Mother’s Dreams
Having a baby is one of the Really Big events in life, and it is no surprise that both pregnancy and birth have a major influence on the structure and content of a mother’s dreams.
It is also not surprising that many of the dreams have a strong negative component to do with maternal responsibility, or depicting the new infant in dreamed situations of danger. These dreams can cause anxiety that can spill over into wakefulness. A new study from Montreal published in the journal Sleep has added something new: these kinds of dreams may be accompanied by complex sleep behaviors such as motor activity, speaking and expressing emotions.
The study from the Sleep Research Centre at the Hôpital du Sacré-Coeur de Montréal in Montréal, Québec, Canada, focused on 273 women, who were divided into three groups: postpartum, pregnant, and women who had not given birth. The subjects completed questionnaires about pregnancy and birth factors, personality and sleep. They were also interviewed and asked about the prevalence of recent infant dreams and nightmares, associated behaviors, anxiety, depression and other psychopathologic factors.
- The percentage of women in all groups who recalled dreams ranged from 88-91%
- Postpartum and pregnant women recalled infant dreams and nightmares with equal prevalence, but more postpartum women reported they contained anxiety (75%) and the infant in danger (73%) than did pregnant women (59%)
- Motor activity was present in twice as many postpartum (57%) as pregnant (24%) or non-pregnant (25%) women
- Expressing emotion was more prevalent among women without children (56%) than postpartum women (27%), but was not different from pregnant women (37%)
- Speaking while asleep was equal among the three groups (12-19%)
- Behaviors were associated with nightmares, dream anxiety and, among postpartum women, post-awakening anxiety (41%), confusion (51%), and a need to check on the infant (60%)
Most pregnant women experience daytime fatigue primarily because the quality of their sleep tends to be worse. Physical discomfort and awakenings are common, particularly during the third trimester.
Snoring often increases during pregnancy and obstructive sleep apnea may develop as the pregnancy progresses.
Two other sleep disorders that are more common during pregnancy are restless legs syndrome (RLS) and sleep related leg cramps. RLS affects nearly 25% of pregnant women and may be related to low iron stores. Leg cramps occur in about 40% of pregnant women, although they usually clear up after delivery. They tend to go away after delivery.
It is easy to understand these dreams from an evolutionary perspective. Though there is also a small literature on mothers who get intuitive flashes about their distressed infants. I have followed this work for many years. When I was an infant I chocked on a banana, and my mother who was some way off “saw” it happening in her mind’s eye and rushed in to find a very small RP who had already turned blue. She swore to her dying day that the tale was true.
And I still cannot eat bananas.
Update on Pramipexole
I have mentioned pramipexole before. In the United States it is approved for the treatment of the signs and symptoms of idiopathic Parkinson’s disease.
I’m always on the look out for medicines that can be part of a package of healthcare, and we need to learn both the pros and cons of new medicines. This looks to be a medicine that can be incorporated into Integrated Medicine. And before you ask, I have no links at all with the manufacturer, Boehringer Ingelheim.
There have been a number of interesting papers presented at the 10th International Congress of Parkinson’s Disease and Movement Disorders in Kyoto, Japan this week.
New data presented have shown that people taking pramipexole (Mirapexin®/ Sifrol®) can experience significant improvements in a broad range of symptoms associated with Restless Legs Syndrome (RLS).
In all studies presented at the meeting, people taking pramipexole reported clinically meaningful improvements in both their night and day-time symptoms, as measured on the International Restless Legs Scale (IRLS). The IRLS measures several aspects of the condition, ranging from discomfort, the need to move around, relief by moving around and then more specific RLS symptoms such as sleep disturbance, day-time tiredness, mood disorder, as well as addressing overall severity, weekly frequency, daily severity, and impact on daily activities.
One of the big problems in the treatment of RLS is that people who have it frequently have other problems as well, such as hypertension, arthritis, gastroesophageal reflux disease, depression, anxiety, and diabetes. So it is essential that the physical component of treatment should not cause any deterioration in associated illnesses. One of the papers presented in Kyoto indicated that pramipexole could be used in people with RLS who are also taking an array of other medicines. That claim is going to have to be checked by the FDA, but the data look very encouraging.
Still, when using medications, there’s no such thing as a free lunch: The most commonly reported adverse reactions in clinical trials for RLS were nausea, headache, and tiredness.
