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Psychiatric Expert Testimony: Emerging
Applications
Psychiatric Expert
Testimony: Emerging
Applications

Edited by Kenneth J. Weiss, MD

and
Clarence Watson, JD, MD

1
1
Oxford University Press is a department of the University of
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Published in the United States of America by
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All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the prior
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Inquiries concerning reproduction outside the scope of the above should be sent to the
Rights Department, Oxford University Press, at the address above.
You must not circulate this work in any other form
and you must impose this same condition on any acquirer.
Library of Congress Cataloging-in-Publication Data
Psychiatric expert testimony : emerging applications / edited by Kenneth J. Weiss,
Clarence Watson.
p.; cm.
Includes bibliographical references and index.
ISBN 978–0–19–934659–2 (alk. paper)
ISBN 978–0–19–934660–8 (updf)
ISBN 978–0–19–934661–5 (epub)
I. Weiss, Kenneth J. editor. II. Watson, Clarence, editor. [DNLM: 1. Forensic Psychiatry—
United States. 2. Brain—pathology—United States. 3. Criminal Law—United
States. 4. Criminals—psychology—United States. 5. Expert Testimony—United States.
W 740] RA1148 614.15—dc23
2014022899
This material is not intended to be, and should not be considered, a substitute for medical or other
professional advice. Treatment for the conditions described in this material is highly dependent on
the individual circumstances. And, while this material is designed to offer accurate information
with respect to the subject matter covered and to be current as of the time it was written, research
and knowledge about medical and health issues is constantly evolving and dose schedules for
medications are being revised continually, with new side effects recognized and accounted for
regularly. Readers must therefore always check the product information and clinical procedures
with the most up-to-date published product information and data sheets provided by the
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for any liability, loss or risk that may be claimed or incurred as a consequence of the use and/or
application of any of the contents of this material.
9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
CON TEN T S

Foreword  vii
by Robert L. Sadoff
Contributors  ix
Introduction  xi
by Kenneth J. Weiss and Clarence Watson

1. Expert Testimony: Legal Principles   1

Clarence Watson
2. Criminal Culpability: A Developmental Approach   14
Nicole Foubister and Frank K. Tedeschi
3. Child Sexual Abuse Investigations: What Every Expert Witness
Needs to Know   30
Julia Curcio-Alexander, Jacqueline Block Goldstein, and Kenneth J. Weiss
4. Stress, Trauma, and the Developing Brain   46
John K. Northrop and Steven J. Berkowitz
5. Autism Spectrum Disorder and Criminal Justice   67
Kenneth J. Weiss and Alexander R. N. Westphal
6. Using fMRI for Lie Detection: Ready for Court?   84
Octavio Choi
7. Sleep Disorders and Criminal Responsibility   102
Clarence Watson, Mark R. Pressman, and Kenneth J. Weiss
8. Neuroimaging and Criminal Culpability   122
Susan E. Rushing and Daniel D. Langleben
9. Chronic Traumatic Encephalopathy   136
Manish A. Fozdar and Helen M. Farrell
10. Designer Drugs and Criminal Responsibility   155
Samson Gurmu and Kenneth J. Weiss

Index  173
FORE WORD

BY ROBERT L . SA DOFF

The field of forensic psychiatry has grown significantly during the past
half-century. Rising from the few physicians who were referred to as alienists
in the 19th century, forensic psychiatry has become one of the major subspe-
cialties of psychiatry. Spurred by the inauguration of the American Academy
of Psychiatry and the Law in 1969, the field has burgeoned to include a
number of major professional organizations, scientific journals, and scores
of textbooks. Under the leadership of Dr. Richard Rosner, fellowship train-
ing in forensic psychiatry began in the 1980s and has led to a current 40
ACGME-accredited training programs in forensic psychiatry throughout the
country. Board certification in forensic psychiatry began with the American
Board of Forensic Psychiatry, and currently certification is authorized under
the aegis of the American Board of Psychiatry and Neurology.
Forensic psychiatry is but one of the many forensic sciences that are
essential to modern-day court cases in which scientific evidence is presented
in both civil and criminal cases. Standards for presenting expert psychiat-
ric testimony have developed through legislation, case law, and professional
organizations. The judge is the gatekeeper to prevent “junk science” from
being presented at trial, and rules have been developed to limit the testi-
mony of various professionals. In addition, professional organizations have
developed ethical guidelines under which their members must testify.
As the use of forensic specialists has grown, so has the need for training
and education in the emerging issues that confront the expert testifying in
court. Drs. Weiss and Watson have assembled a group of authors to illus-
trate the emerging issues for the forensic psychiatric expert. Dr. Weiss is a
senior forensic psychiatrist who has developed an expertise in the history
of medicine, psychiatry, and forensic psychiatry. Dr. Watson, who is also an
attorney, has used his integrative education to improve his skills in the field.
As the editors point out, most cases do not go to trial but are settled. The
forensic psychiatrist has multiple roles to play in civil and criminal cases
aside from testifying in court. The 4 major efforts by the forensic psychiatrist
are examining the plaintiff or defendant, writing a report, consulting with
attorneys, and testifying either at deposition or at trial. Increasingly, the role
of the forensic psychiatrist has become that of a consultant to the lawyer
or at times to the court. The forensic psychiatrist may use his or her educa-
tional skills in teaching lawyers, judges, or even juries emerging issues that
need clarification for a lay audience. Thus, it becomes increasingly important
for the forensic psychiatrist to have expertise in many areas of psychiatry.
However, the ethics of the American Academy of Psychiatry and the Law pro-
hibit the expert witness from testifying in areas beyond his or her expertise.
Training programs in forensic psychiatry have increased not only in number
but also in the scope of the educational experiences of the fellows in training.
This book highlights the emerging issues in forensic psychiatry that every
psychiatrist who enters the courtroom should be aware of before agreeing to
become an expert witness. Even though the expert witness is often a consul-
tant and does not testify, he or she still needs to know the issues surrounding
the case.
The growth of forensic psychiatry has accelerated and the field will con-
tinue to expand and develop in the future. The expert psychiatrist needs to
keep up with advances in the field as well as changes in the legal system.
There are pitfalls and areas of concern that need to be avoided or clearly
understood before entering the legal system. This book is essential for any-
one willing to provide expert testimony and advice to lawyers and judges.

Robert L. Sadoff, M.D. is Clinical Professor of Forensic Psychiatry and

Director, Forensic Psychiatry Fellowship Program, Perelman School of
Medicine, University of Pennsylvania.

[ viii ] Foreword
CONTRIB U TOR S

Steven J. Berkowitz, MD Nicole Foubister, MD

Associate Professor of Clinical Assistant Professor Child and
Psychiatry and Director Adolescent Psychiatry
The Penn Center for Youth and Assistant Professor Psychiatry
Family Trauma Response New York University School of
University of Pennsylvania, Medicine
Perelman School of Medicine NYU Child Study Center
Adjunct Associate Professor Department of Child and
Yale University Child Study Center Adolescent Psychiatry
Department of Psychiatry NYU College of Arts & Science
Octavio Choi, MD, PhD Manish A. Fozdar, MD
Assistant Professor Triangle Forensic Neuropsychiatry,
Department of Psychiatry PLLC
Oregon Health and Science Consulting Assistant Professor
University of Psychiatry, Duke University
Medical Center
Julia Curcio-Alexander, PhD
Adjunct Associate Professor,
Supervising Psychologist and
Campbell University
Coordinator of Evaluation Services
Joseph J. Peters Institute Jacqueline Block Goldstein,
Philadelphia MSW
Associate Director and Child
Helen M. Farrell, MD
Forensic Interviewer
Forensic Psychiatrist and Instructor
Philadelphia Children’s Alliance
Department of Psychiatry
Harvard Medical School
Psychiatrist
Beth Israel Deaconess Medical Center
Boston
Samson Gurmu, MD Susan E. Rushing, MD, JD
Forensic Psychiatrist Department of Psychiatry
State of New Jersey Department of Perelman School of Medicine
Human Services University of Pennsylvania
Division of Mental Health and
Frank K. Tedeschi, MD
Addiction Services at the Ann
Clinical Assistant Professor
Klein Forensic Center
Department of Child and
West Trenton
Adolescent Psychiatry
New Jersey
New York University School of
Daniel D. Langleben, MD Medicine
Associate Professor of Psychiatry and
and Distinguished Research Attending Psychiatrist
Fellow Department of Child and
Annenberg Public Policy Center Adolescent Psychiatry
Perelman School of Medicine Bellevue Hospital, New York
University of Pennsylvania
Clarence Watson, JD, MD
John K. Northrop, MD, PhD Clinical Assistant Professor
Clinical Associate Department of Psychiatry
Department of Psychiatry Perelman School of Medicine
Perelman School of Medicine University of Pennsylvania
University of Pennsylvania
Kenneth J. Weiss, MD
Mark R. Pressman, PhD Clinical Professor
Licensed Psychologist Department of Psychiatry
Sleep Medicine Services Perelman School of Medicine
and University of Pennsylvania
Clinical Professor
Alexander R. N. Westphal,
Lankenau Institute for Medical
MD, PhD
Research
Assistant Professor
The Lankenau Hospital
Department of Psychiatry
Wynnewood, PA
Yale School of Medicine
Clinical Professor of Medicine
Jefferson Medical College
Adjunct Professor of Law
Villanova University

[ x ] Contributors
IN TROD U C T ION

BY K ENNETH J. W EISS A ND CL A R ENCE WATSON

The psychiatric expert witness: boon to jurisprudence or necessary evil?

From our own perspective, we fly the banner of enlightening courts with
science. To civil plaintiffs’ attorneys, we can be the key to a big payoff; to
their defense counterparts, we can be a means to keep purse strings tight.
Prosecutors in criminal cases count on us to find no link between mental
state and behavior, whereas defense attorneys trust that science will explain
or even excuse deviance. Judges, meanwhile, run the gamut from cynical
to adulatory. How the public regards us is often a matter of which sensa-
tional trial appears on television. More often than not, scientific witnesses,
especially in mental health, are viewed as scripted performers in a “battle of
the experts.” Yet, psychiatry appears wedded to jurisprudence and we must
make the best of it—or choose to observe from the sidelines. We trust that,
by reading the contributions to this volume, clinicians will be better pre-
pared to engage in medicolegal matters.

PSYCHIATRIC EXPERTISE: WHAT MAKES IT FORENSIC?

The word forensic, the adjective of the Latin forum, refers to matters in the
public sphere, such as the market or court. Often conflated with the more
famous forensic pathology, forensic psychiatry and psychology are not stud-
ies of death. They are applications of psychiatry and psychology, each having
its own professional body of literature, training, and accreditation. Mental
health professionals and other expert witnesses are visitors to an alien planet
when they enter the legal arena. Those of us who specialize in forensic work
can become comfortable with the language, procedures, and overall feeling
of legal proceedings. Still, experts who are accustomed to being “captain of
the ship” in their own domains may be jolted by differences between mental
health treatment settings and litigation.
 Implied in the word forensic, mental health applications to litigation
(criminal or civil) are conducted in a public setting. In contrast to the sanc-
tity of the therapeutic encounter, once a person’s mental state is brought into
legal proceedings, what was private is no longer so. Of course, there are lim-
its, restrictions, and ethical constraints on certain disclosures. Nevertheless,
raising mental health issues, especially in adversarial proceedings, can put
intimate—even shameful—details of someone’s life under a microscope. For
this reason, it is not advisable for mental health professionals to blur roles
by giving expert testimony for their own clients, a situation referred to as
“wearing two hats.”1 The two-hats problem diminishes objectivity when tes-
tifying about one’s patient and can have a disruptive effect on the therapeu-
tic relationship.

