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Cases That Test Your Skills‘I’ve been abducted by aliens’Patricia Kinne, MD, and Venna Bhanot, MD Ms. S is afraid to sleep at night because that’s when How would you the aliens come. Is she psychotic, or do her nocturnal handle this case? Visit CurrentPsychiatry.com experiences have another cause? to input your answers and see how your edia colleagues responded ﬁculty falling asleep, so h lt I Mmelatonin, 3 Hea Her add pattern CASE ‘I’m not crazy’Ms. S, age 55, presents for treatment because n wde u still on to 6 mg at bedtime. ly sleeping is improved, but se variable. She also triesshe is feeling depressed and anxious. Her o t® Dquetiapine,a25 mg at bedtime, but soon dis- l igh - ersonit due to intolerance.symptoms include decreased concentration,intermittent irritability, hoarding, r y and diﬃ continues Cop For p As our rapport strengthens, Ms. S revealsculty starting and completing tasks. She alsohas chronic sleep diﬃculties that often keep that she has had multiple encounters withher awake until dawn. aliens beginning at age 3. Although she has Fatigue, lack of focus, and poor compre- not had an “alien experience” for about 5 years,hension and motivation have left her un- she does not feel safe sleeping at night and in-employed. She and her teenage daughter stead sleeps during the day. Her eﬀorts to staylive with Ms. S’s elderly mother. Ms. S feels awake at night strain her relationship with hertremendous guilt because she cannot be the mother.mother and daughter she wants to be. Initially, I (PK) diagnose Ms. S with major How would you respond to a patient whodepressive disorder and prescribe sertraline, claims she has been abducted by aliens?100 mg/d, which improves her mood and en- a) explain that there are no such things as aliensergy. However, her inability to stay organized b) insist that she was dreamingresults in her being “let go” from job training. c) issue a mental hygiene warrant and sign a certiﬁcate for immediate hospitalization Ms. S reports similar diﬃculties in school as d) explore the experiences in a supportive,a child. I determine that she meets DSM-IV-TR respectful manner and rule out organic orcriteria for attention-deﬁcit/hyperactivity dis- substance-induced etiologyorder (ADHD). Adding methylphenidate, 10mg bid, improves her concentration and abil- The authors’ observations To read more aboutity to complete tasks. It also reduces the im- Approximately 1% of the U.S. population sleep disorders, see “Sexual behaviorpulsivity that has disrupted her relationships. report alien abduction experiences (AAE)— during sleep: Despite a strong desire to normalize her an umbrella term that includes alleged con- Convenient alibisleep schedule, Ms. S continues to have dif- tact with aliens ranging from sightings to or parasomnia,” abductions.1 Patients rarely report AAE to page 21-30Dr. Kinne is a fellow, department of child and adolescent mental health professionals. In our soci-psychiatry, University of Louisville, Louisville, KY. Dr. Bhanot isassociate professor, department of psychiatry, West Virginia ety, claiming to be an “abductee” implies Current PsychiatryUniversity, Charleston. that one might be insane. A survey of 398 Vol. 7, No. 7 81 For mass reproduction, content licensing and permissions contact Dowden Health Media.
