REM Sleep Behavior Disorder (RBD) is a sleep-related disorder that affects the ability to move during dreams, named for a parasomnia that occurs during the rapid eye movement (REM) phase of sleep. People with RBD act out their dreams and can harm themselves or others while sleeping.
Signs of REM Sleep Behavior Disorder include talking while asleep, shouting while asleep, sleep walking, or acting out violent dreams.
This condition is generally caused by some sort of neurological problem, such as Parkinson's disease, or a medication side effect. Some medications for depression and anxiety can also cause RBD. There are also a few comorbidities and related conditions that we will explain in detail throughout the article.
Treatment for REM Sleep Behavior Disorder will vary depending on the cause of the onset, however in many cases it includes medications and physical safeguards to protect both the sleeper and any sleeping partners that may be affected.
What Is REM Sleep Behavior Disorder?
RBD is a parasomnia that causes people to physically act out portions of the dreams they experience in the rapid eye movement phase of sleep. This occurs because the nerve pathways that are responsible for shutting down physical activity (atonia) during dreams no longer work, allowing the sleeper to move freely.
Depending on the nature of the dream the sleeper experiences, they may find themselves acting violently to defend themselves, or running into objects that could cause an injury to themselves or a partner.
A secondary type of RBD, called Idiopathic REM Sleep Behavior Disorder, is the same condition, without any co-occuring neurological issues. Those with iRBD are at an increased risk for developing neurological issues such as Parkinson's Disease later in life.
What are the Causes of REM Sleep Behavior Disorder?
RBD is most often caused by neurological conditions, such as Parkinson's disease. However, other conditions can cause RBD, including Dementia with lewy bodies, Narcolepsy, Alzheimer’s, alcohol or narcotic addiction, and taking some antidepressant medications.
What are the Risk Factors for REM Sleep Behavior Disorder?
REM sleep behavior disorder primarily affects men over 60 years of age, with about 80% of cases being diagnosed with Parkinson's disease; however, the following factors may also increase the risk of developing the disorder.
- Gender: Males are more likely to develop RBD than females at a risk ratio of 9 to 1.
- Age: REM Sleep Behavior Disorder is most often diagnosed after the age of 50.
- Family History: Having a family history of narcolepsy, Parkinson's disease or other neurological disorders may indicate an increased risk for RBD.
How Common is REM Sleep Behavior Disorder?
REM Sleep Behavior Disorder is quite rare, affecting less than 1 percent of the general population and up to 2 percent of the older population. A much higher percentage of those affected are men over the age of 60.
Which Condition is Most closely associated with REM Behavior Disorder?
Parkinson’s disease is most closely associated with REM Behavior Disorder. Some studies suggest that an early RBD diagnosis could be a significant predictor of the later development of Parkinson's disease.
Other disorders most strongly associated with RBD include dementia with Lewy bodies, Narcolepsy, and multiple system atrophy.
Brain injuries could also contribute to the development of the disease.
What Symptoms can be seen in REM Sleep Behavior Disorder?
Symptoms of REM Sleep Behavior disorder that occur while sleeping include talking, yelling, laughing, crying, other outbursts, and physical behavior, including leaping, walking, attacking, or throwing items.
- Noises – Someone with RBD will often talk in their sleep; however, rather than unintelligible noises, they may form seemingly coherent sentences and recall what they were discussing once awoken. This is because the behavior occurred during REM sleep, not in the other phases. Similarly, if they cry, yell, curse, or laugh, they are likely to remember what caused the outburst once they awaken.
- Physical outbursts – Physical symptoms of REM Sleep Behavior Disorder may seem uncharacteristically violent for the person acting out their dreams. This is because REM Sleep Behavior Disorder may co-occur with nightmares, and the sleeper is often defending themselves from a perceived threat. In other cases, one may be acting normally, but still be unaware of their surroundings, causing harm to themselves or others. This condition is not a psychological problem but a neurological one.
Other physical symptoms may include throwing items, leaping off the bed, or jumping, depending on the activities in the dream they are experiencing.
What are the Complications of REM Sleep Behavior Disorder?
Complications of RBD include accidental injury to oneself or their sleeping partner, later development of a neurological disorder such as Parkinson's disease or Dementia with Lewy Bodies, and Excessive Daytime Sleepiness (EDS).