EXPERT WITNESSES: HISTORICAL AND CULTUR AL ASPECTS

Justice systems have used expert witnesses for centuries. In America,

applied scientific knowledge emerged and accelerated through the 19th cen-
tury. Perceiving that there was money to be made, attorneys and experts
often abused the system by offering opinions that lacked scientific integrity.
Although psychiatric matters were hardly the only application, since our sub-
ject matter was not immediately perceptible to the average person, psychi-
atric experts have often been the subject of suspicion if not outright scorn.
Europeans understood experts as aids to justice. Accordingly, our counter-
parts may wonder what all the fuss is about—why our experts are exhaus-
tively vetted and often kept on a short leash. Our understanding, in part,
is based on the tension between science and the law, a subject too big and
philosophical to cover here. The tension has to do with the differential rates
of change between law (slow) and science (fast, and accelerating). Scientists,
eager to apply knowledge to litigation, among other things, feel the need to
drag legal proceedings into the current century, whereas legislatures and
jurists act as gatekeepers, so that science does not lead the law. Our position,
as seasoned professionals, is that both sides are right. It is not the purpose
of this book to analyze jurisprudence or to influence legislatures as much as
it is to help potential expert witnesses find the right combination of science
and timing to ensure that what they say is in the interest of justice. Too little
science makes us look out of step with other fields, whereas premature appli-
cations may be like lead balloons.
Trial attorneys cannot convey scientific evidence by themselves. Expert
witnesses are required to educate judges and juries, who are considered lay-
persons in relation to the field of inquiry. It is not enough for a criminal
defense lawyer, for example, to suggest to the jury that the manifestly dis-
turbed defendant (at the defense table responding to hallucinations) could

[ xii ] Introduction
not have been sane at the time of a homicide. No, an expert witness must
provide a diagnosis and “connect the dots” between this condition and the
legal standard for criminal responsibility in that jurisdiction (there are dif-
ferences from state to state). It would make sense that a court could appoint
an expert to provide this indispensible function. History tells us, however,
that there is great resistance from lawyers to dispense with partisan experts.
There was a huge spike in using forensic expertise in the 19th century,
coupled with extensive treatises on forensic medicine, toxicology, and the
jurisprudence of insanity.2–4 The culture of American jurisprudence shifted
toward misuse of experts, many of whom lacked credentials and personal
integrity.5 To a degree, the justice system has never fully recovered. Whenever
there is a battle of the experts, citizens tend to look on it as more of a circus
than a truth-seeking venture. One of this book’s objectives is to push the tide
the other way.
Tension is also found in the interplay between the ends of justice, the
march of science, the manner in which experts interpret science, and trends
in societal values. This is best illustrated in a succession of cases of the insan-
ity defense in England6 and in America. Before 1800, traditional jurispru-
dence was that mental excuses for behavior were to be reserved for those
whose capacities were no keener than those of a wild beast. But in 1800,
a deluded James Hadfield shot at King George of England and was acquit-
ted. This thrust the “delusion test” for insanity into the forefront of juris-
prudence, to the dismay of Parliament. The legislature quickly passed a law
permitting the confinement of insanity acquittees, and Hadfield spent his
remaining 40 years in institutions.
Then in 1840, it was Queen Victoria’s turn to face a madman, when
Edward Oxford attempted to assassinate her with pistols. Oxford was found
insane and confined for decades. Three years later, a deluded Scotsman,
Daniel M’Naghten, believing he was shooting Prime Minister Robert Peal,
shot his secretary, Mr. Drummond. By then, defense attorney Cockburn
took advantage of an American textbook, Isaac Ray’s A Treatise on the Medical
Jurisprudence of Insanity.4 Indeed, M’Naghten was acquitted by reason of
insanity, which created tension in Buckingham Palace and Parliament. The
House of Lords quickly responded to restrict the use of the insanity defense,
creating M’Naghten’s Rules. The surviving rule, adopted by many states in
America, is a purely “cognitive” test: Acquittal depends on a thought disorder
causing a “defect of reason” such that, at the time of the act in question, the
defendant did not know that the behavior was wrong. This narrow defini-
tion of insanity continues to be a problem for expert witnesses, who might
want to introduce evidence of emotional or impulse-control disorders into a
defense—and may even demonstrate the basis for them via neuroimaging.
In America, the insanity standard came into focus when John Hinckley
shot President Reagan in 1981. At that time, the federal standard for insanity

Introduction [ xiii ]
included both cognitive (appreciating wrongfulness) and volitional (reduced
ability to conform one’s behavior) prongs. Hinckley was acquitted in his 1982
trial, where an early use of psychiatric testimony based on brain computed
tomography findings was permitted after a difficult process. More impor-
tant, the public outrage at the acquittal, despite Hinckley’s civil commitment,
gave rise to the Insanity Defense Reform Act of 1984. This Act restricted
the role of the expert witness and has been viewed as an aid to prosecutors.
Meanwhile, there is no constitutionally mandated right to an insanity plea
for criminal defendants and, as of 2012, the U.S. Supreme Court has declined
to consider the matter.7 Kansas, Montana, Idaho, and Utah have abolished
insanity pleas, further restricting the possibility of expert witnesses shed-
ding light on criminal behavior.

OPINING ON THE TRUTH: HOLY GR AIL OR

THE FATE OF ICARUS?

Might it be possible to dispense with partisan experts in favor of neutral

conveyors of scientific knowledge? Can scientists be trusted to say, for exam-
ple, if a witness is lying? What about the credibility of a victim’s assertions?
These types of questions have vexed practitioners, courts, and legal scholars
for many years. In practice, expert witnesses are not called to tell judges or
juries the underlying truth of a matter (e.g., guilt or innocence, liability, or
veracity). These are the ultimate issues, the exclusive province of fact find-
ers (judges and juries). It should not be the goal of scientists to replace the
jury system. Rather, we are expected to aid the fact finders by shedding light
on matters that are beyond ordinary knowledge. While the notion that an
expert witness can see the ultimate truth of a matter is seductive, it is not
in keeping with legal procedures and rules of evidence, as Dr. Watson will
review in the next chapter. When an expert witness gets too close to the
province of the fact finder, the testimony may be fatally flawed and barred
from the proceedings. Thus, what seemed to be a quest for the holy grail
could turn out to be an exercise in flying too close to the sun. Like Icarus, the
expert motivated by hubris will crash, and in doing so will damage the client.
Trial lawyers, criminal and civil, are often quick to import scientific knowl-
edge and techniques in support of legal arguments. X-radiation, for example,
was discovered by Roentgen in 1895 and applied to photography of interior
anatomy. Within a year, a patient had sued a doctor for malpractice, arguing
that the doctor had missed a leg fracture sustained in a fall, diagnosed as
a soft-tissue injury. The Colorado case Smith v. Grant was the first in which
X-ray images played a role in determining a standard-of-care question.8 As
it was, malpractice suits were on the rise in turn-of-the-century America.
During the litigation, the court determined that, despite defense counsel’s

[ xiv ] Introduction
objection, photographs using the X-ray process could be produced as sec-
ondary evidence (only in conjunction with expert testimony), on a par with
maps and charts. The matter was settled, but the issues raised about seeking
deeper—or definitive—truth remain with us.9,10 Several of our authors will
discuss the problems and prospects for the use of indirect data in answering
legal questions. The main thing to remember is that these emerging technol-
ogies do not stand on their own as evidence; they support the expert’s opin-
ions, which must be defended sometimes in pretrial evidentiary hearings.
In the 19th century, psychiatrists provided expert testimony on their
observations of individuals. Rather than giving direct opinions on legal mat-
ters, they would respond to hypothetical (“what if”) questions. There was
little other science to shed light on questions of mental states. Phrenology,
dominant through much of the 19th century, did not make its way into the
courtroom by way of a psychiatric defense.11 Yet, the search for indirect
markers of psychological truth remained an elusive goal. The most famous
example of this is the use of the polygraph as a means of lie detection. Other
20th-century techniques, such as hypnosis and narcosis (truth serum), have
had their day but remain controversial because the results tend to border on
the forbidden area of prejudicing the jury. Inferential data from the auto-
nomic nervous system, such as from the polygraph, have a clinical truth but
lack forensic power. The universal phenomenon of blushing may indicate
many things; this is the subject of a recent book.12 As legendary Harvard psy-
chiatry professor Dr. Elvin Semrad used to say, “The autonomic nervous sys-
tem doesn’t lie.” That may be true in the treatment context, where blushing
or dry mouth betrays the patient’s words. But we think that Dr. Semrad, who
likely was never cross-examined, would agree that courts require a different
type of truth, one that is usually beyond the reach of the testifying expert.
Besides, as criminologist Adrian Raine points out, psychopaths lie with their
autonomic nervous systems as well as through their mouths.13 So much for
clinical impressionism!
In the early 20th century, Harvard psychologist Hugo Münsterberg, intent
on applying science to the courtroom, touted a scientific method for verify-
ing eyewitness testimony.14 After a series of psychology experiments using
word-association analysis, he believed he had broken through the barrier
between the laboratory and the real world, thus initiating forensic psychol-
ogy. Professor Münsterberg, otherwise known for originating applied and
forensic psychologies in America, was severely criticized, setting back the
use of expert testimony in cases of questionable memory. The most severe
criticism came from John H. Wigmore, dean of Northwestern Law School,
whose name is virtually synonymous with the law of evidence. Around the
same time, Swiss psychiatrist C. G. Jung researched a word-association test
as a clinical shortcut to uncover neurotic complexes. Sigmund Freud, skepti-
cal of Jung’s methods, belittled his colleague while lecturing to a group of

Introduction [ xv ]
law students in Vienna in 1906.15,16 Freud took a dim view of forensic applica-
tions of psychoanalytic theory and generally refused to participate in trials.
He knew intuitively the difference between psychological theory and forensi-
cally robust testimony.
The idea of technologically aided truth finding will be echoed in this vol-
ume. First, Clarence Watson will review the standards for scientific certainty,
including the Frye17 test for general acceptance of scientific findings and the
Daubert18 test for admissibility. In the 1923 D.C. Circuit Court opinion in
U.S. v. Frye, the proposed scientific lie detection (systolic blood pressure eleva-
tion) was rejected as evidence because it lacked acceptance within the scientific
community. In Chapter 6, Octavio Choi will review the iterations of lie detec-
tion and the circumstances under which expert testimony can be admitted.
The search for truth goes on, but will it be found in brain function or structure?

THE WORK PRODUCT

Expert witnesses rarely enter the courtroom, because more than 9 out
of 10 cases, civil and criminal, do not result in trials. The reason is sim-
ple: Settlements are often a safer course than placing one’s fate in the hands
of strangers. On the civil side, a negotiated or arbitrated settlement means
that the injured party, the plaintiff, will receive monetary damages in a
smaller amount than hoped. The defendant, by settling, will have eliminated
the possibility of a huge jury award. On the criminal side, a settled case means
that the defendant has accepted responsibility for an unlawful act, but often
one that carries a smaller sentence (e.g., for assault with a weapon rather
than attempted murder). The settlement, when approved by the parties and
the judge, ends the litigation and precludes a trial. This outcome, however,
does not eliminate the role of expert witnesses. To the contrary: Experts may
be crucial in bringing closure to these difficult situations.
If most cases are never tried, why would we bother to write about expert
testimony? By testimony we are referring to the totality of the expert’s work
product. Some professionals serve as “consulting experts,” who assist attor-
neys on the sidelines and never issue reports or testimony. Most profes-
sionals engaged by attorneys are “testifying experts,” who form scientific
opinions on matters before the court, put their findings into written reports,
and provide live testimony under oath in depositions or trials.
By far the most prevalent type of work product is the written report.
Indeed, more often than not, the expert report is the only work product in a
case; its importance cannot be overestimated. The psychiatric expert report
has been the standard since the 19th century and is the subject of a book of
its own.19 As Clarence Watson will explain in Chapter 1, most expert medical
opinions, psychiatric or otherwise, must be expressed to a level of confidence

[ xvi ] Introduction
called “reasonable medical certainty” (or a variant, such as reasonable scien-
tific certainty or probability). Over the years, legal authorities have arrived
at this convention, which, simply stated, says that experts must state that
it is more likely than not that there is a causal relationship in the matter at
hand—for example, that the motor vehicle accident caused traumatic stress,
or that schizophrenia caused a cognitive defect that prevented someone from
knowing that an otherwise criminal act was wrong. Sometimes this conven-
tion is called the 51% rule, although generally we would not use a quantitative
description; it is just understood by the lawyers and judge. A higher thresh-
old of certainty is required in civil commitment, where there is a potential for
deprivation of liberty by virtue of what we say. By contrast, the expert witness’
burden is never as high as that of a criminal juror, who, to vote for conviction
of a defendant, must find that the prosecution proved its case beyond a reason-
able doubt. Legal authorities recognize that scientific testimony cannot be held
to that standard. Even fingerprint analysis20 and polygraphic lie detection21 are
not infallible and can be challenged, but do not stand alone as proof.
It is clear that expert witnesses play a supporting role in trials, although
sometimes that role is the center of attention. This is true in medical malprac-
tice cases, where the parties and trier of fact look to experts to define whether
the defendant clinician’s actions were above or below an acceptable level of
competence (standard of care). We will not be focusing on malpractice mat-
ters in this book. How, then, does the expert witness apply his or her educa-
tion, specialized knowledge, skill, and experience to legal matters? Unlike
the medical setting that asks us a health-related question, the legal setting
always engages us with a legal question. We are rarely expected to answer the
legal question itself—only to shed light on it so that a jury or judge can decide.
Examples of typical legal questions are: Does an individual have the mental
capacity to enter into a contract? Was an employee injured by the actions of
the employer? Is a criminal defendant’s mental illness a bar to participating in
a trial? Although one can see how expert testimony would play a pivotal role
in aiding the decision maker, the witness is always subservient to the court
(judge) and its officers (attorneys). The fact that there are usually expert opin-
ions on both sides of cases should keep us humble. However, it does not always
prevent some experts from acting arrogant or grandiose, which can be harmful
to the case and to the profession. And while many expert witnesses in adver-
sarial settings identify with the cause of the party that hired them, assuming
the role of combatant may reduce objectivity and scientific credibility.

