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Postgraduate Medical Journal (January 1976) 52, 26-31. Postgrad Med J: first published as 10.1136/pgmj.52.603.26 on 1 January 1976. Downloaded from

A psychoanalytic view of sleep MALCOLM PINES M.B., F.R.C.P., F.R.C.Psych., D.P.M. Maudsley Hospital

Summary to sleep and therefore actively withdraw our atten- The basic psychoanalytic contributions to theories of tion from the external world. 'We are not in the habit sleep, awakening, falling asleep and the sleep wake- of devoting much thought to the fact that every night fulness continuum are briefly discussed. Some clinical human beings lay aside the wrappings in which they material illustrates the psychopathology underlying have enveloped their skin as well as anything they sleep occurring during the psychoanalytic session. may use as a supplement to their bodily organ, for instance, their spectacles, their false hair and teeth IN the psychoanalytic situation the patient lies down and so on. We may add that when they go to sleep and is asked to 'free associate' in a state of 'quiet and they carry out an entirely analogous undressing of reflecting self observation'. Around this nuclear, their minds and lay aside most of their psychical strictly defined norm radiate states of acquisitions. Thus on both counts they approachProtected by copyright. of all degrees of awakeness and sleepiness. There are remarkably close to the situation in which they began insensible transitions towards reveries and dreams in life. Somatically, sleep is a re-activation of intra- one direction and in the other direction towards uterine existence fulfilling as it does the conditions of directed, secondary processed structured mental repose, warmth and exclusion of stimulus; indeed, in work (Lewin, 1955). The analyst therefore has many sleep many people resume the fetal posture. The opportunities to follow changes in the level of psychical state of a sleeping person is characterized consciousness of his patients from that of elated by an almost complete withdrawal from the sur- hypomanic sleeplessness to gradual or sudden onset rounding world and cessation of all interest in it' of sleep during the session; to follow the develop- (Freud, 1925). 'A dream tells us that something was ment or resolution of insomnia and to study the going on which tended to interrupt sleep and enables mental activity during sleep as revealed during us to understand in what way it has been possible to dreams. He is in a position to confirm what Lawrence fend off the interruption. The final outcome is that Kubie (1949) pointed out: 'We are never either the sleeper has dreamt and is able to go on sleeping; totally awake or totally asleep. These are relative the internal demand which was striving to occupy http://pmj.bmj.com/ and not absolute terms. Parts of us are asleep in our him has been replaced by an external experience waking moments and awake in our sleeping moments whose demand has been disposed of. A dream is and in between lie all gradations of states of activity therefore amongst other things a projection; an and inactivity; investigation and pursuit; assertion, externalization of an internal process.' aggression and destruction or defence withdrawal and Let me define some of the terms we are going to fight or silence, inactivity, dreaming and sleep.' encounter repeatedly that make up the psycho- on are many cases Psychoanalytic views sleep in analytical conceptual shorthand with which we on September 23, 2021 by guest. derived from clinical observations and theoretical handle complex psychological phenomena. Ego is reconstructions before EEG studies (Proceedings, the name given to that collectivity ofmental functions 1942) and there are those who articulate with these that mediate the person's relationship both to the modern studies (Fisher, 1965; Meissner, 1968; external world and to the internal world of vital Hawkins, 1970; Zetzel, 1970; Hartmann, 1973). drives and unconscious mental forces and processes; We begin with Freud's dramatic plunge into the the phenomenon ofconsciousness is a function of the world ofdreams and sleep, with his 'Interpretation of system. Between the conscious and the unconscious Dreams' (Freud, 1900). Note that Freud studied systems lies the pre-conscious, containing images and dreams more than he studied sleep but what he had ideas which are latent, ready to emerge, already to say about sleep is important and set the frame- partly screened and prevented from flooding con- work for most subsequent work. He asserted that sciousness by a process of selective and sleep is an active not a passive process, that we wish inattention. The superego is the name given to the A psychoanalytic view ofsleep 27 Postgrad Med J: first published as 10.1136/pgmj.52.603.26 