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Bad Dreams

[Content warning: Scary stuff, gawking at weird diseases]

My first sign that something was up was when I noticed my Sleep Medicine textbook was written by a Dr. Dement. I reassured myself that it was probably just a coincidence, while secretly knowing I would shout “Expecto patronum!” if I ever ran into him at a conference, just to be sure.

The second sign was the introductory quote. A lot of textbooks have these. They’re usually from a work of great literature, or a poem, or a song that has to do with the medical topic addressed. Anything to show that the doctors in this field are cultured, not just people who learn a bunch of biology without exploring the wider world of the arts. For the Sleep Medicine textbook, the introductory quote was from Les Mis:

But the tigers come at night
With their voices soft as thunder
As they tear your hope apart
As they turn your dream to shame

I like the song, but in context this is really creepy.

The third sign was everything in the textbook. Sleep disorders, and especially disorders of dreaming, read like something out of an Edgar Allen Poe story.

Patients with Epic Dreaming Disorder report emotionally neutral dreams with repetitive content – continually walking up endless staircases, running across unchanging landscapes, cleaning rooms, scrubbing stone walls – which start as soon as their head hits the pillow and don’t end until they awaken. They complain of fatigue upon awakening, as if they have been working all night. When placed in the laboratory, physiological indicators of sleep are normal, and there is no increase in REM sleep time (although we now know that dreams can and do occur in non-REM sleep as well). The condition is currently poorly understood, not treatable, and sufferers report difficulty just trying to get doctors to believe they exist and aren’t making it up.

Somewhat related to epic dreaming are pathological lucid dreams. Normal lucid dreams are fun experiences where you realize you’re dreaming, take control of the dream, and spend the rest of the dream riding dolphins or kissing supermodels. Pathological lucid dreamers realize that they’re dreaming, but this somehow turns the dream into a nightmare in which the dreamer is attacked by demonic figures, all while fully conscious and realizing the nature of the phenomenon. These dreamers report experiencing real pain from the attacks and sometimes go to great lengths to stay awake and avoid having to subject themselves to further dream attacks.

Lovecraft, who knew a thing or two about dreams himself, said that “the oldest and strongest fear is fear of the unknown”, and this is part of why I find night terrors so scary. Night terrors are very simple – a sleeper wakes up very suddenly out of very deep sleep, eyes dilated impossibly wide, screaming at the top of their lungs and sometimes flailing their limbs in front of them as if trying to ward something off or protect themselves from something. When asked why, they do not explain, or cannot remember. The old consensus was that there was no stimulus; the night terrors occur during deep sleep, when dreams were once not believed to be possible. Now researchers are not so sure. One proposal floated seriously in my textbook was that whatever these people see or experience is so traumatic that the brain instantly represses it upon awakening. And this repression occurs so consistently and so completely that no one in the waking world knows or will ever know what causes night terrors.

Sleep paralysis is very common. The body tries to shut down most voluntary movement in sleep so that people don’t act out their dreams; sometimes it jumps the gun and paralyzes people when they are still awake. This would be scary enough as it is, especially since the loss of voluntary control of breathing makes victims misperceive that they are suffocating or choking to death. But driven by some sort of primal urge to make sense of the experience, sufferers often go further and hallucinate monsters immobilizing them. The classic presentation is a ghost or a devil sitting on the victim’s chest, preventing her from breathing. In other cases, the monster will be visible somewhere else in the bedroom, or just a “felt presence” who is not actually seen. I remember being terrified as a child when one of my friends reported seeing the Devil in his bedroom late at night; I was pretty atheist already but I also didn’t expect this particular friend to lie, and I was always a little uncomfortable about the story until I learned that these sorts of hallucinations are actually pretty common. But it’s not just devils and monsters. One of my patients today complained that nearly every night, as she falls asleep, she sees a huge spider crawling towards her over her bedsheets. The Wikipedia article on this condition makes fascinating reading.

Narcolepsy is a disorder of sleep regulation best known for its tendency to put people to sleep suddenly and inappropriately, which can be mildly amusing to onlookers right up until it happens when the person is driving a car. To patients it seems especially unpleasant as they “live their entire lives in constant state of extreme sleep deprivation”. But the narcolepsy symptom that made the biggest impression on me was the loss of the dream-waking distinction. While healthy people are pretty good at keeping dream and reality separate, they both sort of blur together for narcoleptics and they have to guess which of their memories are dreams and which really happened. This sometimes leads to extremely unfortunate consequences – such as sexual assault allegations based on attacks later determined to have occurred in dreams.

