REM Sleep Behavior Disorder

Overview

REM sleep behavior disorder (RBD) is a sleep disorder in which a person physically acts out their dreams. Normally, during the dreaming stage of sleep known as REM (rapid eye movement) sleep, the body's muscles are temporarily paralyzed so that we stay still while dreaming. In RBD, this protective paralysis does not work properly, so dream actions translate into real movements.

People with RBD may talk, shout, punch, kick, or leap out of bed during vivid and often unpleasant dreams. This can lead to injuries for the sleeper or a bed partner. RBD is most common in older adults, particularly men, and it is important partly because in many people it can be an early sign of certain brain conditions that may appear years later.

Symptoms

The hallmark of RBD is acting out dreams during sleep. Features include:

• Talking, shouting, or screaming during sleep
• Arm and leg movements such as punching, kicking, grabbing, or jumping
• Acting out dreams that are often vivid, action-filled, or frightening
• Sometimes falling out of bed or causing injury to oneself or a partner
• Being able to recall the dream clearly if woken during an episode

Episodes usually occur in the later part of the night, when REM sleep is more common. Unlike sleepwalking, the person can typically remember the dream that matched their movements.

Causes

RBD occurs when the brain mechanisms that normally produce muscle paralysis during REM sleep do not function properly. The reasons include:

• Underlying brain conditions: RBD is strongly associated with certain neurological conditions, including Parkinson disease and related disorders. In many people, RBD appears years before such conditions develop.
• Medications: Some antidepressants and other drugs can trigger or worsen RBD.
• Other factors: Alcohol withdrawal and certain other conditions can play a role.
• Idiopathic: In some people no clear cause is found at first.

Because of the link with neurological conditions, RBD is taken seriously and followed over time.

Risk Factors

• Older age, with most cases beginning after age 50
• Male sex, as RBD is more common in men
• Parkinson disease or related neurological conditions
• Use of certain antidepressant medications
• Other sleep disorders, such as narcolepsy

Diagnosis

Diagnosis combines history with a specialized sleep study:

• History: Detailed account of the sleep behaviors, ideally from a bed partner, including the timing and dream content.
• Sleep study (polysomnography): An overnight study in a sleep lab that records brain waves, muscle activity, and movements, and can show the loss of normal muscle paralysis during REM sleep.
• Neurological assessment: Checking for early signs of related brain conditions.
• Medication review: Identifying drugs that may be contributing.

Treatment

Treatment focuses on safety and reducing episodes:

• Making the bedroom safe: Removing sharp or hard objects, padding the area, putting the mattress on the floor if needed, and sometimes a partner sleeping separately to avoid injury.
• Medication: Certain medicines, including melatonin and specific prescription drugs, can reduce the frequency and intensity of episodes under a doctor's guidance.
• Reviewing other medicines: Adjusting drugs that may be triggering RBD, when appropriate.
• Ongoing follow-up: Monitoring for any neurological changes over time.

With safety measures and treatment, many people have fewer and less dangerous episodes.

Prevention

RBD itself cannot always be prevented, but injury can be reduced and triggers minimized:

• Create a safe sleep environment to prevent injury during episodes
• Limit alcohol, which can worsen sleep behaviors
• Review medications with a doctor if they may be contributing
• Maintain regular sleep habits and treat other sleep disorders

When to See a Doctor

See a doctor if you or a bed partner notices:

• Acting out dreams, shouting, or violent movements during sleep
• Injuries to yourself or a partner during sleep
• Vivid, frightening dreams that match physical movements
• New tremor, stiffness, or slowness of movement, which should be evaluated

Prompt assessment is worthwhile because treatment improves safety and because RBD can be an early clue to a neurological condition that benefits from monitoring.

Related Topics

Frequently Asked Questions

References

1. Mayo Clinic. REM sleep behavior disorder.
2. National Institute of Neurological Disorders and Stroke (NINDS). Sleep disorders.
3. MedlinePlus, U.S. National Library of Medicine. Sleep disorders.
4. American Academy of Sleep Medicine. REM Sleep Behavior Disorder.