REM sleep behavior disorder (a type of psychosis related to lack of REM sleep and lack of dreaming)
Parasomnias are undesirable behavioral, autonomic nervous system, or experiential phenomena during sleep, usually characterized by increased motor and/or autonomic activity, sleep-wake state dissociation, altered responsiveness to the environment, and retrograde amnesia.
Specific parasomnias arise during sleep-wake transitions, NREM sleep, or REM sleep and are often divided into two groups:
- Primary parasomnias are disorders of sleep states per se
- and secondary parasomnias are disorders of other organ systems that arise during sleep.
Virtually all primary parasomnias represent an admixture or simultaneous occurrence of elements of both wakefulness and sleep
The most common primary parasomnias are disorders of arousal and REM sleep disorders. Disorders of arousal include confusional arousals, sleepwalking, and sleep terrors, all characterized by partial arousals from NREM sleep.
REM sleep parasomnias include nightmares, characterized by frightening dreams and autonomic arousal, and REM behavior disorder (RBD), characterized by absence of the muscle atonia normally present during REM sleep.
The behaviors associated with primary parasomnias may lead to injury of the patient or bed partner, and may have forensic implications.
Numerous secondary parasomnias, such as sleep-related expiratory groaning, or esophageal spasm, have been reported.
Typically, descriptions have been provided for single cases or very small case series, making scientific evaluation difficult. These phenomena are likely to be quite common, but are often unrecognized, misdiagnosed, or ignored in clinical practice. The pathophysiology, morbidity, and functional consequences of secondary parasomnias are unknown.
Until the 1950s, most people thought of sleep as a passive, dormant part of our daily lives. We now know that our brains are very active during sleep. Moreover, sleep affects our daily functioning and our physical and mental health in many ways that we are just beginning to understand.
Nerve-signaling chemicals called neurotransmitters control whether we are asleep or awake by acting on different groups of nerve cells, or neurons, in the brain.
Neurons in the brainstem, which connects the brain with the spinal cord, produce neurotransmitters such as serotonin and norepinephrine that keep some parts of the brain active while we are awake.
Other neurons at the base of the brain begin signaling when we fall asleep. These neurons appear to “switch off” the signals that keep us awake. Research also suggests that a chemical called adenosine builds up in our blood while we are awake and causes drowsiness. This chemical gradually breaks down while we sleep.
During sleep, we usually pass through five phases of sleep: stages 1, 2, 3, 4, and REM (rapid eye movement) sleep. These stages progress in a cycle from stage 1 to REM sleep, then the cycle starts over again with stage 1 (see figure 1 ).
We spend almost 50 percent of our total sleep time in stage 2 sleep, about 20 percent in REM sleep, and the remaining 30 percent in the other stages. Infants, by contrast, spend about half of their sleep time in REM sleep.
During stage 1, which is light sleep, we drift in and out of sleep and can be awakened easily. Our eyes move very slowly and muscle activity slows.
People awakened from stage 1 sleep often remember fragmented visual images. Many also experience sudden muscle contractions called hypnic myoclonia, often preceded by a sensation of starting to fall.
These sudden movements are similar to the “jump” we make when startled. When we enter stage 2 sleep, our eye movements stop and our brain waves (fluctuations of electrical activity that can be measured by electrodes) become slower, with occasional bursts of rapid waves called sleep spindles.
In stage 3, extremely slow brain waves called delta waves begin to appear, interspersed with smaller, faster waves. By stage 4, the brain produces delta waves almost exclusively.
It is very difficult to wake someone during stages 3 and 4, which together are called deep sleep. There is no eye movement or muscle activity.
People awakened during deep sleep do not adjust immediately and often feel groggy and disoriented for several minutes after they wake up. Some children experience bedwetting, night terrors, or sleepwalking during deep sleep.
When we switch into REM sleep, our breathing becomes more rapid, irregular, and shallow, our eyes jerk rapidly in various directions, and our limb muscles become temporarily paralyzed. Our heart rate increases, our blood pressure rises, and males develop penile erections. When people awaken during REM sleep, they often describe bizarre and illogical tales – dreams.
When Does REM Sleep Occur?
The first REM sleep period usually occurs about 70 to 90 minutes after we fall asleep.
A complete sleep cycle takes 90 to 110 minutes on average. The first sleep cycles each night contain relatively short REM periods and long periods of deep sleep.
As the night progresses, REM sleep periods increase in length while deep sleep decreases. By morning, people spend nearly all their sleep time in stages 1, 2, and REM.
People awakened after sleeping more than a few minutes are usually unable to recall the last few minutes before they fell asleep. This sleep-related form of amnesia is the reason people often forget telephone calls or conversations they’ve had in the middle of the night.
It also explains why we often do not remember our alarms ringing in the morning if we go right back to sleep after turning them off.
Since sleep and wakefulness are influenced by different neurotransmitter signals in the brain, foods and medicines that change the balance of these signals affect whether we feel alert or drowsy and how well we sleep.
Caffeinated drinks such as coffee and drugs such as diet pills and decongestants stimulate some parts of the brain and can cause insomnia, or an inability to sleep. Many antidepressants suppress REM sleep.
Heavy smokers often sleep very lightly and have reduced amounts of REM sleep. They also tend to wake up after 3 or 4 hours of sleep due to nicotine withdrawal. Many people who suffer from insomnia try to solve the problem with alcohol – the so-called night cap.
While alcohol does help people fall into light sleep, it also robs them of REM and the deeper, more restorative stages of sleep. Instead, it keeps them in the lighter stages of sleep, from which they can be awakened easily.
People lose some of the ability to regulate their body temperature during REM, so abnormally hot or cold temperatures in the environment can disrupt this stage of sleep.
If our REM sleep is disrupted one night, our bodies don’t follow the normal sleep cycle progression the next time we doze off. Instead, we often slip directly into REM sleep and go through extended periods of REM until we “catch up” on this stage of sleep.
People who are under anesthesia or in a coma are often said to be asleep. However, people in these conditions cannot be awakened and do not produce the complex, active brain wave patterns seen in normal sleep. Instead, their brain waves are very slow and weak, sometimes all but undetectable.