ART AND IMAGES IN PSYCHIATRY

SECTION EDITOR: JAMES C. HARRIS, MD The Nightmare

HEN MAX EASTMAN VISITED SIGMUND FREUD’S Ephialtes. These giants attacked the gods and, at night, hu- apartment at Berggasse 19, Vienna, Austria, in manbeings,leavingthemgaspinginterrorfromtheirweight; W 1926, he noticed a print of John Henry Fuse- at times they would sexually attack women. li’s (1741-1825) The Nightmare hanging on the wall next Pemell notes that in English, the incubus is called “the to Rembrandt van Rijn’s The Anatomy Lesson.1(p15) Freud Hag or Night-mare, because it takes them in the night.”7(p71) did not refer to Fuseli’s most famous painting in his writ- The English belief was that at night an old hag sat on the ing, but his colleague Ernest Jones chose another version chest of the sleeper and caused suffocation. Pemell wrote, of it as the frontispiece of his book On the Nightmare,2 a “Some will have Incubus [male] or Succubus [female], so- scholarly study of the origins and significance of the night- called from Devils of that name: but these are the con- mare theme. However, the nightmare did not fit easily into ceits of men.”7(p71) Thus, the mare could be of either sex. Freud’s model of dreams as wish fulfillments. Initially he He refers to nocturnal suffocation of the body after the first proposed that nightmares represent superego wishes for sleep, in which the person oppressed is temporarily de- punishment; later he suggested that traumatic nightmares prived of speech and motion. He suggests that the brain represent a repetition compulsion.3(p41) Fuseli’s painting pro- is affected in its actions involving imagination, sense, and vides an opportunity to reexamine how the meaning of the motion and describes its differential diagnosis from noc- word nightmare has evolved. turnal epilepsy: with the Mare there is no convulsion or In a career that lasted more than half a century, Fuseli motion. Pemell proposes that epilepsy obstructs “the fore- created paintings that were recognized as among the most part of the head, but...theMare doth obstruct the hinder- imaginative, dramatic, and sexual in British art. His “styl- part.”7(p72) Among its causes are drunkenness and an abun- ized images of ghosts and fairies, muscle-bound superhe- dance of food taken into the stomach, resulting in crude roes, fainting maidens and voracious viragos are obvious vapors arising in the brain that stop the motion of the prototypesforthefiguresintoday’scomicbooks,actionmov- nerves. Although the person strives to move and speak or ies and computer games.”4(p6) Like these modern fantasy fig- call for help, he cannot and is filled with fear and terror. ures, Fuseli’s paintings express an engaging dynamism, yet He writes that those who have this disease are often in dan- in his day he was best known for his illustrations of the works ger of subsequently developing stroke, vertigo, epilepsy, of John Milton and William Shakespeare. William Blake was or madness and that children so affected may die in the substantially influenced by his style.5 Fuseli was born in night. He then describes treatments, noting that this dis- Zurich, Switzerland, and died in Putney, London, England. ease occurs only at night and primarily in those who sleep His father, a court painter and art historian, insisted that on their back and that the person should be aroused from his son become a clergyman. He was ordained as a Zwing- sleep, but not too violently. lian minister in 1761 but soon abandoned the ministry for Although Pemell ridiculed the belief that the night- literature and painting. Settling permanently in London in mare was caused by devils, the incubus as an evil spirit 1779,hisreputationwasestablishedin1782whenTheNight- that descended on women to have sexual intercourse with mare was exhibited at the Royal Academy,where he became them as they slept was recognized in ecclesiastical and professor in 1799 and its keeper in 1804. He is buried in St civil law in the Middle Ages. The Malleus Maleficarum,9 Paul’s Cathedral next to John Opie and Joshua Reynolds. the Hammer of Witches, was an important text source The subject of the painting is a nighttime assault by for witch trials