Chapter 12

Night Terrors and Other Frightening or Unpleasant Sleep Problems

In This Chapter

Shaking in fear from night terrors

Dealing with nightmares

Understanding hypnagogic hallucinations

Coping with REM sleep behavior disorder

Living with sleep paralysis

Eliminating nocturnal seizures and sleep-related painful erections

Looking at REM-related sinus arrest

Many people in the United States and Canada pay millions of dollars each year just to be scared senseless. No matter what the chill or the spill, they’re game.

Hollywood makes bad horror movies, and people stampede to them, making them major box-office hits. Stephen King’s spooky novels top the best-selling lists, and people troop through one haunted house after another at Halloween, all in hopes of feeling just one little thrill of terror.

But terror is quite a different animal when it comes knocking on your bedroom door uninvited in the middle of the night and interferes with your sleep. That kind of terror is most unwelcome. Unfortunately, millions of Americans have to deal with night terrors and other distressing, frightening, unpleasant, or painful sleep problems.

Sleepers may awaken terrified and inconsolable when they experience an episode of parasomnia like night terrors. Their hearts are racing, and they’re completely panicked. The fascinating thing is that often the person is unable to explain what was so frightening. The sleeper may go back to sleep and awaken the next morning with little or no recollection of the episode.

Other scary parasomnias include nightmares and terrifying hypnagogic hallucinations. (Hypnagogic hallucinations are images that occur when a person is falling asleep; hypnopompic hallucinations take place when a person is waking up.) Both of these parasomnias are essentially frightening dreams, but they arise from different sleep states. In all these scary parasomnias, a sleeper can be so terrified by an image or dream in his mind, and so convinced of the danger’s reality and imminence, that he may seriously injure himself in an attempt to flee. Some sleepers have fallen down a flight of stairs or leaped through a window in a frantic effort to escape. Injury is especially common in people with persistent REM sleep behavior disorder (RBD). RBD can turn sleepers into violent and terrifying strangers who may attack and seriously injure their sleeping bedmates or themselves. Still other conditions, like painful erections, can awaken the sleeper with sudden agonizing pain.

In this chapter, we cover the world of frightening sleep disorders along with their symptoms and treatment options. So hold your partner’s hand, and you can look under the bed together.

Being Scared Out of Your Wits and Not Knowing Why — Night Terrors

Soon after you first fall asleep, you sleep deeply with your brain relaxing into what is called slow wave sleep (SWS) or deep non-REM (NREM) sleep. This period lasts about 45 minutes to an hour and 15 minutes or so. Then you transition back to a lighter sleep, or may even partially awaken for a few seconds. This is part of the normal sleep pattern.

However, some people can’t seem to make the transition between sleep stages as easily, and they get caught somewhere in between sleep and wakefulness, with part of their brain in the awake state and the other part asleep. As we explain in Chapter 11, this problem can result in an arousal disorder; sleep or night terrors are in fact classified as an arousal disorder. The condition affects around 3 percent of all children but less than 1 percent of adults. However, that 1 percent suffers terribly with the condition.

When individuals have sleep terrors, they awaken abruptly, usually from SWS, with racing hearts, profuse sweating, and rapid breathing. They appear terrified. They’re in an agitated state of panic but usually can’t tell you what is so frightening. Sometimes they may describe an image, but it’s usually isolated.

Note that there is a confusion of different medical terms for night terrors, nightmares, and terrifying hypnagogic hallucinations. In the older terminology, children diagnosed with night terrors were said to be suffering from pavor nocturnus, which is a literal translation of night t errors. For years the medical literature referred to a similar condition as incubus. Incubus is the Latin word for “small demon,” which underlines the fact that for centuries people thought that night terrors were somehow related to demonic possession. We’re happy to report they aren’t. The original term nacht mare from which “nightmare” is derived translates to “night spirit” and was often used in the old literature to refer to the same condition. The “night spirit” personification differed as a function of culture and time.

Whether it was Lillith in the Old Testament era, an incubus or succubus in European middle ages, vampires later in eastern Europe, the Old Hag in Scotland, witch-riding in the American Civil War era, or an alien abduction in modern-day Texas, a common thread exists that is currently labeled terrifying hypnagogic hallucination, not nightmare and not night terror. Are you confused yet? You should be! In the following section, we try to make sense out of this unfortunate use of the same terms to describe different things.

