Do you also struggle in your sleep? Do you scream? Let's learn about REM Sleep Behavior Disorder (RBD)!

Has your partner or someone in your household ever told you that you scream, flail, and sometimes even attack someone in your sleep? You may have also woken up with a bruise on your body and wondered, "What happened to me?" This may not just be a bad dream. Today, we're going to talk about this strange sleep behavior, called REM Sleep Behavior Disorder, or RBD.

What is REM Sleep Behavior Disorder (RBD)?

Simply put, REM Sleep Behavior Disorder (RBD) is when you are in the REM (Rapid Eye Movement) stage of sleep, and you actually act out your dreams, that is, physically doing things you do in your dreams, talking in your dreams. You are not aware of them when you are doing these things. This RBD condition falls under the category of parasomnia. Parasomnia is a sleep disorder that disrupts sleep, causing unusual and unwanted physical events or experiences.

When we sleep, there are different stages of sleep. One of these stages is called REM sleep . REM stands for Rapid Eye Movement. This is when the eyes move rapidly. This is when we often have vivid, vivid dreams. We go through these REM cycles several times a night. The first REM cycle begins about 90 minutes after we fall asleep, and it lasts about 10 minutes. Each REM cycle that follows gets longer.

There are two main types of RBD:

1. Isolated (idiopathic) RBD: This means that the condition occurs without any specific cause. Unfortunately, many people with isolated RBD can eventually develop a neurodegenerative condition (a condition that gradually weakens the nervous system). In particular, diseases such as Parkinson's disease (Parkinson's disease), Lewy body dementia (Lewy body dementia) or multiple system atrophy (MSA) (multiple system atrophy). These diseases are also commonly called alpha-synucleinopathies.

2. Symptomatic (secondary) RBD: This is caused by another underlying condition. For example, it can occur in people with a sleep disorder called Type 1 narcolepsy . If a person has both the aforementioned alpha-synucleinopathy and RBD, it is also considered secondary RBD.

Also, people taking certain antidepressants can develop RBD. This is called drug-induced RBD .

Because this RBD can cause unintended harm to you or the person you are sleeping with, it is very important to be aware of this and seek treatment if necessary.

Who is more likely to develop RBD?

REM Sleep Behavior Disorder (RBD) most often affects people over the age of 50.The average age of onset for this disease is around 61 years. However, very rarely, this condition can occur in young children and young adults.

Among people over the age of 50, men are about nine times more likely to develop RBD than women .

RBD is closely associated with certain neurodegenerative disorders. As previously mentioned, it has been found that a large proportion of people with isolated (idiopathic) RBD (i.e. RBD that occurs without any other cause) develop Parkinson's disease, Lewy body dementia, or multiple system atrophy (MSA) within 14 years of diagnosis .

About 36% of people with Type 1 narcolepsy may have secondary RBD. And about 6% of people taking antidepressants may have drug-induced RBD.

How common is RBD?

REM Sleep Behavior Disorder (RBD) is actually a relatively rare condition . It affects about 1% of the general population. In people over the age of 50, it's about 2%.

But these numbers may be lower than they actually are, because RBD can be difficult to diagnose, and about half of people with the condition don't even know they have it .

What are the symptoms of RBD?

The symptoms of RBD can vary from person to person. Some people experience them frequently, while others experience them less frequently. While a person is sleeping, it can feel like they are having a bad dream. Here are some things that can happen:

• The flesh on my body slowly moves, my limbs twitch.
• Talking, shouting, and sometimes bad words are said.
• They pretend to hit or grab someone, or they can even hit or kick the person in bed.
• Jumping out of bed, falling to the floor.

Imagine, your friend, Nilanthi, and her husband, Sugat, are sleeping at night and suddenly shout "Hold on! Hold on!" and stretch out their arms as if to hit someone. Sometimes Sugat falls out of bed and injures himself. When they wake up in the morning, Sugat doesn't remember anything, but he remembers the dream he had. This is the nature of RBDs.

It is said that eight out of ten people with RBD suffer from sleep injuries .

These events can happen once or several times during a single sleep. Some people experience them every night, while others experience them rarely. Symptoms are most severe when a person is having a severe, violent nightmare.

The important thing is, you don't know when these things happen. Most people only find out about it when someone in bed tells them, or when someone at home sees them, or when they wake up in the morning with a wound on their body.

