We all have vivid dreams from time to time and sometimes it may feel so real we could swear it was, but rarely do we ever actually act out our dreams while we are having them. In some cases, an individual may do just that and now we are realizing that this may be a sign of neurologic problems to come later in life.
Rapid eye movement sleep behavior disorder is a sleep disorder in which a person acts out their dreams while they are asleep showing bizarre and often dangerous behavior. The common presenting complaint is a person with concern for acting out violent vivid dreams. Behaviors are usually non-directed and random and may include, kicking, punching, screaming out or even running from the bed while in REM sleep. There have been examples of harm such as a man who dreamt that he was rescuing his wife from an attacker, however, he himself was striking her. Some RBD individuals have been known to strangle their bed partners. The person can be wakened or may spontaneously awaken during an attack and be able to recall the dream vividly that corresponded to their physical actions. This is very different from sleep walking which is much more common, especially in children, and occurs during non-REM sleep. Imbedded in this article is a link to video of a person with RBD giving a simple video example of the illness.
REM sleep behavior disorder predominantly affects older men and may be the first sign of a neurodegenerative disorder such as Parkinson’s disease. Rapid eye movement sleep behavior disorder or RBD is seen in older men, usually older than 60, and involves a lack of atonia with REM sleep. Normally, when we are in REM sleep our body goes into a state of atonia (paralysis) so that we do not act out our dreams. This atonia results from a complicated inhibition of pathways in the central nervous system at the level of the spinal motor neurons. In RBD this atonia is inhibited and there have been cases of severe injury to the afflicted person or their bed partners. Several studies suggest that idiopathic RBD is a potential marker for the later development of neurodegenerative disorders characterized by alpha-synuclein deposition including Parkinson’s disease, multiple system atrophy, dementia with Lewy bodies, and pure autonomic failure.
The prevalence of RBD is 0.38%-0.5% in the general population. Prevalence is much greater in men than women with only approximately 13% of cases in women. Prevalence is greater in patients with psychiatric disorders, possibly related to medications prescribed for psychiatric disorders that affect pathways and neurochemicals in which RBD has in common. RBD can be associated with some psychiatric medications. Risk for the disorder increases after the sixth decade of life but can occur at any age including childhood, though very rare in kids.
Prognosis depends on the cause of RBD with idiopathic RBD well controlled with therapy. This is distinct from secondary RBD which has been seen in vascular disorders, brainstem cancers, and autoimmune/inflammatory diseases and prognosis in these cases is related to the primary causal disorder. In RBD a person may experience serious injury but more often than that is the bed partner of RBD afflicted individuals being seriously injured when they are assaulted by the person with RBD in their sleep. 30% of individuals with narcolepsy may also have RBD. When comorbid with narcolepsy, RBD is then seen often at earlier age and in a closer to 50% male/female ratio.
Treatment of idiopathic RBD is highly effective in 90% of RBD patients with low dose Clonazepam with little evidence of tolerance to drug. However, symptoms promptly return with discontinuation of medication in nearly all who stop therapy, so treatment should be continued indefinitely. An important aspect of treatment of RBD individuals is environmental safety. Potentially dangerous items should be removed from the bedroom and sometimes it is best to place the mattress on the floor or a mat around the bed to reduce injury from a fall.
Because there appears to be a strong relationship with neurodegenerative disorders such as Parkinson’s disease etc. a neurologist consultation early in the disease evaluation should be considered. Careful follow-up is recommended for patient with family counseling and potential consideration of neuroprotective trials on a case by case basis.
