Doghramji, Karl

Sharpless, Brian A.

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Commentary: How to Make the Ghosts in my Bedroom Disappear? Focused-Attention Meditation Combined with Muscle Relaxation (MR Therapy)—A Direct Treatment Intervention for Sleep Paralysis

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Thomas Jefferson UniversityJefferson Digital CommonsDepartment of Sleep Medicine Faculty Papers Sleep Medicine at Jefferson: Hosted by the JeffersonSleep Disorders Center4-3-2017Commentary: How to Make the Ghosts in myBedroom Disappear? Focused-AttentionMeditation Combined with Muscle Relaxation(MR Therapy)-A Direct Treatment Interventionfor Sleep Paralysis.Brian A. SharplessArgosy UniversityKarl DoghramjiThomas Jefferson University, karl.doghramji@jefferson.eduLet us know how access to this document benefits youFollow this and additional works at: https://jdc.jefferson.edu/sleepmedicinefpPart of the Sleep Medicine CommonsThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inDepartment of Sleep Medicine Faculty Papers by an authorized administrator of the Jefferson Digital Commons. For more information, please contact:JeffersonDigitalCommons@jefferson.edu.Recommended CitationSharpless, Brian A. and Doghramji, Karl, "Commentary: How to Make the Ghosts in my BedroomDisappear? Focused-Attention Meditation Combined with Muscle Relaxation (MR Therapy)-ADirect Treatment Intervention for Sleep Paralysis." (2017). Department of Sleep Medicine FacultyPapers. Paper 7.https://jdc.jefferson.edu/sleepmedicinefp/7GENERAL COMMENTARYpublished: 03 April 2017doi: 10.3389/fpsyg.2017.00506Frontiers in Psychology | www.frontiersin.org 1 April 2017 | Volume 8 | Article 506Edited by:Gianluca Castelnuovo,Università Cattolica del Sacro Cuore,ItalyReviewed by:Christopher Charles French,Goldsmiths, University of London, UKJean-Pierre Jourdan,International Association forNear-Death Studies, France*Correspondence:Brian A. Sharplessbasharpless@gmail.comSpecialty section:This article was submitted toPsychology for Clinical Settings,a section of the journalFrontiers in PsychologyReceived: 09 October 2016Accepted: 17 March 2017Published: 03 April 2017Citation:Sharpless BA and Doghramji K (2017)Commentary: How to Make theGhosts in my Bedroom Disappear?Focused-Attention MeditationCombined with Muscle Relaxation(MR Therapy)—A Direct TreatmentIntervention for Sleep Paralysis.Front. Psychol. 8:506.doi: 10.3389/fpsyg.2017.00506Commentary: How to Make theGhosts in my Bedroom Disappear?Focused-Attention MeditationCombined with Muscle Relaxation(MR Therapy)—A Direct TreatmentIntervention for Sleep ParalysisBrian A. Sharpless 1* and Karl Doghramji 21Clinical Psychology Program, American School of Professional Psychology, Argosy University, Northern Virginia, Arlington,VA, USA, 2 Jefferson Sleep Disorders Center, Thomas Jefferson University, Philadelphia, PA, USAKeywords: sleep paralysis, isolated sleep paralysis, cognitive behavior therapy, parasomnia, sleep-wake disordersA commentary onHow toMake the Ghosts in my BedroomDisappear? Focused-AttentionMeditation Combinedwith Muscle Relaxation (MR Therapy)—A Direct Treatment Intervention for Sleep Paralysisby Jalal, B. (2016). Front. Psychol. 7:28. doi: 10.3389/fpsyg.2016.00028We read with interest Dr. Jalal’s recent publication on another potential treatment option forrecurrent isolated sleep paralysis:Meditation Combined with Muscle Relaxation (MR Therapy). Theauthor is to be commended for adding to the limited literature on ameliorating problematic cases ofisolated sleep paralysis (ISP). As recently reviewed (Sharpless, 2016), there are few options available,pharmacological or otherwise, for the chronic and severe cases of ISP, and none of these yet possesscompelling evidence in favor of their efficacy.We appreciate the citation of our work in his article. However, we disagree with the author’sclaim that MR Therapy is the “first direct treatment” for ISP (Jalal, 2016, p. 1). This comment ispuzzling given that our 2015 book (i.e., Sharpless and Doghramji, 2015) was cited in this samemanuscript. Contained within is a manual titled