REM Sleep Behavior Disorder

REM Sleep Disorder Overview

Normal sleep has 2 distinct states: non–rapid eye movement (NREM) and rapid eye movement (REM) sleep (see Sleep: Understanding the Basics for details of various stages of sleep). NREM sleep is divided into 4 stages. During REM sleep, rapid eye movements occur, breathing becomes irregular, blood pressure rises, and there is loss of muscle tone (paralysis). However, the brain is highly active, and the electrical activity recorded in the brain by EEG during REM sleep is similar to that recorded during wakefulness. REM sleep is usually associated with dreaming. REM sleep accounts for 20-25% of the sleep period.

In a person with REM sleep behavior disorder (RBD), the paralysis that normally occurs during REM sleep is incomplete or absent, allowing the person to "act out" his or her dreams. RBD is characterized by the acting out of dreams that are vivid, intense, and violent. Dream-enacting behaviors include talking, yelling, punching, kicking, sitting, jumping from bed, arm flailing, and grabbing. An acute form may occur during withdrawal from alcohol or sedative-hypnotic drugs.

RBD is usually seen in middle-aged to elderly people (more often in men).  

REM Sleep Disorder Causes

The exact cause of REM sleep behavior disorder (RBD) is unknown, although the disorder may occur in association with various degenerative neurological conditions such as Parkinson disease, multisystem atrophy, diffuse Lewy body dementia, and Shy-Drager syndrome. In 55% of persons the cause is unknown, and in 45%, the cause is associated with alcohol or sedative-hypnotic withdrawal, tricyclic antidepressant (such as imipramine), or serotonin reuptake inhibitor use (such as fluoxetine,  sertraline, or  paroxetine) or other types of antidepressants ( mirtazapine).

RBD often precedes the development of these neurodegenerative diseases by several years. In one study, 38% of patients diagnosed with RBD subsequently developed Parkinson disease within an average time of 12-13 years from the onset of RBD symptoms. The prevalence of RBD is increased in persons with Parkinson disease and in multisystem atrophy where it is observed in 69% of these patients. The relationship between RBD and Parkinson disease is complex; however, not all persons with RBD develop Parkinson disease.

REM Sleep Disorder Symptoms

The main symptom of REM sleep behavior disorder is dream-enacting behaviors, sometimes violent, causing self-injury or injury to the bed partner.

The dream-enacting behaviors are usually nondirected and may include punching, kicking, leaping, or jumping from bed while still asleep.

The person may be awakened or may wake spontaneously during the attack and vividly recall the dream that corresponds to the physical activity.

When to Seek Medical Care

Seek medical care if unusual behaviors, such as violent thrashing and kicking, occur during sleep.

Questions to Ask the Doctor

Consider asking your doctor the following questions:

• Do I need to consult a neurologist to rule out associated neurological conditions?
  
  
• How important is it to get imaging studies done?

Also consider whether your bedmate needs to be reassured by a professional about your condition.