ETHICS AND THE EXPERT WITNESS

The persuasive power of the expert witness must be used with caution and
mindfulness. As Robert Sadoff has urged, the expert must try to be efficacious

Introduction [ xvii ]
while minimizing harm.22 Aware of the need for professional standards and
the importance of maintaining credibility in non-healthcare settings, the
professions of forensic psychiatry and forensic psychology have developed
ethical guidelines.23,24 Because the aim of this book is to familiarize forensic
practitioners with emerging applications, we would be remiss if we did not
review essential ethics. It is especially relevant to review ethics when we con-
template using scientific information that might be considered speculative.
The expert witness must remember to stay a step back from any emotional
attachment to a diagnostic tool or interviewing technique to ensure that the
focus of the testimony is on the legal question and not on self-promotion.
The following are key tenets of forensic psychiatric ethics, excerpted from
the guidelines published by the American Academy of Psychiatry and the
Law (AAPL).23
The AAPL ethics guidelines begin by acknowledging the complex-
ity and role ambiguity created by physicians working within legal set-
tings: “Psychiatrists in a forensic role are called upon to practice in a manner
that balances competing duties to the individual and to society. In doing so,
they should be bound by underlying ethical principles of respect for persons,
honesty, justice, and social responsibility”.”23
The fact of a shift in the forensic psychiatrist’s role from healthcare pro-
vider to objective evaluator does not lessen or eliminate the need for confi-
dentiality. While it may be true that placing one’s mental state into litigation
renders the information public to a degree, forensic professionals are bound
to adhere to enhanced requirements for privacy and declaration of intent.
Thus, the AAPL guidelines call for the following:25

• “Psychiatrists should maintain confidentiality to the extent possible,

given the legal context.”
• “Special attention should be paid to the evaluee’s understanding of medi-
cal confidentiality.”
• “A forensic evaluation requires notice to the evaluee and to collateral
sources of reasonably anticipated limitations on confidentiality.”
• “Information or reports derived from a forensic evaluation are subject to
the rules of confidentiality that apply to the particular evaluation, and
any disclosure should be restricted accordingly.”

Practically speaking, the subject of the evaluation (or legally authorized

representative) will need to know that there is no treatment relationship,
that the information will be shared, and, if applicable, that the results of
the assessment could be used by the adverse party in the litigation. The indi-
vidual’s consent should be obtained, except when the assessment has been
court ordered. In that case, the subject should also be informed of the conse-
quences of refusal to cooperate.

[ xviii ] Introduction
 The AAPL guidelines call for honesty and striving for objectivity: “The
adversarial nature of most legal processes presents special hazards for the
practice of forensic psychiatry . . . Psychiatrists should not distort their opin-
ion in the service of the retaining party.”25 Adherence to these principles
requires self-awareness and vigilance. The main pitfalls are overidentifi-
cation with the retaining attorney’s legal position and the shading of one’s
position to earn more.25 Basing financial compensation to the expert on the
outcome of the case (contingency fee), for example, is forbidden. Another
way to ensure objectivity is for the expert to conduct comprehensive evalu-
ations: “Psychiatrists practicing in a forensic role enhance the honesty and
objectivity of their work by basing their forensic opinions, forensic reports
and forensic testimony on all available data.”25 Thus, the cherry-picking of
data or the intentional disregard of information that could conflict with the
referring attorney’s goal lacks integrity. While it may be ethical for lawyers to
do so (with the exception of criminal prosecutors), our code tells us otherwise.
As we discuss emerging applications of psychiatry to the law, the ques-
tion may arise in the reader’s mind as to whether to get involved in a case
requiring knowledge outside of general psychiatry (e.g., polysomnogra-
phy, brain development, or neuroimaging): “Expertise in the practice of
forensic psychiatry should be claimed only in areas of actual knowledge,
skills, training, and experience. When providing expert opinion, reports,
and testimony, psychiatrists should present their qualifications accurately
and precisely.” 25 A treating psychiatrist may send a patient to a diagnostic
radiologist for brain imaging and use the reading to guide therapy. A more
confident clinician will also read the images. However, when it comes to
using meaningful interpretations of images to answer legal questions, the
clinician as expert witness must either be prepared to explain thoroughly
the science and technology behind the imaging technique or to delegate
it to a neuroradiologist. In terms of representing one’s credentials, the
radiologist will not pretend to give a behavioral analysis of the findings
and the psychiatrist will not overclaim expertise on technical matters.
The AAPL guidelines add that “there are areas of special expertise, such
as the evaluation of children, persons of foreign cultures, or prisoners,
that may require special training or expertise.” 25 Thus, as you explore the
potential applications in this book, bear in mind that testimony must be
backed up by technical knowledge or specialized experience that will hold
up to cross-examination.

EMERGING APPLICATIONS: A PREVIEW

Our theme is integration of mental health expertise into civil and criminal
proceedings. Each chapter can stand alone as a review of a type of litigation

Introduction [ xix ]
requiring expert testimony. We encourage all readers to read Chapter 1 first,
to be grounded in the rules of the game. Beyond that, readers can explore
the applications as need or interest arises. We have incorporated DSM-5
nomenclature into these discussions, since finding a common clinical lan-
guage is often a key to formulating and communicating forensic opinions.
Throughout the book we have avoided a prescriptive approach, understand-
ing that each practitioner will incorporate current practice and case law into
reasonably evidence-based reports and testimony. We urge all practitioners
to consult local statutes and court opinions in preparation of their work
product, as the examples given here may not be applicable in all jurisdictions.
In Chapter 1, Clarence Watson will discuss the rules governing expert tes-
timony: when experts are used, what their qualifications must be, and, to a
degree, what they can say. It is important to remember that these rules (e.g.,
the Federal Rules of Evidence) were invented by lawyers in the interest of jus-
tice. That is, we experts do not make the rules—but we must conform to them.
You may indeed be the world’s expert in a scientific matter, but your opinions
on a legal matter may be rejected. How is this possible? As Dr. Watson explains,
the rules governing expert witnesses tell us that testimony must be helpful to
the “trier of fact” (jury or judge) without prejudicing the outcome—in addition
to being scientifically sound. The importance of this principle, for the purposes
of this book, cannot be overemphasized. Our contributors will be discussing
applications of psychiatric testimony that may be challenged as, for example,
too prejudicial or ahead of their time in terms of scientific weight.
We continue the specific content areas with chapters that include two
broad categories: human developmental perspectives in illuminating legal
issues (Chapters 2 through 5) and technological advances that support
expert testimony in emerging fields of interest (Chapters 6 through 10). In
Chapter 2, Nicole Foubister and Frank Tedeschi discuss how knowledge of
human psychological development informs testimony about children and
adolescents. This is increasingly important, as the distinctions between the
juvenile and adult brain structure and functioning are played out in court-
rooms and legislatures. In Chapter 3, Julia Curcio-Alexander, Jacqueline
Block Goldstein, and Kenneth Weiss explore child sexual abuse by way of
interpreting victims’ behavior. They note the phenomenon of “accommoda-
tion” of the victim, which can lead to difficulty prosecuting the perpetrator.
The question they discuss is how clinical evidence of accommodation (such
as denial or recantation) can be expressed in court without the testimony
being considered incriminating against the defendant. In Chapter 4, John
Northrop and Steven Berkowitz add the special circumstances of adverse
childhood experiences and early trauma to the discussion of brain develop-
ment as it pertains to morality, impulse control, and accountability. While it
may sound like a cliché to associate a deprived childhood with later antisocial
behavior, we now have science to back it up. The authors take the position that

[ xx ] Introduction
adverse childhood experiences are, in fact, brain injuries. They also empha-
size that labels, such as posttraumatic stress disorder, are often insufficient
to describe the downstream effects of maltreatment, as manifestations may
take multiple forms. Translating that for juries may make big differences in
outcomes, when culpability is in question. In Chapter 5, Kenneth Weiss and
Alexander Westphal assess our knowledge of autism spectrum disorder as
it applies to analysis of criminal responsibility. The apparent lack of empa-
thy in autism spectrum disorder is a defect in Theory of Mind, distinguished
from the callousness in psychopathy. The authors emphasize the importance
of making this distinction for judges and juries.
Turning to more technology-based applications, we begin with Octavio
Choi’s discussion of neuroimaging and lie detection in Chapter 6. The question
has now become: To what degree can expert witnesses speak to juries with-
out invading their territory of truth finding? This is a deep and leading-edge
subject that forces us to focus on the borders of science and behavior. The
science behind lie detection has evolved since the era of word-association
and systolic blood pressure tests. Here, Dr. Choi focuses on functional MRI
imaging and takes us to the current limits of knowledge and legal admis-
sibility. Clarence Watson, Mark Pressman, and Kenneth Weiss in Chapter 7
discuss scientific knowledge about parasomnias as they apply to analyses of
criminal responsibility. How we measure consciousness and the capacity for
criminal intent may be affected by disorders of sleep. While the law tells us
that sleeping persons are incapable of committing crimes, the proof of sleep
has become an intriguing challenge. In Chapter 8, Susan Rushing and Daniel
Langleben explain how brain imaging can increase insight into human
behavior in criminal and civil cases. The resulting testimony must conform
to the rules of evidence and must not be substituted for ordinary clinical
analysis. Increasingly, courts have been interested in measurable param-
eters of brain development that inform sentencing and how culpability is
decided. In Chapter 9, Manish Fozdar and Helen Farrell raise forensic issues
in an especially active area of clinical concern: chronic traumatic encepha-
lopathy. This condition may give rise to criminal and civil litigation and has
become a fertile area for expert witnesses. Of special interest is the relation-
ship between sports-induced chronic traumatic encephalopathy and claims
that team owners, football helmet makers, and sports leagues share liability
for possible dementia-related outcomes. Samson Gurmu and Kenneth Weiss
take on the emerging interface of designer drugs and criminal responsibility
in Chapter 10. Although there is little guidance from case law, the authors
outline the potential avenues criminal defendants might take to diminish
criminal responsibility. There is no civil right to present a defense of intoxi-
cation, but when someone uses new substances with unknown effects, can a
claim be made for involuntary intoxication? Here, as in other chapters, the
authors will discuss types of testimony from both sides of the case.

Introduction [ xxi ]
 Whereas the rules of evidence are not the domain of science, expert
witnesses have responsibilities to maintain scientific integrity and to help
triers of fact with their difficult jobs. There are many ways to assist legal
processes, and each witness will develop a style that is ethical and informa-
tive. Accordingly, we have embraced an approach that explores each subject
without being prescriptive or formulaic. We urge readers to use the informa-
tion within these chapters as a launching point for fashioning reports and
testimony, not necessarily as a blueprint for constructing the work product.
It is our wish and that of the contributors to assist the justice system by dem-
onstrating scientific progress while maintaining respect for legal traditions.