Cases That Test Your Skills Canadian students that assessed attitudes, HISTORY Terrifying experiences beliefs, and experiences regarding alien Ms. S elaborates on her alien experiences, abductions found that 79% of respondents relating a particularly terrifying example believed they would have mostly negative from her teen years. She was lying awake in consequences—such as being laughed at or bed, looking at the ceiling, where she saw a socially isolated—if they claimed to have jeweled spider with a drill. As the spider de- encountered aliens.1 scended from the ceiling and spread its legs, Persons who have AAE may attend sup- she recalled a noise like a dentist’s drill. As port groups of fellow “abductees” to accu- the spider neared her face, it grew larger and mulate behavior-consonant information larger. Terriﬁed, Ms. S was unable to scream (hearing other people’s abduction stories) for help or move anything except her eyes as and reduce dissonance by being surround- the spider clamped its legs around her headClinical Point ed by others who share a questionable be- and bored into her skull. She reported that al- lief.2 A survey of “abductees” found that though she could feel the drill go in, it wasn’tA survey of 88% report at least some positive aspects painful.‘abductees’ found of the experience, such as a sense of im- Other experiences included giving birth,that 88% described portance or feeling as though they were undergoing examinations or probes, andat least some chosen to bridge communication between communicating with aliens. Although she ispositive aspects extraterrestrials and humans.3 very distressed by most memories, she feels Data collected over 17 years from Min- she beneﬁted from others. For example, as aof the experience nesota Multiphasic Personality Inventory child, Ms. S’s math skills improved dramati- (MMPI) scores of 225 persons who report- cally after an AAE episode; she believes this ed AAE reveal common personality traits, was a gift from the aliens. Ms. S’s AAE mem- including: ories are as vivid to her as memories of her • high levels of psychic energy college graduation. She had been reluctant • self-sufficiency to discuss these events with anyone outside • resourcefulness her family out of fear of being perceived as • a tendency to question authority and “crazy.” to be exposed to situational conflicts.1 Ms. S says she was a shy child who had dif- Other common characteristics include ﬁculty making friends. She was plagued with above-average intelligence, assertiveness, fatigue and worry about family members. She a tendency to be reserved and absorbed believed that aliens might attack her sisters in thought, and a tendency toward defen- and felt obligated to stay awake at night to siveness, but no overt psychopathology.1 protect them. Aside from alien experiences, After Ms. S reveals her alien experienc- Ms. S reports a happy childhood. es, I reassure her in a nonjudgmental man- She has always been an avid reader. At ner that we will explore her experiences age 8 or 9, after reading a book on alien ab- and determine ways to help her cope with duction, she concluded that she had been them. abducted. Later, she joined a group of pro- fessed alien abductees. She feels accepted and validated by this group and has a forum for discussing her experiences without fear of Want to know more? See these articles at CurrentPsychiatry.com ridicule or rejection. Irrational beliefs: Ms. S remains frightened by things that A ubiquitous human trait remind her of aliens. Although she wrote a FEBRUARY 2007 summary of her alien experiences, she can- Psychosis: Is it a medical problem? not draw a picture of an alien, and thoughts Current Psychiatry 82 July 2008 JANUARY 2007 or images of the prototypical “grey” alien trig- continued on page 85
Cases That Test Your Skillscontinued from page 82 Table 1 4 types of sleep paralysis-related hallucinations Intruder Vague sense of a threatening presence accompanied by visual, auditory, and tactile hallucinations—noises, footsteps, gibbering voices, humanoid apparitions, and sensation of being touched or grabbed Incubus Breathing difficulties, feelings of suffocation, bodily pressure (particularly on the chest, as if someone were sitting or standing on it), pain, and thoughts of impending death Vestibular-motor Sensations of floating (levitation), flying, and falling Other Out-of-body experiences, autoscopy (seeing oneself from an external point), and fictive motor movements, ranging from simple arm movements to sitting up to apparent locomotion through the environment Source: References 7,9 Clinical Pointger panic. She also feels somewhat “diﬀerent,” Myers-Briggs Type Indicator (MBTI), and Ms. S’s symptomsnervous, and distant from others. Wechsler Adult Intelligence Scale (WAIS suggested a III)—revealed no evidence of psychosis or diagnosis ofWhat diagnosis do Ms. S’s symptoms and personality disorder, and intelligence was psychosis, seizures,history suggest? within the average range. Mental status false memory, or aa) seizure activity exam was normal. Aside from the alienb) sexual abuse/trauma sleep