Literature Review

Sleep Paralysis (SP) is an experience often accompanied by terrifying hallucinations in

which the mind is awake, but the body is paralyzed. These hallucinoid experiences occur in the

hypnagogic and hypnopompic (HHEs) states of sleep, the former meaning in the on-set, and the

latter referring to the off-set transitional periods of a regular sleep cycle. ​HHEs overall are

defined as combinations of auditory or visual hallucinations that occur during sleep. ​An

interdisciplinary discussion between academic researchers, sleep psychologists, and sociology

experts reveals some crucial trends supporting theories of three major types of hallucinations that

could be related to health conditions hypothesized to increase prevalence or likelihood of

experiencing SP. Hallucinations tend to follow similar structures and exhibit characteristics that

allow them to be categorized, and it is with this in mind that the researchers establish reliable

evidence of trends among HHEs. As Catherine Savini, author of “Looking for Trouble: Finding

Your Way into a Writing Assignment” argues, “we all deal with problems of varying complexity

on a daily basis” and “it's likely that we follow a particular process for meeting these

challenges”. 1​​ The problem here is sleep paralysis, and the process the researchers follow to

understand and solve this particular parasomnia revolves around understanding halluncinoid

experiences to identify conditions that promote prevalence.

In 1999, researchers ​James Cheyne, Steve Rueffer, and Ian Newby-Clark released the

academic paper entitled “Hypnagogic and Hypnopompic Hallucinations during Sleep Paralysis:

Neurological and Cultural Construction of the Night-Mare” This scholarly peer-reviewed article

constitutes sleep paralysis as a “conscious state of involuntary immobility”​2​ that occurs in the
1
​Savini, Catherine. “Looking for Trouble: Finding Your Way into a Writing Assignment.”​ Writing Spaces:
Readings on Writing, Volume 2 ​(2011): 53
2
​Cheyne, J.Allen, Steve D. Rueffer, and Ian R. Newby-Clark. “Hypnagogic and Hypnopompic Hallucinations
during Sleep Paralysis: Neurological and Cultural Construction of the Night-Mare.”​ Consciousness and Cognition​ 8
(1999): 319-337
onset of falling asleep or waking up and discusses the sensory experiences that occur during

sleep paralysis. Cultural interpretations, further detailed in Ether Olunu’s 2018 paper, reveals

that SP-related HHE episodes are believed to be incubus/succubus interactions, meaning that

auditory and visual hallucinations depict some sort of menacing creature (demons, spirits, old

hags, witches, monsters) 3​​ . The researchers in this study hypothesize that HHEs associated with

SP can be organized into groups, a theory that is a common topic of academic discussion

throughout the literature review. The HHEs were broken down into three major categories based

on survey responses that utilized a Likert Scale. The first, portraying a sensed presence, fear, and

auditory and visual hallucinations, was labeled ​Intruder. ​The second consisted of feelings of

pressure on the chest, breathing difficulties, and pain and was therefore labeled ​Incubus. ​The

third was characterized by floating sensations, out-of-body experiences, and occasional bliss and

was subsequently labeled ​Unusual Bodily Experiences.​ 4​​ Throughout this paper, researchers

pursue the validity of the three-factor model and its particular correlation between Intruder and

Incubus experiences. These two were shown to induce the most panic-stricken and hallucinoid

states and may be traced back to underlying health conditions discussed in Dan Denis’s 2018

paper. It is important to note that participants deemed the term “fear” as unable to “do justice to

the abject terror”. 5​​ In the concluding remarks, these researchers note that nocturnal

hallucinations and SP can lead to divergent interpretations of HHEs, each person has a different

experience. However, the study concluded with the finding that HHEs accompanying SP are

consistent within three categorical trends: Incubus, Intruder, and Unusual Bodily Experiences.

3
​Olunu, Esther, Ruth Kimo, Esther Olufunmbi Onigbinde, Mary-Amadeus Uduak Akpanobong, Inyene Ezekiel
Enang, Mariam Osanakpo, Ifure Tom Monday, David Adeiza, Otohinoyi,​ ​Adegbenro Omotuyi, John Fakoya. “Sleep
Paralysis, a Medical Condition with a Diverse​ ​Cultural Interpretation.” ​Department of Basic Medical Sciences,
School of Medicine.​ 8 (2018): 137-142

4
​Cheyne, ​Rueffer, and Clark, “Hypnagogic and Hypnopompic Hallucinations,” 235
5
​Cheyne, ​Rueffer, and Clark, “Hypnagogic and Hypnopompic Hallucinations,” 329
The researchers in this paper explore the depth of those three hallucinoid states and attempt to

understand potential risk factors and causes.

