The Nightmares that Unite Us

In the December 7th and December 9th 2006 issues of the Chronicle Herald of Halifax, columnist Peter Duffy wrote an article in which he claimed to have been the victim of what he described as a case of supernatural sexual assault. The experience was so vivid and traumatic that the otherwise conservative author consulted a psychic astrologer, a priest, and a professor of religious studies in an effort to understand what had happened to him. As he described the experience:

I became aware of a strange presence in the bedroom, something emitting waves of malevolence. […] I don’t know how, [but] I knew it was a demon of some kind. I recoiled in horror, trying to make myself small, unable to tear my eyes away. […] And then it was on top of me, soundless and unstoppable, smothering me, assaulting me. There’s no delicate way to put this; I was vividly aware of this creature violating me. I yelled, but nothing came from my lips.

Observers in subsequent issues of the Herald indicated that what Duffy had experienced was a case of sleep paralysis with hypnagogic hallucinations (SPHH), and that the editors of the paper should have known better than to print his confused account of demon assault in one of Nova Scotia’s major newspapers. The highly public nature of this event and the backlash that accompanied its publication are quite uncommon, and they are an intriguing indicator of the still obscure nature of a physiological experience that occurs at least once in the lifetime of between 5 and 62 percent of the population. Yet importantly, subsequent readers of the Herald knew of the experience and were willing and able to set the record straight in their letters to the editor. The situation would have been much different had the same article been published thirty years ago.

Here I hope to explore the role that folklorists had in drawing attention to the existence and normalcy of SPHH, what they often refer to as “the Old Hag”. More specifically: how did they succeed in doing this and through what channels did their influence take effect? By examining these issues it is hoped that the interdisciplinary shift that this change of focus entailed in both the folkloric and medical communities will also be made manifest. This development owes a great deal to the work of the folklorist David J. Hufford from the Department of Humanities at Penn State University and Robert C. Ness from the Department of Psychiatry at the University of Connecticut Health Centre. Both Hufford’s 1982 book The Terror That Comes in the Night: An Experience-Centered Study of Supernatural Assault Traditions and Ness’ 1978 article “The Old Hag Phenomenon as Sleep Paralysis: A Biocultural Interpretation” attempted to articulate the Old Hag as a unique phenomenon whose widespread cultural occurrence should be understood alongside a particular set of physiological conditions consistent with what psychologists and doctors were designating SPHH. Thus in this paper Ness’ and Hufford’s roles will be particularly important to the investigation.

By exploring the folkloric, anthropological and medical literature surrounding the changing approach to the Old Hag in the past 30 years, I hope to demonstrate how, in contrast to its earlier obscurity and misclassification, the folkloric turn instigated by figures such as Hufford and Ness near the beginning of the 1980s allowed for the isolation of the Old Hag as a stable, medically relevant phenomenon. While not immediately accepted, this suggested approach helped to changed the medical community’s focus on SPHH away from the usual associations with narcolepsy, epilepsy and schizophrenia, towards stress, depression and posttraumatic stress disorder (PTSD). This movement was then predicated on a shift in the medical community’s understanding of the Old Hag’s pathological associations, and was mediated by medical anthropologists’ understanding of culture-bound syndromes, as well as the contributions made by researchers with cultural and ethnic backgrounds other than that of most modern western medical practitioners. The consequence of this “folkloric turn” has been that doctors and psychologists confronted with the Old Hag have increasingly come to see the value of folklore in treating patients experiencing the condition, particularly in cases of PTSD, and several folklorists have begun understanding their rolls as those of healers and medical researchers.

Doctors, Folklorists and the Phenomenon, 1979-1982:

The phenomenology of the Old Hag is typified by a number of striking characteristics: The impression of wakefulness and the capacity to hear things that are actually happening around the subject, total paralysis which sets in either upon waking or falling asleep, a felt presence of some (usually malevolent) entity nearby, auditory and visual hallucinations clearly set in the room in which the victim went to sleep, and pressure on the chest or other part of the body that interferes with respiration. While other experiences have been reported in association with the Old Hag, these are the basic traits most often attributed to the experience.

