Chapter 14

Sleep-Related Hallucinations

Anna Ivanenko and Sachin Relia

Introduction

Hallucinations are perceptual disturbances in the absence of a stimulus that can

occur in the normal healthy individuals, but are most commonly associated with
psychiatric and neurological conditions. Hallucinations can occur in any sensory
modality—visual, auditory, olfactory, gustatory, tactile, proprioceptive, equilibrio-
ceptive, nociceptive, thermoceptive, and chronoceptive. They occur in a conscious
and awake state and are different from illusions, which involve distorted or mis-
interpreted real perception, and from dreams which involve recollection of mental
activity during sleep. In the majority of clinical cases, several types of hallucinations
occur simultaneously and are associated with some degree of emotional distress.
Sleep-related hallucinations are a type of perceptual experience that occurs during
transition to sleep or at awakening. The exact pathophysiology of sleep-related
hallucination remains unknown. However, it has been suggested that they may
represent a state of dissociation with intrusion of dreams into wakefulness [1].
This chapter provides a comprehensive review of clinical characteristics, preva-
lence, differential diagnosis, and treatment of sleep-related hallucinations.

A. Ivanenko ()
Division of Child and Adolescent Psychiatry, Feinberg School of Medicine,
Northwestern University, Ann & Robert H. Lurie Children’s Hospital of Chicago,
Chicago, IL, USA
e-mail: aivanenko@sbcglobal.net
Ann & Robert H. Lurie Children’s Hospital of Chicago,
225 East Chicago Avenue, Chicago, Illinois 60611–2605, USA
S. Relia
Division of Child and Adolescent Psychiatry,
Medical College of Wisconsin, Milwaukee, WI 53326, USA
e-mail: sachinrelia@gmail.com
6492 Bantry Bay St., Dublin, CA 94568, USA

S. V. Kothare, A. Ivanenko (eds.), Parasomnias, 207

DOI 10.1007/978-1-4614-7627-6_14, © Springer Science+Business Media New York 2013
208 A. Ivanenko and S. Relia

Historical Perspective

DSM-IV defines a hallucination as “a sensory perception that has a compelling

sense of reality of a true perception but that occurs without external stimulation of
the relevant sensory organ” [2]. The word hallucination has its roots in the Latin
word “hallucinare” or “allucinere” which means to “wander in mind”. The earliest
use of the word “hallucination” dates back to 1572 when Lavater used it to describe
“ghostes and spirites walking the night”. It was first used in the English language
by Sir Thomas Browne in 1642. An outstanding French psychiatrist Jean-Etienne
Esquirol coined the term “hallucination” into a modern field of clinical psychiatry in
his famous textbook Des maladies mentales, considérées sous les rapports médical,
hygiénique, et médico-légal (1838).
Hallucinations occur in various psychiatric, neurological, and medical condi-
tions. Among subjects who met diagnostic criteria for major depressive disorder
6.8 % reported having episodes of hallucinations [3]. In patients with bipolar dis-
order, psychotic symptoms with hallucinations are present in 20–50 % of patients
[4, 5]. Disturbing visual, auditory, and tactile hallucinations are commonly seen
in patients with Parkinson’s disease (PD) [6] and among patients with Alzheimer’s
disease (AD) ranging from 13 to 16 % [7]. Most notably, hallucinations are asso-
ciated with schizophrenia. It is reported that approximately 74 % of patients with
schizophrenia will experience auditory hallucinations (AH) during the course of
their illness [8]. Hallucinations in patients with schizophrenia are characterized by
poor reality testing, intrusiveness, and are associated with greater subjective distress.

Prevalence of Hallucinations in the General Population

Literature suggests that hallucinations may also occur in the “normal” general popula-
tion. An NIMH study by Tien et al., revealed the lifetime prevalence of hallucinations
as 10 % for men and 15 % for women [9]. In the same study, 2 % of men and 1.3 %
of women also reported visual hallucinations (VH). Several studies have looked
into a prevalence of hallucinations among college students. In a sample of 375
college students, 71 % reported occasional, brief hallucinatory voices during periods
of wakefulness [10]. These findings were replicated by other studies where a
considerable proportion of students reported hearing a voice speaking their thoughts
aloud [11–13].
In the most recent survey of 134 medical students, 74 respondents answered af-
firmatively to one or more screening questions about having hallucinations: 22.2 %
of those described visual and 64.8 %, auditory hallucinations [14]. The majority
reported sleep-related experiences and AH such as hearing the telephone or the
doorbell ring (38.8 %). All subjects had good insight and none had psychotic
symptoms. Only two cases were associated with substance abuse.
Differences in characteristics of hallucinations in clinical and nonclinical
populations have been examined in several studies. Most differences were found
14 Sleep-Related Hallucinations 209

