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1 Sleep Paralysis: phenomenology, neurophysiology and treatment Elizaveta Solomonova 1,2 1 Université de Montréal, Individualized program (Cognitive Neuroscience & Philosophy). 2 Center for Advanced Research in Sleep Medicine, Dream and Nightmare Laboratory, Montreal, Canada To appear in: The Oxford Handbook of Spontaneous Thought: Mind-Wandering, Creativity, Dreaming, and Clinical Conditions. Fox, K & Christoff, K. Eds. Abstract Sleep paralysis is an experience of being temporarily unable to move or talk during the transitional periods between sleep and wakefulness: at sleep onset or upon awakening. Feeling of paralysis may be accompanied by a variety of vivid and intense sensory experiences, including mentation in visual, auditory, and tactile modalities, as well as a distinct feeling of presence. This chapter discusses a variety of sleep paralysis experiences from the perspective of enactive cognition and cultural neurophenomenology. Current knowledge of neurophysiology and associated conditions is presented, and some techniques for coping with sleep paralysis are proposed. As an experience characterized by a hybrid state of dreaming and waking, sleep paralysis offers a unique window into phenomenology of spontaneous thought in sleep. Introduction “I had a few terrifying experiences a few years ago. I awoke in the middle of the night. I was sleeping on my back, and couldn't move, but I had the sensation I could see around my room. There was a terrifying figure looming over me. Almost pressing on me. The best way I could describe it was that it was made of shadows. A deep rumbling or buzzing sound was present. It felt like I was in the presence of evil... Which sounds so strange to say!” (31 year old man, USA) Sleep paralysis (SP) is a transient and generally benign phenomenon occurring at sleep onset or upon awakening. Classified as a rapid-eye-movement (REM) sleep-related parasomnia, SP represents a psychophysiological state characterized simultaneously by qualities of both sleep and wakefulness, wherein the experiencer can open her eyes (Hishikawa & Kaneko, 1965), can be aware of her physical environment but is unable to move and may start seeing, hearing, feeling or sensing something. While documented instances of SP seem to be very consistent across cultures , SP’s lived qualities, phenomenology, and interpretation as a meaningful experience varies depending on the cultural and religious background. Rooting SP in a particular belief system may either help the experiencer recognize that SP is common and transient, or amplify negative qualities of SP by giving more concrete shape to an already terrifying experience of a supernatural assault. The emotional experience of SP is often one of fear, terror and panic. Threatening presences, the vulnerability of being in a paralyzed state, uncontrollable visions - all these elements contribute to intense, predominantly dysphoric, negative affect. Some qualities of spontaneous thought associated with felt presence during SP can be seen as paranoid (Cheyne & Girard, 2007), spatial, or interpersonal/social (Nielsen, 2007, Solomonova, 2008). The vast majority of SP experiences are associated with intense feelings of realism, and are most often characterized by fear and distress, which may carry-over into wakefulness and create a vicious cycle of negative emotional association with sleep, including aversion to going to bed, and even, in extreme cases, can result in symptoms reminiscent of post-traumatic stress disorder (McNally and Clancy, 2005). Yet, some SP experiences are described in positive terms, especially vestibulo-motor phenomena that include out-of-body experiences (OBE), or sensations of flying or floating. While the intuitive and immediate reaction to SP is typically negative, as will be discussed in the section on practical considerations, there are numerous reports of neutral/positive SP. Furthermore, there is a possibility of harnessing the power and potential of the dissociative/overlapping state in order to take active charge of

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SleepParalysis:phenomenology,neurophysiologyandtreatment

ElizavetaSolomonova1,2

1UniversitédeMontréal,Individualizedprogram(CognitiveNeuroscience&Philosophy).2CenterforAdvancedResearchinSleepMedicine,DreamandNightmareLaboratory,Montreal,Canada

Toappearin:TheOxfordHandbookofSpontaneousThought:Mind-Wandering,Creativity,Dreaming,andClinicalConditions.Fox,K&Christoff,K.Eds.

AbstractSleepparalysisisanexperienceofbeingtemporarilyunabletomoveortalkduringthetransitional

periodsbetweensleepandwakefulness:atsleeponsetoruponawakening.Feelingofparalysismaybeaccompaniedbyavarietyofvividandintensesensoryexperiences,includingmentationinvisual,auditory,andtactilemodalities,aswellasadistinctfeelingofpresence.Thischapterdiscussesavarietyofsleepparalysisexperiencesfromtheperspectiveofenactivecognitionandculturalneurophenomenology.Currentknowledgeofneurophysiologyandassociatedconditionsispresented,andsometechniquesforcopingwithsleepparalysisareproposed.Asanexperiencecharacterizedbyahybridstateofdreamingandwaking,sleepparalysisoffersauniquewindowintophenomenologyofspontaneousthoughtinsleep.

Introduction

“Ihadafewterrifyingexperiencesafewyearsago.Iawokeinthemiddleofthenight.Iwassleepingonmyback,andcouldn'tmove,butIhadthesensationIcouldseearoundmyroom.Therewasa

terrifyingfigureloomingoverme.Almostpressingonme.ThebestwayIcoulddescribeitwasthatitwasmadeofshadows.Adeeprumblingorbuzzingsoundwaspresent.ItfeltlikeIwasinthepresence

ofevil...Whichsoundssostrangetosay!”(31yearoldman,USA)

Sleepparalysis(SP)isatransientandgenerallybenignphenomenonoccurringatsleeponsetoruponawakening.Classifiedasarapid-eye-movement(REM)sleep-relatedparasomnia,SPrepresentsapsychophysiologicalstatecharacterizedsimultaneouslybyqualitiesofbothsleepandwakefulness,whereintheexperiencercanopenhereyes(Hishikawa&Kaneko,1965),canbeawareofherphysicalenvironmentbutisunabletomoveandmaystartseeing,hearing,feelingorsensingsomething.

WhiledocumentedinstancesofSPseemtobeveryconsistentacrosscultures,SP’slivedqualities,phenomenology,andinterpretationasameaningfulexperiencevariesdependingontheculturalandreligiousbackground.RootingSPinaparticularbeliefsystemmayeitherhelptheexperiencerrecognizethatSPiscommonandtransient,oramplifynegativequalitiesofSPbygivingmoreconcreteshapetoanalreadyterrifyingexperienceofasupernaturalassault.

TheemotionalexperienceofSPisoftenoneoffear,terrorandpanic.Threateningpresences,thevulnerabilityofbeinginaparalyzedstate,uncontrollablevisions-alltheseelementscontributetointense,predominantlydysphoric,negativeaffect.SomequalitiesofspontaneousthoughtassociatedwithfeltpresenceduringSPcanbeseenasparanoid(Cheyne&Girard,2007),spatial,orinterpersonal/social(Nielsen,2007,Solomonova,2008).ThevastmajorityofSPexperiencesareassociatedwithintensefeelingsofrealism,andaremostoftencharacterizedbyfearanddistress,whichmaycarry-overintowakefulnessandcreateaviciouscycleofnegativeemotionalassociationwithsleep,includingaversiontogoingtobed,andeven,inextremecases,canresultinsymptomsreminiscentofpost-traumaticstressdisorder(McNallyandClancy,2005).Yet,someSPexperiencesaredescribedinpositiveterms,especiallyvestibulo-motorphenomenathatincludeout-of-bodyexperiences(OBE),orsensationsofflyingorfloating.WhiletheintuitiveandimmediatereactiontoSPistypicallynegative,aswillbediscussedinthesectiononpracticalconsiderations,therearenumerousreportsofneutral/positiveSP.Furthermore,thereisapossibilityofharnessingthepowerandpotentialofthedissociative/overlappingstateinordertotakeactivechargeof

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one'sexperienceandtousetheopportunitypresentedbythesimultaneityofwakingandsleepingcognition-apotentialforenteringintoaluciddreamstateorforcontemplativeself-observation.

Neurophysiologically,SPiscurrentlyunderstoodasastatedissociationorastateoverlapbetweenREMsleepandwakefulness(AmericanAcademyofSleepMedicine,2014).DuringSPonecanopenhereyes,lookaroundtheroom,becomeawareofherenvironmentandsimultaneouslyexperienceREMsleep-relatedparalysis(muscleatonia)aswellasintenseandrealisticimagery1ofallsensorymodalities-anightmarespillingintotherealworld.Normally,duringREMsleep,skeletalmuscleatoniablocksmostmotoroutput,effectivelypreventingthesleeperfromactingoutherdreams(Peever,Luppi,&Montplaisir,2014).SPcanalsooccurinthecontextofnarcolepsy(Sharpless&Barber,2011;Terzaghi,etal,2012),butthemajorityofthosewhoexperienceSPreportitinitsisolatedform(oftenreferredtoasIsolatedSleepParalysis),withoutknownmedicalorneurologicalassociation.

Incurrentmedicalandneuroscientificliterature,SPisdiscussedintermsofitspresentationandnegativefactors:SP-associatedmentationisgenerallyseenasanon-desirableeffectofREMsleepintrusionintowaking.InthischapterIproposethatsituatingSPexperiencesasadreamphenomenonwithintheframeworkofembodiedmindandenactivecognitivescience,includingcontemplativeapproachestoconsciousness,isanalternativethataccountsforthephenomenologyofSPasalivedexperience,allowsforrichanddetailedculturalframingoftheexperience,andoffersavenuesforacross-culturalsocialneurophenomenologyofSP.

First,IwilldiscussthephenomenologyandneurophysiologyofSPexperiences.IwillpresentSPingeneral,withoutdistinguishingbetweenitsisolatedandnarcolepsy-relatedform,unlesssuchaseparationiswarranted.IwillstartbypresentingthecurrentstateofknowledgeofSPprevalence,aswellasthevarietiesofimageryaccompanyingSPandtheirculturalsignificance.IwillthendiscussSPintermsofaREMsleepparasomniaandoutlineitsprecipitatingandenablingfactors,aswellassleepanddreamcharacteristicsofthosewhoexperienceSP.Finally,IwillexamineSPinlightofvariousculturalandsharedpractices,includingpreventativemeasures,andpracticesaimedatinterruptingandtransformingSPexperiences.

