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If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.
Most people sleep restfully, with only the occasional toss or turn throughout the night. However, a small number of people experience sleep disturbances called parasomnias.
One type of parasomnia is called REM sleep behavior disorder (RBD). This disorder leads to abnormal behavior while you are asleep.
Here’s what we know about this uncommon condition, including its causes, symptoms, and possible treatments.
What is REM sleep behavior disorder?
Every night, your body cycles through several stages of sleep. These stages are divided into non-rapid eye movement sleep (NREM or non-REM) and rapid eye movement sleep (REM sleep). During REM sleep, your brain activity is similar to wakefulness, but there is no muscle activity except for your eyes and diaphragm. This is the stage where dreaming occurs (Patel, 2021).
In a person with RBD, their muscles don’t stay relaxed during REM sleep, and they act out their dreams while asleep. Their behaviors can include vocalizing, moving around in bed, or even punching and kicking (Khawaja, 2021).
Often, a person can recall the content of their dreams when they wake up, but they aren’t aware of acting them out. The most significant immediate risk of REM sleep behavior disorder is that they can injure themselves or others (Khawaja, 2021).
What are the symptoms of REM sleep disorder?
Only about half of people affected by RBD know that they move around during sleep. Often, an injury or complaint from a bed partner alerts them to the problem (Patel, 2021).
The events of a REM sleep disorder likely appear at least 90 minutes after sleep onset, when REM sleep usually begins. It may also happen again more frequently during the later portion of the night. The later you get in the sleep cycle, the more episodes of REM sleep you’ll typically experience, and the more opportunities for symptomatic episodes to occur (Pham, 2021).
Movements are usually associated with acting out undesirable or violent dreams where the person is being chased or attacked. This is called dream enactment behavior. The person doesn’t usually interact with their physical environment; they interact with their dream content. These behaviors can include (Pham, 2021):
- Talking, laughing, or shouting
- Punching or kicking
- Sitting up
- Flailing arms
- Leaping from the bed
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It is uncommon for an RBD-affected person to experience sleepwalking during an episode, and their eyes are usually closed. The person may wake up from the dream abruptly, not feel any lingering sleepiness, and is typically able to fully recount the dream they were having (Pham, 2021).
What causes REM sleep behavior disorder?
Most cases of RBD are idiopathic, meaning it’s not clear what causes them. About 1% of the general population and 2% of older adults have this condition. It’s more common in older men than women (Khawaja, 2021).
Some cases of REM sleep disorder can be attributed to other medical conditions or medications, especially in younger individuals. These include (Khawaja, 2021):
- Parkinson’s disease
- Neurodegenerative disorders
- Antidepressant medication use
- Vascular lesions
- Demyelinating diseases (conditions that damage the natural coating of nerves)
- Autoimmune or inflammatory disorders
Some symptoms of obstructive sleep apnea may mimic those of RBD. This may be referred to as “pseudo RBD,” but it is not the same as having the disorder (Khawaja, 2021).
Antidepressant medications can bring on RBD symptoms in up to 6% of users, which is more likely in older patients (Khawaja, 2021; Postuma, 2013).
A study of 100 people diagnosed with idiopathic RBD looked at the possible connection between antidepressant use and RBD. The data showed that, in people who already had a mild neurologic disorder and had RBD, antidepressants worsened their symptoms. The study did not show that antidepressant use caused REM sleep disorder (Postuma, 2013).
What are the health risks of REM sleep disorder?
The primary health risk associated with REM sleep behavior disorder is an injury to the affected person or their bed partner during dream enactment. In one clinical series, 79% reported experiencing sleep-related injuries (Khawaja, 2021).
People with idiopathic REM sleep behavior disorder are also at increased risk for developing neurological conditions such as Parkinson’s disease and dementia. Therefore, if you have REM sleep disorder, you should be monitored by a neurologist for developing these and other conditions (Khawaja, 2021).
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Researchers in one study wanted to know if people with RBD had higher mortality rates than other people. With the exception of those with underlying neurodegenerative diseases, RBD seems to have no impact on the risk of death (Zhou, 2016).