Don’t confuse night terrors with nightmares or terrifying hypnagogic hallucinations; they’re three completely different and unrelated events that arise out of different parts of the sleep cycle. Although people who suffer from night terrors may also have nightmares, people who have the occasional nightmare will only very rarely ever experience an episode of night terrors. Other people may have nightmares regularly and never experience a terrifying hypnagogic hallucination.

To help you better understand the difference between night terrors, terrifying hypnagogic hallucinations, and nightmares, we compare them in Table 12-1.

Table 12-1 Comparing Night Terrors, Hypnagogic Hallucinations, and Nightmares

Night Terrors	Terrifying Hypnagogic	Nightmares
	Hallucinations
Not associated with	Sleeper can recall some	Occur during dreams
dreaming	details and remembers
	being unable to move
	and/or feeling crushed
Occur during NREM	Occur during the REM-	Occur during REM sleep
sleep	NREM transition
Sleeper has little or no	Associated with a dream	Sleeper easily recalls
memory of the episode	of a being or monster often	details of this scary dream
	sitting on the dreamer’s
	chest, possibly sucking the
	life force out of him or
	having sex with him
Disoriented and confused	Sometimes disoriented but	No disorientation or
upon awakening	not usually	confusion upon awakening
May be accompanied	No sleepwalking	No sleepwalking
by sleepwalking
Greatly increased heart	Greatly increased heart	Mild or no increase of
rate and blood pressure	rate and blood pressure	heart rate and blood
with other autonomic	with other autonomic	pressure with no other
symptoms (for	symptoms (for example,	accompanying physical
example, sweating)	sweating)	symptoms

Causes

Researchers and doctors still aren’t sure of the exact cause of night terrors. Most experts believe the origin is usually physiological. They believe the intense SWS activity (the type characteristic in childhood) precipitates sleep terrors. Being sleep deprived (which can lead to increased SWS activity) has been known to provoke night terrors. Being off your regular sleep schedule can also contribute to an episode. Furthermore, stress and anxiety can also serve as triggers. However, psychological factors usually play a minor role. Nonetheless, in rare cases, sleep terrors can result from a traumatic experience, the memory of which may even be suppressed during wakefulness (for example, sexual assault).

Certain medications, like tricyclic antidepressants and MAO inhibitors, can reportedly increase the incidence of night terrors, especially if you stop taking them suddenly. Alcohol and drug abuse can also make you more susceptible.

Doctors do know that the underlying biological mechanism of night terrors is the overactivation of the sympathetic autonomic nervous system, but no one knows for sure what causes this overactivation. A tendency definitely exists for the condition to run in families, but researchers haven’t yet identified the gene associated with such attacks.

Until researchers can identify the exact cause of night terrors, and develop effective treatments to prevent episodes, doctors can treat the symptoms preventively.

Symptoms

Night terrors are associated with distinctive and dramatic signs and symptoms, including (from most common to least common):

Waking with a piercing, panic-stricken scream, following by moaning, grunting, or gasping

Racing, pounding heart that may reach a rate as high as 160 to 170 beats per minute

Profuse sweating

Rapid breathing

Extreme agitation

Increased blood pressure

Activation of the fight or flight response (which means when someone feels like he’s in mortal danger, his brain can engage in heightened abilities for fleeing and defending)

Violent body movements with thrashing

Episodes last anywhere from 5 to 20 minutes

Eyes can be wide open or closed; open is more common

Unresponsive to efforts to comfort them, or may even react violently or aggressively toward those trying to help

Poor recall or no memory of the episode upon awakening the next morning

Can occur with sleepwalking

An episode of night terrors isn’t only dangerous for the sleeper, but it can also be perilous for his bedmate. Although not common, people in the throes of an attack have been known to suffer fractures, contusions, and large cuts. If the bedmate attempts to intervene in the episode, she may get injured, not intentionally, but simply out of the unreasoning fear felt by the person experiencing the terror episode.

Treatment

Offering support and assistance to the person suffering from night terrors is the best way to help him through an episode. Talk to the person quietly in a reassuring tone of voice. Be careful about touching him until he starts to calm down. The sleeper may interpret a simple touch as an attack from the “thing” he fears.

If you suffer from night terrors, establish and maintain a regular bedtime. Sleep deprivation is a very common precipitant for sleep terror (especially in children). Also, try to minimize stress and anxiety. Avoid drinking caffeinated beverages late in the day. Avoid becoming overly tired and eating heavy meals close to bedtime, because these situations can predispose you to an episode.

