Monthly Archives: September 2009

REM Behavior Disorder, a Parasomnia

What are Parasomnias?

In sleep medicine we define parasomnias as ‘undesirable events that accompany sleep.’ What makes these disorders so interesting is that they can involve more complex and apparently purposeful behaviors than other disorders of sleep. There are parasomnias that occur in REM sleep, and some in nonREM. Last post about Sleepwalking was one example, here’s another.

REM Sleep Behavior Disorder

During REM sleep your muscles are usually inhibited so that you don’t move during dreams. In this disorder, however, muscle tone is maintained, so the person ends up acting out their dreams. For an unknown reason the dreams that are acted out are usually unpleasant, action-filled and violent. The eyes usually remain closed, and people have been known to sit up, leap from bed, shout, swear, grab, flail their arms, punch, kick, and talk. As you can imagine, sleep-related injury is common for both the patient and their bedpartner. This disorder is more common among men over aged 50, and among those with a neurological disorder such as Parkinson’s disease. If you suspect REM Sleep Behavior Disorder then consult with a sleep clinic.

These are just two of the many types of parasomnias that people can experience. Feel free to email me with questions about other abnormal sleep behaviors if you wish.

Sleepwalking in Seattle


As an 11 year old child, I had a champion sleep walking event – let me tell you about it. Growing up in the Seattle suburbs, we lived in a one story rambler. We were friends with the neighbors, who were our age, and also lived in a rambler. One night, after having the flu, I walked down the long hall, out our front door, around the side of the house, up a 2’ rockery, and into the neighbors’ walk. From there I pulled the string to open the wooden gate, up the 6 stairs to their backdoor, in and through their house to the parents room. There I stood until they woke up, I woke after being walked to their kitchen, and my parents woke when the neighbors pounded on the door delivering me home.

Sleepwalking is a type of parasomnia. Sleepwalking typically does occur in children, and resolves as they go through puberty. Sleepwalking tends to run in families. As you can see from the story above, safety is a primary concern. If your child sleepwalks, you need to make sure that doors and windows are locked, stairs are safely blocked, and other hazards are contained. You can hang a bell over the door, so it will alert you when the child gets up. When someone is sleepwalking it is best to simply guide them back to bed gently.

Create a Great Sleep Environment

Over the centuries, and from place to place throughout the world, sleep environments have varied widely. I once attended a presentation on sleep environments in other cultures. The most striking was in a nomadic culture. The women sleep squatting down, with their skirts stretched tightly across their knees. Their babies sleep on their skirts so as to be safe from the many poisonous snakes in the area.

Fortunately we are able to organize our sleeping place to be the best it can be. We can usually minimize stimuli that interrupt sleep. Below are some tips you can use at home, with the reasoning behind each.

Creating a healthy sleep space at home:
Doing most of these items will take 10 minutes or less – the result can be a more restful night!

– Move your clock from the head of your bed. Place it across the room where it cannot be seen from your pillow. Sleep comes easier if you are not thinking about the time, or how much time you have left to sleep!
– Find someplace else for your pets to sleep. Of all my recommendations this is sometimes the hardest for people to do because they love their pets. I love my pet too, but the fact is that the pets can be waking you up in the night, and leaving you less refreshed the next day.
– Sleep in the same bed each night. As we cycle through the five sleep stages each night we hit Stage 1 sleep every hour and a half or so. At that time people frequently sit up, adjust the covers, scan the room for anything that needs attention, then lie back down. If you are in an unusual room it may take longer to make sure the room is safe and return to sleep.
– Make the room as dark as possible. Even the light from a night-light or clock is enough to interfere with your natural melatonin rhythm.
– Wash your bedding regularly to minimize any allergic reaction to dust and dust mites. Sheets and pillowcases should be washed weekly; pillows, blankets and mattress covers washed at least every quarter; and pillows replaced every two years.
– Remove any workstations from your bedroom. This includes computers, TV, sewing or any other hobbies. Having these activities in your bedroom conditions you to be active and alert in the bedroom instead of relaxed and asleep.