Cognitive Behavioral-Therapy for Isolated SleepParalysis (CBT-ISP) and a corresponding adherence measure (pp. 237–272).CBT-ISP is a brief, systematic approach that focuses upon helping patients both prevent anddisrupt recurrent ISP episodes. In order to better clarify the nature of our own approach and tocompare and contrast it to MR Therapy, we detail CBT-ISP in Table 1 below.As can be seen, there are areas of substantial overlap between CBI-ISP and MR Therapy. Bothhave strong emphases on various forms of relaxation, symptom reappraisals, shifts in attentionaway from episode content, and the practice of disruption techniques while patients are in a supineposition. We should also note that both approaches are based upon panic disorder models.However, there are some notable points of divergence. First, MR Therapy discourages attemptsto move, whereas CBT-ISP actively encourages these attempts in order to directly disruptepisodes and shift attention away from potentially frightening symptoms (e.g., hallucinations).Our approach is based upon empirical work with sufferers who reported that these attempts wereeffective (Sharpless and Grom, 2016). Second, the author discourages attempts to control breathingwhereas we view this as a potential source of relaxation to be used “in the moment.” Third, heencourages the use of prayer as a form of relaxation/meditation whereas we are more cautiousSharpless and Doghramji Commentary on JalalTABLE 1 | Cognitive behavior therapy for isolated sleep paralysis (CBT-ISP).PREPARATORY THERAPEUTIC ACTIVITIESSelf-monitoring of ISP episodes via modified sleep diariesPsychoeducation about the nature of ISPPsychoeducation about the particular nature of ISP hallucinations (if present)Presentation of the cognitive-behavioral model for ISP including the predictable “sequence” of ISP episodes (e.g., the cycle of symptoms, role of maladaptive appraisals,and increasing levels of activation)In-session practice to dispute catastrophic thoughts associated with both paralysis and hallucinations (with instructions for homework)Imaginary rehearsal of disruption techniques (e.g., focused attention to mobilize a finger/toe or making attempts to cough in order to foster the return of movement anddispel hallucinations) during session. This is done while the patient is in a supine position using a chaise/couch. Following imaginary rehearsal, the patient is provided withinstructions for at home practice and in vivo application of these various disruption techniques during ISP episodesAPPROACHES TO ISP EPISODE PREVENTIONUse of ISP-specific sleep hygiene (e.g., ways to avoid sleep disruption, avoiding a supine sleeping position, limiting the use of certain substances prior to bed, removal ofmaladaptive avoidance behaviors)Use of diaphragmatic breathing, progressive muscle relaxation, meditation, and/or mindfulness exercises to reduce overall anxiety levels throughout the day (i.e., not onlyduring ISP episodes)Relapse-prevention instructions are provided during the last therapy session using a “coping-based” approachAPPROACHES TO ISP EPISODE DISRUPTIONApplied diaphragmatic breathing, relaxation, mindfulness, or meditation during ISP episodes with attempts to “remain calm” (e.g., use of reassuring self-talk, use ofdistraction to focus attention away from hallucinations, reappraisal of episode/symptom meanings) in order to both disrupt and shorten ISP episodesIn vivo application of episode disruption techniques. If the initial attempt is ineffective, patients are instructed to flexibly apply secondary disruption techniquesApplication of disruption techniques earlier and earlier in the predictable sequence of ISP episodesAdapted from Sharpless and Doghramji (2015). ISP, isolated sleep paralysis.about this, especially with patients who experience religious-themed hallucinations (e.g., demons, djinn). In general, CBT-ISPmore strongly emphasizes psychoeducation, episode prevention,and consistent self-monitoring of ISP episodes (using modifiedsleep diaries) than MR Therapy, but both agree that directlydisrupting ISP is important.It is obviously preferable to have