How do you diagnose REM sleep disorder?
A healthcare provider must diagnose REM sleep behavior disorder. They will look at your medical history, your symptoms, and conduct a physical exam. You will also need to have a polysomnogram (PSG), known simply as a sleep study (U.S. National Library of Medicine, 2021).
RBD is the only sleeping disorder that must be diagnosed by a sleep study conducted in a lab rather than at home (Khawaja, 2021). Some other sleep disorders can be diagnosed with a home device.
During a sleep study, a trained technician will monitor and record data about your body while you sleep. The data includes (U.S. National Library of Medicine, 2021):
- Brain wave changes
- Eye movements
- Breathing rate
- Blood pressure
- Heart rate
- Electrical activity of the heart and other muscles
The American Academy of Sleep Medicine’s International Classification of Sleep Disorders, third edition, (ICSD) states that criteria for RBD include the following (Pham, 2021):
- Repeated episodes of sleep-related behaviors such as speaking or moving
- Demonstration of those behaviors during REM sleep (in a sleep study), or based on clinical history
- Sleep study recordings that show REM sleep without atonia (temporary paralysis that’s a normal part of REM sleep)
- Sleep behaviors that aren’t otherwise caused by another sleep disorder, mental disorder, medication, substance use, or epilepsy
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Treatment of REM sleep behavior disorder
You (and your bed partner, if applicable) deserve a safe sleeping environment, and that’s the primary goal of treating RBD. Treatment generally involves lifestyle changes and sometimes medications (Khawaja, 2021).
Some suggestions to prevent injuries include (Khawaja, 2021):
- Making sure your bed partners are aware of the condition
- Avoiding sharp, breakable, or otherwise hazardous objects near the bed
- Sleeping alone in severe cases
- Putting extra padding on the side of the bed or the floor nearby
- Considering a sleeping bag to restrict movement
Depending on your situation, your healthcare provider may recommend that you stop taking antidepressant medications (Khawaja, 2021).
The most common medications used to treat RBD are melatonin and clonazepam. Melatonin is a hormone produced by the brain that is associated with your body’s circadian rhythms. Clonazepam is a long-acting benzodiazepine that can significantly reduce limb movement during sleep (Pham, 2021).
If you also have obstructive sleep apnea, treating that with continuous positive airway pressure (a CPAP machine) can help your RBD symptoms as well (Pham, 2021).
If you are concerned that you might have signs of REM sleep behavior disorder or any other sleep disorder, reach out to your healthcare provider. They can help you get any needed testing to confirm a diagnosis. They’ll help you develop a treatment plan to manage your symptoms and monitor for any potential neurological disease. You can find help to guide you toward a better night’s sleep!
- Khawaja I, Spurling BC, Singh S. (2021). REM sleep behavior disorder. [Updated 2021 Apr 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK534239/
- Patel AK, Reddy V, Araujo JF. (2021). Physiology, sleep stages. [Updated 2021 Apr 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK526132/
- Pham CK, Slowik JM. (2021). Rapid eye movement sleep behavior disorder. [Updated 2021 Jan 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK555928/
- Postuma, R. B., Gagnon, J.-F., Tuineaig, M., Bertrand, J.-A., Latreille, V., Desjardins, C., et al. (2013). Antidepressants and REM sleep behavior disorder: isolated side effect or neurodegenerative signal? Sleep, 36 (11), 1579–1585. doi: 10.5665/sleep.3102. Retrieved from https://academic.oup.com/sleep/article/36/11/1579/2558933
- U.S. National Library of Medicine. (2021). Sleep disorders. MedlinePlus. Retrieved from https://medlineplus.gov/sleepdisorders.html
- Zhou, J., Zhang, J., Lam, S. P., Mok, V., Chan, A., Li, S. X., et al. (2016). Mortality and its risk factors in patients with rapid eye movement sleep behavior disorder. Sleep, 39(8), 1543–1550. doi:10.5665/sleep.6016. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4945313/
Dr. Steve Silvestro is a board-certified pediatrician and Senior Manager, Medical Content & Education at Ro.