in the content, emotional quality, and locus of control of the AH. Patient groups
would frequently describe their voices as negative, frightening, and disturbing and
had delusional explanations for them. Nonclinical subjects were able to keep their
hallucinations under control and described them as more positive and less threatening
[15, 16]

Definition of Sleep-Related Hallucinations

A hypnagogic hallucination is a vivid, dream-like sensation that is heard, seen, or

felt, and that occurs near the onset of sleep. Hypnopompic hallucinations are similar
experiences that occur at awakening. The term hypnagogic was coined by Maury from
“hypno” meaning sleep and “agogos” meaning induced [17]. “Pompe” meaning the
act of sending was first used by Myers in 1903 and he coined the term “hypnopompic”
to describe imagery and pictures due to “persistence of some dream-image into first
moments of waking” [18].

Prevalence and Clinical Characteristics of Sleep-Related

Hallucination in the General Population

Hypnopompic and hypnagogic phenomenon is highly prevalent in the general

population. In a study by Ohayon (2000) of approximately 6,000 men and
women, 38.7 % reported hallucinatory experiences [19]. In another study
of 400 subjects, 37 % of the sample reported at least one type of hypn-
agogic hallucinations (HH) and 12.5 % reported hypnopompic hallucinations
occurring at least twice a week in the last year [20]. Women and indi-
viduals of younger age are more likely to report sleep-related hallucinations.
Hypnagogic and hypnopompic hallucinations are usually visual but can be
auditory, tactile, and kinetic. They can last from a few seconds to more than 15 min,
depending on the stage of drowsiness. The main difference between dreams and
HH phenomenon is that in a case of HH the individual experiences himself being
on the outside observing the action. To the contrary, in a dream an individual is
actively involved and there is usually a plot.
Auditory hypnagogic and hypnopompic hallucinations can include crashing
noises, ones’name being called, a doorbell ringing, neologisms, irrelevant sentences,
pompous nonsense, quotations, references to spoken conversations, remarks directed
to oneself, and meaningful responses to ones’ thought of the moment [21].
Visual component of HH can range from simple spots of light to geometric pat-
terns to complex images [22]. Human figures or faces (torsos without heads or vice
versa), animals (real or bizarre), miniature images, or scenery of outstanding beauty
have been described.
210 A. Ivanenko and S. Relia

The most common type of HH is an experience of falling down an abyss, and

perception of something or someone being in the room. Women and younger in-
dividuals are more likely to report these phenomena. The main difference between
HH and actual visual and auditory hallucinations is the significance ascribed by an
individual to the perceptual phenomenon [19].

Case Example 1

An 8-year-old boy presented with his mother after he experienced several episodes of
hypnopompic hallucinations. All episodes were described as similar and consistent of
him waking up from sleep usually within 1–2 h from sleep onset and seeing objects
in the rooms moving away from him “getting farther and farther”. Each episode
would last for several minutes and was accompanied by severe fear, panic, and
emotional agitation. Patient would run into his parents’ bedroom feeling terrified,
shaking, and would refuse to go back to his bedroom. He had full recollection of the
episodes and good insight into these experiences being not real. The patient started
avoiding going to bed due to the fear of having hallucinations during sleep. First
episode occurred during the course of acute respiratory illness when he had fever,
and parents attributed it to the infection. However, the next several episodes did
not seem be associated with any physical illness, although emotional triggers were
identified like starting a new school or transitioning to a new house. His medical,
developmental, and psychiatric history was unremarkable, except for a tendency to
worry a lot and to get easily frustrated. He was not taking any medication at the
time of evaluation. Nocturnal polysomnography (PSG) was conducted to rule out
other intrinsic sleep disorders that showed normal results. Positive bedtime routine
with relaxation at bedtime was recommended as part of therapeutic intervention. The
patient was reassured about these episodes being “not dangerous” and that he can
learn how to control his feelings once they happen again. Formal psychotherapy was
recommended to address symptoms of anxiety and stress management.

