THE MYSTERY. Why are some people afraid to go to sleep at night? Can nightmares and uncontrollable, sometimes violent behaviors be cured? We need to learn to distinguish between harmless sleep behaviors and abnormalities that indicate a serious problem.
In the specialized field of sleep medicine, the best way to discover what is really going on with a patient’s disturbed sleep can be an interview with both the patient and the bed partner. The forty-six-year-old woman in my office had come accompanied by her husband, and it was he who provided the most useful information on his wife’s sleep patterns. She had been referred to the sleep clinic because she was afraid to fall asleep. When she started to describe her problem, she was almost smiling, as though she were somewhat embarrassed about wasting my time with her silly story. Her husband, on the other hand, seemed extremely concerned, even upset. Her problem was that she had “lots of dreams and bad dreams,” which had been plaguing her as far back as she could remember. Even as a young child, her parents would have to come into her room to calm her down after one of these events.
Now, as an adult, she dreaded going to sleep each night because she knew she was likely to have a bad dream. The episodes usually began at about one in the morning, and in most of her dreams, she would be trying to protect herself from a masked man who was trying to stab her. Her husband had been awakened by her dreams, and he was able to observe her reactions. She would yell, turn her head from side to side as though avoiding an attacker, ball up her hands into fists, and strike out. She often hit her husband “pretty hard” while in these dreams, and he had the bruises to show for it. Sometimes her husband would waken her during the more severe episodes, and she would be afraid to go back to sleep. She would try to think pleasant thoughts, and if her husband hugged and soothed her she was sometimes able to drift back into a dreamless sleep. But often she would find herself right back in the same dream. Fear of her nighttime episodes had made it impossible for the couple to travel or stay with other people. She and her husband had experienced this trauma for most of their twenty-eight years together, and now she was desperately seeking relief—for herself and for her husband.
In answer to my questions, she said that she was taking no medications and had never had a brain injury, severe infection, or loss of consciousness. She also had no history or symptoms of psychiatric disorders. For some forty years, she had found sleep a painful experience; it did not refresh her at all. But fortunately her problem was easy to diagnose and a treatment was available that would solve her problem virtually overnight.
Although sleep is normally considered a peaceful activity, it can also be a time when distressing visions and abnormal behaviors occur. Nightmares and terrifying visions can be the result of a number of factors; abnormal behaviors, called parasomnias, occur when the mechanisms that control such behaviors as yelling, screaming, walking, talking, and urinating fail to function or function abnormally while the individual is asleep.
We saw in Chapter 1 that our brains have three states of consciousness: waking, non–rapid eye movement (NREM) sleep, and REM sleep, which is the dream state. For some people, however, the boundaries between the three states can collapse.
When we are awake, both our brain and our muscles are active: we can think and our senses continuously give us information about our environment. Our bodies automatically maintain muscle tone, control our breathing, heart rate, and blood pressure, and make us aware of physical needs such as eating, drinking, and urinating.
During NREM sleep, we continue to receive sensory data from the environment, but the body and brain filter out the irrelevant information. After a few nights of being awakened by a plane flying overhead at 4:00 A.M., we start to sleep through it—but we continue to respond to noises coming from the baby’s room down the hall. Our brains continue to control all the automatic functions; sphincters in the body keep various fluids where they belong; and muscle tone is maintained. Some mental activity and some dreaming may also occur during this state.
REM sleep is the state in which we dream, and when we dream our body is almost entirely paralyzed. The muscles of the arms and legs cannot move. The main breathing muscle, the diaphragm, continues to work, as do sphincters in the intestinal tract, but some of the automatic functions which control body temperature, blood pressure, and heart rate might become erratic.
But when a person experiences a breakdown in the boundaries between these states it can result in several disorders, such as sleep terrors, sleepwalking, and reacting physically to violent dreams. Abnormal behaviors during sleep can occur during both NREM sleep (scientists call these NREM parasomnias) or REM sleep (REM parasomnias).
