Hallucinations

by Oliver Sacks

  A powerfully persuasive form of hallucination, not explicitly sensory at all, is the feeling of the “presence” of someone or something nearby, a presence that may be felt as malevolent or benign. The sense of conviction that someone is there can be irresistible at such times.

  For me, hypnopompic experiences are usually more auditory than visual, and they take a variety of forms. Sometimes they are persistences of dreams or nightmares. On one occasion I heard a scratching sound in the corner of the room. I paid little attention at first, thinking it was just a mouse in the walls. But the scratching grew louder and louder and began to frighten me. Alarmed, I flung a pillow into the corner. But the action (or, rather, the imagined action) of flinging fully awakened me, and I opened my eyes to find that I was in my own bedroom, not the hospital-like room of my dream. But the scratching sound continued, loud and utterly “real,” for several seconds after I woke.

  I have had musical hallucinations (when taking chloral hydrate as a sleeping aid) which were continuations of dream music into the waking state—once with a Mozart quintet. My normal musical memory and imagery is not that strong—I am quite incapable of hearing every instrument in a quintet, let alone an orchestra—so the experience of hearing the Mozart, hearing every instrument, was a startling (and beautiful) one. Under more normal conditions I experience a hypnopompic state of heightened (and somewhat uncritical) musical sensibility; whatever music I hear in this state delights me. This happens almost every morning when I am awoken by my clock radio, which is tuned to a classical station. (An artist friend describes a similar enhancement of color and texture when he lies in bed after first opening his eyes in the morning.)

  Recently, I had a startling and rather moving visual hallucination. I cannot recollect what I was dreaming, if indeed I was dreaming, but when I awoke I saw my own face—or, rather, my face as it was when I was forty, black-bearded, smiling rather shyly. The face was about two feet away, life-sized, in faint, unsaturated pastel color, poised in midair; it seemed to look at me with curiosity and affection, and then, after about five seconds, it faded out. It gave me an odd, nostalgic sense of continuity with my younger self. As I lay in bed, I wondered whether, when young, I had ever had a vision of my present, almost eighty-year-old face, a hypnopompic “hello” across forty years.

  While we may have the most fantastical and surreal experiences in our dreams, we accept these because we are enveloped in our dream consciousness, and there is no critical consciousness outside it (the rare phenomenon of lucid dreaming is an exception). When we awake we can remember only fragments, a tiny fraction of our dreams, and can easily dismiss these as “just a dream.”

  Hallucinations, in contrast, are startling and apt to be remembered in great detail—this is one of the central contrasts between sleep-related hallucinations and dreaming. My colleague Dr. D. has had only one hypnopompic hallucination in his life, and it occurred thirty years ago. But he retains the most vivid memory of it:

  It was a relaxed summer night. I awoke around 2 AM, as I sometimes do in the middle of the night, and next to me, standing six and a half feet tall, was an imposing Native American. A huge man, muscles chiseled, black hair and black eyes. I realized, seemingly simultaneously, that if he wanted to kill me there was nothing I could do, and that he must not be real. Yet he was standing there, like a statue yet very alive. My mind flashed about—how could he have gotten into the house?… Why was he motionless?… This can’t be real. Yet his presence frightened me. He became diaphanous after five or ten seconds, gently vaporizing into invisibility.4

  Given the outlandish quality of some hypnopompic images, their often terrifying emotional resonance, and perhaps the heightened suggestibility that may go with such states, it is very understandable that hypnopompic visions of angels and devils may engender not only wonder or horror but belief in their physical reality. Indeed, one must wonder to what degree the very idea of monsters, ghostly spirits, or phantoms originated with such hallucinations. One can easily imagine that, coupled with a personal or cultural disposition to believe in a disembodied, spiritual realm, these hallucinations, though they have a real physiological basis, might reinforce a belief in the supernatural.

  The term “hypnopompic” was introduced in 1901 by F. W. H. Myers, an English poet and classicist who was fascinated by the emerging study of psychology. He was a friend of William James’s and a founding member of the Society for Psychical Research, where he sought to connect the abnormal and paranormal with normal psychological function. Myers’s work was highly influential.

  Living in the late nineteenth century, a time in which séances and mediums were all the rage, Myers wrote extensively of ghosts, apparitions, and phantoms. Like many of his contemporaries, he believed in the idea of life after death, but he tried to place it in a scientific context. Although he felt that experiences likely to be interpreted as supernatural visitations were especially apt to occur in hypnopompic states, he also believed in the objective reality of a spiritual or supernatural realm, to which the mind might be given brief access in various physiological states, such as dreaming, hypnopompic states, trance states, and certain forms of epilepsy. But at the same time, he thought that hypnopompic hallucinations might be fragments of dreams or nightmares persisting into the waking state—in effect, waking dreams.

  Yet reading Myers’s 1903 two-volume Human Personality and Its Survival After Bodily Death, as well as Phantasms of the Living, the compilation of case histories he and his colleagues (Gurney et al.) published in 1886, one feels that the majority of “psychical” or “paranormal” experiences described are, in fact, hallucinations—hallucinations arising in states of bereavement, social isolation, or sensory deprivation, and above all in drowsy or trancelike states.

  My colleague Dr. B., a psychotherapist, related the following story to me, about a ten-year-old boy who woke one morning “to find a woman dressed in blue hovering at the foot of his bed, surrounded by radiant light”:

  She introduced herself as his “guardian angel,” speaking in a soft, gentle voice. The child was terrified, and turned on the light beside his bed, expecting the image to disappear. The woman remained suspended in the air, however, and he ran from the room, awakening his parents.

  His parents framed the experience as a dream, trying to reassure 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 constitute 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 c
ould 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-Édouard Gélineau, 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 Gélineau, 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. Gélineau 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 prone 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 associated 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 embarrassed, isolated, or misunderstood (as with Gélineau’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 sparse 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 tha
t 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 reassuring 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.”