Sh.e.l.ley Adler, in her book Sleep Paralysis: Night-mares, Nocebos, and the Mind-Body Connection, also brings out the extreme nature of the sense of terror and doom that makes the experience of sleep paralysis unlike any other. She emphasizes that night-mares, unlike dreams, occur when one is awake-but awake in a partial or dissociated way; in this sense, the term "sleep" paralysis is misleading. The terror of this state is heightened by the shallow breathing of REM sleep and a rapid or irregular heartbeat, which can go with extreme excitement. Such overpowering fear and its physiological accompaniments can even be fatal, especially if there is a cultural tradition that a.s.sociates sleep paralysis with death. Adler studied a group of Hmong refugees from Laos who had immigrated to central California in the late 1970s and were not always able to perform their traditional religious rites during the upheaval of genocide and relocation. In Hmong culture, there is a strong belief that night-mares can be fatal; this evil expectation, or nocebo, apparently contributed to the sudden unexplained nocturnal deaths of almost two hundred Hmong immigrants (mostly young and in good health) in the late 1970s and early 1980s. Once they were more a.s.similated and the old beliefs lost their power, the sudden deaths stopped.

The folklore of every culture includes supernatural figures like the incubus and succubus, which a.s.sault the sleeper s.e.xually, or the Old Hag, which paralyzes its victims and sucks their breath away. Such images seem to be universal-indeed, there is a remarkable similarity of such figures in widely disparate cultures, although there are local variations of every sort. Hallucinatory experiences, whatever their cause, generate a world of imaginary beings and abodes-heaven, h.e.l.l, fairyland. Such myths and beliefs are designed to clarify and rea.s.sure and, at the same time, to frighten and warn. We make narratives for a nocturnal experience which is common, real, and physiologically based.

When traditional figures-devils, witches, or hags-are no longer believed in, new ones-aliens, visitations from "a previous life"-take their place. Hallucinations, beyond any other waking experience, can excite, bewilder, terrify, or inspire, leading to the folklore and the myths (sublime, horrible, creative, and playful) which perhaps no individual and no culture can wholly dispense with.

1. Bill Hayes, in his book Sleep Demons, cites an even earlier reference to irresistible, overwhelming sleepiness and probable cataplexy-"It falls upon them in the midst of mirth"-from a little-known 1834 book, The Philosophy of Sleep, by the Scottish physician Robert Macnish.

2. A key figure in the narcolepsy world is Michael Thorpy, a physician whose many books on narcolepsy and other sleep disorders have grown out of a lifetime of experience directing a sleep disorders clinic at Montefiore Medical Center in the Bronx.

3. This simple equation had to be modified later, when it was found that dreams-albeit of a somewhat different kind-could also occur in non-REM sleep.

13

The Haunted Mind

In Charles Bonnet syndrome, sensory deprivation, parkinsonism, migraine, epilepsy, drug intoxication, and hypnagogia, there seems to be a mechanism in the brain that generates or facilitates hallucination-a primary physiological mechanism, related to local irritation, "release," neurotransmitter disturbance, or whatever-with little reference to the individual's life circ.u.mstances, character, emotions, beliefs, or state of mind. While people with such hallucinations may (or may not) enjoy them as a sensory experience, they almost uniformly emphasize their meaninglessness, their irrelevance to events and issues of their lives.

It is quite otherwise with the hallucinations we must now consider, which are, essentially, compulsive returns to a past experience. But here, unlike the sometimes moving but essentially trivial flashbacks of temporal lobe seizures, it is the significant past-beloved or terrible-that comes back to haunt the mind-life experiences so charged with emotion that they make an indelible impression on the brain and compel it to repet.i.tion.

The emotions here can be of various kinds: grief or longing for a loved person or place from which death or exile or the pa.s.sage of time has separated one; terror, horror, anguish, or dread following deeply traumatic, ego-threatening or life-threatening events. Such hallucinations may also be provoked by overwhelming guilt for a crime or sin that, perhaps belatedly, the conscience cannot tolerate. Hallucinations of ghosts-revenant spirits of the dead-are especially a.s.sociated with violent death and guilt.

Stories of such hauntings and hallucinations have a substantial place in the myths and literature of every culture. Thus Hamlet's murdered father appears to him ("In my mind's eye, Horatio") to tell him how he was murdered and must be avenged. And when Macbeth is plotting the murder of King Duncan, he sees a dagger in midair, a symbol of his intention and an incitement to action. Later, after he has had Banquo killed for threatening to expose him, he has hallucinations of Banquo's ghost; while Lady Macbeth, who has smeared Duncan's blood over his slain grooms, "sees" the king's blood and smells it, ineradicable, on her hands.1

Any consuming pa.s.sion or threat may lead to hallucinations in which an idea and an intense emotion are embedded. Especially common are hallucinations engendered by loss and grief-particularly following the death of a spouse after decades of togetherness and marriage. Losing a parent, a spouse, or a child is losing a part of oneself; and bereavement causes a sudden hole in one's life, a hole which-somehow-must be filled. This presents a cognitive problem and a perceptual one as well as an emotional one, and a painful longing for reality to be otherwise.

