What You Need To Know About REM Sleep Behavior Disorder

Rapid eye movement (REM) sleep behavior disorder, or RBD, is a condition that causes people to act out vivid dreams while during the REM stage of sleep.

REM sleep is the final stage in the sleep cycle and occurs at intervals during the night. Your body cycles through multiple sleep cycles while you sleep, typically repeating every 90 to 110 minutes.

The REM stage is distinguished by rapid eye movements and increased dreaming, body movements, pulse, and breathing rate. It is when people experience vivid dreams. If you wake up during REM sleep, you may be able to recall all or a part of your dream.

People with REM sleep behavior disorder act out vivid, often unpleasant, dreams vocally and physically. Dream enactments range in severity from slight hand gestures to violent arm and leg movements. Patients typically seek medical attention when they become concerned about injuring, or potentially injuring, themselves or their bed partner.

In addition to REM sleep behavior disorder, two other sleep disorders occur during REM sleep:

Nightmare disorder

Nightmare disorder causes vivid dreams that create feelings of fear, terror, or anxiety and leave you feeling there is a threat to your survival or safety. This sleep disorder is more likely to occur when an individual is under severe stress, has experienced a traumatic event, is extremely tired, has consumed alcohol, or has a fever.

Recurrent isolated sleep paralysis

This is a condition that typically occurs as you are waking or just before you fall asleep. Episodes can last from a few seconds to several minutes, during which you are unable to move your arms or legs, which often causes you fear or anxiety.

REM sleep behavior disorder is a relatively rare disorder that affects less than 1%  of the global population. Of those it does affect, it is more common in men and adults over 50. RBD often occurs with other sleep disorders and may indicate a neurodegenerative disease.

Symptoms

While your muscles typically relax during the REM sleep stage, people with REM sleep behavior disorder physically act out their dreams.

The condition may develop gradually or suddenly, with episodes occurring a few times a year or even several times a night. Symptoms typically worsen over time unless treated.

Physical symptoms of RBD may include:

  • Movements – Such as suddenly sitting upright in bed, jumping out of bed, as well as kicking, punching, or arm flailing during action-filled or violent dreams, such as being chased or defending yourself from an attack.

  • Vocalizations – Including talking, laughing, shouting, emotional outbursts, or even swearing.

People who have REM sleep behavior disorder aren't typically aware of any behaviors they are exhibiting during an episode, usually only learning of the issue when a roommate or bed partner tells them.

During an episode, a person generally wakes easily, and after waking is alert, coherent, and can remember the dream they were having. REM sleep behavior disorder can cause stress, anxiety, and fear among those who suffer from it.

Because of the sometimes violent nature of the movements caused by REM sleep behavior disorder, people with the disorder, and their bed partners, are at risk of physical injury.

Nearly 90% of spouses of people with RBD report sleep issues¹, and over 60% have experienced a bodily injury as a result of their condition.

Even if the potential for physical harm is reduced, sleep disruptions to the person with RBD or their partner are often severe enough to cause relationship issues.

  1. REM Sleep Behavior Disorder | Sleep Foundation

Causes

While research has yet to determine the exact cause of REM sleep behavior disorder, animal studies¹ suggest that it may be associated with specific neural pathways in the brain. Researchers have indicated that the disruption of these neural pathways may alter muscle responses during REM sleep.

Normally, during REM sleep, your muscles are temporarily paralyzed while your brain is actively dreaming. When your muscles aren't temporarily paralyzed as they should be, the body is able to react to your dreams.

The physical response often starts with small movements, such as talking and twitching, leading to more significant actions, including jumping, kicking, or flailing of the arms, which can harm you or your bed partner.

REM sleep behavior disorder is often associated with other neurological conditions, such as narcolepsy, stroke, multiple system atrophy, Parkinson's disease, or Lewy body dementia. In many cases, REM sleep behavior disorder develops before the onset of one of these neurodegenerative diseases.

Research² shows that 38% of men over the age of 50 who develop REM sleep behavior disorder will eventually also develop one of these neurodegenerative diseases, usually within 13 years. In a follow-up study, researchers found that after 16 years, the number of men who developed a neurodegenerative disease, such as Parkinson's or dementia, after developing REM sleep behavior disorder increased to nearly 81%.

