Changing conceptions of the nightmare in medicine

Brian A. Sharpless, PhD, MA
Washington State University, United States

 The nightmare by Henry Fuseli
The nightmare, 1781
Henry Fuseli
Detroit Institute of Arts

In contemporary parlance the word “nightmare” conjures up images of a scary dream that leaves us shaken and afraid. This fear usually subsides when we wake and realize that we are actually safe in our own bedroom. However, the original conception of the “Nightmare” was much more vivid and terrifying, even seen as potentially deadly.

Before the early 20th century when this semantic shift began, the Nightmare had a much more specific meaning in medical and non-medical literatures. A paradigmatic episode of Nightmare consisted of: (a) paralysis of the entire body except for the eyes, (b) conscious awareness of one’s surroundings, (c) a feeling of weight on the chest, (d) an inability to cry out for help, and (e) extreme terror. The terror during Nightmare was due not only to inescapable paralysis, but also to the perception that someone (or something) was pressing down on and assaulting you. Specific cultures experienced this attacker differently (e.g., incubi/succubi in Rome;1 giant bats in Zanzibar),2 but were unanimous in the frightening nature of this nocturnal assault. The famous painting by Henri Fuseli3 is perhaps the best visual representation of this phenomenon.

Etiological theories for the Nightmare were far-ranging. Perhaps not surprisingly, it was viewed by the lay public as an actual attack by supernatural beings (demons, witches, or vampires).4,5 Thus, Nightmare sufferers were victims of obsession (viz., tormented from the outside as opposed to possession, which is torment from within) from a night-fiend with malevolent and often carnal intent. Various preventive measures such as sleeping with a bible6 or salt under one’s pillow7 were derived from this theory, as evil beings were presumed to detest both.

Physicians from the ancient world to early modernity and beyond eschewed supernatural forces in favor of naturalistic explanations for the Nightmare. When reading these source materials, it is surprising how little theories and treatments changed over five hundred years. Ancient Romans would have certainly recognized and understood the palliative efforts of nineteenth century physicians and vice versa. Using the categories available to them at the time (e.g., humoural theories), they located the origin of Nightmare in somatic causes such as a plethora of blood8,9 or digestive distress.10 Treatments logically followed from theory and included venesection, purgatives, and dietary changes (thinning the diet, reducing body acidity, ingestion of aromatic herbs).8,10-12 Interestingly, treatments for Nightmare were very similar to those for “the sacred disease” of epilepsy.

Some physicians claimed that Nightmare could be a prelude to more serious diseases (e.g., epilepsy, apoplexy) and even lead to death.9,11 Silimachus, a Roman follower of Hippocrates, described Nightmare spreading like a plague throughout Rome and resulting in the death of many citizens.11 The veracity of Silimachus’s claim, however, is clearly suspect.

So where does the Nightmare fit in contemporary psychology and psychiatry? Today, it would be conceptualized as a subtype of sleep paralysis. Sleep paralysis is a common feature of narcolepsy (part of the “narcoleptic tetrad”) and certain seizure disorders, but often occurs alone.13 Recent empirical work found it is common in psychiatric and non-psychiatric samples14 and is associated with a number of psychiatric symptoms, sleep patterns, and pre-existing beliefs.15,16 Much work has been done cataloging the more typical sleep paralysis hallucinations,17 and they do in fact dovetail nicely with descriptions of the Nightmare in folklore and myth. Unfortunately for contemporary sufferers, treatments for sleep paralysis are not yet well-articulated, but REM-suppressing antidepressants may be useful.18

Does the Nightmare persist in contemporary mythologies? Interestingly, and in spite of the fact that sleep paralysis is a fairly well-described REM-based phenomenon that has attracted popular attention, the Nightmare indeed continues. Most notably one can see present-day reinterpretations of the Nightmare in alien abduction narratives.19 Common abduction scenarios include an inability to move, abject fear, feelings of suffocation, and attacks/probings/surgeries when in a prone, defenseless state. The Nightmare also likely plays a role in nocturnal encounters with ghosts. More recently, popular press attention on “shadow people”20 may also be related to the Nightmare/sleep paralysis. Shadow people are indistinct humanoid shapes often seen at night and in the periphery of one’s field of vision.20 These nocturnal intruders are alternately claimed to be the visual manifestations of astral projection or inter-dimensional beings. Thus, as with extraterrestrials, a science fiction element may be operative here as well.

