Objective: To describe a patient who presented with psychopathology in the wake of sleep paralysis and hypnopompic hallucinations, and to discuss the importance of these phenomena to psychiatric diagnoses. Methods: Case report. Results: A 25-year-old black South African woman developed paranoid beliefs and a sad and anxious mood in the wake of her first experience of sleep paralysis and hypnic hallucinations. She had no history of other sleep-related events. Reassurance, explanation of the physiological basis of her experience, and a short course of low-dose diazepam were provided. Her mood and sleep improved promptly and she no longer held paranoid beliefs. She did not experience further episodes of sleep paralysis or hypnic hallucinations and improvement was sustained at 6 months. Conclusions: It pays to probe for the core experiences or events that patients may be explaining by devising ‘delusions’. Acute, nocturnal-onset, first-time psychopathology warrants inquiry for sleep paralysis and hypnic hallucinations. Sleep-related side-effects of psychotropic medications need to be studied more closely.