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The level is the same as all levels before it just harder.

Puppets

The puppets that have been in level 0-2 are in this stage but amped up and a bit more dangerous i.e The Screamer's scream radius (the size of the area that, when entered will cause him to scream will become bigger)

Story

No story is learned in this stage as it is just another stage that, aside from being harder and setting the skill req bar higher, has nothing much of interest. There is a Nightmare Poem at the end "These hands of mine you did not make, much less my breath you stole its shape!"