Accident-proof the bedroom to minimize risk of injury to the sleeper, and secure all doors and windows to keep the sleeper from getting outside.

Adult patients who suffer from frequent episodes of night terrors may well benefit from some counseling or psychotherapy to help them keep the episodes in perspective.

No truly effective drug treatment is available; some doctors prescribe a short course of tricyclic antidepressants to see if they can reduce the frequency and intensity of episodes, and other doctors recommend a dose of a sleep-inducing medication like Benadryl as a way to reduce episodes. Other doctors have reported some success with hypnosis or biofeedback, but the basis for the success or failure of these two techniques isn’t known. No clinical trial data are currently available concerning any particular treatment’s worth.

Confronting the Monster in the Closet — Nightmares

Unfortunately, nightmares don’t just happen on Elm Street. They happen all over the world, to people of all races and both sexes, but males seem to experience nightmares more frequently than females. Strictly speaking, a nightmare isn’t a sleep disorder, and nightmares aren’t necessarily indicative of any underlying physical or psychological ailment. Nightmares are just bad dreams that wake you up that you may or may not fully remember. Nightmares become a disorder when they occur frequently or have such an intensity that they disturb sleep, lead a person to become afraid of sleeping, or produce sleeplessness.

Nightmares occur during REM sleep, the part of the night you’re most likely to dream. But unlike night terrors, where the person is so terrified and disoriented he can’t be comforted, a person who awakens with a nightmare becomes oriented quickly and usually can go back to sleep (although some people do have trouble settling down again after a particularly vivid nightmare). Unless some underlying psychological problem is present, most sleepers forget the troubling images and emotions of their nightmare by the next morning.

You may have heard that people dream in black and white, but that’s just not true. During a study in a sleep lab, two-thirds of the subjects who were awakened during REM sleep remembered dreaming in color.

Causes

Childhood nightmares often relate to some shock or fright a child has experienced or sometimes to a traumatic experience. (See Chapter 14 for more about childhood sleep disorders.) The event somehow figures into the nightmare through a process Freud called daytime residue, even if only in a symbolic way. (Daytime residue refers to the dream process, including features relating to events and experiences that happened during the previous 24 to 72 hours.) As the child matures and figures out how to deal with his fears and emotions in his waking life, nightmares may diminish in frequency and intensity or disappear altogether.

As adults, your nightmares may still be related to something in your day-to-day lives, such as fear of losing your job, a divorce, or financial problems, but you may also experience nightmares completely unrelated to any waking event.

Violent events, like being injured in a car accident or physical assault, or being caught up in a catastrophic event like a war or natural disaster, can produce vivid and frightening nightmares during which you relive the upsetting experience over and over again. This type of recurring dream is a symptom of post traumatic stress disorder (PTSD). PTSD affects about 8 percent of the population, with about twice as many women as men being affected. PTSD can last for years unless you seek appropriate treatment, which may include both psychotherapy, to help you deal with your distress, and medi-cations, to alleviate your symptoms, including recurring nightmares. (See Chapter 5 for more on PTSD and how it affects sleep.)

Alcohol and drug abuse can also lead to nightmares, as can some prescription drugs. Certain foods may trigger nightmares; for example, studies have shown that chocolate can induce violent nightmares in susceptible individuals (while other people may only get violent if you try to keep them away from chocolate!).

Table 12-2 lists some common medications that can trigger nightmares.

Table 12-2 Medications and Substances That Can Cause Nightmares

Taking Can Cause Nightmares	Stopping Can Cause Nightmares
Beta blockers	Barbiturates
Flutamide	Benzodiazepines
Ketamine	Ethanol
Procarbazine
Short-acting barbiturates

Some folks swear that watermelon, anchovies, spicy food, sugar, and artificial preservatives and colorings all cause nightmares, but no scientific data can back up these claims. However, spicy or heavy foods can cause nighttime indigestion that interferes with restful sleep, so avoid eating anything close to bedtime. Gastric pain caused by problematic foods, such as chili or pizza, can be incorporated into dreams and awaken the sleeper so that she realizes she was having a bad dream.

About 5 to 7 percent of adult Americans report they have nightmares, some occasionally, some on a recurring basis. That figure rises dramatically among drug abusers and alcoholics, with 25 percent of them reporting that they experience recurring nightmares.

