Anxiety & Mood
Sleep paralysis: why it happens and what helps
What happens in the body during sleep paralysis, why it can feel like someone is in the room, how common it is, what helps and when to see a doctor.
Sleep paralysis is a brief state in which you wake up or fall asleep fully aware, but cannot move or speak. It happens because the muscle relaxation that comes with REM sleep continues for a short while after you have already woken up. It often comes with intense fear and vivid hallucinations. It is frightening but benign, and it passes on its own.
What happens in the body
In REM sleep, the stage with the most vivid dreams, the body’s muscles relax almost completely. In sleep paralysis the brain wakes up, but this relaxation lasts a little longer. The eyes move, but the body does not obey. Dream activity often carries on too, which is why you see, hear or feel things that are not there [2].
Episodes are usually short: from a few seconds to 20 minutes, with an average of about 6 minutes. The feeling that you cannot breathe is common. Researchers attribute it to the muscle relaxation, which changes how breathing feels [2].
What an episode is like
One study in large samples divided the experiences into three groups [3]:
“The intruder”: a sense that someone or something is in the room, fear, sounds or figures.
“The weight on the chest”: pressure on the chest, difficulty breathing, sometimes pain.
Unusual bodily sensations: a feeling of floating, flying or leaving your body.
Of 185 people with sleep paralysis who were examined with a clinical interview, 57.8% sensed a “presence” in the room and 21.6% saw human figures. Only about 1 in 10 had significant distress because of the episodes [4].
In an international survey, of the 3,523 participants who had had at least one episode, 76% reported intense fear. Most (63.3%) believed it was caused by “something in the brain” and only 7.1% by supernatural causes [5]. Doctors and scholars have described the phenomenon since the time of the ancient Greeks, and in many cultures it has given rise to stories of “night visits”.
How common it is
In a review of 35 studies with 36,533 people, at least one episode of sleep paralysis had been experienced by [1]:
7.6% of the general population,
28.3% of students,
31.9% of psychiatric patients,
34.6% of people with panic disorder.
What makes it more likely
Short or broken sleep. People with sleep paralysis report shorter sleep, taking longer to fall asleep and more symptoms of insomnia. It is also common in people who work shifts [6].
Sleeping on your back. Episodes are more likely in this position.
Stress, trauma and anxiety. In a review of 42 studies, sleep paralysis was particularly common in post-traumatic stress disorder (PTSD) and, to a lesser extent, in panic disorder. It was also linked with substance use and with anxiety symptoms [6].
Is it dangerous? Am I “going mad”?
No. Sleep paralysis is benign. Its hallucinations appear only in the transition from sleep to wakefulness or the other way round, and this is what sets them apart from psychotic experiences. Thoughts such as “I am going mad” or “the paralysis will become permanent” are common, and they make some people start to fear sleep [2].
The “presence” in the room is real as an experience, not as a fact. What you feel is not proof of what is real. And the thought “I am going mad” is a symptom of fear, not a sign of madness.
What to do during an episode
There are no studies showing which technique works best. In a large survey, people themselves reported that small body movements or a noise helped them, with results that varied from person to person [5]. The techniques of the specific cognitive behavioural approach follow the same logic [2]:
Remind yourself what it is: “sleep paralysis, it will pass”.
Try to relax instead of fighting with all your strength.
Focus on a small movement, for example of your fingers or toes.
What helps make episodes less frequent
Most people with sleep paralysis do not need treatment, because they do not have significant distress. For those who do, a 2016 review noted that no randomised treatment trial had yet been carried out. The recommendations rest on small studies, on data from narcolepsy and on clinical experience [2]:
Information and reassurance. Understanding what is happening already helps many people.
A regular sleep schedule. The same time for going to bed and getting up, no alcohol or caffeine before bed and, if possible, not sleeping on your back or on your front.
Treating insomnia or anxiety, when present.
Cognitive behavioural therapy specific to sleep paralysis: a short programme with relaxation techniques and ways to interrupt an episode and to handle the hallucinations and catastrophic thoughts. It is promising, but it has not been tested in large studies.
Medication. In severe cases, antidepressants that suppress REM sleep have been used, such as tricyclics and selective serotonin reuptake inhibitors. The data are limited and come mainly from narcolepsy. The decision is made only after an assessment, and stopping is done only with your doctor, because stopping abruptly can cause a REM sleep “rebound”.
When fear of the next episode makes you stay up late or avoid going to bed, avoidance keeps the problem going: less sleep, and more broken sleep, make episodes more likely. The aim is for sleep to become something ordinary again, step by step, not to wait for the fear to go away first.
Sleep paralysis or something else?
Narcolepsy. Sleep paralysis is one of its symptoms. Narcolepsy, however, is mainly marked by severe sleepiness during the day and by cataplexy, that is, episodes of sudden muscle weakness while you are awake [7].
A panic attack during sleep. You wake up suddenly with a racing heart and fear, but you can move.
Epileptic seizures or other neurological causes. These are rarer, but they need to be ruled out when the picture is not typical.
In the assessment, I first ask how you sleep: hours, awakenings, shifts, caffeine. If your sleep has lost its rhythm, that is where the work starts.
When to ask for help
Episodes are frequent, frighten you or make you afraid of going to sleep.
You have severe sleepiness during the day or episodes of sudden muscle weakness while awake. In that case you need an assessment for narcolepsy by a sleep specialist.
The episodes come with insomnia, panic attacks or recurring memories of trauma.
You are not sure whether it is sleep paralysis or something else.
Safety: Sleep paralysis is not an emergency. But if you have episodes with convulsions, loss of consciousness or weakness that does not pass, get medical help immediately: 166 (ambulance, EKAV) or 112. If you have thoughts of harming yourself, call 166, 112 or the Suicide Prevention Line 1018.
How I can help
Book a psychiatric assessment, at the practice in Trikala or online. See also the page on sleep disorders. If you often stay up late because you find it hard to “close” your day, read the article on ADHD and sleep too. The first conversation about your sleep can also take place from your home: see how working with an online psychiatrist works, or book an appointment.
This article is educational and does not replace individual clinical assessment. Do not change or stop any treatment you are already taking without talking to your doctor.
Sources
Sharpless BA, Barber JP. Lifetime prevalence rates of sleep paralysis: a systematic review. Sleep Med Rev. 2011. https://doi.org/10.1016/j.smrv.2011.01.007
Sharpless BA. A clinician’s guide to recurrent isolated sleep paralysis. Neuropsychiatr Dis Treat. 2016. https://doi.org/10.2147/NDT.S100307
Cheyne JA, Rueffer SD, Newby-Clark IR. Hypnagogic and hypnopompic hallucinations during sleep paralysis: neurological and cultural construction of the night-mare. Conscious Cogn. 1999. https://doi.org/10.1006/ccog.1999.0404
Sharpless BA, Kliková M. Clinical features of isolated sleep paralysis. Sleep Med. 2019. https://doi.org/10.1016/j.sleep.2019.03.007
Rauf B, et al. Isolated sleep paralysis: Clinical features, perception of aetiology, prevention and disruption strategies in a large international sample. Sleep Med. 2023. https://doi.org/10.1016/j.sleep.2023.02.023
Denis D, French CC, Gregory AM. A systematic review of variables associated with sleep paralysis. Sleep Med Rev. 2018. https://doi.org/10.1016/j.smrv.2017.05.005
Bassetti CLA, et al. Narcolepsy — clinical spectrum, aetiopathophysiology, diagnosis and treatment. Nat Rev Neurol. 2019. https://doi.org/10.1038/s41582-019-0226-9
