Special Talk




by Prof. Dr. Michael Wang,
Emeritus Professor of Clinical Psychology, University of Leicester, UK



The experience of awake paralysis is central to psychological trauma and subsequent emotional difficulties following accidental awareness during general anaesthesia (AAGA).1,2 Patients may believe they are dying or have actually died during their awareness experience. Others imagine they will be paralysed for the rest of their life. These misapprehensions lie at the heart of AAGA Post Traumatic Stress Disorder, and their assessment and understanding is key to successful treatment.3
The author presents a case of emergence paralysis in a psychologically resilient former rugby player with a history of 21 previous unremarkable general anaesthetics (mainly for sports injuries and their treatment). The patient describes how an absence of the sensation of chest movement caused him to think he was not breathing and that he would die imminently from asphyxia (despite on-going mechanical ventilation, of which he was unaware). He suffered severe insomnia with six to eight traumatic nightmares (reliving the emergence paralysis experience and imminent death) and awakenings per night during the following four months.  This in turn caused daytime irritability, anxiety and low mood. Cognitive behavioural treatment involved education concerning the effects of muscle relaxants and repeated cognitive exposure4,5 to the moment when he believed death was imminent, using video from a BBC television documentary of the author receiving muscle relaxant without anaesthetic. Following exposure sessions in clinic, the patient viewed the video at home on a daily basis.
Initially there was a reduction in the severity, although not the frequency of nightmares: the patient noticed he was not as distressed by the vivid dreams as hitherto following the early exposure sessions. By the fifth week of exposure treatment, the emergence paralysis nightmares had ceased.
This case illustrates how a patient’s catastrophic misunderstanding of their intra-operative predicament leads to psychological trauma with post-operative sequelae.2,3 Detailed psychological assessment revealed the nature of the original traumatic misapprehension, leading to explanation of the reasons for the experience and effective exposure treatment.4,5

Keywords: Anaesthetic awareness, awake paralysis, post-traumatic stress disorder, cognitive behavior therapy.


  1. Cook TM, Andrade J, Bogod DG, Hitchman JM, Jonker WR, Lucas N, Mackay JH, Nimmo AF, O’Connor K, O’Sullivan EP, Paul RG, Palmer JH, Plaat F, Radcliffe JJ, Sury MR, Torevell HE, Wang M, Hainsworth J, Pandit JJ. The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent and medicolegal issues. Br J Anaesth 2014, 113:560-574
  2. Wang, M. The psychological consequences of explicit and implicit memories of events during surgery. In Ghoneim, M. (ed.) Awareness during Anesthesia. Butterworth-Heinemann: Woburn USA. 2001 pp145-154
  3. Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy. 2000 Apr 30;38(4):319-45.
  4. National Institute for Health and Clinical Excellence: Post Traumatic Stress Disorder: Management [CG26] 2005
  5. Foa EB, Keane TM, Friedman MJ, Cohen JA, editors. Effective treatments for PTSD: practice guidelines from the International Society for Traumatic Stress Studies. Guilford Press; 2008 Oct 24.