If you’re under a lot of stress, you may also find yourself being awakened by a bad dream — one that usually relates, at least symbolically, to the source of the stress. That’s one more good reason to get your stress levels under control as quickly as possible.

Symptoms

Nightmares are bad dreams that wake you up. The sleeper is immediately and fully alert when she wakes up and usually can recall her bad dream vividly and in great detail. (Contrast this to night terrors, where the sleeper can’t tell you what is frightening him.)

Many nightmares have a common theme. You may dream of suddenly finding yourself naked in a public place, that you’re falling or about to fall from an extreme height, or that you’re being chased by some nameless, faceless person or dangerous animal. In general, the process of the dream is your clue to understanding it. For instance, if you’re falling, things are out of your control in the dream, and may also be in your waking life. It is therefore important to know whether or not you land on your feet!

Interpreting dreams

Since ancient times, certain people have been renowned for their ability to interpret the meaning of dreams. The Pharaoh of Egypt rewarded Joseph for correctly interpreting a troubling dream by making him his chief adviser. In the Talmud, a mercenary dream interpreter named Bar Hedia gave favorable dream interpretations to anyone who paid him well, and unfavorable interpretations to people without money. His readings became prophetic because, once people heard his advice, they unconsciously set out to make it come true. This story gave rise to the cliché, “dreams follow the mouth,” meaning that whatever interpretation someone gives to a dream usually comes true.

Remember that dreaming is a process of the dreamer’s brain. The experiences, thoughts, preoccupations, wishes, and fears that the dreamer has during the day are in the same brain that dreams at night. Symbols appearing in dreams have different meanings for different people; universal symbols are only universal to the extent they’re universal within a culture. Nonetheless, people have developed elaborate, complex, and fanciful explanations about dream symbols and dream meanings. Keep in mind that everything in your dream was put there by you; no one scripted the dream for you. The overall process of what is happening in the dream is more informative than any given symbol.

If you want to know more about dream interpretation, check out these interesting Web sites on the subject:

www.mythsdreamssymbols.com/ offers common interpretations to hundreds of dream symbols, arranged alphabetically.

www.dreammoods.com/ features an alphabetical dream dictionary, along with interpretations of the most common dreams and the most frequent appearances and contexts of favorite dream symbols.

If you’re suffering from PTSD, you may dream the same troubling dream over and over again, or relive the same trauma, seeing the same images and feeling the same emotions that accompanied the original triggering event.

Nightmares usually awaken the sleeper; after awake and alert, the sleeper can recall images and emotions from the bad dream very easily. Fortunately, people waking up from nightmares also orient themselves very quickly to reality and can usually get back to sleep, although it can take them a while.

Although having a nightmare may be distressing, most people aren’t troubled by them and don’t ascribe any particular significance to them. They recognize nightmares as a feature of sleep and nothing to worry about. Unless nightmares become persistent and routinely interfere with sleep, you don’t need to seek treatment or counseling.

Nightmares produce distinct emotions, including

Anxiety

Fear

Frustration

Guilt

Sadness

Although these emotions may feel very strong at the time of the nightmare, by the time you wake up, you may not remember the feelings or any of your nightmare’s content other than a vague sense of unease.

Unlike sleep terrors, nightmares produce very few physical symptoms other than a slightly elevated pulse and respiration rate.

Treatment

Most nightmares don’t require any treatment. However, if your nightmares are disturbing you, you can follow the usual advice for going to bed at the same time each night, make sure your sleeping accommodations are comfortable and to your liking, and avoid drugs, alcohol, and heavy meals close to bedtime to minimize the frequency of your nightmares. If you continue to feel disturbed by your nightmares, consult your doctor for appropriate treatment suggestions. Researchers are currently working on several medications with respect to their usefulness for treating nightmares; however, it’s too early to tell if they work.

Hypnagogic Hallucinations (Sometimes Terrifying, Usually Not)

When you were a child, you probably had fun sitting at slumber parties and around campfires telling horror stories. But what if you woke up one night and were completely convinced that a real vampire was actually in the room with you, sitting on your chest sucking your life juices out of you? You were likely having a terrifying hypnagogic hallucination.

