A Case study in sleep paralysis: Rosie

In our assessments of sleep paralysis we came to understand there is a link between sleep paralysis and certain disorders including anxiety, general stress and sleep apnea. The following is a brief diatribe wherein I suggest that there is a greater link between those with schizophrenia and schizophrenia like disorders, who have also been diagnosed with sleep apnea, and sleep paralysis. In particular, I will be providing a brief case study of one client and her apparent symptoms. It must be noted here before proceeding that the suggestions made in this paper are speculative in nature: I can not ascertain their validity or reliability without further assessment and deeper analysis. All qualifying personal information has been removed to uphold confidentiality.

Rosie

Rosie is a geriatric African-Canadian living with an intellectual disability and she has been formally diagnosed with schizoaffective disorder bi-polar type, chronic obstructive pulmonary disease (sleep apnea), and she exhibits obsessive compulsive like behaviours.

She exhibits typical symptoms for her diagnosis including delusional thought (including persecutory delusions), visual and auditory hallucinations, blunted affect, and alogia. She experiences intense mood swings which invariably affect her behaviour, and she has a general negative attitude. This is particularly exhibited in relation to herself, as well as in her relationships with others. She does not appear to put much faith in others’ reliability or loyalty. It is difficult for her to form and maintain relationships, and she is often closed off from others. In times of great stress she will express her anger and frustration with self harm, screams, shouts, expletives, and eventually aggression towards others. This sort of anxiety can be mediated successfully with anticipatory interventions, and due to her propensity towards anxious states it is best to avoid causing more anxiety or stress.

When Rosie is experiencing a hallucination she appears engrossed in the event as if she is watching a film. It is difficult to pull her from this engrossment and she pays little attention to voices and actions outside of the hallucination. She has demonstrated interaction with her hallucinations through her actions and her speech. At times it appears she is talking to herself, when it is more likely that she is actually communicating or interacting with her hallucination. She does not appear to be negatively affected by these hallucinations or delusions, during the day.

It appears that the ferocity and frequency of her hallucinations increase throughout the day, peaking particularly prior to sleep. I am not sure if this is due to added stress about completing nighttime routine, the thought of sleep, or anticipation of increased hallucinatory experiences.

Rosie uses a continuous positive airway pressure (CPAP) machine on a nightly basis. She averages 12 hours of sleep a night, but it appears this sleep is interrupted. This being due primarily to her sleep apnea and COPD. It is my estimation that her hallucinations worsen during sleep, and that this invariably contributes to her interrupted sleep. Not only does this contribute to disrupted sleep, it contributes to her heightened anxiety and stress related to sleep. This in turn increases the likelihood of more hallucinations. I am not sure if these hallucinations stem from her schizoaffective disorder, or if they more likely are linked to sleep paralysis. I can not confidently determine one way or the other.

In moments of sleep paralysis, the dreamer typically is witness to hallucinations, particularly insidious and persecutory hallucinations that cause great fear and stress. In these moments the dreamer tries to escape the situation. Due to the their vividness, these hallucinations appear real, instilling great fear in the one experiencing them.

As Rosie sleeps and dreams she shouts, uses expletives, and screams. Upon arriving to her room to offer assistance, she can be seen with her body twitching, convulsing and thrashing gently. It appears as if she is trying to wake herself up. These may be nightmares, but it is my estimation that she is in fact experiencing sleep paralysis related hallucinations.

I am led to believe this because of the sheer intensity of these hallucinations in comparison to those experienced throughout the day. They appear to be much more intensely felt, and she appears to be much more fearful of these. This indicates to me that they are outside of the realm of normalcy for her. Her attitude towards these hallucinations is that of concern and fear, and it appears as though she is trying to escape the situation both physically and mentally: evidenced by body thrashing and twitching upon regaining control of the body.