that condemned women for having sexual a mare or incubus: the “night-mare.” Thus, originally a intercourse with the devil. night-mare was a night-demon causing dreams, and only By the time the painting was begun, the term nightmare later did the word denote the dreams themselves. Describ- had been codified in Samuel Johnson’s Dictionary, the first ing this frightening event, in 1561 Hieronymus Brun- comprehensive dictionary in the English language, as fol- schwig wrote, “The disease called Incubus that is the Mare lows: “mara, a spirit that, in heathen mythology, was related whych is a sycknesse or fantasye oppressinge a man in his to torment or to suffocate sleepers. A morbid oppression slepe, that to him semeth a great weyght lye upon hys body, in the night resembling the pressure of weight upon the wherefore he groneth and sigheth but cannot speak.”6(p10) breast.”10(p353) Fuseli did not emphasize suffocation; instead The first neurology textbook in the English language, he focused on the incubus, providing a visual representa- Robert Pemell’s De Morbis Capitis; or Of the Chief Internal tion consistent with the themes of contemporary gothic nov- Diseases of the Head,7 refines this definition and includes els. The painting may have influenced the creation of Mary incubus as a specific disorder. He notes that both Greek (ephi- Shelley’s Frankenstein. His drawing The Nightmare Leaving altes) and Latin terminology (incubus) refer to pressure on TwoSleepingWomenemphasizesthesexualthemeandshows the body during sleep as if from a great weight. Jarcho,8 in the Night-Mare as he rides away (Figure 1), leaving 2 nude his review of obsolete diseases, traces the ancient origin of women distraught in bed. The 3 elements in the compo- mare or incubus to Greek myths of giants, among them the sition of the painting—a sleeping woman; a night-mare or

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Figure 1. Fuseli, The Nightmare Leaving Two Sleeping Women, 1810. Figure 2. Fuseli, Portrait of a Lady (reverse side of The Nightmare), late 18th century. incubus squatting on her lower chest, frowning, defiant, and seemingly indifferent to her plight; and the head of a horse that peers through the curtain with wild staring eyes—are all consistent with the Malleus Maleficarum.11 A table at the foot of the bed holds a tray, some jars, and a dressing mir- ror; the shadow of the incubus is reflected on the curtain. sure on the chest, breathing difficulties, and pain, is attrib- Dressed in virginal white, a woman lies on a salmon-pink uted to effects of hyperpolarization of motoneurons on per- coverlet, her head falling off the edge of the bed with her ceptions of respiration. These authors suggest that such left arm dangling on the floor. A poem by Fuseli’s friend Eras- experiences (more common in those who sleep supine) may mus Darwin describes the painting: “[T]hrough the evening be the sources of accounts of supernatural nocturnal assaults fog flits the squab fiend o’er fen, and lake and bog [and] seeks and breathing difficulties traditionally ascribed to the night- some love-wildered maid, by sleep oppressed, alights and 1(p58) mare. Sleep paralysis with hypnagogic and hypnopompic grinning, sits on her breast.” Although the theme is ar- hallucinations is reported in posttraumatic stress disorder. chetypal, there may have been a personal motive for this Comparing Pemell’s account in 1650 with this recent pro- painting. On the reverse side of the canvas is the unfinished posal, he seems prescient in his description of a disorder of Portrait of a Lady (Figure 2). This may be Anna Landolt, the hindbrain; REM sleep is initiated in the pons. a Swiss woman who rejected Fuseli’s romantic advances. What can we learn from studying nightmares? Hart- Deeply hurt, Fuseli wrote to her uncle of his unrequited love mann14 proposes that posttraumatic nightmares may serve and of his dream that he had her in his bed: “[M]y hot and as a paradigm to teach us about the mechanism of affec- tight-clapsed hands about her—fused her body and soul to- tive incorporation of experiences into dreams and that gether with my own—poured into her [a la mode d’incubus] nightmares represent