Sleep Soundly Every Night, Feel Fantastic Every Day (30 page)

  
Sleep-related injury

  
Other risky behavior while looking for or making food

  
Lack of appetite in the morning—morning anorexia

  
Physical consequences of repeatedly bingeing (weight gain)

  
Cannot be better explained by another sleep, medical, or eating disorder

 

 

I'm not asleep … but that doesn't mean I'm awake.

—UNKNOWN

Recently, an interviewer asked me, “Is there one patient who has inspired you?” The patient who came to mind actually fascinated me and was one reason I became interested in sleep medicine. Early in the year 2000, I was just moving into the field of sleep science when a very pleasant woman arrived for an appointment. By the time she consulted with me, she had been to the local emergency room on several occasions. She had jumped out of her bed, onto the bedroom floor, and in every instance she was dreaming that she was diving into a pool. She had to receive stitches to repair the damage on each occasion. I arranged for her sleep study and we were able to document that she had significant and repetitive movements associated with rapid eye movement (REM) or dream sleep.

After hearing this patient's story, one of my goals became to shed more light on this problem. First, I had to learn about it myself. I started researching and quickly realized that she had a sleep disorder called REM sleep behavior disorder (RSBD), a disruption of normal REM sleep. During the REM phase of sleep, the part of the brain that makes the body still and unmoving allows your neurobiology to repair and restore. In RSBD, the brain does not receive the signal to be still and the patient is able to act out his or her dreams. Through the years since I've become an expert on this topic, I have learned that people with RSBD are able to physically act out their dreams, which can range from simple mumbling or other vocalizations to violent punching. Obviously, the violent action that could hurt a bed partner motivates people to see a sleep doctor.

When my patient returned, I told her the diagnosis and that she didn't need to be embarrassed. She was definitely relieved that she wasn't crazy, to use her words. The movement in her sleep had to do with some abnormalities of the circuitry that goes on between the brain stem and spinal cord. I prescribed a medication called clonazepam. This medication acts as a mild sedative and muscle relaxant for the sleeper with active limbs.

This patient saw me regularly for a couple of months, and one day she arrived practically in tears and announced, “Gosh, I'm not doing it anymore, Dr. Rosenberg!” We could not quit smiling because we shared the incredible feelings of the problem solved. No more trips to the ER because she had once again cracked her head on the floor after diving in her sleep.

This patient spurred me on to learn, since no one in our area of Lake Havasu, with the exception of a few physicians in Phoenix, knew anything about RSBD. That's the reason why that patient stands out for me. She was like my bridge from being only a sleep apnea doctor to a sleep specialist whose practice encompasses much more than treatment for apnea.

In the late 1980s, a group of researchers reported patients that were exhibiting signs of a new form of parasomnia, an umbrella term for a collection of strange sleep behaviors. Behaviors such as sleepwalking or sleep eating were studied previously and were found to occur during the non-REM stages of sleep. However, these new cases were different because they occurred during REM sleep. In addition to the normal eye movements for REM sleep, these patients vocalized sounds and had a notable
lack
of the atonia, the muscle paralysis, usually present in REM sleep. This was the first diagnosis of REM sleep behavioral disorder. We now know it is present in about one out of every 200 people. RSBD usually strikes around the age of 50, and mostly in men, whose wild and often violent dreams contradict their peaceful waking lives. The number of women being diagnosed with RSBD has recently been on the rise; however, their symptoms are usually milder.

Symptoms for RSBD include:

1.
 
“Motor attacks” ranging from simple movements such as twitches, jerks, and grimace, to complex behaviors such as searching movements, defensive and or aggressive actions, and vocal sounds. These behaviors are reactions to events occurring in the sufferers' vivid dreams.

2.
 
Occurrence at least 90 minutes after sleep onset, but most oftentake place much later when REM sleep increases in duration.

3.
 
Violent episodes typically happen about once per week but may appear as frequently as four times per night over several consecutive nights.

4.
 
An acute, transient form may accompany REM rebound during withdrawal from alcohol and sedative-hypnotic
agents. Drug-induced cases have been reported with several antidepressants.

 

 

Chapter 2
provides a detailed description of a sleep cycle moving from non-REM stages to REM sleep or dream sleep, and how the sleep cycles repeat throughout your sleeping hours. REM refers to rapid eye movement and accounts for 20% to 25% of sleep time. If you were a sleep technician in a sleep lab, you would observe REM sleep as the sleeper's quickened eye movements and the EEG (electroencephalography) patterns of higher-frequency waves that rise and drop rapidly, a pattern referred to as the sawtooth wave. REM, the final stage of the sleep cycle, is also the lightest stage of sleep. The eye movement mimics that of the waking state, as well as brain activity equivalent to that of “relaxed wakefulness.” We can dream during REM sleep.

Another feature distinguishing REM from other sleep stages is the paralysis of the body, called atonia, which serves to keep the sleeper still and receive positive, regenerative benefits that transpire. The amount of REM sleep we get depends largely on our age. REM comprises nearly 80% of sleep time in newborn babies, and then progressively decreases until it reaches 20% to 25%, which is normal for adults. Most people, if they are getting enough sleep, experience three to five periods of REM sleep per night, with each REM stage getting longer as the night progresses.

Researchers have correlated REM sleep to abilities such as creativity and better problem-solving. We have found that the term “sleep on it” works because in a REM state, the
brain makes connections among one's daily experiences and correlates them to experiences or past memories. However, the quality of sleep matters more than the duration of sleep. Sleep experts agree that REM sleep has a “global effect on the physiological processes regulated by the brain” and performs numerous housekeeping functions. One function is to process the day's memories, particularly those involving emotions and stress, through a complex, chemical process that controls neurons in several areas of the brain.

REM sleep is critical to learning and retaining information, such as language or how-to skills such as playing a piano. It also helps with cognitive development in infants and children, which may explain why they get so much more REM sleep than adults. This is also connected to the earlier theory about dreaming, which was illustrated in a 2001 study conducted by MIT professor Matt Wilson.

In the first stage of the experiment, Wilson implanted multiple electrodes into the brains of his lab rats. Then he trained them to run through mazes, measuring the activity of the neurons in the hippocampus. After determining that each maze created a unique pattern of neural activity, Wilson measured the rats' brain activity again, this time while they were sleeping. Wilson was amazed by the results of his 45 recorded rat dreams, 20 of which were exact replicas of the mazes they ran during the first phase. The rats were using the REM sleep period to consolidate their memories and learn new things. Now imagine all the new skills an infant learns each day. No wonder they need so much REM sleep!

Other studies show that for REM sleep to be useful in integrating learning, an emotional component to the information is required for being consolidated or memorized. Neutral information is better processed during a different part of the sleep cycle. There is much evidence of this theory among many famous artists, writers, and scientists, who have found
inspiration in their dreams. Musicians from Billy Joel and Paul McCartney to Beethoven have stated that they first heard a song in their dreams, and writers Edgar Allan Poe and Mary Shelley often dreamed their story ideas.