REFERENCES

1. Strasberger LH, Gutheil TG, Brodsky A. On wearing two hats: role conflict in
serving as both psychotherapist and expert witness. Am J Psychiatry. 1997;
154(4): 448–456.
2. Beck TR. Elements of Medical Jurisprudence. Albany, NY: Webster & Skinners; 1823.
3. Wharton F, Stillé M. A Treatise on Medical Jurisprudence. Philadelphia, PA:
Kay & Brother; 1855.
4. Ray I. A Treatise on the Medical Jurisprudence of Insanity. Boston, MA: Chas.
Little & Jas. Brown; 1838.
5. Mohr JC. Doctors and the Law: Medical Jurisprudence in Nineteenth-Century
America. Baltimore, MD: The Johns Hopkins University Press; 1993.
6. Eigen JP. Witnessing Insanity: Madness and Mad-Doctors in the English Court.
New Haven, CT: Yale University Press; 1995.
7. Morse SJ, Bonnie RJ. Abolition of the insanity defense violates due process.
J Am Acad Psychiatry Law. 2013; 41(4): 488–495.
8. Goldberg DS. The transformative power of X-rays in U.S. scientific & medical
litigation: mechanical objectivity in Smith v. Grant (1896). Perspect Science.
2013; 21(1): 23–57.
9. Golan T. Laws of Men and Laws of Nature: The History of Scientific Expert Testimony
in England and America. Cambridge, MA: Harvard University Press; 2004.
10. Weiss KJ. Head, examined: Clarence Darrow’s X-ray vision of criminal respon-
sibility. J Psychiatry Law. 2011; 39: 627–661.
11. Weiss KJ. Isaac Ray at 200: phrenology and expert testimony. J Am Acad
Psychiatry Law. 2007; 35(3): 339–345.
12. Crozier WR, de Jong PJ, eds. The Psychological Significance of the Blush.
New York: Cambridge University Press; 2013.
13. Raine A. The Anatomy of Violence. New York: Random House; 2013.
14. Münsterberg H. On the Witness Stand: Essays on Psychology and Crime.
New York: Doubleday, Page & Co.; 1909.
15. Freud S: Psycho-analysis and the establishment of the facts in legal proceed-
ings (1906). The Standard Edition of the Complete Psychological Works of Sigmund
Freud, vol. 9. Edited and translated by J. Strachey. London: The Hogarth Press;
1959: 103–114 (editor’s notes, pp. 99–102).

[ xxii ] Introduction
16. Weiss KJ. Classics in psychiatry and the law: Francis Wharton on involuntary
confessions. J Am Acad Psychiatry Law 2012; 40: 67–80.
17. Frye v. U.S. 293 F. 1013 (D.C. Cir. 1923).
18. Daubert v. Merrell Dow Pharmaceuticals, Inc. 509 U.S. 579, 113 (1992).
19. Buchanan A, Norko MA. The Psychiatric Report: Principles and Practice of Forensic
Writing. Cambridge, UK: Cambridge University Press; 2011.
20. Saks MJ. The legal and scientific evaluation of forensic science (espe-
cially fingerprint expert testimony). Seton Hall Law Review. 2003;
33(4): 1167–1187.
21. Grubin D. The polygraph and forensic psychiatry. J Am Acad Psychiatry Law.
2010; 38(4): 446–451.
22. Sadoff RL. Ethical Issues in Forensic Psychiatry: Minimizing Harm. Chichester,
UK: John Wiley & Sons, Ltd; 2011.
23. American Academy of Psychiatry and the Law. Ethics guidelines for the prac-
tice of forensic psychiatry, adopted May 2005. Available online at www.aapl.
org/ethics.htm. These guidelines are supplemental to the American Psychiatric
Association’s annotations to the American Medical Association’s general
ethics.
24. American Psychological Association. Specialty guidelines for forensic psychol-
ogy. Am Psychol. 2013; 68(1): 7–19.
25. Mnookin JL. Expert evidence, partisanship, and epistemic competence.
Brooklyn Law Review. 2008; 73(3): 1009–1033.

Introduction [ xxiii ]
Random documents with unrelated
content Scribd suggests to you:
and incoherence of dreams through a partial forgetting of what we
have known during the day.
One might even think of reducing the phenomenon of dreaming to
that of memory, and of regarding the dream as the manifestation of
an activity of reproduction which does not rest even at night, and
which is an end in itself. Views like those expressed by Pilcz[51] would
corroborate this, according to which intimate relations are
demonstrable between the time of dreaming and the contents of the
dream from the fact that the impressions reproduced by the dream in
sound sleep belong to the remotest past while those reproduced
towards morning are of recent origin. But such a conception is
rendered improbable from the outset by the manner of the dream’s
behaviour towards the material to be remembered. Strümpell[66]
justly calls our attention to the fact that repetitions of experiences do
not occur in the dream. To be sure the dream makes an effort in that
direction, but the next link is wanting, or appears in changed form,
or it is replaced by something entirely novel. The dream shows only
fragments of reproduction; this is so often the rule that it admits of
theoretical application. Still there are exceptions in which the dream
repeats an episode as thoroughly as our memory would in its waking
state. Delbœuf tells of one of his university colleagues who in his
dream repeated, with all its details, a dangerous wagon ride in which
he escaped accident as if by miracle. Miss Calkins[12] mentions two
dreams, the contents of which exactly reproduced incidents from the
day before, and I shall later take occasion to report an example which
came to my notice, showing a childish experience which returned
unchanged in a dream.[F]
(c) Dream Stimuli and Dream Sources.—What is meant by dream
stimuli and dream sources may be explained by referring to the
popular saying, “Dreams come from the stomach.” This notion
conceals a theory which conceives the dream as a result of a
disturbance of sleep. We should not have dreamed if some disturbing
element had not arisen in sleep, and the dream is the reaction from
this disturbance.
The discussion of the exciting causes of dreams takes up the most
space in the descriptions of the authors. That this problem could
appear only after the dream had become an object of biological
investigation is self-evident. The ancients who conceived the dream
as a divine inspiration had no need of looking for its exciting source;
to them the dream resulted from the will of the divine or demoniacal
powers, and its content was the product of their knowledge or
intention. Science, however, soon raised the question whether the
stimulus to the dream is always the same, or whether it might be
manifold, and thus led to the question whether the causal
explanation of the dream belongs to psychology or rather to
physiology. Most authors seem to assume that the causes of the
disturbance of sleep, and hence the sources of the dream, might be of
various natures, and that physical as well as mental irritations might
assume the rôle of dream inciters. Opinions differ greatly in
preferring this or that one of the dream sources, in ranking them,
and indeed as to their importance for the origin of dreams.
Wherever the enumeration of dream sources is complete we
ultimately find four forms, which are also utilised for the division of
dreams:—

