Dear Dr. Sleep

When she was in the shower in the morning, she would return
to a strange dream as if everything around her is was not real and she did not
recognize the room. Her room was “discombobulated”, shaking and changing its
configurations several times. Another time she saw a monster coming through the
wall, and other things from her vivid dreams appeared during the day. Many
times she woke up puzzled, not recognizing her bed, her pajamas, her room, and
her own cat. She would be startled for several minutes, then she would blink
and somehow she would wake up. At the gas station she saw “a dream” that the
gas started to run from her eyes. She got scared, vigorously moved her eyes and
“snapped” back to reality.

Once she was standing in her kitchen and had a knife in her
hand. Suddenly she saw a strange vision that she stabbed herself in the belly
and she woke up when the first blood came out. Two days previously, after a
long nap, she started to cook and again snapped back to her dream. When she
woke up her left arm was badly burned from scalding water.

She was referred to psychologists with diagnosis of
dissociation and “multiple personalities.” A psychologist told her that she was
depressed and could not deal with her problems. (Rosalie had problems with her
boyfriend.) She was working as a manager in a restaurant. She was coming from
the cooler room to a hot kitchen and the room suddenly would discombobulate and
shift. Clients were talking to her but she could not understand what they were
saying. Her employer told her that she was “schizophrenic.”

Rosalie indicated that most of the time her problems started
during awakenings from sleep in the middle of the night or in the morning. At
those times she felt confused, had sensations as if half her body was absent,
she felt herself as different in age and reacting to her surroundings as if she
were in a different environment, as if her dreams were superimposed on reality
and she could not differentiate what was real or what was her hallucination.

She denied any significant chronic or acute medical problems
except a history of seizures in childhood. Neurological work up including a
sleep deprived EEG was unremarkable (nothing that pointed to a problem). Her
family history revealed a dysfunctional family: with an alcoholic father and a
mother who left the family when Rosalie was six years old. She referred to her
stepmother as cold and as an emotionally abused and weird person.

In 2000 during a domestic argument her boyfriend struck her
so hard that she hit her head against the door and lost consciousness for some
time. Since that time she experienced headaches and strange sensations until
two years later when she developed the symptoms described above. She smokes
half a pack a day and drinks about four cups of coffee a day. Her medications
include : Trileptal, Zonegran, Seroquel. She reported no positive or negative
side effects from these medications.

During a sleep evaluation (Polysomnography test) she
exhibited multiple agitated and confusional arousals. In the morning upon
awakening she was disoriented and told the night technician that she had never
seen him previously. When a doctor with whom she was very familiar attempted to
speak with her over the phone, she did not know who it was and how she came to
be at the clinic. She also did not know where she was going from here and how
she would drive.

Rosalie was brought to the emergency room, operated with all
the procedures of the ER evaluation and subsequently was transferred to a
psychiatric unit. After several hours on the unit, she fell asleep, than woke
up and was panicking realizing that she was in the psychiatric unit. The next
morning she developed a similar episode of dissociative state and was brought
back to the ER for medical evaluation. After she was medically cleared and
completely awake she was discharged. The whole experience was understandably
traumatic for her.

The results of her sleep study demonstrated abnormal sleep
architecture and frequent arousals. During the morning REM stage, the density
of the rapid eye movements increased. When she was awakening from the REM stage
in the early morning, she was still seeing a dream and talking to imaginary
people and moved imaginary objects.

No significant abnormalities on the sleep EEG were noted.


Rosalie’s symptoms could be conceptualized as incomplete
awakenings, as a dissociation state in which fragments of REM sleep were mixed
with the waking reality.

In simple words, her brain was stuck between sleep and
wakefulness, like an elevator between floors, or a car transmission between
speed gears.

Visual images of the REM stage that continue during the
transition between night sleep and morning awakenings are called “hypnopompic
hallucinations” versus evening pre-sleep visualizations, called “hypnagogic
hallucinations.” Morning dissociations with incomplete arousals and hypnopompic
hallucinations are classic symptoms of narcolepsy, but may appear in seizures
disorder, after head traumas, as side effects of medications (hypnotics), street
drugs, infections, and prolonged sleep deprivations.

The clinical significance of this phenomenon is a difference
in the therapeutic approach. Instead of using antiepileptic, antidepressants
and anti-psychotics for treatment, mild stimulants might have more beneficial

Presently, Dr. Rusica Ristanovic (a neurologist from the
Evanston Hospital Sleep Center) and I are collecting several such cases and
preparing an article on sleep-related hallucinations. The reason why this case
was presented is to show that many strange phenomena exist that might not mean
that the person is “crazy,” but rather has a known and very treatable medical
condition related to a sleep disorder. If you happen to know of such cases,
please, help this person to seek medical help from a sleep specialist.