Associate Medical Director, Center for Pediatric Sleep Disorders, Children's Hospital Boston, Instructor in Pediatrics, Harvard Medical School, Boston, MA
Disease is an inalienable and universal part of human existence. Try though we may to ignore, deny, prevent, treat or cure it, it is always present in our lives, whether actively or hidden just around the metaphorical corner. Sharing as we do the same biology, our bodies are afflicted by disease in much the same ways irrespective of where we live; how advanced our society is; whether we are rich or poor; what languages we speak; or which gods we do or do not worship.
What does differ, though, is how we make sense of what disease does to us. How we understand disease, explain it to others and to ourselves, and respond to it are all directly affected by our own personal experiences and those of other community members, present and past, including those we only know of through the shared memories and history which serve as a basis for a common culture.
While two patients with ischemic heart disease may both feel left-sided chest pain and be limited in their exercise tolerance in much the same way, their interpretation of what is happening to them can vary considerably. One patient may understand her symptoms to be the result of blocked coronary arteries, while the other may believe them to be caused by stagnant liver Qi. This is also seen with certain psychiatric disorders. Although two people with paranoid schizophrenia may have very different ideas about who or what is persecuting them, the fundamental nature of their disorder makes their experiences much more similar to each other's than to those of someone suffering from a different disorder such as major depression, for example.
Shelly Adler, professor in the Department of Family and Community Medicine at UCSF, set out to explore the phenomenon of the classic nightmare across cultures and history, how it straddles the mind-body divide, and its possible connection with sudden unexplained nocturnal death syndrome. Although the word “nightmare” has evolved over time to refer to any type of disturbing dream, it was originally used to describe a very specific experience, in which a person is not only unable to move despite being totally awake, but also feels as though he is being smothered, sometimes by a ghostly apparition pressing down on his chest, until the ability to move is recovered and the apparition disappears. Recognizing that, while richly described, the classic nightmare as an entity remains largely unrecognized by both the lay and medical communities in this country, she distinguishes it from the much more pedestrian bad dream by referring to it throughout the book in its hyphenated form, night-mare.
She begins this short but fascinating and engaging book by exploring the etymological root of the “mare” in night-mare, finding that it is common to the “German mahr and Old Norse mara, a supernatural being—usually female—who lay on people's chests at night, suffocating them.” And indeed, as she details the night-mare's presence across time and place, the reader learns that “Old Hag attacks” in Newfoundland, kanashibari in Japan, boratat in Morocco, karabasan in Turkey, and many others all share the same characteristics of paralysis, suffocation, and a menacing presence felt close by.
Sleep physicians recognize sleep paralysis as being one of the components of narcolepsy, as well as a stand alone occurrence in a relatively large percentage of the population. Often a benign phenomenon, it can also be excruciatingly terrifying when part of a night-mare, especially when associated with another one of the hallmarks of narcolepsy: the hypnagogic/hypnopompic hallucination. Both result from the intrusion of REM into wake, and both can occur in the absence of narcolepsy, combining to create a night-mare.
Many of those who have night-mares go through life believing that they suffer from some sort of mental illness, and Adler describes the relief many have felt upon learning of others with similar experiences. Indeed, this reader can attest to being approached by another passenger while reading this book on the trolley who proceeded to unburden himself of his own struggle with night-mares and how they had affected him over the years.
Drawing upon multiple sources, including art, literature, work by other researchers and her own field work, Adler adroitly weaves a cogent narrative which provides insight into this pervasive yet under recognized affliction. She also reminds us, by demonstrating how much more there is to understanding and treating patients than just pills and potions, of how important it is for physicians to broaden their horizons beyond the physical sciences and to include the humanities as well if they wish to provide truly good care to their patients. As she writes in the introduction: “the night-mare, poised as it is between the supernatural and the natural worlds, and between the meaningful and the biological, is perfectly positioned to teach us about the seamless connection between our minds and our bodies.”
Dr. Rosen has indicated no financial conflicts of interest.