REM sleep behavior disorder is a sleep disorder that causes people to physically act out their dreams. This parasomnia occurs during the rapid eye movement (REM) phase of sleep, which is where it gets its name.
Since people with this disorder may become physical while asleep, they risk harming themselves or others, and for this reason, it’s important to know what to look out for in order to seek help. In this article, we’ll detail everything you need to know about REM sleep behavior disorder, including the symptoms, causes, and treatments.
What Is REM Sleep Behavior Disorder?
REM sleep behavior disorder1 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 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 or hurt a partner.
A secondary type of this disorder, called idiopathic REM sleep behavior disorder2 (IRBD), is the same condition but without any co-occurring neurological issues. However, those with IRBD are at an increased risk for developing neurological issues such as Parkinson's Disease, dementia with Lewy bodies, or multiple system atrophy later in life.
Symptoms of REM Sleep Behavior Disorder
Symptoms of REM sleep behavior disorder occur while the person is sleeping and include both noises and physical behaviors1.
- Other outbursts
Someone with REM sleep behavior disorder 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.
- Flailing arms
- Jumping from the bed
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 symptoms3 may include grabbing the air or their partner as well as muscle twitches. The physical symptoms will also depend on the activities in the dream they are experiencing.
Causes of REM Sleep Behavior Disorder
REM sleep behavior disorder is caused by the inability of nerve pathways to keep the body in a state of paralysis during this sleep phase, allowing the individual to physically act out their dreams. According to experts, certain risk factors can increase one’s chance of developing this disorder1.
- Stroke or dementia with Lewy bodies
- Multiple system atrophy
- Parkinson’s disease
- Alcohol or narcotic use
Some antidepressant medication
Additionally, a person’s age and gender can increase their chances of developing REM sleep behavior disorder3.
- Gender: Males are more likely to develop REM sleep behavior disorder than females at a risk ratio of 9 to 1.
- Age: REM sleep behavior disorder is most often diagnosed after the age of 50.
How is REM Sleep Disorder Diagnosed?
REM sleep behavior disorder is typically diagnosed through a series of evaluations that include a physical and neurological exam, talking with the patient’s sleep partner, and a sleep study (polysomnogram). During the sleep study, doctors monitor the heart, lungs, brain activity, limb movements, vocal noises, and blood oxygen levels1.
A patient must meet specific criteria to receive a formal diagnosis for REM sleep behavior disorder1.
- Vocal and physical behaviors during sleep that correlate with the patient’s dream like talking, punching, kicking, or running
- The patient recalls these dreams
- Waking up alert rather than confused or disoriented during an episode
- Increased muscle activity during REM sleep
- No other factors are causing these sleep disturbances, including another sleep disorder or disturbance, mental health issue, medication, or substance abuse.
If one suspects they may have REM sleep behavior disorder, 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.
Medications used to treat REM sleep behavior disorder:
Medications used to treat REM sleep behavior disorder most commonly include clonazepam and melatonin1.
Clonazepam4 is a benzodiazepine medication typically used to treat epilepsy, muscle spasms, panic disorder, and restless legs syndrome. This prescription medication works by increasing a calming chemical in the brain, which could help reduce REM sleep behavior symptoms. However, clonazepam can cause daytime drowsiness so you should avoid taking it before driving or performing any activity in which you need to be fully alert.
Additionally, 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.
Melatonin is a naturally occurring hormone produced by the pineal gland and assists with managing our natural biorhythm or sleep schedule. Melatonin is also available as a supplement and research5 has found it to be an effective treatment for REM sleep behavior disorder by decreasing REM sleep without atonia (lack of muscle tone).
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,6 is relatively small, consisting of about .5 to 2 milligrams of clonazepam or between 3 to 6 milligrams of melatonin before bed.
