Sleep paralysis: A world between wakefulness and sleep

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In 1781, artist Henry Fuseli may have captured on canvas what patients experience during sleep paralysis. The image of a woman draped across a bed, with a demon sitting upon her chest, resonates with patients who experience sleep paralysis today.

Each night, during rapid eye movement (REM) sleep, we all experience atonia. This natural state of paralysis occurs to keep us from acting out our dreams. However, some patients wake during this event and find themselves unable to move or speak.  They may have difficulty taking a deep breath, which gives them a sensation of something sitting on their chest. Many of these patients experience a fear of dying or have hypnogogic or hypnopompic hallucinations.  They often say that the sensation feels dreamlike and real at the same time. Individuals who have personality traits that include imaginativeness, dissociation, and beliefs in the supernatural appear to have higher rates of sleep paralysis.

The Nightmare by Henry Fuseli (1781)

Patients who have suffered through sleep paralysis will never forget the event.  They are often reluctant to discuss what occurred, as many cultures have passed down stories of demons and devils that visit in the night. It is widely believed that patients who speak of alien abductions or demonic attacks may have experienced sleep paralysis. Patients are often told that their bad behavior has caused this to happen, so they feel embarrassed talking about it with a healthcare provider. Many patients often to say to me that they were afraid to say something out of fear that I would think they are “crazy.” In general, the paralysis will last for a few seconds to a few minutes, but it can feel much longer. If the patient is touched or called upon, it will break the paralysis. Otherwise, the patient will lay there, sometimes able to open their eyes, but otherwise have no control of their body.

Sleep paralysis, in the absence of narcolepsy, is also known as isolated sleep paralysis or recurrent isolated sleep paralysis. It is estimated that 3% to 5% of the population has experienced sleep paralysis, but the true prevalence is unknown. One systematic review of literature suggests that 7.6% of the population has experienced at least 1 event of sleep paralysis in their lifetime. Patients with narcolepsy experience sleep paralysis more than patients without the illness and this may be one of the first symptoms of narcolepsy. Other causes include sleep deprivation, schedule disruption, and ingestion of alcohol.

Treatment depends on the severity of the episodes and how it has impacted the patient. One event of sleep paralysis does not warrant ongoing treatment. The patient should be evaluated for narcolepsy because of the increased incidence of sleep paralysis in this population. The most commonly used agents to treat sleep paralysis are tricyclic antidepressants and selective serotonin reuptake inhibitors. Because these medications suppress REM sleep, it is hypothesized they will diminish the events of sleep paralysis.

Reassurance is key. Once patients understand what is causing these events, they are often comforted. This does not mean that it will prevent them from feeling fear during these events, but at least once the “spell” is broken, they can remind themselves that they are not crazy and that there are no demons or aliens in the room with them and that they are safe.

Sharon M. O'Brien, MPAS, PA-C, is a practicing physician assistant and health coach in Asheville, NC. 

Reference

  1. Sharpless BA. A clinician's guide to recurrent isolated sleep paralysis. Neuropsychiatr Dis Treat. 2016; 12: 1761–1767. doi:10.2147/NDT.S100307
  2. Kryger MH, Roth T, Dement WC. Principles and Practice of Sleep Medicine. 6th ed. Elsevier Health Sciences. 2016.
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