Sm. Sri. Med.Vol. 40, No. 12,Pp. 1623-1629,1995 Copyright0 1995Elsevier Science Ltd Pergamon 0277-9536(94)00347-5 Printedin GreatBritain. All rightsreserved 0277-9536/95 S9.50f0.00

REFUGEE STRESS AND FOLK BELIEF: HMONG SUDDEN DEATHS

SHELLEY R. ADLER Division of Medical Anthropology, Department of Epidemiology and Biostatistics, University of California, San Francisco, 1350 Seventh Avenue, CSBS-317,San Francisco, CA 94143-0850.U.S.A.

Abstract-Since the first reported death in 1977, scoresof seeminglyhealthy Hmong refugeeshave died mysteriously and without warning from what has come to be known as Sudden Unexpected Nocturnal Death Syndrome (SUNDS). To date medical research has provided no adequate explanation for these sudden deaths. This study is an investigation into the changing impact of traditional beliefs as they manifest during the stressof traumatic relocation. In Stockton, California, I18 Hmong men and women were interviewed regarding their awarenessof and personal experiencewith a traditional nocturnal spirit encounter. An analysis of this data reveals that the supranonnal attack acts as a trigger for Hmong SUNDS.

Key words-refugee stress. sudden death, ethnomedical pathogenesis

With the fall of the capital city of Vientiane in 1975, for themselvesand their children, a clear idea of who they thousands of Hmong fled their native Laos and- are, of their identity as Hmong, of their place in history and in the cosmic realm of spirits, ancestors’ souls and human often after extended delays in Thai refugee camps- societies(41. began arriving in the United States. The Hmong are more widely known in the West than other Laotian The Hmong who have fled Laos leave behind them ethnic groups because of their efforts on behalf of a homeland ravaged by war, but in their transition to the United States during the war in Viet Nam, the West they are met with new and unique problems. particularly after it spread to Laos and Cambodia. Those Hmong who have come to the United States Thousands of Hmong were funded directly and find themselvessuspended between worlds, in a place secretly by the Central Intelligence Agency to combat where their religion, language and skills are de-con- the Communist Pathet Lao. Hmong men served as textualized and where their previous social support soldiers, pilots, and navigators, and their familiarity system is greatly weakened [S]. In particular, for with the mountain terrain helped make them remark- many Hmong the relocation marks the end of the able scouts and guerrilla fighters [l]. By the end of prevalent form of their traditional religious beliefs the civil war, the Hmong had suffered casualty and practices. rates proportionally ten times higher than those of In the traditional Hmong worldview, the natural Americans who fought in Viet Nam [2]; it is estimated world is alive with spirits. Trees, mountains, rivers, that nearly one-third of the Laotian Hmong popu- rocks and lightning are all animated by distinctive lation lost their lives [l]. When the Laotian govern- spirits. Ancestor spirits not only remain around the ment changed hands after the departure of American living, but play an essential role in complex rituals of troops, large groups of Hmong were forced to flee reciprocity with their living descendants. Laos rather than chance “re-education” camps or The Hmong celebrate their humanity not as a discrete and possible death under the new Communist regime. impenetrable part of the natural order, but as part of the There are currently over 110,000 Hmong living in circle of life of all creation--caught up in the rotation of the the United States, with 70,000 in California’s Central seasons,and deeply connected with the configuration of the mountains. and the reincarnation of life from generation to Valley alone [3]. The city of Fresno is now home to generation, even from speciesto species.Life, in its myriad the largest single community of Hmong in existence. forms, is intimately articulated through souls and spirits [6]. The relocation of this large number of refugeesfrom In interviews with refugees,it becameclear that many Laos to the United States has been characterized by Hmong feared that the ancestor spirits who protected extraordinary difficulties. them from harm in Laos would be unable to travel These displaced and resettled Hmong, while finding across the ocean to the United States and thus could welcome freedom from persecution and physical an rihil- not shield them from spiritual dangers. Solace was ation, are neverthelessgoing through a grave cultural crisis. taken, however, in the conviction that the myriad evil immersed as they are, an infinitesimal minority. in over- whelmingly dominant majority modes of living, norms of spirits who challenged Hmong well-being in Laos behavior, beliefs and values. Everywhere they face the would also be prevented from following the Hmong possibility ofcultural annihilation, and struggle to maintain, to their new home. Among these evil spirits assumed