Complex Nocturnal Visual Hallucinations

A less common variant of HH is the phenomenon of complex nocturnal visual hal-

lucinations (CNVH). CNVH are described as prolonged episodes of complex, vivid
VH, which occur after waking during the night. CNVH differ from HH as these occur
after an individual awakes in the middle of the night. Silber et al. described a series
of 12 patients reporting these symptoms. Mean age of the patients in this series was
40 years, and they reported having an average of 4.4 events per week. Symptoms of
CNVH were described by patients as vivid, detailed, and relatively immobile images
of people and animals. For example, one patient described “a witch-like, short, baggy
woman, clowns, rats, and a brightly colored butterfly” [23]. The images were often
distorted, e.g., woman with hair on only half of her head. The events usually lasted
14 Sleep-Related Hallucinations 211

for less than 5 min but in one patient it persisted for up to an hour. Several patients
left the bed to investigate and one sustained an injury. Of the 12 patients, only one
patient had three recordable events that occurred after arousal from stage 2 and stage
3 of non-rapid eye movement (NREM) sleep on the PSG. Electroencephalography
(EEG) during the hallucinations showed alpha rhythm without any epileptic activity.
Interestingly, most of the patients had associated conditions including dementia with
Lewy bodies (DLB), macular degeneration, and anxiety disorder. Despite clinically
significant associated conditions, CNVH were described as a separate entity from
hallucinatory phenomenon in DLB and PD as patients only had CNVH on waking
up from sleep. To the contrary, patients with DLB, PD, and peduncular hallucinosis
(PH) tend to have hallucinations both during the day and at night.
A case of a girl with attention deficit hyperactivity disorder (ADHD) and opposi-
tional defiant disorder (ODD) was recently reported who experienced a 3-h episode
of nocturnal complex bizarre visual hallucinations when treated with 18 mg Osmotic
release oral system (OROS) methylphenidate (MPH). Later, this child was found to
have episodes of confusional arousal on nocturnal PSG and the authors speculated
that her preexisting physiological vulnerability toward parasomnias increased the
risk of MPH induced sleep side effects [24].

Sleep-Related Hallucinations in Patients with Narcolepsy

Narcolepsy is the central nervous system disorder characterized by excessive daytime

sleepiness, fragmented sleep, and cataplexy. In addition, patients may experience
sleep paralysis and hypnagogic and hypnopompic hallucinations. HHs in patients
with narcolepsy can be very pervasive, vivid, and disturbing. Literature analysis
indicates high prevalence of HHs across different studies. Visual, auditory, tactile,
olfactory, somatic, and vestibular hallucinations were reported by 79.4 % of patients
with narcolepsy when clinical characteristics were studied in 129 patients [25]. Sim-
ilar rate of HHs (79.7 %) was found among patients with narcolepsy when using the
Stanford Center for Narcolepsy Sleep Inventory [26]. Additional analysis of HHs
demonstrated VH in 83 % of cases, kinetic in 71 %, and auditory in 45 % of patients.
A cross-sectional study was performed by Fortuyn et al. [27] to compare psychotic
symptoms among three samples of subjects: 60 patients with narcolepsy-cataplexy,
102 patients with schizophrenia, and 120 normal controls. A total of 83 % of
patients with narcolepsy experienced hallucinations “ever in life” compared to 70 %
of patients with schizophrenia. However, only 4 % of patients with schizophrenia
reported having HHs compared to 65 % of those with narcolepsy. Patients with nar-
colepsy reported HHs when going to sleep at night and waking up in the morning as
well as during daytime sleep episodes. AH in patients with narcolepsy were often of
nonverbal quality such as footsteps, animal noises, door openings, door bell rings,
etc. VH associated with narcolepsy were more fragmentary and often reported in
combination with auditory and tactile modality. Kinetic hallucinations like flying
were reported as a frequent hypnagogic phenomena with some cases of out-of-body
experiences being described. Occasionally, patients reported olfactory HHs of bad
212 A. Ivanenko and S. Relia

