COMPARATIVE PREVALENCE OF ISOLATED SLEEP PARALYSIS IN KUWAITI, SUDANESE, AND AMERICAN COLLEGE STUDENTS 'x'

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1 Psychological Reports, 2004,95, O Psychological Reports 2004 COMPARATIVE PREVALENCE OF ISOLATED SLEEP PARALYSIS IN KUWAITI, SUDANESE, AND AMERICAN COLLEGE STUDENTS 'x' ABDELWAHID AWADALLA, GHENAIM AL-FAYEZ Department of Psychiatry, Faculty of Medicine Kuwait University MICHAEL HARVILLE California School of Professional Psychology-Fresno Alliant International University HIROKO ARIKAWA Forest Institute of Professional Psychology Springfield, Missouri MARIE E. TOMEO, DONALD I. TEMPLER, ROCKY UNDERWOOD California School of Professional Psychology-Fresno Alliant International University Summary.-A questionnaire measuring the incidence of isolated sleep paralysis was administered to 527 Kuwaiti, 762 Sudanese, and 649 American college students in what was the first study assessing the prevalence of isolated sleep paralysis in two Middle Eastern countries. Using the item "unable to move," 28.8% of Kuwaiti, 29.9% of Sudanese, and 24.5% of American participants reported experiencing the disorder at least once. When a second item, "pressure to the chest," was also used, the respective percentages were 19.2%, 20.7%, and 11.4%. With both criteria, the Kuwaiti and Sudanese had a significantly greater prevalence than did the American students. The Kuwaiti and Sudanese students did not differ significantly from each other in the percentage who reported the symptoms. The present study explored the prevalence of several symptoms of isolated sleep paralysis in college students in Kuwait and in the Sudan, comparing the prevalence rates with each other and with a sample of American college students. Sleep paralysis is often associated with narcolepsy, a neurological condition in which the person has uncontrollable naps (American Sleep Disorders Association, 1990). The narcolepsy tetrad consists of sleep attacks, cataplexy, sleep paralysis, and hypnogenic hallucinations (Chabas, Taheri, Renier, & Mignot, 2003). When the sleep paralysis experience occurs outside of a diagnosis of narcolepsy, it is called isolated sleep paralysis. Isolated sleep paralysis is a condition that usually occurs either at sleep 'This study was supported by Faculty of Medicine, Kuwait University Research Grant MQ 91/00. Address enquiries to D. I. Templer, California School of Professional Psychology-Fresno, Alliant International University, 5130 San Clinton Way, Fresno, CA

2 318 A. AWADALLA. ET AL. onset (hypnogogic), upon awakening (h ypnopompic), or during the transition between falling asleep and awakening (Conesa, 2000). In many cultures are descriptions of symptomatology of isolated sleep paralysis, but its earliest western medical description appears to be an account by E. Binns jn Binns termed isolated sleep paralysis a "day-mare." Schneck (1977) also reported an early description of isolated sleep paralysis in 1876 by S. Weir Mitchel who described sleep paralysis as "night palsy." However, Wilson (1928) was to be given credit for coining the term "sleep paralysis." In modern western history, Schneck (1944, 1948, 1952, 1960, 1961, 1966, 1977) holds an important place in research on isolated sleep paralysis as an investigator who brought its phenomenology to therapeutic circles and encouraged other researchers to pursue this work. In North America, the issue of isolated sleep paralysis seems not to be topical among clinicians and laypersons. However, studies have shown a high prevalence rate (62%) of isolated sleep paralysis experience in Newfoundland (Spanos, McNulty, DuBreuil, Pires, & Burgess, 1995); and in the United States, it appears to be more common in Black than White persons (Bell, Shakoor, Thompson, Dew, Hughley, Mays, & Shorter-Gooden, 1984). However, the ethnicity variable in prevalence of isolated sleep paralysis was not supported by other reports (Ness, 1978; Firestone, 1985). Isolated sleep paralysis was also frequently reported and recognized by several names in nonwestern cultures. The Japanese refer to at least some episodes of isolated sleep paralysis as "kanashibari" (Fukuda, Miyasita, Inugami, & Ishihara, 1987; Fukuda, Inamatsu, Kuroiwa, & Miyasita, 1991; Fukuda, 1993). The Chinese refer to these episodes as "ghost oppression" (Wing, Lee, & Chen, 1994). In Nigeria, it is called "oppression" among Christian faith healers (Ohaeri, 1997). It appears that there is a high prevalence of isolated sleep paralysis in Nigeria (Ohaeri, Odejide, Ikuesan, & Adeyemi, 1989; Ohaeri, Adelekan, Odejide, & Ikuesan, 1992). There are apparently no published studies on this disorder in Middle Eastern or Gulf states, and they have no name for it. It should be noted that the Sudan is an intersection between Africa and the Middle East, and both African and Arabic (Islamic) cultures and languages are evenly practiced. In several Asian studies, feeling pressure on the chest was regarded as an important component of isolated sleep paralysis. For example, in the Wing, et al.'~ study (1994) with Chinese subjects, "pressure on the chest" was the most common symptom after "unable to move and to speak." In the Fukuda, et al. study (1987) with Japanese subjects, "pressure on the chest" was the most common symptom after "unable to move," "unable to speak," and anxiety. In the research of Arikawa, Templer, Brown, Cannon, and Thomas-Dodson (1999), 70% of their Japanese subjects with sleep paralysis reported pressure on the chest.