on 1 January 1976. Downloaded from area of the personality where social relations have feeling that includes all motor and sensory memories entered most noticeably into the nature of the person concerning one's own person, united into a charac- through his acceptance of the standards and prac- teristic feeling experience. The mental ego is an inner tices of his early environment. The asocial, helpless, mental experience from which, by conversion, dependent infant has, in a few brief years, to become processes can be projected either into the body as in a person with a unique, recognizable personality, conversion hysteria or outside the body into the able to move away from the family of origin and external world as in . prepared to lead a self-regulated relatively indepen- As we gradually fall asleep both ego feelings dent existence. You will hear me use the word undergo modifications. Pleasurable fantasies replace cathexis, a term for the investment of the mental dull workaday and our attention falls upon function with a hypothetical charge of energy that the body which is experienced as changing in many can fluctuate quantitatively. Cathexis can be attached ways, altering in its dimensions, its movements and or withdrawn from a part of the body schema or most particularly its boundaries. Those 'frontier from part of the mental apparatus. Withdrawal can zones' of the body, that is those parts of the body and be voluntary or involuntary; in the latter case it is the environment immediately about it, begin to blur likely to be caused by mental conflict, classically as in and to fuse. Processes taking place within the body a sensory anaesthesia or in motor paralysis. The are experienced now as taking place in the outside term ego feeling will be explained later. As already world. All this time a certain type of heightened self stated, Freud saw sleep as a regressive state, a observation is taking place. A mental ego thus is still reversion to early states of being, and spoke of a active, functioning, nearer to the waking level than dream as a guardian of sleep. Impressions of the day does the body ego, though the body ego can quickly before, day residues, become linked up during sleep revert to its usual level of function if the body is with the drives that constantly press for discharge moved or if the person wills it so. Normally sleep into consciousness, basically sexual and aggressive supervenes fairly smoothly with the loss of waking Protected by copyright. drives. The state of sleep allows the psychic repre- consciousness but a partial form of consciousness is sentatives of these drives to emerge as wishes and restored in the dream state where now a 'dream ego' impulses. Censorship is reduced by the state of sleep can be recognized that differs in certain ways from but is not lost and the dream represents the accept- the waking ego. able compromise between the primitive drive and the Under certain conditions this smooth onset of requirements of conscience and the censor. The sleep does not occur. Probably we all remember how, result of this 'dream work' is the dream. Already in as children, lying hot and sick in bed, the wallpaper 1900 Freud understood that the dream represents a begins to approach and to recede, we feel giddy as if wakening of the sleeper, hence the dictum that the sinking or floating, sometimes feeling sick, though dream is the guardian of sleep. This dictum should sometimes this has a pleasant feeling to it. The mouth, now be reversed as EEG studies show that REM hands and skin all feel different, there is a doughy, periods are the necessary background for dreaming; crumbly feeling of fullness in the mouth, which is sleep, therefore, is the guardian of the dream. He strange and unusual. Paying attention to these emphasized the motor paralysis that accompanies phenomena does not make them disappear, thinking http://pmj.bmj.com/ the dream state so that the dreamer has no access to of them afterwards will often vividly recall the motility and therefore is safe from carrying out sensations. The rhythm of near and far, larger and forbidden actions. Withdrawal of attention from the smaller, continues until we fall asleep. The acute external world brings about a greater exposure to the observer of these phenomena, Otto Isakower (1938), inner world of bodily and mental stimuli. The end whose name has been given to this state, pointed out result is not action but perception; in the waking its affinity with auras and dja4 vu, where a similar state perception leads to action. intensified self observation and preservation of a on September 23, 2021 by guest. The mental state in sleep: the dream ego. Federn certain distance from the experience, which is not (1953) has given us most sensitive and acute insights regarded as