odors. Narcolepsy patients compared to patients with schizophrenia have more

insight about their perceptual experiences and understanding that they are not real.
In a more recent study, clinical characteristics of hallucinations and their risk
factors were compared in 100 patients of narcolepsy with and without cataplexy and
100 patients with PD [28]. Hallucinations occurred more frequently and with more
motor and multimodal aspects in narcolepsy with cataplexy (59 %) than in narcolepsy
without cataplexy (28 %). Compared to PD, the hallucinations in narcolepsy were
more frequently auditory and more often associated with sleep. Interestingly, patients
with cataplexy had reduced immediate insight into the unreality of their hallucina-
tions compared to other patients in the study, which is possibly due to multimodal
nature and dream-like characteristics of their hallucinations. The risk factors for hal-
lucinations in cases of narcolepsy included sleep paralysis and rapid eye movement
(REM) behavior disorder. The authors suggested that high frequency of halluci-
nations in patients with narcolepsy with cataplexy may indicate that hypocretin-1
deficiency promotes hallucinations.
Modafinil is one of only few drugs approved by the Federal Drug Administra-
tion (FDA) for the treatment of narcolepsy. Armodafinil is a R-isomer of modafinil
which became available in 2007 for the treatment of excessive daytime sleepiness
associated with narcolepsy and has a longer half-life of 10–15 h than that of the
S-enantiomer. Both compounds are well tolerated with the most frequent side ef-
fects reported as headache and nausea. Modafinil and armodafinil has been widely
used for the treatment of excessive daytime sleepiness in patients with various sleep
disorders and other neurological conditions. However, there have been cases of hal-
lucinations and other psychotic symptoms caused by modafinil described in patients
with narcolepsy, Kleine-Levin syndrome, and DLB [29–31]. Hallucinations induced
by the administration of modafinil should be not be mistaken for HH associated with
the natural course of narcolepsy as they remit with the discontinuation of modafinil.
Reduction in the dose of modafinil may also help to alleviate undesirable side ef-
fects. Since there are limited research data available on the risks factors associated
with modafinil-induced agitation and hallucinations, it should be used with caution,
especially at higher therapeutic doses.

Sleep-Related Hallucination Associated with Medication Use

Use of sedative hypnotics has been associated with sleep-related behaviors, including
reports of sleep-related hallucinations. Zolpidem, an imidazopyridine derivative is
a widely prescribed and highly effective pharmacological agent for the treatment
of insomnia. It is a relatively short-acting, with a terminal elimination half-life of
1.5–3.2 h. Zolpidem was shown to be associated with the rare episodes of complex
sleep-related behaviors like VH, delirium, sleepwalking, amnesia, and nocturnal
eating.
A number of cases have been described of patients who developed hallucinations
shortly after taking zolpidem prior to initiating sleep. A post-marketing study of zolpi-
dem reported 0.3 % of patients experiencing hallucinations [32]. The authors of the
study proposed several factors to be considered when prescribing zolpidem: gender
14 Sleep-Related Hallucinations 213

because women have been found to have a higher serum levels of zolpidem than men
by 40 % dose; hallucinations occurred with doses above 5 mg per day and were dose-
dependent; protein-binding affinity; and since high proportion of zolpidem is protein
bound, patients with low levels of free albumin may have higher concentration of free
zolpidem. Also, medications that are highly protein bound may displace zolpidem
from its carrier protein, therefore creating elevated serum levels of free zolpidem,
so are the drugs causing. CYP3A4 isoenzyme inhibition; zolpidem metabolized
via the CYP3A4 isoenzyme. Medication, especially antidepressants, may decrease
zolpidem metabolism leading to toxicity [33]. The majority of patients who expe-
rienced hallucinations from zolpidem were taking antidepressants like paroxetine
and fluvoxamine at the same time. Possible interactions between serotonin reuptake
inhibitors (SSRIs) and zolpidem should be considered when drugs are prescribed
concomitantly [34].

