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What Is Rem Sleep Behavior Disorder

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What Is Rem Sleep Behavior Disorder

Violent dreams: Diagnosing REM sleep behavior disorder

REM sleep behavior disorder is a condition characterized by sudden body movements and vocalizations while a person experiences vivid dreams during REM sleep. It is a specific type of parasomnia, which describes abnormal behaviors during sleep.

During normal REM sleep, the body experiences temporary muscle paralysis, known as atonia, while the brain shows activity similar to wakefulness. Blood pressure rises, breathing becomes irregular, and the eyes dart in all directions rapidly . The temporary paralysis of REM sleep allows us to dream safely, lying still while the brain is active. This paralysis involves most skeletal muscles and excludes muscles that help us breathe, digest, and some muscles of the eyes. REM sleep accounts for about 25 percent of a total nights sleep, with most of it taking place during the second half of the night.

For individuals with REM sleep behavior disorder, normal muscle paralysis does not occur, enabling the person to physically act out their dreams. REM sleep behavior disorder can manifest as small muscle twitches and quiet sleep talking to loud shouting, punching, kicking, grabbing their bed partner, and jumping out of bed. Interestingly, the dreams associated with REM sleep behavior disorder are often intense and frightening. Individuals may dream about being chased or attacked, and they can unknowingly enact the dream in real life.

Enhancing Healthcare Team Outcomes

Sleep behavior disorder is often difficult to diagnose and manage. Thus, it is best managed with an interprofessional team that includes mental health nurses. The primary goal of treatment is to provide patients with a safe sleeping environment for them and their bed partners. Healthcare professionals can achieve this through non-pharmacologic approaches and pharmacotherapy if needed. It is important to counsel patients and their bed partners on avoidance of potentially hazardous and injuries objects near the patients, for example, firearms or glass objects. Bed partners should be educated on the disease, and the patients enactments during dreams are not under voluntary control.

How Should Clinicopathologic Studies Be Performed In Patients With Rbd

It is imperative to plan for autopsy in any willing individual with iRBD as well as those with RBD associated with any neurodegenerative disease. Ideally, performing detailed histologic examinations in those who had PSG-proven RBD and those who had no history of RBD-like behavior and had PSG confirming normal EMG atonia during REM sleep, will be most informative.

There are many challenges to studying tissue to determine which are the key populations of neurons +/- glia that are critical to RBD pathophysiology. Whether the brainstem networks involve the nuclei proposed in the RBD pathophysiology scheme as shown in and , or others in combination with these nuclei, or other nuclei completely different than those proposed, needs to be examined. Stereologic studies which involve neuronal count quantification, while certainly very laborious, are likely to be informative. Yet some of the brainstem nuclei have unclear borders, or they span a convoluted area of tissue which complicates the technical aspects of quantifying multiple nuclei.

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Myth #: Rbd Is Primarily A Psychiatric Condition

Fact: RBD is a neurological condition recognized by medical and mental health professionals.

People may mistakenly think that REM sleep behavior disorder is mainly a mental health issue because it has to do with disrupted sleep caused by dysfunction in the brain. The myth is likely reinforced by the conditions inclusion in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition by the American Psychiatric Association .

In actuality, the DSM-5 contains many physical health and mental health disorders, especially when physical health disorders connect to psychological symptoms like depression and anxiety. The DSM-5 lists many sleep-wake disorders including:

  • Insomnia
  • Restless leg syndrome
  • REM sleep behavior disorder

No one would likely consider narcolepsy and restless leg syndrome firstly as psychiatric conditions, so the same standards should apply to RBD. RBD is a neurological condition, not a psychiatric condition.

When a person is in REM sleep, the brain is supposed to shut down muscles to prevent movement. In REM sleep behavior disorder, these nerve pathways do not function properly, resulting in unwanted and unexpected movements.

Myth #: Rem Sleep Behavior Disorder Is Difficult To Treat

Study tree of the MSA patients. RBD = REM sleep behavior ...

Fact: Treatment for RBD is effective and accessible.

People may think that REM sleep behavior disorder is difficult to treat because the condition appears so complex and multifaceted. This belief is completely false.