entirely real, pertain. He suggested that into this, for which we need to use his terminology. an 'estrangement' takes place between two parts of His term ego feeling defines 'a feeling of bodily and the ego, the body ego and the mental 'perceptual' mental relation in respect to time and content', ego; the latter remains more awake and observes how and is related to the continuity in time, space and the other has already regressed a long way back to a causality of the person. It is subjective experience of perceptual experience organized under the influence many ego functions synthesized into a feeling of of an early 'mouth dominated' experience like that of unity. Many waking and -going to sleep experiences a suckling babe that is falling asleep at the breast. can be differentiated by applying Federn's concepts. This breast fluctuates in experienced size as the He discriminated between a 'mental' ego and a infant loses grasp of consciousness. Attention is 'body' ego feeling. The body ego is a compound withdrawn from outside to inside, the distinction 28 Malcolm Pines Postgrad Med J: first published as 10.1136/pgmj.52.603.26 on 1 January 1976. Downloaded from

between what is me and what is not me, which exists the presence of both internal and external reality; only in a rudimentary form in a small baby, is then we proceed to integrate these dual aspects of a progressively lost. The child or adult is in fact single reality and finally become aware of conflicting hallucinating an experience 'as if I have the breast' needs, for instance whether to go on sleeping or to and thereby regains in comforting what has arise. Having mastered this exquisite and tormenting in fact been lost, yet which remains for us the prime choice I rise triumphant, displaying the highest levels symbol of comfort. Later, Bertram Lewin (1946, of will power of the day, reassuming the mantle of 1948, 1950), writing of the process of sleep onset of self (though sometimes I wonder if a greater display the suckling babe, described a merger with the breast of will would be to stay in bed rather than to arise, where the experience is of sinking into it, as it were mere slave to destiny). being 'swallowed up' in a pleasurable manner; Before EEG studies confirmed it, many analysts alternatively the babe may imagine himself to have were aware of a sleeping-waking cycle at night. internalized nipple and breast or bottle, his source of Jekels (1945) pointed out, following Freud, that we bliss, and is falling asleep as it were in total possession know the dreamer as one who is awake in sleep, who of what to us as observers is external and part of is active in this phase of sleep and that the whole mother but which to him is entirely his and part of state of sleep is one of differing levels of activities, him. According to Lewin's very acute dream obser- from active withdrawal to active awakening. He vations the visual perception of the flattened breast emphasized that sleep represents a threat to the unity surface which is the last waking impression of the and continuity of the personality and that we are babe is taken into his perceptual world. It flattens threatened by a loss of self in sleep. In analytic out and becomes the 'screen' upon which are pro- terminology the ego partly merges with the id, jected his dream images. (Just so does the pampered returning whence it came. To our waking selves there passenger waft through the air on a celestial jumbo, is something here of the threat of death, loss of watching on a screen whatever we project on to it of differentiation and loss of self. Just as the schizo-Protected by copyright. our own adult synthetic dreams.) In some dreams phrenic patient will feel that the world is dying when this very screen is seen blank, or we may suddenly in reality it is his own ego that is becoming threatened see this dream screen rolling up and disappearing. It and weakened by withdrawal ofenergy or by eruption may appear as a gelatinous film or as a blank page or from the layers of the , so does record. Lewin suggested that the screen is the mental sleep threaten us with death. 