Nightmares are dreams that are frightening and vivid. I find it surprising that people do not complain of these more often, as most people dream three to five times a night. The reason is that most of the time nightmares are of no consequence, and people either forget them when they wake up or learn to ignore them. Some people cannot remember any of their dreams; others remember one or more a night. Women report having nightmares more often than men (women are probably more willing to report them).
Patients with posttraumatic stress disorder (PTSD) frequently have terrifying dreams that replay the traumatic event they have lived through. They might awaken from the dreams sweating and terrified, with their heart pounding. Because these experiences are so distressing, some develop a fear of falling asleep. Although PTSD is commonly found among persons who have served in the armed forces and seen combat, it can occur in any person who has experienced or witnessed severe physical or psychological trauma. I have known people who have had these dreams nightly for forty or fifty years.
Persons with PTSD should seek help from medical practitioners. Scientists believe that a contributor to PTSD is activation of receptors in the brain that also control blood pressure; these nightmares can be treated with an old drug called prazosin, which was initially used to treat high blood pressure. Indeed, research in 2016 reported that PTSD sufferers with higher blood pressures were more likely to respond to this treatment.
Children, too, can acquire a fear of going to sleep. When a child has a nightmare, the parent should demonstrate that the fear is unfounded. If, for instance, the child thinks there is something hiding under the bed or in the closet, the parent should look in these places with the child to show that there is nothing there. In rare cases when the problem persists, parents should seek help from a doctor or a psychologist.
People who are extremely sleep deprived or who have narcolepsy sometimes dream even before they fall asleep. Sometimes they dream after they have awakened. This is not normal behavior. People do not usually dream until they have been asleep for roughly ninety minutes.
As we saw in the previous chapter, the dreams that people have as they are falling asleep or after they have awakened are called hypnagogic and hypnopompic hallucinations. Sometimes these hallucinations consist of mundane and fleeting thoughts; sometimes, however, they can be vivid and even frightening. When people are having these hallucinations, they generally know that the visions are “not real.” But they may not realize that the visions are dreams. The strangest example I ever saw of a person experiencing hypnagogic hallucinations was a young woman who was in an intensive care unit. She had a severe form of sleep apnea associated with a neurological condition that made her extremely sleepy during the daytime, and as I approached her, I could see that she was talking to an invisible object that seemed to be about fifteen yards away from her. She told me that she was talking to the giant Cheshire cat “over there.” She then turned to me and smiled and said, “Of course I know there is no Cheshire cat over there. This is just some sort of dream.”
The ability to recognize that the hallucination is not real is quite different from the experience of a patient with schizophrenia who has hallucinations. The schizophrenic patient believes that the hallucinations are real. The inability to differentiate reality from hallucination is, in fact, one of the hallmarks of schizophrenia (see Chapter 16).
Dreamlike hallucinations might also occur in people who are awake, even as they are participating in an activity. I’ve even had patients who had hypnagogic hallucinations as they were driving! People experiencing such hallucinations should stop driving and consult their doctor.
We tend not to treat these hallucinations. Instead we focus on the conditions that cause them. The hallucinations themselves are usually not distressing to adults, though they can be to children. The most likely trigger for this type of hallucination is sleep deprivation caused by lifestyle, and people who experience them should consider making lifestyle changes that will enable them to sleep more. If sleep deprivation is not the cause of the hallucinations, daytime sleepiness is not present, and the hallucinations are not occurring during risky activities such as driving, doctors might need only to reassure patients that the hallucinations are not a sign of something dangerous. I might suggest REM-suppressing drugs (usually antidepressants) to narcolepsy patients if the hypnagogic hallucinations are frequent (occurring more than once a week) and disturbing.
Patients who have entered the blurred state between REM and NREM sleep are not paralyzed, as they normally are during REM sleep, and thus might find themselves reacting physically to nightmares, thrashing about or kicking. They have a condition called REM behavior disorder (RBD). People with this problem, which is more commonly found in men than in women, have been known to inflict severe injuries on their bed partners, who should encourage the dreamer to seek help for such behavior. Most of the time, the violent activity is related to a dream that includes being attacked by an unknown but terrifying person or animal. One patient of mine dreamt that he was being attacked on the beaches of Normandy during World War II.