As far as neurological conditions go, RBD is simple to treat. Before the treatment begins, a person with symptoms of a sleep disorder needs a proper diagnosis.

A formal sleep study is an essential part of the diagnostic process since a number of sleep issues could produce symptoms that overlap with REM sleep behavior disorder. Without a sleep study, people may confuse RBD with:

  • Other sleep issues like non-REM disorders
  • Nocturnal seizures
  • Sleep apnea

Once the specialist finds the proper diagnosis, treatment may begin. REM sleep behavior disorder treatment frequently focuses on the use of a medication called clonazepam to address symptoms. Clonazepam, sold under the brand name Klonopin, effectively reduces or eliminates symptoms of RBD in 90% of cases.

When Klonopin is not helpful, people may use antidepressants or a melatonin supplement to treat REM sleep behavior disorder. These options can reduce aggression and violence during the night.

Regardless of the treatment effectiveness, someone with RBD should consider making their bedroom as safe as possible. They should set up some RBD safeguards like:

  • Padding the area around the bed
  • Removing sharp or dangerous items
  • Protecting the windows
  • Reducing obstacle in the bedroom
  • Sleeping alone

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Myth #: People With Rbd Cant Remember Their Dreams

Fact: Upon waking, people with RBD can clearly recall the dream details.

This myth may be another example of REM and non-REM sleep disorder confusion. People with non-REM disorders cannot remember the dreams connected to their behaviors because there are no associated dreams.

According to the DSM-5, there are two main types of non-REM sleep arousal disorders: sleepwalking and sleep terrors. Sleep terrors, often called night terrors, involve a person exhibiting a scared or panicky reaction during a period of sleep.

During a sleep terror, the person will display signs of:

  • Dilated pupils
  • Quick breathing
  • Sweating

Episodes last for a few minutes, and the person may never truly wake during a night terror. In the morning, they will have no memory of the event or a triggering dream. Amnesia is a central feature of non-REM sleep disorders because dreams do not create these episodes.

Someone with REM sleep behavior disorder will almost always remember their dreams. Since the episodes occur during the dreaming part of sleep, the people, location and content of the dream stay fresh in the persons mind when they awake.

Who Gets Rem Behavior Disorder

The presence of neurological disorders have shown to increase the risk of RBD by as much as 50%, including parkinsons disease and multiple system atrophy, and RBD in people without these disorders could indicate an increased risk of developing them in the future. Other factors that influence the intensity of REM sleep may also play a role in RBD rates, including alcohol consumption or withdrawal, strokes, brain tumors, sleep deprivation, and medication use. In the case of alcohol or medication use, RBD may only be acute, rather than chronic as it is in most other cases.

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Treating Rem Sleep Behavior Disorder And Co

Frequently, RBD co-occurs with drug and alcohol addictions and other mental health conditions, such as depression and anxiety. Since these conditions can aggravate RBD, they need to be treated at the same time, which is a treatment approach known as dual-diagnosis care.

The treatment for these conditions may vary, and can include medications and psychotherapy. However, since certain medications, such as some classes of antidepressants, can make RBD symptoms and ultimately depressive symptoms worse, care must be taken to treat these other disorders in ways that do not worsen RBD.

Substance abuse can often lead to sleep disorders such as RBD. If you or a loved one are struggling with alcohol or drug dependence and poor sleep, specialized help is available. Contact The Recovery Village today to learn about how our co-occurring disorders treatment can help you.

What Role Does Video Play In The Diagnosis Of Rbd

REM Sleep Behavior Disorder

During the past decade, numerous authors have concerned themselves with the analysis of video recordings of RBDpatients. Video analysis methods ranged from description only to a severity classification . To the best of our knowledge, the first study on this topic wasperformed by Emilia Sforza in 1988 . Over the past 10 years, our grouphas also worked on video classification of motor events in RBD patients . We were able to show that even among patients with severe RBD, the majority of motor events are very small elementary movements. The far better-known dramatic, violent behaviors are comparatively rare, even in severe RBD, and should as such be interpreted as the proverbial tip of the iceberg. Furthermore, we were able to demonstrate that the majority of elaborate and violent motor events were initiated during REM sleep with rapid eye movements , such that one can speak of a gating function of REM sleep with rapid eye movements. Simple myoclonic background jerking is, however, observed during the entire phase of REM sleep.

