and had suicidal ideation, but had made no suicidal attempt. ... next few days she also hada dream in which some people ... This problem had so affected his life.
EXPERIENCE OF ISOLATED SLEEP PARALYSIS IN CLINICAL PRACTICE IN NIGERIA Jude Uzoma Ohaeri, MD Ibadan, Nigeria
The supernatural fears associated with the experience of isolated sleep paralysis in the culture of developing countries is sometimes associated with the evolution of somatic symptoms of psychological origin in patients predisposed to neurotic illness. Patients rarely spontaneously volunteer these fears and doctors pay them scant attention. Illustrative case histories that demonstrate the dynamics of the clinical presentation, as well as the treatment approach, are highlighted. It is hoped that doctors in general medical practice and in psychological medicine in developing countries where belief in supernatural causation of illness is rife will consider these factors in order to provide more effective treatment. (J Nati Med Assoc. 1992;84:521-523.) Key words * isolated sleep paralysis * fears supernatural causation -
Following the description of the pattern of isolated sleep paralysis among some Nigerians," 2 the author has become conscious of the role played by this phenomenon in the precipitation and perpetuation of somatic complaints of psychological origin in clinical practice. It appears now that whereas some of the neurotic patients visiting the clinic have commonly been plagued by the fear (of supernatural consequences) generated by this phenomenon, they have either not usually communicated these fears or the clinicians have not given sufficient attention to such complaints. From the Department of Psychiatry, University College Hospital, Ibadan, Oyo State, Nigeria. Requests for reprints should be addressed to Dr Jude U. Ohaeri, Dept of Psychiatry, University College Hospital, Ibadan, Oyo State, Nigeria. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 6
Clinicians, not being aware of how to handle such complaints, could simply regard them as part of the animistic beliefs that characterize the social culturefor which doctors, of course, feel no responsibility. Elsewhere, it has been argued that belief in the supernatural causation of illness is not peculiar to the peoples of developing countries3 and clinicians could skillfully use the knowledge of these beliefs in treating patients in the clinical setting.4'5 Using illustrative case histories, this article describes how attacks of isolated sleep paralysis-and the animistic fears generated by this-can be associated with the presentation of neurotic complaints among Nigerians, and then highlights the treatment approach of the author. The idea is to encourage clinicians to inquire into the experience of isolated sleep paralysis, especially among their neurotic patients, in order to enhance the effectiveness of treatment.
CASE PRESENTATIONS It is not the contention of this paper that the experience of isolated sleep paralysis per se directly leads to the development of neurotic complaints in most cases. In fact, the impression one has is that the patient is already predisposed to falling ill (eg, through a combination of personality disposition and psychosocial stressors), and the supernatural fears arising from the isolated sleep paralysis experience simply intensify the already existing psychic conflicts, thereby helping to raise the patient's condition to a clinical dimension. The first case to be presented, which is typical of the more common situation, is illustrative of this. In the second case presented, the main problem was repeated attacks of isolated sleep paralysis, which baffled the patient who, because no remedies seemed to be effective, expressed his fears in somatic symptoms. The second case is illustrative of this. 521
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Case 1 A 21-year-old "born again" Southern Nigerian woman who has recently graduated from one of the local universities is currently spending her 1-year compulsory National Youth Service in a rather remote village in one of the northern states. She comes from a Christian monogamous home, of lower middle class status. There are no family pathologies. She was referred by a cardiologist. She presented with a 6-month history of feelings of vibration all over the body, apprehension, preoccupation with the thought of dead relations and friends, sudden feelings of a lump in the throat, palpitation, and trembling from inside the body. She cried frequently without cause and had suicidal ideation, but had made no suicidal attempt. She had ideas of reference and wondered whether people thought she was a witch. In her good moods, she would have a reverie of getting married after youth service and start a postgraduate program (she had a good degree). But these moments were short-lived. She was baffled by her symptoms because she thought they were of physical origin, having commenced after receiving treatment for malaria. When encouraged to recount the day-by-day development of her symptoms, she stated that 24 hours after finishing a course of oral chloroquine treatment, she felt vibrations in her back. The next day, as she was about to wake up in the morning, she felt a weight on her chest; it seemed to her as if a bird was on her chest. She found she could not move her body, could not even shout for help, and this alarmed her. It was at that time she felt she saw a bird on her chest. Within a minute or so, the whole episode was over and she got up with a headache. Because she had no intimate friends in the town where she was staying, she left for home the next day to see her parents. Her mother was alarmed at the news of what happened and first took her to a prophetess in one of the syncretic churches, and then to a native healer. Both faith healers were unanimous in the thinking that witches were after the girl and that she needed protection. When in the next few days she also had a dream in which some people gave her a meal, this confirmed her mother's suspicion that some witches were trying to induce the patient into their sect. This is a popular belief among the Yorubas of Nigeria. By this time, the symptoms had intensified. Getting no relief from these faith healers, she moved from one medical clinic to the other, from where she had repeated laboratory investigations and treatment for malaria. She had no hallucinations in clear consciousness and no delusions. Before the onset of the symptoms, however, she described herself as one who was easily afraid, tending 522
to dwell on thoughts of misfortunes. She had become a "born again" Christian after high school, following a feeling of remorse she had for terminating an unwanted pregnancy. It must be pointed out here that the relationship of the presenting complaints with isolated sleep paralysis experience became clear only after she was requested to give a day-by-day account of the genesis of the symptoms. To the over six medical doctors she had consulted before being referred to the psychiatrist, there had been no mention of her isolated sleep paralysis and dream experiences.