1623 1624 Shelley R. Adler to have been left behind was the nocturnal pressing According to descriptions of the Nightmare spirit spirit dub tsog (pronounced ‘da cho’) [7]. It soon [26], the sleeper suddenly becomes aware of a became frighteningly apparent, however, that this presenceclose at hand. Upon attempting to investi- notorious evil spirit had made the journey to America gate further, the victim is met with the horrifying as well. realization that he or sheis completely paralyzed. The presenceis usually felt to be an evil one, and often this impression is confirmed by a visual perception of the HMONG SUDDEN UNEXPECTED NOCWRNAL DEATH SYNDROME being, which places itself on the sleeper’schest and exerts a pressure great enough to interfere with Since the first reported case, which occurred respiration. The classic nightmare experience, then, in 1977, more than 100 Southeast Asians in the is characterized by the following symptoms: the United States have died from the mysterious dis- impression of wakefulness, immobility, sensation of order that is now known as SUNDS, the Sudden pressure on the chest, realistic perception of the Unexpected Nocturnal Death Syndrome [8]. The environment, and intense fear. (To avoid confusion, sudden deaths have an unusually high incidence I use Nightmare [upper case] to refer to the spirit or among Laotians, particularly male Hmong refugees. demonic figure to which these nocturnal assaults are All but one of the victims have been men, the median attributed and nightmare [lower case] to refer to age is 33, the median length of time living in the the basic experience; that is, the impression of United States before death is 17 months [9], all wakefulness, immobility, realistic perception of the were apparently healthy, and all died during environment, and intense fear [27]). sleep. The rate of death from SUNDS has reached The casedefinition presented in the Final Report of alarming proportions: at its peak in 1981-1982, the SUNDS PIanning Project [15] emphasizes the the rate of death among 2544-year-old Hmong men need to observe closely people “who fit the demo- (92/100,000) [IO] was equivalent to the sum of the graphic characteristics of SUNDS” and who have rates of the five leading causes of natural death transient nocturnal events that include among United States males in the same age group []]I. “(1) a senseof panic or extreme fear, Despite numerous studies of SUNDS, medical (2) paralysis (partial or complete); scientists have not been able to determine exactly (3) a sense of pressure on the chest; what is causing the deaths of these seemingly healthy (4) a sensethat there is an alien being (animal, people in their sleep [12]. Biomedical studies human, or spirit) in the room; [and] have taken into account such varied factors as toxi- (5) a disturbance in sensation (auditory, visual cology [13-171, heart disease [12, 18, 191, genetics or tactile).” [14, 15, 20,211, metabolism [15], and nutrition (par- This list of five symptoms of SUNDS-related ticularly thiamine deficiency [22]), but are no nearer events is identical to the characteristics of the night- to a comprehensive answer. Current medical opinion mare experience as it is known in countless folk appears to favor the role of abnormalities of the traditions, including those of the Hmong. Since the cardiac conduction system, although a 1988 report conditions described by Holtan et al. as “SUNDS- from the Centers for Disease Control indicates the related” are consistent with the symptoms of a incompleteness of this solution: “Only at night, in Nightmare attack, I decided to investigate the times of unusual stress, and possibly in conjunction possibility that SUNDS is initiated by such a con- with other, as yet undefined, factors are these people frontation. at risk of developing abnormal electrical impulses in Based on preliminary fieldwork and a review of the heart that result in ventricular fibrillation and previous research,I developed the hypothesis that the sudden death” [9]. supranormal nocturnal experience traditionally known as the nightmare and familiar to the Hmong THE