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Analyses In Patients With Rbd Plus Parkinsonism And/or Dementia

The major clinical syndromes and histopathologic disorders which cause dementia and/or parkinsonism are shown in . As shown in this figure, numerous cases of RBD have been reported in association with certain neurodegenerative disorders, but not reported to date in association with most others. RBD is frequently associated with clinically-diagnosed Parkinson’s disease,, , -, , , , , , – dementia with Lewy bodies,, , , , , – and multiple system atrophy., , , , , , – Pure autonomic failure has also been reported., RBD was identified in several members of a kindred with a parkin mutation, and Lewy body disease pathology has been reported in a different large kindred with parkin mutations. Many of the cases described in the reports noted above have had postmortem examination, and all such cases have had Lewy body disease or MSA confirmed at autopsy.

The clinical syndromes and histopathologic disorders associated with each proteinopathy in the major neurodegenerative disorders which cause dementia and/or parkinsonism. Those syndromes and disorders which are commonly associated with REM sleep behavior disorder are shown in red, and those which have been rarely associated with RBD are shown in blue. Those syndromes and disorders associated with RBD in which at least 1 pathologically-verified case has been identified are in italics. Those in black print have not been reported in association with RBD.

What Treatments Are Available For Rem Sleep Disorder

Once you receive a diagnosis, there are several options for REM sleep behavior disorder treatments, including both behavioral approaches and medication. First, you should modify your sleeping area to reduce the chances of injury.

  • Remove any potential hazards, such as glass objects and bedside furniture
  • Consider a zipped up sleeping bag to reduce limb movement
  • Add bed rails or another barrier to the sides of your bed
  • Pad the floor next to your bed
  • Install a customized bed alarm to interrupt RBD episodes
  • Place your mattress directly on the floor

Your doctor may suggest switching or stopping antidepressant treatment as certain medications can make RBD symptoms worse . Severe symptoms may also require medication. Melatonin is usually the first-line treatment. However, its imperative not to make any changes to your medication or attempt to self-medicate for this disorder without speaking to your sleep physician.

Its important to educate your sleep partner on the nature of RBD and its symptoms. If your symptoms are severe, you and your partner can consider sleeping separately. There is no cure for RBD, but with the right treatment, you can ensure a safe, comfortable sleeping environment for you and your sleep partner.

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Rem Sleep Disorder Symptoms

The main symptom of REM sleep behavior disorder is dream-enacting behaviors, sometimes violent, causing self-injury or injury to the bed partner.

The dream-enacting behaviors are usually nondirected and may include punching, kicking, leaping, or jumping from bed while still asleep.

The person may be awakened or may wake spontaneously during the attack and vividly recall the dream that corresponds to the physical activity.

Rem Sleep Disorder Causes

REM Sleep Behavior Disorder Gets a Textbook: Carlos H ...

    The exact cause of REM sleep behavior disorder is unknown, although the disorder may occur in association with various degenerative neurological conditions such as Parkinson disease, multisystem atrophy, diffuse Lewy body dementia, and Shy-Drager syndrome. In a majority of persons the cause is unknown, and in the other half, the cause is associated with alcohol or sedative-hypnotic withdrawal, tricyclic antidepressant , or serotonin reuptake inhibitor use or other types of antidepressants .

    RBD often precedes the development of these neurodegenerative diseases by several years. In one study, 38% of patients diagnosed with RBD subsequently developed Parkinson disease within an average time of 12-13 years from the onset of RBD symptoms. The prevalence of RBD is increased in persons with Parkinson disease and in multisystem atrophy where it is observed in 69% of these patients. The relationship between RBD and Parkinson disease is complex however, not all persons with RBD develop Parkinson disease.

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    Rem Sleep Behavior Disorder Symptoms

    REM sleep behavior disorder symptoms can include:

    • Minor movements of the limbs
    • More pronounced body movements such as punching, flailing, kicking, sitting up in bed, or jumping out of bed
    • Vocalizations including talking, yelling, or screaming

    People arent aware of these behaviors during episodes, and in fact, many people only find out that they have REM sleep behavior disorder when they are told about their symptoms by a bed partner or roommate.

