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REM Sleep Parasomnias

REM Sleep Behavior Disorder – Sleep Paralysis – Hypnagogic Hallucinations – Hypnopompic Hallucinations – Nightmares

Parasomnias are some undesirable phenomena associated with sleep. Sleep quality often remains unaffected by parasomnias but they may be disturbing for the bed partner. Most of parasomnias are not considered pathological and some are experienced by almost everyone. This article describes the most common REM sleep parasomnias.

REM Sleep Behavior Disorder (RBD)

REM sleep behavior disorder is one of very few parasomnias that are considered pathological. Most of skeletal muscles get “paralyzed” during REM sleep phase. The purpose of paralysis is prevention of acting within the context of the dreams that normally occur in this sleep phase. REM sleep behavior disorder is caused by lack of sufficient muscle paralysis during REM sleep.


Depending on severity of REM sleep behavior disorder, the symptoms may range from falling out of bed and kicking the bed partner to a violent behavior, such as running, jumping, or fighting, often in self-protective manner. Talking, screaming, or laughing may accompany the attack.
Unlike sleepwalking, the eyes are closed and people rarely go outside the room. Behavior during the attack is totally dependent on the dream content. The attack usually lasts for about 2 minutes. There is a decent recollection of the dream content upon awakening.
The major concern in this sleep disorder is safety of the patient and the bed partner. The vast majority of patients diagnosed with REM sleep behavior disorder have only brief movements but they may be strong enough to through the person out of bed or cause an injury.
As an example, one of my patients managed to fracture both feet while asleep. The same patient had frequent falls out of bed and once even broke his wife’s ribs.


REM sleep behavior disorder is caused by damage to specific area of the brainstem, which is responsible for muscle paralysis during REM sleep.
Even though strokes and MS may occasionally cause this syndrome, the most common reasons are Parkinson’s disease, Lewy Body Dementia and Multiple System Atrophy.
REM sleep behavior disorder predates the first symptoms of these diseases by about 12 years on average.
Over 80% of patients with REM sleep behavior disorder will develop one of the above mentioned conditions within 20 years.
REM sleep behavior disorder is 8 times more common in men, typically after age 50.
About 30% of Parkinson’s disease patients have this condition when tested in a sleep lab.


Clonazepam, taken at bed time, is the most effective drug for REM sleep behavior disorder. Other potentially effective agents are Mirapex and Melatonin.
Several drugs can exacerbate or even provoke RBD. These include SSRIs, SNRIs (especially Venlafaxine), alcohol and caffeine.

Sleep Paralysis

Sleep paralysis is inability to move upon awakening or, less frequently, while falling asleep. The phenomenon is kind of an opposite phenomenon to REM sleep behavior disorder. In RBD, normal paralysis during REM sleep is lacking. In sleep paralysis, REM related inability to move persists into the state of wakefulness.

On average, sleep paralysis episode lasts from seconds to around a minute. This sleep phenomenon is classical for narcolepsy and may occur in other sleep disorders.

It is frightening but harmless. Many otherwise healthy people occasionally experience sleep paralysis. In the absence of other sleep disorders it is provoked by distortion of sleep architecture caused by sleep deprivation, erratic sleep pattern, stress, anxiety, physical exhaustion, or stimulant overuse.

Sleep paralysis without narcolepsy occasionally runs in families.

Sleep paralysis is an intrusion of REM sleep phenomenon into the state of wakefulness. It is often accompanied by hallucinations (REM sleep related dreams) described below.

Hypnagogic and Hypnopompic Hallucinations

Hypnagogic (while falling asleep) and hypnopompic (upon awakening) hallucinations are dreams in the state of wakefulness.

This experience may be frightening, especially when hallucinations and paralysis come together. People report near-death or out-of-body experience. They see demons, angels, and supernatural phenomena. These phenomena are like echoes from the REM sleep. They are typical for narcolepsy sufferers but may also occur in otherwise healthy people. These phenomena may be brought up by sleep deprivation and other factors mentioned above.

Some people are frightened by this experience. This is more common in those who suffer preexisting anxiety disorder.
No treatment is needed for sleep paralysis and sleep related hallucinations unless associated with other disorders.


Nightmares are scary and disturbing dreams, which are remembered upon awakening. Normally, dreams are forgotten. They are remembered only upon awakening during the dream. Only the last dream is remembered. Nightmares are more common in children and are strongly associated with post-traumatic stress disorder, anxiety and stress.

According to Sigmund Freud, we wake up from scary dreams when the dream mechanism fails to complete its job. Waking up leaves the conflict unresolved and the dream content reaches the consciousness.
It makes perfect sense to me. REM sleep sorts out and organizes the experiences during the day. Inability of dream work to complete the task causes the awakening.

Nightmares do not have to be treated unless they cause additional fear and stress. Treating of the underlying anxiety disorder should help.
Desensitization technique can be beneficial. Patients are asked to wright down or draw the dream content. Rewriting the dream scenario with a different ending is another approach.

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