It is generally accepted that the modern medical study of dream phenomenon begins with the work of Sigmund Freud. However, Freud was often uncomfortable with bad dreams, for they challenged one of the central dogmas of his interpretive method: They could not easily be described as repressed wishes. The early work of attempting to understand them would be left to a disciple of Freud’s, the welsh psychologist Ernest Jones. His On The Nightmare concluded by claiming that many nightmare phenomena, including several that have since become associated with the Old Hag, were representative of sexual angst, in which a state of guilt is turned back upon the dreamer resulting in their frightening dreams. While this study was ultimately superseded, it nevertheless represents the earliest modern medical attempt to account for a variety of bad dream experiences and set the framework for later discussions.

Up until at least 1984 doctors and psychologists tended to view consistent bad dreams or experiences consistent with the Old Hag as indicative of some underlying pathology. For instance, the psychologist Ernest Hartmann, while seemingly unaware of the Old Hag as such, observed in his 1984 work on nightmares that extreme cases were often indicative of schizophrenic, or pre-schizophrenic personality types. The common co-occurrence of SPHH consistent with the Old Hag in narcoleptics was also the focus of many of these early studies. While the association in this case is entirely justified, people with narcolepsy do experience the Old Hag on average much more frequently than those without it, this connection had the further result of leading some researchers to suspect that the presence of Old Hag symptoms might necessarily be a sign of narcolepsy. While not as prevalent in the medical literature, clinical accounts also indicate that people coming to their physician during this time were often diagnosed as potential epileptics. Together these three tentative diagnoses, schizophrenia, narcolepsy and epilepsy, constituted doctors’ and psychologists’ primary response to patients describing Old Hag symptoms in the period prior to the folkloric turn.

In 1978 Robert C. Ness published a paper in Culture, Medicine and Psychiatry entitled “The Old Hag Phenomenon as Sleep Paralysis: A Biocultural Interpretation”. The main thesis of his paper was that the phenomenon of the Old Hag experienced by many Newfoundlanders was best explained by identifying it with SPHH, and that its widespread nature largely ruled out the exclusively pathological view advanced by many of his colleagues. As he argued at the time: “My opportunity to live and work for 13 months with people who had experienced attacks of the Old Hag convinced me that they were not suffering from any distinctive form of chronic or episodic emotional disturbance”. Furthermore, what was unusual at the time was that while Ness was acting in his role as a psychologist, his methodologies were decidedly folkloric.

Four years after the publication of Ness’ article, in 1982, the folklorist David Hufford published The Terror That Comes in the Night: An Experience-Centered Study of Supernatural Assault Traditions. This broad ranging study of the Old Hag likewise concluded that the cultural experience must be understood alongside the medical designation of SPHH, and that it was not necessarily associated with the pathologies usually attributed to it. More than this, Hufford stressed the widespread nature of the experience, the problems that modern western medicine has faced in attempting to properly isolate it, and how these difficulties had definite clinical consequences. For Hufford, understanding the Old Hag in folkloric terms had “potential medical and psychological significance”. This significance was owed partially to his view that “folk knowledge is sometimes well in advance of scientific knowledge”, as well as his conviction that it provides “an arena for genuinely interdisciplinary research”. In many ways his book was a self-conscious call to arms to the folkloric and medical communities to unite for the better understanding of the Old Hag.

The Meeting of Minds:

One of the earliest points of contact between folkloric and medical studies of the Old Hag in the years after the publication of Hufford’s and Ness’ work can be seen in the anthropological and psychological writings of the time period centered around the concept of the “culture-bound syndrome”. Even while being considered a “blurred” distinction at the time in which it was proposed, Ronald C. Simons, from the Department of Psychiatry at Michigan State University, described this class of syndrome as follows in his introduction to The Culture-Bound Syndromes: Folk Illnesses of Psychiatric and Anthropological Interest:

Unlike the categories of standard Western psychiatric nosology culture-bound syndromes are restricted to specifiable peoples and locales, hence the term ‘culture-bound’. Thus their full explications require description not only of the behaviors and experiences which are considered deviant, but also of the ways those behaviors and experiences are embedded in specific social systems and cultural context.