With the three major categories of HHEs determined, Cheyne set out to explore

situational factors that play a role in SP. In his individual 2002 study, sleep psychologist James

Cheyne published “Situational Factors Affecting Sleep Paralysis and Associated Hallucinations:

Position and Timing Effects”. Cheyne researched two major situational factors to determine the

prevalence of HHEs during sleep paralysis. The first is body position, and the second is timing

(beginning, middle or end of sleep).​6​ Cheyne determined the influence of these factors through

two separate studies. The first explored sleeping position, the second timing effects. Despite

respondents reporting falling asleep in a variety of positions, it was most common for an episode

to occur while the victim was frozen supine, flat on their back. This allows greater auditory and

visual access to any appearing hallucinations, which Cheyne identifies as Incubus, Intruder, and

Unusual Bodily Experiences, cultivating the theory of three dominant HHEs. Furthermore, ​SP

will occur more frequently at initial sleep onset and during sleep, and it is typically associated

with fading light and darkness, rather than the sleep offset. Cheyne concluded with a believable

hypothesis that SP is more prevalent in the supine position and in the initial onset and middle of

sleep. The findings regarding HHEs parallel Denis’s 2018 article and Cheyne’s 1999 research,

and add the prospect that sleeping position and timing has a major impact on the prevalence of

SP.

Building upon the skeptical bed of research searching for health conditions that affect SP

and HHEs, a 2010 team of researchers composed of ​Brian​ ​Sharpless, Kevin McCarthy, Dianne

Chambless, Barbara Milrod, Shabad-Ratan Khalsa, and Jacques Barber published “Isolated Sleep

6
​Cheyne, J.Allen. “Situational Factors Affecting Sleep Paralysis and Associated Hallucinations: Position and
Timing Effects.” ​European Sleep Research Society ​no. 11 (2002): 175
Paralysis and Fearful Isolated Sleep Paralysis in Outpatients with Panic Attacks”.​ The authors

emphasize the medical field’s inattention to isolated sleep paralysis and conduct a study that will

facilitate research on the parasomnia. The researchers emphasize Cheyne's hypothesis that SP is

more likely to occur when lying in a supine position, and in further support of Cheyne and his

1999 research team’s findings, the article argues that “fear is a common consequence of

episodes”. 7​​ Due to the interest in fear and panic as a factor that could influence SP, the

researchers employed self-reporting survey documentation to prove that a majority of

participants showed significant fear during their episodes. It was determined that there is a

difference between isolated sleep paralysis and fearful isolated sleep paralysis as observed in a

single incident. Fear plays a significant role in the validity of central arguments, “fight or flight,”

they say. But when an individual is unable to fight, or unable to flee, that panic and fear can

increase tenfold. People try to understand SP, holding onto cultural interpretations of ghosts and

witches discussed further by Esther Onulu’s 2018 research team. The SP experience as a whole

is given an unscientific explanation because it is so under researched by the medical field. It can

be concluded that there are a multitude of factors influencing sleep paralysis episodes, and those

regarding health conditions are discussed in detail by Denis’s 2018 team.

The medical field has little knowledge about sleep paralysis, its causes, or reliable

methods of treatment. There is much speculation regarding factors that consistently cause an

episode of SP, but in 2018, Dan Denis, Christopher French, and Alive Gregory published “A

Systematic Review of Variables Associated with Sleep Paralysis”. The researchers in this

peer-reviewed study used a systematic review to determine variables frequently associated with

7
​Sharpless, Brian A., Kevin S. McCarthy, Dianne L. Chambless, Barbara L. Milrod, Shabad-Ratan Khalsa, and
Jacques P. Barber. "Isolated Sleep Paralysis and Fearful Isolated Sleep Paralysis in Outpatients with Panic Attacks."
Journal of Clinical Psychology​ 66, no. 12 (2010): 1296
SP. The researchers incorporated a literature search with articles to cross reference variables.

Building upon findings reported by Cheyne and his 1999 team and the common theme, these

researchers found that there are three major categories of HHEs and determined some hesitant

factors that promote SP. Stress and trauma were found to be factors closely associated with

frequency of SP. A history of childhood sexual abuse, physical abuse, and PTSD from traumatic

events were shown to promote HHEs of Intruder or Incubus simulations. Additionally, there

appears to be moderate genetic influence. Hereditary sleep patterns including narcolepsy,

insomnia, and mental illness, may in fact contribute to SP episodes, according to the systematic

review. Furthermore, individuals with mental health issues, specifically psychiatric disorders and

medication use, are shown to have a higher prevalence of SP. Individuals who suffer from PTSD,

panic attacks and anxiety disorders, are shown by multiple studies to be the most reliably at risk

for SP. 8​​ The researchers found a great deal of variation within the variables believed to

contribute to frequency and intensity of SP. There exists a multitude of hesitantly established

factors that induce SP: it is grossly misunderstood. This is why people choose to interpret the

parasomnia into something understandable, something believable, something they can more

easily explain.