the failure to master a dominant and my spirit....Anyone who touches her now commits adul- powerful emotion. The question remains whether the con- tery and incest. She is mine, and I am hers, And each earthly tent of nightmares or of hypnopompic hallucinations, night since I left her I have lain [in my imagination] in her 11(p195) which do not necessarily arise following traumatic cir- bed.” Was Fuseli’s Nightmare in some sense a self- cumstances, can be meaningful and have developmental portrait? significance in Carl Jung’s pathway to individuation.15 Nightmare disorder is currently defined as “disturb- ing mental experiences that generally occur during REM James C. Harris, MD [rapid eye movement] sleep and that often result in awak- ening.”12 They are marked by a dominant emotion, usu- ally anxiety, fear, or terror but also anger, rage, embar- REFERENCES rassment, disgust, and other dysphoric emotions; these 1. Powell N. Fuseli: The Nightmare. New York, NY: Viking Press; 1972. emotions are associated with disturbing dream content. 2. Jones EJ. On the Nightmare. London, England: Hogarth Press; 1949. Nightmares immediately following or appearing a month 3. Hartmann E. The Nightmare: The Psychology and Biology of Terrifying Dreams. or more after a trauma (posttraumatic stress disorder) New York, NY: Basic Books Inc; 1984. 4. Myrone M. Henry Fuseli. Princeton, NJ: Princeton University Press; 2001. can also occur during non-REM sleep. Recent studies of 5. Harris JC. The Wood of the Self-Murderers: The Harpies and the Suicides. Arch posttraumatic nightmares emphasize that sleep-related Gen Psychiatry. 2003;60:229. breathing problems may accompany them. However, the 6. Brunschwig H. A Most Excellent and Perfecte Homish Apothecarye or Homely Physik Booke, for All the Grefes and Diseases of the Bodye. Hollybush J, trans. most likely contemporary diagnosis for night-mare is not Cologne: By [the heirs of] Arnold Birckman; 1561:leaf 10a. nightmare disorder but isolated sleep paralysis with ter- 7. Pemell R. De Morbis Capitis; or Of the Chief Internal Diseases of the Head. Lon- don, England: Philemon Stephens; 1650. rifying hypnagogic or hypnopompic hallucinations. 8. Jarcho S. Some lost, obsolete, or discontinued diseases: serous apoplexy, incu- 13 Cheyne et al found that almost 30% of 870 univer- bus, and retrocedent ailments. Trans Stud Coll Physicians Phila. 1980;2:241-266. sity students reported at least 1 experience of sleep paraly- 9. Summers M, ed. The Malleus Maleficarum [1486-1487]. Kramer H, Springer J, trans. New York, NY: Dover; 1971. sis and that three quarters of these also reported at least 1 10. Johnson S, Lynch J (ed). Samuel Johnson’s Dictionary: Selections From the 1755 hallucinoid experience; slightly more than 10% experienced Work That Defined the English Language. Delray Beach, Fla: Levenger Press; 2002. 3 or more. Fear was positively associated with hallucinoid 11. Moffitt JF. A pictorial counterpart to “Gothick” literature: Fuseli’s The Nightmare. Mosaic: Journal for the Interdisciplinary Study of Literature. 2002;35:173-196. experiences, most clearly with a sense of the presence of an 12. Pagel JF, Nielsen T. Nightmare disorder. In: Hauri P, ed. International Classifi- intruder. They propose a 3-factor model of hypnagogic and cation of Sleep Disorders: Diagnostic and Coding Manual. Rochester, Minn: Ameri- can Academy of Sleep Medicine. In press. hypnopompic experiences. One factor, “intruder,” consist- 13. Cheyne JA, Rueffer SD, Newby-Clark IR. Hypnagogic and hypnopompic hallu- ing of sensed presence, fear, and auditory and visual hallu- cinations during sleep paralysis: neurological and cultural construction of the cinations, is conjectured to originate in a hypervigilant state night-mare. Conscious Cogn. 1999;8:319-337. 14. Hartmann E. Nightmares after trauma as paradigm for all dreams: a new ap- initiated in the midbrain and involving the amygdaloid com- proach to the nature and functions of dreaming. Psychiatry. 1998;61:223-238. plex. Another correlated factor, “incubus,” comprising pres- 15. Edinger EF. Ego and Archetype. Baltimore, Md: Penguin Books; 1972.

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