I. External (objective) sensory stimuli.

II. Internal (subjective) sensory stimuli.
III. Internal (organic) physical excitations.
IV. Purely psychical exciting sources.
I. The External Sensory Stimuli.—The younger Strümpell, son of
the philosopher whose writings on the subject have already more
than once served us as a guide in the problem of dreams, has, as is
well known, reported his observations on a patient who was afflicted
with general anæsthesia of the skin and with paralysis of several of
the higher sensory organs. This man merged into sleep when his few
remaining sensory paths from the outer world were shut off. When
we wish to sleep we are wont to strive for a situation resembling the
one in Strümpell’s experiment. We close the most important sensory
paths, the eyes, and we endeavour to keep away from the other
senses every stimulus and every change of the stimuli acting upon
them. We then fall asleep, although we are never perfectly successful
in our preparations. We can neither keep the stimuli away from the
sensory organs altogether, nor can we fully extinguish the irritability
of the sensory organs. That we may at any time be awakened by
stronger stimuli should prove to us “that the mind has remained in
constant communication with the material world even during sleep.”
The sensory stimuli which reach us during sleep may easily become
the source of dreams.
There are a great many stimuli of such nature, ranging from those
that are unavoidable, being brought on by the sleeping state or at
least occasionally induced by it, to the accidental waking stimuli
which are adapted or calculated to put an end to sleep. Thus a strong
light may force itself into the eyes, a noise may become perceptible,
or some odoriferous matter may irritate the mucous membrane of
the nose. In the spontaneous movements of sleep we may lay bare
parts of the body and thus expose them to a sensation of cold, or
through change of position we may produce sensations of pressure
and touch. A fly may bite us, or a slight accident at night may
simultaneously attack more than one sense. Observers have called
attention to a whole series of dreams in which the stimulus verified
on waking, and a part of the dream content corresponded to such a
degree that the stimulus could be recognised as the source of the
dream.
I shall here cite a number of such dreams collected by Jessen[36] (p.
527), traceable to more or less accidental objective sensory stimuli.
“Every indistinctly perceived noise gives rise to corresponding dream
pictures; the rolling of thunder takes us into the thick of battle, the
crowing of a cock may be transformed into human shrieks of terror,
and the creaking of a door may conjure up dreams of burglars
breaking into the house. When one of our blankets slips off at night
we may dream that we are walking about naked or falling into the
water. If we lie diagonally across the bed with our feet extending
beyond the edge, we may dream of standing on the brink of a
terrifying precipice, or of falling from a steep height. Should our head
accidentally get under the pillow we may then imagine a big rock
hanging over us and about to crush us under its weight.
Accumulation of semen produces voluptuous dreams, and local pain
the idea of suffering ill treatment, of hostile attacks, or of accidental
bodily injuries.”
“Meier (Versuch einer Erklärung des Nachtwandelns, Halle, 1758,
p. 33), once dreamed of being assaulted by several persons who
threw him flat on the ground and drove a stake into the ground
between his big and second toes. While imagining this in his dream
he suddenly awoke and felt a blade of straw sticking between his
toes. The same author, according to Hemmings (Von den Traumen
und Nachtwandeln, Weimar, 1784, p. 258) dreamed on another
occasion that he was being hanged when his shirt was pinned
somewhat tight around his neck. Hauffbauer dreamed in his youth of
having fallen from a high wall and found upon waking that the
bedstead had come apart, and that he had actually fallen to the
floor.... Gregory relates that he once applied a hot-water bottle to his
feet, and dreamed of taking a trip to the summit of Mount Ætna,
where he found the heat on the ground almost unbearable. After
having applied a blistering plaster to his head, a second man
dreamed of being scalped by Indians; a third, whose shirt was damp,
dreamed of being dragged through a stream. An attack of gout
caused the patient to believe that he was in the hands of the
Inquisition, and suffering pains of torture (Macnish).”
The argument based upon the resemblance between stimulus and
dream content is reinforced if through a systematic induction of
stimuli we succeed in producing dreams corresponding to the
stimuli. According to Macnish such experiments have already been
made by Giron de Buzareingues. “He left his knee exposed and
dreamed of travelling in a mail coach at night. He remarked in this
connection that travellers would well know how cold the knees
become in a coach at night. Another time he left the back of his head
uncovered, and dreamed of taking part in a religious ceremony in the
open air. In the country where he lived it was customary to keep the
head always covered except on such occasions.”
Maury[48] reports new observations on dreams produced in
himself. (A number of other attempts produced no results.)
1. He was tickled with a feather on his lips and on the tip of his
nose. He dreamed of awful torture, viz. that a mask of pitch was
stuck to his face and then forcibly torn off, taking the skin with it.
2. Scissors were sharpened on pincers. He heard bells ringing,
then sounds of alarm which took him back to the June days of 1848.
3. Cologne water was put on his nose. He found himself in Cairo in
the shop of John Maria Farina. This was followed by mad adventures
which he was unable to reproduce.
 4. His neck was lightly pinched. He dreamed that a blistering
plaster was put on him, and thought of a doctor who treated him in
his childhood.
5. A hot iron was brought near his face. He dreamed that
chauffeurs[G] broke into the house and forced the occupants to give
up their money by sticking their feet into burning coals. The Duchess
of Abrantés, whose secretary he imagined himself in the dream, then
entered.
6. A drop of water was let fall on his forehead. He imagined
himself in Italy perspiring heavily and drinking white wine of
Orvieto.
7. When a burning candle was repeatedly focussed on him through
red paper, he dreamed of the weather, of heat, and of a storm at sea
which he once experienced in the English Channel.
D’Hervey,[34] Weygandt,[75] and others have made other attempts to
produce dreams experimentally.
Many have observed the striking skill of the dream in interweaving
into its structure sudden impressions from the outer world in such a
manner as to present a gradually prepared and initiated catastrophe
(Hildebrandt)[35]. “In former years,” this author relates, “I
occasionally made use of an alarm clock in order to wake regularly at
a certain hour in the morning. It probably happened hundreds of
times that the sound of this instrument fitted into an apparently very
long and connected dream, as if the entire dream had been especially
designed for it, as if it found in this sound its appropriate and
logically indispensable point, its inevitable issue.”
I shall cite three of these alarm-clock dreams for another purpose.
Volkelt (p. 68) relates: “A composer once dreamed that he was
teaching school, and was just explaining something to his pupils. He
had almost finished when he turned to one of the boys with the
question: ‘Did you understand me?’ The boy cried out like one
possessed ‘Ya.’ Annoyed at this, he reprimanded him for shouting.
But now the entire class was screaming ‘Orya,’ then ‘Euryo,’ and
finally ‘Feueryo.’ He was now aroused by an actual alarm of fire in
the street.”
Garnier (Traité des Facultés de l’Âme, 1865), reported by
Radestock,[54] relates that Napoleon I., while sleeping in a carriage,
was awakened from a dream by an explosion which brought back to
him the crossing of the Tagliamento and the bombarding of the
Austrians, so that he started up crying, “We are undermined!”
The following dream of Maury[48] has become celebrated. He was
sick, and remained in bed; his mother sat beside him. He then
dreamed of the reign of terror at the time of the Revolution. He took
part in terrible scenes of murder, and finally he himself was
summoned before the Tribunal. There he saw Robespierre, Marat,
Fouquier-Tinville, and all the sorry heroes of that cruel epoch; he
had to give an account of himself, and, after all sort of incidents
which did not fix themselves in his memory, he was sentenced to
death. Accompanied by an enormous crowd, he was led to the place
of execution. He mounted the scaffold, the executioner tied him to
the board, it tipped, and the knife of the guillotine fell. He felt his
head severed from the trunk, and awakened in terrible anxiety, only
to find that the top piece of the bed had fallen down, and had actually
struck his cervical vertebra in the same manner as the knife of a
guillotine.
This dream gave rise to an interesting discussion introduced by Le
Lorrain[45] and Egger[20] in the Revue Philosophique. The question
was whether, and how, it was possible for the dreamer to crowd
together an amount of dream content apparently so large in the short
space of time elapsing between the perception of the waking stimulus
and the awakening.
Examples of this nature make it appear that the objective stimuli
during sleep are the most firmly established of all the dream sources;
indeed, it is the only stimulus which plays any part in the layman’s
knowledge. If we ask an educated person, who is, however,
unacquainted with the literature of dreams, how dreams originate,
he is sure to answer by referring to a case familiar to him in which a
dream has been explained after waking by a recognised objective
stimulus. Scientific investigation cannot, however, stop here, but is
incited to further research by the observation that the stimulus
influencing the senses during sleep does not appear in the dream at
all in its true form, but is replaced by some other presentation which
is in some way related to it. But the relation existing between the
stimulus and the result of the dream is, according to Maury,[47] “une
affinité quelconque mais qui n’est pas unique et exclusive” (p. 72). If
we read, e.g., three of Hildebrandt’s “Alarm Clock Dreams,” we will
then have to inquire why the same stimulus evoked so many different
results, and why just these results and no others.
(P. 37). “I am taking a walk on a beautiful spring morning. I
saunter through the green fields to a neighbouring village, where I
see the natives going to church in great numbers, wearing their
holiday attire and carrying their hymn-books under their arms. I
remember that it is Sunday, and that the morning service will soon
begin. I decide to attend it, but as I am somewhat overheated I also
decide to cool off in the cemetery surrounding the church. While
reading the various epitaphs, I hear the sexton ascend the tower and
see the small village bell in the cupola which is about to give signal
for the beginning of the devotions. For another short while it hangs
motionless, then it begins to swing, and suddenly its notes resound
so clearly and penetratingly that my sleep comes to an end. But the
sound of bells comes from the alarm clock.”
“A second combination. It is a clear day, the streets are covered
with deep snow. I have promised to take part in a sleigh-ride, but
have had to wait for some time before it was announced that the
sleigh is in front of my house. The preparations for getting into the
sleigh are now made. I put on my furs and adjust my muff, and at last
I am in my place. But the departure is still delayed, until the reins
give the impatient horses the perceptible sign. They start, and the
sleigh bells, now forcibly shaken, begin their familiar janizary music
with a force that instantly tears the gossamer of my dream. Again it is
only the shrill sound of my alarm clock.”
Still a third example. “I see the kitchen-maid walk along the
corridor to the dining-room with several dozen plates piled up. The
porcelain column in her arms seems to me to be in danger of losing
its equilibrium. ‘Take care,’ I exclaim, ‘you will drop the whole pile.’
The usual retort is naturally not wanting—that she is used to such
things. Meanwhile I continue to follow her with my worried glance,
and behold! at the door-step the fragile dishes fall, tumble, and roll
across the floor in hundreds of pieces. But I soon notice that the
noise continuing endlessly is not really a rattling but a true ringing,
and with this ringing the dreamer now becomes aware that the alarm
clock has done its duty.”
 The question why the dreaming mind misjudges the nature of the
objective sensory stimulus has been answered by Strümpell,[66] and
almost identically by Wundt,[76] to the effect that the reaction of the
mind to the attacking stimuli in sleep is determined by the formation
of illusions. A sensory impression is recognised by us and correctly
interpreted, i.e. it is classed with the memory group to which it
belongs according to all previous experience, if the impression is
strong, clear, and long enough, and if we have the necessary time at
our disposal for this reflection. If these conditions are not fulfilled,
we mistake the objects which give rise to the impression, and on its
basis we form an illusion. “If one takes a walk in an open field and
perceives indistinctly a distant object, it may happen that he will at
first take it for a horse.” On closer inspection the image of a cow
resting may obtrude itself, and the presentation may finally resolve
itself with certainty into a group of people sitting. The impressions
which the mind receives during sleep through outer stimuli are of a
similar indistinct nature; they give rise to illusions because the
impression evokes a greater or lesser number of memory pictures
through which the impression receives its psychic value. In which of
the many spheres of memory to be taken into consideration the
corresponding pictures are aroused, and which of the possible
association connections thereby come into force, this, even according
to Strümpell, remains indeterminable, and is left, as it were, to the
caprice of the psychic life.
We may here take our choice. We may admit that the laws of the
dream formation cannot really be traced any further, and therefore
refrain from asking whether or not the interpretation of the illusion
evoked by the sensory impression depends upon still other
conditions; or we may suppose that the objective sensory stimulus
encroaching upon sleep plays only a modest part as a dream source,
and that other factors determine the choice of the memory picture to
be evoked. Indeed, on carefully examining Maury’s experimentally
produced dreams, which I have purposely reported in detail, one is
apt to think that the experiment really explains the origin of only one
of the dream elements, and that the rest of the dream content
appears in fact too independent, too much determined in detail, to be
explained by the one demand, viz. that it must agree with the
element experimentally introduced. Indeed one even begins to doubt
the illusion theory, and the power of the objective impression to form
the dream, when one learns that this impression at times experiences
the most peculiar and far-fetched interpretations during the sleeping
state. Thus B. M. Simon[63] tells of a dream in which he saw persons
of gigantic stature[H] seated at a table, and heard distinctly the awful
rattling produced by the impact of their jaws while chewing. On
waking he heard the clacking of the hoofs of a horse galloping past
his window. If the noise of the horse’s hoofs had recalled ideas from
the memory sphere of “Gulliver’s Travels,” the sojourn with the
giants of Brobdingnag and the virtuous horse-creatures—as I should
perhaps interpret it without any assistance on the author’s part—
should not the choice of a memory sphere so uncommon for the
stimulus have some further illumination from other motives?
II. Internal (Subjective) Sensory Stimuli.—Notwithstanding all
objections to the contrary, we must admit that the rôle of the
objective sensory stimuli as a producer of dreams has been
indisputably established, and if these stimuli seem perhaps
insufficient in their nature and frequency to explain all dream
pictures, we are then directed to look for other dream sources acting
in an analogous manner. I do not know where the idea originated
that along with the outer sensory stimuli the inner (subjective)
stimuli should also be considered, but as a matter of fact this is done
more or less fully in all the more recent descriptions of the etiology of
dreams. “An important part is played in dream illusions,” says
Wundt[36] (p. 363), “by those subjective sensations of seeing and
hearing which are familiar to us in the waking state as a luminous
chaos in the dark field of vision, ringing, buzzing, &c., of the ears,
and especially irritation of the retina. This explains the remarkable