disorder experiences, Ms. S denied any memory ofc) schizoaﬀective disorder childhood trauma. Interviews did not reveald) schizotypal personality disorder symptoms compatible with narcolepsy.e) sleep disorder Diagnostic testing ruled out hallucino- sis related to seizures. I also ruled out falseThe authors’ observations memory related to sexual abuse or trauma,Reviewing AAE literature led me to con- which is commonly found in patients whosider several diagnoses, including: present with AAE. • psychosis Collaborative information from relatives • seizures did not uncover a history of psychosis. She • false memory (sexual abuse, trauma) and family members reported, however, • narcolepsy that Ms. S’s father and 1 sister had periodic • sleep paralysis. sleep disturbances with associated halluci- A medical workup ruled out common nations. I began to suspect sleep paralysis.organic causes of psychosis. Results werenormal for brain MRI, ECG, comprehensive What is the prevalence of sleep paralysis?metabolic panel, thyroid function tests, com- a) 5%plete blood count with differential, serum b) 17%alcohol, urinalysis, and urine drug screen. c) 20% Electroencephalography (during drows- d) 30% e) 60%iness) revealed abnormal activity (oc-currences of widely scattered bursts ofnonspecific, round, sharply contoured The authors’ observationsslow waves in the left frontal region) only Full-body paralysis normally accompaniesin the F7 electrode. In the absence of clini- rapid eye movement (REM) sleep, whichcal symptoms and when found in a single occurs several times a night.4 Sleep paraly-lead, this is considered a normal variant. sis is a transient state that occurs when an Current Psychiatry Psychological testing—including MMPI, individual becomes conscious of this im- Vol. 7, No. 7 85 continued on page 90
Cases That Test Your Skills Table 2 • They sought explanations for whatthey perceived as anomalous experiences. Diagnostic criteria • They “recovered” abduction memo- for sleep paralysisries in therapy (with the help of techniques A. Patient complains of inability to movesuch as hypnosis) or spontaneously (after the trunk or limbs at sleep onset or uponreading books or seeing movies or televi- awakeningsion shows depicting similar episodes).4 B. Brief episodes of partial or complete Ms. S reported no daytime sleep attacks, skeletal muscle paralysiscataplexy, or rapid onset of dreaming. Be- C. Episodes can be associated withcause her reported AAEs were spread out hypnagogic (preceding sleep)and the last occurred approximately 5 years hallucinations or dreamlike mentationago, I decided against conducting a sleep D. Polysomnographic monitoringstudy because it likely would be low yield demonstrates at least 1 of the following: Clinical Pointand costly. I reached a diagnosis of sleep pa- 1. Suppression of skeletal muscle toneralysis-familial type, chronic based on: 2. A sleep-onset REM period During sleep • an absence of organic or psychiatric 3. Dissociated REM sleep paralysis episodes, dysfunction E. Symptoms are not associated with individuals often • a familial pattern of sleep disturbances other medical or mental disorders, such sense a threatening • the temporal pattern and description as hysteria or hypokalemic paralysis presence that some of her symptoms (Table 2).11 Minimal criteria are A plus B plus E describe as alien All of Ms. S’s episodes occurred at night Note: If symptoms are associated with aor times of quiet restfulness. She usually familial history, the diagnosis is sleep visitationsslept on her back, which may be a risk fac- paralysis-familial type. If symptoms are not associated with a familial history, thetor for sleep paralysis.12 diagnosis is sleep paralysis-isolated type Severity criteria Mild: <1 episode per month TREATMENT Reassurance, therapy Moderate: >1 episode per monthEﬀective treatment for Ms. S required helping but <1 per weekher to understand that an organic condition Severe: ≥1 episode per weekwas the foundation of her experiences. I be- Duration criteriagan by conveying the sleep paralysis diagno- Acute: ≤1 monthsis and my understanding of the occupational Subacute: >1 month but <6 monthsand personal consequences that this condition Chronic: ≥6 monthshad had for her. I explained the physiology of REM: rapid eye movement Source: Reference 11sleep paralysis and that memories or halluci-nations (dreamlike mentation) are preservedin an extremely vivid fashion because her eyes treatment, Ms. S cites multiple improvements,are open. I acknowledged the realistic charac- with no recurrence of sleep paralysis episodes.ter of her experiences and the resulting symp- She continues to take sertraline, which relievestoms of posttraumatic stress disorder (PTSD). her depression and anxiety, and methylpheni- I refer Ms. S to a therapist for psychother- date to improve her attention and concentra-apy. The therapist begins by using trauma tion. She has taken on more responsibility atinformed techniques to address Ms. S’s PTSD. home, cleaning, preparing meals, helping herAs she improves, her therapy evolves into a daughter choose a college, and attending tocombination of narrative and supportive psy- her mother’s health issues. Ms. S still has dif-chotherapy, and then family systems therapy to ﬁculties with her sleep patterns, and her newaddress issues with her daughter and mother. psychiatrist is exploring the possibility of a bi- Current Psychiatry In a follow-up visit 1 year after beginning polar component to her mood disorder. Vol. 7, No. 7 91 continued
