20 May REM sleep behavior disorder – dreaming in 4D
Who doesn’t like to dream? Fantasizing, travelling to other worlds, having super powers, spending time with loved ones who are no longer with us… Dreaming makes the impossible possible. However, not everyone experiences dreams in the same way, like people with REM sleep behavior disorder (RBD).
REM: rapid eye movement,
refers to the stage of sleep where the most vivid dreams occur.
refers to the stage of sleep where the most vivid dreams occur.
What is REM sleep behavior disorder?
When you dream, everything you see and feel is all created in your mind and no matter what may be happening in your dream, you remain still. However, this is not the case for people with REM sleep behavior disorder, as when they dream, they experience episodes of:
- Physically moving their limbs, or even standing up and carrying out activities associated with waking
- Talking, shouting, hitting or punching
- Jumping out of bed
- Screaming, crying or moaning (incomprehensible)
- Depending on the dream, they may be rude, have an angry expression, or even laugh or sing
- Very vivid dreams
Although this may seem exciting, this disorder can be dangerous, since the person could injure themselves while unconscious or end up injuring the person they are sharing a bed with.
In general, the dreams that they experience are more like nightmares. For example, they may dream that they are being assaulted, chased, attacked by an animal, caught up in an argument or fight or falling off a cliff… generally distressing scenarios.
Their dreams can be associated with familiar scenarios or, in some cases, even be comical, of a sexual nature, or food-related.
The 3 phases of sleep
In order to understand what RBD is, you need to know how sleep progresses through the 3 stages:
- Wakefulness (when you are still awake)
- Rapid eye movement (REM) sleep
- Non-rapid eye movement (NREM) sleep
RBD occurs during the REM phase of sleep, which starts 90 minutes after falling asleep. In this phase, brain activity is similar to that produced when you are awake. REM sleep is characterized by temporary muscle paralysis.
In the case of RBD, it is harder to tell when one phase ends and the other begins, as characteristics of one stage carry over, or “invade”, the others. It is believed that this happens because the neurological “barriers” that separate the different phases of sleep do not function properly, although the cause of such occurrences has yet to be proven.
People with RBD do not experience muscular paralysis during the REM stage of sleep like most people, which allows them to act out action-filled dreams by talking, twitching, moving and even sleepwalking.
Episodes of RBD tend to occur in the early hours of the morning when REM sleep is more common.
An episode of RBD may occur with each phase of REM sleep and a person may experience 4 episodes per night. They may only occur once a week or in some cases, just once a month.
How do you know if you have REM sleep behavior disorder?
Usually, other people will notice this behavior while you are sleeping. They may notice you move around a lot when you sleep, or sometimes hit them without realizing. For this reason, this type of disorder can often have a negative impact on relationships.
It is harder to tell if you sleep alone. However, unexplained bruises and injuries, feeling exhausted in the morning, moving objects without realizing, or finding that your bed is a mess when you wake up, can all be signs that you have RBD.
Unlike sleepwalking, people with RBD have their eyes closed when they exhibit abnormal behavior while they are sleeping.
Below, are some risk factors that may increase your chances of developing a REM sleep behavior disorder:
- It can affect men and women at any age, but it is more common in men above the age of 50
- Having other sleep disorders like narcolepsy
- Taking medication for depression
- Having a brain tumor
- Suffering from a neurodegenerative disorder (Parkinson’s, multisystem atrophy, stroke or Lewy body dementia)
- Heavy use of medication, narcotics or alcohol
- Withdrawal from alcohol and narcotics
A characteristic symptom of this disease is that, upon waking, patients can recall the content of their dream but not the sleep-related events.
A concern for those with RBD is that 80% of cases suffer from dementia or Parkinson’s.
According to researcher John Peever of the University of Toronto, changes in sleep behavior may be a warning sign for certain degenerative neurological diseases like Parkinson’s, multisystem atrophy and Lewy body dementia, among others.
Therefore, if you suspect that your sleep is not as deep as it should be, you should talk to your doctor.
Can REM sleep behavior disorders be treated?
Although this disorder cannot be cured, the good news is that RBD can usually be treated successfully. But first, it is important that you see your doctor to obtain a proper diagnosis and ensure that what you have really is a sleep disorder.
The diagnostic criteria established in 2005 by the American Academy of Sleep Medicine are as follows:
- Presence of REM sleep without reduced muscle tone (atonia), or a constant or intermittent increase in muscle activity in the limbs or chin.
- At least one of these two:
- You notice that you move a lot or frequently during sleep and these movements cause injuries.
- Abnormal behavior during REM sleep detected during a polysomnography.
Polysomnography: a study carried out while you are sleeping to detect any abnormal muscle movements, evaluate brain activity, breathing quality and how often you wake up during the REM phase of sleep.
Other diseases must be ruled out before treating the patient for RBD :
- REM-sleep epilepsy
- Non-REM parasomnias (confusional arousals, night terrors and sleepwalking)
- Periodic leg movements
- Recurring sleep paralysis
- Hallucinations in patients with neurodegenerative diseases
- Post-traumatic stress disorder
- Symptoms cannot be explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.
The polysomnography could reveal an absence of brain activity that triggers a seizure and point to disorders other than RBD that could be causing movements during sleep. In the case of a diagnosis of REM sleep behavior disorder, it should be treated with medication when:
- There is a risk of injury
- The patient is deeply affected by their nightmares
- Movements during sleep are affecting their bed partner
Patients with milder symptoms do not require treatment
Certain drugs can be used to reduce movement during this phase of sleep, such as clonazepam. However, these drugs can result in side effects such as confusion in older people, daytime drowsiness and, occasionally, medication abuse.
Some studies have shown that high doses of melatonin are effective for treating this disorder. Melatonin is a hormone with many functions, including regulating the sleep-wake cycle.
This disorder has also been treated using pramipexole, a dopamine (a neurotransmitter related to emotions) agonist, in cases of chronic disorders and to prevent chronic degenerative conditions, but the results remain inconclusive.
The goal… Sleeping safe and sound
In addition to taking any medication prescribed to you by your doctor, you can also improve symptoms of RBD by:
- Making your sleeping environment safer, moving the bed away from other furniture or any sharp/breakable objects to prevent possible injuries
- Sleeping alone until your sleep movements subside
- Padding corners of furniture
- Installing padded bed rails to prevent you from falling out of bed during REM sleep, or placing cushions on the floor
- Closing or locking your bedroom door, so that it is more difficult to open and closing any windows to stop you from falling out if you sleepwalk.
If you tend to wake up suddenly in the middle of the night, either sitting bolt upright or jumping out of bed, and feel exhausted the next day, talk to your doctor. As we mentioned earlier, this condition can be related to neurodegenerative diseases like Parkinson’s, which should be treated as quickly as possible.
Sleep disorders should be taken very seriously and require proper treatment. For more information on other sleep disorders and how to prevent them, visit:
Breakdown in REM sleep circuitry underlies REM sleep behavior disorder [John Peever, 2014]
Melatonina para los trastornos del sueño [Javier Garjón Parra, 2014]
Trastorno de conducta durante el sueño REM [MF. Sellés Galiana y MM. García Navarro, 2007]
El trastorno de conducta del sueño REM [Alex Iranzo de Riquer, 2013]