tendency of the dream to delude the eyes with numbers of similar or
identical objects. Thus we see spread before our eyes numberless
birds, butterflies, fishes, coloured beads, flowers, &c. Here the
luminous dust in the dark field of vision has taken on phantastic
figures, and the many luminous points of which it consists are
embodied by the dream in as many single pictures, which are looked
upon as moving objects owing to the mobility of the luminous chaos.
This is also the root of the great fondness of the dream for the most
complex animal figures, the multiplicity of forms readily following
the form of the subjective light pictures.”
 The subjective sensory stimuli as a source of the dream have the
obvious advantage that unlike the objective stimuli they are
independent of external accidents. They are, so to speak, at the
disposal of the explanation as often as it needs them. They are,
however, in so far inferior to the objective sensory stimuli that the
rôle of dream inciter, which observation and experiment have proven
for the latter, can be verified in their case only with difficulty or not
at all. The main proof for the dream-inciting power of subjective
sensory excitements is offered by the so-called hypnogogic
hallucinations, which have been described by John Müller as
“phantastic visual manifestations.” They are those very vivid and
changeable pictures which occur regularly in many people during the
period of falling asleep, and which may remain for awhile even after
the eyes have been opened. Maury,[48] who was considerably troubled
by them, subjected them to a thorough study, and maintained that
they are related to or rather identical with dream pictures—this has
already been asserted by John Müller. Maury states that a certain
psychic passivity is necessary for their origin; it requires a relaxation
of the tension of attention (p. 59). But in any ordinary disposition a
hypnogogic hallucination may be produced by merging for a second
into such lethargy, after which one perhaps awakens until this oft-
repeated process terminates in sleep. According to Maury, if one
awakens shortly thereafter, it is often possible to demonstrate the
same pictures in the dream which one has perceived as hypnogogic
hallucinations before falling asleep (p. 134). Thus it once happened
to Maury with a group of pictures of grotesque figures, with distorted
features and strange headdresses, which obtruded themselves upon
him with incredible importunity during the period of falling asleep,
and which he recalled having dreamed upon awakening. On another
occasion, while suffering from hunger, because he kept himself on a
rather strict diet, he saw hypnogogically a plate and a hand armed
with a fork taking some food from the plate. In his dream he found
himself at a table abundantly supplied with food, and heard the rattle
made by the diners with their forks. On still another occasion, after
falling asleep with irritated and painful eyes, he had the hypnogogic
hallucination of seeing microscopically small characters which he
was forced to decipher one by one with great exertion; having been
awakened from his sleep an hour later, he recalled a dream in which
there was an open book with very small letters, which he was obliged
to read through with laborious effort.
Just as in the case of these pictures, auditory hallucinations of
words, names, &c., may also appear hypnogogically, and then repeat
themselves in the dream, like an overture announcing the principal
motive of the opera which is to follow.
A more recent observer of hypnogogic hallucinations, G. Trumbull
Ladd,[40] takes the same path pursued by John Müller and Maury. By
dint of practice he succeeded in acquiring the faculty of suddenly
arousing himself, without opening his eyes, two to five minutes after
having gradually fallen asleep, which gave him opportunity to
compare the sensations of the retina just vanishing with the dream
pictures remaining in his memory. He assures us that an intimate
relation between the two can always be recognised, in the sense that
the luminous dots and lines of the spontaneous light of the retina
produced, so to speak, the sketched outline or scheme for the
psychically perceived dream figures. A dream, e.g., in which he saw
in front of him clearly printed lines which he read and studied,
corresponded to an arrangement of the luminous dots and lines in
the retina in parallel lines, or, to express it in his own words: “The
clearly printed page, which he was reading in the dream, resolved
itself into an object which appeared to his waking perception like
part of an actual printed sheet looked at through a little hole in a
piece of paper, from too great a distance to be made out distinctly.”
Without in any way under-estimating the central part of the
phenomenon, Ladd believes that hardly any visual dream occurs in
our minds that is not based on material furnished by this inner
condition of stimulation in the retina. This is particularly true of
dreams occurring shortly after falling asleep in a dark room, while
dreams occurring in the morning near the period of awakening
receive their stimulation from the objective light penetrating the eye
from the lightened room. The shifting and endlessly variable
character of the spontaneous luminous excitation of the retina
corresponds exactly to the fitful succession of pictures presented to
us in our dreams. If we attach any importance to Ladd’s
observations, we cannot underrate the productiveness of this
subjective source of excitation for the dream; for visual pictures
apparently form the principal constituent of our dreams. The share
furnished from the spheres of the other senses, beside the sense of
hearing, is more insignificant and inconstant.
III. Internal (Organic) Physical Excitation.—If we are disposed to
seek dream sources not outside, but inside, the organism, we must
remember that almost all our internal organs, which in their healthy
state hardly remind us of their existence, may, in states of excitation
—as we call them—or in disease, become for us a source of the most
painful sensations, which must be put on an equality with the
external excitants of the pain and sensory stimuli. It is on the
strength of very old experience that, e.g., Strümpell[66] declares that
“during sleep the mind becomes far more deeply and broadly
conscious of its connection with the body than in the waking state,
and it is compelled to receive and be influenced by stimulating
impressions originating in parts and changes of the body of which it
is unconscious in the waking state.” Even Aristotle[1] declares it quite
possible that the dream should draw our attention to incipient
morbid conditions which we have not noticed at all in the waking
state owing to the exaggeration given by the dream to the
impressions; and some medical authors, who were certainly far from
believing in any prophetic power of the dream, have admitted this
significance of the dream at least for the foretelling of disease.
(Compare M. Simon, p. 31, and many older authors.)
Even in our times there seems to be no lack of authenticated
examples of such diagnostic performances on the part of the dream.
Thus Tissié[68] cites from Artigues (Essai sur la Valeur séméiologique
des Réves), the history of a woman of forty-three years, who, during
several years of apparently perfect health, was troubled with anxiety
dreams, and in whom medical examination later disclosed an
incipient affection of the heart to which she soon succumbed.
Serious disturbances of the internal organs apparently act as
inciters of dreams in a considerable number of persons. Attention is
quite generally called to the frequency of anxiety dreams in the
diseases of the heart and lungs; indeed this relation of the dream life
is placed so conspicuously in the foreground by many authors that I
shall here content myself with a mere reference to the literature.
(Radestock,[54] Spitta,[64] Maury, M. Simon, Tissié.) Tissié even
assumes that the diseased organs impress upon the dream content
their characteristic features. The dreams of persons suffering from
diseases of the heart are generally very brief and terminate in a
terrified awakening; the situation of death under terrible
circumstances almost always plays a part in their content. Those
suffering from diseases of the lungs dream of suffocation, of being
crowded, and of flight, and a great many of them are subject to the
well-known nightmare, which, by the way, Boerner has succeeded in
producing experimentally by lying on the face and closing up the
openings of the respiratory organs. In digestive disturbances the
dream contains ideas from the sphere of enjoyment and disgust.
Finally, the influence of sexual excitement on the dream content is
perceptible enough in every one’s experience, and lends the strongest
support to the entire theory of the dream excitation through organic
sensation.
Moreover, as we go through the literature of the dream, it becomes
quite obvious that some of the authors (Maury,[48] Weygandt[75]) have
been led to the study of dream problems by the influence of their
own pathological state on the content of their dreams.
The addition to dream sources from these undoubtedly established
facts is, however, not as important as one might be led to suppose;
for the dream is a phenomenon which occurs in healthy persons—
perhaps in all persons, and every night—and a pathological state of
the organs is apparently not one of its indispensable conditions. For
us, however, the question is not whence particular dreams originate,
but what may be the exciting source for the ordinary dreams of
normal persons.
But we need go only a step further to find a dream source which is
more prolific than any of those mentioned above, which indeed
promises to be inexhaustible in every case. If it is established that the
bodily organs become in sickness an exciting source of dreams, and if
we admit that the mind, diverted during sleep from the outer world,
can devote more attention to the interior of the body, we may readily
assume that the organs need not necessarily become diseased in
order to permit stimuli, which in some way or other grow into dream
pictures, to reach the sleeping mind. What in the waking state we
broadly perceive as general sensation, distinguishable by its quality
alone, to which, in the opinion of the physicians, all the organic
systems contribute their shares—this general sensation at night
attaining powerful efficiency and becoming active with its individual
components—would naturally furnish the most powerful as well as
the most common source for the production of the dream
presentations. It still remains, however, to examine according to
what rule the organic sensations become transformed into dream
presentations.
The theory of the origin of dreams just stated has been the
favourite with all medical authors. The obscurity which conceals the
essence of our being—the “moi splanchnique,” as Tissié terms it—
from our knowledge and the obscurity of the origin of the dream
correspond too well not to be brought into relation with each other.
The train of thought which makes organic sensation the inciter of the
dream has besides another attraction for the physician, inasmuch as
it favours the etiological union of the dream and mental diseases,
which show so many agreements in their manifestations, for
alterations in the organic sensations and excitations emanating from
the inner organs are both of wide significance in the origin of the
psychoses. It is therefore not surprising that the theory of bodily
sensation can be traced to more than one originator who has
propounded it independently.
A number of authors have been influenced by the train of ideas
developed by the philosopher Schopenhauer in 1851. Our conception
of the universe originates through the fact that our intellect recasts
the impressions coming to it from without in the moulds of time,
space, and causality. The sensations from the interior of the
organism, proceeding from the sympathetic nervous system, exert in
the day-time an influence on our mood for the most part
unconscious. At night, however, when the overwhelming influence of
the day’s impressions is no longer felt, the impressions pressing
upward from the interior are able to gain attention—just as in the
night we hear the rippling of the spring that was rendered inaudible
by the noise of the day. In what other way, then, could the intellect
react upon these stimuli than by performing its characteristic
function? It will transform the stimuli into figures, filling space and
time, which move at the beginning of causality; and thus the dream
originates. Scherner,[58] and after him Volkelt,[72] attempted to
penetrate into closer relations between physical sensations and
dream pictures; but we shall reserve the discussion of these attempts
for the chapter on the theory of the dream.
 In a study particularly logical in its development, the psychiatrist
Krauss[39] found the origin of the dream as well as of deliria and
delusions in the same element, viz. the organically determined
sensation. According to this author there is hardly a place in the
organism which might not become the starting point of a dream or of
a delusion. Now organically determined sensations “may be divided
into two classes: (1) those of the total feeling (general sensations), (2)
specific sensations which are inherent in the principal systems of the
vegetative organism, which may be divided into five groups: (a) the
muscular, (b) the pneumatic, (c) the gastric, (d) the sexual, (e) the
peripheral sensations (p. 33 of the second article).”
The origin of the dream picture on the basis of the physical
sensations is conceived by Krauss as follows: The awakened
sensation evokes a presentation related to it in accordance with some
law of association, and combines with this, thus forming an organic
structure, towards which, however, consciousness does not maintain
its normal attitude. For it does not bestow any attention on the
sensation itself, but concerns itself entirely with the accompanying
presentation; this is likewise the reason why the state of affairs in
question should have been so long misunderstood (p. 11, &c.). Krauss
finds for this process the specific term of “transubstantiation of the
feeling into dream pictures” (p. 24).
That the organic bodily sensations exert some influence on the
formation of the dream is nowadays almost universally
acknowledged, but the question as to the law underlying the relation
between the two is answered in various ways and often in obscure
terms. On the basis of the theory of bodily excitation the special task
of dream interpretation is to trace back the content of a dream to the
causative organic stimulus, and if we do not recognise the rules of
interpretation advanced by Scherner,[58] we frequently find ourselves
confronted with the awkward fact that the organic exciting source
reveals itself in the content of the dream only.
A certain agreement, however, is manifested in the interpretation
of the various forms of dreams which have been designated as
“typical” because they recur in so many persons with almost the
same contents. Among these are the well-known dreams of falling
from heights, of the falling out of teeth, of flying, and of
embarrassment because of being naked or barely clad. This last
dream is said to be caused simply by the perception felt in sleep that
one has thrown off the bedcover and is exposed. The dream of the
falling out of teeth is explained by “dental irritation,” which does not,
however, of necessity imply a morbid state of excitation in the teeth.
According to Strümpell,[66] the flying dream is the adequate picture
used by the mind to interpret the sum of excitation emanating from
the rising and sinking of the pulmonary lobes after the cutaneous
sensation of the thorax has been reduced to insensibility. It is this
latter circumstance that causes a sensation related to the conception
of flying. Falling from a height in a dream is said to have its cause in
the fact that when unconsciousness of the sensation of cutaneous
pressure has set in, either an arm falls away from the body or a flexed
knee is suddenly stretched out, causing the feeling of cutaneous
pressure to return to consciousness, and the transition to
consciousness embodies itself psychically as a dream of falling.
(Strümpell, p. 118). The weakness of these plausible attempts at
explanation evidently lies in the fact that without any further
elucidation they allow this or that group of organic sensations to
disappear from psychic perception or to obtrude themselves upon it
until the constellation favourable for the explanation has been
established. I shall, however, later have occasion to recur to typical
dreams and to their origin.
From comparison of a series of similar dreams, M. Simon[63]
endeavoured to formulate certain rules for the influence of the
organic sensations on the determination of the resulting dream. He
says (p. 34): “If any organic apparatus, which during sleep normally
participates in the expression of an affect, for any reason merges into
