Why do I undress in my sleep?

What dominates in women and what in men?

The transition between physiological and pathological movements during sleep is fluid; the environment and situation can make movement during sleep dangerous. For clarification, drug, toxic or psychiatric causes must be ruled out. Polysomnography in the sleep laboratory is essential. The following article deals with disorders for which there is a gender difference.

A married couple, both 70 years old, introduce themselves during the consultation hour. The woman reports that in recent months she has been increasingly woken up by her husband's violent movements in his sleep. He literally "fights" and has shaken her once before. He later reported that he had caught a thief in a dream. The woman also reports that she herself wakes up almost every night with a tingling sensation in her legs. She then has to get up and walk around. Sometimes these symptoms start with watching TV in the evening.

Are movements normal during sleep? In principle, yes - everyone moves several times during the night, otherwise perfusion disorders and pressure ulcers would occur. The movements are to be regarded as pathological if they lead to sleep disturbances, injuries or impairments of the bed partner or if they have an effect on the day-to-day well-being [2, 5, 9].

The third International Classification of Sleep Disorders of the American Academy of Sleep Medicine [1] lists two groups associated with movement during sleep.
  1. Sleep-related movement disorders such as restless legs syndrome, sleep-related leg cramps or myoclonus.
  2. Parasomnias, which are divided according to the stage of sleep at which they occur. Non-REM parasomnia includes, for example, B. sleep-related eating, sleepwalking and pavor nocturnus. REM sleep-related parasomnias include REM sleep behavior disorder, recurrent sleep paralysis, and nightmares. There are also other parasomnias (e.g. nocturnal wetting).

This article only explains those conditions for which gender differences are described. An attempt should be made to show the causes for these differences.

Restless legs syndrome

Restless legs syndrome is more common with age and affects up to 10% of the population [8, 11]. Women are more often affected in a ratio of 1.5-2: 1. The diagnosis, which can be determined from clinical criteria, is usually made late.

The four essential diagnostic criteria of RLS [3, 8, 11] are:
  1. An urge to move the legs, rarely the arms, which is accompanied by unpleasant sensations (such as tingling, pulling, pain).
  2. Appearance and intensification of the complaints at rest.
  3. The symptoms stop with movement or can be improved significantly with activity.
  4. There is a clear dependence on the time of day with an increase in symptoms in the evening and at night.

This usually results in severe problems falling asleep and staying asleep with an impact on daytime performance. The patients are just as difficult in their quality of life as z. B. Diabetic impaired.

Detection of periodic leg movements during sleep / PLMS or wakefulness / PLMW in polysomnography is not mandatory (Fig. 1). They occur in more than 80% of patients, but show a high variability from night to night and do not correlate with the severity of the RLS.

The female gender is per se a risk factor for the development of RLS. Different genes play a role in the familial form of RLS. An autosomal dominant inheritance is postulated. There is also a preference for the female sex in the family trees.

Often the secondary RLS is associated with the following causes:
  1. Iron deficiency - iron plays a key role in the genesis of RLS and in response during the course of therapy. Iron is among other things. a coenzyme in L-dopa synthesis. Here, too, there is a predominance of the female sex, especially in the period up to menopause. The RLS can occur for the first time or repeatedly in pregnancies. Here too, there is often an iron deficiency.
  2. Renal insufficiency regardless of dialysis requirement - no gender preference here
  3. Drugs can provoke RLS (Table 1). It becomes clear that these drugs are often used for symptoms of the RLS (e.g. mirtazapine for difficulty falling asleep and staying asleep; antihistamines for itching) and thus strengthen the RLS even more.

In principle, points 1 - 3 play an increasingly important role with increasing age. Because women live longer than men, more women than men are affected with age.

Parasomnias

Parasomnias are present at certain stages of life in childhood and adolescence. However, they can persist into adulthood or recur. This is usually followed by an inpatient clarification on the question of sleep-related epilepsy [3, 7, 13].

Arousal disorders usually occur during deep sleep in the first third of the night. There is usually no muscle tone during this phase of sleep. Pavor nocturnus involves a simple straightening up, often accompanied by a scream and autonomous involvement (tachycardias, tachypneas) with intense fear, incomprehensible verbalizations, arm movements, and rarely jumping up. In adults, the episodes are usually short; in children, they can last 30-40 minutes.

Somnambulism (sleepwalking) involves getting up out of deep sleep followed by walking around and complex, sometimes targeted actions with, however, reduced ability to react. There is a risk of injury to the sleepwalker, especially in unfamiliar surroundings. Since arousal disorders have impaired consciousness, those affected cannot remember the events. The actions are often inadequate (e.g. showering in full clothing). It can therefore lead to dangerous actions with injuries to yourself or others. Since the pain threshold is increased, those affected do not wake up even if they are injured [12].

Violence towards others usually occurs in adult men, so there is a gender preference here. A special form is abnormal sexual behavior during sleep (sexsomnia) [1, 6], also more common in men. There is inadequate masturbation, inadequate, violent sexual behavior towards the partner, but also towards children.

The trigger for sleepwalking (but also sexsomnia) in adulthood is often preceded sleep deprivation with then consecutive, increased deep sleep. Other provocators are alcohol and drugs. There appears to be a genetic predisposition to sleepwalking [1].

Therapeutic interventions are only necessary if there is daytime sleepiness or if there is a risk of self-harm or harm to others. Behavioral counseling includes protection against injuries and accidents (locking windows and doors at night, padding).

REM sleep behavior disorder (RBD) is becoming increasingly important [1, 3, 10]. Men are predominantly affected. Physiologically, muscle atony protects the sleeper from acting out dreams. A lack of inhibition at the level of the medullary neural interconnection enables those affected to move (Fig. 2). The patients act out dream contents, which mostly contain attack and persecution. In addition to self-harm (approx. 30%), the bed partner is particularly at risk (64% risk to others). The RBD should be further clarified neurologically, as 80% of those affected develop neurodegenerative diseases (Parkinson's disease, dementia with Lewy Bodies, multiple system atrophy). RBD can occur decades before other symptoms of Parkinson's disease [1, 4, 10].

In the case report outlined above, it can be assumed that the man suffers from REM sleep behavior disorder, the woman from RLS. Clarification and therapy are necessary for both.


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Conflicts of Interest: The author has not declared any.

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