In people with Parkinson’s disease, pramipexole may cause them to fall asleep without any warning, even while doing normal daily activities such as driving. This is obviously very serious, and before the medicine gets an RLS indication in the USA, the FDA will really check this out in great detail. When taking pramipexole hallucinations have been known to occur and sometimes patients may feel dizzy, sweaty or nauseated upon standing up. In Parkinson’s disease, there is also a warning that as with many other medicines used to treat it, including pramipexole may be associated with impulse control disorders/compulsive behaviors.
So we need to keep an eye on safety, but so far the data is very encouraging, and we may soon have something else to add to an integrated treatment program for people with RLS.
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Here’s a P.S. On November 10th, 2006, pramipexole was approved for use in RLS by the FDA. Here’s the announcement:
Ingelheim/Germany, 10 November 2006 – Boehringer Ingelheim announced today that the U.S. Food and Drug Administration (FDA) has approved pramipexole, a non-ergot dopamine agonist, for the treatment of moderate to severe primary Restless Legs Syndrome (RLS).1 This is an important milestone for pramipexole (Mirapexin® / Sifrol® / Mirapex®), which was already approved throughout the European Union in April 2006 for this second indication.
Pramipexole
Pramipexole is a remarkably interesting medicine about which you are likely to hear a lot in the near future. It is an agonist, which means that it has a positive effect, on D2 dopamine receptors and also on a little-known group of dopamine receptors, known as the D3 group. If you want to get really clever the dopamine receptor D3 group is abbreviated to DRD3. Pramipexole has been in use for almost a decade in the treatment of Parkinson’s disease, and approximately 9.1 million prescriptions for pramipexole have been written in the U.S. since its launch in 1997. It is not without its problems. In Parkinson’s disease it may cause dizziness, involuntary movement, hallucinations, headache, difficulty falling asleep, sleepiness, and nausea. Some people have also had behavioral dyscontrol while taking it.
At a meeting in Athens in February of 2006, we saw confirmation of something that had been shown in previous research: pramipexole seems to be a very effective treatment for restless legs syndrome (RLS). A study published in the journal Neurology has given us a more detailed understanding of the risks and benefits of pramipexole.
The investigators report a 12-week, multicenter, double-blind, randomized, placebo-controlled study of fixed daily doses of pramipexole (0.25 mg, 0.50 mg, and 0.75 mg) involving 344 patients with moderate to severe RLS. Data from 339 patients were analyzed to evaluate the effect of pramipexole treatment on efficacy and safety. The mean age of patients was 51.4 years and the mean duration of RLS symptoms was 5.1 years. The results were very promising, even though half of the patients on placebo also showed an improvement. The most commonly reported side effect included nausea (19.0%), headache (17.8%), insomnia (10.5%) and somnolence (10.1%).
In Europe pramipexole it has been approved for use in this indication. It is marketed as Sifrol® / Mirapexin® In the United States we currently only have one approved medical treatment for RLS, and that is the GlaxoSmithKline medicine ropinirole (Requip), that works at the same D3 receptors in the brain and spinal cord. Ropinirole is effective in a proportion of people with RLS, but it has also been linked to sleepiness, drops in blood pressure and fainting, so those are included in its label.
RLS may be associated with some other illnesses so I was very interested to see two reports of the use of pramipexole in bipolar depression as well as a report of its possible use in REM Behavior Sleep Disorder.
One of the most exciting potential uses for pramipexole may be in some people with fibromyalgia. I’ve mentioned that fibromyalgia, bipolar disorder and some other psychiatric illnesses may be connected. The idea that we might be able to use just one medicine to support our Integrated Medicine approach is very attractive, and also helps point us toward a deeper understanding of what exactly goes wrong at the physical level in RLS, depression and fibromyalgia.
I’ll keep you posted.
Recognizing Restless Legs
I’ve recently written a couple of articles about restless legs syndrome (RLS), following which I got this question:
"Dear Dr. Petty, I’ve thought that I’ve got RLS, and so did my doctor, but I’ve just heard about something called akathisia, and another doctor has told me that I might have that instead. Is there any way to tell them apart? The doctor seemed to think that they were the same thing. Have you heard of akathisia, and are there any tips for working out what I’ve really got?"
Yes, I do indeed know what akathisia is, and this is a good question. I’ve seen many experts who have mixed up the two conditions. Both may be present in the same person, and there may be some small degree of overlap, but an experienced neurologist should be able to tell them apart without too much trouble.