TheexperientialexamplesofSPusedinthepresentchapterareallderivedfromanInternet-basedstudyofSP(Solomonovaetal,2008).Ourresearchgroupcollected193responsesfrompeoplewithrecurrentSPexperiences,usingamodifiedversionoftheWaterlooUnusualSleepExperiencesQuestionnaire(Cheyne,Newby-Clark,&Rueffer,1999).Ourparticipantswererecruitedonline,usingwordofmouth,andviaadvertisingonSP-relatedforums,informationandsupport.

Definitionsandprevalence

IdiopathicSP(SPnotassociatedwithnarcolepsy,andwithoutknowncause)isabenignandtransientparasomnia(Howell,2012),occurringduringtransitionsbetweenwakeandsleep:atsleeponsetoruponawakening.TheDiagnosticandStatisticalManualofMentalDisorders(DSM-5)classifiesisolatedSPaccompaniedbyfearfulmentationasaninstanceofanightmaredisorder(AmericanPsychiatricAssociation,2013).DuringanepisodeofSP,characteristicsofREMsleepintrudeuponseeminglyawakeconsciousness:thusthepersonexperiencingSP,whilehavinganimpressionofbeingawakeandawareofherenvironment,isunabletoinitiatevoluntarymovements(i.e.,experiencesREMsleepmuscleatonia/paralysis),andmayalsoexperienceintenseandrealisticsensationsinanysensorymodality-REMsleep-relatedmentation(AmericanAcademyofSleepMedicine,2014).SPshouldbedistinguishedfromnightterrors–earlynightawakeningswithfeelingsofpanic/terror,typicallyassociatedwithsomnambulism-spectrumarousalfromslowwave(Stages3and4)non-REM(NREM)sleep.Nightterrorsarecharacterizedbysuddenawakeninginanagitatedstate,anxiety,bodymotilityandgeneralamnesiawithregardstounderlyingcognitiveexperience(Szelenberger,Niemcewicz&Dabrowska,2009).

PrevalenceestimatesofSPrangewidely,andmaydependongeographicandculturalfactors.AsystematicreviewofSPprevalencehasrevealedthatstudiesreportSPlifetimeprevalencefromaslowas1.5%topossibly100%inthegeneralpopulation(Sharpless&Barber,2011).Theauthorsindicatedthat

1InthischapterIwillusetheterms‘imagery’and‘mentation’interchangeablytorefertovisual,auditory,somatosensoryandevensocialexperiencesduringSP.Theterm‘imagery’hereisthereforenotrestrictedtothevisualdomain.Iprefer‘imagery’and‘mentation’to‘hallucination’inordertoemphasizethedream-likeprocessofspontaneousimaginationthattakesplaceduringSP,andtode-emphasizetheassociationwithdelusionalthoughtandpathologies,associatedwiththeterm‘hallucination’.

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aboutoneinfiveindividualsmayhaveexperiencedSPatleastonceintheirlifetime(of36,533personsintheirreview).PrevalenceestimationofSPisdifficultduetonumerousfactorssuchasethnicityandculturalbackground,includingvariablefamiliaritywiththephenomenonandinthewordingofquestions(Fukuda,1993).Forexample,inacross-culturalstudy,Fukudaandcolleagues(2000)reportedthatwhileitisunclearwhetherSPisequallyprevalentinCanadaandJapan,thelackoffamiliarityandofanormativeculturalframeworkforSPinCanadamaycontributetothefactthatmanyCanadian,butnotJapanese,respondentsqualifiedSPasakindofadream,andwouldnothave,therefore,readilyrecognizedSPinaprevalencestudy.Anadditionalreasonforunder-diagnosisofSPintheWestmaybethefactthatthosewhoexperienceSPmaybemisdiagnosedashavingpsychiatricdisturbances(Hufford,2005).ThedevelopmentaltrajectoryofSPistraditionallyassociatedwithanonsetduringadolescence,whichmayindicateaprocessassociatedwithsleeparchitecturematuration(Wing,Lee&Chen,1994).However,inonestudyofolderadults,abimodalonsetpatternwasreported,withasecondpatternofonsetofSPepisodesaftertheageof60yearsold(Wingetal,1999),suggestingapossibilitythatSPmayhaveavarietyofonsetconditions.

NeurologicallyandphenomenologicallySPissituatedontheREM-sleepbaseddream/nightmarecontinuum.Inthischapter,IwillapproachSPexperiencesasavariantofintensifiedordisturbeddreaming,andwillsituatethemwithinaframeworkofembodimentandenactivism.

The4EAcognitionandoneiricmentationRecentyearshaveseenthedevelopmentofaparadigmshiftfromastrictlyneurocentricviewofthe

mind,apositionthatcanbestatedas“embrained”(Morris,2010),toadiversefamilyofapproachesthatconsiderthemindembodied(Varela,Thompson&Rosch,1991;Gallagher,2005),enactive(Noe,2004;Thompson,2005;Stewart,Gapenne&DiPaolo,2010),extendedintoandembeddedinthephysicalandsocialworld(Clark&Chalmers,1998;Menary,2010),andaffective(Colombetti,2013;Pessoa,2013).Whiletheseapproachesareinmanyrespectsquitedifferent,theyhavesometimesbeenlabeledas4EA(embodied,embedded,extended,enactive,affective)cognition,withacommonthemeofofferingarobustalternativetocomputational,connectionist,andneuro-reductionistviewsofthemind(Wheeler,2005;Protevi,2012).Thesetheoriesattempttosituatecognition,brainactivity,andpsychophysiologywithinthelargercontextsoflivedsubjectiveexperience,byemphasizingtherolesofdevelopmentalsensorimotorattunementtotheworld,aswellasoftheactiveandmotivatedprocessesofperceptionandsense-making,theimportanceofthesocialandculturalmilieu,andtheroleofemotionandaffect.

Sleepanddreamingphenomenahavebeenonlyrarelyaddressedby4EAtheorists(withtheexceptionofThompson2014,2015a,b),andtheprevailingviewofthesleepingmindtodaysituatessleepmentationasbeingfirmlyconstrainedwithinthebrain(Rechtschaffen,1978;Hobson,Pace-Schott&Stickgold,2000;Revonsuo,2006).AsRevonsuostates:“Theconsciousexperienceswehaveduringdreamingareisolatedfrombehavioralandperceptualinteractionswiththeenvironment,whichrefutesanytheorythatstatesthatorganism-environmentinteractionorotherexternalrelationshipsareconstitutiveoftheexistenceofconsciousness”(Revonsuoetal,2015:3).Alternatively,situatingdreammentationwithinaframeworkof4EAapproachesimpliesthatthedreamingsubjectisnotentirelyisolatedordisconnectedfromenvironmentalandsomaticstimuli,andthatherexperientialselfretainsaffective,social,sensorimotorandsense-makingqualities.Dreamingthenisnotpassivelylivedasapurelymentalsimulation(Revonsuoetal,2015),butcanbeseenasaprocessofactiveimagination(Thompson,2014)rootedinthedreamer’sphysical,socialandaffectiveworld(Solomonova&Sha,2016).IproposethatSPexperiences,byvirtueoftheirspecialkindofoverlapbetweenandsimultaneouspresenceofbothwakinganddreamingcognition,areperfectcandidatesforneurophenomenologicalresearchonspontaneousthoughtinsleep,whichwouldhelpilluminateparticularqualitiesofdreamingcognitionthatmayotherwisebeinaccessibletoreflectiveconsciousnessuponawakeningfromadream.

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Phenomenologyofsleepparalysisexperiences

Figure1.Arepresentationofsleepparalysisexperience2.Thesleeperisawakenedsuddenlyandseesamenacing

shadowycreatureontopofhim.Heexperiencesthesensationofbeingpushedintothebed,whilethebeditselfisswirlinginasortofatornado.Thetwofacesofthedreamerrepresentthe“double”consciousnessduringsleepparalysis:heissimultaneouslyterrifiedofthesupernaturalattackerandalsoknowsthatifhedoesnotresisttheexperienceandallowshimselftodriftbackintosleephemayhavealuciddream(thislucidconsciousnessisrepresentedasasleepingfacewithacolorfulbrain,denotingvibrantpossibilitiesoflucidity.Artist:BenjamenSamaha,Montreal,Canada2016.Reproducedwithartist’spermission.

Inadditiontotransientexperienceofmuscleparalysis,themostdramaticqualityofSPisitssensory

content,characterizedbyvivid,intrusiveaudio-visualandsomatosensoryimagery.TheexperienceofSPcanbeextremelyrealistic,haveaquasi-perceptualandwake-likequality,andmaybeaccompaniedbytactileandkinestheticsensations.Reflectivethoughtprocesses,self-awarenessandmetacognitiveabilitiesseemtoberelativelypreservedduringSPexperiences,andpeoplewhohavehadmultipleSPexperiencesmaydevelopa“feel”forrecognizingSPimagery.

SP-associatedexperiencesaretypicallyreferredtoashallucinations(hypnagogic,whenoccurringatsleeponset,orhypnopompic,whenhappeninguponawakening),sincetheseoccurduringotherwiseseeminglyawakeconsciousness(Liddon,1967;AmericanAcademyofSleepMedicine,2014).ThisentailsthatapersonwhoexperiencesSPseessomethingthatisnotthere,somethingthatisdistortedorfalse.SuchaviewpresupposesthatduringSPoneiseffectivelyawakeandismisinterpretingherexperience.AnotherwayoflookingatSPistosituateitwithinthespectrumofdreammentationanddreamingimagination.Whiledreamingtoohasbeenseenasadelusional/hallucinatoryactivity,analternativeview,inlinewithembodiedmindtheoriesandenactiveapproach,hasalsobeenproposed:“Whenyouhallucinate,youseemtoperceive 2Excerptfromthedreamer’saccount:“Thetransitionbetweenwakeandsleepisacrucialmomenttoenterintotheworldofdreams.DuringthistransitiononcountlessoccasionsIwouldawakensuddenlynotbeingabletomove.Duringthisexperienceitseemsthattheveryessenceoffearpermeatesmyconsciousness.Eerinessgoesthroughmysoul,freezesmybloodandinterruptsallsubstantialnotionofmybeing.Nowordscandescribethatvisceralsensation,andinparallel,nowordscancomeoutofmymouth.Awareofthelackofmuscletonus,ItrytoescapethisinevitableMachiavellianblackbeast,thatmaterializesinmyheadbeforemyeyesandonmychest,slowingdownmybreathing.Moreover,mysensesaregrabbedbyanimpressionoffightingahurricanethatmaydragmeoutofmybody.Thiscyclone,thathasablackholeinlieuofaneye,forcesmetofightit,andthisfightseemscrucialtomysurvival(…)Inaddition,thereareauditoryexperiences,anamalgamofpetrifyingwordsandvibrationsthatfeellikesuddengustsofwindintheeardrums.Allthishappenswhenbybodyfeelslikeastatue,withoutapossibilityofscreaming.(…)Onoccasion,withdeterminationandlucidity,Icanhavepoweroverthisswirlofstillness.(…)Itakebacksomecontrolofmyimaginaryhands,andthenIholdthemouttoMorpheusforadazzlingandcolorfuldanceinadeepandenlightenednight”.(MaleSPsufferer,alsodiagnosedwithnarcolepsy.Montreal,Canada.AccounttranslatedfromFrench).