Case Example 2

A 10-year-old Caucasian female with a long history of ADHD and OCD who has
also been suffering from the sleep onset and maintenance insomnia took 6.25 mg of
zolpidem-CR at bedtime for the first time. At the time of zolpidem administration,
she was taking sertraline and adderall XR. Prior to being prescribed zolpidem,
she was treated with behavioral sleep interventions and several medications with
sedative properties including melatonin, trazadone, and clonidine. None of them
were effective in reducing sleep onset latency and in improving sleep continuity.
Shortly after taking zolpidem-CR she began to experience visual and auditory hal-
lucinations. The patient reported seeing pictures on the walls moving and angels
flying in the room. She also heard voices coming from pictures talking to her
and angels singing songs and became frightened and agitated by these perceptual
experiences. Her mother took her to the Emergency Room at the University
Medical Center where she remained until hallucinations subsided. According to
the patient’s mother, these episodes lasted for several hours, the patient appeared
confused, and was responding to internal stimuli by talking back to the “voices” and
running after “angels” in the room. She subsequently fell asleep. All her symptoms
cleared without treatment and she had full recollection of the entire episode on the
next day.

Sleep-Related Hallucinations Associated with Charles Bonnet

Syndrome

Nocturnal VH of variable etiologies have been described in the literature going

back to 1760 when Charles Bonnet first published a case of complex VH in his
grandfather who developed visual impairments from cataracts [35]. Subsequently,
214 A. Ivanenko and S. Relia

Menon et al. [36] conducted a study of complex VH in the visually impaired

individuals. They described characteristics of complex VH as being associated with
intact mental functioning, absence of any neurological/psychiatric disease, intact
insight, and hallucinations present only in the visual domain.
Charles Bonnet Syndrome (CBS) can be understood as a deafferentation syn-
drome similar to phantom limb pain. It has been proposed that symptoms arise when
cortical structures are disconnected from subcortical afferents. Absence of an ap-
propriate input can lead to these deafferentation syndromes in different modalities.
Neuroimaginig studies have supported a hypothesis that CBS is a cortical release
phenomenon. Normally, external stimuli is perceived in the retina and transmitted
to the primary visual cortex (BA 17) and then to secondary areas and association
cortices (BA 18, 19, 37). In general, perception of external visual stimuli has an
inhibitory effect on endogenous activation of the visual cortex. Visual impairment
releases visual cortex from the regulation by external stimuli resulting in VH [37].
In a study of 505 patients with visual impairments, 60 met the criteria for CBS. VH
caused distress in about 28 % of the patients [38]. Most commonly, hallucinations
were reported in the evening (35 %) and at night (23 %). Clinical characteristics of
hallucinations ranged from simple images of objects to a bizarre visual experience
of “two miniature policemen guiding a midget villain to a tiny prison van”. Approx-
imately 65 % of the patients reported poor lighting as a favorable circumstance for
the hallucinations [38]. There is no specific treatment for VH associated with CBS
except for reassurance and education.

Sleep-Related Hallucinations Associated with Parkinson’s

Disease and Lewy Body Dementia

PD and DLB are neurodegenerative conditions classified as alpha-synucleinopathies.

Hallucinations may occur either spontaneously or as a side effect of dopaminergic
medications. In PD, the prevalence of complex VH ranges from 22 to 38 % [39]. Risk
factors for VH include older age, longer duration of symptoms, cognitive impairment,
severity of PD, presence of sleep disorder, and visual impairments. Hallucinations
can range from benign phenomenon, such as presence of sensation, passing lights,
visions at the periphery of visual field to elaborate hallucinations, such as wild
animals and fantastic human creatures. The hallucinations are either experienced
during the day or in the form of CNVH.
One potential pathophysiological mechanism suggests the deposition of Lewy
body in the brainstem causing dysfunction of this key brain structure responsible for
the state transitions between wakefulness, NREM, and REM sleep. This may lead to
intrusion of REM phenomenon into wakefulness causing hallucinations. The other
putative mechanism is a Lewy body deposition in the neocortical areas of the visual
cortex, which gives rise to hallucinations as a cortical release phenomenon.
14 Sleep-Related Hallucinations 215

Sleep-Related Hallucinations in Patients with Peduncular

Hallucinosis (PH)

PH is a syndrome that involves hallucinations caused by lesions in the brainstem in-

cluding pons, midbrain, or subcortical structures including thalamus. This syndrome
was originally described by Lhermitte in association with a rostral brainstem lesion
in a patient with visual and tactile hallucinations [40]. The etiology of this syndrome
is usually vascular, however, there have been cases of brain tumors and postoperative
complications of brain stem surgery reported in the cases of PH [22, 41, 42]. The
hallucinations consist of visual images similar to HH. They may last from minutes
to several hours and may persist into waking. Interestingly, hallucinations seem to
follow a diurnal pattern; they disappear during the day and reoccur in the evening
[22].

