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Sleep Disorders

Realistic Nightmares and Unusual Events

12/16/2011

Question:

Hi, my nightmares vary from real-like physical pain, to endless riddles, to being violent towords people I don`t know, endless `waking up` in dream into another dream. Sometimes I wake up paralyzed and with taste of sesame in my mouth. When I was a child, things like this happend only around full moon, bit now they have no order. In mornings I feel very tired and I radiate incredible wormth for about an hour. My boyfriend is worried because I constently shake upper part of my body violently for hours. I can also talk and walk without knowing. Few times I looked at him with totaly black eyes. I will be very gratefull for your opinion, because I`m getting quite worried, thank you for your time.

Answer:

Throughout history, dreams were considered as a communication from higher powers or a window to the future. At the turn of the century, dream interpretation and analysis was considered to provide an understanding of the individual personality and tendencies. While none of these notions have been proven experimentally, dreams and dream recall continue to be an intriguing experience that we try to explain and make sense of.

Dreaming mainly occurs in a stage of sleep called Rapid Eye Movement (REM) sleep. This stage of sleep recurs several times in a night of normal sleep. Therefore, dreaming likely occurs every night. What is less common is our dream recall. A common cause of dream recall is awakening at a time of sleep that is close to the time of the dream. However, it is not mandatory that one awakens during the night for dream recall to occur. Many individuals report vivid recall of their dreams in the morning without much sleep disturbance. It is worth noting that a relatively long period of REM sleep occurs normally towards the end of the night's sleep. Therefore, we often awaken for the day coming out of a REM period and may be more likely to recall the dreams that occurred in it. When vivid dreams are associated with discomfort, unpleasant emotion, or fear they may be classified as "nightmare disorder". The recurrence of the vivid dream, the context of the dream, along with the concern the patient feels are all factors that make a recurrent vivid dream more of a nightmare. Again, it is not mandatory that one awakens from sleep for the dream to become a nightmare. However, awakening from sleep with recall of the dreams occurs frequently.

Some individuals have "habitual dreams" that develop over a long period of time in which they begin to expect the same dream. Likewise, being concerned about the meaning and context of dreams results in obsessing over dreams and can increase their recurrence, creating a cycle of recurrent dreams. The effect of lack of sleep due to work or insufficient sleep hygiene can cause our bodies to try to make up for lost REM sleep on the nights we allow ourselves to sleep longer. This may have the effect of having more dreams on these nights of make up sleep. This may be why many individuals associate a “good night sleep” with having dreams that they recall.

Conditions that may cause excessive dream recall include sleep disruption, effects of certain medications and drugs, mood disorders, and medical conditions. Antidepressants and a variety of medications can promote dreams and nightmares by changing the architecture of sleep and increasing the duration of the dreaming stage (REM sleep). Post-traumatic stress disorder, depression and anxiety disorders can have similar effects. Additionally, alcohol, and recreational drugs can promote nightmares via different mechanisms. Sleep disorders may cause excessive dream recall or nightmares by disrupting the architecture of sleep and promoting frequent arousals. These disorders include obstructive sleep apnea and periodic limb movement of sleep. Medical disorders that can cause disruption of sleep include gastro esophageal reflux and arthritic pain. Hormonal changes in women are also important factors in dream occurrence due to the hormonal effect on REM sleep. Absent any other identifiable causes of nightmares, the patient is considered as having a "nightmare disorder".

You also describe sleep walking and talking. These are not uncommon, especially in younger individuals and they sometimes decrease with age. However, sleep waking in particular, can pose some risk to the patient who tends to wander out of the sleeping environment and may be exposed to physical barriers. Some patients may be at risk for falling down stairs or walking outside into cold weather. In these cases, a careful review of the sleeping arrangement with the doctor may be very helpful. In more extreme cases, treatment with medication that alter the sleep architecture can be used.

You further describe shaking movements that can last for hours. Seizures are the most concerning movement disorder of sleep. However, shaking “for hours” would be highly unusual for a seizure disorder. Therefore, it is not very likely that you are having nightly seizure activity. The condition I mentioned earlier, periodic limb movement disorder of sleep (PLMD), may also affect the upper body as well as the legs.

Finally, I will comment on the "sesame taste". This may be due to gastro esophageal reflux disorder (GERD, also known as heartburn), which can occur at certain time of the night. GERD can further disrupt sleep and cause arousals. Sleep apnea may be associated with a similar symptom due to the abrupt chest and throat muscle contractions.

I suggest that you follow these general sleep hygiene recommendations:

As you can see, there are a number of possibilities for the symptoms you are experiencing and this can be complex - a number of factors need to be considered. I recommend you discuss your problems further with your primary care doctor and ask for a referral to a Sleep Specialist for further evaluation. It is likely that your situation can be significantly improved once the diagnosis has been made and treatment initiated.

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Response by:

Rami N Khayat, MD Rami N Khayat, MD
Clinical Associate Professor of Pulmonary, Allergy, Critical Care & Sleep
College of Medicine
The Ohio State University