Sleep violence is sleepwalking’s more aggressive cousin. Those who suffer from this condition will unknowingly attempt violence against their friends and loved ones in their sleep. My textbook presents the case of a man who presented to a sleep clinic because nearly every night he was beating up his wife, who slept next to him in the bed, leaving some pretty impressive bruises and understandable marital discord (while I felt bad for the couple, I also wondered why they were still sleeping in the same room; I kick my girlfriend out of bed because ze tosses and turns too much). But the granddaddy of all sleep violence cases is the one where a man drove 23 km miles to his in-laws’ house, assaulted his father-in-law, and stabbed his mother-in-law to death. Now at some point you have to wonder – are we just taking this guy’s word for it that he was asleep the whole time? And so my textbook wanders into the fascinating world of “forensic sleep medicine” – the field where experts try to figure out whether someone who says they committed a crime while sleepwalking is telling the truth. In this case, they found that he probably was – his EEG was extraordinarily irregular, consistent with a very very severe sleepwalking disorder – and in the end he was found innocent.

Prodromal dreams are very creepy and there’s a lot of debate over whether they exist as a real thing. At their worst, they seem like plain old magical thinking – dreams that warn you of a medical problem you would otherwise be unaware of, like dreaming of breast cancer, visiting the doctor, and learning you really have the disease. But research seems to back up at least some of these, with particular interest in prodromal cardiac dreams. In one study, frequent dreams about death were found to have a strong relationship with ejection fraction (a measure of cardiac health), and severe cardiac events (eg heart attacks) were found to be preceded by extraordinarily strong nightmares more often than chance. More romantic people like to think of this as “your body sending you a message”, but I don’t know if anyone’s ruled out the more prosaic explanation that people can have a pretty good idea of their cardiac health – whether through symptoms, medical test results, or educated guesses based on lifestyle – and their anxiety about this gets reflected in their dreams.

And then there’s Sudden Unexpected Death Syndrome, which is actually even worse than the name suggests. I know I’ve written about it before, but I never really get used it it being a real disease instead of something out of a horror story.

This condition occurs only in people of Southeast Asian origin. It goes like this. They are young and healthy, in their 30s and 40s. Then one night, usually around 3 AM, they start moaning in agony, thrashing about, and die suddenly in their sleep.

But it can actually be even worse than that. There are some anecdotal reports that at least some of these deaths are not as unexpected as the name of the syndrome implies, that patients have nightmares that they will soon die in their sleep. Sometimes they will go to heroic efforts to avoid sleeping. A description of such a case from Los Angeles:

He was about twenty-one; I’ve subsequently found out this is a phenomenon in Laos, Cambodia. Everybody in his family said almost exactly these lines: ‘You must sleep.’ He said, ‘No, you don’t understand; I’ve had nightmares before—this is different.’ He was given sleeping pills and told to take them and supposedly did, but he stayed up. I forget what the total days he stayed up was, but it was a phenomenal amount—something like six, seven days. Finally, he was watching television with the family, fell asleep on the couch, and everybody said, ‘Thank god.’ They literally carried him upstairs to bed; he was completely exhausted. Everybody went to bed, thinking it was all over. In the middle of the night, they heard screams and crashing. They ran into the room, and by the time they got to him he was dead. They had an autopsy performed, and there was no heart attack; he just had died for unexplained reasons. They found in his closet a Mr. Coffee maker, full of hot coffee that he had used to keep awake, and they also found all his sleeping pills that they thought he had taken; he had spit them back out and hidden them.

This happens sufficiently often among Southeast Asians that it is a recognized part of the various cultures of the region:

The nightmare demons of the Far East can be lethal. In Japan, this type of death is known as pok-kuri; the Filipinos call it bangungot or batibat; and the Hmong people of Vietnam and Laos call it tsob tsuang. In Thailand, the being to fear is the phi am or ‘widow ghost’ who comes to steal away the souls of young men. Some men defend themselves from phi am by wearing lipstick at night, so that the ghost mistakes them for women and leaves them alone.