Sleep-Related Hallucinations in Patients with Epilepsy

Hallucinations commonly occur in patients with epilepsy. Frontal lobe seizures

frequently manifest during sleep compared to other types of partial seizures. VH asso-
ciated with epilepsy are usually described as brief, stereotyped, and fragmentary. Hal-
lucinations may be associated with other seizure manifestations, such as altered con-
sciousness, motor activity, and behavioral automatisms. Visual images are unlikely to
be identified by the patient, and may appear in color or in black and white. Complex
VH have also been described in epilepsy but they occur rarely. Proposed pathophys-
iological mechanism of hallucinations in patients with epilepsy includes possible
activation of primary sensory areas of cortex causing simple visual or auditory phe-
nomena. Another possible etiology suggests that seizures originating in the visual
or auditory association cortex can cause more complex hallucinations and mem-
ory flashbacks [43]. Differential diagnosis of this perceptual phenomenon includes
epileptic illusions, déjà vu, jamais vu, macropsia, micropsia, depersonalization,
derealization, and other perceptual abnormalities seen in patients with various forms
of epilepsy [44].

Sleep-Related Hallucinations Associated with Migraine

VH can be a part of classical aura in migraine or a part of manifestation of migraine

coma or familial hemiplegic migraine. The prevalence of migraines in the general
population has been estimated to be between 15 and 29 % [45]. As many as one third
of patients with migraines have an aura and about 99 % of them have some type
of visual symptoms [46]. The classic visual aura starts as a flickering, uncolored,
unilateral zigzag line in the center of the visual field that gradually progresses toward
the periphery, often leaving a scotoma that lasts less than 30 min. These auras (or
216 A. Ivanenko and S. Relia

simple VH) can occur at the time of sleep onset. Rare cases of complex VH described
in the literature can be seen in patients with hemiplegic migraine or other complex
forms of the disorder [22]. Functional imaging studies have revealed that migraine
auras are due to spreading cortical hypoperfusion suggesting that HH associated with
migraines are of a primary neurological origin rather than vascular.

Nocturnal Hallucinations in Alzheimer’s Disease (AD)

Sleep disturbances are common in patients with AD, which is the most common
cause of dementia. According to the recent multicenter study, approximately 4.9 %
of patients with AD report having hallucinations and frequent REM-sleep related
symptoms [47]. In another study, clinical characteristics of hallucinations were stud-
ied in 218 patients with AD in relation to sleep-wake cycle [48]. A total of 12 %
of patients acknowledged having hallucinations. The majority of reported hallu-
cinations were visual and occurred during wakefulness and in a small number of
patients. VH occurred close to sleep onset or a specific sleep phase. Vivid dreams
(11 %) and violent sleep-related behaviors (10 %) were reported by many patients
with AD and were more frequently associated with hallucinations in AD. The authors
suggested that disordered REM sleep has a potential role in the pathophysiology of
hallucinations in AD.

Evaluation

A comprehensive clinical evaluation is recommended for cases presenting with

sleep-related hallucinations. The clinical evaluation should include physical and
neurological examination and a psychiatric evaluation. Past medical, psychiatric,
and neurological history should be obtained including history of prescription med-
ication and illicit substance use/abuse. Use of certain medications like zolpidem or
dopaminergic drugs may cause sleep-related hallucinations that usually clears on
its own once medication has been discontinued. Special attention should be given
to precipitating events, such as the occurrence of hallucinations during periods of
heightened stress like grief or severe emotional trauma.
Sleep-related hallucinations are primarily diagnosed by clinical history and do not
require additional instrumental assessment. However, in cases of excessive daytime
sleepiness being associated with sleep-related hallucinations, additional PSG fol-
lowed by multiple sleep latency test (MSLT) would be recommended for evaluation of
suspected narcolepsy. If sleep-related seizures are suspected, a routine wake and sleep
EEG, sleep-deprived EEG, or video-EEG may be needed to help with differential
diagnosis. Neuroimaging studies may be an important part of the clinical evaluation
in cases when sleep-related hallucination is associated with neurological disease.
Urine toxicology screening is very helpful when substance abuse is being
suspected.
14 Sleep-Related Hallucinations 217