In the collection Ness’ essay on the Old Hag serves as a main feature for the discussion of the “sleep paralysis taxon”, and Simons makes a point of quoting at length The Terror that Comes in the Night, “a remarkable volume by David Hufford”. Furthermore, the follow-up to the section on sleep paralysis comments on the “striking” similarities in symptomology of the Old Hag in Ness’ article and the experience of uqamairineq and uqumanigianiq in an article on Eskimo SPHH presented in the same volume by Joseph D. Bloom, from the Department of Psychiatry at the University of Oregon, and Richard D. Gelardin, from the Anchorage Community College. While the concept of the culture-bound syndrome often stood on a shaky footing, it clearly opened up a space in which medical researchers, anthropologists and folklorists such as Hufford could have their work mentioned in the same volume, and exposed to a wider professional audience than their isolated disciplines.

Outside of the concept of culture-bound syndromes it is informative to look at the work of Carl C. Bell, an associate professor of clinical psychiatry at the University of Illinois School of Medicine. In 1986 Bell published an article in the Journal of the National Medical Association entitled “Further Studies on the Prevalence of Isolated Sleep Paralysis in Black Subjects”. In reviewing the existing literature on sleep paralysis Bell explicitly mentions the contributions made by Hufford. More than this, his discussion of the folklorist occupies most of the space dedicated to the previous literature, and emphasizes Hufford’s “significant contribution” to the study and understanding of SPHH. The widely cited paper was a follow up to a number of studies Bell had already published on the prevalence of isolated sleep paralysis in African American communities. In particular, a look at his 1984 article “Prevalence of Isolated Sleep Paralysis in Black Subjects” does much to shed light on his early reception of the folkloric contribution.

Two things in particular are interesting about Bell’s earlier work. Unlike most of the studies of his subject matter in the medical community, he does not emphasize the typical pathologies of the Old Hag, but instead draws his reader’s attention to its association with stress, depression and PTSD. As he observes:

being black in this society is associated with stress due to racism with its attendant lack of parity in housing, health care, employment, nutrition, education, and opportunities […]. It may well be that the high amounts of sleep paralysis seen in this population are the results of ‘survival fatigue’

Furthermore, it is apparent that Bell was not unaware of the cultural dimension of the Old Hag that exists in African American communities. As he comments near the end of his paper:

One finds cultural evidence for the high incidence of sleep paralysis in blacks in American black folklore, with references to the experience ‘the witch is riding you.’ This may refer to the common report of sleep paralysis victims that they feel as if someone is sitting on their chest or standing over their bed. Certainly, a genetic predisposition toward sleep paralysis among blacks would help to explain the finding that black cultural cosmology in black Africa is in part based on the existence of genies and spirits.

Hufford would argue that it was the presence of a cultural tradition that allowed African American’s to elaborate their experience, creating only the appearance of a greater incidence rate than in other populations. However, Bell’s attempt to link the cultural expression of the Old Hag with the prevalence of sleep paralysis represents a dramatic shift in the professional medical community’s approach to the condition. That his work represents a kind of milestone is further emphasized by his statement at the beginning of his paper that: “This study represents the first survey to measure the incidence of this disorder in a black population of healthy subjects and psychiatric patients”. By placing “healthy subjects” alongside those with some recognized pathology Bell was able to get a clearer picture of the prevalence of Old Hag experiences in the African American community that he studied. Two factors in particular, Bell’s desire to shift the focus away from the traditional pathologies of the Old Hag, as well as his attention to the cultural elaborations of sleep paralysis among African Americans, made him predisposed to the kind of accounts that the folklorists were making to describe the Old Hag. Also, the fact that Bell himself is an African American may not have been entirely unimportant in shaping his novel approach to the study of the experience.

In general there were two main responses to the initial presentation of the folkloric turn in studies of the Old Hag: it was either absent in the writings of psychologists and doctors when addressing symptoms of SPHH, or the roll of folklore in isolating it as a condition was addressed. When it is addressed, it is done so by medical practitioners who, while working within the rubric of modern western medicine, are often from alternative cultural or ethnic backgrounds. This is particularly so in the case of Japanese researchers, in whose culture the concept of the Old Hag already exists under the name of kanashibari. However, notably, in cases in which the researchers are embedded in the tradition of modern western medicine, their subjects of study are often refugee immigrant groups or other minorities in whose culture the Old Hag has some form of definite expression.