Because dreamers with this disorder can react physically, they can be a danger to themselves and bed partners. I had a patient who dreamt he was being chased by a moose and a bear (go figure) and was running away from the animals toward a building. He arrived at the building, but the door was closed, and the animals were coming closer and closer. He started to bang his fists on the building—only to be awakened by his wife’s screams. He had been pounding her, not the building. I have had other patients report that they have banged their fists through glass, broken lamps, and damaged furniture. In one case, a patient lunged out of bed, fell on the floor, broke his neck, and died. RBD is a serious condition, and sufferers need to get treatment!
Ninety percent of the people who have RBD are men (though we do not know why), but women need to be aware of the disorder as well since they are likely to be secondhand sufferers from it: two-thirds of men who suffer from RBD have assaulted and often injured their spouses. People who have had head trauma or an infection of the brain earlier in their lives are more likely to get the disorder, and it is more common among alcoholics. It has also been reported as a rare complication of certain antidepressants. Some people with this condition may go on to develop Parkinson’s disease or other severe neurological conditions years or decades later.
Medical science has not known about RBD for very long: it was first described in 1987. People with RBD are often embarrassed to talk about it, or they are inhibited by fears that they might have a psychiatric condition. Although RBD bears some similarities to PTSD, the two are very different. Most PTSD patients have terrible recurrent nightmares, but they cannot react physically to what they are dreaming because the dreams occur in REM sleep and they are paralyzed. However, some PTSD patients will also have RBD, and they will react physically to their dreams. People who react physically to violent dreams, especially if they have injured themselves or others, should seek medical help. Some patients (and their bed partners) have suffered for forty or fifty years, yet RDB can often be treated effectively with clonazepam, an anti-epilepsy medication, and melatonin, a hormone (see Chapter 20).
In this disorder, which usually affects adults, the sleeper wakes up from a dream and finds that he or she cannot move. Sleep paralysis can be quite frightening, especially the first few times it happens. Sometimes the sensation of paralysis occurs while the sleeper is actively dreaming, and if the content of the dream is frightening, the sensation can increase the fear. A sleeper might dream that there was someone in the room or that something unpleasant was happening in the house, such as a robbery. I have treated women who dreamt of a devil-like creature that was about to sexually violate them and men who dreamt that they were about to be raped by a creature resembling an old woman. Sexually disturbing dreams like these have been described in several countries around the world. Episodes of sleep paralysis might last only a few seconds or perhaps a few minutes. What sometimes snaps the person out of the paralysis is being touched by another, but the sleeper can do nothing to stop the paralysis. It goes away on its own.
Sleep paralysis is another disorder caused by the blurring of the boundary between wakefulness and REM sleep. The sleeper’s brain is awake, but one of the manifestations of REM, the paralysis, remains.
Sleep paralysis is a feature of narcolepsy, but it can also occur in people who are experiencing severe sleep deprivation. I have seen some cases of sleep paralysis that ran in families. Although sleep paralysis in itself is not dangerous, if the patient finds it distressing, I usually treat it in the same way I treat sleepwalking. If reassurance does not help, in more severe cases I might prescribe a drug such as clonazepam or one of the antidepressants that suppress REM sleep. People experiencing disturbing sleep paralysis should consult with their doctor.
Sleepwalking occurs when parts of the brain are asleep and other parts, the ones that control walking and other physical activities, are in some way awake. The part of the brain responsible for thinking and alertness is asleep, and sleepwalkers usually have no recollection of sleepwalking after they wake up. Although for humans it is unusual to have the brain be awake and asleep at the same time, it is a common state for some other animals. Certain marine mammals—for example, dolphins—can continue to swim around while one side of their brain is asleep and resting because the other side of their brain is wide awake and controlling various functions. This ability may be what allows marine mammals to spend their whole lives in the water.
As many as 10 to 15 percent of Americans have sleepwalked at some time, particularly when they were children. Sleepwalking becomes much less common as people leave the teenage years, although I have had several adult sleepwalking patients. While sleepwalking, the person gets out of bed and starts walking, demonstrating what is best described as robotlike behavior. The walking might seem purposeful—for example, the sleepwalker might go to the kitchen—but it generally is not. One of my sleepwalking patients, a child, would walk into the laundry room and urinate into the laundry hamper.