I never experienced hallucinations after the deaths of my parents or my three brothers, though I often dreamt of them. But the first and most painful of these losses was the sudden death of my mother in 1972, and this led to persistent illusions over a period of months, when I would mistake other people in the street for her. There was always, I think, some similarity of appearance and carriage behind these illusions, and part of me, I suspect, was hyper-alert, unconsciously searching for my lost parent.

Sometimes bereavement hallucinations take the form of a voice. Marion C., a psychoa.n.a.lyst, wrote to me about "hearing" the voice (and, on a subsequent occasion, the laugh) of her dead husband:

One evening I came home from work as always to our big empty house. Usually at that hour Paul would have been at his electronic chessboard playing over the game in the New York Times. His table was out of sight of the foyer, but he greeted me in his familiar way: "h.e.l.lo! You're back! Hi!" ... His voice was clear and strong and true; just the way it was when he was well. I "heard" it. It was as if he were actually at his chess table and actually greeting me once more. The other part was that, as I said, I couldn't see him from the foyer, yet I did. I "saw" him, I "saw" the expression on his face, I "saw" how he moved the pieces, I "saw" him greet me. That part was like one sees in a dream: as if I were seeing a picture or a movie of an event. But the speech was live and real.

Silas Weir Mitch.e.l.l, working with soldiers who had lost limbs in the Civil War, was the first to understand the neurological nature of phantom limbs-they had previously been regarded, if at all, as a sort of bereavement hallucination. By a curious irony, Mitch.e.l.l himself suffered a bereavement hallucination following the sudden death of a very close friend, as Jerome Schneck described in a 1989 article:

A reporter brought the unexpected news one morning and Mitch.e.l.l, greatly shaken, went up to tell his wife. On the way back downstairs he had an odd experience: he could see the face of Brooks, larger than life, smiling, and very distinct, yet looking as if it were made of dewy gossamer. When he looked down, the vision disappeared, but for ten days he could see it a little above his head to the left.

Bereavement hallucinations, deeply tied to emotional needs and feelings, tend to be unforgettable, as Elinor S., a sculptor and printmaker, wrote to me:

When I was fourteen years old, my parents, brother and I were spending the summer at my grandparents' house as we had done for many previous years. My grandfather had died the winter before.

We were in the kitchen, my grandmother was at the sink, my mother was helping and I was still finishing dinner at the kitchen table, facing the back porch door. My grandfather walked in and I was so happy to see him that I got up to meet him. I said, "Grampa," and as I moved towards him, he suddenly wasn't there. My grandmother was visibly upset, and I thought she might have been angry with me because of her expression. I said to my mother that I had really seen him clearly, and she said that I had seen him because I wanted to. I hadn't been consciously thinking of him and still do not understand how I could have seen him so clearly.

I am now seventy-six years of age and still remember the incident and have never experienced anything similar.

Elizabeth J. wrote to me about a grief hallucination experienced by her young son:

My husband died thirty years ago after a long illness. My son was nine years old at the time; he and his dad ran together on a regular basis. A few months after my husband's death, my son came to me and said that he sometimes saw his father running past our home in his yellow running shorts (his usual running attire). At the time, we were in family grief counselling, and when I described my son's experience, the counsellor did attribute the hallucinations to a neurologic response to grief. This was comforting to us, and I still have the yellow running shorts.

A general pract.i.tioner in Wales, W. D. Rees, interviewed nearly three hundred recently bereft people and found that almost half of them had had illusions or full-fledged hallucinations of a dead spouse. These could be visual, auditory, or both-some of the people interviewed enjoyed conversations with their hallucinated spouses. The likelihood of such hallucinations increased with the length of marriage, and they might persist for months or even years. Rees considered these hallucinations to be normal and even helpful in the mourning process.

For Susan M., bereavement stimulated a particularly vivid, multisensory experience a few hours after her mother died: "I heard the squeaking of the wheels of her walker in the hallway. She walked into the room shortly afterward and sat down on the bed next to me. I could feel her sit down on the mattress. I spoke to her and said I thought she had died. I don't remember exactly what she said in return-something about checking in with me. All I know is I could feel her there and it was frightening but also comforting."