It is now a part of American culture as well – it was a string of cases of Sudden Unexpected Death Syndrome in Los Angeles that inspired the movie Nightmare on Elm Street.

Luckily there is now a more prosaic explanation. Sudden Unexpected Death Syndrome is believed to mostly be the same thing as Brugada Syndrome, a very unusual cardiac disease caused by mutations in a gene coding for a vital heart protein. It can be controlled with an implantable defibrillator, which can restart the heart if it falls into an otherwise fatal arrhythmia.

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39 Responses to Bad Dreams

  1. Gunlord says:

    I remember reading an old book that claimed the incidence of sudden-death syndrome among the Hmong was evidence that the dream-stealing “ghosts” like the Tsuang were real. I suppose that author would be disappointed to hear of Brugada Syndrome…

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  2. Fnord says:

    Isn’t a “feeling of impending doom” supposed to be a common symptom of heart attacks? Seems to tie right in with the prodromal cardiac dreams.

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    • oetpay says:

      Yes. This is also a symptom of anaphylaxis and some jellyfish stings, as it happens, though no word on whether the sense of impending doom is always the same.

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  3. Sniffnoy says:

    “Sleep paralysis” link is broken (missing http://).

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  4. Broken link on sleep paralysis:

    The Wikipedia article on this condition makes fascinating reading.

    Should be makes fascinating reading, with https:// at the beginning.

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  5. jrayhawk says:

    Re: “your body sending you a message”

    Collapsing health is entirely capable of causing both heart problems and suicidal ideation and similar morbid thoughts through e.g. cytokines inhibiting serotonin production, cortisol elevation needed for catabolizing tissues also halting hormone production through pregnenolone steal, etc.

    An enhanced acceptance of risk of death might be an adaptive feature in a tribal setting with a lot of shared genetics.

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    • Scott Alexander says:

      Are you claiming that the body evolved some mechanism by which the brain would pick up on circulating cytokines and translate them into dreams/emotions?

      Or that circulating cytokines disrupt brain function enough that this shows up as altered thought processes which coincidentally end up being about death and therefore sort of correct?

      Or something else?

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      • James Babcock says:

        I believe the body has several fairly generic health-problem detection mechanisms. I believe these are, in several imperfect, tied into food selection (the brain can learn that a food causes or alleviates a health problem, and generate specific cravings or aversions); to the immune system (which can detect whether bacterial species are new, and attacks species whose appearance coincided with a health problem); and yes, to emotions.

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      • RiversHaveWings says:

        Peripherally released cytokines are known to induce sickness behavior. Sickness behavior is pretty similar (some say possibly identical) to major depression, which can cause morbid thoughts.

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        • jrayhawk says:

          Bingo. Major depression, insofar as it can be meaningful to characterize biochemically (the reader is encouraged to insert psych-vs-pharma and monoamine-treatment-sucks flamewars here, but keep it to themselves), is biochemically characterized by inflammatory and catabolic pathways, most notably serotonin disregulation (in production, clearance, and/or recycling) and cortisol elevation, and can be experimentally induced by such means.

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    • Mestroyer says:

      An enhanced acceptance of risk of death might be an adaptive feature in a tribal setting with a lot of shared genetics.

      I’m not sure what this has to do with the rest of your post, but…

      It would have to not only be a tribal setting where most genes were shared, but also where most new genes were shared, which seems impossible.

      A gene that only helps the other genes it is grouped into an individual with is not selected for. This is why Richard Dawkins called genes “selfish”. They don’t “optimize” for the survival of the tribe, the survival of the individual, or even the reproduction of the individual (directly). Each gene “optimizes” for copies of itself.

      An example that Dawkins gives is the T-haplotype in house mice, which hacks meiosis so that when the mouse has only one copy, it is passed on 90% of the time instead of 50%. When it has two copies, the mouse is sterile or dies young.

      Now that I think about it, perhaps reading The Selfish Gene when I was a teenager was a formative experience that enabled me to dodge some anthropomorphizing mistakes when thinking about AI.

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  6. Dave says:

    1: I took a class entitled “Sleep and dreams” from Dr. Dement. It was one of my favorite classes in college. In it I learned to lucid dream. I also learned just how little we understand about sleep and dreams, starting with basic things like why we even have either. I haven’t kept up with the research, but I gather there hasn’t been a lot of progress.

