Rem Sleep Disorder: A Disturbance In Dreamland

REM sleep behaviour disorder (RBD) is a sleep disorder that causes people to act out their dreams. During the REM stage of sleep, the body typically experiences temporary paralysis, but for people with RBD, this paralysis does not occur, and they may act out their dreams physically and vocally. This can include shouting, screaming, punching, kicking, and jumping out of bed. RBD is a parasomnia, a sleep disorder that involves undesirable physical events or experiences that disrupt sleep. It is a rare condition, affecting less than 1% of the general population, and typically begins after the age of 50. It is more common in men and is associated with neurodegenerative disorders such as Parkinson's disease, Lewy body dementia, and multiple system atrophy.

REM sleep behaviour disorder

RBD occurs during the rapid eye movement (REM) stage of sleep, during which the eyes move rapidly under the eyelids, and heart rate, breathing and blood pressure all increase. REM sleep is also when vivid dreaming occurs. There are usually several REM cycles per night, with the first beginning about 90 minutes after falling asleep and lasting for around 10 minutes. Each cycle that follows gets longer.

There are two main types of RBD: isolated (idiopathic) and symptomatic (secondary). Isolated RBD occurs spontaneously without an underlying cause, while symptomatic RBD is caused by an underlying condition, such as Type 1 narcolepsy, or the use of certain antidepressants (known as drug-induced RBD).

RBD is most common in people over the age of 50, with an average onset age of 61. Among those over 50, men are nine times more likely to have RBD than women. RBD is also strongly associated with certain neurodegenerative disorders, particularly Parkinson's disease, Lewy body dementia and multiple system atrophy (MSA). In fact, around 97% of people with isolated RBD will develop one of these conditions within 14 years of their RBD diagnosis.

The exact cause of RBD is unknown, but it is thought to be linked to an issue in the part of the brainstem called the pons, which controls muscle paralysis during sleep. Temporary paralysis does not occur in people with RBD, which is why they are able to act out their dreams.

To diagnose RBD, a healthcare provider will ask the patient questions about their symptoms and medical history, and may also ask their bed partner or housemates about their sleeping behaviour. The patient will also undergo a physical and neurological exam, and may be referred to a sleep specialist. To receive an official diagnosis of RBD, the patient will need to undergo an in-lab video sleep study or polysomnography, which will record their breathing rate, brain wave activity and muscle movements during sleep.

The primary goal of RBD treatment is to create a safe sleeping environment and reduce the risk of injury to the patient and their bed partner. This may involve removing sharp or heavy objects from the bedroom, placing pillows around the bed, or sleeping on a mattress on the floor. If symptoms are severe, the bed partner may need to sleep in a separate room. It is also recommended that individuals with RBD avoid alcohol, as this can trigger an episode.

If safety measures are insufficient to prevent injury, medication may be prescribed to manage symptoms. Melatonin, clonazepam and pramipexole have all been shown to reduce symptoms in some cases, although there are currently no U.S. Food and Drug Administration (FDA)-approved medications specifically for RBD.

Parasomnias

There are two types of parasomnias: REM-related and non-REM-related. REM-related parasomnias occur during the rapid eye movement (REM) stage of sleep, which is when vivid dreaming occurs. Non-REM parasomnias, on the other hand, occur during the first three stages of sleep, when individuals are in a state of non-rapid eye movement (non-REM) sleep.

Some common examples of parasomnias include:

• Sleep terrors: Individuals wake up suddenly in a terrified state, screaming or crying in fright.
• Sleepwalking (somnambulism): Individuals get out of bed and move about with their eyes open, but are actually asleep. They may perform complex activities or strange behaviours.
• Confusional arousals: Individuals appear to be partially awake but are confused and disoriented. They may sit up, cry, or mumble, and have trouble understanding or responding to questions.
• Sleep-related eating disorder: Individuals eat and drink while partially awake, consuming unusual or dangerous items.
• Nightmare disorder: Vivid dreams that cause feelings of fear, terror, or anxiety. Individuals may have trouble falling back asleep and often recall the dream in detail.
• Recurrent isolated sleep paralysis: Individuals are unable to move or speak during sleep. This may be caused by an extension of REM sleep, where muscles are in a relaxed state.
• REM sleep behaviour disorder (RBD): Individuals act out their dreams physically and/or vocally while in REM sleep. They are unaware of their actions and may cause injury to themselves or their bed partner.

Lack of REM sleep symptoms

Sleep is vital to our health and well-being. When we sleep, we pass through different phases, each with its own unique characteristics. One of these phases is REM (rapid eye movement) sleep, which occurs about 90 minutes into sleep and recurs every 90 minutes until we awaken.

During REM sleep, our eyes move rapidly, our brain activity is similar to its activity when we are awake, and we experience vivid dreams. While our brain is active, our muscles are temporarily paralysed, preventing us from acting out our dreams.

So, what happens when we don't get enough REM sleep? What are the symptoms of a lack of REM sleep?

Fatigue and Sleep Deprivation

One of the most common symptoms of insufficient REM sleep is fatigue. You may feel drowsy during the day, leading to decreased energy levels and a lack of motivation to engage in physical activities. This can result in poor decisions and careless actions, which can be dangerous to your health and well-being.