- Accidental Injury – Accidental injury to self or bed partner occurs because the sleeper is acting out their dreams and cannot distinguish between reality and dream. Someone sleepwalking will be somewhat limited in their ability to act out physically; however, this may not be the case with someone experiencing REM Sleep Behavior Disorder. The lack of muscle inhibition allows the sleeper to hit as hard as they may while awake or jump just as far as they might normally.
- Development of Neurological Disorder – Because RBD is associated with the development of other neurological disorders such as Parkinson's disease or Dementia with Lewy Bodies, many people experience some form of memory loss while awake. They may find themselves more confused, tired, or otherwise more forgetful than they would like to admit. However, this progression is more likely to occur in later stages of co-morbid diseases such as Parkinson's disease.
- Excessive Daytime Sleepiness – Excessive Daytime Sleepiness is one of the top complaints among people with RBD. This is because of the lack of quality sleep experienced while dreaming during REM sleep and common co-morbid sleep conditions like narcolepsy.
How is REM Sleep Disorder Diagnosed?
RBD is typically diagnosed through a sleep study or polysomnography. At this time, it is the only way to diagnose REM Sleep Disorder with certainty. Doctors evaluate brain waves and muscle tone while the patient sleeps. If REM Sleep Behavior Disorder is present, doctors will see several instances where there are periods of abnormal brain activity, including atonia (muscle paralysis), when muscles should otherwise be active when awake.
Doctors may also find disruptions in limb movement or unusual breathing patterns that further indicate this disorder.
A doctor may also conduct a physical examination to ask if the patient has noticed any symptoms in their sleep, such as kicking or talking. In some cases, a doctor can diagnose this disorder from only a questionnaire about sleep behaviors. However, this should not be used to rule out other disorders that do not have quite as distinctive signs.
If one suspects they may have RBD, they should go to their doctor as soon as possible. This condition can be hazardous if left untreated and must be taken seriously if there are any concerns.
What are the REM Sleep Disorder Treatments?
Treatment for RBD typically involves a combination of preventative measures, safety measures, and medication that suppresses REM sleep, such as certain antidepressants or antipsychotics. These medications suppress muscle activity during REM sleep, allowing one to act out less frequently and potentially reduce the risk of injury. This suppression may also help alleviate other symptoms associated with REM sleep, such as EDS and memory loss.
What Medications can be Used to Treat REM Sleep Disorder?
Medications used to treat REM sleep disorder most commonly include clonazepam and melatonin, though in some cases, an antidepressant called Trazodone has been successful in treating the condition as well.
Clonazepam is a benzodiazepine medication typically used to treat anxiety and insomnia. Benzodiazepines are classified as minor tranquilizers since they have a calming effect on people suffering from anxiety, PTSD, or other nervous system disorders, and as such, they are also popular medications for sleeping. They may also be used to treat seizures since they work on the part of the brain that regulates mood and sleep cycles.
Melatonin is a naturally occurring hormone in most people's bodies produced by the pineal gland. It is known as an antioxidant and assists with managing our natural biorhythm or sleep schedule. It may also be used to help obscure REM periods in people with RBD, so they do not act out their dreams when asleep.
While antidepressants are a known cause for symptoms of RBD, certain antidepressants such as Trazodone seem to be more effective without causing REM to be disrupted. Trazodone is typically used to treat insomnia, anxiety, depression, and other mood disorders but has effectively treated RBD symptoms while not disrupting REM sleep patterns.
Additionally, the dose required to suppress REM sleep without disrupting it is very low. This makes Trazodone one of the more preferred medications for treating RBD. It is also not habit-forming or addictive, making it ideal for long-term use without adding to other issues. Lastly, studies show that Trazodone effectively suppressed sleepwalking, sleep terrors, and RBD symptoms with fewer side effects than traditional treatments.
A doctor would prescribe the most appropriate medication based on the symptoms exhibited by an individual with REM Sleep Behavior Disorder; however, the most common dosage is relatively small, consisting of about .5 to 1 mg of Clonazepam or between 5 and 10 mg of melatonin before bed.
It's important to keep in mind that Clonazepam is a controlled substance in the United States; therefore, it may be addictive or habit-forming, and there are rules regarding how much one can purchase at a time. Therefore, it is essential to discuss medications with both primary care providers and psychiatrists before beginning any new supplement.