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whatisnotthere.(…)Whenyouimagine,youevokesomethingabsentandmakeitmentallypresenttoyourattention”(Thompson,2014:179).InthischapterIadoptthislatterviewandwillrefertoSPexperiencesasvariantofspontaneousthought/mentationormentalimagery,ratherthanhallucinationsordelusions.

Kindsofsleepparalysisexperience

AfactoranalysisbyCheyneandcolleagues(1999)showedthatSPmentationtypicallyfallsintothreegeneralcategories.ThefirstcategoryisIntruder,anditischaracterizedbyafeltpresence,fear,aswellasauditoryandvisualimagery.ThepersonwhoexperiencesSPfeelsthatsomeoneisinthehouseorintheirroom.Thisexperienceissometimesaccompaniedbyseeingorhearingsomeoneorsomethingsentientmovearoundthehouse.ThesecondcategoryofSPexperiencesisknownasIncubus,inwhichthefeltpresenceisinterpretedasasupernaturalassaultandisoftenaccompaniedbyasensationofshallowbreathing,afeelingofbeingsmothered,pressureonthechest,orpain.Inthiscase,thesleeperoftenseesandfeelsthemaleficentbeingontopofher.Thethirdcategory,UnusualBodilyExperiences,appearstobeaseparate,lesswell-known,andaqualitativelydifferentkindofSPexperience:theseareoftendescribedaspositiveevents,suchassensationsoffloating,out-of-bodyexperiences(OBEs),andfeelingsofbliss.BothIntruderandIncubuscategoriestypicallyincludetheexperienceoffeltpresence–adistinctsensationthatsomeonesentientisintheimmediatevicinityofthesleeper(Cheyne,2005).

MostliteratureonSPfocusesalmostexclusivelyonthefirsttwokinds,IntruderandIncubus,possiblyduetotheirparticularlyintensifiedfeltpresenceimagery,whichcontributestodistressingSPexperiences(Solomonovaetal,2008;Cheyne,2013).However,neutralandpositiveinstancesofSPhavealsobeendescribed,andthethirdcategory,UnusualBodyExperiences,orvestibulo-motorexperiences,isoftencharacterizedbypleasantsensationsandaspiritofexploration,accompanyingsensationsofflying,out-of-bodyexperiences,orautoscopy(observationofone’sownbodyfromanunusual/novelpointofview)(Brugger,Regard&Landis,1997).

FeltPresence“JustbeforegoingtosleeporifawokensuddenlyIfeelasthoughapresence,usuallyadarkshadow

figureisstandingoverthebedstaringdownatme,orpacingbackandforth.”(22yearold,gendernotreported,USA).

AmongallSPexperiences,feltpresence,thedistinctsensationthatanothersentientbeing,humanornot,ispresentintheextracorporealspaceoftheexperiencer,isarguablythemostsalient,terrifying,andrich..FeltpresenceisconsistentlyreportedasthemostcommonSP-associatedexperience–about80%ofepisodes(Cheyneetal,1999),whichproducesmostfearandSP-relatedstateofdistress(Solomonovaetal,2008).OnesalientfeatureoffeltpresenceexperiencesduringSPisthefactthatitisadistinctsensation,andmayoccurintheabsenceofvisual,auditory,ortactileimagery.FeltpresenceexperiencesduringSPhavebeenclassifiedasaparanoiddelusion(Cheyne&Girard,2007),anexpressionofspatialsocialimagery(Nielsen,2007),andasavariantofbasicintersubjectiveexperienceoftheworld(Solomonova,Frantova,&Nielsen,2010).

Feltpresenceexperiencesareofteninterpretedwithintheculturalframeworkavailabletotheexperiencer(seethefollowingsectionontheculturalneurophenomenologyofSP),butsomebasiccharacteristicsseemtobecommonacrossculturesandages(Cheyne,2001):1)feltpresenceoftenmanifestsfromambiguousstimuli:itisoftendescribedas“shadowy”,anditsphysicalcharacteristicsareoftenunclear;2)theexperiencermayreportadistinctsensationofbeingwatched,andthatthepresencehassomeintentionstowardsthedreamer;theserangefromsomevagueinteresttofull-blownassault;3)feltpresenceisusuallyaccompaniedbyintenseemotions(oftenfearwhenthepresenceisinterpretedasthreatening),sometimestothepointofadistinctfeelingofdread,imminentdeath,orbeinginthepresenceofevil.Positiveemotions,however,arealsopossible,especiallywhentheexperienceisunderstoodasvisitationsbydeceasedrelativesorvisionsofthedivine.

Intruder

ConsiderthefollowingexamplesoffeltpresenceexperiencesoftheIntrudertype:A26-year-oldmanfromtheUnitedStatesreports:“Itfeltasifsomeonewaswatchingmebutsilentlystandingbehindme”.Inthisexamplethepresenceisfeltinadistinctandclearway,butnotseenorheard,yettheexperiencerknowswhereinspacethepresenceislocated.Similarly,a29-year-oldwomanfromUSAregularlyexperiencesthe

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malevolentpresencewithouteverseeingit:“…feelingofevilthatiswatchingormonitoring;neverabletoactuallyseethis"evilentity".Evenintheabsenceofdirectvisual,auditoryortactileimageryshefeelsthatsheisobservedandthatthepresenceis“evil”.TheambiguousqualitiesofthephysicalattributesofSPvisitorscanbeillustratedbythefollowingtwoexamples.A39-year-oldmanfromUSAwrites:“The"presence"isatallblack/darkestgreyshadowofahumanformwithoutanyfeatures.Itstandsinthedoorwaytomybedroomwaitingtobe"noticed".Likewise,a30-year-oldwomanexperiencedvariouswaysinwhichthepresencewasmanifestingduringherSPattacks:“Onceitseemedashadowwasleavingtheroom.Oneothertimetheshadowseemedtohave"wild"hairorifitdoesn'thavehairatall,itlookedassomesortofblacksomething”.

IncubusTheIncubusexperiencehappenswhentheIntruderphysicallyoppressesthesleeper,sometimesina

ratherdramaticway.Inwordsofa52-year-oldmanfromtheUnitedStates:“Myworstexperiencewasbeingchokedbyamanwhoburstintomybedroom.TheexperiencewassorealandfrighteningthatIwasveryafraidofmySPformanymonthsafter.”TheIncubustakesmanyforms,includinghuman,supernaturalandmorerarely,animal:“Ioftenhallucinatecreatureslikelargecats-lionsortigers,…wrappingthemselvesfirmlyaroundmeandcrushingmybody”writesa20-year-oldwomanfromEngland.

SomeofthemostdramaticandpotentiallytraumaticSPIncubusexperiencesareinstancesthatarelivedassexualassaultoralienabduction.Considerthefollowingexample,reportedbya40-year-oldmanfromtheUnitedStates:“Whenitisa"DarkMan"episode,hemostlikelytouchesme.Eitherbylayingacrossmybody,inasexualwayorinthebeginning,hewouldgrabmeanddragme.IalwaysfeltthatifIletgo,hewouldpullmeoutofmybody”.Similarly,a29-year-oldwomanfromSpaindescribesherdistressingSPexperience:“…extremeterror,thefeelingthatairisdenseanddarker,thatshadowsboilandtakeshape…Ihearsomelowtonenoises,voices,tactilefeelingofgrabbing,ofnakedcoldskin,and,veryrarely,apresence.Verydarkwithroundeyes,spider-likefingers,thatlaughs,messesupthebed,andmakesmefeelterror,withsomesexualapproaches…”.InastudylinkingreportsofspacealienabductiontoSPepisodesMcNallyandClancypresentthiscase:“…femaleabductee…wascompletelyparalyzed,andfeltelectricalvibrationsthroughoutherbody.Shewassweating,strugglingtobreathe,andfeltherheartpoundinginterror.Whensheopenedhereyes,shesawaninsect-likealienbeingontopofherbed”(McNally&Clancy,2005:116).

PositivefeltpresenceexperiencesanddoublingWhilemosteasilyrecognizableandmostcommonlydocumentedcasesoffeltpresenceduringSP

havetodowithathreateningandominous“visitor”,someevidencesuggests,however,thatthepresenceisnotalwaysunderstoodashostile.Suchexperiencesincludeperceptionoffriendsandfamily;visitationfromdeceasedrelativesorbenevolentspirits;anderoticencounterswherethesenseofpresenceiscomforting.A20-year-oldSPsuffererfromtheUnitedStateswrites:“OnceortwiceIhavethoughtthatmyfriendorroommatewasstandingoverme.Iwasconfusedbutnotafraid.”Similarly,encounteringdeceasedfamilymembersinvisionsorindreamscanbeexperiencedasapositivespiritualevent,andpossiblyplayahealingroleinprocessesofbereavement(Garfield,1996;Belickietal,2003).

Finally,anotherrarekindofSP-relatedfeltpresenceepisodeinvolvesfirstanexperienceof“someonethere”,andthenadoublingofthedreamer’sownbody,aself-projectionintotheextracorporealspace.Someindividualsreportthatthefeltpresenceentitiesarebecominganexternalizedviewofthemselves:“SometimesIfeelthatthepresenceismyself,thatIcanwatchmyself”,reportsa21-year-oldmanfromJamaica;“IswitchtoanotherworldandImyselfbecomeapresence”,writesa19-year-oldmanfromRussia.