If someone wakes you up at this time, you can easily wake up. When you wake up, you are alert and remember your dreams. This is called night terrors.It's different from night terrors. It's hard to wake someone up, and even when they wake up, they seem very agitated and confused.

Sometimes people with Obstructive sleep apnea (OSA) (obstruction of breathing during sleep) can also show these symptoms. This is called pseudo RBD . In such people, when OSA is treated, the behaviors disappear.

What are the causes of RBD?

Normally, when we are in REM sleep, when we dream, many of our muscles (especially skeletal muscles) temporarily lose their function. This is called muscle atonia . This happens so that we can dream safely without actually doing the things we are doing in our dreams. Imagine what would happen if we didn't have that! If we actually ran in our dreams and actually jumped in our dreams, we could get into an accident, right?

But people with RBD don't experience this temporary loss of muscle function called muscle atonia. That's why they unconsciously act out and talk about things they do in their dreams. Researchers still don't fully understand why this happens. There are many complex neural pathways involved in REM sleep.

Causes of Isolated (idiopathic) RBD

One major theory is that isolated (idiopathic) RBD is caused by a problem in the pons, a part of the brainstem, that causes muscle atonia during REM sleep. Some cells in the pons control muscle contraction during REM sleep. Lesions in the pons have also been linked to Parkinson's disease, Lewy body dementia, and MSA. Because of the strong association between isolated RBD and these diseases, researchers believe that a problem in the pons may be the cause.

One study showed that 97% of people with isolated RBD develop one of these neurological diseases within 14 years of their RBD diagnosis, with Parkinson's disease being the most common.

Causes of Secondary (symptomatic) RBD

People with narcolepsy have low levels of a brain chemical called orexin or hypocretin . This chemical controls sleep, wakefulness, and appetite. When this chemical is low, it can disrupt REM sleep, leading to RBD.

Causes of Drug-induced RBD

Researchers believe that RBD caused by some antidepressants may be due to an imbalance of the neurotransmitters dopamine and serotonin , which are involved in REM sleep.

How to diagnose RBD? (Diagnosis)

If you have symptoms of RBD, you should definitely see a doctor.The doctor will ask you about your symptoms and your medical history. If you have someone you sleep with or family members with, the doctor may also ask them about your sleep habits.

The doctor will examine you physically and perform a neurological exam. You may also be referred to a sleep specialist.

To find out for sure if you have RBD, you need to have an in-lab video sleep study, also known as a polysomnogram (PSG) . This is usually done in a hospital or sleep center, where you spend an entire night under camera monitoring. This test records the following things about your body while you sleep:

• Heart rate.
• Breathing rate and airflow.
• Brain wave activity.
• Eye movements.
• Muscle movements of your chin and upper extremities.

According to the International Classification of Sleep Disorders, Third Edition (ICSD-3), all of the following must be present to be diagnosed with RBD:

• You keep having episodes where you talk in your sleep and/or make complex movements.
• These behaviors must be confirmed by a polysomnography (PSG) test and must occur during REM sleep. Or, based on your clinical history, they must be suggestive of REM sleep.
• The PSG test should show that you have muscle atonia (loss of muscle life) during REM sleep. (REM sleep without atonia - RWA).
• Seizure-related activity should disappear during REM sleep.
• These sleep problems should not be well explained by another sleep disorder, another illness, a mental illness, a side effect of medication, or a substance use disorder.

How is RBD treated?

The main goal when treating this RBD is to provide safe sleep for you and your partner . There are various strategies and sometimes medications for this.

Steps to take for safety

Here are some things you can do to create a safe sleep environment:

• Remove sharp, glass, and heavy objects from around the bed.
• Place something soft, such as a pillow, between you and the headboard or nightstand.
• Place a mattress on the floor next to the bed in case you fall out of bed, or install padded bedside rails on both sides of the bed.
• For some people, sleeping in a sleeping bag may also help.

If your symptoms are very severe, it may be best for you to sleep alone in a separate room for the safety of your sleeping partner.

Also, you should avoid drinking alcohol as much as possible , as alcohol can increase the incidence of RBD and make the condition worse.

Medications for RBD

If your symptoms are severe, and safety measures alone cannot prevent injury, your doctor may prescribe medication to control your symptoms. Although there are no FDA-approved medications specifically for RBD, studies have shown that melatonin, clonazepam, and pramipexole can sometimes reduce symptoms.