How do Antidepressants affect REM Sleep Disorder?
The effects of antidepressants on REM Sleep Disorder are usually adverse. While treatment for REM sleep disorder typically includes a combination of anti-anxiety medication, there is evidence that antidepressants, in particular, may cause the symptoms associated with this disease. SSRIs, or selective serotonin reuptake inhibitors, are medications designed to block the reabsorption of the neurotransmitter serotonin in the brain. This causes serotonin levels to remain higher in the brain, resulting in more available serotonin for use.
However, it also disrupts REM sleep and may cause RBD symptoms. For this reason, SSRIs are not typically preferred medications for treating REM Sleep Behavior Disorder and may need to be eliminated to alleviate symptoms. The effects of antidepressants on sleep can also be seen in other sleep disorders, which is why it’s important to discuss any medication side effects with your doctor as soon as they arrive.
What are the Home Remedies for REM Sleep Behavior Disorder?
Home remedies for REM sleep behavior disorder are rarely effective. However, the most commonly known effective remedy is sleeping in a dark bedroom conducive to sleep at night but not napping during the day. Exposure to bright light in the morning typically resets our biorhythm helping us fall asleep easier at night and avoid naps during the day.
Natural ways to help sleep include maintaining a regular sleep schedule, the most critical at-home remedy for treating this disorder. We all have internal circadian clocks that regulate our daily activities. Therefore, it’s essential to maintain a strict sleeping and waking schedule not to disrupt these internal clocks more than necessary.
Exercise is another common at-home remedy for this disorder, especially exercise that gets your heart rate up. This can be beneficial in regulating our biorhythm and preparing us for sleep at night. However, too much vigorous exercise before bed may cause a person to stay awake later, which is why incorporating low-intensity exercise during the day is more effective.
Incorporating a combination of these remedies is the best option for combating REM sleep behavior disorder, but medications are typically necessary to treat this disease. Consult your doctor before starting any new supplementation or exercise routine.
Can a Quality Mattress Help to Treat REM Sleep Behavior Disorder?
No, a quality mattress cannot treat REM Sleep Behavior Disorder; however, it may help mitigate complications of the disorder, such as soreness from moving around frequently in sleep. A high-quality mattress may also allow one to sleep more soundly, causing fewer disruptions in the night.
Mattress quality can be determined by its durability and ability to solve common issues, such as poor spinal alignment, painful pressure points, and high motion transfer. While many sleep preferences are highly subjective, for those with RBD, a mattress with at least three inches of memory foam at the top of the mattress could make a difference.
Memory foam could make frequent or sharp movement more difficult, potentially waking the sleeper and stopping the behavior before it causes problems. Additionally, a mattress with thick memory foam may also reduce motion transfer to allow a sleeping partner to rest undisturbed by motion. Individually pocketed springs can also help mitigate motion transfer because the coils compress individually rather than together, creating less bounce.
A larger mattress that allows for more space between sleepers can also prevent accidental injury. A king-size bed might be the definition of a mattress for good sleep and preferable to close quarters if it makes it more difficult for a thrashing sleeper to reach their partner.
What are the other Sleep Disorders similar to RBD?
Other sleep disorders similar to RBD include night terrors, narcolepsy, sleepwalking, and sleep-related epilepsy.
Night terrors – Night terrors are most often seen in children, with symptoms including loud screams, thrashing of the limbs, and inconsolable terror during an episode. Night terrors can occur in adults and typically occur in deep sleep when one is difficult to wake up and may be combined with emotional reactions such as sweating, screaming, and even thrashing around in an attempt to flee.
- Narcolepsy – Narcolepsy is a disorder caused by disrupted REM sleep, leading to excessive daytime sleepiness or sudden bouts of sleep even when at rest.
- Sleepwalking – Sleepwalking is a disorder resulting from an activated brain state during non-REM sleep that occurs in deep, slow-wave sleep. This can cause a person to rise from slumber and display complex motor activity such as walking around while they are fast asleep.
- Sleep-related epilepsy – Sleep-related epilepsy is a disorder associated with seizures due to temporary electrical overactivity in the brain during sleep, leading to sensory or motor phenomena.