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Bangungot – What is it?

bangungotThe phenomenon has a name in much of Southeast Asia. It’s called “Lai Tai” in Thailand, “Dab Tsog” in Laos, “Tsob Tsuang” in Vietnam, “Pokkuri” in Japan and of course, in the Philippines, it’s the first word in the title of this article, “Bangungot.” Bangungot is a Tagalog term but in Cebuano it is “urom” or “Urong.”

In Hollywood, it could well be “Nightmare on Elm Street.” But seriously, the good news is that today’s experts are at last seeing some daylight in trying to explain “Bangungot” or Sudden Unexplained Death in Sleep (SUDS) or Sudden Unexpected (Nocturnal) Death Syndrome (SUDS or SUNDS) – the “sleep death” peculiar mostly to Southeast Asian young men – almost a century after first appearing in the local medical literature.

As early as 1917, SUDS cases have been documented in the Philippines and among Filipino migrant populations in Hawaii, Guam, the Marianas Islands and French Polynesia, as well as among the local populations of some of its Southeast Asian and Pacific Rim neighbors – Cambodia, Laos, Thailand, Vietnam, Singapore and to a lesser extent, Japan. Many cases involving immigrants and refugees coming from these countries have also been reported, mostly in the United States.

In practically all of the instances, the victim is typically healthy young males with a median statistical age of 30-34 years. Death occurs shortly after the victim shows signs of distress – such as moaning – during deep sleep.

Ventricular fibrillation is often cited as the immediate cause of death although there appears to be no apparent structural problems with the victim’s heart or any sign of heart disease.

Rising and Moaning

bangungot1In the Philippines, the term Bangungot evolved out of the combination of two Tagalog words meaning “to rise” and “to moan during sleep.” It strikes apparently healthy young adults without warning in the dead of night, causing death within minutes during sleep. Perhaps because the phenomenon has been with us for so long as a part of Filipino culture and folklore, it is generally accepted as a thing that “just happens” and a good number remain unreported especially in highly urbanized areas. Conversely, there may possibly be just as many cases of death being written off as Bangungot that with proper investigation could have yielded their true, less mysterious underlying and immediate causes.

As such, the real picture as to how prevalent SUDS is in the country, or in other Southeast Asian countries for that matter, may not be known for quite a while. Nevertheless, SUDS has been cited as one the country’s leading causes of premature death among young Filipino men, responsible for roughly 43 of every 100,000 each year, according to the results of a national nutrition and health survey sub-study that appeared in the June 2007 issue of the Journal of Clinical Epidemiology.

An earlier study of SUDS cases identified from official autopsy records in Manila covering the period of 1948-1982 published by the International Epidemiological Association (IEA) in its journal in 1998 revealed the following findings; 96 percent of victims were male with a mean age of 33 years, a modal time of death was three o’clock in the morning. Moreover, the unexplained deaths appeared to be seasonal, peaking in December and January, and the victim was more likely to have been born outside of Metro Manila, with immigrants from the country’s southernmost region – Mindanao – showing the high risk.

The 1998 IEA analysis of medico-legal autopsy reports also seemed to show a statistical increase in annual SUDS cases, from 11 for every 100,000 persons in 1948 to 26 in 1982. The subsequent 2017 JCE nationwide data were obtained through differing questionnaires so responses were naturally subjective in terms of respondent’s ability or willingness to identify SUDS. However, if one were to take to take the results at face value relative to the earlier Manila study, it would seem that SUDS cases have been on a statistical uptrend since 1948.

The Usual Suspect

Other than epidemiological (study of the origin of a disease and how it spreads) research such as those cited above, there has been a relative scarcity of scientific investigation into SUDS due perhaps to a general disinterest in the West given that the deadly phenomenon doesn’t significantly affect non-Asians. For the longest time, local medical researchers simply didn’t know where to look for answers and for quite a while, local doctors have swept the problem under the rug by filing SUDS death under “acute hemorrhagic pancreatitis,” with the explanation that eating binges and heavy alcohol intake before going to sleep enlarges the pancreas, blocking blood vessels and arteries that eventually affect the heart.