multiple treatmentapproaches available in a clinician’s armamentarium as opposedto one. Efficacy rates for ISP approaches are not yet known, andit is very likely that both of these approaches will need to bemodified in response to emerging data.In closing, we believe that CBT-ISP (Sharpless and Doghramji,2015) is the first direct treatment for ISP. However, it may beimportant to note that academic debates about temporal priorityand differences in treatment foci are really moot points unlessthe phenomenon of recurrent ISP is more frequently assessed inresearch and clinical practice. This does not yet appear to be thecase. At least two studies to date have shown that a minority ofpatients experience ISP to such a degree that it is associated withsignificant clinical consequences (Sharpless et al., 2010; Sharplessand Grom, 2016). Unfortunately, at the time of this writing thereare not yet any empirically-supported treatment options availablefor sufferers.AUTHOR CONTRIBUTIONSAll authors listed have made substantial, direct, and intellectualcontribution to the work, and approved it for publication.REFERENCESJalal, B. (2016). How to Make the Ghosts in My Bedroom Disappear? Focused-Attention Meditation Combined with Muscle Relaxation (MR Therapy)—A Direct Treatment Intervention for Sleep Paralysis. Front. Psychol. 7:28.doi: 10.3389/fpsyg.2016.00028Sharpless, B. A. (2016). A clinician’s guide to recurrent isolated sleepparalysis. Neuropsychiatr. Dis. Treat. 12, 1761–1767. doi: 10.2147/NDT.S100307Sharpless, B. A., and Doghramji, K. (2015). Sleep Paralysis: Historical,Psychological, and Medical Perspectives. New York, NY: Oxford UniversityPress. doi: 10.1093/med/9780199313808.001.0001Sharpless, B. A., and Grom, J. L. (2016). Isolated sleep paralysis:fear, prevention, and disruption. Behav. Sleep Med. 14, 134–139.doi: 10.1080/15402002.2014.963583Sharpless, B. A., McCarthy, K. S., Chambless, D. L., MiIrod, B. L., Khalsa, S.,and Barber, J. P. (2010). Isolated sleep paralysis and fearful isolated sleepparalysis in outpatients with panic attacks. J. Clin. Psychol. 66, 1292–1306.doi: 10.1002/jclp.20724Conflict of Interest Statement: Both authors have received royalties from OxfordUniversity Press for the publication of their book Sleep Paralysis: Historical,Psychological, and Medical Perspectives.Copyright © 2017 Sharpless and Doghramji. This is an open-access article distributedunder the terms of the Creative Commons Attribution License (CC BY). The use,distribution or reproduction in other forums is permitted, provided the originalauthor(s) or licensor are credited and that the original publication in this journalis cited, in accordance with accepted academic practice. No use, distribution orreproduction is permitted which does not comply with these terms.Frontiers in Psychology | www.frontiersin.org 2 April 2017 | Volume 8 | Article 506

Commentary: How to Make the Ghosts in my Bedroom Disappear? Focused-Attention Meditation Combined with Muscle Relaxation (MR Therapy)-A Direct Treatment Intervention for Sleep Paralysis.

Name not available

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GENERAL COMMENTARY
published: 03 April 2017
doi: 10.3389/fpsyg.2017.00506
Frontiers in Psychology | www.frontiersin.org 1 April 2017 | Volume 8 | Article 506
Edited by:
Gianluca Castelnuovo,
Università Cattolica del Sacro Cuore,
Italy
Reviewed by:
Christopher Charles French,
Goldsmiths, University of London, UK
Jean-Pierre Jourdan,
International Association for
Near-Death Studies, France
*Correspondence:
Brian A. Sharpless
basharpless@gmail.com
Specialty section:
This article was submitted to
Psychology for Clinical Settings,
a section of the journal
Frontiers in Psychology
Received: 09 October 2016
Accepted: 17 March 2017
Published: 03 April 2017
Citation:
Sharpless BA and Doghramji K (2017)
Commentary: How to Make the
Ghosts in my Bedroom Disappear?
Focused-Attention Meditation
Combined with Muscle Relaxation
(MR Therapy)—A Direct Treatment
Intervention for Sleep Paralysis.
Front. Psychol. 8:506.
doi: 10.3389/fpsyg.2017.00506
Commentary: How to Make the
Ghosts in my Bedroom Disappear?