Bodyexperiencesinsleepparalysis

Most(ifnotall)SPepisodesaredefinedbyanalteredexperienceofthebody.Theseincludesimpleexperienceofmuscleparalysis;sensationsassociatedwithsupernaturalassault,includingtouch,pressureonthechest,orevenchoking;feelingsofunusualvibrationsorfallingintoavortex;andout-of-bodyexperiences,includingflying,falling,ormovingaroundone’shouse.

OneofthemostsalientfeaturesofSPistheREMsleep-relatedmuscleatonia.Theinabilitytomoveisastrikingandunusualexperienceformostindividuals,andthemismatchbetweensensingthebodyandthe

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lossofvoluntarycontroloverthebody’smovementsmaycontributetoarangeofsomatosensoryexperiences.Asdiscussedabove,someofthemostintenseSPepisodesmayinvolveafeelingofbeingassaultedortouchedbyasupernaturalentity.Forinstance,a34-year-oldmanfromUSAdescribesthefollowingexperience:“Feltmyarmspinnedacrossmychestinastraitjackethold,felthandsonmychestpinningmeagainstawall”.Perceptionofnotbeingabletofullybreathe,oftenaccompaniedbyfeelingofpressureonthechest,maybeprevalentinasmuchas57%ofSPepisodes(Sharplessetal,2010).

AlthoughmostaccountsofandresearchonSPexperiencehavecenteredonparalysisaccompaniedbyterrifyingmentationandbyfeltpresence,notallSPexperiencesarecharacterizedbyimageryandmanyaresimplyexperiencesoftransientbodyparalysisduringthetransitionbetweensleepandwakefulness,withoutanyotheraccompanyingmentalactivity(AmericanAcademyofSleepMedicine,2001).Additionally,SPepisodesmaybepredominantlysomatosensoryinnature:Cheyne(1999)characterizestheseexperiencesasVestibulo-Motormentation.

Autoscopy,out-of-bodyexperiences,vibrations,floating,fallingandbodydoublingexperiences(Cheyne,2002)areallpossiblewithintheSPframeworkduetoitsrelianceondream-supportingREMsleepmechanisms.Duringadream,especiallyaluciddream(whereinoneisawareofthefactthatsheisdreaming),itispossibletohavesimultaneousexperienceofone’sdreambodyandrealbodyatthesametime.Thompson(2014)distinguishesbetweenthedreamingself(Ithedreamer)andthedreamego(Iasdreamt)astwocoincidingmodesofself-experience,whichmaysometimesbeexperiencedinparallel.Thedreamingselfisthesleepingself,itisthe“I”ofthewakinglife,nowengaginginthepracticeofsleepanddreaming.Thedreamego,ontheotherhand,istheexperientialself,immersedinthedreamscenario.TheIasdreamtisthetemporary“I”thattakesonthefirst-personperspectiveasasubject(andsometimesanobject)ofthedreamworld.Seenfromthispointofview,SPepisodesmayrepresentanintenseexperienceofthedreamingego,lackingadreambodyandtemporarily“stuck”withinherimmobilizedsleepingbodyofthedreamingself/Ithedreamerwhileexperiencingdream-likementation.Thisfeelingofbeingstuck,coupledwithawarenessoftheoverlapbetweenstatesofvigilance,maythentransformitselfintoasituationofperceptualdoublingofbodyimagery.

ContrarytomostSPepisodeswithafeltpresencecomponent,somebodilyexperiencesaredescribedinquitepositiveterms.Forinstance,a20-year-oldwomanfromEnglanddescribesthischaracteristicofhertypicalSPepisode:“Generally,theexperiencesstartwithalow,pleasantvibrationthatmovesthroughmybodyindefinedwaves,fromthefeetup.Ifeelthemmoststronglyinthethroatandinmyeardrums”.

Out-of-bodyexperiencesarealsorelativelycommoninSP–asmuchas39%ofSPexperiencershavehadoneatsomepoint(Cheyne,2002).A39-year-oldwomanfromtheUnitedStateswrites:“Ifloatedoutofmybedintothekitchen.But,asIfloatedovermybed,Isawlikethisbeastfigurecrouchedoveronthefrontofmybed.Ifloatedoveritdowntothekitchen.ThatiswhereIsawthisbeautifulkaleidoscope-likeleaves.Theyweresovibrant…Ithenfloatedbacktomyroomintomybody”.InthisexamplethereisacombinationofvariousSPcharacteristics:dream-likementationsuperimposedontotheenvironment,anocturnalvisitor,andanalteredsenseofthebody.

SPexperiencesarealsosometimesaccompaniedbyfalseawakenings—dreamswhereonehasavividandrealisticfeelingofwakingupintheirownbedandengaginginusualactivitiesonlytorealizethattheyarestillasleep(Buzzi,2011).Whilefalseawakeningsaretypicallycharacterizedasdreamexperiences,theirphenomenologyintermsofrealismandpossiblestateoverlapistoadegreesimilartoSP.InCheyne’sreport(2002),58%ofpeoplewhoexperienceSPalsoexperiencedfalseawakeningsatleastoccasionally.Additionally,falseawakeningsareoftenassociatedwithfeelingsofdread,anxiety,andoppression(Green&McCreery,1994;NielsenandZadra,2011),similarlytoSP.ThefollowingtwoexamplesfromourInternet-basedsampleillustratesuchcases:a24-yearoldmanfromtheUnitedStatesreports:“…sometimesIthinkIhavemoved...sometimesevengottenupandwalkedaroundonlytofindthatInevergotupatall.”Inasimilarvein,a21-yearoldmanfromJamaicadescribeshisexperience:“IwillwakeupintoanotherdreaminsidemybedroomandthinkIamawakeandrealizeIamstillsleepingminuteslaterandthesameprocedurerepeatsseveraltimes”.

Emotions

…Extremeanxietyandfear,mindisawake,butbodyisasleep.IfeelasthoughIamtrappedandcannotcommunicatewiththosearoundme.(23-year-oldwoman,USA)

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ThemostprevalentemotionassociatedwithSPexperiencesisfear.Indeed,themostnaturalreaction

towakingupunabletomoveispanic,andthesensationofconstrictedbreathing(consistentwithREMsleepphysiology)mayincreasethestateofdistress.Sharplessandcolleagues(2010)introducedthetermfearfulisolatedsleepparalysistodenoteSPexperiencescharacterizedbyanintensestateofdistress.

Asmuchas90%ofreportedSPepisodesaredescribedasfearful(Cheyne,Rueffer,&Newby-Clark,1999).Similarly,inanIrishUniversitystudents'sample,fearwasfoundtobethemostprevalentemotion,with82%ofrespondentsstatingthattheyhaveexperiencedfearatsomepointduringaSPepisode(O’Hanlon,Murphy,&DiBlasi,2011).Moreover,nightmarefrequencywaspreviouslyreportedasapredictorofSPoccurrence(Liskovaetal,2016).ThisdatasuggeststhatSP,oratleasttheFearfulformofSP,canbeseenasanintensifiedformofanightmare:arecentstudybyRobertandZadra(2014)reportedthatabout65%ofnightmaresand45%ofbaddreamsarecharacterizedbyfear.

OneapproachtoclassifytheaffectiveandpersonalimpactofSPexperiencesistoassessnotonlyfrequencyorintensityofSPepisodes,butalsodistressassociatedwithSPexperiences(Solomonovaetal,2008;Cheyne&Pennycook,2013).TowhatextentistheindividualaffectedbySP?Towhatextentdonegativeemotionscarry-overfromanSPepisodeintowakinglife?DoSPexperiencespromoteanegativerelationshipwithsleep?Thesequestionshavebeensuccessfullyexaminedinpreviousresearchonnightmares(Belicki,1992;Blagrove,Farmer&Williams,2004),showingthattheindividualimpactofnegativeandintensedreamexperiencesdependsmoreonatrait-likereactivity,sometimesreferredtoasaffectdistress(Nielsen&Levine,2007).Thistraitisthoughttorepresentageneraldysfunctionofaffectregulationnetwork,andithasbeenshowntobeabettermeasureofhowmuchnightmaresinfluencewakinglifeemotionalwell-beingthanfrequencyorintensityofself-reportednightmareoccurrence.Furthermore,affectdistressmediatesreactivity,negativeinterpretationanddegreeofnegativereactiontonightmares(Belicki,1992;Levin&Fireman,2002).AccordingtoNielsenandLevine(2007;Levine&Nielsen,2009),dreaminghelpsregulateemotionalmemoryconsolidationandemotionalreactivityviafearextinction.Nightmares,therefore,representacaseofproblematic/dysfunctionalprocessesoffearextinction.Incombinationwithotherfactors,affectdistressislikelytoplayaroleinformation,experienceandinterpretationofSP.

PositiveemotionsassociatedwithSParemuchlessstudied,anditisnotpossibletoaccuratelyestimatetheirprevalence.Onepossiblereasonforthisislackofappropriatescreening(SPisoftendiagnosedasanunpleasantphenomenon)andlackofmedical/psychiatricconcern:patientsarenotverylikelytodescribesuchexperiencestotheirhealthpractitioner,sincetheyarenotbotheredbythem.Inaddition,thecurrentdiagnosticcriteriaforarecurrentisolatedSPaslistedinthelatesteditionoftheInternationalClassificationofSleepDisorders–3dedition(AmericanAcademyofSleepMedicine,2014),includethattheepisodesmustcause“clinicallysignificantdistressincludingbedtimeanxietyorfearofsleep”.Suchaprovisionwouldeffectivelyexcludeallpossiblepositiveandnon-distressingSPphenomenafrominvestigationand/ordiagnosis.Nonetheless,inaweb-basedSPstudyCheyne(2002)reportsthatinadditiontoanger(30%ofrespondents)andsadness(23%),bliss(17%)anderoticsensations(17%)arealsosometimespresentinSP.

Visualandauditoryexperiences

Feltpresenceisthemostprevalent,themostemotionallydisturbing,andthemostsalientSP-relatedexperience.Therefore,itisunsurprisingthatmostvisualandauditorymentationduringSPusuallyhassomethingtodowiththeseunwelcomevisitors.Theentities,however,whilefeltinaverydistinctiveandconcreteway,areoftendescribedvisuallyasrathergeneralandvagueshadowybeings.Visualexperiencesarereportedtooccurin54%–56%andauditoryexperiencesin55%-60%(Solomonovaetal,2008;Cheyne,2002)ofSPsufferers.