Case 2 This 37-year-old man is a top management executive of one of the multinational companies and hails from a Muslim polygamous home of middle class status. He was referred by a neurologist. Since adolescence, he had been experiencing at least weekly attacks of isolated sleep paralysis. He had not worried about this because his father had similar problems, and in his father's case, the frequency of attacks reduced considerably with advancing years. But this man's own attacks were increasing in frequency with years. In his early undergraduate years in one of the local universities, he had been so worried by this problem that he had gone to sleep on the premises of one of the Pentecostal churches who had promised him "deliverance" from the spirits causing the isolated sleep paralysis. He stopped attending Christian faith healers because he had attacks of isolated sleep paralysis in all the nights he spent at the church. For many years thereafter, he continued to see only native doctors because the family opinion (which he agreed to) was that the problem was partly "spiritual," and they thought it would follow the same course as the father's. Eventually, the man had to see a doctor because he thought it was affecting his social functioning and a friend had suggested it might be "epilepsy." The isolated sleep paralysis experience alarmed him because in the midst of the paralysis, when he felt his life was most threatened, he could not even move his body to touch his wife sleeping beside him for help. This problem had so affected his life functioning that he was afraid of sleeping outside his home. On one occasion when he went to a conference at the new Federal capital of the north, he had to invite his driver to sleep with him in his five star hotel room. In addition, he had stopped bathing in the evenings, because in his experience this was associated with isolated sleep paralysis. Before being referred to the psychiatrist he had had a JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 6
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skull radiograph, two electroencephalograms, and biochemical investigations, all of which revealed no abnormality. By the time he came to the psychiatric clinic, he was also worried by peppery sensations on the head, and a fear of dying and leaving his young family to suffer.
TREATMENT APPROACH The author's treatment approach in cases of isolated sleep paralysis is illustrated with Case 2. First, a detailed history highlights the predisposing, precipitating, and perpetuating factors. The fears the patient harbors about the nature of the illness should also be explored. An inquiry into the patient's dreams can be of help in this regard. The patient is then given proper information about the nature of isolated sleep paralysis, including the fact that people simply ascribe supernatural causation to this problem worldwide because of ignorance. The patient is made to realize that isolated sleep paralysis will not lead to one being choked to death, or to the brain being damaged or to one becoming epileptic. It is also stressed that to become afraid during the episode seems to intensify the condition, and no amount of struggling will bring life to the muscles, therefore, the best thing to do is simply refuse to panic, assert one's will to be calm and trust confidently (as his experience has shown) that the attack will soon be over. In addition, while the attack lasts, he could in his mind affirm to himself that he has nothing to be afraid of and that the attack will soon be over. The main point in this counseling session consists of addressing the various conflicts associated with the isolated sleep paralysis experience, and in persuading the patient to seriously consider the fact that his life is not endangered by the experience per se, and that he can continue with his normal life functioning even if the experience recurs. He is also taught how to put himself in a state of relaxation through breathing evenly, and he is to do this about 2 hours before going to bed at night. The man in Case 2 was requested to consider the fact that if the witches were really after his life, not only would he not have survived since adolescence, but he also would not likely have attained the high office he currently enjoyed. At any rate, if the faith healers were correct in their theory of supernatural causation, then it should have been possible all these years to ameliorate the condition by some of their practices. At follow-up, the man failed to turn up for the first appointment, and only showed up 3 weeks later. He had traveled out of town to coordinate a conference for his JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 6
company. He said that he had just one attack of isolated sleep paralysis 2 days after the first appointment. During the episode, he resisted the urge to be afraid and simply stayed calmly on his bed. In the next 2 days when the attack did not come again, he tried to precipitate it by having a cold bath in the evening. He was surprised that there was no attack of isolated sleep paralysis. Subsequently, he felt bold enough to travel out of town on official assignment. Since then he has attended follow-up three times in 6 months, during which time he said he had what he considered to be mild attacks of isolated sleep paralysis about once forthnightly. He no longer had the peppery sensations on the head, was no longer afraid of dying, the attacks of isolated sleep paralysis were no longer terrifying, and he could travel out of town to do his work without the usual fears. He said that once the attack comes, he would just remember what the doctor told him: stay calm and let the attack pass off quietly. As for the woman in Case 1, once her fears about isolated sleep paralysis and dreams were allayed, her neurotic symptoms quickly subsided. After 6 months of follow-up, she has voluntarily discontinued use of anxiolytics and is now functioning well.
CONCLUSION This condition is highlighted to emphasize that doctors practicing in developing countries in general medical practice and in psychological medicine should take into consideration that fears of supernatural causation contribute to certain experiences in the clinical presentation of their patients. It is reasonable to suggest that once the conflicts associated with these beliefs are addressed in the proper perspective of the total presentation, the patients will have a better chance of recovery. The problem is that such patients rarely spontaneously volunteer these fears, and clinicians therefore have to develop the skill to elicit the complaints. Literature Cited 1. Ohaeri JU, Odejide AO, Ikuesan BA, Adeyemi JD. The pattern of isolated sleep paralysis among Nigerian medical students. J Natl Med Assoc. 1989;81:805-808. 2. Ohaeri JU, Adelekan MF, Odejide AO, Ikuesan BA. The pattern of isolated sleep paralysis among Nigerian nursing students. J Natl Med Assoc. 1992;84:67-70. 3. Ohaeri JU. African traditional medicine: a stage in the peoples' history. Africa Notes. 1988;1 2:24-28. 4. Ohaeri JU. Articulating a new philosophical basis for traditional medicine practice in Africa. J Afric Phil Stud. 1988;1:1-1 1. 5. Madu SN, Ohaeri JU. A traditional healer's approach to the treatment of obsessional neurosis. Tropic Geogr Med. 1 989;41 :383-387. 523