    When a person is having an episode, they can usually be awoken relatively easily. When they wake up, they are usually alert, coherent, and can recall the content of the dream.

    REM sleep usually begins about 90 minutes after you fall asleep, and REM sleep stages get longer in the second half of the night. For that reason, episodes of REM sleep behavior disorder frequently arise later in a sleep period.

    Episodes can occur once or multiple times during the night. People may experience them a few times per year or every night. REM sleep behavior disorder can develop suddenly or gradually, but symptoms typically worsen over time.

    Polysomnographic Characteristics Of Normal Rem Sleep

    The REM stage of sleep is normally characterized by low voltage intermixed frequency EEG waves, rapid eye movements, and markedly decreased skeletal muscle tone . REM sleep is also called paradoxical sleep where EEG is desynchronized. On polysomnographic monitoring, REMs are characterized as irregular sharp conjugate eye movements with initial duration < 500ms. Saw-tooth waves form a distinctive pattern occurring in REM sleep, which are temporally associated with REMs. They are triangular waves with frequency of 2-6 Hz with maximum amplitude in central leads . An example of a 30-sec epoch of REM sleep is shown in Figure 1A.

    Figure 1: A) Polysomnographic recording of normal REM sleep in a 30 second Epoch. Saw tooth waves are encircled in red. Orange arrow is pointing at rapid eye movements and blue arrow demonstrates suppressed chin EMG tone. B) A 30 second Epoch demonstrates sleep spindles most prominent in central leads, denoted by blue arrow recorded in N2 sleep stage.

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    Exams And Tests For Rem Sleep Disorder

    Neurologic examination

    The neurologic examination is often normal. However, symptoms and signs of Parkinson disease, such as hand tremor at rest, slowness in movement, and muscle stiffness that may suggest an underlying neurologic cause of REM sleep behavior disorder , should be considered.


    Polysomnographic video recording is the single most important diagnostic test in persons with RBD. This test is usually conducted in a sleep study center. The person undergoing testing is required to sleep at the center while the following parameters are monitored:

    • Electrical activity of the brain
    • Electrical activity of the heart
    • Movements of the muscles
    • Eye movements
    • Respiratory movements

    These parameters are monitored as the person passes through the various sleep stages. Characteristic patterns from the electrodes are recorded while the person is awake and during sleep. Continuous video recording is done to observe behaviors during sleep. It is important to rule out other causes of REM sleep disturbance including conditions such as obstructive sleep apnea . OSA can cause a person to have restless sleep but the sleep should not be violent. Another condition noted first on laboratory sleep study in REM without atonia which may be a mild form or precursor to RBD in some patients.

    Additionally, the video recording shows body movements coinciding with the EEG pattern of REM sleep.

    Imaging studies

    How To Diagnose Rem Sleep Behavior Disorder

    51 What is REM sleep behavior disorder

    RBD is a disorder that can get worse over time. This can put you or your bed partner in danger. RBD also tends to be linked to other medical problems. You should seek a sleep doctors advice if you suspect that you might have RBD.

    The doctor will ask you about your medical history. Your family history may also provide important details. The doctor should do a full exam. This should include a neurologic exam. You may be asked to complete a sleep diary. This will monitor your progress before and after treatment. You may be asked to rate your sleep with a simple questionnaire. This will help show how your sleep is affecting your daily life. Be sure to inform the doctor of any past or present use of any of the following:

    • Drugs
    • Alcohol
    • Medications

    Also, tell the doctor if you have ever had any other sleep disorder. You may also need to see a neurologist.

    Tests may be needed if your medical exam shows something abnormal. People with RBD are at risk for other sleep disorders. As a result, you will likely need a sleep study. This study is called polysomnography. It charts your brain waves, heartbeat, and breathing as you sleep. It also records how your arms and legs move. This shows if there are other disorders that are related to your sleep problems. Examples of these disorders include sleep apnea and periodic limb movement disorder. The best sleep study will also record your sleep on video. This will show if you get out of bed and do anything unusual during the night.

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