Colin Snow
Fighting in your sleep could be a sign of REM sleep behaviour disorder (RBD), a parasomnia in which people physically act out their dreams during the rapid eye movement (REM) stage of sleep. During normal REM sleep, the body experiences temporary muscle paralysis, but for people with RBD, this paralysis does not occur, allowing them to unknowingly act out their dreams. RBD can lead to accidental injury to oneself or one's bed partner, and it is more prevalent in people over 50 years old, with men being nine times more likely to have RBD than women.
| Characteristics | Values |
|---|---|
| Name of Disorder | REM Sleep Behavior Disorder (RBD) |
| Prevalence | Affects about 1% of the general US population, 2% of the global population aged 15+, and 0.38% of people over 70 |
| Age | Most common in people over 50, with an average onset age of 61 |
| Gender | More common in men, who are nine times more likely to have RBD than women |
| Symptoms | Physically acting out dreams, punching, kicking, shouting, jumping out of bed, sleepwalking, sleep terrors, abnormal nocturnal sleep behaviors, violent nightmares, abnormal sexual behaviors, dissociative behaviors, nocturnal seizures, etc. |
| Diagnosis | Requires a sleep study or clinical history to confirm episodes occur during REM sleep, and that the patient experiences REM sleep without atonia |
| Treatment | Melatonin, temazepam, Posey bed alarms, sleeping in separate rooms, removing dangerous items from the bedroom, sleeping on a mattress on the floor, etc. |
| Prognosis | RBD is associated with neurodegenerative diseases like Parkinson's, Lewy body dementia, and multiple system atrophy |
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What You'll Learn
REM sleep behaviour disorder (RBD)
Fighting in your sleep could be a symptom of REM sleep behaviour disorder (RBD), a parasomnia involving unusual and undesirable physical events or experiences that disrupt sleep. During RBD episodes, individuals may make sudden, forceful, and violent movements such as flailing, punching, and kicking, in response to vivid dreams. They may also vocalise through talking, shouting, laughing, or crying out with emotion. These movements can cause injury to oneself or one's bed partner.
RBD is a complex sleep disorder affecting the brain and is closely related to Lewy body dementia (LBD), Parkinson's disease, and multiple system atrophy (MSA). It is considered one of the earliest warning signs of these neurodegenerative diseases. Individuals who already have these conditions are more likely to develop RBD. Additionally, those with narcolepsy, a sleep disorder causing chronic daytime drowsiness, are at a higher risk of developing RBD. Certain medications, such as newer antidepressants, alcohol and drug abuse, smoking, occupational pesticide exposure, and previous head injuries, may also contribute to the development of RBD.
The onset of RBD can be gradual or sudden, with episodes occurring occasionally or frequently, even multiple times per night. It tends to worsen over time. While it primarily affects people over 50, with an average age of onset at 61, it is being increasingly diagnosed in women under 50, young adults, and children, often in association with narcolepsy, antidepressant use, or brain tumours. Men are nine times more likely to develop RBD than women.
RBD is characterised by the absence of muscle atonia, the temporary paralysis of skeletal muscles during REM sleep, allowing individuals to dream safely without acting them out. Without this paralysis, individuals with RBD unknowingly act out their dreams, which can be violent in nature. Treatment options for RBD include medication regimens, such as melatonin and temazepam, and the use of bed alarms that trigger a voice alert when a sleeper's movements become excessive.
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NREM parasomnia
The treatment for NREM parasomnias typically involves a combination of medication, therapy, and lifestyle measures. Non-pharmacological interventions, such as cognitive behavioural therapy (CBT), melatonin, and mindfulness-based stress reduction (MBSR) have shown promise in treating NREM parasomnias. Standard management strategies include safety plans, reassurance, and general measures to improve sleep hygiene, such as avoiding sleep deprivation, caffeine, and alcohol consumption close to bedtime.
A unique case of chronic violent NREM parasomnia was reported by Danish et al. in 2018, where a 55-year-old obese male patient with a history of parasomnia would wake up in the first few hours of sleep, feeling afraid and sometimes "fighting" back at wild animals attacking him. He would find himself "wrestling" with pillows, falling off the bed, and running into furniture. This case was successfully treated with a combination of bedtime clonazepam therapy and control of severe obstructive sleep apnea (OSA) with nCPAP.
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OSA pseudo-RBD
Fighting in your sleep could be a sign of REM sleep behaviour disorder (RBD), a parasomnia in which sleepers physically act out their dreams, often violently. RBD is a relatively rare condition, affecting around 1% of the US population. However, it is important to note that RBD is strongly associated with neurodegenerative disorders, and most people with RBD will eventually develop Parkinson's disease, Lewy body dementia, or multiple system atrophy.