Treatment

Although, there are no specific interventions for sleep-related hallucinations, it has

been reported that simple hypnagogic and hypnopompic hallucinations and CNVH
in normal healthy individuals usually resolve spontaneously or with reassurance. Pa-
tients with medication-induced CNVH may benefit from withdrawal of the offending
agent (e.g., beta adrenergic agonists or zolpidem). Treatment of the underlying neu-
rological disorder like migraine, epilepsy, and narcolepsy is an essential part of the
management in patients with hallucinations secondary to these conditions. In pa-
tients with hallucinations associated with PD, AD, and DLB, acetylcholinesterase
inhibitors and antipsychotics have been tried but potential risks should be considered
while prescribing this class of medication. There have been some studies suggest-
ing the use of tricyclic antidepressants for treatment of sleep-related hallucinations
[23]. Most medications that improve cataplexy in patients with narcolepsy have a
potential to reduce HH and sleep paralysis. Tricyclic antidepressants have been most
commonly used for the indication of cataplexy. Other classes of antidepressants like
SSRIs and norepinephrine reuptake inhibitors have been successfully implicated in
the treatment of cataplexy and other REM sleep dissociation phenomena associated
with narcolepsy with significantly less side effects and better tolerability [49]. In a
recent case series of children with narcolepsy, venlafaxine at a low dose (37.5 mg
once daily) was shown to be effective in treating cataplexy attacks and HH [50].
Sodium oxybate has been approved by the FDA for the treatment of narcolepsy
and had shown conflicting results in terms of controlling HH based on the few
available clinical trials. In one study, 76 % of patients with narcolepsy reported
reduced frequency in CNVH with doses up to 9 g [51]. Another study failed to
demonstrate improvements in HH among patients with narcolepsy when treated
with sodium oxybate [52].

Conclusion

Sleep-related hallucinations represent a diverse range of perceptual experiences that

occur either on falling asleep or at awakening. They are being reported in healthy
individuals and in patients with various clinical conditions. CNVH represent a
distinct form of sleep-related experience that occurs when the individual wakes in
the middle of the night and implies detailed vivid images of people or animals with
reduced insight during the episode. Hypnagogic and hypnopompic hallucinations
are frequently associated with narcolepsy syndrome and tend to respond to medi-
cations with REM-suppressing effects. The exact pathophysiology of sleep-related
hallucinations remains unknown, although two hypotheses have been proposed: dis-
sociation of sleep states and cortical release phenomenon. Comprehensive clinical
evaluation is warranted for patients who present symptoms of sleep-related hal-
lucinations. Instrumental assessment of sleep and neurophysiological functions of
the brain may be indicated when intrinsic sleep disorders or neurological disorders
218 A. Ivanenko and S. Relia

are being suspected. Treatment of underlying/comorbid clinical conditions helps to

alleviate sleep-related hallucinations in patients with associated medical, neurolog-
ical, and psychiatric disorders. In cases of uncomplicated nocturnal hallucinations,
psychological reassurance is usually sufficient to relieve clinical symptoms.

Practical Points

• Sleep-related hallucination is a type of perceptual experience that occurs during

transition to sleep (hypnagogic) or at awakening (hypnopompic) and can be of
any sensory modality.
• Nocturnal hallucinations are frequently reported in general population and are
usually self-limited.
• Sleep-related hallucinations are often associated with narcolepsy, neurological,
and psychiatric disorders.
• Complex nocturnal visual hallucinations (CNVH) are a form of sleep-related
phenomena that occur upon awakening in the middle of the night.
• CNVH either represent a benign idiopathic condition or are associated with neu-
rological disorder like dementia of Lewy body or use of medications like beta
adrenergic blockers.
• Evaluation of sleep-related hallucinations involves comprehensive clinical assess-
ment with additional instrumental testing such as video-EEG, PSG, MSLT, and
neuroimaging if neurological or other intrinsic sleep disorder is suspected.
• Uncomplicated benign sleep-related hallucinations usually resolve spontaneously
or with reassurance.
• Treatment of the underlying clinical condition such as narcolepsy, epilepsy, mi-
graine, Parkinson’s disease, dementia of Lewy body, and others was shown to be
effective in reducing occurrence of sleep-related hallucinations.

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