SPmaybeaccompaniedbyauditoryexperiences,rangingfromabstractandmechanicalsounds,suchaselectricsoundsandsoundsofbuzzing,tovividauditoryimagery,consistentwithSPexperienceofanIntruderoranIncubus.Soundsoffootstepsandofvoicesareoftenreported(Cheyne,Rueffer&Newby-Clark,1999;Cheyne,2002;Solomonovaetal,2008).

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CulturalgroundingofSP

Figure2.HenryFuseli.TheNightmare.1781.DetroitInstituteofArt.PublicDomainimage:https://commons.wikimedia.org/w/index.php?curid=15453518

Whilesleepparalysisisalesser-knownsleepphenomenonintheWest,itisquiteprevalentandis

well-describedinmanyothercultures.DuetothelackofgeneralawarenessofSPintheWest,itisrarelydiscussedinthecontextoffamilymedicineorpsychology.Cross-culturalworkonSPrevealedthatitisrootedinavarietyofreligiousbeliefsandculturalschemas,includinginterpretationsoftheexperienceandtechniquestoengagewiththenocturnalvisitors.SomeofthecommonqualitiesofSPacrosscultures(Adler,2011)include:1)sensationofbeingawake;2)perceptionoftheenvironment;3)paralysis;4)feelingoffearanddread;5)feltpresence;6)chestpressure/breathingdifficulties;7)supineposition;6)variousunusualbodysensations.Theseapparentlyculturally-invariantqualitiesofSP-relatedoccurrencesoftheexperienceofasupernaturalattackhavebeenatthecenterofthephenomenologicalandcross-culturalcognitiveresearchonSP.

Figure2isareproductionofaneighteenth-centuryworkbyHenriFuselientitledTheNightmare.Itrepresentsasleepingwomaninasupinepositionbeingoppressedbyamaleficentcreaturesittingonherchestandwithanominouspresenceofthenight-mare.ItislikelythattheearlyuseoftheEnglishtermnightmarewastodescribeintenseSP(Orly&Haines,2014).Culture-specificpresentationsofSP-relatedfeltpresenceexperiencestypicallyinvolveamaleficentsupernaturalbeing,suchasawitchoranevilspirit.SomeexamplesfoundacrossculturesincludethekanashibaridemoninJapan(Fukudaetal,1987;Arikawa,Templer&Brown,1999);kokmaintheWestIndies(Ness,1983);“oldhag”inNewfoundland(Hufford,1989);pandafecheinItaly(Jalal,Romanelli&Hinton,2015);uqumangirniqamongtheInuitofBaffinIsland(Law&Kirmayer,2005);andmanyothers(foracomprehensivelistoftermsforSPexperiencesseeAdler,2011).Figure3illustratesapossibleSPrepresentation(Orly&Haines,2014):aJapanesedemonYamachichioppressesandinhalesthebreathofthesleeper.

ThefirstsystematicculturalexplorationofSPwasdonebyHufford(1989):hedescribedaphenomenonspecifictoNewfoundland–the“oldhag”witchattack.InhisbookHufforddiscussesthetensioninsituatingSPexperiencessomewherebetweenthe‘culturalsourcehypothesis’,whereinculturalinterpretationsandframinginfluencehowanexperienceunfolds,andthe‘experientialsourcehypothesis’,wheresomeinvariantlivedexperiences,suchasSP,mayinfluencethedevelopmentofaspiritual

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interpretationandformationofculturalbeliefs(Hufford1989,2005).Similartothisnotion,McNamaraandBulkeley(2015)proposedanexperientialhypothesistodescribehowdreamsandotherdream-associatedexperiences,includingvisionsandtranscendentalexperiences,canbeseenasacornerstoneandasourceofreligiousbelief(McNamara&Bulkeley,2015).Accordingtothisview,anumberofcultural,religiousandparanormalbeliefsareshapedprimarilybydirectexperienceandthenframedwithinaparticulartradition,whichimbuesthemwithexistentialandmetaphysicalmeaning,anotionthatisreminiscentofWilliamJames’groundingofmysticalexperienceinthephenomenologyoflivedexperience(James,1985).

Theeffectofframingsuchintensesubjectiveexperienceswithinaculturaltraditioncanhaveatleasttwokindsofpotentiallyopposingeffects.Ontheonehand,manyculturesprovidenotonlysupernaturalexplanationsofSP,butalsoremediesandprotectiveritualsagainstit(someofwhicharedescribedinthelaterpartofthischapter),thusrootingtheSPinaframeworkwhichallowsforsharednarrativeandforpracticalinterventions.Ontheotherhand,intenseandfearfulSP,wheninterpretedassupernaturalassault,hasapotentialfortraumatizingthesleeper,thuscreatingaviciouscircleofanxiety,aversiontosleep,facilitationoffutureSPepisodes(Hintonetal,2005;Sharplessetal,2010),andincreasingthelevelofdistressvia“culturalfearpriming”(Ohayonetal,1999;Jalal,Romanelli,&Hinton,2015).Forinstance,theIncubusexperience,whenseenaspartoftheChristiantraditionstartingwiththelateAntiqueperiod,accordingtoGordon(2015),gainedadditionalstigmatizingpower,withaconnotationofanillicitsupernaturalsexualexperience.NotonlywereSPvictimslivingthroughawakingnightmareofanencounterwithademonicassailant,theywerealsoseenasresponsibleforhavingsummoneditduetotheirownsinfulpredisposition/thoughts/impurities.

ItisimportanttonotethatwhileSPcanincludearangeofexperiences,suchaspositiveexperiences,neutralemotions,vestibulo-motorphenomena,out-of-bodyexperiences,andothers,mostculturalinterpretationsofSPdealspecificallywithoverlappingaspectsofIntruderandIncubus.

Figure3.TakeharaShunsen.Yamachichi.Publicdomainimage:

https://commons.wikimedia.org/w/index.php?curid=2074508

Neuralbasis,associatedconditions,andprecipitatingfactors

Humansleepistypicallydividedintotwokinds:REMsleepandNREMsleep.HealthyadultsalternatebetweenNREMandREMincycleslastingabout90minutes,foratotalof5-6cyclesoveranightofsleep.

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Whileitispossibletoexperiencedreaminginallstagesofsleep,REMsleepistypicallycharacterizedbythemostvivid,realistic,bizarre,andemotionallyintensesleepmentation(Nielsen,2000).Othervividdreamexperiences,suchasnightmares(Nielsen&Levin,2007)andluciddreams(LaBerge,Levitan&Dement,1986),arealsotypicallyassociatedwithREMsleep.

Withinthecontextofnarcolepsy,sleepparalysisisapartofthediagnostictetrad,alongsidedaytimesleepiness,cataplexy,andhypnagogichallucinations(Thorpy,2016).Thereisnotsufficientdatatoassesswhethertherearesignificantdifferencesinphenomenologybetweennarcolepsy-associatedSPandtheisolatedform.

SPepisodesarecharacterizedbysimultaneouspresenceofwakingthoughtandofREMsleeppsychophysiology(Mahowald&Schenck,1991,2005;Terzaghietal.,2012),andthesleepercanoftenopenhereyesandbecomerelativelyawareofherenvironment,whileREMsleep-relatedspontaneousmentation-vividdreaming-superimposesontootherwiseawakeconsciousness.Thisimagerymayoccuratsleeponset(hypnagogic)oruponawakening(hypnopompic).OthercharacteristicsofREMsleep,suchasairwayocclusionandrapidshallowrespiration(Gouldetal.,1988)maycontributetothefeelingofbeingsuffocatedortheperceptionofshortnessofbreathoftenreportedbySPsufferers.Additionally,inonestudyobstructivesleepapneawasfoundtobeapossibleprecipitatingfactorforISP(Hsiehetal,2010).

LittleresearchhasbeendoneonthesleepcharacteristicsofSPsufferers.SomepreliminarydatasuggeststhattheSPsleepprofilemaybesimilartothatoffrequentnightmaresufferers(Nielsenetal,2010),inthatSPparticipantsappear,paradoxically,toexhibitlessREMsleeppressure,havemore“skipped”REMsleepperiods,andshownoincreaseineyemovementdensity(asopposedtohealthycontrols)throughoutthenight(Solomonova,etal,2012).SPparticipantsalsoshowhigherdeltapowerduringsleepthannon-SPcontrols(Marquisetal,2015),whichsuggestsalterationofprocessesofwake-NREM-REMregulation.

Someofthevestibulo-motorcharacteristics,suchasautoscopy,out-of-bodyexperiences,andfeelingsofphysicaltransformation,maystemfromdisturbancesinrightparietalregions(Jalal&Ramachandran,2014):themismatchbetweenintendedmotormovementandinabilitytomovemaycontributetounusualphysicalsensations.

SPmaybeexperimentallyelicitedinlaboratorysettings,butonlyusinganarduousprotocolofrepeatedsleepinterruption.Forexample,SPepisodeswereexperimentallyinducedbylettingparticipantssleepuninterruptedforthefirstNREMperiod,thuseliminatingmostoftheslow-wavesleeppressure(atendencyofslow-waveNREMsleeptotakeprecedenceandoccupyalargeproportionofearlynightsleep),andthenrepeatedlyawakeningparticipantsafter5minutesofREMsleephaveelapsed,thusaugmentingREMsleeppressureandfacilitatingsleep-onsetREMperiods(SOREMPs).SOREMPsmaybeseenasafacilitatingfactorinaREM-wakestatedissociationthoughttocharacterizeSPexperiences.Itshouldbenoted,however,thatevenwithinsuchcontrolledsettingsanddemandingprotocols,ratesofSPwererelativelylow:6episodestotalin16participantswhoalreadyhadatendencytowardrecurrentisolatedSP(Takeuchietal.,1992),and8episodesfrom184sleepinterruptionsin13SPsufferers(Takeuchietal,2002).TheseresultssuggestthatincidenceofSPatsleeponsetmaysignifyanindividual’spropensitytoenterintoREMsleepdirectlyuponfallingasleep.ThisfurthersupportstheideathatSPmayresultfromalterationsinwake-REM-NREMregulationpatterns,resultinginstateoverlap.