Hypnagogic hallucinations are sensory events that occur at sleep onset and aren’t the same as delusions or hallucinations experienced by people with psychosis. Usually in a hypnagogic hallucination, you see a dreamlike vision or even smell something, and it all seems very real. They can happen just when you’re falling asleep or when you’re waking up. A large majority of people experience them at one time or another.

Just in case anyone at the office happens to ask: If a dreamlike image occurs as you’re falling asleep, it’s referred to as hypnagogic. If it occurs while you’re waking up, it’s called hypnopompic.

People with narcolepsy (see Chapter 10) experience hypnagogic hallucinations more frequently than people who don’t have a sleep disorder, and about 4 to 8 percent of narcoleptics experience a more extreme form called terrifying hypnagogic hallucinations that is very rarely seen in the general population.

Although hypnagogic hallucinations usually aren’t frightening, sometimes they can be terrifying. The witches, goblins, ghosts, and ghouls of fairy tale lore likely have their inspiration in these sometimes-demonic apparitions. As we mention earlier in this section, this sleep phenomenon used to be classed as incubus and part of pavor nocturnes, often involving the sleeper being attacked by a demon who sat on his chest, making breathing difficult and causing the sleeper to feel paralyzed.

Causes

Researchers haven’t identified a real cause for hypnagogic and hypnopompic hallucinations, but as with so many other conditions, being under a high level of stress can certainly lead to an increase in the frequency of hallucinogenic episodes. Hallucinations that occur with another condition, such as narcolepsy, may arise as a symptom of that condition.

Symptoms

Hallucinations that occur during sleep transitions can produce a variety of symptoms, mostly sensory in nature. Sleepers are sure that they see, feel, hear, or smell something extraordinary and frequently frightening. Even though the event is brief, the feelings the hallucination produces are quite strong, and sleepers may be utterly convinced that what they experienced was quite real. Usually, however, and especially on reflection, the person knows that the experience wasn’t real but just seemed real. Sometimes a person may be concerned that he’s losing his mind, slipping over the edge, as it were. However, a true loss of the ability to recognize reality seldom exists, unless the person has a coexistent psychiatric disorder.

Sometimes sleep paralysis accompanies the hallucination, which certainly is real and only serves to make the hallucination all the more terrifying, because the sleeper can’t react or respond to what he thinks is happening in his bedroom. The sleep paralysis can elevate a frightening situation to the level of panic. Some people may also feel like they’re suffocating or unable to breathe during the hallucination. The common description is that their chest feels crushed, sometimes as a result of a monster or witch sitting on their chest. (See “Frozen to the Bed — Sleep Paralysis,” later in this chapter for more on sleep paralysis.)

Common hallucinations include a stranger or intruder in the bedroom, footsteps approaching the bed, or wild animals or evil-looking monsters invading the bedroom. Sometimes sleepers report hearing a bell or seeing a flash of light. They may feel quite fearful, as if they were about to die or be murdered right in their beds. Then, just as quickly as it started, the hallucination ends.

Visiting aliens

As times change, so do the manifestations in sleep disorders. Alien visitations have become more common. The sleeper awakens in his room with a feeling that some presence is near. He becomes aware that he is paralyzed, and then a ghostlike figure or figures appear in his bedroom. They may be semi-transparent or shimmering in appearance and seem to hover. They make strange noises and may even communicate telepathically. Because many people aren’t as superstitious as their ancestors, they may not even be very fearful. Some people have told us about how these “visitors” have provided information to the patient about things that were happening or going to happen. In some cases, however, the person claims to have been abducted, had all sorts of things done to him, but then he’s returned to his bedroom and bed, apparently uninjured. This phenomena is all likely the modern day equivalent of incubus, vampires, and witch riders. We would classify the experience as terrifying hypnagogic hallucinations with sleep paralysis.

Treatment

Unless the symptoms are persistent and a cause of distress, you don’t need to seek treatment for hypnagogic or hypnopompic hallucinations. If you have narcolepsy and develop these hallucinations, particularly if sleep paralysis accompanies them, ask your doctor for a prescription.

When Sleep Turns Violent — REM Sleep Behavior Disorder

About 2 percent of all sleepers suffer from REM sleep behavior disorder (RBD), or episodes of violent, aggressive behavior during the night. These episodes aren’t only distressing, but can also be very dangerous for both the sleeper and his bedmate.

RBD primarily affects men, with 87 percent of the patients in one survey being male. The risk of RBD increases with age, and it becomes more prevalent after age 60.