    2: I get sleep paralysis about one a month. It’s usually pretty scary, because you’re just waking up and muddled and confused, so it’s hard to identify. One you do though, it’s just a matter of waiting.

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  7. Tom Hunt says:

    One of my more vivid dream-related memories involves a dream in which a volcano formed in the middle of our living room. The family immediately went up the stairs to avoid poisonous gases (this made sense in the dream). I was last up, breathed some gas, and collapsed unable to continue (or breathe). This then segued into sleep paralysis leading to waking. (The odd thing is that this did not feel particularly horrifying at the time, or in retrospect. Go figure.)

    (I never seem to get normal dreams. Naked at work. Now there’s a dream scenario for you. I only get the ones that look like you took Tolkien and five different anime and put them in a blender soaked in LSD.)

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  8. Jackson says:

    continually walking up endless staircases, running across unchanging landscapes, cleaning rooms, scrubbing stone walls

    …building a stone tower block by block, trying to cross a narrow bridge stretching over a chasm, waking every five minutes, being aware that it’s just a dream but convinced that if you can just make it across without falling in this time you’ll be able to remain asleep…

    Do you know if this one’s anxiety-related, Scott? The other components of my sleeping disorder – blazing with body heat at night, being just on the cusp of sleep and suddenly jerking awake, heart racing – are more common to sufferers of anxiety, so it wouldn’t surprise me.

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    • Anonymous says:

      >being just on the cusp of sleep and suddenly jerking awake, heart racing

      How would you describe this? I’ve suffered from this occasionally in the past month or so. I would say my anxiety has also increased significantly over that time period. I typically will be drifting off to sleep when I feel a sensation in my chest, and then a quick tightness like I’m having a panic attack, and then it subsides. My heart will race for a bit (probably doesn’t exceed 90 or 100bpm, although I’ve never actually taken a measurement. For comparison, my resting heart rate is typically 60 – 70bpm) It’s like the “butterflies in your stomach” sensation, but in my chest.
      I don’t think it’s a heart issue because I exercise frequently and experience no other symptoms (e.g. chest tightness when completely awake, heart pain, etc.).

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  9. rsaarelm says:

    Another fun thing with sleep paralysis is that it seems to be pretty much the same thing as what you get when you start out a wake-induced lucid dream. I don’t get spontaneous sleep paralysis, but I can cause the wake-induced lucid dreams on and off by messing with my sleep cycle. Then the sleep paralysis is basically where I notice I’m immobilized, then try standing up anyway, and this translates into moving in a lucid dream. The Sleep paralysis Reddit has a continuing stream of people going “this is horrible, make it stop” and then every now and then someone going “Wake-induced lucid dreams are fun! How can I induce more sleep paralysis?”. I don’t know if the people having chronic sleep paralysis actually have a different and more unfun condition than I get with spontaneous sleep paralysis, or if they really could just stay calm and trigger a lucid dream instead of panicing every time. Also, how can you induce more sleep paralysis? Wake-induced lucid dreams are fun.

    Wake-induced lucid dreams also seem to explain claims of astral projection. They take some time to get going, so when they start, my brain is still pretty sure I’m on my bed in my bedroom. And then figures out that I’m obviously walking around, and tries to provide some familiar scenery.

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  10. Daniel says:

    I don’t understand why it’s called “Epic dreaming”. It sounds to me more like first-level rat-hunting grind dreaming.

    Seriously, googling “epic dreaming” returns among the top 10 results 3 links to technical medical literature using the term, one link to this blog post via Kaj Sotala’s Google+, and the other 6 are things like:

    > Epic Dreaming is a dream that is so profound that leaves us breathless. They are also called great dreams or cosmic dreams and happens to everybody once in a while…

    > I’m curious about vivid and epic dreaming. I’ve had really vivid and epic dreams almost every night on the paleo diet…

    > Part of the theory of epic dreaming involves the concept that all human knowledge is accessible to an individual…

    Why is something described as “emotionally neutral dreams with repetitive content” called epic?

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    • Rowan says:

      Because the dreams last the entire night, i.e. are really, really long, like epics.