Frequently Asked Questions
1. What are the complications of REM Sleep Behavior Disorder?
The complications of REM sleep behavior disorder include:
- Accidental injury to oneself or their sleeping partner
- Later development of a neurological disorder such as Parkinson's disease or Lewy body dementia
- Emotional distress
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: As mentioned, this sleep disorder is associated with the development of other neurological disorders such as Parkinson's disease or Lewy body dementia, so 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 comorbid diseases such as Parkinson's disease.
Emotional distress: People with REM sleep behavior disorder may experience significant emotional distress as a result of their condition. For example, the person may worry about hurting themselves or their partner. If they regularly sleep alone, they may avoid certain social situations such as camping or staying over at a friend or relative’s home.
2. How common is REM Sleep Behavior Disorder?
REM Sleep Behavior Disorder is rare, affecting roughly 1 percent of Americans and 2 percent of adults over 50. Additionally, men are more likely to develop this disorder than women3.
3. Which condition is most closely associated with REM Sleep Behavior Disorder?
The conditions most closely associated with REM sleep behavior disorder are Parkinson’s disease, Lewy body dementia, narcolepsy, and multiple system atrophy1.
4. What are the other sleep disorders similar to RBD?
Night terrors, narcolepsy, sleepwalking, and sleep-related epilepsy.
Night terrors: – Night terrors are most often seen in children, with symptoms including 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.
5. How do antidepressants affect REM Sleep Behavior 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 disease1.
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 sleep7 and may cause REM sleep behavior disorder 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.
6. What are home remedies for REM Sleep Behavior Disorder?
Home remedies for REM sleep behavior disorder focus on creating a safe space for you and your partner, and there are several ways to go about this. If you are prone to jumping out of bed or falling on the floor, a pad beside the bed could help. It’s also helpful to put in guard rails if possible, and if you cannot, keep any dangerous or sharp objects out of the bedroom. Additionally, your partner may prefer to sleep in a separate bed or room until symptoms are better managed.
Along with these safeguards, you can practice good sleep hygiene, which is a term for daytime and nighttime habits that can foster more restful sleep. For instance, try sleeping in a dark bedroom and not napping during the day. Darkness promotes sleep onset and taking naps could make it harder for you to fall asleep at night.
Another sleep hygiene tip is to maintain a regular sleep schedule. 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, so if you have to work out in the evening, do more low-intensity exercises like yoga or pilates.
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.
7. 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 you 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 REM sleep behavior disorder, 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.
- “REM sleep behavior disorder”. Mayo Clinic. Last modified January 18, 2018. https://www.mayoclinic.org/diseases-conditions/rem-sleep-behavior-disorder/symptoms-causes/syc-20352920.
- Iranzo, Alex., Santamaria, Joan., Tolosa, Eduardo. “Idiopathic rapid eye movement sleep behaviour disorder: diagnosis, management, and the need for neuroprotective interventions”. National Library of Medicine. https://pubmed.ncbi.nlm.nih.gov/26971662/#:~:text=Idiopathic%20rapid%20eye%20movement%20(REM,sleep%20disorder%20is%20not%20harmless. 2016.
- “REM Sleep Behavior Disorder (RBD)”. Cleveland Clinic. Last modified November 22, 2022. https://my.clevelandclinic.org/health/diseases/24465-rem-sleep-behavior-disorder-rbd.
- “Clonazepam”. National Health Service. Last modified January 2, 2020. https://www.nhs.uk/medicines/clonazepam/.
- McGrane, Ian R., Leung, Jonathan G., St Louis MD, Erik K., Boeve MD, Bradley F. “Melatonin Therapy for REM Sleep Behavior Disorder: A Critical Review of Evidence”. Sleep Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306603/#!po=69.4444. 2015.
- Ahmed MD, Syed M.S. “REM Sleep Behavior Disorder Medication”. Medscape. https://emedicine.medscape.com/article/1188651-medication. 2019.
- Arnaldi MD, Dario., Famà, Francesco., et. al. “The Role of the Serotonergic System in REM Sleep Behavior Disorder”. Sleep. https://academic.oup.com/sleep/article/38/9/1505/2418018. 2015.