AssociatedconditionsLittleisknownabouttheepidemiologyofSP,butgrowingevidencepointstoacombinationof

geneticandexperientialfactors.TheonlystudytodatetoexaminegeneticfactorsassociatedwithSPhasreportedmoderateheritabilityandthatthiseffectwasassociatedwithfactorsknowntocontributetodisruptedsleepcycles(Denisetal.,2015).Sleepfragmentationanddisruptioninwake-NREM-REMregulationareanimportantfactorfacilitatingSPoccurrence,butitisuncertainwhetheralltypesofSPcanbeexplainedbyapropensityforsleepfragmentation.SomeethnicgroupsseemtobemorelikelytoexperienceSPthanothers.TheHmongpopulationinWisconsin,forinstance,hadasignificantlyhigherincidenceofSPthananon-Hmongcohort(Youngetal,2013),withasmuchas31%ofinterviewedHmongparticipantreportingatleastweeklyoccurrenceofSPepisodes.IndividualsofAfricandescentalsoseemtohaveelevatedratesofSP(Belletal,1984;Friedman&Paradis,2002).

Linksbetweenaffectivedisorders,especiallydepressionandanxiety,andSPhavealsobeenreported.ArelationshiphavebeenfoundbetweenSPanddepressionmagnitudeandanxiety(Szklo-Coxe,Young,Finn,&Mignot,2007),socialphobiaandpanicdisorder(Paradis&Friedman,2005;Ottoetal,2006;Sharplessetal,2010)andsocialanxiety(Simard&Nielsen,2005),especiallywiththesensationofbeingobserved

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(Solomonovaetal,2008).ChangesinREMsleepregulationareoftenfoundinmooddisorders,especiallyindepression(Arargun&Cartwright,2003;Nofzingeretal,1994)

Therelationshipbetweentrauma,especiallypost-traumaticstressdisorder(PTSD),andSPhasbeennotedbyanumberofresearchers.McNallyandClancyfoundthattherewasahigherproportionofSPreportsinparticipantswithahistoryofchildhoodsexualabuse(McNally&Clancy,2005a),andAbramsandcolleagues(2008)reportedthatsexualabusesurvivorsreportmoredistressingandmorefrequentSPincidence.Inaddition,higherratesofSPwerefoundinHmongpopulationinrelationtotraumaticVietnamWarexperiences(Youngetal,2013),aswellasinKhmer(Hintonetal,2005a)andCambodianrefugees(Hintonetal,2005b).Similarly,SharplessandGrom(2013)reportthatsomecasesofSPonsetinadolescentsbeginafterthelossofafamilymember.ConsideringthatSPmaybeconceptualizedasanightmarespectrumexperience,thisrelationshipmayrepresentthesamedysfunctionintheaffectregulationnetwork(LevinandNielsen,2007;Nielsen&Levin,2007)astheonethathasbeenproposedtobeinvolvedinnightmareproduction.PTSD-relatedsleepdisturbanceshavebeenextensivelydocumented(Spoormaker&Montgomery,2008;Germain,Buysse&Nofzinger,2008),includingREMsleepdysregulationandincreasednightmares(Melmanetal,2002;Germain,2013),whichinitselfmaycontributetoalteredREMsleeppressure,inturnfacilitatingoccurrenceofSPepisodes.

SinceSPisoftenassociatedwithintense,detailed,andtroublingvisions,alinkbetweenSPandpsychiatricdisordershasbeenhypothesized.Research,however,showsnoconsistentrelationshipbetweenpsychiatricconditionsandSP,withtheexceptionsofPTSD,panicdisorder,andsocialanxiety.InonestudyanumberoflinksbetweenSPandpsychiatricconditionswerefound(Ohayonetal.,1999);thesefindings,werechallenged,however,byaninternet-basedstudy(Solomonovaetal.,2008),withalargersamplesize,inwhichnostronglinksbetweenpsychopathologyandSPweredescribed.However,whileisolatedSPoftenpresentsitselfintheabsenceofpsychopathology,higherratesofhypnagogicandhypnopompicexperiences(dreamexperiencesoccurringduringthetransitionbetweensleepandwake:atsleeponsetoruponawakenings,respectively),someofwhichmaybeassociatedwithSP,areoftenfoundinpsychosis(PlanteandWinkelman,2008).

PrecipitatingfactorsIntheirrecentbook,SharplessandDoghramji(2015)listanumberofplausibleprecipitatingfactors

forSPoccurrenceinsusceptibleindividuals.Sleepfragmentationandinsufficientsleepareamongthemostobviousfactors.REMsleepdeprivationhasbeenshowntoincreaseREMsleeppressurecontributingtoREMreboundeffectandintensifieddreamsatsleeponset(Nielsenetal,2005).PoorsleepqualitywithfrequentawakeningsanddisruptionsmayalsofacilitateREM-wakeoverlap,creatingfruitfulconditionsfortheoccurrenceofSOREMPs(Takeuchietal,1991,2002;Spanosetal,1995).Shiftwork,jet-lag,useofsleepdisruptingmedication,stress,anxiety–allthesefactorsaffectsleepandmayfacilitateaSPepisode.AlcoholconsumptionwasalsoreportedtopromoteSP(Golzari&Ghabili,2013;Munezawaetal,2011),probablyduetoitseffectonalteringsleeparchitecture(Roehrs&Roth,2001).SleepinginasupinepositionalsoappearstoenhancetheriskofaSPepisode(Sharplessetal,2010).

NeurocognitiveconsiderationsAreturntofeltpresenceWhileundoubtedlyfeltpresencesareahallmarkofSP,especiallyoftheintenseandfrightening

episodes,presenceexperiencesarenotrestrictedtothisparasomniaandarereportedinavarietyofconditions,thuspossiblyrepresentingamoregeneralandbasicsocialimageryprocess(Nielsen2007,Solomonova,Frantova&Nielsen,2011).Arguably,themostsalientandcompellingfeltpresenceoccursinthecontextofmysticalandspiritualexperiences.Otto(1958)introducedtheideaofthenuminousasacornerstoneofreligiousmysticalexperiences.Someoftherecentworkcomesfromanthropology:theecstaticpresenceofGodismanifestedinthecommunityofEvangelicalChristiansintheUSA(Luhrmann,2012).Otherexamplesoffeltpresencehavebeendocumentedinsituationsthatarephysicallyandemotionallystrainingornovel.Someexamplesoftheseexperiencesincludehighaltitudeclimbing(Brugger,Regard,Landis,&Oelz,1999);feelingofthepresenceofababyinpostpartummothers(Nielsen&Paquette,2007);presenceofdeceasedrelativesinthecontextofbereavement(Simon-Buller,Christopherson&Jones,1989;Taylor,2005;Keen,Murray&Payne,2013);inextremeenvironments,suchassolitarysailing(seealsochapterbySuedfeld

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inthisvolume),survivinginremoteandhostileenvironments(Suedfeld&Mocellin,1987),andothers.Whileinmostcasesfeltpresenceisexperiencedspontaneously,insomecasesitmaybeaproductofsustainedmentalpractices(asinprayerandsomeformsofmeditation).Onecontemporarynon-religiousphenomenonistulpamancy(Veissiere,2016)–along-termpracticeofconjuringupimaginarycompanions,that,overtime,maybeexperiencedasalmostasrealasotherpeople.

Additionally,beingabletohaveafeltsenseofothersmaybeseenasaprerequisiteforthedevelopmentofsubjectivity.Recentworkinphenomenologyandenactivismsuggeststhatdevelopmentofsenseofselfdependscruciallyonsensingothers,asearlyasinutero(Gallagher,2005;Ammaniti&Gallese,2014),thatthesenseofone’sownbodydependsonthesenseofothers(Maclaren,2008)andthattheself-otherdynamicisanecessaryconditionforthesenseofself(Zahavi,2014).Evidencefromdreamresearchtoosuggeststhatdreamprocessesarerelationalandintersubjective.Thefactthatdreamsaremostoftenaboutotherpeoplehasbeenconceptualizedassimulationsofsocialinteraction(Revonsuo,2016)andasrepresentationsofindividualattachmentstyles(McNamaraetal,2001).Additionally,dreams,similarlytowaking,canbeseenasadynamicinteractionbetweenthe“self”-relatedand“non-self”elementsofdreamcontent(everythingextraneoustothedreamer).Thesenon-selfelements(non-humancharacters,dreamenvironment,evendreamobjectscanbeseenasa“dreamother”duetotheirinherentrelationalproperty(Solomonovaetal2015)andtothefactthatdreamenvironmentinitsentiretyaffectivelymotivatesdreamertoengagewithit.

.TowardaculturalneurophenomenologyofSP

SPhasoftenbeencharacterizedasdissociative(Terzaghietal.,2012)state,sinceiteffectivelycombinescharacteristicsof'waking'consciousness(self-awareness,accesstoautobiographicalmemory,abilitytoopeneyesandperceivetheenvironment)withREM-sleepphenomena,specificallymuscleatonia/paralysisandmentation/dreams.ThisnotionofSPasdissociativehasbeenattheheartofthepreviousneurobiologicalworkonthelinkbetweendreamingandREMsleep.TherelativedeactivationofthedorsolateralprefrontalcortexcharacteristicofREMsleep(Hobson,Stickgold&Pace-Schott,1988;Maquet,2000)hasbeenlonghypothesizedtobeattherootofthelossofautobiographicmemoryandoftheinabilitytoappreciatethecontentsofthedreamas"bizarre"orimplausibleinrelationtoreality.ThishasledtothehypothesisthatinREMsleepdreamingoneiseffectivelydelusionalandinastateofatransientpsychosis(Hobson,2004).InSP,similarly,thereisoftenincompleteautobiographicalaccess.ThisassociationbetweenSPandREMsleephasalsodisplacedtheexperienceofSPfromthepsycho-spiritualdomainofmeaningfulencounterswithmenacing/unreal/supernaturalothers,intoamorereductionistaccountofuncontrollableandinescapableREM-initiatedhallucinations. Incontrast,anaccountofSPinthecontextofanoneiricphenomenologyandina4EAperspectivemayallowforamorenuancedreadingoftheseexperiences.Anemergingneurophenomenologicalframeworkofsleepchallengesstrictdistinctionsbetweenwake,NREM,andREMsleep.Indeed,whileSPisoneoftheexamplesofsimultaneouspresenceofREMsleepandwakeprocesses,itisnottheonlyphenomenonthatatteststothefluidityandinterpermeabilityofstatesofconsciousness.LuciddreamingisanotherexampleofREM-wakeco-occurrence(LaBerge,1986);REMsleepbehaviourdisorderischaracterizedbypreservedmotoroutputduringREMdreaming(Peever,Luppi&Montplaisir,2014);somnambulismepisodescombineNREMandwakephysiologyandphenomenology(Zadraetal,2004);andavarietyofdream-enactingbehaviours,suchaslaughing,simplemovement,cryingandlookingforababyinbed,areprevalentinnormalpopulations(Nielsen&Paquette,2007;Nielsen,Svob&Kuiken,2010).

