Sleep Punching: What Your Body Language Says About You

Hitting things in your sleep could be a sign of REM sleep behaviour disorder (RBD), a parasomnia in which you physically act out your dreams while in the rapid eye movement (REM) stage of sleep. During normal REM sleep, the body enters a state of temporary paralysis, known as muscle atonia, to prevent acting out dreams. However, for people with RBD, this paralysis does not occur, leading to unintentional physical movements that can cause harm to oneself or one's bed partner. RBD is often associated with underlying neurological disorders, such as Parkinson's disease, Lewy body dementia, or multiple system atrophy. It is important to seek medical advice and treatment to manage RBD and prevent potential injuries.

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REM sleep behaviour disorder (RBD)

Hitting things in your sleep could be a sign of REM sleep behaviour disorder (RBD). During normal REM sleep, your body enters a state of temporary muscle paralysis called atonia, which prevents you from acting out your dreams. However, people with RBD experience a failure of this paralysis mechanism, allowing them to physically act out their dreams. This can range from small muscle twitches and whispering to more violent behaviours like punching, kicking, shouting, and jumping out of bed.

RBD is a rare parasomnia that disrupts sleep and can cause unintended injuries to oneself or one's sleep partner. People with RBD may experience vivid dreams, typically involving threats to survival or safety, and may recall dream content upon waking, such as calling for help or trying to defend themselves. The disorder can lead to poor sleep quality, fatigue, distress, and psychological symptoms like anxiety about falling asleep.

RBD is often associated with underlying neurological conditions, particularly Parkinson's disease, Lewy body dementia, and multiple system atrophy. It can serve as an early indicator of these conditions, with 50-80% of patients diagnosed with isolated RBD (no known underlying cause) developing one of these neurodegenerative disorders within a decade. Additionally, sleep deprivation, smoking, head injury, and exposure to pesticides may be risk factors for developing RBD.

Treatment for RBD focuses on managing symptoms and creating a safe sleep environment. This may include medication to suppress muscle activity during REM sleep, such as clonazepam, or implementing safeguards like padded bedrails or moving the mattress to the floor to prevent injuries. Establishing a healthy sleep routine can also help improve sleep quality and reduce the severity of RBD symptoms.

While RBD can be distressing and disruptive, proper diagnosis and management can help individuals regain a sense of control and proactively address potential underlying conditions.

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RBD as a precursor to neurological conditions

Acting out dreams by hitting things in your sleep is a symptom of REM sleep behaviour disorder (RBD). This is a parasomnia, or sleep disorder, in which the body physically acts out dreams during the rapid eye movement (REM) stage of sleep. During normal REM sleep, the body is in a state of temporary muscle paralysis, but for people with RBD, this paralysis does not occur, and they may experience anything from small muscle twitches to punching, kicking, shouting, and jumping out of bed. RBD can cause serious injury to oneself or one's bed partner, and it has been linked to neurological conditions.

RBD is associated with a high risk of developing neurodegenerative alpha-synucleinopathy diseases. Over 70% of people with RBD will develop one of these diseases, including Parkinson's disease, dementia, or multiple system atrophy, within 12 years of their diagnosis. The risk is even higher within a decade, with one study showing that 97% of people with isolated RBD developed one of these conditions within 14 years. This is because RBD is caused by a failure to inhibit spinal motor neurons during REM sleep, which is associated with neurodegenerative disorders.

In addition, RBD is often caused by neurological lesions affecting sleep/wake regulatory brain regions, most commonly within the brainstem. The onset of RBD symptoms may also coincide with the initiation of certain drugs, such as antidepressants, which cause RBD behaviours in up to 6% of users.

The strong association between RBD and neurological conditions has important implications for diagnosis and treatment. Individuals suspected of having RBD should be referred to a specialist Sleep Medicine or Neurology service for a diagnostic assessment. This assessment typically consists of a general and neurological examination to rule out differential diagnoses, along with tests and rating scales designed to assess specific sleep and neurodegenerative aspects of the condition. Information from bed partners is also important, as they can provide a more accurate history of sleep-related behaviours and aid in assessing the severity of the RBD.

While there is no known way to prevent RBD due to unchangeable risk factors such as age, there are treatment options available to manage the disorder and prevent injury. These include medication such as melatonin, temazepam, and clonazepam, as well as the use of devices that trigger voice alerts when a sleeper's movements become excessive.

Treatment options for RBD

Hitting things in your sleep could be a sign of REM sleep behaviour disorder (RBD). During normal REM sleep, the body enters a state of temporary muscle paralysis, allowing us to dream safely without acting out our dreams. However, for people with RBD, this paralysis does not occur, and they may experience anything from small muscle twitches to more violent movements like punching or kicking. This can result in serious injuries to themselves or their bed partner.