NIGHTMARE SPIRIT acts as a trigger for the sudden nocturnal deaths [28]. In order to study the prevalence of the nightmare Biomedicine thus provides no adequate answer to phenomenon and the role of the nightmare in tra- the question of what causesSUNDS; from my van- ditional Hmong culture, I interviewed a representa- tage point in the social sciences,however, I propose tive sample of 118 Hmong in Stockton, California. that an investigation of Hmong traditional belief can In the course of researchit was necessaryto establish reveal the event that triggers the fatal syndrome. The the veracity of a series of facts: first, that the focus of this research is a supranormal nocturnal Hmong supranormal experience that I had isolated experience that I refer to as the ‘nightmare’ and that was in fact a culture-specific manifestation of the is familiar to the Hmong. I use the word ‘nightmare’ universal nightmare phenomenon; second, that not in the modern senseof a bad dream, but rather Hmong belief regarding the experienceforms a collec- in its original denotation as the nocturnal visit of an tive tradition; third, that the Hmong nightmare, evil being that threatens to press the very life out of in specific contexts, causescataclysmic psychological its terrified victim [23-251. stress;and fourth, by drawing on the growing medical Hmong refugeessudden’ nocturnal deaths 1625 and anthropological literature on ethnomedical might bring about their deaths, set their alarm pathogenesis, that intense psychological stress can clocks to awaken them every 20 or 30 minutes [ 151. cause sudden death. Ironically, this type of sleep disruption may actually The nightmare syndrome appears to be universal in cause sleep-onsetREM and nightmares (through the its occurrence. There are innumerable instancesof the mechanism of ‘REM pressure’ [36-381). nightmare throughout history and in a multitude of cultures; from the ancient Greek ephialtes (=leap upon) and Roman incubus( = lie upon) to contempo- THE HMONG NIGHTMARE rary examples such as French cauchemar (from La. In the Hmong language, the Nightmare spirit is calcare = to trample upon, squeeze), German Alp- referred to as dub tsog (‘da cho’). Dab is the Hmong druck (= elf pressure), Newfoundland “Old Hag” word for spirit, and is often used in the senseof an [23,24,29], Polish zmora, and Mexican pesudiila [30]. evil spirit. Tsog is the specific name of the Nightmare The nightmare’s significance and impact vary con- spirit, and also appears in the phrase used to denote siderably in different cultural settings, but the core a Nightmare attack, tsog tsuam (‘cho chua’). Tsuam nightmare phenomenology appears to be stable cross- means “to crush, to press, or to smother” [39]. culturally [3 11. In the sample of Stockton Hmong, a total of 58% (36 men, 33 women) had experienced at least one THE NIGHTMARE AND SLEEP RESEARCH nightmare. The interviews and the personal narra- tives they elicited clarified that the Hmong supra- The consistent features of the nightmare are better normal experience that I had isolated was in fact a understood with the assistance of concepts from cultural manifestation of the Nightmare phenom- laboratory sleep research. Somnologists distinguish enon. The following is a portion of a narrative from between two major divisions of sleep: active sleep (or a 33-year-old Hmong man who had a nightmare REM) and quiet sleep. REM sleepis characterized by experience shortly after his arrival in the United brain waves resembling those of wakefulness. Unlike States: the waking state, however, the body is paralyzed, apparently to keep the sleeper from acting out his or First, 1was surprised, but right away,I got realscared. I was lying in bed.I wasso tired, becauseI wasworking very hard her dreams [32]. In rare instances, this normal muscle then. I wantedto go to school,but I had no money.I kept inhibition or atonia occurs during partial wakeful- waking up, becauseI was thinking so much about my ness. This condition is known as ‘sleep paralysis’, a problems.I heard a noise, but when I turned-tried-1 stage in which the body is asleep, but the mind is could not move.My bedroomlooked the same,but I could not. Often sleep paralysis is accompanied by hypna- see-in the corner,a dark shapewas coming to me. It came to the bed,over my feet,my legs.It was very heavy,like a gogic hallucinations, which consist of complex visual, heavy weight over my whole body, my legs, my chest. auditory, and somatosensory perceptions occur- My chestwas frozen-like I was drowning, I had no air. ring in the period of falling asleep and resembling I tried to yell so someonesleeping very close to me will dreams [33]. hear.I tried to move-using a force that I can-a strength that 1 can have. I thought, “What if I die?’ After a long Sleep paralysis and hypnagogic hallucinations are time, it went away it just left. I got up and turned all the products of ‘sleep-onset REM’, a REM stage that lights on. I was afraid to sleepagain. occurs earlier than usual, when the individual is still partially conscious [24,30, 341Sleep-onset REM With regard to the emit term for the nightmare accounts for the subjective impression of wakeful- experience, 97% of the informants used either dab ness, the feeling of paralysis, and, as a result, the tsog or tsog tsuam. All of those who were able to tremendous anxiety that mark the nightmare experi- provide a name for the nocturnal encounter could ence. Researchers have shown convincingly that also define it. This widespread awareness of the sleep-onset REM accounts for the subjective im- Nightmare tradition clearly established that Hmong pression of wakefulness, the feeling of paralysis, and, belief regarding the nightmare forms a collective as a result, the tremendous anxiety that mark tradition. the nightmare experience [23,24, 271 I extend these explanations of nightmare symptoms to include the DAB TSOC AND HMONG RELOCATION fact that the sense of oppression or weight on the chest and the attendant feature of lying in a supine Since Hmong who maintain their traditional position are a result of the fact that when the sleeper religious beliefs and practices and those who have is lying on his or her back, the atonic muscles of converted to Christianity both die of SUNDS, the tongue and esophagus collapse the airway. The the testing of the hypothesis of a belief-triggered relaxed muscles not only hinder breathing, but actu- disorder necessitatedan exploration of the influence ally create a sensation of suffocation, strangulation or of the Nightmare on Hmong of both religions. In pressure on the chest of the terrified sleeper[35]. The the sample, 54% of traditional Hmong and 72% of connection between Nightmare attacks and sleep Christian Hmong had experienced at least one night- paralysis is highlighted by the fact that Hmong mare. The interview data reveals that psychological women report that some men, fearing that deep sleep stress regarding religious practice is present among 1626 ShelleyR. Adler both traditional and Christian Hmong refugees in discrepancy in the ratio of male to female SUNDS the United States and also that this stress is exacer- deaths. bated in both groups by the supranormal nocturnal Since both Hmong men and women suffer from assaults. Traditional Hmong face great difficulty Nightmare attacks, however, why are SUNDS in practicing their religion as they had done in deaths almost exclusively male? The answer lies in the Laos. The inability to obtain animals for slaughter, meaning of Nightmare attacks in traditional Hmong disruption of clan ties and the scarcity of shamansall culture. Hmong informants explained that among contribute to the problem of performing expected other religious requirements, one’s ancestor spirits religious duties. Many Christian Hmong also retain must be fed annually. If the ancestor spirits are traditional beliefs and have anxieties about not neglected, they become angry, deserting the individ- fulfilling their religious requirements. Some Christian ual, the head-of-household, and leaving him vulner- Hmong converted out of a sense of obligation to able to evil spirit attacks. Most of the Hmong church sponsors and many experience peer disap- informants perceived a direct causal relationship be- proval and clan ostracization. Although the more tween failure to perform traditional Hmong rituals devout Christians I spoke with denied any ambiva- and Nightmare attacks. (Etiologies related to either lence, many of the Christian Hmong informants traditional spirits or to the lack of traditional described ways in which they combined the two religious practice constituted 81% of all the night- religions in order to prevent incurring the Hmong mare causes suggested.)One Hmong man summar- spirits’ wrath. It is striking that of the informants who ized the widely held belief as follows: offered an explanation for the causeof SUNDS. 