Acting Out Dreams? Understanding REM Sleep Behavior Disorder
Have you heard of REM Sleep Behavior Disorder (RBD)? This condition is common in people with Lewy Body Dementia (dementia with Lewy bodies and Parkinson’s disease dementia). In fact, RBD can be an early sign of Lewy Body Dementia. However, it can also occur in those with other types of dementia, as well as in people with multiple system atrophy. It can also be triggered by strokes, certain antidepressants, alcohol, and barbiturate withdrawal.
So, what is RBD? It’s a condition in which a person acts out their dreams, often involving action-filled or violent scenarios. This might include talking, cursing, yelling, laughing, or crying in their sleep, as well as physical movements like flailing arms, kicking, punching, biting, or even jumping out of bed. Imagine being attacked or chased in a dream and then acting it out while still asleep. As you can imagine, this can lead to dangerous situations.
These behaviors usually occur about 90 minutes after falling asleep, primarily in the second half of the night when REM sleep is more common. RBD can start subtly, with small twitches or brief jerks, which might be dismissed as normal or go unnoticed for years. Over time, these movements can become more intense. Bed partners are often the first to notice these behaviors, so it’s important to pay attention to any unusual activity during sleep, even if it seems harmless at first. If you or your partner experience these symptoms, it may be a good idea to consult a doctor or sleep specialist for further evaluation.
Why does this happen? During REM sleep, most people experience temporary muscle paralysis (atonia), which prevents them from acting out their dreams. In people with RBD, this paralysis is impaired, allowing dream enactment.
The good news is that although most RBD behaviors are violent due to vivid dreams, treatment is usually unnecessary unless the person is at risk of harming themselves or their bed partner.
However, if the dream enactment becomes dangerous, certain safety precautions are recommended:
- Remove any sharp or dangerous objects from the sleeping area.
- Pad sharp corners of bedside furniture.
- Allow the person to sleep alone to protect others.
- Lower the bed if it’s height adjustable.
- Consider using bed bumpers or placing a soft mat next to the bed to prevent falls or injuries.
These non-pharmacological measures should be implemented before or alongside any medications. If RBD symptoms are severe, doctors may recommend medications like melatonin or clonazepam to reduce dream enactment. However, clonazepam should be used cautiously, especially in people with Lewy Body Dementia, as it can cause sedation, confusion, impaired cognition, unsteadiness, or even paradoxical agitation.
On another positive note—sleepwalking is not typically associated with RBD. Sleepwalking usually occurs during non-REM sleep, so the primary concern with RBD is acting out dreams, not wandering around.
Now, RBD is typically diagnosed through a review of medical history, a physical and neurological exam, and an overnight sleep study (polysomnogram). The sleep study monitors brain and body activity during REM sleep, capturing behaviors and ruling out other sleep disorders. The polysomnographic video recording is the most important diagnostic test and is typically done at a sleep center.
Example Case Study:
At 54, James was referred to a sleep disorder clinic after breaking his wrist while diving out of bed during a dream about being hit by a train. The previous month, he had hit his wife while dreaming of a tiger attack. His wife reported similar incidents over the past few years, although James couldn’t always recall the dreams. Otherwise healthy and not on medication, his physical exam and neuroimaging were normal. A sleep study ruled out sleep apnea but revealed REM sleep without atonia. James was initially treated with clonazepam, which reduced his dream enactment but caused daytime sedation, so he switched to melatonin, which improved his symptoms. After three years, James developed Parkinson’s disease. (reference: Australian Family Physician)
Where to Find Help and Resources
If you or someone you know is struggling with RBD, seeking help from a specialist can make a significant difference. Sleep disorder clinics, neurologists, and sleep medicine specialists can provide the diagnostic tools and treatments necessary to manage RBD effectively.
American Academy of Sleep Medicine (AASM): Find accredited sleep centers and sleep specialists near you. (https://sleepeducation.org/sleep-center/)
References:
https://order.nia.nih.gov/sites/default/files/2024-04/lewy-body-dementia-nia.pdf
https://www.lbda.org/wp-content/uploads/2015/09/treatment.pdf
https://www.thieme-connect.com/products/ejournals/pdf/10.1055/s-0043-1777111.pdf
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