Obstructive sleep apnea (OSA) is a common sleep disorder that can sometimes mimic symptoms of RBD. This condition is known as "OSA pseudo-RBD". OSA is caused by repetitive obstruction of the upper airway during sleep, resulting in disrupted sleep and abnormal nocturnal behaviours. In some cases, OSA can induce confusional arousals during REM sleep with vivid dreaming, leading to immediate post-arousal dream-enacting behaviours (DEB) that can include locomotion, agitation, and violence. These behaviours can be mistaken for RBD, especially since OSA can also cause REM sleep fragmentation, making it more difficult to detect complex motor behaviours.
It is important to distinguish between pseudo-RBD associated with OSA and RBD concomitant with OSA, as these conditions have different clinical implications and treatment options. Video polysomnography (vPSG) is mandatory to establish an accurate diagnosis, and CPAP treatment is often used to confirm the diagnosis and treat concomitant RBD and OSA. Cardiopulmonary coupling (CPC) analysis can also be used to screen for RBD among patients reporting DEB.
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Neurodegenerative disease
Acting out dreams and engaging in violent behaviour while asleep can be a symptom of REM sleep behaviour disorder (RBD). People with RBD physically act out their dreams without knowing it, which can lead to injuries to themselves or their bed partner. RBD is a parasomnia, a sleep disorder that involves undesirable physical events or experiences that disrupt sleep.
RBD is strongly associated with neurodegenerative disorders, particularly Parkinson's disease, Lewy body dementia, and multiple system atrophy (MSA). In fact, about 97% of people with isolated (idiopathic) RBD will develop one of these neurodegenerative conditions within 14 years of their RBD diagnosis. Furthermore, circadian disruption and sleep disorders, such as insomnia, hypersomnia, nightmares, and circadian rhythm disorders, are often observed in patients with neurodegenerative diseases and can increase the risk of developing such diseases.
While the primary focus of research on neurodegenerative diseases has been on their clinical features, there is emerging evidence of a profound link between these conditions and sleep disturbances. Sleep plays a critical role in maintaining overall health and well-being, and its disruption can have significant implications for individuals with neurodegenerative disorders. Sleep disturbances may even accelerate or exacerbate neurodegeneration through mechanisms involving oxidative stress, inflammation, and impaired protein clearance.
Therefore, it is crucial to recognise the role of sleep in the management and potential slowing of the progression of neurodegenerative diseases. By understanding the intricate relationship between sleep disorders and neurodegenerative diseases, researchers can explore sleep-related interventions as a novel approach to managing these conditions.
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Treatment options
Fighting in your sleep could be a symptom of REM sleep behaviour disorder (RBD). This is a parasomnia, a sleep disorder that involves undesirable physical events or experiences that disrupt sleep. During an episode of RBD, the sleeper is typically acting out a dream, often a violent one, and can cause injury to themselves or their bed partner. RBD is relatively rare, affecting about 1% of the general US population, but it is more common in people over 50, and men in this age group are nine times more likely to have it than women.
If you are experiencing symptoms of RBD, it is important to seek treatment. Treatment options for parasomnias such as RBD include:
- Medication: Medication is rarely necessary for parasomnias, but if it is, it is typically prescribed for three to six weeks. Benzodiazepines or anti-anxiety medications are commonly prescribed.
- Cognitive behavioural therapy (CBT): A form of therapy that can help to manage symptoms.
- Sleep hygiene: This includes following a regular sleep schedule, getting seven to nine hours of sleep per night, turning off lights and electronic devices, keeping the room temperature cool, and avoiding caffeine.
- Sleep study and imaging tests: A sleep study (polysomnogram) can help providers monitor and record brain waves, heart rate, eye movements and breathing during sleep. Video electroencephalogram (EEG) or sleep EEG can record brain activity during sleep, while CT or MRI scans can detect brain degeneration or other possible causes.
- Addressing underlying conditions: In some cases, RBD may be caused by an underlying condition, such as obstructive sleep apnea (OSA), which can be treated with continuous positive airway pressure (CPAP) therapy.
- Creating a safe sleeping environment: This may include the use of bed alarms or other devices that trigger an alert when a sleeper's movements become excessive.
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Frequently asked questions
Fighting in your sleep could be a symptom of REM sleep behaviour disorder (RBD). This is a parasomnia in which you physically act out your dreams while in the rapid eye movement (REM) stage of sleep.
The main symptom of RBD is physically acting out dreams, which can include anything from small muscle twitches and whispering to punching, kicking, shouting, and jumping out of bed. People with RBD may also make noises such as talking, laughing, shouting, or yelling for help.
Treatments for RBD include melatonin, sleeping environment modifications, and sleeping in a separate bed from one's partner.