AmorecontinuousviewofmentationinsleepincludesviewingSPasaformofoneiricexperience:asaprocessofintensifiedmind-wandering(Foxetal,2013),asaprocessofcreativity(Hartmann&Kunzendorf,2013),orasenactiveimagination(Thompson,2014),aprocessofsense-makinginarich,embodiedandintersubjectiveworld(Solomonova&Sha,2016).Inhisdiscussionofluciddreaming,Thompson(2014)proposesthatinadditiontoseeingthisstateasadissociativesuperimpositionoftwodistinctstatesofconsciousness,itmaybesimultaneouslyapproachedasanintegrativestate,thusallowingforanintegrationoftwodifferentyetrelatedwaysofself-experience.

WhileSPsufferersfeelawakeandintheirownbed,therealismoftheexperienceandthequalityoftotalimmersionarecompletelyoverpoweringtothedreamer,sothatsheisunabletoappreciatethedreamlikequalityortheunrealityoftheSPepisode.Thehighprevalenceoftactileandphysicalsensations

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probablycontributestothiseffect.Thereare,however,numerousaccountsoflong-timeSPexperiencersthatarecharacterizedbyacertain'feel'fortheexperienceassomewherebetweenrealandunreal.SP-relatedexperiencesmayhaveaverycompellingandrealisticquality,buttheyareusuallyliveddifferentlyfromwakingexperiences,asakindofaliminalstate.

Considerthefollowingexample:whiletheparticipantisexperiencingintenseemotionandisquiteabsorbedintheunfoldingontheSP,heseemstohaveakindofadualawarenessregardingthenatureofhisSP:

“…Can’t.Move.Notamuscle.Notaneyelash.It'softenaccompaniedbyhallucinations.Sothisbizarreorterrifyingeventishappeningallaroundme,andIamcompletelyunabletorespondordefendmyself.SometimesIknowit'snotreal,somewhereinmymind,butitlooksreal,anditsoundsreal,andI'mterrifiedorrevolted(ormaybejustbemused),butIcannotwakemyselfuptostopit.”(30-year-oldman,USA)

Similarly,inanotherexampletheexperiencerisalsohesitanttoascribeanyparticularstatetoherexperience:

“…Imightbeansweringwrong,becauseIseethebeingsinmydream-stateimmediatelybeforewaking.Buttheirpresenceseemssoreal,Iwouldcomparetheexperiencetohavingthemaccompanyingmeintheroom”.(48-year-oldwoman,USA)

GroundingSPinitsculturalcontextallowsustoappreciatethevarietyoffactorscontributingto

qualitiesofthelivedexperience,anditmaynotbepossibletodissecttherelativecontributionofthemultitudeofneural,phenomenologicalandculturalnarrativefactors(Kirmayer,2009).Importantly,inthecurrentmedicalcontext,reducingSPtoadysfunctionofREMpsychophysiologymayalsohaveanimportanteffectonreducingthepotentialforadeeperexplorationofSPasaspiritualexperience(Hufford,2005).

TheculturalneurophenomenologyofSPisapowerfultoolforinvestigatingSPfromthe4EAcognitionperspective.Asneurophysiological,experientialaccountsofSPshow,thedreamerisinfactembodied–theoneiricscenarioisdependentonthedreamer’sstateofconsciousness(REMintrusion)andonthedreamer’sphysiologicalstate(atonia,shallowrapidbreathing).Sheisembeddedinaphysical(interpretsambiguousstimuliaroundher)andinaculturalworld(theseambiguousstimulitakeonafamiliarshape/areinfusedwithadeeperculturalandinterpersonalsignification).Thesleeperisalsoextendedintotheworld–thewholeenvironment,bothdreamtandreal,ispartofherongoingexperience;andherexperienceisenactive–thereisarelationalquality:sheisnotapassiveobserveroftheoneiricdramaunfoldingbeforehereyes,butrathersheisdeeplyengaged(Solomonova&Sha,2016).

InordertoelucidateneurophenomenologicalqualitiesofSPingreaterdetail,futureworkmayusemicrodynamicphenomenology/elicitationinterviews,aimedatuncoveringthefine-grainedtemporalandstructuralqualitiesoflivedexperience(Nielsen,thisvolume;Petitmengin,2006;Petitmengin&Lachaux,2013),inadditiontoneurophysiologicaldataanddeepawarenessofthecultural,religiousandspiritualcontextoftheexperiencer.

Sleepparalysispractices:prevention,disruption,treatmentandexploration

WhileSPremainsarelativelyunknownphenomenoninmuchofEuropeandAmerica,anumberofpracticalculture-specificpracticeshavebeendevelopedtoprotectthesleeperfromthenegativeinfluenceofpresumedsupernaturalforces.Whilesomeofthesemethodshavedeeprootsintheirrespectivemetaphysicalcontexts,andthereforeneedtobegroundedinexistingreligiousandmysticalpractices,anumberofpracticalandconceptuallyneutralrecommendationshaveemerged,andseembeneficialformostSPsufferers,regardlessofbackground.

NoestablishedtreatmentforSPcurrentlyexists;itsclinicalmanagementisinsteadoftenfocusedontreatingcomorbidproblems.AccordingtoareviewbySharpless&Doghramji(2015),psychoanalysis,cognitive-behaviouraltherapy(CBT),hypnosis,andeducationinsleephygienehavebeeninvestigatedinrelationtoSP,butnoempiricalconsensusonefficacyofsuchinterventionsiscurrentlyavailable.BasedontheavailableevidenceonSPandcognitive-behaviouralapproachestotreatmentofsleepdisorders,especiallyinsomnia,theauthorsproposeamanualforCBT-ISP.ThisisapromisingfirststeptowardfindingasystematicmethodofdealingwithSP.SparseevidenceforpharmacologicalinterventionsforSPalsoexists:inonestudyitwassuggestedthatREMsleep-suppressingantidepressantsmayprovidetemporaryrelief(PlanteandWinkelman,2008),andtreatmentofnarcolepsymayreduceSPfrequency(Mamelaketal.,2004).

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Antidepressantsandanxiolyticswerealsousedinseverecases(Hsiehetal.,2010).TerrillonandMarques-Bonham(2001)proposedthatmanagementofSPmightbenefitfromadministrationofmelatonin,whichwouldhelpnormalizethecircadianrhythm.Thecostofsideeffectsassociatedwiththesetreatments,however,mayoutweighthebenefit,andShaplessandDoghramji(2015)argueforacautiousapproach,tailoredtoeachindividualsituation.

Whilemethodsfordealingwithsleepparalysishavenotbeensystematicallyexploredbyempiricalpsychologyorcognitivescience,thecontemporarycontextofInternet-facilitatedsupportgroupsandinformationsharingpracticesarechangingthesolitaryandculture-boundnatureofSPattacks.Furthermore,anumberofmethodshavebeenanecdotallyreportedanddocumentedonlineandinprint,thatseeSPexperiencesasanopportunityratherthananuisance,andpromoteexplorationofone’sownconsciousnessviaSP-supportedluciddreamingorevencontemplativeapproachestoSP(Hurd,2010).Onepopularsupportgroup-mailinglistisknownas“Awarenessduringsleepparalysis”(ASP),andaredditgrouponSPcountsover4000users,sharinginformationonthephenomenologyoftheirexperiencesandmethodsofovercomingthem.

CulturalandclinicalpracticesassociatedwithSPcanberoughlyseparatedintothreekinds:1)preventativepractices,focusedonavoidingSP-enablingcircumstances;2)disruptivepractices,designedtostopSPinthemiddleoftheexperience;and3)observational/explorativepractices,aimingatobservingSPandpossiblytransformingitintoapositiveevent,suchasaluciddreamoranout-of-bodyexperience.

RaisingawarenessofSP-associatedphenomenaitselfmaybeoneofthemostimportantfactorsinreducingfearanddistressbefore,duringandafterSPoccurrence(Ottoetal.,2006;Sharplessetal,2010).Indeed,knowingthattheexperienceistransient(willnotlast),benign(doesnotcontainanyrealdanger),andcommon(issharedwithmanyindividualsacrosstheworld)arepowerfultoolsforpsychologicaldistancingandforfacilitatinganeventualobservational,asopposedtofullyimmersiveandfatalistic,attitudetowardSP.KnowingaboutSPphenomenologyandneurophysiologyandhavingaccesstoculturalgroundingwithavailablesymbolicgestureshelpsprevent,disruptandtransformanegativeexperienceintoatoolforself-exploration.Figure4summarizestheintricatelinksbetweenprecipitatingfactorsandeffectsofSPexperiencesinlightofdisruptive,andobservational/transformationalpractices.

Methodsforpreventingsleepparalysis

Whileundoubtedlyhelpful,simplyknowingthebasisofSPmaynotbeenoughtoalleviateterroranddistressassociatedwiththeexperiences,anddisruptiontechniquesareclearlywarranted.A25-year-oldmanfromtheUnitedStatesreports:“Thishappenssometimeseverynight,sometimesonlyonceeveryfewweeks.EventhoughI'know'whatishappening,andthatIaminnodanger,itisalwaysterrifying”.ThefirststudytosystematicallyassesspreventionstrategiesforSPbySharplessandGrom(2014)hassuggestedthatwhilenofoolproofmethodforpreventingSPisyetknown,somestrategies,suchasavoidingsleepingonone’sback(supineposition),maintainingoptimalsleephygiene(avoidingstimulants,noise,irregularsleeppatternsandanythingthatcontributestosleepfragmentation),andpre-sleeprelaxationpracticesmayhelpinpreventingSP.