3 COMPARATIVE PREVALENCE OF ISOLATED SLEEP PARALYSIS 3 19 Moreover, a history of sleep paralysis was found in 35% of 1,029 Hong Kong college students, 22% of 264 Japanese college students, and 22% of 202 American college students. Using a more restrictive definition that includes pressure on the chest, it was experienced by 16% of Hong Kong students, 9% of Japanese students, and 12% of American students (Lee, Yeung, Templer, Arikawa, Miller, Yu, Yoo, Chan, Kan, Kwan, Wong, & Yau, 1998). METHOD The study was more exploratory method than hypothesis-based. The participants were a randomly selected sample of students from different colleges and universities in Kuwait, Sudan, and the United States. The Kuwaiti and Sudanese students were approached individually on their campuses. The students were asked to complete a 10-item paper-and-pencil questionnaire, a process that required approximately 5 to 20 minutes. The English version of the questionnaire employed by Lee, et al. (1998) was translated into Arabic and written in a language that resembled common speech so that the participants would be able to read the questions comfortably. The Arabic version was back translated and pretested by an academic researcher to ensure the clarity of questions and instructions. The students were informed of the confidentiality and voluntary nature of participation and their right not to participate. Research assistants remained with the students while they completed the questionnaires to clarify items that were not well understood. All 527 Kuwaiti college students and 762 Sudanese college students were administered the Lee, et al. Arabic version of the questionnaire. The Kuwaiti participants, 205 (38.9%) male and 322 (61.1%) female, ranged in age from years with a mean of 19.6 yr. and a standard deviation of 3.8. The Sudanese participants, 363 (47.6%) male and 399 (52.4%) female, ranged in age from years with a mean of 23.1 yr. and a standard deviation of 3.8. The same recruitment procedure above was followed with American college students. The 649 participants, 309 (47.6%) male and 340 (52.4%) female, ranged in age from with a mean of 23.4 yr. and a standard deviation of 6.6. All students were administered the original English version of the Lee, et al. questionnaire contained in Table 1. TABLE 1 QUESTIONNAIRE ADMINISTERED TO ALL PARTICIPANTS Age Male Female Religion Ethnicity Country of Birth If an Asian or Asian American please state more specific ethnicity, e.g., Chinese. How long have you been living in the country you are now living in? 1. Have you ever woken up from sleep and A. Been unable to move? Yes No B. Felt something or someone on your chest? Yes No

4 A. AWADALLA. ET AL. RESULTS Table 2 contains the number and percentage of Sudanese, Kuwaiti, and American participants who reported isolated sleep paralysis by two different criteria. The first was experiencing being "unable to move" and the second was "unable to move plus pressure on the chest." Using these definitions, the percentages who experienced isolated sleep paralysis differed using the "unable to move" criterion (F,,>,,> = 3.73, p =.O2) and the "unable to move plus pressure on the chest" criterion (E;,3,2 = 12.79, p <.OOl). The American sample had a lower percentage of participants who had isolated sleep paralysis by the "unable to move" criterion than did the Sudanese (p=.o1) and the Kuwaiti (p =.03) participants, who did not significantly differ from each other. The Americans had a lower percentage of participants who had isolated sleep paralysis using "unable to move plus pressure on the chest" than did the Sudanese (p <.OO1) and the Kuwaiti (p <.OOl) participants, who did not differ from each other. TABLE 2 NUMBER AND PERCENT OF 762 SUDANESE, 527 KUWAITI, AND 649 AMERICAN PARTICIPANTS WHO REPORTED ISOLATED SLEE PARALYSIS USING CRITERIA "UNABLE TO MOVE" AND "UNABLE TO MOVE PLUS PRESSURE ON CHEST" Criteria Sudan Kuwait USA n % n % n % Unable to move Unable to move plus pressure on chest DISCUSSION Perhaps the most important aspect of this study is that it is the first one on isolated sleep paralysis in the Gulf and Middle Eastern countries. About one-fifth of sampled Kuwaiti college students and about one-fifth of sampled Sudanese college students reported isolated sleep paralysis as defined by "unable to move plus pressure on the chest." About 30% reported the syndrome as defined by the "unable to move" criterion. It is apparent that isolated sleep paralysis not only exists and is common in students of Kuwait and Sudan, but it is more common than in American college students in the present study, and more common than in Hong Kong, Japanese, and American college students in a previous study using the two symptoms "unable to move plus pressure on the chest" as a criterion for isolated sleep paralysis (Lee, et al., 1998). It is remarkable that in neither Kuwait nor Sudan is isolated sleep paralysis a recognized, named disorder. Perhaps the prevalence similarities of isolated sleep paralysis in Kuwaiti and Sudanese students could be attributed to the common religion of Islam or the common Arabic culture.

