January 2021 | Reviewed by: Andrea Matsumura, MD
What is REM sleep behavior disorder?
REM sleep behavior disorder (RBD) is a parasomnia. A parasomnia involves undesired events that happen while sleeping.
RBD occurs when you act out vivid dreams as you sleep. These dreams are often filled with action. They may even be violent. Episodes tend to get worse over time. Early episodes may involve mild activity. Later episodes can be more violent. RBD is often ignored for years. At some point, it is likely to result in an injury. Either the person dreaming or the bed partner may be hurt.
RBD can be confused with sleepwalking and sleep terrors. In these other disorders, you are usually confused upon waking up and there is no dream reenactment. You do not become rapidly alert. In contrast, it is normally easy to wake a person with RBD who is acting out a dream. Once awake, you are also able to recall clear details of the vivid dream.
The details of this dream match the unusual behavior of an RBD episode. These actions may include any of the following:
- Shouting
- Swearing
- Flailing
- Grabbing
- Punching
- Kicking
- Jumping
- Leaping
For example, a man with RBD may dream of playing in a game of football. In this case, he might dive from his bed to catch the winning touchdown pass. He might also dream of being chased by an attacker. This may cause him to leap out of bed to run away.
People with RBD rarely walk, have their eyes open, or leave the room. These are all common signs of sleepwalking. RBD episodes do not involve eating or drinking. They also do not involve sexual activity or going to the bathroom.
RBD episodes occur during REM sleep. Normal sleep consists of a series of REM dream episodes. They occur about every 1.5 to 2 hours each night. This means that an RBD episode tends to first appear at least 1.5 hours after falling asleep. Episodes may continue to occur until waking up in the morning. Active RBD episodes may appear as many as four times per night. They may also occur as rarely as once per week or per month. RBD does not normally appear during a nap.
RBD by itself does not cause the dreamer to be sleepy during the day. But it is often found along with other sleep disorders. These disorders may cause daytime sleepiness. Examples of these disorders include the following:
An RBD episode often disrupts the sleep of a bed partner. This is how a person with RBD may become aware of the problem. RBD is a medical problem. It is not a psychiatric disorder. People with RBD do not normally have a mental problem.
What are symptoms of REM sleep behavior disorder?
Someone with RBD may:
- Kick, jump, punch, flail, shout, or leap out of bed while they are still asleep
- Have a bed partner that expresses concern about their unusual behaviors while sleeping
- Perform actions that match vivid dreams that they clearly recall
- Have sleep activities that result in an injury to them or their bed partner
What are risk factors for REM sleep behavior disorder?
RBD most often occurs in men. It can appear at any age. But it most often emerges after men are 50 years old. It is uncommon in women and children. Less than 1% of people have it. It appears more often in the elderly. RBD is also seen more often in people with some neurologic disorders. It occurs at a higher rate in people who have one of the following conditions:
- Parkinson disease (33%)
- Multiple system atrophy (90%)
- Lewy Body Dementia
People found to have RBD may develop Parkinson disease many years later. Those with RBD should watch for symptoms of Parkinson, such as tremors.
People with RBD are at higher risk for the following sleep disorders:
- Narcolepsy
- Periodic limb movement disorder
- Sleep apnea
RBD can also be related to other factors that increase the intensity of REM sleep. These include the following:
- Alcohol withdrawal
- Sleep deprivation
- Brainstem brain tumors
- Stroke
- Use of certain medications
Episodes of RBD may increase due to the following:
- Sleep or REM sleep deprivation
- Other sleep disorders
- Alcohol
- Some medications
A genetic link for RBD has not yet been identified.
How to diagnose REM sleep behavior disorder?
RBD is a disorder that can get worse over time. This can put you or your bed partner in danger. RBD also tends to be linked to other medical problems. You should seek a sleep doctor’s advice if you suspect that you might have RBD.
The doctor will ask you about your medical history. Your family history may also provide important details. The doctor should do a full exam. This should include a neurologic exam. You may be asked to complete a sleep diary. This will monitor your progress before and after treatment. You may be asked to rate your sleep with a simple questionnaire. This will help show how your sleep is affecting your daily life. Be sure to inform the doctor of any past or present use of any of the following:
- Drugs
- Alcohol
- Medications
Also, tell the doctor if you have ever had any other sleep disorder. You may also need to see a neurologist.
Tests may be needed if your medical exam shows something abnormal. People with RBD are at risk for other sleep disorders. As a result, you will likely need a sleep study. This study is called polysomnography. It charts your brain waves, heartbeat, and breathing as you sleep. It also records how your arms and legs move. This shows if there are other disorders that are related to your sleep problems. Examples of these disorders include sleep apnea and periodic limb movement disorder. The best sleep study will also record your sleep on video. This will show if you get out of bed and do anything unusual during the night.
How to treat REM sleep behavior disorder?
Safety measures need to be addressed first. Some bedroom safety precautions include:
- Removing weapons from your bedroom.
- Moving objects away from your bedside, including nightstands, lamps, or other objects that could cause injury.
- Moving your bed away from windows.
- Placing a large object, like a dresser, in front of windows.
- Padding hard furniture near your bed, like your headboard.
- Using soft carpet in your bedroom or placing a soft mat or rug next to your bed.
- Sleeping with a pillow between you and your partner or sleeping separately from your partner.
Any factors known to aggravate RBD symptoms should be avoided or treated. Your treatment plan may include:
- Maintaining a normal total sleep time. Sleep deprivation will increase RBD.
- Avoiding certain medications and alcohol. They can cause or increase RBD.
- Treating all other sleep disorders that disrupt your sleep and increase RBD. Untreated sleep apnea may worsen RBD symptoms.
- Regular monitoring for any neurologic symptoms, such as tremors or other Parkinson symptoms.
RBD tends to respond to treatment with medications. Your sleep doctor can prescribe the medications that are appropriate for you.