Correspondence

More Things That Go Bang in the Night

N Engl J Med 1993; 328:1570-1571May 27, 1993

Article

To the Editor:

Kowey et al. (Dec. 24 issue)1 described four patients with implantable cardioverter-defibrillator devices who had nocturnal sensations of cardioversion, in some instances with observed “jolting” and verbal outcries. These episodes resemble a variety of sleep-onset phenomena referred to as the exploding-head syndrome. Patients with this syndrome report hearing loud explosion-like noises as they are falling asleep2. Many report seeing flashes of light or having difficulty breathing. They may have epigastric or precordial sensations. Electric feelings “ascending from the abdomen to the head, to be followed by a violent explosion,” have been reported3. The patient often awakens with a sense of anxiety and forceful heartbeat. Attacks occur during relaxed wakefulness preceding sleep4. Stress may contribute to the occurrence of the episodes. Although these symptoms are rarely reported during the medical history taking, the condition is believed to be “fairly common,” according to one report2. The patients reported by Kowey et al. may have had the exploding-head syndrome, with their descriptions couched in terms of their greatest fear, defibrillation.

James Bowen, M.D.
Pacific Medical Center, Seattle, WA 98144

4 References

1
Kowey PR, Marinchak RA, Rials SJ. Things that go bang in the night. N Engl J Med 1992;327:1884-1884
Full Text | Web of Science | Medline

2
Pearce JMS. Clinical features of the exploding head syndrome. J Neurol Neurosurg Psychiatry 1989;52:907-910
CrossRef | Web of Science | Medline

3
Oswald I. Exploding head. Lancet 1988;2:625-625
CrossRef | Web of Science

4
Sachs C, Svanborg E. The exploding head syndrome: polysomnographic recordings and therapeutic suggestions. Sleep 1991;14:263-266
Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We appreciate the discussion of the exploding-head syndrome by Dr. Bowen. We can see that our brief description of our patients' symptoms may have suggested this interesting phenomenon. However, a more careful scrutiny of the facts in the cases does not substantiate an overlapping of the two entities. First, exploding-head syndrome usually presents in older people and is thought to be fairly common. Although we asked regularly about sleep disturbances, only 4 of the 84 patients in our long-term follow-up reported the symptom complex we described1. Second, no patients in the series reported by Pearce had myoclonic jerks with their episodes, whereas our patients had such jerks2. Third, all the patients discussed by Pearce experienced noise but not pain, whereas most of our patients had a distinct chest soreness after the event2. Finally, some observers have noted an association between exploding-head syndrome and hearing loss and tinnitus and have suggested that the phenomenon is caused by rupture of the labyrinth membrane or perhaps even a sudden opening of the eustachian tube3. None of our patients had any acoustical symptoms. We conclude that our patients did not have this syndrome. Although exploding-head syndrome is not thought to be related to any form of neurosis or psychosis and may in fact have a physiologic explanation, we believe that nocturnal phantom shocks are an indication of maladjustment to the presence of an implantable cardioverter-defibrillator that may require psychiatric evaluation.

Peter R. Kowey, M.D.
Roger A. Marinchak, M.D.
Seth J. Rials, M.D., Ph.D.
Lankenau Hospital and Medical Research Center, Wynnewood, PA 19096

3 References