REM Sleep Behavior Disorder

Dreams are one of the mysterious happenings in the world and is still being studied by experts, but dreams appear differently during REM sleep behavior disorder. Let me tell you about this odd disorder.

REM Sleep behavior disorder is when people “act out” their dreams. For example, people with this condition this may “sleep talk” or for rare cases, “sleepwalking” may also occur.

This condition apparently occurs when there is a loss of normal voluntary muscle atonia during REM sleep which leads to uncontrolled motor behavior responding to the person’s dreams.

Rapid eye movement behavior disorder occurs when there is a loss of normal voluntary muscle atonia during REM sleep resulting in motor behavior in response to dream content.

It is categorized among other parasomnia which may be confused for other sleep disorders. The condition is classified as either idiopathic or symptomatic.

Idiopathic REM sleep behavior disorder is the term used when disease is not associated with another ongoing neurological condition.

Most people with the disorder will convert to a synucleinopathy—usually Parkinson’s disease or dementia with Lewy bodies—within 4 to 9 years from diagnosis of this condition, and 11 to 16 years from onset of symptoms.

When the condition is caused by an specific, underlying illness, REM sleep behavior disorder is referred to as symptomatic REM sleep behavior disorder and becomes considered a symptom of the underlying disorder.

Up to almost 92% of patients with idiopathic REM sleep behavior disorder will go on to develop a neuro-degenerative disorder.

The disorders most strongly associated with RBD are the synucleinopathies, particularly Parkinson’s disease, dementia with Lewy bodies, and to a lesser extent, multiple system atrophy.

During the REM stage of our sleep or “dreaming sleep” stage, there are nerve pathways inside our brains that prevent muscles from moving.

However, with the REM sleep behavior disorder, those nerve pathways become disabled, causing a person to move without being restricted by the brain and unconsciously act out their dreams.

Dreams become vivid or completely detailed for people with this disorder.

These dreams often involve screaming, shouting, laughing, crying, arm flailing, kicking, punching, choking, and even jumping out of bed. The actions in an episode can result in injuries to oneself or one’s bed partner.

It is believed that violent dreams tend to be easily recalled by patients and act it out since it contains more impact than regular, non-violent dreams.

When having an episode, some people are forced to stay away from their affected bed partner to avoid unwanted injuries caused by the unconscious person.

Normally, once the person with the condition awakens, they are not aware of what happened but they are aware of what was happening in their dream.

For a normal sleep cycle, REM sleep may be experienced at intervals of between 90 minutes and two hours every night, which means REM sleep behavior disorder episodes may occur up to four times a night.

Episodes occur more towards the morning hours because that is when REM sleep is more frequent.

When awakened, people can usually recall the dream they were having, which will match the actions they were performing during sleep.

In a rare case, the episodes may only happen once a week or once a month.

The prevalence of this condition as of 2017 is estimated to be 0.5–2% overall, and 5–13% of those aged 60 to 99, but as times change, these numbers are constantly changing.

It is more common in males overall, but equally frequent among men and women below the age of 50. As of today, 2019, more women are now being diagnosed with this disorder, especially those under age 50.

This may partially be due to a referral bias, as violent activity carried out by men is more likely to result in harm and injury and is more likely to be reported than injury to male bed partners by women.

It’s also possible that it may reflect a true difference in prevalence as a result of genetic or androgenic factors. Typical onset is in the 50s or 60s.

Young adults and children can also develop the disorder, usually in association with narcolepsy, antidepressant use or brain tumors.

Symptoms

Usually, symptoms of REM sleep behavior disorder may begin years or decades before other the onset of another condition.