Anumberofculture-specificpreventativeritualisticmeasurestopreventSPexist.Theseincludeplacingavarietyofdefensiveobjectsintheroomorinthebedbeforegoingtosleep,suchasavarietyofknives(Hufford,1982,Law&Kirmayer,2005);sprinklingsalt(acommonanti-witchremedy)(Roberts,1998);puttingabroombottom-up(Paradis&Friedman,2005)orapileofsandatthebedroomdoor(Jalal,Romanelli&Hinton,2015);andmanyothers.PuttingaBibleintheroom(Hufford,1982)andsayingaprotectiveprayerbeforebedtimearealsothoughtofaseffectivedeterrents.Otherritualisticactions,designedtodeter,divertandchaseawayunwelcomesupernaturalvisitorswerealsodocumentedinavarietyofcontexts(Sharpless&Doghramji,2015).

Techniquesfordisruptingsleepparalysis

Whilepreventativemeasures,whetherculturallyembeddedoraimedatincreasedawarenessandpromotionofsleephygiene,maybeeffectiveinreducingthefrequencyofSPepisodes,manymethodsfordealingwithanongoingSPexperiencealsoexist.ConsideringthatmostSPexperiencesarecharacterizedby

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fearandotherunpleasantsensations,itisnotsurprisingthatinonestudythemajorityofparticipantsreportedhavingattemptedtodisrupttheongoingSPexperience.Movingtheextremitiesandself-monitoring(raisingawareness,promotingcalm)maybehelpfulduringtheSPepisode(Sharpless&Grom,2014).Notallattemptsorallstrategiesareequallysuccessful,butitseemsthatattemptingmicromovements,insteadoftryingtogetuportoscream,aremosteffective.Culture-boundritualsincludesayingaprayer(Hufford,1982),makingasignofacrosswithone’stongue(Davies,2010),andaskingsomeonetophysicallyshaketheoppressedsleeper(LawandKirmayer,2005).

Observational/transformationalpractices

OnemayarguethatISPandluciddreamingarepolaropposites.However,theysharethesameunderlyingpsychophysiologyandseemtoinvolvesimilarmechanisms:botharedependentuponREMsleepmechanisms;botharecharacterizedbysimultaneouspresenceofthedreamstateandbythefeelingofbeingawake,includingactivationofhigherordermetacognitivefunctionsindicativeofsomedegreeofwakingthoughtprocesses(LaBerge,Levitan&Dement,1986;Voss,Holzmann,Tuin,&Hobson,2009;Dresleretal,2012;Filevichetal,2015);andinbothcasesmuscleatoniaispresent.Thecrucialdifferencebetweenthetwostatesisthequalityandthefocusofawarenessandmetacognition:inluciddreamingoneisawareoftheillusorynatureofthedreamscenario,whereasinSPthedreamerisoftenabsorbedbythevision,notalwaysfullyrealizingthatitisdreamlike,and,incaseoffearfulSP,istooabsorbedinthepanickystateofperceivedimminentdanger.

ThelinkbetweenSPandluciddreaminghasnotbeensystematicallyinvestigatedinempiricalresearch,buttwostudiesreportapositivecorrelationbetweenfrequencyofluciddreamingandSP(Denis&Poerio,2016;Solomonova,Nielsen&Stenstrom,2009),suggestingthattheREM-wakeintertwinedstate,characterizingSP,maybeatrait-likephenomenonpredisposingindividualstoSPontheonehand,andfacilitatinglucidityinREMsleepdreamsontheother.

TransformingSPintoapositiveexperience,suchasanOBEoraluciddream,orutilizingSPexperiencesasameansofcontemplativeinsightintoone’sownmind,maybecomeapracticeinitself,sincenotonlytechniquesfordisruptingandpreventingSPexistinthecontemporarydigitalculture,butalsotechniquesforinducingSP,withthehopethattheexperiencewillfunctionasaportaltoadesirablealteredstateofconsciousness(Hurd,2010).ThefollowingtworeportsillustratethetransformativepotentialofSP:

“IhavewokenupfromdreamingandfoundIcan’tmoveoropenmyeyes.Igetthefeelingoflemonadebubblinginmybody,especiallymyhead.Itisveryfrightening.ButsinceIhavebeenhavingOBE3sInowrelaxandgowiththeflowofsleepparalysisandsometimesIactuallyachieveanOBE”(40-year-oldman,Australia)“AtfirstIwasveryfrighteneduntilIfoundtheASPemailgroupandfoundthatIwasnottheonlyonebeing“visited”bythisbeingduringsleepparalysis.…WhenitfirststartedhappeningitwasmoreofanassaultandIhadtofightterriblytoescape.Butafteryears,IlearnedtoignoreandnowI’vebeentryingtocommunicatewiththepresence”.(40-year-oldman,USA)

3OBE=out-of-bodyexperience

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Figure4.Predisposing,precipitatingfactorsandexperienceandoutcomeofsleepparalysisepisodes.

Furtherconsiderationsandfuturedirections

Intermsofpossibleavenuesfortreatment,sinceSPcanbeconceptualizedasaformofnightmareoccurringinamixedstateofconsciousness,nightmaretreatmenttechniquescouldbeusefulinapproachingSP.Currently,themostusedandrecommendedtechniquefortreatingchronicnightmaresistheImageryRehearsalTherapy(Krakowetal,1995;Krakow&Zadra,2006),whichconsistsof“rehearsing”andtransformingdysphoriconeiricimageryinasafecontext.ThismethodhasbeeneffectiveintreatingPTSD-relatednightmares(Krakowetal,2001;Germainetal,2004;Cooketal,2010;Casement&Swanson,2012),whichseemsparticularlyappropriateforintenseandtrauma-relatedSPexperiences.Similarly,treatmentofnightmaresbyluciddreamingisapromisingavenue(Zadra&Pihl,1997;Spoormaker&VanDenBout,2006;LaBerge,2009).ConsideringthatneurophysiologicallybothstatesarecharacterizedbyanoverlapbetweenREMsleepandwakefulness,andthatanumberoffolkapproachestreatingSPasaportaltoluciddreamsalreadyexist,masteringluciddreamingcouldbeaneffectiveapproachtotransformationofanongoingSPepisode.Suchastrategymayalsobehighlyeffectiveinde-stigmatizinganddesensitisingtheexperiencer,andespeciallyinincreasinghermasteryandagencyoverherspontaneousoneiricexperiences.

Contemplativepractices,suchasmeditationorpranayama(yogicbreathing)mayalsobeusefulindealingwithrecurringSPepisodes.ThereiscurrentlynoempiricalevidenceforcontemplativetechniquesandSPmanagement,withtheexceptionofacasestudybyJalal(2016),butanecdotalevidencefrompractitionersaswellasgrowingempiricalliteraturelinkingcontemplativepracticeswithstressmanagement,emotionregulation,andincreasedself-awareness,providegroundsforfutureresearch.

Recentyearshaveseenanimportantincreaseinempiricalstudiesontheeffectsofmeditationandmeditation-basedmindfulnessinterventions.Therearedocumentedbenefitsofcontemplativepracticeinclinicalpopulationsincludingpositiveeffectsinmooddisorderssuchasanxietyanddepression(Hoffmanetal,2010;Goyaletal,2014),socialanxiety(Goldin&Gross,2010),andPTSD(Kearneyetal,2013).Atleastfourkindsofmeditationarecurrentlyinvestigatedinrelationtomentalhealth:focusedattention,openmonitoring(Lutzetal,2008),self-transcendence(Travis&Shear,2010)andlovingkindnessmeditation(Hoffman,Grossman&Hinton,2011).Differentkindsofmeditationpracticesmayrecruitdifferentneuralnetworks(Foxetal,2016),andparticularpsychologicalandneuroplasticchanges,associatedwithmeditationpractice,likelydependonthekindanddurationofmeditationexperience(Lutzetal,2015).ThesedifferentkindsofcontemplativepracticemaybehelpfulintargetingdifferentkindsofrecurrentSPexperiences,promotingde-automatization(Kang,Gruber&Gray,2013):deconstructingpatternsofbehaviour/reactivity.

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MeditationmaybeeffectiveinSPmanagementasawayofcultivatinganon-judgementalor‘non-sticky’observationalattitudetoarisingimagery,sensationsandemotions,andinlettingtheexperienceunfold.Inaddition,oneimportantfeatureofmostmindfulness-relatedpracticesisthefocusontheexperienceofthebody(Kerretal,2013),andsomeevidencesuggeststhatmeditationpracticemayimproveawarenessofone’sownbodystates(Solomonovaetal,2016)andincreaseintrospectiveaccuracyforsomaticexperience(Foxetal,2012).Breathingpractices,suchaspranayama,maybeparticularlyeffectiveintransformingSPasitishappeningduetothefactthatmanySPepisodesarecharacterisedbyafeelingofdisordered/insufficientbreathing.Arecentstudy(Seppäläetal,2014)reportedthatbreathingexerciseswereeffectiveindecreasingPTSDsymptomsinwarveterans.ThisimpliesthatpracticingtechniquesthatimproveawarenessofbodysensationsmaylowerthereactivitytoSPepisodes,thusloweringthedistressingqualityoftheexperience,andincreasingthepotentialfordisruptingortransformingSP.

Acknowledgements:

TheauthorwassupportedbySocialSciencesandHumanitiesResearchCouncil(SSHRC)ofCanadaandbyaJ.-A.DeSèvesSacre-CoeurHospitalFoundationdoctoralscholarship.ThanksareduetoToreNielsen,PhilippeStenstromandMichelleCarrfornumerousconversationsonsleepparalysisanditsinterpretation,andtothemembersoftheDreamandNightmareLaboratoryattheCenterforAdvancedResearchinSleepMedicine.AdditionalthanksareduetoDonDonderiandElenaFrantova,aswellastoallparticipantswhohaveconsentedtosharetheirexperienceswithus.SpecialthankstoBenjamenSamaha(artist)andtotheanonymousSPsuffererforgenerouslyofferingthenarrativeandthedrawingofasleepparalysisepisode.

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