For the last decade, I’ve been plagued by intensely violent nightmares. When I wake, I can remember much of what happened, and the details are extremely upsetting. What could be behind this?
David Ralston, via email.
Dr Martin Scurr replies: To understand what may be happening, it is important first to separate out two likely explanations.
One possibility is rapid eye movement, or REM, sleep disorder, a condition in which people physically act out vivid dreams while still asleep — sometimes in a forceful or violent way.
REM sleep disorder belongs to a wider category of sleep problems known as parasomnias. It can be alarming for anyone who sees it happening and may also pose a risk of injury, both to the person sharing the bed and to the sleeper themselves.
Most dreaming takes place during REM sleep, a stage in which the muscles of the arms and legs are usually temporarily immobilised. In people with REM sleep disorder, however, this protective paralysis does not occur as it should, allowing them to move during dreams.
As a result, they may kick, punch, clutch at the air or thrash about, and may also shout or scream. These events can happen more than once during the same night.
The disorder is most commonly diagnosed in men aged over 50. The way to investigate it properly is through referral to a specialist sleep clinic, where you may be offered polysomnography — an overnight test that records your breathing, brain activity and body movements while you sleep.
In rapid eye movement (REM) sleep disorder, vivid dreams are acted out, often violently, while asleep. This is one of a group of sleep disorders called parasomnias. But if you’re not acting out your dreams – just remembering them – the nightmares may be a side-effect of certain medications
However, if you’re not acting out your dreams – just remembering them – the nightmares you report may be a side-effect of some medications you mention you take in your longer letter.
The one known to be associated with unpleasant dreams is bisoprolol, a beta blocker used to treat high blood pressure.
It would be useful to know if this problem started after you were first prescribed bisoprolol.
If so, don’t just stop the drug but seek the expertise of your GP or cardiologist, who may be able to recommend an alternative not associated with this effect.
Last Christmas, after immense pain in the left side of my back, I was diagnosed with blood clots in the lungs and prescribed the blood thinner apixaban for three months. I’m now pain free but there’s been no mention of further checks to see if the clots have gone. Do I need to worry?
Angela Golding, Hereford.
What you describe leads me to conclude that you had a pulmonary embolism, a clot that blocks blood flow in the arteries within the lungs.
These most often start in a deep vein in the leg, known as a deep vein thrombosis (DVT) – the clot can travel to the heart and, from there, reach the lungs.
From your longer letter, it does not sound like there were any investigations to detect the origin of your pulmonary embolism – unless you were observed to have signs in a leg, such as swelling or an obvious increase in the veins close to the skin’s surface. This seems unusual.
The apixaban prescribed was correct and as you continued to feel well through the three-month course, it can be assumed you were effectively protected from further clots and the clots in your lung resolved by natural mechanisms. This is good news.
However, I have further questions as it’s important to establish the likely cause of the initial DVT.
First, had there been any period of immobility or long-distance travel before your episode? These increase the risk considerably as being stationary for so long means the blood can pool in the veins, leading to a clot forming.
Second, are you taking hormone replacement therapy? Oestrogens are a known risk factor for deep vein clotting.
Thirdly, have you experienced any unintentional weight loss in recent months, or changes in bowel habit, unusual urinary symptoms or night sweats?
If none of these have occurred, I would want to carry out some blood tests and checks on liver and kidney function, to assess your general health. I’d also consider ultrasound scans of both legs.
I suggest you go back to your GP and raise your concerns.
In my view… There’s a better test for prostate cancer
I know this paper has been behind the major campaign calling for a national prostate cancer screening programme. And I understand the huge disappointment that government advisors have now rejected this.
But I think this was sensible, as the test that’s been proposed – a blood test for PSA (prostate specific antigen) – gives too many false negative and false positive results.
I prefer the Stockholm3 test, which includes six factors – including age, family history, protein markers and genetics – providing far more information than PSA testing alone. The test then produces a percentage risk score of significant prostate cancer – from this we can then decide whether to scan.
This more nuanced test means that patients with a low PSA but a high Stockholm3 risk rating (who might otherwise have been missed) get an urgent scan – while patients with a raised PSA but who are at lower risk avoid a potentially harmful biopsy.
However, it’s expensive – around £300. My hope is it becomes more popular and then, as more men have it, on the basis of economies of scale it becomes the standard.
