His parents framed the experience as a dream, trying to rea.s.sure the child. He was unconvinced, unable to make sense of the event. His family had no religious background, and he found the image of the angel alien. He began to experience a pervasive sense of dread and developed insomnia, fearful that he would awaken to find the woman again. His parents and teachers described him as agitated and distracted, and he increasingly withdrew from relationships with peers and activities. His parents called their pediatrician, who referred the child for psychiatric evaluations and psychotherapy.

The child had no prior history of problems in functioning, sleep disorder, or physical illness, and he appeared to be well-adjusted. He made effective use of therapeutic consultations, where he continued to ... make sense of what had happened, coming to understand the event as a type of hallucination that commonly occurs following arousal from sleep.

Dr. B. added, "Although there would appear to be a high prevalence of hypnopompic hallucinations among healthy, well-adjusted persons, they are potentially traumatic, and it is crucial to explore the meaning and implications of such phenomena for the individual."

Experiences so far out of the ordinary const.i.tute a severe challenge to one's world picture, one's belief system-how can they be explained? What do they mean? One sees poignantly with this young patient how reason itself can be rocked by such nighttime visions, which insist on their own reality.

1. The Reverend Henslow was a son of the botanist John Stevens Henslow, who was Darwin's teacher at Cambridge and was instrumental in getting him a position aboard the Beagle.

2. Feeling that hypnagogic hallucinations could extend and enrich the imagination, Poe would jerk himself suddenly to full wakefulness while hallucinating, so that he could make note of the extraordinary things he saw, and he often brought these into his poems and short stories. Poe's great translator, Baudelaire, was also fascinated by the unique quality of such visions, especially if they were potentiated by opium or hashish. A whole generation in the early nineteenth century (including Coleridge and Wordsworth, as well as Southey and De Quincey) was influenced by such hallucinations. This is explored by Alethea Hayter in her book Opium and the Romantic Imagination and by Eva Brann in her magisterial The World of the Imagination: Sum and Substance.

3. Hypnopompic hallucinations are far less common than hypnagogic ones, and some people have hypnagogic hallucinations upon awakening, or hypnopompic ones while falling asleep.

4. Spinoza, in the 1660s, described a similar hallucination in a letter to his friend Peter Balling:

When one morning, after the day had dawned, I woke up from a very unpleasant dream, the images, which had presented themselves to me in sleep, remained before my eyes just as vividly as though the things had been real, especially the image of a certain black and leprous Brazilian whom I had never seen before. This image disappeared for the most part when, in order to divert my thoughts, I cast my eyes on a book or something else. But as soon as I lifted my eyes again, without fixing my attention on any particular object, the same image of this same negro appeared with the same vividness again and again, until the head of it finally vanished.

12

Narcolepsy and Night Hags

Sometime in the late 1870s, Jean-Baptiste-edouard Gelineau, a French neurologist from a wine-making family, had occasion to examine a thirty-eight-year-old wine merchant who had been having attacks of sudden, brief, irresistible sleep for two years. By the time he came to Gelineau, he was having as many as two hundred a day. He sometimes fell asleep in the middle of a meal, the knife and fork slipping from his fingers; he might drop off in the middle of a sentence or as soon as he had been seated in a theater. Intense emotions, sad or happy, often precipitated his sleep attacks and also episodes of "astasia," in which there was a sudden loss of muscular strength and tone, so that he would fall helplessly to the ground, while remaining perfectly conscious. Gelineau regarded this conjunction of narcolepsy (a term he coined) and astasia (we now call it cataplexy) as a new syndrome-one with a neurological origin.1

In 1928 a New York physician, Samuel Brock, presented a broader view of narcolepsy, describing a young man of twenty-two who was p.r.o.ne not only to sudden sleep attacks and cataplexy but also a paralysis, with the inability to talk or move, following his sleep attacks. In this state of sleep paralysis (as the condition was later to be named), he had vivid hallucinations, which he experienced at no other time. Though Brock's case was described in a contemporary (1929) review of narcolepsy as "unique," it soon became apparent that sleep paralysis and the hallucinations a.s.sociated with it were far from uncommon and should be regarded as integral features of a narcoleptic syndrome.

It is now known that the hypothalamus secretes "wakefulness" hormones, orexins, and that these are deficient in people who have congenital narcolepsy. Damage to the hypothalamus, from a head injury or a tumor or disease, can also cause narcolepsy later in life.

Full-blown narcolepsy can be incapacitating if untreated, but it is mercifully rare, affecting perhaps one person in two thousand. (Milder forms may be appreciably commoner.) People with narcolepsy are apt to feel embarra.s.sed, isolated, or misunderstood (as with Gelineau's patient, who was regarded as a drunk), but awareness is spreading, in part because of organizations such as the Narcolepsy Network.