'Sleep, the death ofeach representative of the wish to sleep and to remain day's life' (Macbeth: Shakespeare). The Greeks gave asleep. The dream stimuli, which are in fact the to Hermes a dual aspect, that of bringer of sleep and 'awakeners', appear on the screen as the dream dreams and that of the chthonic god, the bringer of images. Above a certain intensity of stimulation the death (Death and his Brother Sleep: Shelley). dreamer will awaken, particularly ifthe person's body Wakening is a restitution of the ego and a return to is experienced with marked definition and strength in life. Even in sleep we awaken periodically to re- his outlines and actions during the dream. It is as if assert our 'selves'. Jekels suggests that it is through the body ego, normally dormant and almost non- this process of constant wakening in sleep that our existent in dreams, has been re-awakened, recathec- 'collapsed' egos contact the images of others during http://pmj.bmj.com/ ted, vested with psychic energy and with this drive to dreams and prepare us thereby to reassert our claim motility the sleeper awakens. Thus, the dream ego is on life so that by morning we may return to life closer to the mental ego than the body ego. Body thoroughly equipped with both will power and a contours in dreams are usually less complete, if they readiness for action. In terms of our poetic psycho- are represented at all. Although in dreams we meet analytical theory of instincts, the life instincts and well defined other persons there is no feeling of death instincts hold alternate sway during sleep and

strangeness attached to the fact that we lack clear once only does the victory pass to the latter. on September 23, 2021 by guest. definition ourselves (Federn, 1953). Studies of The sleep awakedness boundary establishes for the wakening (Fedem, 1953; Grotjahn, 1942; Isakower, infant its early sense of the reality of the external 1954; Grand and Pardes, 1974) show that these world and differentiates it from hallucination and different ego functions can recover sequentially: first dream. The external world provides real gratifica- we regain contact with and recognition of our bodies, tions and frustrations. This process is valvular the stranger in the bed becomes myself and is linked (Lewin, 1949): the external world penetrates deep up with the sense of my mental existence and con- into the sleep world, but the opposite process of tinuity with myself: I look to see where did I put my emergence of the sleep world into the waking world watch, my glasses, to see what time it is, perhaps to is prevented by some mental mechanisms. Should see who that is who shares my bed. Thus first we these break down we see the major waking dream of regain possession of the body ego, then of the mental schizophrenia or the minor waking dreams of dis- ego and its functions of cognition, of awareness of turbed ideation and effects; sometimes states of A psychoanalytic view ofsleep 29 Postgrad Med J: first published as 10.1136/pgmj.52.603.26 on 1 January 1976. Downloaded from depersonalization or of frustration and rage which a a catatonic state indicating the enormous tension patient will bring to a session later can be traced to struggle not to give way to outbursts of destructive the aftermath of a dream. Such dream effects pene- rage. On some occasions this defence failed and she trate into the waking world more easily during was driven to attack me physically. This patient also states of pre-menstrual tension. Lewin has reported clearly showed that extinction of consciousness on manic patients whose manic behaviour seems to occurs when, in fantasy, all life is destroyed, both in represent a repressed dream content that follows on a inner and outer worlds. She had a very great fear of 'blank' dream. Strange though it may seem, there are lying on the couch and allowing herself access, via some powerful resemblances between the manic state introspection, to the contents of the mind. For and the dream state in that in both there is a loss of months at a time she had to sit tensely in an armchair mental structure. In the dream clinging tightly to it with indrawn legs as if to attain merge; in the manic state it is the ego and superego some degree of security in limited space; the un- that lose their differentiation and thereby the patient bounded space of the couch with its invitation to feels that all bounty is rightfully his and no restraint relaxation of tight control of mental processes need exist. This resembles the wish fulfilment dreams threatened loss of control ofego boundaries that had of the small child. Thus the manic patient is living a to be maintained by a constant state of arousal and pathological wish fulfilment dream full of by paranoid scrutiny of the environment. Once on of pain and loss. Similarly a state of elation may moving back to the couch after months in the chair follow sleep of the 'benign stupor' state which itself she recited a horrifying caricature of a 'listen with may follow a consciously or dream experienced wish mother' story in which the children listening to the to be dead. story were all slaughtered, thrown out of the window Dreams that reveal frank primitive wishes of incest with their brains splashing on to the pavement or of murder may lead to 'vast careers' of denial below; then their mothers too were slaughtered, then leading eventually to drug-induced stupors or to their fathers, then the radio speakers, followed by the