Focused-Attention Meditation
Combined with Muscle Relaxation
(MR Therapy)—A Direct Treatment
Intervention for Sleep Paralysis
Brian A. Sharpless 1* and Karl Doghramji 2
1Clinical Psychology Program, American School of Professional Psychology, Argosy University, Northern Virginia, Arlington,
VA, USA, 2 Jefferson Sleep Disorders Center, Thomas Jefferson University, Philadelphia, PA, USA
Keywords: sleep paralysis, isolated sleep paralysis, cognitive behavior therapy, parasomnia, sleep-wake disorders
A commentary on
How toMake the Ghosts in my BedroomDisappear? Focused-AttentionMeditation Combined
with Muscle Relaxation (MR Therapy)—A Direct Treatment Intervention for Sleep Paralysis
by Jalal, B. (2016). Front. Psychol. 7:28. doi: 10.3389/fpsyg.2016.00028
We read with interest Dr. Jalal’s recent publication on another potential treatment option for
recurrent isolated sleep paralysis:Meditation Combined with Muscle Relaxation (MR Therapy). The
author is to be commended for adding to the limited literature on ameliorating problematic cases of
isolated sleep paralysis (ISP). As recently reviewed (Sharpless, 2016), there are few options available,
pharmacological or otherwise, for the chronic and severe cases of ISP, and none of these yet possess
compelling evidence in favor of their efficacy.
We appreciate the citation of our work in his article. However, we disagree with the author’s
claim that MR Therapy is the “first direct treatment” for ISP (Jalal, 2016, p. 1). This comment is
puzzling given that our 2015 book (i.e., Sharpless and Doghramji, 2015) was cited in this same
manuscript. Contained within is a manual titled Cognitive Behavioral-Therapy for Isolated Sleep
Paralysis (CBT-ISP) and a corresponding adherence measure (pp. 237–272).
CBT-ISP is a brief, systematic approach that focuses upon helping patients both prevent and
disrupt recurrent ISP episodes. In order to better clarify the nature of our own approach and to
compare and contrast it to MR Therapy, we detail CBT-ISP in Table 1 below.
As can be seen, there are areas of substantial overlap between CBI-ISP and MR Therapy. Both
have strong emphases on various forms of relaxation, symptom reappraisals, shifts in attention
away from episode content, and the practice of disruption techniques while patients are in a supine
position. We should also note that both approaches are based upon panic disorder models.
However, there are some notable points of divergence. First, MR Therapy discourages attempts
to move, whereas CBT-ISP actively encourages these attempts in order to directly disrupt
episodes and shift attention away from potentially frightening symptoms (e.g., hallucinations).
Our approach is based upon empirical work with sufferers who reported that these attempts were
effective (Sharpless and Grom, 2016). Second, the author discourages attempts to control breathing
whereas we view this as a potential source of relaxation to be used “in the moment.” Third, he
encourages the use of prayer as a form of relaxation/meditation whereas we are more cautious
Sharpless and Doghramji Commentary on Jalal
TABLE 1 | Cognitive behavior therapy for isolated sleep paralysis (CBT-ISP).
PREPARATORY THERAPEUTIC ACTIVITIES
Self-monitoring of ISP episodes via modified sleep diaries
Psychoeducation about the nature of ISP
Psychoeducation about the particular nature of ISP hallucinations (if present)
Presentation of the cognitive-behavioral model for ISP including the predictable “sequence” of ISP episodes (e.g., the cycle of symptoms, role of maladaptive appraisals,
and increasing levels of activation)
In-session practice to dispute catastrophic thoughts associated with both paralysis and hallucinations (with instructions for homework)
Imaginary rehearsal of disruption techniques (e.g., focused attention to mobilize a finger/toe or making attempts to cough in order to foster the return of movement and
dispel hallucinations) during session. This is done while the patient is in a supine position using a chaise/couch. Following imaginary rehearsal, the patient is provided with
instructions for at home practice and in vivo application of these various disruption techniques during ISP episodes
APPROACHES TO ISP EPISODE PREVENTION
Use of ISP-specific sleep hygiene (e.g., ways to avoid sleep disruption, avoiding a supine sleeping position, limiting the use of certain substances prior to bed, removal of
maladaptive avoidance behaviors)
Use of diaphragmatic breathing, progressive muscle relaxation, meditation, and/or mindfulness exercises to reduce overall anxiety levels throughout the day (i.e., not only
during ISP episodes)
Relapse-prevention instructions are provided during the last therapy session using a “coping-based” approach
APPROACHES TO ISP EPISODE DISRUPTION
Applied diaphragmatic breathing, relaxation, mindfulness, or meditation during ISP episodes with attempts to “remain calm” (e.g., use of reassuring self-talk, use of
distraction to focus attention away from hallucinations, reappraisal of episode/symptom meanings) in order to both disrupt and shorten ISP episodes
In vivo application of episode disruption techniques. If the initial attempt is ineffective, patients are instructed to flexibly apply secondary disruption techniques
Application of disruption techniques earlier and earlier in the predictable sequence of ISP episodes
Adapted from Sharpless and Doghramji (2015). ISP, isolated sleep paralysis.