Getting a Handle on the Hag:

In March 2005 the journal Transcultural Psychology published an issue entirely dedicated to sleep paralysis (SPHH) consistent with Hufford’s articulation of the Old Hag. Hufford made a contribution to the collection with his article “Sleep Paralysis as Spiritual Experience”, and many of the entries featured a distinctly folkloric approach in the psychological treatment of a wide variety of ethnic groups. With the general acceptance of the Old Hag as a stable, wide spread and cross-cultural phenomenon, attention has turned away from the pathologies of schizophrenia, narcolepsy and epilepsy, and is now focused on the more purely psychological conditions of stress, depression and PTSD. This new direction is in keeping with both Hufford’s and Bell’s treatment of the experience, and resulted in the production of novel methods of diagnosis and treatment.

Devon E. Hinton’s paper “‘The Ghost Pushes You Down’: Sleep Paralysis-Type Panic Attacks in a Khmer Refugee Population”, in which a population of Cambodian refugees from the Khmer Rouge period were examined for cases of SPHH, is demonstrative of this trend. One of the keys to his observations is that “SP [sleep paralysis] is a core aspect of the Cambodian refugees response to trauma; when assessing Cambodian refugees, and traumatized refugees in general, clinicians should assess for its presence“. This emphasis on the experience of the Old Hag in a culture in which there is a definite equivalent led the researchers to emphasize the importance of detecting the presence of the condition in sufferers of PTSD. This roll is particularly importance, since, as the study concludes:

Increased daytime anxiety and panic initiated by SP will subsequently lead to yet more conditioning of fear to arousal symptoms; increased arousal; and more night-time awakening. In turn, these three processes lead to more SP. Hence, a self-perpetuating cycle is initiated.

This sentiment in mirrored in a 2008 study of the link between PTSD resulting from childhood abuse and SPHH. In it the clinical psychologist Murray P. Abrams et al from the University of Regina likewise conclude that: “It is therefore reasonable to suggest that SP may itself be a substantially traumatizing experience, irrespective of whether or not it is specifically related to a prior trauma”. What is particularly notable in these works is that they do not suggest that individuals who experience the Old Hag and associated phenomenon are at any greater risk of schizophrenia or epilepsy. Indeed, the opposite is now the case. The presence of Old Hag symptoms is seen as a factor that should dissuade doctors and psychiatrists from making hasty diagnoses of schizophrenia, particularly in the case of immigrants. For example, Joop de Jong, a psychiatrist and professor of mental health and culture at the Vrije Universiteit Amsterdam, in his 2005 study of cultural variations in the presentation of isolated sleep paralysis emphasizes that this greater understanding can prevent the misdiagnosis of otherwise normal patients. As he says:

It is quite obvious that mental health professionals should be aware of the existence of this diagnosis, because the hallucinatory experiences may easily result in false-positive diagnoses of psychoses, especially among immigrant groups who more likely receive a diagnosis of (paranoid) schizophrenia.

This statement is far removed from Hartmann’s 1984 work and its accompanying support for a largely schizophrenic or pre-schizophrenic treatment of a wide array of Old Hag and nightmare phenomenon.

As seems evident from these considerations, the folkloric turn also brought with it novel methods of treatment, particularly in the area of PTSD, in which it was realized that the Old Hag could produce a feedback loop in which sufferers of PTSD are further traumatized. Attempting to disrupt this loop is seen as a new goal of treatment and is often accomplished merely by informing the patient of the normalcy and non-life threatening nature of the experience. As a testament to the interdisciplinary nature of this insight, the methods of addressing the “cycle of trauma” recognized in Abrams’ paper directly references Hufford’s work: “Education alone may provide relief, […] such information may also help ameliorate the initial shock and fear commonly associated with a SP episode (Hufford, 2005)”. These sentiments have also been mirrored elsewhere in the recent literature.