Cases That Test Your Skills The authors’ observations Related Resources Like other traumas, AAE can induce symp- • American Academy of Sleep Medicine. International classiﬁcation of sleep disorders, revised: diagnostic and coding toms of acute or chronic PTSD. The various manual. Chicago, IL: American Academy of Sleep Medicine; psychoses, personality disorders, and dis- 2001:166-9. sociative disorders that could account for • Cheyne JA. Sleep paralysis and associated hypnagogic and hypnopompic experiences. http://watarts.uwaterloo. abduction experiences are characterized ca/~acheyne/S_P.html. by delusions, so conduct ongoing assess- Drug Brand Names ment for these conditions in patients who Methylphenidate • Ritalin Sertraline • Zoloft Quetiapine • Seroquel report AAE. However, evidence suggests Disclosure that serious psychopathology is no more The authors report no ﬁnancial relationship with any common among “abductees” than among company whose products are mentioned in this article or the general population.12 with manufacturers of competing products.Clinical Point Persons reporting AAE exhibit physi- the UFO abduction phenomenon: hypnotic elaboration, ologic reactivity as profound as that of extraterrestrial sadomasochism, and spurious memories.No drugs are survivors of combat or sexual assault.13 Psychol Inq 1996;7(2):99-126.FDA-approved This reactivity confirms that the emotional 3. Bader CD. Supernatural support groups: who are the UFO abductees and ritual-abuse survivors? J Sci Study Religfor treating sleep power of the memory is as evocative and 2003;42(4):669-78. 4. Clancy SA, McNally RJ, Schacter DL, et al. Memory distortionparalysis, but use problematic as the physiologic reactions in people reporting abduction by aliens. J Abnorm Psychol 2002;111(3):455-61.pharmacotherapy attributable to genuine (documented) 5. Girard TA, Cheyne JA. Individual differences in lateralization traumatic events. Because patients have of hallucinations associated with sleep paralysis. Lateralityto address anxiety 2004;9(1):93-111. difficulty differentiating these hallucina- 6. Cheyne JA. The ominous numinous: sensed presence andand depression tions from actual events, they experience “other” hallucinations. Journal of Consciousness Studies 2001;8(5-7):133-50. emotional pain and suffering. Fifty-seven 7. Cheyne JA, Newby-Clark IR, Rueffer SD. Relations among hypnagogic and hypnopompic experiences associated with percent of sleep paralysis patients who re- sleep paralysis. J Sleep Res 1999;8:313-7. port AAE attempt suicide.14 8. Cheyne JA, Rueffer SD, Newby-Clark IR. Hypnagogic and hypnopompic hallucinations during sleep paralysis: Offer patients with AAE psychotherapy neurological and cultural construction of the night-mare. Conscious Cogn 1999;8(3):319-37. to deal with long-term effects of trauma 9. Cheyne JA. Sleep paralysis and the structure of waking- and problems with mood, sleep, daily nightmare hallucinations. Dreaming 2003;13(3):163-79. 10. Spanos NP, Cross PA, Dickson K, et al. Close encounters: functioning, and/or relationships. an examination of UFO experiences. J Abnorm Psychol 1993;102(4):624-32. There are no FDA-approved medica- 11. American Academy of Sleep Medicine. International tions for treating sleep paralysis. Phar- classification of sleep disorders, revised: diagnostic and coding manual. Chicago, IL: American Academy of Sleep Medicine; macotherapy can be used to address 2001:166-9. psychiatric symptoms such as the depres- 12. Holden KJ, French CC. Alien abduction experiences: some clues from neuropsychology and neuropsychiatry. Cognit sion and anxiety Ms. S exhibited. Neuropsychiatry 2002;7(3):163-78. 13. McNally RJ. Applying biological data in forensic and policy arenas. Ann N Y Acad Sci 2006;1071:267-76. References 14. Stone-Carmen J. A descriptive study of people reporting 1. Patry AL, Pelletier LG. Extraterrestrial beliefs and experiences: abduction by unidentified flying objects (UFOs). In: Pritchard an application of the theory of reasoned action. J Soc Psychol A, Pritchard DE, Mack JE, et al, eds. Alien discussions: proceedings 2001;141(2):199-217. of the abduction study conference held at MIT. Cambridge, MA: 2. Newman LS, Baumeister RF. Toward an explanation of North Cambridge Press; 1994:309-15. Bottom Line Assess patients who report alien abductions for psychosis, seizures, false memory, narcolepsy, and sleep paralysis. During sleep paralysis, patients may sense a threatening presence they interpret as intruders or aliens—and experience visual, tactile, and auditory hallucinations—that they perceive as real. Psychotherapy and Current Psychiatry 92 July 2008 pharmacotherapy can help patients manage the impact of these episodes.