Hypnagogia, misdiagnosis and Kermit the Frog

It’s a too-common newbie mistake: a therapist fresh out of grad school assesses a client who reports mild anxiety and maybe a little depression. Do they hear voices? Sure… every now and again. The poor client winds up misdiagnosed with Psychotic Disorder NOS, because the rookie assessor didn’t ask a crucial follow-up question: “When do you hear these voices?”

Hypnagogic  hallucinations are visual, auditory, or tactile hallucinations that occur while drifting off to sleep.  The term ‘hypnagogia’ is taken from the Greek for “inducing sleep”,  and was coined by Napoleon III’s librarian, Louis Ferdinand Alfred Maury. Bódizs, Sverteczki, et al [i] suggested that elements of REM sleep continue in the hypnagogic space between full wakefulness and true sleep. If they’re right (and follow-up EEG studies [ii] support the hypothesis), it would seem our dreams can briefly blend with our waking awareness, like a computer-generated movie monster matted in with the actors. Psychic researcher Frederic Myers noted something similar can happen when we wake, and termed this a hypnopompic state. The DSM says this part of the normal human experience, like the illusion of hearing someone call your name.  I won’t count any reports of hallucinations in bed as a sign of mental illness, even if the client insists they were wide awake at the time.

Necessary follow-up questions can fall victim to time pressures. In community mental health, the pressure can come from management less concerned about about  precise diagnosis than they are about meeting Medicaid timelines . In private practice, the pressure can come from clients impatient to move past formalities and start fixing their problems. A client’s eligibility to adopt a child or buy life insurance can hang on the question of, “Have you ever been diagnosed with…?” Misdiagnoses based on something as ordinary as hypnagogia can affect them long after their actual mental health problems are resolved.

How ordinary are hypnagogic hallucinations? Muppets have them:

Key lines come at the start of the third verse:

“Have you been half asleep, and have you heard voices?
I’ve heard them calling my name.”

@ 2011 Jonathan Miller All Rights Reserved

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