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Sleep Disorders

I know I am awake but cant tell what is real

08/26/2010

Question:

I have been married for about 3 years and my wife and I have noticed that I sometimes wake up from a dream and continue to act out the dream. However, I am fully aware that I am awake but I am not able to distinguish what is reality and what has been created by my imagination. I will wake up and think that snakes are in the bed or that there is something in the room with us. I`ve even woken up and thought that we were being bombed by Russia (thunder). This happens probably 3 or 4 times a month. When this does happen I will urge my wife to get out of the bed or will try to protect her from whatever it is that I think is in the room. This, of course, wakes her up and she thinks I am a crazy person. She has gotten use to this and has learned that I will eventually come back to reality.

The other topics I have read on the website do not deal with my issue exactly. Most people act out their dreams and do not realize what they are doing. I am fully aware of what I am doing and where I am but I can not distinguish reality from the story line of my dream at the time of waking up. I also remember everything about the incident. Have you ever heard of this? Any tips?

Answer:

Let me start by explaining some terminology and providing some information about normal sleep. Dreaming is thought to occur primarily in the stage of sleep called Rapid Eye Movement (REM) sleep. This stage of sleep recurs several times in a night of normal sleep. Therefore, dreams occur every night for most individuals. During sleep, we transition through several stages in a regular recurring pattern. These stages can be broadly classified into REM and non-REM sleep. Therefore, normal sleep cycles through these stages throughout the sleep period. Individuals usually have REM sleep roughly every 90 minutes on average.

Abnormal activity during sleep is called parasomnia. These abnormal activities can occur in both REM and non-REM sleep and therefore, can be classified into REM and non-REM parasomnias.

Now back to dreaming. It is almost certain that we dream several times per night when we go into the REM stage of sleep. What is less common, however, 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. Some individuals report vivid recollection of their dreams in the morning without much sleep disturbance.

What you are reporting is a pattern of dream enactment behavior in which you apparently attempt to “act out” your dreams. This could be the result of a number of sleep-related conditions, though this is most commonly encountered in a condition called “REM behavior disorder” RBD). Other conditions classified as non-REM parasomnia, in which patients experience activity during sleep, are not typically associated with “dream recall”. Other possibilities for the symptom’s you are experiencing might include sleep-related hallucinations, sleep apnea, some psychiatric conditions, side effects of certain medications, post-traumatic stress disorder and seizures. However, your description is most suggestive of RBD and will need further evaluation.

REM behavior disorder is an uncommon condition in which individuals lose the muscle paralysis that usually accompanies REM sleep (dream sleep) and thus may act out their dreams. This tends to occur later in the night and most individuals have some recall of what they were doing (thought they do not have control over it). Depending on the nature of the dream, this can lead to injurious behavior to the patient, such as from falling out of bed, running into walls or furniture or hitting objects, or their bed partner. Frequently, the nature of the dreams is violent (such as fighting or struggling to get away from someone or something), even in nonviolent individuals, and thus they may be prone to harming themselves or others. Certain factors may help to precipitate episodes, such as being sleep deprived, using alcohol or illicit substances or having an acute illness. It is most commonly seen in middle to older aged men. It can occur in women as well, though this is fairly uncommon.

The diagnosis of RBD needs to be confirmed by a sleep physician evaluation which will have to include an overnight sleep study. If confirmed that this is RBD, there are several treatment options available. Sedatives are used with a high degree of success in most cases. In additional to medical therapies, simple safety maneuvers should be instituted in the home such as covering windows with heavy drapes, removing furniture with sharp corners and eliminating access to potentially harmful objects such as weapons or sharp or heavy objects.

Determining your diagnosis is extremely important for a number of reasons. First, it needs to be established if indeed this is REM behavior disorder or another condition mimicking REM behavior disorder. Second, the diagnosis may have long-term implications for your health and well-being. Third, these conditions are generally treatable once a diagnosis is made. And fourth, it’s important for the safety of yourself and others around you to identify and treat this condition.

There are a number of sleep centers across the country that could evaluate the problem and you can locate these on the American Academy of Sleep Medicine website at www.aasmnet.org.

For more information:

Go to the Sleep Disorders health topic, where you can:

Response by:

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