Children are Sleep Deprived

Children are sleep deprived just as adults are – 27% of children get less sleep than they need each school night. How much sleep does a child need? Preschoolers (ages 3 to 5) need about 11 to 12 hours, children aged 6 to 12 need 10 to 11 hours, and high school students need 9 to 9.5 hours.

If a child doesn’t get enough sleep they can have mood and behavior problems. For example, they may be irritable, overly emotional, have difficulty cooperating or controlling impulses. Teens especially will take more risks when they are sleep deprived.

School performance is also impaired by sleep deprivation. It becomes more difficult to pay attention, creativity declines, and memory is impaired. Certainly not what we want for our children in school!

Tips to help your children get the sleep they need:
If you suspect your children are not getting the sleep they need to feel good and do well in school there are steps you can take today to improve their sleep.

First, set a consistent wake up time for your child. The time you wake up is the most important for setting your body clock. Next, get them to bed 15 minutes earlier every couple days, until they awaken refreshed on their own. When a preschool or grade school child is getting enough sleep they will be able to awake on their own (this may not be true of teens, more on teen sleep another time).

“Screen time” in front of a computer or television can interfere with easily falling asleep both because of the bright light and because it is mentally stimulating. So establish a bedtime routine that does not involved the TV or computer.

Caffeine stays active in the body for 6 to 8 hours. Ensure your child is not having any caffeine after noon to help sleep well at night.

Overweight and Sleep Deprived

Weight Loss
Recent research has established that when a person is sleep deprived by even just a few hours (say sleeping 6 hours a night), their appetite and metabolism are affected. When you are sleep deprived you will feel more hungry, and want to eat more fatty and starchy foods than when you are well rested. Also your blood sugar regulation will change, so that your blood sugar is higher than when you get adequate sleep. For those of you who’d like to lose weight, make it easier to make healthy food choices by getting the sleep you need.

Are you sleep deprived?
If you must always be awakened by an alarm, find yourself yawning through the day, or have low energy you may be sleep deprived. Recent polls of Americans showed that 16% of Americans are getting less than 6 hours of sleep per night, and 27% characterized themselves as not getting the sleep they need.

To remedy sleep deprivation try going to bed slightly earlier each night, until you feel energetic and ready to start the day when the alarm goes off. Keep your wake time the same each day, as this is most important to set your body clock. Ideally you will get to the point that you will wake up ready to go even before the alarm! That will be a great feeling!

Behavioral Treatment for Insomnia

How does Insomnia develop?
Frequently there is an initial stressor that causes a person to not sleep as well. This could be either a happy event such as a wedding, or a stressor such as a job change. It is normal to have disrupted sleep for a short while. This is called acute insomnia.

Chronic insomnia is defined as lasting more than one month. In this case the person has frequently developed thoughts and habits that perpetuate the insomnia, even after the initial event is over.

What are treatment options?
The primary goal is to treat the underlying cause of the insomnia. There are both prescription drug treatments and behavioral treatments for insomnia. When insomnia is due to a medical or mental disorder the underlying disorder must also be treated.

Behavioral treatment for insomnia is a well-thought out approach that addresses several contributing factors in a systematic way. The therapeutic components include:
– Relaxation techniques. Example: Focusing only on the breath, breathe in slowly for a count of three, out for a count of three.
– Stimulus Control therapy. Example: Be in bedroom only when drowsy or asleep.
– Sleep Restriction therapy. Example: Limit time in bed just to the time spent asleep. In other words, no long periods of lying in bed trying to sleep.
– Education about sleep. Example: Waketime determines when you will get sleepy, so setting a consistent waketime will allow you to fall asleep easily at bedtime.

Research has shown that behavioral treatment for insomnia is more effective than prescription drug treatment, even two years after treatment.