Further evidence points towards Rosie’s condition as being related to sleep paralysis. Hishikawa and Shimizu (1995) inform us that motor paralysis due to REM sleep can cause breathing difficulties, including what may appear like choking or suffocating. It may feel as if there is a weight or pressure on the chest, making it difficult to breathe deeply without feeling as if one is being suffocated. This is interesting to note because Rosie has been diagnosed with COPD. Could these feelings also be intensified through sleep paralysis? We know sleep apnea to be one disorder that contributes to the onset of sleep paralysis. While Rosie is diagnosed similarly, could this be contributing to her (as of yet undiagnosed) sleep paralysis? Simply put, her pre-existing breathing condition contributes to sleep paralysis, and her sleep paralysis contributes to her breathing condition, ad infinitum.

Although this information helps us in conceptualizing her sleep paralysis condition, what we are most interested in is the hallucinatory components of sleep paralysis, in particular Rosie’s nighttime hallucinations. I am unable to confirm sleep paralysis as a primary diagnosis for Rosie. Sleep paralysis at this point is mere speculation based on variance in hallucination profile from day to night, the intensity of the hallucination, and the apparent escape tactics used while experiencing these hallucinations. I do believe however, that due to the constant state of stress and anxiety Rosie is in daily, along with her diagnosis of COPD/sleep apnea, that it would be highly likely for her to experience sleep paralysis from time to time. Anywhere from 8% to 44% of people will experience sleep paralysis at one point in their lives, and according to psychologists at Penn State and Pennsylvania University, sleep paralysis occurs more frequently in students and psychiatric patients (Penn State News, 2011). Further, the sleep paralysis project reports that sleep paralysis more often occurs in African American individuals (www.thesleepparalysisproject.org). These statistics do not determine with any clarity that Rosie is in fact experiencing sleep paralysis, they merely contribute to my belief that she is.

In order to determine if Rosie is experiencing sleep paralysis we would need to study her case much further. We are still left with three unanswered questions. Does Schizophrenia contribute to sleep paralysis hallucinations (and what should we consider the primary diagnosis: sleep paralysis or schizophrenia?) Are hallucinations experienced by persons diagnosed with schizophrenia and schizophrenia like disorders more vivid, insidious or threatening in sleep paralysis? And does schizophrenia heighten one’s awareness of hallucinatory experiences, thus making it not only more likely for a person with schizophrenia to experience sleep paralysis, but for them to also be more aware of the accompanying hallucinations?

We are left wondering if the diagnosis of schizoaffective disorder is correct, or if perhaps hallucinatory complications arise due to sleep paralysis. Constant stress and anxiety contribute to sleep paralysis, and sleep paralysis is accompanied by hallucinations. We must consider daytime hallucinations. These could be explained by hypnagogic sleep paralysis: sleep paralysis which occurs prior to sleep. It would make sense for Rosie to be in a constant state of exhaustion due to her disrupted sleep caused by COPD. This could be cause for a general lethargy, perpetuated of course by anxiety and stress. The cycle of over-tiredness due to the avoidance of sleep or experiencing disrupted sleep is continuous and unrelenting. This lays way for sleep paralysis and hallucinations, the fear of which contributes to the avoidance and disruption of sleep.

Due to our prior observation that daytime hallucinations appear different from nighttime hallucinations, it would not make sense for us to dismiss schizoaffective disorder as the primary diagnosis. Although I am sure upon further analysis we could make a compelling case for why daytime hallucinations occur, and are experienced differently from nighttime hallucinations, we will not expel resources to do so now.

Rosie is but one case of many, and I believe it is important to conduct further research into the relationship between schizophrenia and schizophrenia like disorders and sleep paralysis. I propose some of our questions would be answered, and upon uncovering these answers we would lay way for many many more questions.

References:

Hishikawa, Y., & Shimizu, T. (1995). Physiology of REM sleep, cataplexy, and sleep paralysis. In S. Fahn, M. Hallett, H.O. Lüders, & C. D. Marsden (Eds.). Advances in neurology (Vol. 67, pp. 245-271). Philadelphia: Lippincott-Raven.

Psychologists chase down sleep demons. (2011). Retrieved from: http://news.psu.edu/story/154433/2011/10/17/research/psychologists-chase-down-sleep-demons

Prevalence. (2017). Retrieved from: http://www.thesleepparalysisproject.org/about-sleep-paralysis/prevalence/

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