the state of excitation to which it is usually aroused by that affect, the
dream thus produced will contain presentations which fit the affect.”
Another rule reads as follows (p. 35): “If an organic apparatus is in
a state of activity, excitation, or disturbance during sleep, the dream
will bring ideas which are related to the exercise of the organic
function which is performed by that apparatus.”
Mourly Vold[73] has undertaken to prove experimentally the
influence assumed by the theory of bodily sensation for a single
territory. He has made experiments in altering the positions of the
sleeper’s limbs, and has compared the resulting dream with his
alterations. As a result he reports the following theories:—
 1. The position of a limb in a dream corresponds approximately to
that of reality, i.e. we dream of a static condition of the limb which
corresponds to the real condition.
2. When one dreams of a moving limb it always happens that one
of the positions occurring in the execution of this movement
corresponds to the real position.
3. The position of one’s own limb may be attributed in the dream
to another person.
4. One may dream further that the movement in question is
impeded.
5. The limb in any particular position may appear in the dream as
an animal or monster, in which case a certain analogy between the
two is established.
6. The position of a limb may incite in the dream ideas which bear
some relation or other to this limb. Thus, e.g., if we are employed
with the fingers we dream of numerals.
Such results would lead me to conclude that even the theory of
bodily sensation cannot fully extinguish the apparent freedom in the
determination of the dream picture to be awakened.[I]
IV. Psychic Exciting Sources.—In treating the relations of the
dream to the waking life and the origin of the dream material, we
learned that the earliest as well as the latest investigators agreed that
men dream of what they are doing in the day-time, and of what they
are interested in during the waking state. This interest continuing
from waking life into sleep, besides being a psychic tie joining the
dream to life, also furnishes us a dream source not to be under-
estimated, which, taken with those stimuli which become interesting
and active during sleep, suffices to explain the origin of all dream
pictures. But we have also heard the opposite of the above assertion,
viz. that the dream takes the sleeper away from the interests of the
day, and that in most cases we do not dream of things that have
occupied our attention during the day until after they have lost for
the waking life the stimulus of actuality. Hence in the analysis of the
dream life we are reminded at every step that it is inadmissible to
frame general rules without making provision for qualifications
expressed by such terms as “frequently,” “as a rule,” “in most cases,”
and without preparing for the validity of the exceptions.
 If the conscious interest, together with the inner and outer sleep
stimuli, sufficed to cover the etiology of the dreams, we ought to be
in a position to give a satisfactory account of the origin of all the
elements of a dream; the riddle of the dream sources would thus be
solved, leaving only the task of separating the part played by the
psychic and the somatic dream stimuli in individual dreams. But as a
matter of fact no such complete solution of a dream has ever been
accomplished in any case, and, what is more, every one attempting
such solution has found that in most cases there have remained a
great many components of the dream, the source of which he was
unable to explain. The daily interest as a psychic source of dreams is
evidently not far-reaching enough to justify the confident assertions
to the effect that we all continue our waking affairs in the dream.
Other psychic sources of dreams are unknown. Hence, with the
exception perhaps of the explanation of dreams given by Scherner,[58]
which will be referred to later, all explanations found in the literature
show a large gap when we come to the derivation of the material for
the presentation pictures, which is most characteristic for the dream.
In this dilemma the majority of authors have developed a tendency
to depreciate as much as possible the psychic factor in the excitations
of dreams which is so difficult to approach. To be sure, they
distinguish as a main division of dreams the nerve-exciting and the
association dreams, and assert that the latter has its source
exclusively in reproduction (Wundt,[76] p. 365), but they cannot yet
dismiss the doubt whether “they do not appear without being
impelled by the psychical stimulus” (Volkelt,[72] p. 127). The
characteristic quality of the pure association dream is also found
wanting. To quote Volkelt (p. 118): “In the association dreams proper
we can no longer speak of such a firm nucleus. Here the loose
grouping penetrates also into the centre of the dream. The ideation
which is already set free from reason and intellect is here no longer
held together by the more important psychical and mental stimuli,
but is left to its own aimless shifting and complete confusion.”
Wundt, too, attempts to depreciate the psychic factor in the
stimulation of dreams by declaring that the “phantasms of the dream
certainly are unjustly regarded as pure hallucinations, and that
probably most dream presentations are really illusions, inasmuch as
they emanate from slight sensory impressions which are never
extinguished during sleep” (p. 338, &c.). Weygandt[75] agrees with
this view, but generalises it. He asserts that “the first source of all
dream presentations is a sensory stimulus to which reproductive
associations are then joined” (p. 17). Tissié[68] goes still further in
repressing the psychic exciting sources (p. 183): “Les rêves d’origine
absolument psychique n’existent pas”; and elsewhere (p. 6), “Les
pensées de nos rêves nous viennent de dehors....”
Those authors who, like the influential philosopher Wundt, adopt
a middle course do not fail to remark that in most dreams there is a
co-operation of the somatic stimuli with the psychic instigators of the
dream, the latter being either unknown or recognised as day
interests.
We shall learn later that the riddle of the dream formation can be
solved by the disclosure of an unsuspected psychic source of
excitement. For the present we shall not be surprised at the over-
estimation of those stimuli for the formation of the dream which do
not originate from psychic life. It is not merely because they alone
can easily be found and even confirmed by experiment, but the
somatic conception of the origin of dreams thoroughly corresponds
to the mode of thinking in vogue nowadays in psychiatry. Indeed, the
mastery of the brain over the organism is particularly emphasized;
but everything that might prove an independence of the psychic life
from the demonstrable organic changes, or a spontaneity in its
manifestations, is alarming to the psychiatrist nowadays, as if an
acknowledgment of the same were bound to bring back the times of
natural philosophy and the metaphysical conception of the psychic
essence. The distrust of the psychiatrist has placed the psyche under
a guardian, so to speak, and now demands that none of its feelings
shall divulge any of its own faculties; but this attitude shows slight
confidence in the stability of the causal concatenation which extends
between the material and the psychic. Even where on investigation
the psychic can be recognised as the primary course of a
phenomenon, a more profound penetration will some day succeed in
finding a continuation of the path to the organic determination of the
psychic. But where the psychic must be taken as the terminus for our
present knowledge, it should not be denied on that account.
(d) Why the Dream is Forgotten after Awakening.—That the
dream “fades away” in the morning is proverbial. To be sure, it is
capable of recollection. For we know the dream only by recalling it
after awakening; but very often we believe that we remember it only
incompletely, and that during the night there was more of it; we can
observe how the memory of a dream which has been still vivid in the
morning vanishes in the course of the day, leaving only a few small
fragments; we often know that we have been dreaming, but we do
not know what; and we are so well used to the fact that the dream is
liable to be forgotten that we do not reject as absurd the possibility
that one may have been dreaming even when one knows nothing in
the morning of either the contents or the fact of dreaming. On the
other hand, it happens that dreams manifest an extraordinary
retentiveness in the memory. I have had occasion to analyse with my
patients dreams which had occurred to them twenty-five years or
more previously, and I can remember a dream of my own which is
separated from the present day by at least thirty-seven years, and yet
has lost nothing of its freshness in my memory. All this is very
remarkable, and for the present incomprehensible.
The forgetting of dreams is treated in the most detailed manner by
Strümpell.[66] This forgetting is evidently a complex phenomenon; for
Strümpell does not explain it by a single reason, but by a
considerable number of reasons.
In the first place, all those factors which produce forgetfulness in
the waking state are also determinant for the forgetting of dreams.
When awake we are wont soon to forget a large number of sensations
and perceptions because they are too feeble, and because they are
connected with a slight amount of emotional feeling. This is also the
case with many dream pictures; they are forgotten because they are
too weak, while stronger pictures in proximity will be remembered.
Moreover, the factor of intensity in itself is not the only determinant
for the preservation of the dream pictures; Strümpell, as well as
other authors (Calkins), admits that dream pictures are often rapidly
forgotten, although they are known to have been vivid, whereas
among those that are retained in memory there are many that are
very shadowy and hazy. Besides, in the waking state one is wont to
forget easily what happened only once, and to note more easily
things of repeated occurrence. But most dream pictures are single
experiences,[J] and this peculiarity equally contributes towards the
forgetting of all dreams. Of greater significance is a third motive for
forgetting. In order that feelings, presentations, thoughts and the
like, should attain a certain degree of memory, it is important that
they should not remain isolated, but that they should enter into
connections and associations of a suitable kind. If the words of a
short verse are taken and mixed together, it will be very difficult to
remember them. “When well arranged in suitable sequence one word
will help another, and the whole remains as sense easily and firmly in
the memory for a long time. Contradictions we usually retain with
just as much difficulty and rarity as things confused and
disarranged.” Now dreams in most cases lack sense and order.
Dream compositions are by their very nature incapable of being
remembered, and they are forgotten because they usually crumble
together the very next moment. To be sure, these conclusions are not
in full accord with the observation of Radestock[54] (p. 168), that we
retain best just those dreams which are most peculiar.
According to Strümpell, there are still other factors effective in the
forgetting of dreams which are derived from the relation of the
dream to the waking state. The forgetfulness of the waking
consciousness for dreams is evidently only the counterpart of the fact
already mentioned, that the dream (almost) never takes over
successive memories from the waking state, but only certain details
of these memories which it tears away from the habitual psychic
connections in which they are recalled while we are awake. The
dream composition, therefore, has no place in the company of
psychic successions which fill the mind. It lacks all the aids of
memory. “In this manner the dream structure rises, as it were, from
the soil of our psychic life, and floats in psychic space like a cloud in
the sky, which the next breath of air soon dispels” (p. 87). This is also
aided by the fact that, upon awakening, the attention is immediately
seized by the inrushing sensory world, and only very few dream
pictures can withstand this power. They fade away before the
impressions of the new day like the glow of the stars before the
sunlight.
As a last factor favouring the forgetting of dreams, we may
mention the fact that most people generally take little interest in
their dreams. One who investigates dreams for a time, and takes a
special interest in them, usually dreams more during that time than
at any other; that is, he remembers his dreams more easily and more
frequently.
 Two other reasons for the forgetting of dreams added by Bonatelli
(given by Benini[3]) to those of Strümpell have already been included
in the latter; namely, (1) that the change of the general feeling
between the sleeping and waking states is unfavourable to the
mutual reproductions, and (2) that the different arrangement of the
presentation material in the dream makes the dream untranslatable,
so to speak, for the waking consciousness.
It is the more remarkable, as Strümpell observes, that, in spite of
all these reasons for forgetting the dream, so many dreams are
retained in memory. The continued efforts of the authors to
formulate laws for the remembering of dreams amounts to an
admission that here too there is something puzzling and unsolved.
Certain peculiarities relating to the memory of dreams have been
particularly noticed of late, e.g., that a dream which is considered
forgotten in the morning may be recalled in the course of the day
through a perception which accidentally touches the forgotten
content of the dream (Radestock,[54] Tissié[68]). The entire memory of
the dream is open to an objection calculated to depreciate its value
very markedly in critical eyes. One may doubt whether our memory,
which omits so much from the dream, does not falsify what it
retained.
Such doubts relating to the exactness of the reproduction of the
dream are expressed by Strümpell when he says: “It therefore easily
happens that the active consciousness involuntarily inserts much in
recollection of the dream; one imagines one has dreamt all sorts of
things which the actual dream did not contain.”
Jessen[36] (p. 547) expresses himself very decidedly: “Moreover we
must not lose sight of the fact, hitherto little heeded, that in the
investigation and interpretation of orderly and logical dreams we
almost always play with the truth when we recall a dream to
memory. Unconsciously and unwittingly we fill up the gaps and
supplement the dream pictures. Rarely, and perhaps never, has a
connected dream been as connected as it appears to us in memory.
Even the most truth-loving person can hardly relate a dream without
exaggerating and embellishing it. The tendency of the human mind
to conceive everything in connection is so great that it unwittingly
supplies the deficiencies of connection if the dream is recalled
somewhat disconnectedly.”
 The observations of V. Eggers,[20] though surely independently
conceived, sound almost like a translation of Jessen’s words: “...
L’observation des rêves a ses difficultés spéciales et le seul moyen
d’éviter toute erreur en pareille matière est de confier au papier sans
le moindre retard ce que l’on vient d’éprouver et de remarquer;
sinon, l’oubli vient vite ou total ou partiel; l’oubli total est sans
gravité; mais l’oubli partiel est perfide; car si l’on se met ensuite à
raconter ce que l’on n’a pas oublié, on est exposé à compléter par
imagination les fragments incohérents et disjoints fourni par la
mémoire ...; on devient artiste à son insu, et le récit, périodiquement
répété s’impose à la créance de son auteur, qui, de bonne foi, le
présente comme un fait authentique, dûment établi selon les bonnes
méthodes....”
Similarly Spitta,[64] who seems to think that it is only in our
attempt to reproduce the dream that we put in order the loosely
associated dream elements: “To make connection out of
disconnection, that is, to add the process of logical connection which
is absent in the dream.”
As we do not at present possess any other objective control for the
reliability of our memory, and as indeed such a control is impossible
in examining the dream which is our own experience, and for which
our memory is the only source, it is a question what value we may
attach to our recollections of dreams.
(e) The Psychological Peculiarities of Dreams.—In the scientific
investigation of the dream we start with the assumption that the
dream is an occurrence of our own psychic activity; nevertheless the
finished dream appears to us as something strange, the authorship of
which we are so little forced to recognise that we can just as easily
say “a dream appeared to me,” as “I have dreamt.” Whence this
“psychic strangeness” of the dream? According to our discussion of
the sources of dreams we may suppose that it does not depend on the
material reaching the dream content; because this is for the most
