REM Sleep Disorder: Why Acting Out Your Dreams Can Turn Into a Nightmare

Middle-aged men are at greatest risk for RBD

REM Sleep Disorder: Acting Out Your Dreams Can Turn Into a Nightmare

“I had the weirdest dream last night!”

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Most of us laugh about the strange scenarios we encounter as we dream our way through REM (rapid eye movement) sleep.

But those dreams are no laughing matter for people with REM sleep behavior disorder (RBD) — or their partners.

A switch in the brainstem

Normally, our bodies are paralyzed during REM sleep (except for our eye muscles and our diaphragm, which allows us to breathe).

But in RBD, “because a switch in the brainstem is no longer immobilizing you, your muscles are free to carry out the actions in your dreams,” says sleep medicine specialist Carlos Rodriguez, MD.

So you act them out — and you may do so with screaming, violence or foul language that are completely out of character.

“Patients can injure themselves diving out of bed into a chest of drawers, running into a wall or hitting a window,” he says.

“They can accidentally strike a bed partner — ironically, while trying to protect them from danger in their dream.”

Who’s at risk for RBD?

RBD is most commonly observed in men over 50 years of age. But RBD can develop earlier in life — even in children.

“In younger patients, RBD is most frequently observed in association with narcolepsy and in patients on antidepressant medications,” says Dr. Rodriguez.

RBD can also accompany other parasomnias, like sleep-related eating disorder, sleepwalking, confusional arousals, sexsomnia and night terrors. When this happens, he notes, men and women are more equally affected, and typically at younger ages.

How RBD differs from night terrors

Sleepwalking or night terrors may look like RBD, but they’re disorders of arousal. Your eyes are open, and although you don’t recall it, you’re somewhat aware of your environment.

“That’s why sleepwalkers can negotiate a path through the bedroom, leave the house or even drive a car,” explains Dr. Rodriguez.

“In REM sleep disorder, the eyes are typically closed, patients do not have awareness of their environment, and they can’t make it too far from the bed.”

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Seizures, sleep apnea (episodes of choking that can partially awaken you during dreams) sleep terrors and post-traumatic stress disorder can also mimic RBD.

Time of night is also a clue

We cycle through each stage of sleep every 90 to 120 minutes, says Dr. Rodriguez. And each time we do, our REM sleep progressively lengthens.

So RBD tends to happen during the last half of the night, while sleepwalking and night terrors tend to occur during the first third of the night.

“If a sleep disturbance occurs within 60 minutes of falling asleep, it’s probably not RBD,” he says.

Only one way to diagnose RBD

The only way to diagnose RBD is with a sleep study. “A prior study geared to diagnose sleep can miss the diagnosis; you need one specifically for RBD,” says Dr. Rodriguez.

Sleep studies allow experts to observe whether or not the muscles are paralyzed during REM sleep. They look for increased muscle tone while the patient is in REM sleep.

What to do if you have RBD

Safety is paramount if you or your partner have REM sleep disorder.

“The most important thing to consider is modifying your sleep environment,” says Dr. Rodriguez. “You have to make the bedroom a safe place.”

Options to try include:

  • Putting your mattress on the floor so you have less distance to fall.
  • Moving furniture away from the immediate vicinity so won’t hit anything if you run or dive.
  • Padding the corners of your bedroom furniture.

“We also want your partner to consider sleeping in another bed, or room, until your REM sleep disorder is under control,” he says.

How RBD is treated

Medications can help with the symptoms of RBD but cannot cure it.

“They can quiet disruptive screaming and keep partners in the same bed, which is a wonderful thing,” says Dr. Rodriguez.

The safest and easiest medicine to tolerate is melatonin. The other commonly used medicine is clonazepam, a benzodiazepine also used to treat anxiety and seizures.

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“Clonazepam is very effective in controlling symptoms, but many patients can’t tolerate its side effects,” he says. These include:

  • Cognitive problems, which may worsen existing memory issues.
  • Unsteadiness, which increases the risk of falls.
  • Worsening sleep apnea, as the drug relaxes the throat muscles.

In addition, says Dr. Rodriguez, some other medications seem to provoke or unmask RBD.

“If a 40-year-old is starting to act out dreams after starting an antidepressant such as venlafaxine (Effexor®), I’ll see if we can switch to an antidepressant that does not aggravate RBD called bupropion (Wellbutrin®). But this solution isn’t for everyone.”

If your medicine helps you, switching may not be in your best interests, he notes.

Be sure to speak up

Many people who act out their dreams don’t tell their doctors, says Dr. Rodriguez.

“Maybe you feel embarrassed, but you have to share this with your physician,” he says.

It’s the only way to keep you and your partner safe — and in the same bed.

In addition, RBD is linked to developing neurodegenerative disorders, most commonly Parkinson’s disease, Lewy body dementia and multiple system atrophy.

Researchers are working hard to develop early diagnostic tests and drugs that might protect the brain.

“If researchers can identify a drug that’s neuroprotective, we may be able to slow, arrest or prevent further deterioration,” he says.

It will be good for your doctor to know you may be a candidate when such tests or drugs become available.

 

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