Subsequent research has confirmed these findings, with 30% of people who experience REM sleep disorder developing a neurodegenerative disease, such as Parkinson's or dementia, within three years³ and 66% within 7.5 years.

REM sleep behavior disorder is also sometimes caused by medications, specifically antidepressants¹, such as tricyclic antidepressants and serotonin-specific reuptake inhibitors.

Diagnosis

Diagnosing REM sleep behavior disorder and other sleep disorders begins with a consultation with a sleep disorder specialist.

During your initial consultation, the specialist will interview you and your bed partner about your sleep symptoms, current medication, your medical history, family history, along with alcohol and substance use.

They may also suggest that you keep a sleep diary and ask your bed partner to participate by keeping track of your sleep behaviors over a certain period. 

In addition, they may schedule sleep disorder tests for you, which can include one or more of the following:

Sleep study

While some sleep studies can be performed at home, if your doctor suspects a sleep disorder, they may recommend you undergo an in-lab sleep study. In-lab sleep studies are performed in a sleep laboratory where your brain waves, heart rate, eye movements, breathing, actions, and behaviors are monitored and video recorded while you sleep.

Video or sleep electroencephalogram (EEG)

An EEG is a test that detects and records electrical impulses in the brain using small metal discs attached to your scalp. A sleep EEG enables your doctor to monitor and record your brain activity during the REM stage of your sleep.

Neurologic examination

A neurologic examination may include a CT or MRI scan to examine the skull, spine, meninges, cranial nerves, and other physical factors that may be causing your symptoms. In addition, a neurologic exam enables your doctor to detect degeneration of the brain or other neurologic issues that may be the cause of your symptoms.

Treatments

Treating REM sleep behavior disorder can involve a combination of medication, lifestyle changes, and injury prevention techniques via a treatment plan customized to your individual needs.

Medication

The main medication used to treat REM sleep behavior disorder is often melatonin because it has fewer side effects and similar efficacy to other types of medication. Melatonin is also safer for older people who may be at risk of falling, have sleep apnea, or have dementia.

A prescription medication called clonazepam is also commonly used to treat REM sleep behavior disorder and it has been shown to effectively reduce symptoms in 55 to 79% of individuals¹.

However, clonazepam comes with several side effects, such as sleepiness, forgetfulness, and impaired balance. It can also contribute to or worsen sleep apnea.

Lifestyle

Making lifestyle changes to reduce or eliminate the potential triggers of REM sleep behavior disorder is often recommended as part of a treatment plan. For instance, alcohol and some prescription medications can significantly contribute to REM sleep behavior disorder.

Lifestyle changes may also include steps that promote quality sleep, such as maintaining a consistent sleep schedule.

Injury prevention techniques

If you have REM sleep behavior disorder, creating a safe sleep environment is an essential step. Many individuals with the disorder report injuries, including bruising, cuts, fractures, blunt trauma, and head trauma.

Along with any injuries you may cause to yourself, your bed partner is also at risk of injury when they sleep next to you while you are acting out violent dreams because of your condition.

Injury prevention techniques may include:

  • Moving furniture, clutter, and other objects away from your bedside area

  • Moving your bed away from the window

  • Placing padding on the floor surrounding your bed

  • Putting the mattress on the floor

Doctors & specialists

If you or a loved one thinks you may have REM sleep behavior disorder, you should immediately consult your doctor.

However, since REM sleep behavior disorder is a rare condition, your doctor may not be aware of it or the danger it presents, so it is a good idea to go into your appointment having read up about the condition.

After consulting with your doctor, if they suspect you have REM sleep behavior disorder, they should refer you to a sleep medicine or neurology specialist for diagnosis and treatment.


Clinical trials for rem sleep behavior disorder

Actively recruiting
National Adaptive Trial for PTSD Related Insomnia
AL, AZ, CA, CT and 18 more locations (US)
Actively recruiting
CBT-I Augmentation of TOP for Sobriety and Insomnia in AUD
PA (US)
Actively recruiting
Reduce Emotional Symptoms of Insomnia With Smart Treatment
MI (US)