74% suggestedan etiology that was directly spirit-related At leastonce a yearthose evil spiritsmust be fed.If someone forgetsto feedthem, then they will comeback and disturb or involved the absence of traditional religion and you. If you havetsog rsuam, the ancestorspirit is supposed ritual from their lives. to protect you. If you feed the ancestorsregularly, then I have noted an increased incidence of nightmares wheneveryou have tsog warn, the ancestorspirits will during informants’ times of stress.(Emotional stress, protect you. Usually the father, the head-of-household,is responsiblefor feedingthe evil spirits. Womenhave night- physical exhaustion and sleep deprivation have been mares,too, but not as often as men. The evil spirit would shown to be predisposing factors for sleep-onset first attack the head-of-household.Coming to this country, REM, see [27,4042].) According to the traditional peopletend to forget to do the rituals.A lot of peopleeither belief informants described, tsc)~ t.rnunt assaults are ignoreor forget to practicetheir religiousbelief. Men are rarely, if ever. fatal on the first encounter. the oneswho are responsiblefor feedingboth the evil spirits and the ancestorspirits. Since they are not doing their part, It is believedthat onceyou haveone of thosenightmares- it is logical that their soul should be taken away. you are visitedby oneof the dub tsogevil spirits-once you are seenby one of thoseevil spirits. often they will come This explanation clearly has great significance for the back to you, until you have the worst nightmare and investigation of SUNDS etiology in that it contains probablydie. a matter-of-fact description of the precise manner in Usually the lethal potential manifests only after an which a man’s failure to full% traditional religious individual has been given time to rectify a situation, obligations can result in his death. The inability to but chooses not to, or is unable to, appease the fulfil roles and responsibilities with regard to religion intruding spirit. As one informant explains, because (as well as in their lives generally) has a calamitous of traditional countermeasures undertaken in Laos. impact on the psyche of many Hmong males. SIJNDS deaths did not occur prior to the Hmong Although Hmong women do experience Night- exodus: “There were nightmares, but the sudden mare attacks and are aware of the roles of both spirits death was unheard of. It might have happened, but and the absenceof traditional religious practices m I never heard of it”. None of the informants I SUNDS deaths, they also know that dab fsog ~111 interviewed recalled incidents of SUNDS deaths in seek out their husbands, fathers or brothers as Laos [43]. the individuals held accountable. As one Hmong informant recalled of her own nightmare experience “Even though I was very, very scared, I thought it

DAB TSOG ACD HMO!% SUNDS was good my husband wasn’t there. so the spirit wouldn’t hurt him.” Several informants suggested Aside from the conflict between Hmong traditional that the one woman who died of SUNDS must have religion and Christianity, Hmong refugees have been unmarried or widowed and therefore, as the experienced a host of hardships including language head of her household, the individual who was held and employment problems, changing generational accountable by the spirits, and gender roles [44], survivor guilt [45] and trauma- If the nightmare is usually a transient, non- induced emotional and psychological disorders pathological phenomenon. how can it trigger a fatal [4648] These changes can affect all Hmong immi- disorder among Hmong refugees?Nightmare assaults grants in varying degrees, but Hmong men, in par- occurred in Laos. but none of the informants I ticular, have had their roles dramatically altered. interviewed recalled incidents of SUNDS deaths This gender dichotomy is mirrored by the vast in their homeland. I propose that the differences Hmong refugeessudden’ nocturnal deaths 1627 between the Hmong way of life in pre-war Laos and munities that characterized Hmong life in Laos their current situation in the United States are appear to have fostered traditional cultural practices responsible for this phenomenon. The various whose presence alleviated, but whose subsequent resettlement stressesI have discussedmanifest most loss provokes, feelings of terror and impending strongly during the initial arrival period, thus ex- death associated with negative supranormal plaining the overwhelming preponderance of deaths encounters. Therefore, although the dub tsog attack in the two-year period following resettlement in the in Laos was akin to the worldwide Nightmare tra- United States [49]. dition, the peculiar stresses of the recent Hmong The subject of intense emotional stressas the cause refugee