, in the other).
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 Based on clinical data from a study of cerebral vascular disease conducted at the Second (Cornell) Neurology Service, Bellevue Hospital, and supported by Grant No. B-2352, National Institute for Neurological Diseases and Blindness, U. S. Public Health Service.
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 The terms experiential and referential are used in the sense described by Weinstein et al. (16), based on Sapir's classification of symbols: "Referential symbols include such forms of language as letters, numbers, and signals that are universally agreed upon as conveying certain specified information. Condensation symbols or experiential symbols are those which express a particular relationship of the person to the object or event."