Ray P. wrote to me after his father died at the age of eighty-five, following a heart operation. Although Ray had rushed to the hospital, his father had already lapsed into a coma. An hour before his father died, Ray whispered to him: "Dad, it's Ray. I'll take care of mom. Don't worry, everything is going to be alright." A few nights later, Ray wrote, he was awakened by an apparition:

I awoke in the night. I did not feel groggy or disoriented and my thoughts and vision were clear. I saw someone sitting on the corner of my bed. It was my Dad, wearing his khaki slacks and tan polo shirt. I was lucid enough to wonder initially if this could be a dream but I was certainly awake. He was opaque, not ethereal in any way, the nighttime Baltimore light pollution in the window behind him did not show through. He sat there for a moment and then said-did he speak or just convey the thought?-"Everything is all right."

I turned and swung my feet to the floor. When I looked [back toward] him, he was gone. I stood and went to the bathroom, got a drink of water, and went back to bed. My dad never returned. I do not know whether this was a hallucination or something else, but since I provisionally do not believe in the paranormal, it must have been.2

The hallucinations of grief may sometimes take a less benign form. Christopher Baethge, a psychiatrist, has written about two mothers who lost young children in a particularly traumatic way. Both had multisensory hallucinations of their dead daughters-seeing them, hearing them, smelling them, being touched by them. And both were driven to delusional, otherworldly explanations of their hallucinations: one believed that "this was her daughter's attempt to establish contact with her from another world, a world in which her daughter continues to exist"; the other heard her daughter cry out, "Mamma, don't be afraid, I'll come back."3

Recently I tripped over a box of books in my office, fell headlong, and broke a hip. This seemed to happen in slow motion. I thought, I have plenty of time to put out my arm to break the fall, but then-suddenly-I was on the floor, and as I hit, I felt the crunch in my hip. With near-hallucinatory vividness, in the next few weeks, I reexperienced my fall; it replayed itself in my mind and body. For two months I avoided the office, the place where I had fallen, because it provoked this quasi-hallucination of falling and the crunch of breaking bone. This is one example-a trivial one, perhaps-of a reaction to trauma, a mild traumatic stress syndrome. It is largely resolved now, but it will, I suspect, lurk in the depths as a traumatic memory that may be reactivated under certain conditions for the rest of my life.

Much deeper trauma and consequent PTSD (post-traumatic stress disorder) may affect anyone who has lived through a violent crash, a natural cataclysm, war, rape, abuse, torture, or abandonment-any experience that produces a terrifying fear for one's own safety or that of others.

All of these situations can produce immediate reactions, but there may also be, sometimes years later, post-traumatic syndromes of a malignant and often persistent sort. It is characteristic of these syndromes that, in addition to anxiety, heightened startle reactions, depression, and autonomic disorders, there is a strong tendency to obsessive rumination on the horrors which were experienced-and, not infrequently, sudden flashbacks in which the original trauma may be reexperienced in its totality with every sensory modality and with every emotion that was felt at the time.4 These flashbacks, though often spontaneous, are especially liable to be evoked by objects, sounds, or smells a.s.sociated with the original trauma.

The term "flashback" may not do justice to the profound and sometimes dangerous delusional states that can go with post-traumatic hallucinations. In such states, all sense of the present may be lost or misinterpreted in terms of hallucination and delusion. Thus the traumatized veteran, during a flashback, may be convinced that people in a supermarket are enemy soldiers and-if he is armed-open fire on them. This extreme state of consciousness is rare but potentially deadly.

One woman wrote to me that, having been molested as a three-year-old and a.s.saulted at the age of nineteen, "for both events smell will bring back strong flashbacks." She continued:

I had my first flashback of being a.s.saulted as a child when a man sat next to me on a bus. Once I smelled [his] sweat and body odor, I was not on that bus anymore. I was in my neighbor's garage and I remembered everything. The bus driver had to ask me to get off the bus when we arrived at our destination. I lost all sense of time and place.

Particularly severe and long-lasting stress reactions may occur after rape or s.e.xual a.s.sault. In a case reported by Terry Heins and his colleagues, for example, a fifty-five-year-old woman who had been forced to watch her parents' s.e.xual intercourse as a young child and then forced to have intercourse with her father at the age of eight experienced repeated flashbacks of the trauma as an adult, as well as "voices"-a post-traumatic stress syndrome that was misdiagnosed as schizophrenia and led to psychiatric hospitalization.

People with PTSD are also p.r.o.ne to recurrent dreams or nightmares, often incorporating literal or somewhat disguised repet.i.tions of the traumatic experiences. Paul Chodoff, a psychiatrist writing in 1963 about the effects of trauma in concentration camp survivors, saw such dreams as a hallmark of the syndrome and noted that in a surprising number of cases, they were still occurring a decade and a half after the war.5 The same is true of flashbacks.

Chodoff observed that obsessive rumination on concentration camp experiences might diminish in some people with the pa.s.sage of time, but others

communicated an uncanny feeling that nothing of real significance had happened in their lives since their liberation, as they reported their experiences with a vivid immediacy and wealth of detail which almost made the walls of my office disappear, to be replaced by the bleak vistas of Auschwitz or Buchenwald.