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SP often occurs without narcolepsy. The criteria for recurring isolated sleep paralysis RISP is undergoing four or more episodes per year Bell et al. REM mentation can generate vivid sensory experiences, hypnogogic predormital or hypnopompic post dormital hallucinations in all sensory modalities. Sleep paralysis is often associated with great fear and terror, and sometimes impending death Hufford, ; Jalal and Hinton, Unsurprisingly, the experience has been linked to symptoms of anxiety and trauma e. Supernatural accounts of the phenomenon are common across cultures, ranging from demonic and ghost attacks to space alien abduction Wing et al.

Notwithstanding the great fear associated with the experience, there are few treatments available for SP. To date, there are no published clinical trials or outcome data for treating SP. My colleague Devon Hinton has conducted some of the most extensive work in treating SP carried out among traumatized Cambodians e.

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He specifically targeted sleep disturbances and anxiety symptoms which are implicated in the onset of SP e. Another approach to psychoeducation about SP specifically focuses on the hallucinations by telling sufferers that supernatural accounts of SP are common Ohaeri et al. To the best of my knowledge, there are no direct treatment interventions available for SP that are applied during the actual attack.

At the onset of an SP attack, the individual will feel the effects of REM respiration such as hypoxia and hypercapnia, occlusion of airways and shallow rapid breathing Douglas, Somatic symptoms, coupled with the awareness that one is paralyzed, can activate a host of psychological symptoms; including fear and worry that are worsened by catastrophic cognitions about the attack e.

This in turn may generate an amygdaloid fight-flight reaction and panic-like arousal. As the individual attempts to move to overcome the paralysis, somatic symptoms and arousal are exacerbated. That is, the execution of motor programs in the absence of dampening proprioceptive feedback can lead to heightened sensations of bodily tightness and pressure, and even pain and spasms in limbs Cheyne et al.

Moreover, the desynchrony between motor-execution and feedback from limbs, may lead to distortions in body image, causing bodily hallucinations such as phantom limbs, floating sensations, and OBEs. Such body image disturbances might also cause hallucinations of shadowy-figures. For example, Ramachandran and I recently proposed that the shadowy-figure often seen during SP arises due to a disturbance in the multisensory processing of body and self at the temporoparietal junction see Jalal and Ramachandran, The content and interpretation of hallucinations, are driven by multiple processes including hypervigilance for threat, the emotion of fear, and somatic sensations such as pressure on the chest and limbs, and REM-induced sexual arousal i.

This cycle may also cause future episodes of SP as the individual acquires conditioned fear of the experience; leading to more nighttime awakening due to increased nocturnal arousal and hyper-alertness to symptoms of paralysis which predisposes to SP. In light of this proposed model of SP attacks, as we shall see, meditation might constitute an efficacious direct treatment intervention for SP. One aspect of meditative practice includes maintaining attention toward chosen meditative objects Wallace, and attending to beneficial thoughts Gethin, For example, attention may be focused inward on an attentional object, and whenever distracted by external stimuli or inner thoughts, attention is brought back to the inner-object of focus.

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This in turn allows the person to be released from uncontrollable thoughts, and enter into a calm mental state free from distractions. I propose that a type of focused inward-attention meditation combined with muscle relaxation be applied directly during SP as an intervention to ameliorate and possibly eliminate the attack one could call this treatment approach, meditation-relaxation or MR therapy for SP. As SP entails seconds to minutes of conscious awareness and a sense of agency, the intervention can readily be applied during the episode.

I specifically propose the following steps to be implemented. Step I: reappraisal of the meaning of the attack : at the onset of the attack, the individual should reappraise the meaning of his SP episode by telling himself that the experience is common, benign, and temporary, and that the hallucinations are a typical byproduct of REM mentation i. Eyes should remain closed throughout the SP episode and the person should stay calm and avoid movement.

Ideally, the individual would have received prior psychoeducation about the nature of SP and associated hallucinations. Step II: psychological and emotional distancing : next, the individual should tell himself that since the experience is common, benign, and temporary, there is no reason to be afraid or worried.

