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REM Sleep Behavior Disorder

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What is it?

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, the sleeper is usually confused upon waking up. He or she does not become rapidly alert. In contrast, it is normally easy to wake a person with RBD who is acting out a dream. Once awake, he or she is 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 rapid-eye-movement (REM) sleep. Normal sleep consists of a series of REM dream episodes. They occur about every 1 ½ to 2 hours each night. This means that an RBD episode tends to first appear at least 1 ½ 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. People with RBD are not more aggressive or violent than others when awake. RBD is a medical problem. It is not a psychiatric disorder. People with RBD do not normally have a mental problem.


Who gets it?

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 one percent 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’s disease (33%)
  • Multiple system atrophy (90%)

People found to have RBD may develop Parkinson’s disease many years later. Those with RBD should watch for symptoms of Parkinson’s such as tremor.

People with RBD are at higher risk for the following sleep disorders:

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 do I know if I have it?

  1. Do you ever kick, jump, punch, flail, shout, or leap out of bed while you are still asleep?
  2. Has your bed partner expressed concern about your unusual behaviors while sleeping?
  3. Do these actions match vivid dreams that you clearly recall?
  4. Have any of these sleep activities resulted in an injury to you or your bed partner?

If your answer to the first question and at least one of the others is yes, then you might have REM sleep behavior disorder.

It is also important to know if there is something else that may be related to REM behavior disorder such as the following:

  • Another sleep disorder
  • A neurologic condition such as Parkinson’s disease
  • A medical condition
  • Medication use
  • Substance or alcohol abuse

Do I need to see a sleep specialist?

Yes. 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 doctor’s advice if you suspect that you might have RBD.


What will the doctor need to know?

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 the Epworth Sleepiness Scale. 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.


Will I need to take any tests?

Tests may be needed if your medical exam shows something abnormal. People with RBD are at risk for other sleep disorders. As a result, your doctor will likely have you take an overnight sleep study. This is called a polysomnogram. It charts your brain waves, heart beat, 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 the bed and do anything unusual during the night.


How is it treated?

RBD tends to respond to treatment with medications. Clonazepam is often used. However, treatment also requires the following:

  • Bedroom safety precautions

    * Move objects away from the patient’s bedside. This includes night stands, lamps, or other objects that could cause injury.

    * Move the bed away from the window.

    * Place a large object such as a dresser in front of the window.
  • Maintain a normal total sleep time. Sleep deprivation will increase RBD. Monitor for any sleepiness.
  • Avoid certain medications and alcohol. They can cause or increase RBD.
  • Treat any and all other sleep disorders that will disrupt your sleep and increase RBD.
  • Undergo regular monitoring for any neurologic symptoms. This includes tremor or other Parkinson symptoms.

By Sharon L. Schutte-Rodin, MD
Updated on October 21, 2005

More Information
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Comparing Parasomnias

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