experience have transformed its outcome. In of sudden death is a motif well-represented in world conclusion, the power of traditional belief in the folklore throughout history and has also been a topic nightmare-compounded with such factors as the of serious biomedical investigation. A number of trauma of war, migration, rapid acculturation, anthropological and biomedical studies suggesta link and the inability to practice traditional healing and betweenpsychological stressand suddendeath, seefor ritual--causes cataclysmic psychological stress that example [S&55]. In the medical anthropological and can result in the deaths of male Hmong refugeesfrom ethnomedical literature, the notion of beliefs playing a SUNDS [57]. significant role in illnesscausation (noceboeffect) or its remedy (placebo effect) is widely held [56]. Robert A. Acknowledgements-The author wishes to express her Hahn and Arthur Kleinman’s notion of the pathogenic gratitudeto Judith Barker,Carole Browner, Michael Owen Jones, Linda Mitteness and Don Ward for thoughtful effects of belief or “ethnomedical pathogenesis”, is a discussionon variousaspects of this research.A specialnote particularly useful concept for the study of the role of of thanksto the Hmong men and women who shared their traditional belief in SUNDS. Significantly, the concept personal beliefs and experienceswith me. of ethnomedicogenicillness and healing, with its em- phasis on the relationship betweenthe mind/spirit and REFERENCES body, is compatible with the holistic traditional Hmong worldview regarding health. Quincy K. Hmong: History qf a People. EastWashing- ton UniversityPress, Cheney, 1988. Since Nightmare assaults and other spirit-related Cerquone J. Refugees from Laos: In Harm’s Wq. U.S. problems did occur in Laos, it is significant that Committee for Refugees,Washington, DC, 1986. Hmong refugees in the United States attribute Profiles of fhe Highland Lao Communities in the United SUNDS to traditional spirits. I believe that the Stares. United States Department of Health and Human Services,Washington, DC, 1988. differences between the Hmong way of life in pre-war 4 Johnson C. Dab Neeg I?mooh: Mylhs, Legend,s, and Laos and their current situation in the United States Folktales from the Hmonp of Laos. Macalester College. are responsible for this phenomenon. Traditional St. Paul,‘MN, 1985. .’ ” Hmong culture has sustained a severedisruption. The 5 Muecke M. A. In search of healers: southeast Asian Hmong have undergone a seemingly endless series refugeesin the American health care system. Western J. Med. 139, 835-840, 1983. of traumatic experiences:the war in Laos, the Pathet 6 Conquergood D. I am a Shaman: A Hmong Life Story Lao takeover and subsequent Hmong persecution with Ethnographic Commenrary. pp. 45546. University (including the threat of genocide), the harrowing of Minnesota, Minneapolis, 1989. nighttime escapes through jungles and across the Hmong rvasan exclusivelyoral languageuntil the 1950s Mekong River, the hardships of refugee camps in when Christian missionariesin Laos developeda written form using the Roman alphabet. In this essay,under- Thailand, and finally resettlement in the United lined Hmong terms representwords in the Hmong States, with not only housing. income, language and language written in the Roman Popular Alphabet employment concerns, but the separation of families (RPA). For easeof pronunciation I provide an English and clans, inability to practice traditional religion, transliteration in quotation marks. The disorder is also known by the acronym SUDS, and hasty conversions to Christianity, among many Sudden Unexplained Death Syndrome. I think that others. These recent changes appear to account for both the unpredictablenature of the syndromeand the the fact that, while SUNDS deaths occur in the fact that 98 percent of the deaths occurred between United States, no informant I interviewed was aware IO:00 p.m. and 8:00 a.m. [9] warrant the inclusion of both the words ‘unexpected’and ‘nocturnal’ in the label. of any SUNDS deaths in pre-migration Laos, Thus, Sudden Unexpected Nocturnal Death Syndrome is When dub tsog tormented sleepers in Laos, it a more accurate description of the disorder. My use of did so in a sociocultural context that sustained a the term SUNDS is consistentwith that of The SUNDS fundamental structure of support. Hmong shamans PlanningProject at Saint Paul-RamseyMedical Center. conducted prescribed rituals designedto ascertain the Parrish R. G. Death in the Night: Mysterious Syndrome in Asian Refugees.In 19119Medical