In closing, the Nightmare has undergone significant modification from a malevolent, dangerous, real-world attacker in possession of paranormal powers to the much more feeble and anemic scary dream that we know so well today. However, as with most experiences possessing personal and historical significance, the Nightmare and pockets of earlier beliefs persist to the present.

References

  1. Davies O. “The nightmare experience, sleep paralysis and witchcraft accusations.” Folklore. 2003;114(2):181.
  2. Nickell J. “The skeptic-raping demon of zanzibar.” Skeptical Briefs. 1995;5(4):7.
  3. Fuseli H. The nightmare. 1781.
  4. Kramer H, Sprenger J. The malleus maleficarum. Mineola, NY: Dover Publications; 1971.
  5. Hufford D. The terror that comes in the night: An Experience-centred study of supernatural assault traditions. Philadelphia, PA: University of Pennsylvania Press; 1982.
  6. Ness RC. “The old hag phenomenon as sleep paralysis: A biocultural interpretation.” Culture, medicine and psychiatry. 1978;2:15-39.
  7. Jones E. On the nightmare. 2nd Impression ed. London, United Kingdom: Hogarth Press and the Institute of Psycho-analysis; 1949.
  8. Aegineta P. The seven books of Paulus Aegineta. Translated from the Greek with a commentary embracing a complete view of the knowledge possessed by the Greeks, Romans, and Arabians on all subjects connected with medicine and surgery. London: Syndeham Society; 1844.
  9. Bond J. An essay on the incubus, or night mare. London: D. Wilson and T. Durham; 1753.
  10. Macnish R. The philosophy of sleep. First American ed. New York: D. Appleton and Company; 1834.
  11. Aurelianus C. On acute diseases and chronic diseases. Chicago: University of Chicago Press; 1950.
  12. Waller J. A treatise on the incubus, or night-mare, disturbed sleep, terrific dreams, and nocturnal visions with the means of removing these distressing complaints. London: E Cox and Son; 1816.
  13. American Academy of Sleep Medicine. International classification of sleep disorders: Diagnostic & coding manual. 2nd edition ed. Darien, IL: American Academy of Sleep Medicine; 2005.
  14. Sharpless BA, Barber JP. “Lifetime prevalence rates of sleep paralysis: A systematic review.” Sleep Medicine Reviews. 2011;15(5):311.
  15. Sharpless BA, McCarthy KS, Chambless DL, MiIrod BL, Khalsa S, Barber JP. “Isolated sleep paralysis and fearful isolated sleep paralysis in outpatients with panic attacks.” J Clin Psychol. 2010;66(12):1292-1306.
  16. Ramsawh HJ, Raffa SD, White KS, Barlow DH. “Risk factors for isolated sleep paralysis in an African American sample: A preliminary study.” Behavior Therapy. 2008;39(4):386-397.
  17. Cheyne JA, Rueffer SD, Newby-Clark IR. “Hypnagogic and hypnopompic hallucinations during sleep paralysis: Neurological and cultural construction of the night-mare.” Consciousness and Cognition: An International Journal. 1999;8(3):319-337.
  18. Plante DT, Winkelman JW. “Parasomnia: Psychiatric considerations.” Sleep Medicine Clinics. 2008;3:217-229.
  19. Clancy SA. Abducted: How people come to believe they were kidnapped by aliens. Cambridge, MA: First Harvard University Press; 2007.
  20. Offutt J. Darkness walks. San Antonio, TX: Anomalist Books; 2009.

BRIAN A. SHARPLESS, PhD, MA, is an assistant professor of psychology and director of the Psychology Clinic at Washington State University. He received his PhD in clinical psychology and M.A. in philosophy from the Pennsylvania State University and completed his pre-doctoral internship at Pennsylvania Hospital. After graduation, he finished a post-doctoral clinical fellowship (Pennsylvania Hospital) and post-doctoral research fellowship (Center for Psychotherapy Research) at the University of Pennsylvania. Prior to his position at WSU, he was on faculty at the Pennsylvania State University. Current research interests include anxiety, sleep disorders, psychoanalytic therapy, and the history and philosophy of clinical psychology.