Sleepwalking seems to occur most often during very deep (slow wave) sleep. Children spend more of the night in deep sleep than adults do, so it follows that they sleepwalk more often than adults. Deep sleep is also more common in the first third of the night, which is when sleepwalking is most likely to occur. Adults and children who are sleep deprived also fall into a deep sleep more quickly and tend to sleepwalk more often. Sleepwalking seems to run in some families and is also found more often in people who are under stress or who have been drinking alcohol. Defendants accused of violent crimes have offered the defense that they were sleepwalking and sometimes even been acquitted, though it is difficult to prove what state a person was in when the crime was committed.
Most of the time, sleepwalking is not dangerous unless the walker ventures outside or turns on appliances (such as a stove). Usually, he or she returns to bed, still asleep. In cases where the sleepwalking is not associated with dangerous actions, nothing needs to be done. People encountering a family member sleepwalking should not waken the person, but lead him or her back to bed. Sleepwalkers who are awakened too abruptly might be upset and have trouble falling asleep; they also might become overly concerned about what their sleepwalking signifies. If the sleepwalker has been discovered in a dangerous situation, then the chance of harm must be reduced. Alarms could be installed for a sleepwalker who has stumbled down the stairs, for instance. It’s a mystery to me (though a good thing) that people do not hurt themselves more often when they are in this state.
Patients whose sleepwalking results from sleep deprivation, stress, or alcohol abuse can address this with their doctor. If sleep deprivation is the culprit, getting proper amounts of sleep usually solves the sleepwalking problem—in severe cases of sleepwalking, the sleepwalker might not know the best techniques for getting the right amount of sleep, and a sleep doctor can help. If the sleepwalking occurs on nights when the person has been drinking, the problem might be solved by eliminating alcohol consumption. When the sleepwalking seems to be related to stress, the doctor should try to help the sleepwalker find and eliminate the cause of the stress. This might involve referring the patient to a psychologist.
Because these treatments are usually effective, I seldom recommend medications for sleepwalking unless they can suppress sleepwalking for patients who have had dangerous episodes. I had one patient, for example, who found herself walking in a cemetery several blocks from her house, wearing only her nightgown. She was barefoot, the temperature was below freezing, and there was snow on the ground. I will also sometimes recommend medications when the patient is traveling; sleepwalking in a strange environment can be dangerous. The medication I recommend most often is clonazepam, but sleepwalkers should discuss all medications with their doctor to determine whether a particular one is right for them.
Sleep talking is quite common among adults and children. Most of the “talk” is gibberish, although a listener might be able to make out individual words. I have not heard of people blurting out secrets during sleep talking episodes. This might be considered an embarrassing condition, but it is not one that requires treatment.
This disorder, which can occur in both children and adults, is also called “night terrors.” Sufferers get out of bed abruptly, sometimes screaming with their eyes wide open, sometimes sweating. They appear to be terrified, and some look as though they are about to commit a violent act.
Although the sleeper might appear to be reacting to a dream, usually he or she is not. Sleep terrors are a form of sleepwalking, and the treatment is the same. There is no need to awaken people who are having these episodes; it is best to calmly put them back to bed. The following morning, they usually have no recollection of the event. Sleep terrors are a bizarre form of behavior, but they are rarely dangerous enough to require treatment.
Enuresis, or urinating in bed, occurs when the mechanisms that keep the sphincters of the urinary system working fail to function properly. This is a problem mainly found in children (and twice as often in boys than in girls) and the elderly. In children, the problem is caused by slow development of bladder control. In the elderly, it is generally related to changes in anatomy brought on by the aging process or is a symptom of a disease.
Childhood enuresis can be very troubling for both the child and the parents. Children might develop a fear of going to sleep or sleeping at a friend’s house because they are afraid that they will wet the bed. Parents should take a child with this problem to be evaluated by a pediatrician in case there is a medical reason (for example, sleep apnea or a urinary tract infection) for it. The pediatrician can then advise the family about what to expect and how to handle the problem. In many cities, there are specialized clinics that deal with this situation.
