Concerns regarding sleep disorders in Hmong immigrants in the US emerged when an astonishingly high mortality rate of Sudden Unexplained Nocturnal Death Syndrome (SUNDS) was documented in Hmong men.
In 1981, an unusual new condition came to the attention of the medical community: based on mortality reports first appearing in 1977, the Centers for Disease Control (CDC) issued an international note that Southeast Asian refugees, primarily Hmong, to the US were dying in their sleep (Centers for Disease Control, 1981). What made this occurrence unusual was, not only the circumstances of the nocturnal deaths, but the fact that the victims were young men, previously in good health. Reports of these cases increased over the following six years; a mortality rate of 92/100,000 showed these Hmong men were dying at a rate equivalent to the leading five causes of death for American-born men of the same age range.
In contrast to the novelty of SUNDS to Western science in 1981, Hmong and other South–East Asian populations have long feared the personal experience epitomized by SUNDS. Culture-specific names have been given to this experience; Hmong refer to the terrifying nighttime occurrence of the crushing spirit on their chest as dab tsog (Adler, 1995; Bliatout, 1982; Fukuda, Miyasity, Inugami, & Ishihara, 1987; Holtan et al., 1984). Victims of visits from this spirit report that dab tsog sat on their chest with crushing force, making it impossible to move and “took their breath”. Although parallels are drawn between SUNDS and the dab tsog experience, the high fatality of the medical syndrome of SUNDS differs from that of dab tsog: historical and ethnographic reports indicate that the experience of dab tsog is not rare or fatal, and is often experienced repeatedly by the victims (Adler, 1995, 2011). Thus, the cultural pattern, collective knowledge and universal description of dab tsog suggest a prevalent bio-psychosocial condition of which only a limited number of cases results in a SUNDS fatality. In a study of 118 Hmong in California, 58% reported at least one experience of the dab tsog visit; in-depth interviews clearly indicated widespread fear, stress, and dread of sleep abnormalities in the Hmong population (Adler, 1994).
Victims discovered in the night terrors are unarousable, and in the few successfully aroused patients, terrifying dreams were often experienced.40 In addition, frequent experiences of “dab tsog (frightening night spirit pressing on chest),” nightmares, sleep paralysis, and hypnogogic hallucinations still exist in Hmong after immigrating to the United States for decades, probably putting Hmong at high risk for SUNDS.41
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