und He&h Annual nature of the individual’s transgressionand sought to (Edited by Berstein E. and Tomchuck L.), pp. 2866290. appease the angry spirits in order to prevent the Encyclopedia Britannica, Chicago, 1988. possibility of the sleeper’sdeath during a subsequent Baron R. C. and Kirschner R. H. Sudden night-time nocturnal encounter. In the United States, while the death among south-east Asians too. The Lancet 8327, majority of Hmong retain many of their traditional 764, 1983. Munger R. G. Suddendeath in sleepof Laotian-Hmong beliefs, in many instances they have lost their reli- refugeesin Thailand: a case-control study. Am. J. Pub. gious leaders and ritual responses.The insular com- Hllh 77, II 87, 1987. 1628 Shelley R. Adler

12. Beginning in 1981, a number of researchersbegan to 31. Hufford D. J. Inclusionism versus reductionism in note similarities between SUNDS and the sudden the study of culture-bound syndromes. Culture, Med. deaths of Filipino and Japanesemen from disorders Psychiat. 12, 503, 1988. known respectively as bangungut and pokkuri e.g. 32. Dement W. C., Frazier S. H. and Weizman E. D. The Refs 110.18. 19.491. These findines are sienificant in American Medical Association Guide to Better Sleep. illustrating that despite peculiar cultural maiifestations Random House, New York, 1984. and elaborations, the phenomenon of SUNDS (like the 33. Hartmann E. The Nightmare: The Psychology and nightmare itself [31]), appears to be consistent across Biology of Terrifying Dreams. Basic Books, New York, unrelated cultures. 1984. 13. Baron R. C., Thacker S. B., Gorelkin L., Vernon 34. Parkes J. D. Sleep and Its Disorders. W. B. Saunders, A. A., Taylor W. R. and Choi K. Sudden deaths London, 1985. among southeast Asian refugees: an unexplained noc- 35. Kellerman H. SleepDisorders: Insomnia and Narcolepsy. turnal phenomenon. J. Am. Med. Assoc. 250, 2947, Brunner/Mazel, New York, 1981. 1983. 36. Rechtschaffen A. and Dement W. C. Narcolepsy 14. Bissinger H. G. More cities report death syndrome. and Hypersomnia. In Sleep: Physiology and Pathology St. Paul Pioneer Press 6 February, Fl, 4, 1981. (Edited by Kales A.), pp. 119-130.J. B. Lippincott, PA, IS. Bhatout B. T. Hmong Sudden Unexpected Nocturnal 1969. Death Syndrome:A Cultural Study. Sparkle Publishing, 37. Riley T. C. Clinical Aspects of Sleep and Sleep Dis- OR, 1982. turbances. Butterworth Publishers, Boston, 1985. 16. Hohan N., Carlson D., Egbert J., Mielke R. and Thao 38. Takeuchi T., Miyasita A., Sasaki Y., Inugami M. and T. C. Final Report of the SVNDS Planning Project. Fukuda K. Isolated sleep paralysis elicited by sleep St Paul-Ramsey Medical Center, St Paul, MI, 1984. interruption. Sleep 15, 217, 1992. 17. Pyle J. Death stalking refugees. The News Tribune 39. Heimbach E. E. White Hmong-English Dictionary. (Tacoma, Washington). 16 April: Cl, 1981. Cornell University Press, Ithaca,-1979 18. Kirschner R. H.. Eckner F. A. 0. and Baron R. C. The 40. Hishikawa Y. Sleeu Paralvsis. In Narcolepsy:. _ Proceed- cardiac pathology of sudden, unexplained, nocturnal ings of the First International Symposiumon Narcolepsy, death in southeast Asian refugees.J. Am. Med. Assoc. Advancesin SleepResearch (Edited by Guilleminault C., 256, 2700, 1986. Dement W. C. and Passouant P.), Vol. 3, pp. 97-124. 19. Otto C. M., Tauxe R. V., Cobb L. A., Greene H. L., Spectrum Publications, New York, 1976. Gross B. W., Werner J. A., Burroughs R. W., Samson 41. Rechtschaffen A. and Dement W. C. Narcolepsy and W. E., Weaver D. and Trobaugh G. B. Ventricular hypersomnia. In Sleep: Physiology and Pathology fibrillation causes sudden death in southeast Asian (Edited by Kales A.), pp. 119-130.J. B. Lippincott, PA, immigrants. Ann. Intern. Med. 100, 45, 1984. 1969. 20. Marshall E. The Hmong: dying of culture shock? 42. Riley T. C. Clinical Aspectsof Sleepand Sleep Disturb- Science 212, 1008, 1981. ances. Butterworth Publishers, Boston, 1985. 21. Munger R. G. and Hurlich M. G. Hmong deaths. 43. Despite the uniformity of opinion among informants Science 213, 952, 1981. regarding the absence of SUNDS deaths in pre- 22. Rejiigee Health Issues Quarterly. Update: sudden migration Laos, it is important to note that the forensic unexplained death syndrome among southeast Asian diligence to account for unusual death in Laos is not refugees. 