Tom saw the ball take off a split second before he heard the crack of the bat. It was a line drive just a few feet off the ground, and it was coming his way. He stretched out his arm and dove to the right. The next thing he knew, he was lying on the floor beside his bed and had nearly put his fist through the bedroom wall.
With a bemused smile, he lifted his hand and showed me the scrapes on his knuckles. “I tell you, doc, I thought I was playing ball again. It was so real.”
He had once played semiprofessional baseball, and he was still in good shape at 67. Now he and his wife sat in my exam room as he described the intensely vivid dream he’d had two nights before. His wife nodded her head in agreement.
“Sometimes he hits me,” she said.
“Yeah,” her husband agreed. “It’s the oddest thing. I’m asleep when it happens. I don’t even know I’m doing it.”
My antennae went up and I quickly scanned her up and down. I noted a couple of old bruises on her bare arms.
“He’ll thrash in bed at night, sometimes kick, and maybe even take a swing at me,” she added.
I looked from him to her and then back to him. Had he been abusing her? There was no sense of tension, and I caught no furtive glances or avoidance of eye contact with me. They both just looked perplexed. For 20 years I had known them to be devoted to each other. My patient was the last person I would suspect of spousal abuse. And if this really was abuse, why were they here in my office telling me a story about wild dreams? Still, fading bruises on the wife’s forearms might be defensive injuries.
Did they fit the profile? I briefly considered the risk factors for spousal abuse, or what is now called intimate partner violence: a history of substance abuse, recent unemployment, low academic achievement, a history of physical abuse. None were present. The injuries associated with intimate partner violence—located about the face and neck and in areas covered by clothing, such as chest, breasts, and abdomen—to my knowledge had never occurred in this couple. In my gut I didn’t believe this was intimate partner violence, but abuse can occur in even the most unexpected settings, and I couldn’t afford to miss it. If abuse is suspected, I am required to report it. I needed to know more.
They told me that the vivid dreams and bizarre nighttime behavior had been going on for two years. “Last week he was screaming in his sleep,” Tom’s wife offered.
“Screaming?” I asked him.
“Yeah. I dreamed I was in a courtroom and we lost the case and I started screaming at my lawyer.” He shook his head, baffled and even embarrassed by his imagined behavior.
I shook my head too. Something was definitely wrong. I thought about the stages of normal sleep. When we go to bed at night, we cycle through two states. The more distinctive state is REM (rapid eye movement) sleep. Although we are profoundly asleep in this state, a measuring device called an electroencephalogram, or EEG, attached to the scalp will show brain wave activation that paradoxically looks almost like the activity of the brain when a person is awake. Most of our dreaming occurs during this period. It is also the time when we consolidate memory and refresh ourselves psychologically. (Anyone who has ever been sleep-deprived for a couple of days knows how important this is.) But one thing we don’t do while dreaming in REM sleep is move.
A cardinal feature of REM sleep is atonia, which is the complete absence of activity in all voluntary muscles. During a dream, we lie in our beds as if paralyzed, but one group of muscles continues to operate. Our eyeballs move about in bursts of activity, presumably “watching” the adventures unfolding within our slumbering brains. Hence the term rapid eye movement sleep.
In non-REM (NREM) sleep, the other sleep state, an EEG will show the slowed electrical patterns of decreased brain activity. Normally we cycle through NREM and REM sleep several times each night.