part common to the dream life and waking life. One may ask whether
in the dream it is not changes in the psychic processes which call
forth this impression, and may so put to test a psychological
characteristic of the dream.
No one has more strongly emphasized the essential difference
between dream and waking life, and utilised this difference for more
far-reaching conclusions, than G. Th. Fechner[25] in some
observations in his Elements of Psychophysic (p. 520, part 11). He
believes that “neither the simple depression of conscious psychic life
under the main threshold,” nor the distraction of attention from the
influences of the outer world, suffices to explain the peculiarities of
the dream life as compared with the waking life. He rather believes
that the scene of dreams is laid elsewhere than in the waking
presentation life. “If the scene of the psychophysical activity were the
same during the sleeping and the waking states, the dream, in my
opinion, could only be a continuation of the waking ideation
maintaining itself at a lower degree of intensity, and must moreover
share with the latter its material and form. But the state of affairs is
quite different.”
What Fechner really meant has never been made clear, nor has
anybody else, to my knowledge, followed further the road, the clue to
which he indicated in this remark. An anatomical interpretation in
the sense of physiological brain localisations, or even in reference to
histological sections of the cerebral cortex, will surely have to be
excluded. The thought may, however, prove ingenious and fruitful if
it can be referred to a psychic apparatus which is constructed out of
many instances placed one behind another.
Other authors have been content to render prominent one or
another of the tangible psychological peculiarities of the dream life,
and perhaps to take these as a starting point for more far-reaching
attempts at explanation.
It has been justly remarked that one of the main peculiarities of
the dream life appears even in the state of falling asleep, and is to be
designated as the phenomenon inducing sleep. According to
Schleiermacher[61] (p. 351), the characteristic part of the waking state
is the fact that the psychic activity occurs in ideas rather than in
pictures. But the dream thinks in pictures, and one may observe that
with the approach of sleep the voluntary activities become difficult in
the same measure as the involuntary appear, the latter belonging
wholly to the class of pictures. The inability for such presentation
work as we perceive to be intentionally desired, and the appearance
of pictures which is regularly connected with this distraction, these
are two qualities which are constant in the dream, and which in its
psychological analysis we must recognise as essential characters of
the dream life. Concerning the pictures—the hypnogogic
hallucinations—we have discovered that even in their content they
are identical with the dream pictures.
The dream therefore thinks preponderately, but not exclusively, in
visual pictures. It also makes use of auditory pictures, and to a lesser
extent of the impressions of the other senses. Much is also simply
thought or imagined (probably represented by remnants of word
presentations), just as in the waking state. But still what is
characteristic for the dream is only those elements of the content
which act like pictures, i.e. which resemble more the perceptions
than the memory presentations. Disregarding all the discussions
concerning the nature of hallucinations, familiar to every
psychiatrist, we can say, with all well-versed authors, that the dream
hallucinates, that is, replaces thoughts through hallucinations. In
this respect there is no difference between visual and acoustic
presentations; it has been noticed that the memory of a succession of
sounds with which one falls asleep becomes transformed while
sinking into sleep into an hallucination of the same melody, so as to
make room again on awakening, which may repeatedly alternate
with falling into a slumber, for the softer memory presentations
which are differently formed in quality.
The transformation of an idea into an hallucination is not the only
deviation of the dream from a waking thought which perhaps
corresponds to it. From these pictures the dream forms a situation, it
presents something in the present, it dramatises an idea, as Spitta[64]
(p. 145) puts it.[K] But the characteristic of this side of the dream life
becomes complete only when it is remembered that while dreaming
we do not—as a rule; the exceptions require a special explanation—
imagine that we are thinking, but that we are living through an
experience, i.e., we accept the hallucination with full belief. The
criticism that this has not been experienced but only thought in a
peculiar manner—dreamt—comes to us only on awakening. This
character distinguishes the genuine sleeping dream from day
dreaming, which is never confused with reality.
The characteristics of the dream life thus far considered have been
summed up by Burdach[8] (p. 476) in the following sentences: “As
characteristic features of the dream we may add (a) that the
subjective activity of our mind appears as objective, inasmuch as our
faculty of perception perceives the products of phantasy as if they
were sensory activities ... (b) sleep abrogates one’s self-command,
hence falling asleep necessitates a certain amount of passivity.... The
slumber pictures are conditioned by the relaxation of one’s self-
command.”
It is a question now of attempting to explain the credulity of the
mind in reference to the dream hallucinations, which can only
appear after the suspension of a certain arbitrary activity.
Strümpell[66] asserts that the mind behaves in this respect correctly,
and in conformity with its mechanism. The dream elements are by
no means mere presentations, but true and real experiences of the
mind, similar to those that appear in the waking state as a result of
the senses (p. 34). Whereas in the waking state the mind represents
and thinks in word pictures and language, in the dream it represents
and thinks in real tangible pictures (p. 35). Besides, the dream
manifests a consciousness of space by transferring the sensations
and pictures, just as in the waking state, into an outer space (p. 36).
It must therefore be admitted that the mind in the dream is in the
same relation to its pictures and perceptions as in the waking state
(p. 43). If, however, it is thereby led astray, this is due to the fact that
it lacks in sleep the criticism which alone can distinguish between the
sensory perceptions emanating from within or from without. It
cannot subject its pictures to the tests which alone can prove their
objective reality. It furthermore neglects to differentiate between
pictures that are arbitrarily interchanged and others where there is
no free choice. It errs because it cannot apply to its content the law of
causality (p. 58). In brief, its alienation from the outer world
contains also the reason for its belief in the subjective dream world.
Delbœuf[16] reaches the same conclusion through a somewhat
different line of argument. We give to the dream pictures the
credence of reality because in sleep we have no other impressions to
compare them with, because we are cut off from the outer world. But
it is not perhaps because we are unable to make tests in our sleep,
that we believe in the truth of our hallucinations. The dream may
delude us with all these tests, it may make us believe that we may
touch the rose that we see in the dream, and still we only dream.
According to Delbœuf there is no valid criterion to show whether
something is a dream or a conscious reality, except—and that only in
practical generality—the fact of awakening. “I declare delusional
everything that is experienced between the period of falling asleep
and awakening, if I notice on awakening that I lie in my bed
undressed” (p. 84). “I have considered the dream pictures real
during sleep in consequence of the mental habit, which cannot be put
to sleep, of perceiving an outer world with which I can contrast my
ego.”[L]
As the deviation from the outer world is taken as the stamp for the
most striking characteristics of the dream, it will be worth while
mentioning some ingenious observations of old Burdach[8] which will
throw light on the relation of the sleeping mind to the outer world
and at the same time serve to prevent us from over-estimating the
above deductions. “Sleep results only under the condition,” says
Burdach, “that the mind is not excited by sensory stimuli ... but it is
not the lack of sensory stimuli that conditions sleep, but rather a lack
of interest for the same; some sensory impressions are even
necessary in so far as they serve to calm the mind; thus the miller can
fall asleep only when he hears the rattling of his mill, and he who
finds it necessary to burn a light at night, as a matter of precaution,
cannot fall asleep in the dark” (p. 457).
“The psyche isolates itself during sleep from the outer world, and
withdraws from the periphery.... Nevertheless, the connection is not
entirely interrupted; if one did not hear and feel even during sleep,
but only after awakening, he would certainly never awake. The
continuance of sensation is even more plainly shown by the fact that
we are not always awakened by the mere sensory force of the
impression, but by the psychic relation of the same; an indifferent
word does not arouse the sleeper, but if called by name he
awakens ...: hence the psyche differentiates sensations during
sleep.... It is for this reason that we may be awakened by the lack of a
sensory stimulus if it relates to the presentation of an important
thing; thus one awakens when the light is extinguished, and the
miller when the mill comes to a standstill; that is, the awakening is
due to the cessation of a sensory activity, which presupposes that it
has been perceived, and that it has not disturbed the mind, being
indifferent or rather gratifying” (p. 460, &c.).
If we are willing to disregard these objections, which are not to be
taken lightly, we still must admit that the qualities of the dream life
thus far considered, which originate by withdrawing from the outer
world, cannot fully explain the strangeness of the dream. For
otherwise it would be possible to change back the hallucinations of
the dream into presentations and the situations of the dream into
thoughts, and thus to perform the task of dream interpretation. Now
this is what we do when we reproduce the dream from memory after
awakening, and whether we are fully or only partially successful in
this back translation the dream still retains its mysteriousness
undiminished.
Furthermore all the authors assume unhesitatingly that still other
more far-reaching alterations take place in the presentation material
of waking life. One of them, Strümpell,[66] expresses himself as
follows (p. 17): “With the cessation of the objectively active outlook
and of the normal consciousness, the psyche loses the foundation in
which were rooted the feelings, desires, interests, and actions. Those
psychic states, feelings, interests, estimates which cling in the waking
state to the memory pictures also succumb to ... an obscure pressure,
in consequence of which their connection with the pictures becomes
severed; the perception pictures of things, persons, localities, events,
and actions of the waking state are singly very abundantly
reproduced, but none of these brings along its psychic value. The
latter is removed from them, and hence they float about in the mind
dependent upon their own resources....”
This deprivation the picture suffers of its psychic value, which
again goes back to the derivation from the outer world, is according
to Strümpell mainly responsible for the impression of strangeness
with which the dream is confronted in our memory.
We have heard that even falling asleep carries with it the
abandonment of one of the psychic activities—namely, the voluntary
conduct of the presentation course. Thus the supposition, suggested
also by other grounds, obtrudes itself, that the sleeping state may
extend its influence also over the psychic functions. One or the other
of these functions is perhaps entirely suspended; whether the
remaining ones continue to work undisturbed, whether they can
furnish normal work under the circumstances, is the next question.
The idea occurs to us that the peculiarities of the dream may be
explained through the inferior psychic activity during the sleeping
state, but now comes the impression made by the dream upon our
waking judgment which is contrary to such a conception. The dream
is disconnected, it unites without hesitation the worst contradictions,
it allows impossibilities, it disregards our authoritative knowledge
from the day, and evinces ethical and moral dulness. He who would
behave in the waking state as the dream does in its situations would
be considered insane. He who in the waking state would speak in
such manner or report such things as occur in the dream content,
would impress us as confused and weak-minded. Thus we believe
that we are only finding words for the fact when we place but little
value on the psychic activity in the dream, and especially when we
declare that the higher intellectual activities are suspended or at least
much impaired in the dream.
With unusual unanimity—the exceptions will be dealt with
elsewhere—the authors have pronounced their judgments on the
dream—such judgments as lead immediately to a definite theory or
explanation of the dream life. It is time that I should supplement the
résumé which I have just given with a collection of the utterances of
different authors—philosophers and physicians—on the
psychological character of the dream.
According to Lemoine,[42] the incoherence of the dream picture is
the only essential character of the dream.
Maury[48] agrees with him; he says (p. 163): “Il n’y a pas des rêves
absolument raisonnables et qui ne contiennent quelque incohérence,
quelque anachronisme, quelque absurdité.”
According to Hegel, quoted by Spitta,[64] the dream lacks all
objective and comprehensible connection.
Dugas[19] says: “Le rêve, c’est l’anarchie psychique, affective et
mentale, c’est le jeu des fonctions livrées à elles-mêmes et s’exerçant
sans contrôle et sans but; dans le rêve l’esprit est un automate
spirituel.”
“The relaxation, solution, and confusion of the presentation life
which is held together through the logical force of the central ego” is
conceded even by Volkelt[72] (p. 14), according to whose theory the
psychic activity during sleep seems in no way aimless.
The absurdity of the presentation connections appearing in the
dream can hardly be more strongly condemned than it was by Cicero
(De Divin. II.): “Nihil tam praepostere, tam incondite, tam
monstruose cogitari potest, quod non possimus somniare.”
Fechner[52] says (p. 522): “It is as if the psychological activity were
transferred from the brain of a reasonable being into the brain of a
fool.”
Radestock[35] (p. 145) says: “It seems indeed impossible to
recognise in this absurd action any firm law. Having withdrawn itself
from the strict police of the rational will guiding the waking
presentation life, and of the attention, the dream whirls everything
about kaleidoscopically in mad play.”
Hildebrandt[35] (p. 45) says: “What wonderful jumps the dreamer
allows himself, e.g., in his chain of reasoning! With what unconcern
he sees the most familiar laws of experience turned upside down!
What ridiculous contradictions he can tolerate in the orders of
nature and society before things go too far, as we say, and the
overstraining of the nonsense brings an awakening! We often
multiply quite unconcernedly: three times three make twenty; we are
not at all surprised when a dog recites poetry for us, when a dead
person walks to his grave, and when a rock swims on the water; we
go in all earnestness by high command to the duchy of Bernburg or
the principality of Lichtenstein in order to observe the navy of the
country, or we allow ourselves to be recruited as a volunteer by
Charles XII. shortly before the battle of Poltawa.”
Binz[4] (p. 33) points to a dream theory resulting from the
impressions. “Among ten dreams nine at least have an absurd
content. We unite in them persons or things which do not bear the
slightest relation to one another. In the next moment, as in a
kaleidoscope, the grouping changes, if possible to one more
nonsensical and irrational than before; thus the changing play of the
imperfectly sleeping brain continues until we awaken, and put our
hand to our forehead and ask ourselves whether we really still
possess the faculty of rational imagination and thought.”
Maury[48] (p. 50) finds for the relation of the dream picture to the
waking thoughts, a comparison most impressive for the physician:
“La production de ces images que chez l’homme éveillé fait le plus
souvent naître la volonté, correspond, pour l’intelligence, à ce que
cont pour la motilité certains mouvements que nous offrent la chorée
et les affections paralytiques....” For the rest, he considers the dream