The consequences go further than this in Hinton’s paper however, for an attention to the folk beliefs of people suffering from the Old Hag comes to play a direct roll in the diagnosis and treatment of the various stresses contributing to the condition:

One should determine when the SP events began. If the episodes commenced during the Khmer Rouge period, trauma events at that time are implicated; if the onset of SP was at a later point, issues of interpersonal conflict, such as acting-out of children or gang involvement or spousal abuse, may be especially important. One should ask about self-treatment. One should elicit patient’s thoughts about the origin of SP. Also, one should carefully document the phenomenology of the sleep paralysis and post-sleep paralysis state.

These folk beliefs can thus provide important clues as to the origins and potential treatment methods of the stresses associated with the Old Hag, and is largely achieved through a more careful attention to what individuals believe about their own health, and by creating a space in which disclosure of experiences outside of the usual rubric of modern western medicine is encouraged.

The new options this approach has provided for the treatment of patients experiencing the Old Hag has been acknowledged by others. As early as 1992, Jude Uzoma Ohaeri from the Department of Psychiatry at the University College Hospital likewise concluded that: “It is hoped that doctors in general medical practice and in psychological medicine in developing countries where belief in supernatural causation of illness is rife will consider these factors in order to provide more effective treatment”. If the growing number of works that recognize this point is any indication of prevailing trends, we may conclude that from the interplay of folklore and medicine a novel phenomenon has been identified and treatments derived, which would not have been possible without the medical insights of the folklorists, or the cultural attention of the doctors involved.

The interdisciplinary victory represented by this new understanding of the Old Hag brought with it changing views in the medical and folkloric communities about the value of each other’s work. Several folklorists and medical anthropologists such as Shelly Adler, from the Division of Medical Anthropology in the Department of Epidemiology and Biostatistics at the University of California, have begun to see their roll as that of active medical researchers with valuable insights on the origin and identification of culturally defined illnesses. Nowhere is this understanding more forcefully expressed than in Adler’s work:

The ease with which folk tradition isolates the nightmare experience [the Old Hag], however, is in marked contrast to the continuing confusion that characterizes current scientific investigations into the phenomenon. Perhaps the most difficult problem involves distinguishing the specific nightmare incident from other sleep disorders, particularly the night terror, Pavor nocturnus. The terms nightmare and night terror are often used interchangeably and are incorrectly assumed to refer to the same experience. Even among researchers who have considered a possible connection between SUNDS [Sudden Unexpected Nocturnal Death Syndrome] and certain “dreams” of the Hmong (e.g., Lemoine and Mougne 1983; Melles and Katz 1988; Tobin and Friedman 1983), progress is impeded by the lack of consistent use of an accurate characterization of the nightmare.

Likewise, clinical psychologists such as those represented in the May 2005 issue of Transcultural Psychiatry have increasingly come to recognize the importance of cultural variations in the presentation of the Old Hag, and its consequences for diagnosis and treatment.

It is also interesting to note the process of social construction that has taken place in dealing with Old Hag symptoms both before and after the folkloric turn. It is probable that western medicine’s outlook on hallucinatory symptoms helped to shape the pathological interpretation of early accounts of the Old Hag. In such a context patients reporting dramatic spiritual or paranormal experiences, particularly those from cultural backgrounds outside of the norm of modern medical practice, were much more likely to be seen as suffering from a major psychological condition. This had the combined effect of making patients less likely to come forward with this set of symptoms, as well as serving to further isolate minority and immigrant cultural groups from mainstream medicine.

However, elements of social construction can likewise be seen after the folkloric turn. In the case of Carl Bell’s research it seems evident that an emphasis on the subjugation of minorities played into the interpretation of the Old Hag as the product of stress, depression and PTSD. Adler’s touching articulation of the plight of Hmong immigrants in America further demonstrates this trend. Yet it must also be noted that as an experience whose cultural elaboration has taken on greater emphasis, the degree to which it is considered “culturally” constructed becomes much more flexible and informative than with the earlier pathological view.