Safe Sleeping Environment

The primary goal of RBD treatment is to create a safe sleeping environment to prevent injuries. This may include removing sharp objects and weapons from the bedroom, placing padding on the floor, installing padded bed rails, moving furniture and other trip hazards away from the bed, and even sleeping on a mattress on the floor.

Medication

Clonazepam, typically used to treat anxiety, is often considered a first-line therapy for RBD as it can help suppress muscle activity during REM sleep. Melatonin is also sometimes used in conjunction with clonazepam. Other medications that have shown some efficacy in clinical trials include rivastigmine, memantine, 5-hydroxytryptophan, and the herbal medicine yokukansan.

Alert Devices

Using devices that trigger a voice alert when a sleeper's movements become excessive can help to wake the person and reduce the intensity of their movements.

Underlying Conditions

RBD can be a harbinger of more serious neurological conditions such as Parkinson's disease, dementia with Lewy bodies, or multiple system atrophy. It is important to regularly see a healthcare provider to monitor for these conditions and address any other symptoms that may develop, such as issues with movement or cognitive changes.

Lifestyle Changes

Lifestyle factors such as sleep deprivation, smoking, and exposure to pesticides may also contribute to RBD. Addressing these factors through lifestyle changes could potentially help manage the disorder.

Other parasomnias

Parasomnias are disruptive behaviours or events that affect sleep. They can occur when falling asleep, during sleep, or when waking up. Parasomnias can be classified into three groups based on the stage of sleep they affect: non-rapid eye movement (NREM) sleep, rapid eye movement (REM) sleep, and parasomnias that do not fit into either category.

REM Sleep Behaviour Disorder (RBD)

REM sleep behaviour disorder is a rare parasomnia in which individuals physically act out their dreams during the REM stage of sleep. This occurs because the body does not enter the typical state of muscle paralysis, known as atonia, that occurs during REM sleep. As a result, individuals with RBD may experience anything from small muscle twitches and whispering to punching, kicking, shouting, and jumping out of bed. RBD is often associated with violent dreams, such as being attacked by bees or defending against thugs. It is more common in older individuals and is more prevalent in males, with an average onset age of 61 years old.

Exploding Head Syndrome

Exploding head syndrome is a parasomnia that causes individuals to hear loud noises or explosive crashing sounds in their heads as they are falling asleep or waking up. It can also be accompanied by imaginary flashes of light or sudden muscle jerks.

Sleep-Related Hallucinations

Sleep-related hallucinations involve experiencing false perceptions as one is falling asleep or waking up. Individuals may see, hear, or feel things that are not real.

Sleep-Related Eating Disorder

Sleep-related eating disorder is a parasomnia where individuals consume food and beverages in a hurried and uncontrolled manner during their sleep. They may eat foods they would typically avoid when awake, such as uncooked chicken or sticks of butter. This parasomnia can lead to dangerous situations, including consuming toxic or inedible items, choking, or sustaining injuries from preparing or cooking food.

Sexsomnia

Sexsomnia is a parasomnia where individuals engage in sexual behaviours during sleep, including intercourse, masturbation, sexual assault, touching their bed partner, or making sexual vocalizations.

Sleep Texting

Sleep texting is a parasomnia where individuals compose and send text messages while asleep.

Confusional Arousals

Confusional arousals occur when individuals wake up feeling confused and disoriented. They may sit up, have their eyes open, cry, or speak slowly. This parasomnia can last from a few minutes to several hours and is more common in children, tending to decrease with age.

Safeguarding your bedroom

Hitting things in your sleep could be a symptom of REM sleep behaviour disorder (RBD). People with RBD act out their dreams, which can range from small movements like whispering or twitching to more violent actions like punching, kicking, shouting, and jumping out of bed. RBD can be a harbinger of neurological disorders such as Parkinson's disease, Lewy body dementia, or multiple system atrophy. If you think you might have RBD, consult a medical professional.

For RBD

• Keep sharp objects and weapons out of the bedroom.
• Place padding on the floor in case you fall out of bed.
• Install padded bed rails or move your mattress onto the floor.
• Move furniture, clutter, and other tripping hazards away from the bed.
• Talk to your doctor about medication to treat RBD.

General Bedroom Safety

• Install smoke and carbon monoxide alarms.
• Ensure your bedroom meets fire safety requirements.
• Use a monitored smoke and carbon monoxide detection system as part of a burglar alarm.
• Extinguish candles and check for other fire hazards before going to bed.
• Do not leave devices charging under sheets or blankets.
• Store guns and other weapons in a secure safe to prevent accidents and burglaries.
• Limit screen time before bed, especially for children.
• Avoid blue light exposure before bed by using blue light filters or night mode.
• Keep phones out of the bedroom or in a designated spot outside the bedroom.
• Maintain a bedroom temperature of 65-75°F (18-24°C) and a humidity level of 30-50% to protect your hair and scalp.

Frequently asked questions