If there is no medical problem, parents can try using an alarm system that is triggered when the bed gets wet. The alarm wakes up the child, who eventually learns bladder control. If this treatment is not effective, the doctor might recommend one of several medications. Desmopressin acetate (DDAVP) is a medication that imitates the effect of a chemical produced by the pituitary gland that reduces the amount of urine. This drug, which is immediately effective, can be taken just before bedtime either in a nose spray or in pill form. A low dose of the antidepressant imipramine taken one to two hours before bedtime has been used for many years to treat children who wet the bed, but this medication is successful less than half the time. These treatments do not cure the problem, though. Usually the problem is solved as the child develops and gains greater bladder control.
Incontinence can also become a problem for people as they age. Uri-nary tract infections, diabetes, diseases of the prostate in men, and vaginal infections in women may play a role. About one in twenty older women (over sixty-five) worldwide wets the bed at night. If it is not possible to solve the medical problem causing the incontinence, then the only solution may be to use an incontinence pad. If there is no medical problem, then exercises that help tighten the muscles used in the control of urination (called Kegel exercises) might be helpful.
Excessive sweating during sleep can be extremely distressing and embarrassing. I have had patients who developed a fear of sleeping because of the discomfort caused by waking up with drenched sheets and pillows. Patients who experience severe night sweats should consult a doctor: such sweating can be associated with menopause, but it can also be a problem for patients with sleep apnea, restless legs syndrome, hyperthyroidism, certain infections, and cancers. In some cases doctors are unable to find the cause.
Bruxism is an increase in the activity of the jaw muscles during sleep. This condition can be found in children and adults; it is equally common in females and males, and it is more common among people who are heavy users of tobacco and alcohol. Scientists do not know much about it, but it is more commonly found in people under stress. It can also occur as a reaction to certain drugs. The grinding can wear down the sleeper’s teeth, as well as being disruptive for bed partners. For some sufferers, stress reduction will also take care of the bruxism. But if the sleeper’s teeth are wearing down, or if he or she experiences pain in the jaw, the tooth grinder should consult a dentist, who might recommend a mouth guard to be worn at night.
One of the most unusual problems we see in the sleep clinic is a disorder in which a sleeper repeatedly bangs his or her head against a mattress, a crib, or a wall. Some people rock their bodies throughout the night. Worldwide, the disorder is found in about 10 percent of seven-year-olds, though the number decreases among older children, and most children grow out of it. This condition is four times more common in males than in females, although we do not know why. It can be frightening to see, especially for parents, but this is not a serious problem. The patients are fine when they wake up. Since some people with neurological problems display similar movements, it is a good idea to consult a doctor. If the cause is not neurological, we do not normally treat the disorder unless the person is in danger of self-injury.
The woman who had dreamed almost nightly for forty years that she was going to be stabbed by a masked man had REM behavior disorder. I could not determine the cause of her problem because she had no history or evidence of brain damage, had never been in a coma or lost consciousness as far as she knew, was not an alcoholic, and was not on any medication that might lead to this problem. I recommended to her family doctor that she be started on clonazepam, which is also used to treat some forms of epilepsy and panic disorder. It is sometimes prescribed to help patients fall asleep because it seems to make the brain less likely to respond to stimuli, including the stimuli from dreams. When I spoke to my RBD patient several months after she began taking the medication, she was dramatically improved. She no longer feared dreaming about the killer. Her husband told me that she sometimes still moved a great deal during sleep, but the hitting had stopped.
The disorders mentioned in this chapter are not usually dangerous to the sleeper, but sufferers from them might want to see their doctor, to ensure that these are not symptoms of a more serious disorder. The exception is REM behavior disorder, which generally is more dangerous to the bed partner, although it can be debilitating for the patient, who is not getting enough of the right kind of sleep. The disorder is more common among males, but women are frequently the victims of the physical assaults and violence that accompany it. People exhibiting violent behavior in bed need to see a doctor or sleep specialist about treatment.