As we explain in Chapter 1, even though your body is fairly still during sleep, your brain becomes quite active during REM sleep, the stage of sleep where you may dream. During REM sleep, your body’s muscles are in a state of atonia, or what is commonly called sleep paralysis. (See “Frozen to the Bed — Sleep Paralysis” later in this chapter for more information.)

The neurotransmitter glycine is responsible for controlling spinal activity. During REM sleep, the brainstem stops sending messages that tell your muscles to move.

Although doctors and researchers don’t know exactly why you become atonic during REM sleep, they speculate that it’s one of nature’s safeguards, designed to keep you from getting out of bed during a dream and injuring yourself while you try to act out your dream. Even as your brain enters REM sleep, your body remains still and quiet, perhaps to make sure that you keep sleeping peacefully even though you’re dreaming.

If you have RBD, you really can hurt yourself or your bedmate. In one survey, 32 percent of RBD patients injured themselves seriously enough during an episode to require medical attention, while 64 percent had inflicted injuries during an RBD assault on their bedmates that required medical attention.

In RBD, something goes wrong with the mechanism that paralyzes the body. The result: As you begin to dream, you actually act out your dream. You may be dreaming that you’re playing football and leap up from bed and tackle your dresser, run headfirst into a wall, or dive over the goal line that in reality is your bathroom. The episodes are so intense that you can easily injure yourself or your bedmate without realizing what you’re doing. RBD differs largely from sleepwalking because the actions are in response to the dream content, and you can recall, sometimes in great detail, your dream upon awakening. Also, you’re acting on the dream’s content, not in the real world. So for instance, a sleepwalker can walk over to a window, open it, and step out. By contrast, in RBD, you may leap through the window dreaming about diving off a diving board into a pool.

Causes

In many cases, the cause of RBD is unknown. But some known medical conditions can precipitate the development of RBD, including some brain tumors, dementia, multiple sclerosis, certain types of brain atrophy, a progressive type of palsy, and even Parkinson’s disease. In fact, in some cases, RBD precedes the development of Parkinson’s disease by several years, but not all patients with RBD get Parkinson’s, so the connection isn’t automatic. Researchers also think the degeneration of neurons in the brainstem play a significant role.

Symptoms

When a person with RBD enters REM sleep, he may start to violently act out his dreams. He may kick, punch, jump, get up, run away from the bed, or engage in other intense physical activity. He is difficult to awaken, and violent and combative when approached by another person.

Treatment

Place the mattress on the floor to minimize injuries from falls, and pad or remove sharp or potentially dangerous objects from the bedroom.

Clonazepam is the drug of choice for treating RBD. It’s successful in controlling violent episodes in about 90 percent of patients. However, people with liver disease, sleep apnea, or glaucoma can’t take it. You must indefinitely continue the medication in order to maintain control of the violent episodes. Violent behavior reoccurs very quickly if the medication is stopped.

If the patient also has Parkinson’s disease, L-dopa is very helpful in controlling symptoms of RBD and Parkinson’s. Some success has also been reported with other medicines used for Parkinson’s disease, such as pramipexole.

Frozen to the Bed — Sleep Paralysis

Sleep paralysis is a normal bodily function. Everyone experiences it every night as their brains purposely prevent motor activity to keep them from getting out of bed and hurting themselves when they enter REM sleep. But you don’t have any awareness of this nightly phenomenon. Only when you become aware that you can’t move does sleep paralysis become a problem.

Have you ever awakened and felt like you were nailed to your bed because you simply couldn’t move a muscle? Or that something heavy was sitting on your chest, crushing the life out of you?

You’re not dreaming. You experienced an episode of sleep paralysis, or the inability to voluntarily move any of your large muscle groups, like your arms and legs. Sleep paralysis can also affect the ability to speak.

The feelings of fear and foreboding, and vivid hallucinations can also accompany sleep paralysis. (See “Hypnagogic Hallucinations [Sometimes Terrifying, Usually Not]” earlier in this chapter.)

If sleep paralysis occurs when you’re falling asleep, it’s called predormital. If it occurs when you’re waking up, it’s called postdormital.

Causes

Doctors don’t know precisely what causes sleep paralysis, but the theory is that Mother Nature built this safeguard in the brain to keep people from acting out their dreams. Most of the time you’re unaware of it. However, if you awaken suddenly while going from one sleep state to another, it may be that some features of the previous sleep state linger. That is, the switch isn’t complete, and thus you may have a REM sleep feature like paralysis persist into the awake state.