That in fact, fear and worry catastrophizing the event will only make the episode worse and possibly prolong it, and are unnecessary emotions. Step III: inward focused-attention meditation : the individual should then focus his attention inward on an emotionally salient positive object e. He should sustain his full attention on this inner-object and engage it emotionally i. Bodily symptoms and external stimuli i. Step IV: Muscle relaxation : while engaging in focused inward-attention meditation, the individual should relax his muscles and avoid flexing them; and avoid controlling breathing and under no circumstances attempt to move.

He should adopt a non-judgmental attitude of acceptance toward physical symptoms.

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It is recommended that the method be practiced regularly, even in the absence of SP. For example, the individual may lay down in the supine position [i. This would make it easier for the individual to apply the treatment once SP occurs, and not become too overwhelmed by subjective fear e. In general, long-term meditation training, might be useful as prior preparation, and possibly increase the effectiveness of the intervention. It might help the individual reach a relaxed meditative state more rapidly during SP, and enable him to sustain attention away from threatening stimuli for longer periods; e.

Ongoing meditation training might be particularly useful as RISP often occurs in clinical populations with anxiety disorders; including panic disorder Bell et al. High rates of SP may arise from the disturbed sleep characteristic of these clinical populations for details see Jalal and Hinton, In this respect, research has shown that long-term meditation practitioners spend more time in slow wave sleep SWS Mason et al.

The proposed intervention may be advantageous for several reasons. By first reappraising the meaning of the attack and addressing catastrophic cognitions; and engaging in emotional distancing from the event, the initial panic and arousal that occur when realizing one is paralyzed may be reduced. Consistent with this, research has found that emotional regulation strategies such as reappraisal and cognitive distancing are associated with decreased amygdala activation Beauregard et al.

Moreover, as focused attention and emotion centeredness demand cognitive resources, attention directed away from threatening stimuli e. Such focused meditation may in turn facilitate a relaxed meditative state and, possibly, a shift from sympathetic to parasympathetic dominance e.

Inward-attention meditation in particular, has been found to be associated with lower levels of anxiety, feelings of calm and positive affect, and greater levels of alpha brain wave activity Nagendra et al. Finally, muscle relaxation, whilst enhancing the relaxed state, may critically also, minimize tendencies to move during SP. This may reduce somatic symptoms such as chest pressure, muscle spasms, and prevent hallucinations that occur due to body image disturbances e.

Joe, a man in his early thirties, experiences SP occasionally. His episodes can be terrifying, and may include vivid hallucinations. One afternoon when Joe was taking a nap, he suddenly found himself awake but unable to move. Petrified, he soon noticed that his body was floating in the air above his bed, and could hear voices of family members outside his bedroom.

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All the while experiencing these bizarre kinetic, auditory and visual hallucinations, he started to feel an overwhelming evil and threatening presence. The fear and horror would escalate with each passing moment. Joe realized that the many sensory inputs i. So Joe resorted to focused inward-attention meditation: he closed his eyes and focused all his attention on a pleasant inner-object e. Almost immediately thereafter, he noticed the terrifying hallucinations had vanished. His body had also become more relaxed. He soon awoke from his SP. Joe had begun rehearsing the treatment, so it felt more natural to apply the steps.

As the paralysis came over him, he felt an immense pressure on his chest, making breathing difficult; he closed his eyes, relaxed his muscles and stayed calm.

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To his utter surprise, he saw the vague frame of three helpless and innocent-looking young boys in front of him. This was in stark contrast to his many past SP experiences, where he has encountered all kinds of horrors, including sexual molestation by demons.

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He no longer fears SP! Jonah, who is in his late teens, experiences SP times a week. His episodes are usually terrifying and include hallucinations of demonic possession. Jonah applied MR therapy as often as possible, for about eight weeks to treat his SP, and also practiced the treatment steps outside SP, as preparation. It took a few SP episodes for him to get used to MR therapy, and overcome the panic and overwhelming fear that would ensue. While he felt some discomfort initially, by the end of the eight weeks he had become familiar with the treatment.

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