Protected by copyright. hypomania. The fear of sleep leads to a pathological whole population of the world and finally even sleep substitute for it is self-induced, that is a self- God died; at that point when her world was emptied induced magically controlled sleep state through the of all other persons and the overwhelming destruc- use of drugs or alcohol. tive rage threatened 'ego-extinction', to destroy the Disturbed sleep. Sleep as a reaction to and escape last vestiges of self she fell into a deep slumber. from emotional stress can be observed directly in The same patient also demonstrated vividly to me psychoanalytic sessions. The shift to the sleep end of a soundly established analytic finding, that sleep the continuum of sleep wakefulness can be studied withdrawal is a defence against a to an directly, and observations have been reported from infantile state of fascinated arousal with terrifying early in the history of (Ferenczi, fantasies of parental sexual intercourse, the 'primal 1914; Davison, 1945; Stone, 1947). There is general scene'. First described by Freud in the 'Wolf Man' agreement that sleep appears as a defence against the case history (Freud, 1918) this finding has received threat of emergence of frightening impulses and frequent confirmation. The reconstruction is that the fantasies, often of destructive rage or of sexual infant is awakened by the sound and sometimes by http://pmj.bmj.com/ submission, that consciousness is lost and motility the sight of parental intercourse, but the infant abandoned as a safeguard against conscious aware- construes this as a savage and frightening assault by ness and the actual danger of impulsive action. Some one parent upon the other, frequently as a castration authors maintain that this withdrawal state repre- and that the infant, highly aroused by this stimula- sents a hypnosis-like phenomenon rather than a true tion, attempts to resort to sleep as a defence, al- sleep state, though it may pass into sleep proper though the sleep may now be disturbed by dreams or

(Fliess, 1953; Dickes, 1965; Silber, 1970). nightmares in which the psychic stimulation con- on September 23, 2021 by guest. A patient of mine frequently lost consciousness in tinues, but to some extent now bound by the dream- her sessions over a period of many months. She was work. Isakower (1938) suggested, and Fink (1967) constantly threatened by outbursts of rage, which confirmed, that the so-called Isakower phenomenon occurred most frequently towards the end ofsessions. often appears as a defence against the emergence of She would fall 'asleep' when she was still lying on the primal scene material and that a regression to the couch or else sleep supervened with narcoleptic-like security of the hallucinated maternal breast is sought suddenness during the move from couch to door. The for as a reassurance. The wish to stay asleep so as not 'sleep' was profound and rousing was often difficult. to witness coitus is often paralleled in the session by On some occasions when I had to leave her and the patient's unwillingness to 'see' what is becoming returned an hour or two later she would still be clear in the analytic material. In mypatient's analysis, lying motionless in the same position as she had episodes have occurred where following dreams and fallen. Sometimes the rigidity of the body resembled fantasies have made it abundantly clear that she 30 Malcolm Pines Postgrad Med J: first published as 10.1136/pgmj.52.603.26 on 1 January 1976. Downloaded from was beginning to experience the most intense jealous Some theories as to the basic nature of sleep and rage towards her parents, and towards me, in the have been derived from these studies, yet for their ability to produce babies and still sleep retains its ancient elusive magic. that this jealousy led to painful, now conscious fantasies of destroying infants and myself through smashing heads in. This became acted out through References paranoid tirades against me for to understand DAVISON, C. (1945) Disturbances of sleep mechanism. failing Psychoanalytic Quarterly, 14, 478. her which I experienced as having my mind ham- DICKES, R. (1965) The defensive function of an altered state mered in. Reciprocally my voice and words were of consciousness -a hypnoid state. Journal ofthe American experienced by her as painful intolerable assaults Psychoanalytical Association, 13, 356. upon her ears and upon her mind. now FEDERN, P. (1953) and Psychosis (Ed. by E. Thus, though Weiss). Imago Publishing Co., London. in the waking state, the repressed, warded off FERENCZI, S. (1914) On falling asleep during analysis. In: fantasies were acted out without the patient recog- Further Contributions to the Theory and Technique of nizing what she was doing and avoiding contact with