People who suffer with sleep paralysis describe episodes as a demonic experience, and

the episode itself often feels straight out of a terrifying paranormal production. Except ​you​ are

the main character, and there are no special effects, it’s all real. If medical professionals and

doctors remain somewhat baffled by SP, the public could have grounds to be utterly panicked.

But in an attempt to explain SP, cultures define the medical condition as a paranormal

experience. The 2018 team of researchers led by Esther Olunu published “Sleep Paralysis, a

8
​Denis, Dan, Christopher C. French, Alive M. Gregory. “A systematic review of variables associated with sleep
paralysis.” ​Sleep Medicine Reviews​ 38 (2018): 142-155
Medical Condition with a Diverse Cultural Interpretation”, and this sociology article provides a

closer look at the interpretation of SP and hallucinoid experiences culturally. Sleep paralysis was

not always explained or understood logically through medicine. Early researchers hypothesized

that SP was associated with the supernatural being “Incubus”, a theory that Cheyne discussed.

Today, we understand that sleep paralysis is more common amongst individuals suffering from

underlying health conditions discussed in Dan Denis’s 2018 academic paper.​ ​People choose to

interpret episodes through folklore and myth in an attempt to explain sleep paralysis. This article

reported most common interpretations of SP across 18 regions in the world, and a repetitive

theme was encounters with “witches”, “ghosts”, and “demons”. Sleep paralysis has received

more attention from the unscientific world than the medical field; sufferers resort to ritualistic

practices, religious institutions and leaders, superstitions, and placebo diets in an attempt to

eradicate the parasomnia. 9​​ The researchers call on the medical field to explore sleep paralysis

more in-depth to raise awareness and provide medically sound explanations of the parasomnia.

This would help the public gain a better understanding of the risk factors that cause episodes and

the steps to take to eliminate occurrences.

Cultural interpretations of sleep paralysis are simply a band aid, there must be more

research to build a strong medical foundation consisting of causes and subsequently methods of

treatment. SP is a medical condition, not a fairy tale. A common trend emerged characterizing

three major HHEs that are suspected to be influenced by a multitude of health related conditions

and situational factors. The researchers’ discussion shows belief that lack of awareness about this

parasomnia contributes to fear, and suggests that if SP were better understood as a common

phenomenon and explored at its core that illusion of infrequency and invalidation could subside.

9
​Olunu, Esther, ​et al.​ “Sleep Paralysis, a Medical Condition with a Diverse Cultural Interpretation.” ​Department of
Basic Medical Sciences, School of Medicine.​ 8 (2018): 140
 References

Cheyne, J.Allen. “Situational Factors Affecting Sleep Paralysis and Associated Hallucinations:

Position and Timing Effects.” ​European Sleep Research Society n​ o. 11 (2002): 169-177

Cheyne, J.Allen, Steve D. Rueffer, and Ian R. Newby-Clark. “Hypnagogic and Hypnopompic

Hallucinations during Sleep Paralysis: Neurological and Cultural Construction of the

Night-Mare.”​ Consciousness and Cognition​ 8 (1999): 319-337

Denis, Dan, Christopher C. French, Alive M. Gregory. “A systematic review of variables

associated with sleep paralysis.” ​Sleep Medicine Reviews​ 38 (2018): 141-157

Olunu, Esther, Ruth Kimo, Esther Olufunmbi Onigbinde, Mary-Amadeus Uduak Akpanobong,

Inyene Ezekiel Enang, Mariam Osanakpo, Ifure Tom Monday, David Adeiza, Otohinoyi,

Adegbenro Omotuyi, John Fakoya. “Sleep Paralysis, a Medical Condition with a Diverse

Cultural Interpretation.” ​Department of Basic Medical Sciences, School of Medicine.​ 8

(2018): 137-142

Savini, Catherine. “Looking for Trouble: Finding Your Way into a Writing Assignment.”

Writing Spaces: Readings on Writing, Volume 2 ​(2011): 52-70

Sharpless, Brian A., Kevin S. McCarthy, Dianne L. Chambless, Barbara L. Milrod,

Shabad-Ratan Khalsa, and Jacques P. Barber. "Isolated Sleep Paralysis and Fearful

Isolated Sleep Paralysis in Outpatients with Panic Attacks." ​Journal of Clinical

Psychology​ 66, no. 12 (2010): 1292-306.