Despite this, narcolepsy often goes undiagnosed. Jeanette B. wrote to me that her narcolepsy had not been diagnosed until she was an adult. In elementary school, she said, "I thought I had schizophrenia, because of my hypnagogic hallucinations. I even wrote a paper on schizophrenia in sixth grade (never mentioning that I thought that was my problem)." Much later, when she went to a narcolepsy support group, she wrote, "I was astounded to find that many in the group not only had hallucinations, but the very same hallucinations as I did!"

When I heard recently that the New York chapter of the Narcolepsy Network was due to have a meeting, I asked if I might come along to listen to members discuss their experiences and to talk with some of them myself. Cataplexy-the sudden, complete loss of muscle tone with emotion or laughter-affected many at this meeting, and it was freely discussed. (Cataplexy, indeed, can scarcely be hidden. I spoke to one man, by chance a friend of the comedian Robin Williams's, who said that whenever he met Robin, he would lie down on the ground preemptively; otherwise, he was sure to fall down in a fit of laughter-induced cataplexy.) But hallucinations were another matter: people often hesitate to admit to them, and there was little open discussion of the subject, even in a room full of narcoleptics. Nonetheless, many people later wrote to me about their hallucinations, including Sharon S., who described her own experience:

I wake on my stomach to the sensation that the mattress is breathing. I cannot move and the terror sets in as I "see" the marbled grey skin with spa.r.s.e black hairs underneath me. I am sprawled on the back of a walking elephant.... The absurdity of my hallucinations causes me to collapse with cataplexy.... [Another time] as I am waking from a nap I "see" myself in the corner of the bedroom.... I am close to the ceiling, slowly floating to the floor by parachute. During the hallucination it seemed perfectly normal and I am left with a very peaceful, serene feeling.

Sharon has also had hallucinations while driving:

[I am driving] to work, and getting increasingly sleepy; suddenly, the road ahead rises up in front of me and hits me in the face. It is so realistic. I jerk my head back. It certainly woke me up. This experience is different from my other hallucinations in that my eyes were open and I was seeing my actual surroundings, but with distortion.

While most of us have a robust sleep-wake cycle, with sleep occurring predominantly at night, people with narcolepsy can have dozens of "microsleeps" (some lasting for only a few seconds) and "in-between states" each day-and any or all of these may be charged with intensely vivid dreams, hallucinations, or some almost-indistinguishable fusion of the two. Sudden, narcolepsy-like sleep without cataplexy may also occur in toxic states or with various medications (especially sedatives), and there is often some tendency to it with aging, in the dozing or nodding off of the elderly into brief, dream-charged sleeps.

I have these increasingly often myself. Once, while reading Gibbon's autobiography in bed-this was in 1988, when I was thinking and reading a great deal about deaf people and their use of sign language-I found an amazing description by Gibbon of seeing a group of deaf people in London in 1770, immersed in an animated sign discourse. I immediately thought that this would make a wonderful footnote for the book I was writing, but when I came to reread Gibbon's description, it was not there. I had hallucinated or perhaps dreamt it, in a flash, between two sentences of text.

Stephanie W. had her first narcoleptic hallucination when she was five, walking home from kindergarten. She wrote to me that her hallucinations frequently occur during the daytime, and she presumes they happen before or after very short microsleeps:

However ... I am not able to detect that a microsleep has occurred unless something in my environment noticeably "jumps" forward or changes in some way-as it did, for example, when I still drove a car and would find that my vehicle had unaccountably leapt forward on the road during a microsleep.... Prior to treatment for narcolepsy, I had many periods during which I experienced hallucinations on a daily basis.... Some were utterly benign: an "angel" which would appear periodically over a particular highway exit ... hearing a person whispering my name repeatedly, hearing a knock at the door which no one else hears, seeing and feeling ants walking on my legs.... Some were terrifying [like the] experience of visually seeing the people before me take on the appearance of being dead....

It was especially difficult as a child to be experiencing things that the people around me did not also sense. The attempts that I remember making to talk with adults or other kids about what was going on repeatedly elicited anger and suspicion that I was "crazy" or lying.... It got easier as an adult. (Although when I was treated within the mental health system, I was told that I had "Psychosis with unusually strong reality testing.")

Receiving the correct diagnosis-narcolepsy-was deeply rea.s.suring to Stephanie W., as was meeting others with similar hallucinations in the Narcolepsy Network.2 With this diagnosis and the prescription of effective medication, she feels there has been a complete change in her life.

Lynn O. wished that her doctors had told her earlier that her hallucinations were part of a narcoleptic syndrome. Prior to her diagnosis, she wrote,

These episodes happened frequently enough throughout my life that instead of suspecting a sleep disorder, I suspected paranormal activity in my life. Are there many people who integrate the experiences in this manner? Had I been better educated about this disorder, perhaps instead of suspecting I was being interfered with, haunted, spiritually challenged or perhaps mentally ill, I would have sought more constructive help earlier in life. I am now forty-three years old. And I have found a new peace in life in realizing many of these experiences have had to do with this disorder.

In a later letter, she observed, "I find myself in the fresh stage of having to reevaluate many of my 'paranormal' experiences, and I find I am having to reintegrate a new view of the world based on my new diagnosis. It is like letting go of childhood or, rather, letting go of a mystical, almost magical view of the world. I must say, perhaps I am experiencing a touch of mourning."