Signs that you might have REM Sleep Behavior Disorder:
- Strange behavior during sleep
  - Talking, screaming, cursing, shouting, laughing, crying, arm flailing, kicking, punching, choking, and jumping out of bed during sleep
- Having vivid dreams about violence or an attack, or chase
  - Being able to clearly recall the details of the dream where an episode of the disorder possibly occurred is a strong sign of REM sleep behavior disorder.
- Sleep walking
- Reduced motor abilities
- Changes to postures such as walking, sitting or standing
- Mild cognitive impairment
- Altered sense of smell
- Color vision impairments
- Sexual dysfunction
- Depression
- Sleep deprivation
- Interrupted sleep
- Parkinson’s disease
  - Half of those with Parkinson’s disease, about 88% of them are also diagnosed with REM sleep behavior disorder.
- Dementia
  - About 80% of people with Lewy body dementia have REM sleep behavior disorder.
- Narcolepsy
  - A long term neurological disorder that involves a decreased ability to regulate sleep-wake cycles.
- Guillain Barre syndrome
  - A rapid-onset muscle weakness caused by the immune system damaging the peripheral nervous system.
- Limbic encephalitis
  - A form of encephalitis, a disease characterized by inflammation of the brain.
    
    Limbic encephalitis is caused by autoimmunity: an abnormal state where the body produces antibodies against itself.
- Morvan’s syndrome
  - A rare autoimmune disease that causes multiple, irregular contractions of the long muscles, cramping, weakness, pruritus, hyperhidrosis, insomnia, and delirium.

Please keep in mind that some of the signs here include several other diseases or conditions that may cause REM sleep behavior disorder or become worsened by it.

Causes

It is a fact that the underlying cause of REM sleep behavior disorder is not fully understood, but it is becoming quite possible that it is a symptom of other developing diseases.

Here is a list of possible causes to REM sleep behavior disorder.

Loss of voluntary normal muscle atonia
Using specific drugs
Alcohol abuse
Drug withdrawal effect
Shy-Drager syndrome
Damaged brain stem
Hereditary, genetics
An old head injury
Exposure to pesticides
Depression
Using antidepressants
Trauma
Age
Narcolepsy
Parkinson’s disease
Lewy body dementia
Multiple system atrophy
Other neurological degenerative disorders

REM Sleep behavior disorder shows that 55% of people are revealed to be diagnosed with an unknown cause.

45% people on the other hand, are diagnosed with the condition with cause associated alcohol or sedative-hypnotic withdrawal, using antidepressants such as imipramine or serotonin re-uptake inhibitor use.

There has been studies of animals that may explain REM sleep behavior disorder.

Animals that have suffered lesions in the brain stem have exhibited symptoms similar to the REM sleep behavior disorder.

Apparently, cats with lesions affecting the part of the brain stem that involves the inhibition of locomotive activity will have motor activity during REM sleep.

The animals will arch their backs, hiss, and bare their teeth for no reason while the waves inside their brain registers normal REM sleep.

Diagnosis

There are only two ways to properly diagnose REM sleep behavior disorder.

One is by documenting a history of complex, dream-enactment sleep behaviors and the second way is by conducting a sleep study or “polysomnography”

A sleep study will need patients to sleep over at a sleep center or allow technicians and doctors to observe their sleep behaviors at night.

Since most patients are not aware of their dream enacting episodes, it is common for their partners or anyone close to them to be asked for details by doctors.

(Related: “How to Do a Sleep Study?”)

Differential Diagnosis

There are other conditions that may be confused with or should be differentiated from REM sleep behavior disorder.

Other sleep disorders may also display strange or violent behaviors but it is not the same disease.

Here are some common conditions that are often mistaken for REM sleep behavior disorder.

Sleepwalking (Non-REM)
- Sleep walking in REM and Non-REM are two different things. Non-REM sleep walking is a whole new, different sleeping disorder.
Sleep terrors
Periodic limb movement disorder
Restless leg syndrome
Severe obstructive sleep apnea
Dissociative identity disorder

Treatment

REM sleep behavior disorder can actually be treated, despite the fact that we still do not fully know its real cause.