People with circadian rhythm disorders like jet lag or shift-work sleep disorder may be more subject to sleep paralysis. (For more information, see Chapter 8.) Missing a few nights’ sleep or severe chronic stress can also lead to an episode.

Approximately 16 percent of people who experience sleep paralysis have been diagnosed with panic disorder. Although people with panic disorder may be slightly more subject to sleep paralysis, they’re by no means the only group that suffers from the problem. People who suffer from depression or bipolar disorder are also more subject to sleep paralysis.

As you fall deep into sleep, you progressively lose muscle tone, and it becomes increasingly difficult for your brain to activate a muscle contraction. When you enter REM sleep, the muscles that are normally under voluntary control are in a state of almost complete atonia, meaning you’re literally unable to move them. However, the atonia doesn’t affect the muscles that are controlled by the autonomic nervous system, including the muscles that control heartbeat and breathing. Those muscles, luckily, keep on working normally.

Some clinical evidence suggests that the neurotransmitters or brain chemicals responsible for relaying messages to activate muscle movement become inactive during REM sleep.

Symptoms

The sleeper awakens feeling like he can’t move, and that his limbs are very heavy and weighted down. He may also feel a suffocating pressure on his chest and real feelings of terror or dread. Some sleepers also report feeling a “presence” in the room, as if some other person or some thing was there with them. Part of the fear arises from the fact that they feel like the presence intends to do them harm. Sleep paralysis episodes last anywhere from 30 seconds to 5 minutes or more.

The crushing pressure and inability to breathe fully during an attack of sleep paralysis led to speculation in times past that some sort of demon (incubus) or old woman (hag) was seated on the sleeper’s chest, crushing him as they drew out the life force.

Some people feel as if they’re floating out of their bodies and above their beds watching themselves during an episode of sleep paralysis, while others report feeling like they’re being forced through a narrow tube or tunnel.

The sleeper may also see light auras and hear sounds like a ringing bell, particularly if a hallucination accompanies the sleep paralysis.

Treatment

People who allow themselves to get overly tired or who get off their regular sleep schedules are more prone to episodes of sleep paralysis. Regular exercise can help strengthen the muscles and decrease the severity of the episodes. Maintaining a regular bedtime also helps.

Avoid sleeping on your back if you can, because most episodes of sleep paralysis occur in that position. Sleeping on your back is also associated with the inability to breathe fully and the feeling of intense pressure on your chest.

Some individuals report that being touched by someone breaks the paralysis. Also in some cases, rapidly moving the eyes back and forth (the eyes aren’t paralyzed) can break the paralysis if the movement is vigorous enough.

If your episodes are frequent, severe, persistent, and a source of distress, ask your doctor for an appropriate medication.

Dealing with Nocturnal Seizures or Sleep Epilepsy

Some people with epilepsy may suffer from nocturnal seizures, or epileptic attacks that occur while they’re sleeping. Doctors do think nocturnal seizures are related to sleep stages because the seizures usually occur during sleep transition or Stage 2 sleep, just as the person is falling asleep or waking up. They also commonly occur during the transition to SWS, just as the brain wave discharges become more synchronous.

Some people who have nocturnal seizures don’t ever have seizures during the daytime, but most patients must deal with the possibility of a seizure occurring around the clock. These sleep-related seizures may also occur during naps.

Causes

So many different things can cause seizures that we’d need an entire chapter just to list them all. The cause of many nocturnal seizures is unknown. However, being overly tired can contribute to the frequency of seizures.

In addition, overdosing or withdrawing suddenly from some medications can trigger seizures. These medications include tricyclic antidepressants, lithium, barbiturates, benzodiazepines, opioid narcotics, some bronchodilators, antipsychotics, and high doses of penicillin. Chronic drug abuse can also lead to seizures, as can certain infections like meningitis and encephalitis, brain tumors, and degenerative disorders.

If you have nocturnal seizures and you’re having trouble sleeping, stay away from over-the-counter (OTC) sedatives because they can make seizures worse. Ask your doctor for an appropriate medication to help you sleep, and avoid the use of stimulants like caffeine to help overcome daytime drowsiness because many stimulants can also bring on seizures.