• Melatonin: This is a hormone naturally produced by the pineal gland in our brain. It is essential for regulating our sleep-wake cycle. Synthetic melatonin is available as a medication. This is considered the first-line treatment for RBD because it has very few side effects. The doctor will start with a low dose and gradually increase the dose until the symptoms subside.
• Clonazepam: This is a sedative. Researchers are not yet sure how it helps with RBD. However, many people with RBD find that taking a low dose of clonazepam before bed reduces or eliminates nightmares, screaming, and sleepwalking. However, clonazepam can have some unpleasant side effects. This is why your doctor may prescribe it if melatonin doesn't provide enough relief.
• Pramipexole: This is a dopamine agonist. Doctors mainly prescribe it for Parkinson's disease and restless leg syndrome. But recent research has shown that it can also reduce the symptoms of RBD. Researchers believe that this drug works because RBD is a condition caused by a lack of dopamine (dopaminergic deficiency disorder).

Can RBD be prevented?

In most cases, there is nothing we can do to prevent RBD. This is because there are risk factors that we cannot prevent or change. For example, your age, or whether you have narcolepsy or a neurodegenerative condition.

But if RBD is caused by things like alcohol, and if the symptoms increase, the RBD may go away once you stop using those things.

What is the prognosis of RBD?

The future course of RBD, that is, where the disease will go, depends on several factors:

• Whether there is an underlying cause. That is, whether it is due to narcolepsy (secondary RBD), an antidepressant (drug-induced RBD), or whether it just happened (spontaneously - isolated RBD).
• How severe your symptoms are and whether they are causing you any harm.
• Whether to seek treatment or not.
• Whether you have a nervous system disease along with RBD.

The most important and serious aspect of RBD is its association with neurological diseases, particularly Parkinson's disease, multiple system atrophy, and Lewy body dementia. Increasing evidence suggests that RBD may be an early warning sign of these diseases. This is especially true if RBD occurs spontaneously, without any other cause, and is not due to narcolepsy or a medication.

RBD can cause serious harm to you and/or your sleeping partner, so it is very important to seek treatment.

The prognosis for people with RBD and a neurological condition is generally not good. For example, it has been found that people with early-stage Parkinson's disease and RBD have a lower quality of life than people with early-stage Parkinson's disease but no RBD.

What are the possible complications of RBD?

These people are at high risk of injuring themselves or others in bed due to their sometimes violent movements in their sleep. Also, as sleep is frequently interrupted, this can affect overall sleep quality.

Possible types of injuries:

• Bruises.
• Cuts.
• Sprains.
• Broken bones.
• Serious conditions such as head injuries and subdural hematomas (bleeding inside the skull) .

Sometimes these injuries can be life-threatening .

It is reported that 90% of partners of people with RBD have sleep problems , and more than 60% have suffered physical injuries .

Therefore, it is very important to seek treatment for RBD and at least create an environment for safe sleep.

When should you see a doctor about RBD?

• If you have been diagnosed with isolated RBD (RBD with no other cause), you will need to see a doctor regularly to check for signs of neurological diseases that may be closely related to it (Parkinson's, Lewy body dementia, MSA).
• If you develop any new symptoms, such as issues with movement or cognitive changes, see a doctor immediately.
• If you or someone you sleep with suffers an injury due to RBD, seek medical advice immediately.

Is RBD a mental illness?

No, REM Sleep Behavior Disorder (RBD) is not a mental illness. It is not like a mood disorder or an anxiety disorder. RBD is a sleep disorder – specifically a type of parasomnia.

It can be very distressing and upsetting to accidentally injure yourself or someone you sleep with. If your partner tells you that you are struggling or screaming in your sleep, don't take it lightly. Talk to a doctor. They may recommend a sleep study to see if they have RBD, and may suggest treatment if necessary. Remember, the most important thing is to create a safe sleep environment to prevent injury.

Finally, remember this (Take-Home Message)

So, if you or someone you know is behaving strangely in their sleep – screaming, flailing their arms, falling out of bed, etc. – don't just dismiss it as a bad dream. It could be REM Sleep Behavior Disorder (RBD).

Especially if it causes injury to yourself or others, be sure to seek medical advice. Remember, this can also be an early sign of some serious neurological diseases. Therefore, it is very important to detect it early and take the necessary measures. Your sleep, your partner's sleep, and the safety of both are very important. So take care of this.