Akathisia is most commonly seen in people taking certain types of medication that act on the brain. However something indistinguishable from akathisia was described three hundred years before we had any of these medicines. So medications are most certainly not the only cause.
I’d like to direct you to a new article by our friends over at Psychiatric Resource Forum, where you will find an article that goes through the clinical features and causes of akathisia and the nine classical features that distinguish akathisia from RLS.
Let me know if that does not give you the answer that you need, and I’ll happily write a more detailed account of how to distinguish the two.
Good luck, and let me know if I can help you further.
Restless Legs Syndrome and Integrated Medicine
In the last entry we looked at RLS: what it is, and some of the conventional approaches to treating it. I now want to spend a moment talking about some of the other approaches that we have tried. For most of these there is very little evidence, so we use them in conjunction with conventional medicine.
If you want to try any of them, discuss them with your health care provider, so that he or she can guide you toward the best ways of putting treatments together.
- Diet: A low sugar diet helps some people, and it is always worth keeping a food diary for a week to see if there’s any association between something that you’ve eaten and a worsening of your symptoms.
- If you like juicing, there have been a number of anecdotal reports of the use of carrot, celery and spinach juices helping some people. (I am writing this while we are still in the middle of the spinach/E. coli scare, so leave this one out until the FDA has given us the all clear.
- There have been publications about the use of vitamins E and B and folic acid in RLS. Vitamin E can cause a GI upset in some people and if used in too high a dose (above 800IU/day) may elevate blood pressure; folic acid has to be used with caution in people on anticonvulsants. If you try these options, bear in mind that no supplement is likely to work unless it is taken for at least a month.
- Acupuncture sometimes helps: there are three acupuncture points in the legs that come up in the prescription: Urinary bladder 57, Spleen 6 and Stomach 36.
- Homeopathic remedies have been reported to help, and I’ve had some success. The precise remedy always depends on the precise characteristics of the individual, but the most common ones have been Rhus Toxicodendron, Causticum, Tarentula Hispanica and Zincum Metallicum. If you live in a place in which there are good homeopaths available for consultation, it’s another option.
- Several herbal remedies have been reported to help: Passion Flower, Cimicifuga, Valerian, Black Cohosh and Piper Methysticum. Just remember that some of the herbs sold in health food stores don’t contain what they should, and Valerian and Black Cohosh have recently been associated with liver toxicity in some people.
- Here is an old trick from China: take a one inch piece of fresh ginger root and grate it into a bowl of warm water. Then soak your feet in the water for about ten minutes. I’ve never seen that one work myself, by some people whom I respect have.
I also think it important not to neglect the psychological aspects of this problem, and sometimes some psychotherapy can be a helpful adjunct.
Finally, ask yourself what the RLS is trying to teach you.
These are all options that have been tried and have helped some people. If you are not having success from conventional medicine alone, or if you don’t care for conventional medicine, then discuss these options with a professional, use your intuition, and let us know if you have success.
Restless Legs Syndrome
Restless legs syndrome (RLS) is a common (3-15% of the population) and sometimes very unpleasant problem in which people have uncontrollable urges to move their legs. If they do not move, they will begin to feel uncomfortable, painful or odd sensations in their legs, and sometimes also in other parts of the body. The restlessness may last for minutes or even hours. Movement affords people very temporary relief. The sensations are usually between the ankle and the knees, but they can also involve the thighs. If other parts of the body are involved it always makes us question the diagnosis.
The severity of the problem is highly variable, running from a mild annoyance to an incapacitating problem. In most people the symptoms are worse when sitting or at night, and often lead to loss of sleep. Not surprisingly many people feel of exhausted and irritable during the day.
With such enormous variations in the severity of the problem, and even the parts of the legs affected, it is highly likely that RLS is a symptom of a group of illnesses.
The International Restless Legs Syndrome Study Group (IRLSSG) identified four criteria that must be present for an RLS diagnosis:
- An urge to move, usually due to uncomfortable sensations that occur primarily in the legs.
- Motor restlessness, expressed as activity, that relieves the urge to move.
- Worsening of symptoms by relaxation.
- Variability over the course of the day-night cycle, with symptoms worse in the evening and early in the night.
About 80% of the people with restless legs syndrome also suffer from a separate condition called periodic limb movements in sleep (PLMS). Periodic limb movements in sleep are involuntary jerking movements in extremities, usually the legs. You can have PLMS without having RLS, and vice versa.