about this, especially with patients who experience religious-
themed hallucinations (e.g., demons, djinn). In general, CBT-ISP
more strongly emphasizes psychoeducation, episode prevention,
and consistent self-monitoring of ISP episodes (using modified
sleep diaries) than MR Therapy, but both agree that directly
disrupting ISP is important.
It is obviously preferable to have multiple treatment
approaches available in a clinician’s armamentarium as opposed
to one. Efficacy rates for ISP approaches are not yet known, and
it is very likely that both of these approaches will need to be
modified in response to emerging data.
In closing, we believe that CBT-ISP (Sharpless and Doghramji,
2015) is the first direct treatment for ISP. However, it may be
important to note that academic debates about temporal priority
and differences in treatment foci are really moot points unless
the phenomenon of recurrent ISP is more frequently assessed in
research and clinical practice. This does not yet appear to be the
case. At least two studies to date have shown that a minority of
patients experience ISP to such a degree that it is associated with
significant clinical consequences (Sharpless et al., 2010; Sharpless
and Grom, 2016). Unfortunately, at the time of this writing there
are not yet any empirically-supported treatment options available
for sufferers.
AUTHOR CONTRIBUTIONS
All authors listed have made substantial, direct, and intellectual
contribution to the work, and approved it for publication.
REFERENCES
Jalal, B. (2016). How to Make the Ghosts in My Bedroom Disappear? Focused-
Attention Meditation Combined with Muscle Relaxation (MR Therapy)—
A Direct Treatment Intervention for Sleep Paralysis. Front. Psychol. 7:28.
doi: 10.3389/fpsyg.2016.00028
Sharpless, B. A. (2016). A clinician’s guide to recurrent isolated sleep
paralysis. Neuropsychiatr. Dis. Treat. 12, 1761–1767. doi: 10.2147/NDT.S1
00307
Sharpless, B. A., and Doghramji, K. (2015). Sleep Paralysis: Historical,
Psychological, and Medical Perspectives. New York, NY: Oxford University
Press. doi: 10.1093/med/9780199313808.001.0001
Sharpless, B. A., and Grom, J. L. (2016). Isolated sleep paralysis:
fear, prevention, and disruption. Behav. Sleep Med. 14, 134–139.
doi: 10.1080/15402002.2014.963583
Sharpless, B. A., McCarthy, K. S., Chambless, D. L., MiIrod, B. L., Khalsa, S.,
and Barber, J. P. (2010). Isolated sleep paralysis and fearful isolated sleep
paralysis in outpatients with panic attacks. J. Clin. Psychol. 66, 1292–1306.
doi: 10.1002/jclp.20724
Conflict of Interest Statement: Both authors have received royalties from Oxford
University Press for the publication of their book Sleep Paralysis: Historical,
Psychological, and Medical Perspectives.
Copyright © 2017 Sharpless and Doghramji. This is an open-access article distributed
under the terms of the Creative Commons Attribution License (CC BY). The use,
distribution or reproduction in other forums is permitted, provided the original
author(s) or licensor are credited and that the original publication in this journal
is cited, in accordance with accepted academic practice. No use, distribution or
reproduction is permitted which does not comply with these terms.
Frontiers in Psychology | www.frontiersin.org 2 April 2017 | Volume 8 | Article 506


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Commentary: How to Make the Ghosts in my Bedroom Disappear? Focused-Attention Meditation Combined with Muscle Relaxation (MR Therapy)-A Direct Treatment Intervention for Sleep Paralysis.

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