5 COMPARATIVE PREVALENCE OF ISOLATED SLEEP PARALYSIS 32 1 A final caveat is that it is not known whether any of the present participants had narcolepsy. Isolated sleep paralysis is sleep paralysis without narcolepsy. The Diagnostic and Statistical Manual of Mental Disorders-IV of the American Psychiatric Association (1994) states that the prevalence of narcolepsy varies from.o2% to.16% and that 30 to 50% of persons with narcolepsy have sleep paralysis. So on this basis, it can probably be assumed that few, if any, of the present participants had narcolepsy. REFERENCES AMERICAN PSYCHIATRIC ASSOCIATION. (1994) Diagnostic and statistical manual of mental disorders. (4th ed.) Washington, DC: APA. AMERICAN SLEEP DISORDERS ASSOCIATION. (1990) International classifcation of sleep disorders: diagnostic and coding manual. Rochester, MN: Author. ARIKAWA, H., TEMPLER, D. I., BROWN, R., CANNON, W. G., &THOMAS-DODSON, S. (1999) The structure and correlates of kanashibari. Journal of Psychology, 133, BELL, C. C., SHAKOOR, B., THOMPSON, B., DEW, D., HUGHLEY, E., MAYS, R., & SHORTER-GOODEN, K. (1984) Prevalence of isolated sleep paralysis in Black subjects. Journal of the National Medical Assocation, 76, CHABAS, D., TAHERI, S., RENIER, C., &MIGNOT, E. (2003) The genetics of narcolepsy. American Review of Genornics and Human Genetics, 4, CONESA, G. (2000) Geomagnetic, cross-cultural and occupational faces of sleep paralysis: an ecological perspective. Sleep and Hypnosis, 2, FIRESTONE, M. (1985) The "old hag" sleep paralysis in Newfoundland. The Journal of Psychoanalytic Anthropology, 8(1 I), FUKUDA, K. (1993) One explanatory basis for the discrepancy of reported prevalence of sleep paralysis among healthy respondents. Perceptual and Motor Skills, 77, FUKUDA, K., INAMATSU, N., KUROIWA, M., & MIYASITA, K. (1991) Personality of healthy adults with sleep paralysis. Perceptual and Motor Skills, 73, FUKUDA, K., MIYASITA, A., INUGAMI, M., & ISHIHARA, K. (1987) High prevalence of isolated sleep paralysis: Kanashibari phenomenon in Japan. Sleep, 10, LEE, S., YEUNG, S. W., TEMPLER, D. I., ARIKAWA, H., MILLER, J. L., Yu, L., YOO, L. D., CHAN, P., KAN, A., KWAN, W., WONG, M., & YAU, J. (1998) Nature of isolated sleep paralysis in Japan, Hong Kong, and United States. Onlinelournal ofpsychology, 4, NESS, R. C. (1978) The "old hag" phenomenon as sleep paralysis: a bio-cultural interpretation. Culture, Medicine, and Psychiaty, 2, OHAERI, J. U. (1997) The prevalence of isolated sleep paralysis among a sample of Nigerian civil servants and undergraduates. African Journal of Medical Sciences, 26, OHAERI, J. U., ADELEKAN, M. F., ODEJIDE, A. O., &IKUESAN, B. A. (1992) The pattern of isolated sleep among Nigerian nursing students. Journal of the National Medical Association, 84, OHAERI, J. U., ODEJIDE, A. O., IKUESAN, B. A., &ADEYEMI, J. D. (1989) The pattern of isolated sleep among Nigerian medical students. Journal of the National Medical Association, 81, SCHNECK, J. M. (1944) Case of addiction to Demerol. Bulletin of the Menninger Clinic, 8, SCHNECK, J. M. (1948) Sleep paralysis, psychodynamics. Psychiatric Quarterly, 22, SCHNECK, J. M. (1952) Sleep paralysis. Americdn Journal of Psychiaty, 108, SCHNECK, J. M. (1960) Sleep paralysis without narcolepsy or cataplexy: report of a case. Journal of the American Medical Association, 173, SCHNECK, J. M. (1961) Sleep paralysis. Psychodynarnics, 2, SCHNECK, J. M. (1966) Legal insanity, moral insanity, and Standhal's "le rouge et le noir." Medical Histoy, 10,

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