Many people with narcolepsy have auditory or tactile hallucinations along with visual ones, as well as complex bodily feelings. Christina K. is p.r.o.ne to sleep paralysis, and often her hallucinations go with this, as in the following episode:

I had just lain down in bed, and after a few rounds of changing positions I ended up face down. Almost immediately I felt my body go more and more numb. I tried to "pull" myself out of it, but I was already too deep into the paralysis. Then it was almost as if someone sat down on my back, pressing me deeper into the mattress ... the weight on my back got heavier and heavier, and I was still not able to move. [Then] the thing on my back got off and laid down next to me.... I could feel it lying beside me, breathing. I got so scared and thought that this couldn't be anything other than real ... because I had been awake all along. It felt like an eternity before I managed to turn my head towards it. Then I laid eyes on an abnormally tall man in a black suit. He was greenishly pale, sick-looking, with a shock-ridden look in the eyes. I tried to scream, but was unable to move my lips or make any sounds at all. He kept staring at me with his eyes almost popping out when all of a sudden he started shouting out random numbers, like FIVE-ELEVEN-EIGHT-ONE-THREE-TWO-FOUR-ONE-NINE-TWENTY, then laughed hysterically.... I started feeling able to move again, and as I came back to a normal state the image of the man became more and more blurry until he was gone and I was able to get up.

Another correspondent, J.D., also described the hallucinations a.s.sociated with sleep paralysis, including the feeling of pressure on her chest:

Sometimes I would see things like huge centipedes or caterpillars crawling all over my ceiling. Once I thought my cat was on the shelf in my room. She seemed to be rolling around and turning into a rat. The worst was when I would hallucinate that a spider was on my chest. I couldn't move. I would try to scream. I am TERRIFIED of spiders.

On one occasion, she had a hallucination resembling an out-of-body experience:

I hallucinated that my body floated up to the ceiling towards the end of my bed, and then all of a sudden my body quickly dropped through the floor to the first level of the house and then dropped through that floor and into the bas.e.m.e.nt. I could see everything in each room. The floors did not seem to break when I went through them. I just pa.s.sed through them.

There was little physiological understanding of sleeping, dreaming, or sleep disorders until 1953, when Eugene Aserinsky and Nathaniel Kleitman at the University of Chicago discovered REM sleep-a distinctive stage of sleep with characteristic rapid eye movements, as well as characteristic EEG changes. They also found that if their subjects were woken during REM sleep, they would always report that they had been dreaming. It seemed, then, that dreaming was correlated with REM sleep.3 In REM sleep the body is paralyzed, except for shallow breathing and eye movements. Most people enter the REM stage ninety minutes or so after falling asleep, but people with narcolepsy (or those with sleep deprivation) may fall into REM at the very onset of sleep, plunging suddenly into dreaming and sleep paralysis; they may also wake at the "wrong" time, so that the dreamlike visions and the loss of muscle control characteristic of REM sleep persist into the waking state. Even though the person is wide awake, he may be a.s.saulted by dream- or nightmare-like hallucinations, made even more terrifying by an inability to move or speak.

But one does not have to have narcolepsy to experience sleep paralysis with hallucinations-indeed, J. A. Cheyne and his colleagues at the University of Waterloo have shown that somewhere between a third and half of the general population has had at least occasional episodes of this, and even a single episode may be unforgettable.

Cheyne et al. explored and categorized a huge range of sleep-paralysis-related phenomena, based on reports from three hundred student subjects as well as a large and varied population who responded to an internet questionnaire. They concluded that isolated sleep paralysis (that is, sleep paralysis without narcolepsy), being relatively common, "const.i.tutes a unique natural laboratory for the study of hallucinoid experiences" but stressed that such hallucinations cannot be compared to ordinary hypnagogic or hypnopompic experiences. The hallucinations accompanying isolated sleep paralysis, they wrote, are "substantially more vivid, elaborate, multimodal and terrifying," and therefore more likely to have a radical impact on anyone who experiences them. These hallucinations may be visceral, auditory, or tactile as well as visual and are accompanied by a feeling of suffocation or pressure on the chest, the sense of a malignant presence, and an overall sense of absolute helplessness and abject terror. These, of course, are the cardinal qualities of the nightmare, in its original sense.

The "mare" in "nightmare" originally referred to a demonic woman who suffocated sleepers by lying on their chests (she was called "Old Hag" in Newfoundland). Ernest Jones, in his monograph On the Nightmare, emphasized that nightmares were radically different from ordinary dreams in their invariable sense of a fearful presence (sometimes astride the chest), difficulty breathing, and the realization that one is totally paralyzed. The term "nightmare" is often used now to describe any bad dream or anxiety dream, but the real night-mare has dread of a wholly different order; Cheyne speaks of "the ominous numinous" here. He suggests that the term for the night-mare proper be spelled with a hyphen, and this convention has been adopted by other workers in the field.