The Real Name Behind Rem Sleep Behavior Disorder

REM sleep behaviour disorder (RBD) is also known as REM sleep behaviour disorder (RSBD). It is a parasomnia, a sleep disorder that involves unusual and undesirable physical events or experiences that disrupt sleep. People with RBD act out their dreams, often violently, and can cause injury to themselves or their bed partner.

Parasomnia

NREM Parasomnias

Also known as "disorders of arousal", NREM parasomnias occur when sleepers partially wake up. Their eyes may be open and they may appear to act with intention, but they are not fully conscious. Some common NREM parasomnias include:

• Night terrors: sleepers abruptly wake up feeling afraid, often within a few hours of falling asleep.
• Sleepwalking: sleepers get out of bed and perform complex actions, such as getting dressed or preparing food, while still asleep.
• Confusional arousals: sleepers wake up in a state of extreme confusion and may cry, moan, or mumble.
• Sleep-related abnormal sexual behaviours: sleepers engage in sexual activities without being aware of their actions and often cannot recall them the next day.

REM Parasomnias

REM parasomnias occur during the REM stage of sleep or in the transition out of it. Individuals usually remember these episodes. Some common REM parasomnias include:

• Nightmares: bad dreams that cause sleepers to wake up feeling anxious and upset.
• REM sleep behaviour disorder: individuals physically act out their dreams, which can be violent and lead to injuries.
• Sleep paralysis: individuals wake up unable to move or speak and may experience terror, hallucinations, or both.

Other Parasomnias

Some parasomnias are not associated with a particular sleep stage and can occur at any time during sleep or when falling asleep/waking up. These include:

• Bedwetting: considered parasomnia when it occurs at least twice a week in people over the age of five.
• Exploding head syndrome: individuals hear a sudden loud noise, often accompanied by a flash of light, when falling asleep or waking up.
• Sleep-related hallucinations: individuals see, hear, or feel things that are not there when falling asleep or waking up.
• Sleep-related dissociative disorders: episodes where a person's sense of self or identity, or control/perception of their body, is disrupted.

Neurodegenerative Disorders

REM sleep behavior disorder (RBD) is a parasomnia involving dream enactment behavior associated with loss of atonia during rapid eye movement (REM) sleep. During REM sleep, most of the body's muscles undergo temporary paralysis, known as muscle atonia, while the brain remains highly active, resulting in vivid dreams. However, for individuals with RBD, this paralysis is incomplete or absent, allowing them to physically act out their dreams. This condition can lead to injuries to oneself or one's bed partner and is often associated with neurodegenerative disorders.

RBD is strongly linked to neurodegenerative diseases, particularly Parkinson's disease, Lewy body dementia, and multiple system atrophy (MSA). These conditions are classified as alpha-synucleinopathies and are considered a subtype of RBD called symptomatic or secondary RBD. The relationship between RBD and Parkinson's disease is well-established, with RBD often preceding the development of Parkinson's by several years. Studies indicate that a significant percentage of individuals diagnosed with RBD eventually develop Parkinson's disease, Lewy body dementia, or MSA.

In addition to its association with neurodegenerative disorders, RBD has also been linked to the use of certain antidepressants, including serotonin reuptake inhibitors and tricyclic antidepressants. This form of RBD is referred to as drug-induced RBD. Additionally, acute forms of RBD can arise during withdrawal from substances such as alcohol or sedative-hypnotic drugs.

The diagnosis of RBD is confirmed through an in-laboratory sleep study (polysomnography) with video recording, which helps identify abnormal behaviors during REM sleep and excludes other sleep disorders. Treatment for RBD focuses on creating a safe sleeping environment and may include medications such as melatonin, clonazepam, or pramipexole to reduce the risk of injury.

RBD is a complex disorder that requires careful management to ensure the safety of both the affected individual and their bed partner. It is also a potential indicator of underlying neurodegenerative conditions, making early diagnosis and treatment crucial.

Diagnosis

REM sleep behaviour disorder (RBD) is a parasomnia, a sleep disorder that involves unusual and undesirable physical events or experiences that disrupt sleep. It is characterised by the physical and/or vocal enactment of dreams during the rapid eye movement (REM) stage of sleep. Those with RBD are often unaware of their actions while asleep and can cause injury to themselves or their bed partner.

To receive a diagnosis of RBD, a person must meet several criteria. These include:

• Repeated episodes of sleep-related vocalisations and/or complex movement behaviours that correspond to what is happening in a dream.
• Episodes occur during REM sleep, as confirmed by an in-laboratory polysomnogram (in-lab sleep study) or clinical history.
• Episodes include sleep without atonia, as confirmed by polysomnography.
• The episodes are not attributed to another sleep or mental health disorder, medication side effects, substance abuse or another cause.

To diagnose RBD, a healthcare provider will ask questions about symptoms and medical history. They may also ask any bed partners or housemates questions about the patient's sleeping behaviour. A physical exam and neurological exam will also be performed, and the patient may be referred to a sleep specialist.

An in-lab video sleep study, or polysomnogram, is required for an RBD diagnosis. Sleep studies test and record specific body functions during sleep, such as breathing rate and airflow, brain wave activity, and muscle movements of the chin and upper extremities.

Treatment

REM sleep behaviour disorder (RBD) is a parasomnia involving dream enactment behaviour associated with loss of atonia during rapid eye movement (REM) sleep. Treatment for RBD is tailored to the individual and can involve a combination of lifestyle changes, medication, and injury prevention techniques.

The primary treatment goal is to reduce the risk of injury to the patient and their bed partners. This may involve lowering the bed, safeguarding any weapons, cushioning or padding sharp surfaces, placing patients in sleeping bags, and separating the sleeping partner from the patient.

Medications used to treat RBD include melatonin, clonazepam, and pramipexole. Melatonin is the preferred first-line medication due to its low risk of side effects. Clonazepam is a long-acting benzodiazepine that has been considered the first-line pharmacological therapy for a long time. Pramipexole is a dopamine agonist primarily prescribed to treat Parkinson's disease and restless leg syndrome.

In addition to these treatments, it is important to address any underlying causes or contributing factors such as antidepressant use, alcohol consumption, or other medical conditions.

Risk Factors

REM sleep behaviour disorder (RBD) is a parasomnia involving dream enactment behaviour associated with a loss of atonia during rapid eye movement (REM) sleep. Predisposing factors that increase the risk of RBD include:

• Elderly age: RBD usually begins after age 50, with an average onset age of 61.
• Male sex: Among people over 50, men are nine times more likely to develop RBD.
• Narcolepsy: RBD has been found in nearly 30% of young individuals with narcolepsy type I.
• Antidepressant use: Certain antidepressants, such as tricyclic antidepressants and serotonin reuptake inhibitors, can trigger RBD.
• Neurological disorders: RBD is strongly linked to neurodegenerative diseases, particularly Parkinson's disease, Lewy body dementia, and multiple system atrophy.
• Substance use: Alcohol and sedative-hypnotic drug withdrawal can trigger an acute form of RBD.
• Traumatic brain injury: Studies suggest a potential association between RBD and traumatic brain injury (TBI).
• Psychiatric disorders: RBD is found to be 5-10 times more likely to develop in patients with psychiatric disorders.
• Other medical conditions: RBD can also be secondary to other medical conditions, such as multisystem atrophy or Shy-Drager syndrome.

Frequently asked questions