While we are dreaming, no matter how vivid our dreams are, we will live those dreams only mentally since our body is not moving or doing anything. However, people who suffer from REM behavior disorder (RBD) are trying to act out their dreams by moving their limbs while still sleeping. Rapid eye movement sleep behavior disorder is a sleep-related disorder which belongs to the group of parasomnias, and it is characterized by the absence of paralysis which typically occurs during our REM sleep.
So, whatever is going on in the dream world of patients with RBD, they will try acting it out, which can be painful for their partners because it would not only disrupt their sleep but also hurt them physically since people can be kicked, punched or even pushed out of bed by their unconscious partner. Somehow people with RBD do not usually have a problem with more mild dreams, their dreams are always dynamic, intense, there is a lot of screaming or fighting, so it can represent a significant problem for them and their partner or roommate. However, it is important to mention that the combination of RBD and extremely violently behavior is rare since it occurs in only 0.5 of the RBD cases.
Sleep talking and sleepwalking can also occur, which is why the RBD is often mixed with these disorders or wrongly diagnosed. The difference is that RBD is a more severe form which combines various symptoms, but the good news is that it can be treated successfully.
Brief History of RBD
To understand how this disorder was recognized and diagnosed, we have to go back to 1958. when several cases of RBD were described for the first time. Two doctors of medicine from the University of Minnesota, Carlos Schenck and Mark Mahowald, pointed out a few case histories of people who suffered from RBD. Doctors described several cases of people mostly older than 50 years, who all have had similar stories, people behaved violently during sleep, they were jumping out of bed, hitting their partner because they believed they were attacked, a war veteran even injured himself during an episode of fighting in his dream, etc.
Patients did not have any pleasant dreams, they all had vivid nightmares in which they were fighting against criminals, snakes, army or monsters. But, they were dealing with their “imaginary” problem in the real world, and sometimes they hurt themselves or others, and that is when it becomes a problem.
The doctors reported that all the men were very friendly and calm individuals during the day and that they did not have any neurological or psychiatric issues. And that is the case with most RBD patients, they are peaceful and “normal,” so their often violent behavior during sleep has nothing to do with their character or any other individual feature. Doctors concluded that RBD strikes mostly men and that it is more common among the elderly population, people who are 50 or older are at higher risk, although there have been a few cases of children with RBD, but that is more of an exception than a rule. They also noticed that many patients show occasional rhythmic movements in their legs, while they are in non-REM sleep phase.
Mahowald and Schenck also did a telephone survey which included more than 4900 people, from 15 to 100 years old, they found out that around 2% of the respondents experienced violent behavior during sleep, however, they estimated that probably only one quarter of them owes it to RBD, which lead to their conclusion that 0,5% of the US population struggles with RBD.
REM Sleep Behavior Disorder Symptoms
People with RBD are unable to remain still while they are dreaming, which means that they physically act out everything they are going through in their dreams or nightmares. This disorder can show up all of a sudden, or it can gradually progress until it reaches its final form. The frequency of these episodes varies; they can occasionally occur like once in a week or month, but they can also happen multiple times during one night, there is no rule or a way to predict them.
Some of the most common symptoms of RBD include:
- Movements, such as hitting, kicking, punching, jumping out of bed, etc. all in response to those action-packed, intense dreams in which people are usually fighting for their life in fights, battles, or being chased.
- Sounds, such as shouting, talking, cursing, emotional outcries, and so on, are also typical symptoms of RBD.
- People with RBD are able to recall those episodes even if they are awakened during it.
If during those nighttime physical activities people injure themselves or their bed partners, that is usually a clear signal that they need to seek professional help.
RBD Causes and Risk Factors
Most parasomnias are more common among children, and they can be easily outgrown, however, RBD affects mainly adults. Symptoms of RBD can appear at any age, but people who are in their fifties or sixties are at the highest risk of experiencing RBD disorder, and when it comes to sex, the vast majority of people affected by it are men.
A genetic link for the RBD is not identified, so it is not officially confirmed that it can be passed on genetically and the exact cause of RBD is unknown, but it can be triggered and worsen due to some other sleep disorders, sleep deprivation, medications, alcohol, traumas or post-traumatic stress disorder.