Regardless of the degree to which interpretations of the Old Hag have been culturally constructed, the background of these considerations would benefit from further study. For instance, what changes took place from the 1980s to the present in the ways that the medical community approached the problems of war related trauma in immigrant and refugee populations? Alongside the notable case of Carl Bell, how did the socio-economic and cultural position of African Americans and other minorities change in relation to the medical community to allow for the study of the Old Hag? It may very well be that a large part of this shift is due to an increase in the number or activity of medical practitioners whose cultural backgrounds varied from that of traditional modern medicine. If this is the case it would not be unreasonable to suspect that the assumptions and biases that led early researches to associate hallucinatory experiences with severe mental pathologies might be absent or modified in their work. The role of Japanese researchers in particular is worthy of further study, for Japanese medicine represents a unique fusion of modern western medical practice within a non-western culture that already had a developed notion of the Old Hag in the form of kanashibari.

On the side of the folklorists, it would be fruitful to note how many of them had experienced the Old Hag before becoming interested in its role in their area of study. This is the case with Hufford, who first experienced the condition while a student at university. The typical stresses of university students, with frequent disruptions in sleep, constant deadlines and alienating figures of authority, combined with growing pressure placed upon them by larger class sizes and poor job prospects for the future, may increase the rate of the Old Hag in this population. If so, it would be worthwhile to examine the role that student life has played in shaping the interests of folklorist to see if changing levels of stress and depression made it ever more likely that they would direct their attention towards this experience.

That the folkloric turn of the 1980s did occur and helped to shape the ways in which the symptoms of the Old Hag were treated by psychologists and doctors now seems certain. The shift away from diagnoses of schizophrenia, narcolepsy and epilepsy, towards those of depression, stress and PTSD that was instigated by the folklorists was mediated to the larger medical community by researchers that studied or were part of minority groups who often had some discreet notion of the Old Hag as a stable and non-pathological phenomenon. The psychological concept of the culture-bound syndrome also played a part in widening the medical audience for this particular interpretation of the symptoms of the Old Hag. Once adopted, it cleared the way for novel methods of treatment and clinical practice that saw their most immediate consequences for immigrant refugees whose concerns had been previously marginalized or misdiagnosed as being more pathological than they actually were. By looking into the channels through which this process took place, and at the larger cultural issues that set the context for this change, it will be possible to glean yet further insights into a common human experience that has been silenced for longer than can be explained by traditional accounts of dispassionate medical research. At the very least, it highlights the importance and value of heterodoxy to modern western medicine, and forces a reevaluation of the role of folk beliefs in the mental health of individuals. It is hoped that we may now be able to come to terms with the experience of the Old Hag and gain some further insights into its future role at the crossroads of folklore and medicine.


For More Information:

http://en.wikipedia.org/wiki/Sleep_paralysis

The Devil’s Trill: http://www.youtube.com/watch?v=YonqEbar8cM
http://www.youtube.com/watch?v=V5SwrXt6Mk8

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—. “Making Sense of Angels and Demons”. The Chronicle Herald [Halifax] December 9th 2006, Metro and Provincial, The Mail Star: B4.

Fukuda, Kazuhiko, et al. “Recognition of Sleep Paralysis Among Normal Adults in Canada and Japan” In Psychiatry and Clinical Neuroscience Vol. 54. (2000), p. 292-293.

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Hughes, Charles C., “The Sleep Paralysis Taxon: Commentary” in The Culture-Bound Syndromes: Folk Illnesses of Psychiatric and Anthropological Interest. Ed. Ronald C. Simons and Charles C. Hughes. D. Reidel Publishing Company: Dordrecht, 1985.

—. “Sleep Paralysis as Spiritual Experience” In Transcultural Psychiatry, Vol. 42 (1) (2005) 11-45.

—. The Terror that Comes in the Night: An Experience-Centered Study of Supernatural Assault Traditions. University of Pennsylvania Press: Philadelphia, 1982.

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—. “Introduction: The Sleep Paralysis Taxon” in The Culture-Bound Syndromes: Folk Illnesses of Psychiatric and Anthropological Interest. Ed. Ronald C. Simons and Charles C. Hughes. D. Reidel Publishing Company: Dordrecht, 1985.

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http://www.dailygrail.com/Guest-Articles/2010/6/Taming-the-Night-Mare

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