Medication for REM Sleep Behavior Disorder
1. Melatonin
2. Clonazepam
3. Tramadol
4. Mirtazapine
5. Antidepressants
6. Beta blockers
Lifestyle changes for better sleeping quality
1. Follow a proper sleep schedule
2. Eat a healthy, balanced diet
3. Try to exercise regularly
4. Stay hydrated
5. Avoid horror movies before bed
6. Limit alcohol consumption before bed
7. Limit or avoid smoking nicotine before bed
Other options for improving patient’s quality of life
1. Healthy environment
2. Remove dangerous objects
3. If trauma is present, avoid triggering the trauma events
4. Keep a soft cushion around the bed
5. Consider moving the mattress to the floor
6. Some patients sleep with sleeping bags or wear mittens

Risks

There are plenty of risks for those who have REM sleep behavior disorder. Though most of it can be “minimal”, there’s no denying that they can be prone to accident if things don’t go well.

Inflicting physical injuries on one’s self
Potentially attacking other people
Risk of death by accidents
Restless nights of sleep
Unconscious depression
Uncontrolled weight gain
Worsening other conditions
Inviting other illnesses
Anxiety
Instigating fear or distress for your family

REM sleep behavior disorder also often precedes the development of certain neurodegenerative diseases by several years.

In one study, 38% of patients diagnosed with REM sleep behavior disorder subsequently developed Parkinson’s disease within an average time of 12 to 13 years from the onset of REM sleep behavior disorder’s symptoms.

It is also a fact that REM sleep behavior disorder is seen in 69% of people with Parkinson’s disease and multisystem atrophy. This number may change prior to time.

The link between REM sleep behavior disorder and Parkinson’s disease is still complex, but not all those who develop REM sleep behavior disorder also get diagnosed by Parkinson’s disease.

History

The first ever report possibly describing the REM sleep behavior disorder was way back 1960s and 1970s, when Michel Jouvet described brain lesions in cats that led to loss of atonia in REM sleep.

According to research, the first series of cases of REM sleep behavior disorder was described by two different personalities. They are Mark Mahowald, MD and Carlos Schenck, MD, of the University of Minnesota.

In 1985, they outlined several case histories of people with REM sleep behavior disorder in “Principles and Practice of Sleep Medicine” published by W.B Saunders, Company 2000.

The cases were reported as the following.

“A 77-year old minister had been behaving violently in his sleep for 20 years, sometimes even injuring his wife”
“A 60-year old surgeon would jump out of bed during nightmares of being attacked by criminals, terrorists and monsters”
“A 62-year old industrial plant manager who was a war veteran often dreamed of being attacked by enemy soldiers and fights back in his sleep, sometimes injuring himself.”
“A 57-year old retired school principal was inadvertently punching and kicking his wife for two years during vivid nightmares of protecting himself and family from aggressive people and snakes”
— Principles and Practice of Sleep Medicine (W.B Saunders, Company 2000)

Sleep Cycle

To understand the REM Sleep Behavior Disorder much better, understanding the sleep cycle can definitely help. There are 4 stages that we will enter as we sleep.

The first 3 stages are the “Non-REM” sleep while the 4th stage is the REM sleep.

Stage 1
- The lightest stage of the non-REM sleep and is often defined by the presence of slow eye movements. This stage can be easily disrupted which may cause awakening or arousal.
  
  Some people may experience hypnic jerks or abrupt muscle spasms or even feel the sensation of “falling” when drifting in and out of the first stage.
Stage 2
- Stage 2 is the first actual stage of defined non-REM stage and sleep cannot be easily interrupted at this point.
Stage 3
- This stage is known as the deep non-REM sleep and is the most restorative stage of sleep. It consists of delta waves or sleep waves.
Stage 4
- The final stage is the rapid eye movement stage and commonly referred to as the “dreaming stage”. Eye movements are rapid, moving from side to side.
  
  Unlike the non-REM stages, awakenings and arousal can actually occur easier in REM stage but waking at this point can leave the person feeling excessively sleep.