Besides that, there seems to be a connection between RBD and some neurological problems, since many people with them tend to develop RBD also. For example, around 33% of people who suffer from Parkinson’s disease will get RBD, and also 90% of those who have multiple system atrophy. And vice versa, people with RBD can develop Parkinson’s disease even after many years, so they should pay attention to Parkinson’s key symptoms such as tremor, rigidity, issues with posture or walking, etc. In some cases, the RBD occurred even 50 years prior to the symptoms of other neurological diseases. The researchers still do not know why such a significant amount of people with RBD has a strong predisposition for Parkinson’s disease. Considering the statistics, it is understandable why people with RBD are concerned about the possibility and risks for the parkinsonian disorder. Regular visits to a neurologist and early diagnosis with proper treatment are currently the only solution that science has to offer.
Patients suffering from RBD can sometimes struggle to understand what is going on, especially if they unintentionally hurt someone dear to them, that is when they develop hypnophobia. This phobia represents a fear of falling asleep since people are afraid of they might do, they feel ashamed and uncomfortable because they cannot control what will they do once they fall asleep, so they rather avoid it and stay awake as long as possible.
When it comes to other sleep disorders, people suffering from RBD have a higher risk for a few others:
- Narcolepsy – the first described case of a patient with both narcolepsy and RBD, dated back in 1992. Around 15% of narcoleptic patients have RBD, and although their features are the same with the patients who have RBD only, the episodes are not so frequent.
- Sleep apnea – RBD and obstructive sleep apnea are the most common sleep disorders among patients with Parkinson’s disease. A study showed that RBD could mitigate the severity of OSA, but together they can only aggravate cognitive impairment among patients with Parkinson.
- Periodic limb movement disorder – the repetitive movements usually affect legs, but they can rarely impact the arms too. Patients who have a severe form of PLMS have higher chances to experience some of the RBD symptoms such as unpleasant dreams followed by abnormal sleep behavior.
Treatment and Tips for RBD
If it is not treated correctly, RBD tends to get worse over time. However, the good news is that RBD is not a permanent state and it can be treated successfully with drugs. RBD responds well to medications such as clonazepam, which is also often used for the treatment of Parkinson’s disease. Clonazepam is a benzodiazepine, and it successfully eliminates the RBD symptoms 90% of the time, another advantage of this medication is that people rarely develop tolerance to it, even if they have been using it for years. Clonazepam will relax the body and suppress muscle activity during sleep. In case that clonazepam is not working, as an alternative people go for melatonin or antidepressants as they also keep violent behavior under control. People who suffer from sleep apnea, gait disorder or dementia should be very cautious when using clonazepam and follow the instructions and prescribed dosage.
We mentioned that clonazepam is also used for Parkinson’s disease, but, that does not mean that people who take it for RBD will prevent the development of PD. There are theories that RBD is in fact, an early symptom of PD, MS, or dementia with Lewy bodies, but the studies have not confirmed that yet since not everyone will RBD will later have some of these disorders.
When the symptoms and nocturnal behavior are not so severe, a few simple things may secure a more safe sleep environment, so you can try out these tips first before you start using medications, but often the combination of lifestyle changes and drugs works the best.
- The first thing you need to do is to remove almost everything around your bed. That includes your nightstand, a lamp, sharp or fragile objects, anything that can potentially injure you when you start moving your hands. If you fell out of the bed before, try placing some padded or cushioned barriers around it or place something soft like a mattress topper next to your bed, to cushion your fall. Another option is to place your mattress on the floor or some lower mattress foundation. You should also move your bed away from the window.
- People with RBD should stick to a certain sleep routine, and avoid all-nighters or going late to bed because sleep deprivation can only aggravate their symptoms.
- Pay a visit to a sleep clinic. There you will be involved in a sleep study to diagnose precisely which type of sleep disorder you have, and you will get proper instructions for your treatment. Usually, the performed study will be an overnight polysomnographic video recording, which will record any odd behavior during sleep.
- Alcohol should be avoided as well as certain medications which can increase RBD, so do not take any drugs on your own without checking the side effects or consulting with your doctor.
- You should do annual checkups and monitoring for any neurological symptoms. Also if you already have symptoms of some other sleep disorder start treating it immediately.
- It is recommended that your bed partner sleeps in another room until the RBD symptoms are put under control. It will prevent accidental injuries, arguments and it will give your partner a chance to sleep without disruption. Partners of people with RBD usually have an essential role in their treatment, since they are the only ones that can describe what was going on exactly and point out the key symptoms or help with tracking the history of the disorder.