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      • gwern says:

        Are epic dreams really that long or is one just left with memories of them being long? As in, on EEGs does one observe unbroken multi-hour bouts of REM sleep, or is it the usual 5-20 minute chunks spread over a night? (I’d look it up but given that Yvain’s link went to a single paper with no online copy, it seems there’s not a lot written about epic dreaming disorder.)

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        • Douglas Knight says:

          Scott explicitly said that there is no increase in REM. He suggests two hypotheses. One is that the duration is an illusion. The other is that they have these epic dreams without REM. These seem like very easy hypotheses to distinguish: just wake up the subject while not in REM. His other link is to a blog titled “Non-Rem Dreaming. . . why is it so tiring!” that clearly takes the second hypothesis.

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  11. nydwracu says:

    I wonder if it’s A Thing to always remember dreams after taking naps, or after waking up and falling back to sleep less than four hours or so before waking up in the morning, but almost never otherwise…

    (…except for the first week I started melatonin, where I had constant horrible nightmares — I really am glad I almost never have dreams at night, since when I do they’re always bad — but vivid dreams when starting melatonin is definitely A Thing and thankfully it went away after a week.)

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  12. Khoth says:

    I think it’s a shame you didn’t mention Exploding Head Syndrome, because it’s the best name for a sleep disorder ever. (It’s not as bad as it sounds)

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  13. Steve says:

    Heh. My Filipino partner tells me that batibot is slang for masturbation, but there is no etymological connection between batibot and the demon batibat. I think moral crusaders in the Philippines are missing an opportunity.

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  14. Steve without a Filipino partner says:

    > One of my patients today complained that nearly every night, as she falls asleep, she sees a huge spider crawling towards her over her bedsheets. The Wikipedia article on this condition makes fascinating reading.

    I see the spider too! About once every few months, I’ll see a big spider, cockroach, or other skittering fauna as I’m falling asleep.

    I had full-on sleep paralysis several times as a kid, with a scary demon or witch in a dark corner of my room, and a chorus of malevolent whispering voices just under comprehensibility. Somewhere in my early teens, I either read about sleep paralysis or realized the nature of the phenomena; and the witch disappeared, the voices became the blood rushing through the veins around my ears in the silent room, and I just focused on wiggling fingers or toes until I could sit up.

    I do see an actual spider or cockroach in my apartment once every few months, though; so that illusion’s harder to dispel before it occurs.

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    • Andy says:

      This is really interesting – the sense data created by the brain during sleep paralysis may be a reflection of your environment. Which does explain to me, a little, why people in cultures with succubus or witchcraft myths around sleep paralysis report the same kinds of sensations – they’re reinforced by hearing stories of “What witchcraft does.”

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      • Kaj Sotala says:

        I once dreamt that there was a vast fleet battle going on, and me and my fellow space marine had boarded an enemy star destroyer, fighting our way to the center of the vessel. There, in a central location and having momentarily managed to lose our pursuers, we had initiated the countdown for the massive-yield nuclear charges that we carried with us and which would tear the enemy ship apart. My inability to move was because, as a part of the self-destruct sequence, the joints in my battle armor had locked into place. Thus I could just close my eyes and remain motionless while bathing in the bliss of joyful expectation of my coming martyr death in the service of the empire.

        Not sure if it was “real” sleep paralysis, since I didn’t open my eyes until the dream ended, but the inability to move was certainly there. But if it was real, then I’m just happy that my brain draws on this kind of imagery instead of going with the more traditional route.

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  15. Swimmy says:

    The spider happened to me just once, several years ago, and when I got to that part of the post I had a small chill.

    I woke up to find a spider the size of a 20-lb dog sitting on my chest, and I got the impression it had paralyzed me with venom or was otherwise too heavy, so I couldn’t move. I panicked, and by the time my body woke up maybe 10-20 seconds later I immediately chucked all the blankets to the floor as quickly as I could. When I went to investigate, of course there was nothing, and though I didn’t know about sleep paralysis I figured out what had happened very quickly.

    I also had a sleep paralysis event in which I was drowning. My dream ended with me driving a car into a lake, and I woke up unable to breathe, somehow thinking I was still in the car even though I was in my bed. Hard to explain, and pretty miserable, but once it’s happened to you before it’s only scary for a few seconds.

