REM Behavior Sleep Disorder: Acting Out Dreams

Acting out dreams during sleep is known as REM Sleep Behavior Disorder (RBD). It falls within the category of sleep-related movement disorders and, in some cases, can be pretty dangerous. 

It is relatively rare, affecting approximately 0.5 to 1.5% of the general population. It is more common in patients over the age of 50 and affects men more than women. It is often linked with neurodegenerative diseases, including Parkinson's Disease and dementia.

RBD occurs during the REM (Rapid Eye Movement) stage of sleep, when most people are usually paralyzed to prevent physical movements. In individuals with RBD, this paralysis is lost, allowing them to act out their dreams. These episodes can be vivid and sometimes violent, posing a risk of injury to both the affected individual and their bed partner, which is why early detection and intervention are essential.

In this article, we will explore the symptoms, causes, and treatment options for RBD, offering valuable insights to help you or your loved ones achieve better sleep and overall health.

Physical Movements during Sleep

One of the most striking and potentially dangerous symptoms of REM Sleep Behavior Disorder (RBD) is the physical acting out of dreams. This can vary from minor gestures to violent actions, and may include kicking, punching, arm flailing, and even jumping out of bed. The loss of paralysis during REM sleep enables these actions and can cause injuries not only to the individual but also to their bed partner or anyone nearby.

Talking during Sleep

Individuals with RBD are often vocal during their sleep. This can vary from quiet talking or laughing to loud shouting, screaming, or even cursing. Such sounds can be emotionally charged, and directly linked to the vivid and often intense dreams characteristic of RBD. They can be just as disruptive as physical movements, disturbing the sleep of both the individual and their bed partner. 

Recollection of Dreams

Individuals with RBD can usually remember their dreams if awakened during an episode. This shows there is a strong connection between brain activity during REM sleep and the physical behaviors exhibited. This recollection can offer valuable insights into the nature of the dreams and aid in diagnosing and managing the disorder.

Neurological Linkages

REM Sleep Behavior Disorder (RBD) is often closely associated with various neurodegenerative conditions. This includes Parkinson's disease, Lewy body dementia, and multiple system atrophy. Studies show that most individuals with RBD eventually develop one of these neurodegenerative diseases. For example, up to 97% of people with isolated (idiopathic) RBD may develop Parkinson's disease, Lewy body dementia, or multiple system atrophy within 14 years of their RBD diagnosis.

Medication and Substance Influence

RBD can be caused by certain medications and substances. Antidepressants, particularly those in the classes of tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs), have been linked to the development of RBD. They can disrupt the normal balance of neurotransmitters such as dopamine and serotonin, which play important roles in regulating REM sleep.

The use or withdrawal from alcohol and sedative-hypnotic drugs can lead to acute forms of RBD. These substances can interfere with the neural pathways that control muscle atonia during REM sleep, promoting the symptoms of RBD.

Age and Gender Factors

RBD is more likely to occur after the age of 50 and affects more men than women. Men are nine times more likely to develop RBD than women in this age group.

However, it also affects children and younger adults, and can be seen in patients with narcolepsy or brain tumors. 

Medicinal Treatments

The management of REM Sleep Behavior Disorder (RBD) often involves the use of medications to reduce or eliminate the symptoms. Two of the most commonly prescribed medications for RBD are melatonin and clonazepam.

Melatonin, a hormone that regulates sleep-wake cycles, is generally considered the first-line treatment due to its efficacy and relatively few side effects. It is typically administered in doses ranging from 3 to 12 mg at bedtime, and studies have shown it to be effective in reducing the frequency and intensity of RBD episodes.

Clonazepam, a benzodiazepine, is another widely used medication for RBD. It works by enhancing the neurotransmitter gamma-aminobutyric acid (GABA), which helps to calm down neural activity. Clonazepam is usually prescribed at a dose of 0.25 to 2.0 mg taken 30 minutes before bedtime. While it can be effective, it may cause side effects such as daytime sleepiness, decreased balance, and worsening of sleep apnea, especially in individuals with obstructive sleep apnea (OSA).

Other medications such as pramipexole (a dopamine agonist), temazepam, lorazepam, and zolpidem are available, although the evidence for their effectiveness is more limited. These medications are often used when melatonin and clonazepam are not effective or there is an intolerance.

Lifestyle and Environmental Changes

It is important that individuals with RBD have a safe sleep environment to prevent injuries to themselves and their bed partners. There should be no sharp objects, weapons, or hazardous materials in the bedroom.

Strategies such as padding the floor near the bed, securing windows, and moving furniture away from the bed can help minimize the risk of injury. It may be advisable for the bed partner to sleep in a separate room until the symptoms subside.

Avoiding alcohol and other substances that can trigger or exacerbate RBD episodes is also important.

Continuous Monitoring and Professional Care

Continuous monitoring and professional care are crucial in managing RBD. A diagnosis includes a physical and neurological exam, and often a nocturnal sleep study (polysomnogram) to confirm the presence of increased muscle activity during REM sleep.

Following diagnosis, the healthcare provider can prescribe the necessary medication and offer advice on lifestyle changes that will help manage and reduce the symptoms. They will also monitor the effectiveness of the treatment and make adjustments where required. 

As there is a strong link between RBD and other neurodegenerative diseases, regular assessments and follow-up appointments are necessary. This will help detect symptoms of these disorders early, so they can be managed appropriately.

Talk to Your Doctor

REM Sleep Behavior Disorder (RBD) is a complex and potentially dangerous sleep condition in which individuals act out their dreams during REM sleep. Symptoms include vivid dreams, physical movements, and vocalizations, which are not only disruptive but may cause injury to the individual and also their bed partner. It is an early indicator of underlying neurodegenerative diseases such as Parkinson's disease, Lewy body dementia, and multiple system atrophy. 

RBD is managed with medications including melatonin and clonazepam. Additionally, making environmental adaptations to create a safe sleep environment is essential. Regular follow-ups with a healthcare provider are vital for monitoring the condition and adjusting treatment plans as needed.

If you or your loved one is experiencing symptoms of RBD, it is important to seek early diagnosis and intervention. This can reduce the risk of injuries and improve overall quality of life. Remember, RBD is not just a sleep disorder; it can also serve as an early indicator of more serious neurological conditions, making timely intervention critical.