4, I, 1989. comparable to that of the United States, particularly 23. Hufford D. J. A new approach to the “Old Hag”: the in the isolated rural villages in which the Hmong nightmare tradition reexamined. In American Folk lived. Although it is therefore impossible to know Medicine: A Symposium (Edited by Hand W. D.), with certainty whether SUNDS deaths occurred in pp. 73385. University of California Press, Berkeley, Laos, the conviction on the part of Hmong immigrants 1976. that the deaths were absent is a significant element 24. Hufford D. J. The Terror That Comes in the Night. in their dichotomization of experience between pre- University of Pennsylvania Press, PA, 1982. migration Laos and post-resettlement America. 25. Ward D. The little man who wasn’t there: encounters 44. Donnelly N. D. The changing lives of refugee Hmong with the supranormal. Fabula: J. Folklore Stud. 18, 213, women. University of Washington doctoral disser- 1977. tation. University Microfilms International, Michigan, 26. The word mara, from which “nightmare” is derived, can 1989. be traced to a proto-Indo-European root that most 45. Tobin J. J. and Friedman J. Spirits, shamans, and likely referred to a nocturnal pressing spirit. (Kluge F. nightmare death: survivor stress in a Hmong refugee. Etymologisches Wiirterbuch der Deutschen Sprache. Am. J. Orthopsychiat. 53, 439, 1983. Walter de ruyter, Berlin, 1960.) 46. Westermeyer J. Hmong deaths. Science 213, 952, 27. I am indebted to David J. Hufford for his characteriz- 1981. ation of the nightmare in The Terror That Comesin the 47. Westermeyer J. Prevention of mental disorder among Night (1982). Although I have altered his configuration Hmong refugees in the U.S.: lessons from the period slightly [based on the results of my own fieldwork 19761986. Sot. Sci. Med. 25, 941, 1987. in Jerusalem (1987788) and Los Angeles (198687)] 48. Westermeyer J. A matched pairs study of depression Hufford’s criteria. which are unique in the literature on among Hmong refugees with particular reference the subject, remain the foundation of the minimal to predisposing factors and treatment outcome. Sot. requirements for the nightmare experienceas I present Psychiat. Psyrhiat. Epidemiol. 23, 64. 1988. them. 49. Parrish R. G., Tucker M., Ing R., Encarnacion C. and 28. Adler S. R. Sudden unexpected nocturnal death Eberhardt M. Sudden unexplained death syndrome in syndrome among Hmong immigrants: examining the southeast Asian refugees:a review of CDC surveillance. role of the “nightmare”. J. Am. Folk/ore 104, 54, Morbidity and Mortality Weekly Rev. 36, 43, 1987. 1991. 50. Brodskv M. A.. Soto D. A., Iseri L. T.. Wolff L. J. and 29. Ness R. C. The old hag phenomenon as sleep paralysis: Allen Be.J. Ventricular tachyarrhythmia associatedwith a biocultural. interpretation. Culture, Med. Psychiat. 2, psychological stress:the role of the sympathetic nervous 15, 1978. system. J. Am. Med. Assoc. 257, 2064, 1987. 30. Foster G. M. Dreams. character, and cognitive orien- 51. Cannon W. Voodoo death. Am. Anthropol. 44, 169, tation in Tzintzuntzan. Ethos I, 106, 1973. 1942. Hmong refugees’ sudden nocturnal deaths 1629

52. Engel G. L. Sudden and rapid death during psychologi- Nightmare spirits, do nightmare experiencesprecipitate cal stress:folklore or folk wisdom? Ann. Intern. Med. 74, similar disorders among other peoples?Although those 771, 1971. affected by SUNDS are overwhelmingly Laotian 53. Greene W. A., Goldstein S. and Moss A. J. Psychosocial Hmong men, individuals belonging to other groups, aspects of sudden death: a preliminary report. Arch. notablv Filiuinos. Thai. Khmu and Cambodians, have Intern. Med. 129, 725, 1972. died of wha; appears to be SUNDS. A detailed discus- 54. Lown B., Verrier R. and Corbalan R. Psychologicstress sion of these potentially parallel phenomena is beyond and threshold for repetitive ventricular response. the aim of the present paper, but it is important to note Science 182, 834, 1973.- that my preliminary investigation of Khmu and Thai 55. Rahe R. H.. Romo M.. Bennett L. and Siltanen P. sudden deaths indicates that individuals of both groups Recent life changes, myocardial infarction, and abrupt perceivea connection between Nightmare spirit attacks coronary death.Arch.-Intern. Med. 133, 221, 1974. and sudden deaths in situations of extreme psychologi- 56. Hahn R. A. and Kleinman A. Belief as oathoeen. cal stress. Any definitive statement regarding a corre- belief as medicine: “voodoo death” and the“‘plac;bo lation between these Nightmare spirits and SUNDS. phenomenon” in anthropological perspective. Med. however, requires an in-depth study of the type pre- Anthrop. Q. 14, 6, 1983. sented in this paper that focuses on the beliefs and 57. Given that myriad cultures possesstraditions of evil experiencesof the non-Hmong groups affected.