RLS may start at any age, including early childhood, and is a progressive disease for a certain percentage of sufferers, although it has been known for the symptoms to disappear permanently in some sufferers. The condition runs in families; children of RLS sufferers are more likely than other people to develop RLS.
It has some similarities to a syndrome known as akathisia that occurs in people taking some medications that work in the dopamine pathways of the brain. There are some subtle ways of telling the two apart, but RLS also seems to be caused by disturbances in one of the dopamine pathways of the brain.
It has been known for many years that there is an association between RLS and iron deficiency, but this link is probably not causal: just giving iron only helps a proportion of sufferers. But because of this link, everyone with RLS should have their ferritin levels tested; ferritin levels should be at least 75 mcg for those with RLS. If it’s below this level, iron supplements may help, but they are best administered by a physician, because ferritin needs to be monitored and there are down sides to taking too much iron. In a moment I’ll tell you about some very new research on iron and RLS
Caffeine and other stimulants usually make RLS worse. Restless legs syndrome frequently occurs during pregnancy. About 15% of pregnant women develop RLS symptoms during the last few months of their pregnancy. The sensations usually stop after the woman delivers the baby.
We normally divide RLS into primary and secondary. Primary RLS usually starts before age 40 and the onset is often slow. The RLS may disappear for months, or even years. But it can be progressive and get worse as the person ages.
Secondary RLS often had a sudden onset and may be daily from the very beginning. Apart from pregnancy, secondary RLS is a result of a number of medical conditions, so it is always important to rule them out. They include:
- Iron deficiency anemia
- Macrocytic anemia due to folate or vitamin B12 deficiency
- Diabetes mellitus
- Peripheral neuropathy
- Alcohol abuse
- Some types of cancer, particularly of the lung
- Celiac disease
- Renal failure
- Inflammatory arthritis
There have been reports of associations of RLS with other illnesses, but most seem rare. Interestingly people who undergo surgery often find that RLS symptoms become worse, which may be another clue as to the cause of the problem.
An international conference entitled SLEEP 2006, the 20th Anniversary Meeting of the Associated Professional Sleep Societies took place from June 17-22, 2006 in Salt Lake City, Utah. There were a great many interesting papers this year, including several on RLS
An international group of collaborators presented the results of the first population-based pediatric RLS survey. They used the National Institutes of Health pediatric RLS diagnostic criteria and collected data from over 10,000 families. The criteria for definite RLS were met in 1.9% of 8- to 11-year-olds and in 2% of 12- to 17-year-olds. Two different papers explored the value of using a single screening question to identify possible RLS patients. Those who answered, “Yes,” then answered more detailed questions to determine whether they met the International RLS Study Group diagnostic criteria.
A single screening question can eliminate people without RLS rapidly and direct appropriate subjects to further evaluation. Two groups of researchers found a high level of sensitivity with the question, "When you try to relax in the evening or sleep at night, do you ever have unpleasant, restless feelings that can be relieved by walking or movement?"
As I mentioned, it has been known for decades that RLS may be associated with low iron, and especially with low ferritin levels. These may be present in symptomatic RLS patients during pregnancy and in people with iron-deficiency anemia and end-stage renal disease. Previous studies had suggested that supplemental iron was beneficial for RLS patients with low ferritin levels. One paper presented further evidence of the possible efficacy of supplemental iron in the treatment of selected RLS patients with a prospective, randomized, placebo-controlled, double-blind study of RLS patients with low to normal ferritin levels (15-75 mcg/L). The RLS subjects were given either placebo or iron 325 mg twice daily and were monitored with a validated RLS symptom scale. The preliminary findings showed that the iron supplementation group had significant increases in their ferritin levels and had improved quality of life compared with those on placebo; however, the interim data presented did not show a significant change in the RLS symptom score. The study is ongoing.
Treatment for RLS is based on how disruptive the symptoms are. Apart from iron, people should review their lifestyle and see what changes could be made to reduce or eliminate their RLS symptoms. These include: Finding the right level of exercise (too much worsens it, too little may trigger it)
Eliminating caffeine
Stopping smoking
Reducing alcohol intake
Several drugs have been tried for RLS: Some of the same medications used in Parkinson’s disease, benzodiazepines, anticonvulsants like carbamazepine and gabapentin.
Last month saw the publication of an important paper indicating that the medicine pramipexole, another anti-Parkinsonan drug, helps many people with RLS
In the next article I shall review some of the other approaches used by Integrated Medicine.