Psychoanalysis. International Psychoanalytic Library, her painful past memories-'the return of the No. 11, London, Hogarth Press. FINK, G. (1967) An analysis of the Isakower phenomenon. repressed'. Journal of the American Psychoanalytical Association, 15, Sleep in the analytic session can also represent 281. progressive moves. This was pointed out by Scott FISHER, C. (1965) Psychoanalytic implications of recent (1952). He observed that in some patients the research on sleep and dreaming. Journal of the American Psychoanalytical Association, 13, 2, 197. regressive sleep state and the fantasies accompanying FLIESS, R. (1963) The hypnotic invasion: a clinical observa- wakening in the session led to a deepening of the tion. Psychoanalytic Quarterly, 22, 497. level of analysis and to fuller reconstructions of FREUD, S. (1900) The Interpretation of Dreams (Ed. by J. earlier infancy. He suggests asking the patient 'if you Strachey). Standard Edition, Vol. 4. Hogarth, London. FREUD, S. (1925) A Metapsychological Supplement to the fell asleep how would you wish to be awakened?' Theory of Dreams (Ed. by J. Strachey). Standard Edition,Protected by copyright. The patient's wish gives some indication of the wish Vol. 19, 219. Hogarth, London. fulfilment fantasies that he has of waking to a world FREUD, S. (1918) From the History of an Infantile . where pain is absent and satisfaction abundant and Standard Edition, Vol. 17. Hogarth, London. GRAND, S. & PARDES, H. (1974) The transition from sleep instant. He observed that the sleep in the session can to wakefulness: implications of the study of laboratory be a defence against the recall of either a sleep dream dream reports for the psychoanalytic situation. Journal of or a day dream. the American Psychoanalytical Association, 22, 1, 58. I believe that with the patient I have already cited, GROTJAHN, M. (1942) The process of awakening. Psycho- analytic Review, 19, 1. her capacity to fall asleep in a rage and then to be HARTMANN, E. (1973) The Functions ofSleep. Yale University awakened by me, finding herself covered with a rug Press. and offered care and concern helped to begin to form HAWKINS, P. (1970) Dream Research and Psychoanalytic a nucleus of a sense of safety in a relationship that Theory in Sleep and Dreaming (Ed. by E. Hartmann). International Psychiatry Clinics, Series 7. Little, Brown, could survive her omnipotent rage and that without Boston. this our relationship could not have been established. ISAKOWER, 0. 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Selected Writings of Bertram D. Lewin (Ed. by J. Arlow). on September 23, 2021 by guest. Psychoanalysts have contributed to the under- Psychoanalytic Quarterly Inc., New York. standing of sleep by studying: (1) the psychoanalytic LEWIN, B. (1948) Interferences from the dream screen. In: Selected Writings of Bertram D. Lewin (Ed. by J. situation and its relationship to sleep; (2) the sleep- Arlow). Psychoanalytic Quarterly Inc., New York. wakefulness continuum and the sleep-wakefulness LEWIN, B. (1950) Addenda to the theory of oral eroticism. cycle; (3) the normal processes offalling asleep and of In: Selected Writings of Bertram D. Lewin (Ed. by J. wakening; (4) the mental state of the sleeper and Arlow). Psychoanalytic Quarterly Inc., New York. LEWIN, B. (1949) Mania and sleep, In: Selected Writings of dreamer; (5) conditions that promote good sleep or Bertram D. Lewin (Ed. by J. Arlow). Psychoanalytic induce bad sleep; (6) the relationship of sleep and Quarterly Inc., New York. psychosis; (7) the experimental study of dreaming LEWIN, B. (1955) Dream psychology and the analytic and the place of dreaming in the economy of mental situation. In: Selected Writings of Bertram D. Lewin (Ed. byJ. Arlow). Psychoanalytic Quarterly Inc., New York. life; (8) the functions of sleep and dreaming in MEISSNER, W.W. (1968) Dreaming as a process. International infantile maturational processes. Journal of Psychoanalysis, 49, 1, 63. A psychoanalytic view ofsleep 31 Postgrad Med J: first published as 10.1136/pgmj.52.603.26 on 1 January 1976. Downloaded from

PROCEEDINGS (1942) Symposium on neurotic disturbances of STONE, L. (1947) Transference sleep in a neurosis with sleep. International Journal of Psychoanalysis, 23. duodenal ulcer. International Journal of Psychoanalysis, Scorr, C. (1952) Patients who sleep or look at the psycho- 28, 18. analyst during sessions. Technical considerations. Inter- ZETZEL, E. (1970) Is the domain of the psychological still national Journal of Psychoanalysis, 33, 465. floating? International Psychiatry Clinics, 7, 2. SILBER, A. (1970) Functional phenomenon. Historical concept, contemporary defence. Journal of the American Psychoanalytical Association, 18, 519. Protected by copyright. http://pmj.bmj.com/ on September 23, 2021 by guest.