    I sometimes have conversations in my sleep, with my eyes open. I made my wife cry once doing this, because I cancelled some plans she was excited about. She was stunned when I asked later if they were still on. I still feel bad about it, and I’d much rather have more episodes of briefly scary sleep paralysis than conversations I don’t remember.

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  16. St. Rev says:

    Last night, I dreamed of a novel algorithm for deriving a fair (i.e. uniformly distributed) coin from a biased one, woke up halfway, realized it was incorrect, but was able to construct a valid algorithm based on the same idea. Then forgot about it until this post reminded me.

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  17. Nate says:

    I will very rarely experience epic dreaming (usually when I’m sick). The first time was when I was in high school, when I was in the hospital after surgery. It started out as working on a number puzzle. Each time I had the dream, I realized there was more and more to it–mind you, this was over the course of about 15 years–and I dreamed that a whole network of dreamers was working with me on it. Once, a voice told me that the puzzle was nearly complete. The next time, I actually finished it, although I have no memory of its actual content.

    I’ve had epic dreams a couple times since then, but not about the puzzle.

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  18. Miranda says:

    “Sleep paralysis is very common.”

    The first time this ever happened to me, I was in first-year university and thought I was having a stroke. Once I knew that sleep paralysis was a thing, it was less freaky–but I’ve still had occasional creepy hallucinations, and it’s very distracting. It happens most frequently when I’m very tired and take a nap during the day; this dissuades the behaviour of taking daytime naps when I’m tired.

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  19. Aaron Brown says:

    epic dreaming

    This American Life has featured Mike Birbiglia’s story of his epic sleepwalking. This was later turned into a good movie called Sleepwalk with Me.

    Anything to show that the doctors in this field are cultured, not just people who learn a bunch of biology without exploring the wider world of the arts.

    Frank Zappa, in the introduction to The Real Frank Zappa Book:

    The epigraphs at the heads of chapters (publishers love those little things) were researched and inserted by Peter [Occhiogrosso, the book's ghostwriter] — I mention this because I wouldn’t want anybody to think I sat around reading Flaubert, Twitchell and Shakespeare all day.

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  20. Matthew says:

    So, last night was something new. I had a multiple-choice nightmare.* It was your standard chased-by-monsters type of dream, except at several points, the action literally paused as I was given two options to choose from. Unfortunately, every choice led to horrible outcomes. Basically, I had a Choose Your Own Adventure (TM) — OF DOOM!**

    Random firing of my synapses produces interesting metaphors for life.

    —————–

    I have a typology of bad dreams:

    1. Horror movie-type dreams, usually without the weird branching above. I actually don’t mind these dreams, for probably the same reason people with stronger stomachs than mine like roller coasters. It’s a scary adventure.

    2. Relationship stress dreams. Dreams about bad interpersonal conflict. For me, this is usually dreams about my emotionally abusive ex-wife doing horrible things to me, though I occasionally also have them about my children behaving much more awfully than ever happens in reality, or about other women I was interested in rejecting me in more harsh and humiliating ways than what actually happened. These are by far the worst kind of bad dreams. According to this article, type 1 is more common in men and type 2 is more common in women. This was true for me in childhood but reversed after my abusive marriage. These dreams are by far the worst kind of bad dream for me.

    3. Tedious failure dreams. This might be a variant of epic dreaming, but it doesn’t last all night nor leave me tired. These dreams involve me trying and failing to perform some simple task over and over and over again. The most common variants are trying to make an important phone call and misdialing repeatedly (this one can actually happen inside a horror dream, where I’m failing to call for help/prevent a disaster) and repeatedly failing to get my contact lenses into my eyes. Tedium is much worse than surreal fear, but better than relationship terror.

    *My dreams almost never wake me up, which according to the linked article means they’re not actually nightmares. I somewhat dispute this, because they can be very intense; I’m just not lucky enough to wake up from intense bad dreams.

    **This overlaps about 90% with the outcome of an actual Choose Your Own Adventure (TM), of course.

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  21. Mara says:

    The sudden nocturnal death syndrome can be intentionally induced by members of a tribe of southeast Asian dream-sorcerers called the Tcho-Tcho. For more detailed information on this you can listen to Douglas Dietrich’s radio show ‘Critical Omissions’ from April 22 2014 where he gives a very detailed account of this not very well known mystery.

    https://www.youtube.com/watch?v=RuC7wf-JNgE

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