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Sleep Disorders

Fantasy Dreaming and Hallucinations

10/27/2009

Question:

I had been fantasy dreaming a few weeks back and woke one morning about four to five weeks ago hearing the voices and seeing the people in my head. This has been going on every day and night since that first morning four or five weeks ago. They now claim they are angels and have been threatening to a family member and myself. Can you please advise me on this.

Answer:

Without information about your age, gender and medications as well as more detailed history about the timing of these events, it is difficult to speculate extensively on what the condition might be. It sounds as though what you’re describing is both a visual and auditory hallucination, though it is not clear if these are all occurring during your sleep (i.e. actual dreams with dream recall in the morning), upon awakening or during wakeful times. This distinction (sleep-related vs. nonsleep-related) is significant. I will assume in answering you, that you have never experienced this before and that you are not on medications, and using or abstaining from recreational drugs or alcohol.

REM sleep, or "dream sleep," is often irrational and is not under our control. Typically, REM sleep does not occur right with sleep onset unless an individual is severely sleep deprived or has a sleep disorder. REM sleep usually occurs around 80-90 minutes into sleep and then recurs about every 1.5 to 2 hours during the night. Episodes of REM sleep grow longer as the night progresses and the majority of nightmares and dreams typically occur from the middle of the night onward. Thus we often awaken in the morning from a dream episode. When dreams overlap with the transition to wakeful time, these are called sleep-related hallucinations.

Sleep-related hallucinations are prominent, vivid, dreams that are difficult to distinguish from reality as they appear to have visual, tactile and auditory components. They can occur at sleep onset (hypnagogic) or while waking up (hypnopompic). These events are common (reported in about 12% of the population) and may be associated with sleep paralysis. Sleep-related hallucinations may be associated with narcolepsy and are one of the phenomena commonly seen with narcolepsy. However, many people have hypnopompic or hypnagogic hallucinations without having narcolepsy, which is always associated with daytime sleepiness. There are a number of factors that could lead to sleep-related hallucinations in individuals who do not have a primary sleep disorder. Sleep deprivation or a varying sleep schedule can be factors associated with sleep-related hallucinations, as well as other parasomnias. Certain medications, abuse of alcohol or other illicit substances, and certain psychiatric conditions can also lead to sleep-related hallucinations.

Other primary sleep problems that could present this way include a nightmare disorder or night terrors. These dreams, while disturbing to you don’t seem to be consistent with the so called nightmare disorder. Particularly, that you remain consumed by their contents well into wakefulness and during the day. Nightmares are usually accompanied by a sensation of terror and awakening with complete recall of the dream in a frightened state. Night terrors tend to occur in children much more than in adults. They take place during non-REM (non dream) sleep. Although the individual may arouse and scream, they are unaware of their surroundings and unresponsive to attempts at comfort. They generally do not recall the event when they awaken.

Aside from sleep disorders, I am left with being concerned about a group of disorders called psychoses. These might include an underlying psychiatric problem, such as schizophrenia, which can be associated with visual and auditory hallucinations that may also be prominent at night. The auditory component of your symptoms is particularly concerning for that. Depression or anxiety can also influence dreams and may present as nightmares. Certain medications have been reported to increase the frequency of nightmares, such as certain heart medications, antihistamines, antidepressants or medications used to treat Parkinson’s disease.

It certainly sounds as though your symptoms are quite distressing to you and are having a significant impact on your daily life. I encourage you to see your general doctor soon, and do not be embarrassed to share your symptoms with your doctor. There remains a possibility that this is just a benign sleep disorder; but it is important to address the concern that this may represent psychosis.

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Response by:

Rami N Khayat, MD Rami N Khayat, MD
Clinical Associate Professor of Pulmonary, Allergy, Critical Care & Sleep
College of Medicine
The Ohio State University