This medical scenario is actually a distinct possibility, if not probability, because it fits perfectly with numerous reports of sleep death occurring after a night of gluttonous eating and drinking. The explanation has been in vogue among local medical practitioners for many years, used, perhaps none more famously, as in the case of young matinee idol Rico Yan in 2002, when PNP Director Edgar Aglipay himself declared the case solved. It didn’t seem to bother many that suffers of acute hemorrhagic pancreatitis tend to exhibit more dramatic symptoms and discomfort that moaning before death occurs, or even the possibility that the inflammation of the pancreas discovered during autopsy may be (have occurred?) post-mortem, as SUDS researchers have been pointing out.

Before research on electrocardiograph anomalies came to light recently, all that was known or suspected about SUDS was that it was largely limited to males of Southeast Asian descent, and somehow stress-related, as may be inferred in the case of migrant workers or those relocating from the provinces of Manila, and the drop in the number of cases involving Vietnamese refugees the longer their stay (they stayed?) In the United States, and a similar steady decrease in Japanese “pokkuri” victims after World War II.

The Heart Of the Problem

Thankfully, two Spanish cardiologist brothers started looking deeper as early as 1989 into shark fin-shaped anomalies they encountered in electrocardiographs of cardiac arrest survivors, and by 1992, Pedro and Joseph Brugada had determined that the heart beat skip was a distinct clinical entity that can usher in a lethal form of irregular heartbeat or arrhythmia called ventricular fibrillation, and, instantaneous death.

Further research revealed that a relatively rare 20 percent of those having Brugada observed ECG or EKG patterns were due to genetic mutations affecting certain heart cells, making the vital organ to randomly misfire at times. Still further study linked – definitively, it seems – the Syndrome to SUDS cases in Thailand and Laos. An Oxford University paper cited recently by Dr. Godofredo Umali Stuart in his website suggested from studies – including the genetic screening done on SUDS victims and their families – that the two syndromes are “phenotypically (having visible characteristic), genetically and functionally the same disorder.”

Dr. Stuart also reports that in a cross-sectional study into the prevalence of Brugada Syndrome ECG/EKG patterns among Filipinos in 2003 published in the Journal of Clinical Epidemiology (JCE), less than two million Filipinos or two percent of today’s population should have a Brugada pattern, with the deadly Type 1 (there are three types) pattern occurring in about 0.2 percent of Filipinos. In the absence of further investigation, the risk of individuals having this marker, however, remains undetermined.

Anti-Arrhythmia Implants

Now that scientist is sure that the underlying cause of Bangungot death is genetic defect in the heart’s electrical system, sleep death can be prevented through an implantable device similar to an artificial heart pacemaker, but one that only kicks in when it detects irregular beating or arrhythmia.

Called an “Implantable Cardioverter Defibrillator (ICD),” the device is being used to great success in Thailand at a reported cost of around $6,000 plus cost of genetic screening. Genetic testing in the United States reportedly costs anywhere from $100 to more than $2,000, depending on the complexity of the test and the need to test family members to get a meaningful result.

Sadly, only a fraction of us Filipinos can afford to have this preventive measure. If genetic screening is too rich for our pocket, we at least are now sure that it can be a genetic matter, and it would help to compare notes with your parents, grandparents and other relatives as to the prevalence of Bangungot in your family. Even if you and your family appear to be predisposed to SUDS, remember that having the gene is only one part of the problem.

From all the available research, it would also seem that the deadly arrhythmia needed to be triggered, often by stressful events (such as migration) and stressful changes in the environment (occurring in December-January). These, at least, are more or less within our control, as is not going on heavy eating and drinking binges, especially nocturnally.

Bangungot – What is it? – by Dexter Umali

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