Psychogenic etiology of Sleep Paralysis, Hypnagogic Hallucination and Sleep Apnea

It is taken for granted that parasomnias like "sleep paralysis" and "sleep apnea" are organic/somatic disorders. If there are psychogenic factors in these illnesses,  it is assumed that they play an ancillary role, and in all likelihood have nothing to do with the primary etiology. The medical logic used to justify such an assumption is that stress is a non-specific noxious factor. It has a psychophysiologic role but there is no evidence that  the nature of the psychological conflicts determines as to what part of the body and what pathophysiological process will succumb to the stress.

Recently I came across a patient who remembered the exact time period when her sleep paralysis started and the specific conflict [psychological stressor] that started it. The woman who is now in her mid-twenties reported the following:

"When I was 10 my parents got divorced. They explained to us as what was going to happen, so I cannot blame them that they kept us in dark and the horrible surprise traumatized us. But what they did, did not make sense, and perhaps it did traumatize me. My dad was a nice man. My mom should not have divorced him. Though they fought a lot. Most of the time he was gone. And I think she felt trapped for getting married too early in life, because he got her pregnant. She was not ready to give up being single when I came in to this world. She resented me and resented the marriage. She did not really love him. She wanted out. Anyway, my mom's complaints against him appeared unjustified to me. I felt so sorry for him.

"One day mom took us to our aunt, her sister, and told us that she will be gone for a while to help move somebody. That somebody was us. She had got us, the children, out of the way to go and pack and move. But she did not pack some of the stuff that I specially liked. She left many things behind.

"The next we knew we were living with our grandparents, her parents.

"I did not like staying there a bit, and wanted to be in my house, with my Dad. And that's when the sleep paralysis started. In the night, when I would fall asleep, I would see myself walking out of the bedroom only to realize that I was not really walking but dreaming. But it felt as if I was really walking. It was scary. And I would struggle to come out of the sleep. But unable to do so. I would feel like I was trapped. My brain would be awake, but my body will stay paralyzed. I would moan and whisper. From the awake part of the brain I would keep sending messages to the asleep part to get up. I would imagine myself rocking. Finally the messages would succeed in moving my head and neck. And then I would  actually rock back and forth, waking up at last, my stomach in knots"

This narration immediately made me think whether "sleep walking" too at its core does not start with some disturbing conflict which requires the person to leave the cocoon of his bed.  It was not difficult to analyze that what she was trying to do in her dream was to leave her grandparents house and reunite with her father. But this wish was against the wishes of her mother and would have aroused the latter's ire. And it was this fear that was generating the scary affect. For it makes no sense otherwise as to why the dream imagery of just walking out of the room would generate so much fear. 

From that point onwards the girl regularly dreamt of walking out of her bedroom, only to realize that it was a  dream. But a dream in which part of her mind was awake, and a dream from which she could not wake out of because of sleep paralysis.  And the dream was so vivid, and so scary, that it had the character of hallucination.

Over time another factor got added to the dream. Paranormal entities! She could feel the presence of other people in the dream but whom she could not see, This led her to start believing in ghosts, and her house being haunted. Sometimes the fear of ghosts was so strong that out of fright she would stop breathing as not to make those ghosts aware of her presence.

Does the germ of sleep apnea lies in such fright emerging in sleep/dream?

Over time these ghosts became more aggressive and she would feel them covering her face and nose, or submerging her in water. She would hold her breath in response, till she could hold the breath no more, forcing her to swim upwards to the surface, ending with her waking up gasping for air. 

The ghost like entities would walk past her, watch over and touch her, sit or stand next to her bed. She hated the touching. It would make her twitch and jerk. Sometime touching would go to the extent of moving her hand or caressing her face. She described the experience as if she was being messed around with. But she rejected the construction that the touching perhaps had its roots in sexual touching that she may  have experienced as a child. She said she was never sexually or physically abused. 

However, the construction led her to admit that lately this ghost like character which messed with her, had been taking on the visage of her father and her boyfriend. And their presence in the dream gave her some comfort and lessened the scary feeling. It also lessened the fear associated with the dream of drowning and struggling to come to the surface for air, the sleep apnea dreams. 

So the original overwhelming wish to reunite with her father which had started the sleep paralysis, and which had progressed into, or rather had found another dimension in sleep apnea, found some relief when she turned her father, and her boyfriend (a father substitute), into guardians watching over her while she dreamt forbidden things. So while they appeared to cause the scare, they really had been conjured up by the dream to give a face to the scary feeling and deep down they were comforting in nature and had the stamp of her father, her childhood protector.

Some other things the patient brought up with regard to her sleep paralysis that are worthy of additional  comments.  She considered these dreams symbolic of being out of control. And the scary feeling that emerged while dreaming was at bottom a fear of  being out of control. And the way she tried to regain control was to keep reminding herself, even while dreaming, that it was a dream and try to wake herself out of it through moaning, groaning and sending messages to rock back and forth and overcome the sleep paralysis.

Patient also brought a recurrent dream which bolstered the view that behind the sleep paralysis there was fear of going out of control. Ever since her teenage years - perhaps around 15 or 16 years when she started driving - she would have dreams in which she would be driving and would suddenly find that her brakes are not working. The accompanying affect was that of fear. "For I am a very controlled person. Though at times I have been reckless and irresponsible. But for the most part I hate being out of control."

Now we know from psychoanalytic literature that brakes failing in one's vehicle in dreams is a typical symbol of one's libido being out of control. So once again the theme of this recurrent dream of her vehicle being out of control was continuation of the dream of her passion for her father - walking out of the grandparents house for him - being out of control. 

In the next session she reported that before the sleep paralysis dreams started at age 10, she had another set of dreams. It was less of a dream and more a weird feeling. It was not a normal dream. For there were no pictures. No people. No faces. It was just a lot of sadness. There was anxiety and fear. "It started when my parents moved in to the house they built. Just before the divorce." 

When I objected that if there were no pictures could it be considered a dream she said well there were two visual objects. Two identical objects one small and other big; somehow communicating with each other.

And she added, "Nothing could make me more miserable than dreaming this very big object communicating with the very small one. I would wake up bowling my eyes out. I would be so scared too."

First she could give no association to the dream of the big and small object. Very reluctantly she said may be the bigger object is being mean to the smaller one.

A construction was made that perhaps it was her mother being mean towards her.

The patient immediately associated to this construction by giving details of how the mother was the disciplinarian at the house and would go overboard with it. "I remind her of my father. But I also remind her of her own mother, who she hates." And then she added, "You are right about the big object being my mother and the small one myself.  For the two objects are always identical. And I am a spitting image of my mother."

So the sadness accompanying the dream of the two objects was sadness over her poor relationship with her  mother.

With help of some more associations, the details of which I will spare you, we could find two further meanings that lay behind that dream.

The big and small objects symbolized the differences between the sexes. Her utter sadness, anxiety and fear attached to the dream were connected with her comparing her genitals with that of male sex and feeling  miserable about it. She claimed that she really feared her father, and felt greatly inferior to him specially when she compared her subdued squeaky female voice to his deep masculine one.
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The other mental complex that had found expression was the most interesting. The big object stood for her mother and the smaller one for her father. For her father was short and the mother was tall, and she was always yelling and being mean to him.

It was this meanness of her mother to her father that made her feel sad, miserable and sympathetic towards  her dad. And it was this sympathy for her dad, and the counter impulse that she should side with her mother lest it provokes her wrath that had weaved the dream of sleep paralysis.