Cognitive Issues and Memory Problems

A lack of REM sleep can also lead to problems with memory and cognition. You may experience difficulty concentrating, impaired critical thinking, and issues with problem-solving. Additionally, the lack of sleep can affect your ability to learn new skills and consolidate memories, as REM sleep is believed to be crucial for procedural memory and memory consolidation.

Mood Disorders and Emotional Instability

Not getting enough REM sleep can impact your mood and emotional state. You may experience irritability, anxiety, or depression. Changes in mood can also lead to more disturbed dreaming and an increased frequency of nightmares.

Weakened Immune System

REM sleep is important for maintaining a healthy immune system. A lack of REM sleep can weaken your body's defence mechanisms, making you more susceptible to illnesses and infections.

Cardiovascular Health and Metabolic Disorders

Sleep deprivation, including a lack of REM sleep, can have serious implications for cardiovascular health. It can increase the risk of cardiovascular disease and metabolic disorders such as obesity and type 2 diabetes.

Other Health Risks

The impact of insufficient REM sleep goes beyond what we've discussed so far. It can also contribute to an increased risk of cancer, stroke, and neurodegenerative diseases like Alzheimer's. Additionally, it can affect your pain tolerance and sensitivity to pain.

If you suspect that you are not getting enough REM sleep or are experiencing any of these symptoms, it is important to consult a healthcare professional or a sleep specialist. They can provide guidance and help you improve your sleep quality.

Treatment options

REM sleep behaviour disorder (RBD) is a parasomnia, a sleep disorder that involves undesirable physical events or experiences that disrupt sleep. It is important to seek treatment for RBD as it can lead to accidental injury to yourself or your bed partner.

The main goal of treatment for REM sleep behaviour disorder is to create a safe sleeping environment for you and your bed partner. This can be achieved through certain strategies and, in some cases, medications.

Safety Measures

• Removing sharp, glass, and heavy objects from the bedroom.
• Placing pillows between the sleeper and surrounding structures, such as the headboard or a nightstand.
• Placing a mattress on the floor next to the bed in case of falling out of bed, or using padded bedside rails.
• Sleeping in a sleeping bag.
• If the symptoms are severe, it may be safer for the bed partner to sleep in a separate room.

Medication

• Melatonin: This is considered the first-line medication for treating RBD as it rarely causes side effects. It is a hormone that the body naturally produces to regulate the sleep-wake cycle.
• Clonazepam: A sedative that helps reduce nightmares and vocalisations during sleep. However, it can cause unpleasant side effects.
• Pramipexole: A dopamine agonist primarily prescribed for Parkinson's disease and restless leg syndrome. It has been found to be effective in treating RBD symptoms, as the disorder may be related to a dopaminergic deficiency.

General Recommendations for Better Sleep

• Follow good sleep hygiene practices: Get 7-9 hours of sleep per night, maintain a cool and dark bedroom environment, avoid caffeine and strenuous exercise close to bedtime, etc.
• Maintain a regular sleep-wake schedule: Go to bed and wake up at the same time every day, even on weekends.
• Limit or avoid alcohol and recreational drugs: Alcohol can trigger RBD episodes and worsen the condition.
• Exercise regularly: Try to get about 30 minutes of daily exercise, but do so several hours before bed.
• Establish a relaxing bedtime routine: Engage in soothing activities such as reading or taking a warm bath before bed.
• Avoid screens and gadgets in the bedroom: The blue light emitted by electronic devices can interfere with your sleep.

It is important to consult a healthcare professional or sleep expert if you are experiencing sleep problems or if the above strategies are not effective. They can help evaluate your sleeping patterns and determine the best treatment options for you.

Diagnosis

If you think you may have a REM sleep disorder, it is important to consult a healthcare provider. Diagnosis of REM sleep behaviour disorder (RBD) usually begins with a physical and neurological exam to rule out other potential causes, such as alcohol, medications, or narcolepsy. Your doctor will also look for symptoms of Parkinson's disease, such as hand tremors or muscle stiffness.

If you sleep with a partner, your doctor may ask them about any unusual behaviours you display while sleeping, such as talking or moving your limbs. They will ask your partner to describe these behaviours in detail.

You may then be referred to a sleep lab for a polysomnogram, an overnight sleep study. During this study, sensors will monitor your breathing, eye movements, arm and leg movements, brain and heart activity, and blood oxygen levels. It is common to videotape the exam to record any unusual behaviour during sleep.

After the exam, a sleep physician will review your medical history, symptoms, and the results of your polysomnogram to determine whether a diagnosis of RBD is appropriate.

According to the American Academy of Sleep Medicine's International Classification of Sleep Disorders, a person must meet four criteria to receive a diagnosis of RBD:

• Repeated episodes of acting out dreams with vocalisations or arm and leg movements that correspond to what is happening in the dream.
• Episodes occur during REM sleep, as confirmed by a sleep study or your clinical history.
• Episodes include sleep without muscle paralysis, as confirmed by polysomnography.
• The episodes are not attributed to something else, such as another sleep or mental health disorder, medication side effects, or substance abuse.

Parasomnias are more common in children than in adults, with non-REM sleep disorders being more prevalent in children than REM sleep disorders. The most common parasomnias in children under 15 are confusional arousal, sleep terrors, sleepwalking, and sleep-related eating disorder. If you are concerned about your child's sleep, consult a healthcare provider.

Frequently asked questions