Symptoms

Nocturnal seizure symptoms vary according to the type of seizure disorder a person has. Most people with nocturnal seizures experience classic seizure symptoms, including muscle stiffening, twitching, jerking, loss of consciousness, and perhaps even loss of bladder control, followed by a period of confusion and disorientation when they regain consciousness. Patients may also feel extremely fatigued at the end of a nocturnal seizure, a feeling exacerbated by the time of the event.

There are dozens of distinct seizure disorders, but most nocturnal seizures are called tonic-clonic or grand mal seizures, which means that first, muscles stiffen (tonic phase), and then they twitch (clonic phase).

Treatment

You may be tired of hearing us repeat this advice, but we only say it so often because it’s true. Patients can minimize the frequency and intensity of nocturnal seizures by adopting a regular pattern of bedtime and awakening and by making sure they get enough sleep. You can trigger nocturnal seizures by not getting enough sleep, and interestingly, even by getting too much. In other words, anything that interferes with your normal sleep-wake patterns can trigger nocturnal seizures. Stress management is also important.

Your doctor determines any medical treatment for nocturnal seizures not by the time of day the seizure occurs, but by the type of seizure you suffer. Some anecdotal evidence suggests that sleeping with a light on or with a loudly ticking clock close to the bed may reduce the incidence of nocturnal seizures. In addition, your doctor may suggest increasing the evening dose of anticonvulsant medication to control nocturnal seizures. If you don’t achieve good control of your seizures with these steps, ask your doctor about switching to a time-release anticonvulsant for your evening dose to inhibit seizure activity throughout the sleeping hours.

Suffering with Sleep-Related Painful Erections

Fortunately, sleep-related painful erections are rare, affecting less than one-tenth of 1 percent of men. But for those men who do have the problem, the disorder is devastating and a real thief of sleep.

Sleep-related painful erections are a parasomnia associated with REM sleep. Getting an erection is normal for men when they’re asleep, especially as they enter the REM stage of sleep associated with dreaming. However, the erection isn’t a product of the dream content, it occurs regardless of what the man is dreaming about. In fact, doctors observe a sleeping man for erectile activity to determine if impotence is physical or psychological in origin. (If the man experiences a normal erection during REM sleep but is impotent, then the impotence is likely to be a psychological rather than a physical problem.)

Causes

The cause of sleep-related painful erections isn’t known. Some evidence indicates that it’s sometimes associated with penile plaques similar to the coronary artery-clogging cholesterol plaques that can trigger heart attacks. But plaques aren’t a sufficient cause, which means that many men with plaques don’t have painful erections. The man has no pain with sexual erections during the day. One theory is that the penile blood pressure increases too much when an erection occurs during REM sleep, thus producing the pain; however, at present this hypothesis is speculative.

Symptoms

With sleep-related painful erections, a man’s erection is very intense and so painful that it wakes him up. Sometimes the problem is so bad the man becomes afraid to fall asleep, and suffers severe insomnia and sleep deprivation as a result.

Treatment

Certain antidepressants like MAO inhibitors that suppress REM sleep may be helpful in treating this disorder. The medical literature also reports administration of the antipsychotic clozepine is helpful in some cases, but patients must be monitored for agranular cytosis, a potentially fatal drop in white blood cells. Some doctors have tried another atypical antipsychotic medicine, olanzapine, with mixed findings. Drugs that suppress erections can provide relief (for example, lupron); however, they also produce impotence.

Hidden Danger — REM-Related Sinus Arrest

REM-related sinus arrest is a rare disorder that causes the heart to stop beating for several seconds during REM sleep. If patients display any symptoms during the day, they’re usually vague.

REM-related sinus arrest may be responsible for the sudden deaths of many apparently healthy young people during sleep. Researchers first reported it after noticing it in a group of presumed healthy volunteers who were being screened in a sleep lab for participation in an experiment.

Causes

Doctors and researchers don’t yet know the exact cause of REM-related sinus arrest, but speculate some defect or anomaly in the autonomic nervous system that governs breathing and circulation causes it.

Symptoms

With this condition, the heart stops beating repeatedly during REM sleep periods throughout the night, sometimes for as long as 9 to 20 seconds in observed patients. The individual may have noted weakness or fainting at night when he had to get up for one reason or another (for example, going to the toilet). Otherwise, the person may have no symptoms.

Treatment

In some cases, your doctor needs to implant a cardiac pacemaker or prescribe an antiarrhythmia medication.