REM sleep behavior disorder (RBD) is a sleep disorder in which complex movements take place during the dream phase. The patient reacts aggressively to certain dream contents. RBD is often the precursor to Parkinson’s disease, Lewy body dementia, or MSA (multiple system atrophy).
What is REM sleep behavior disorder?
REM sleep behavior disorder is a parasomnia (abnormal behavior during sleep) that occurs during the REM sleep phase. This leads to vivid dreams with often aggressive content, in which the person affected reacts by hitting, kicking or screaming. This often causes the person next to the bed to be attacked and even injured. Self-harm also occurs. The dream is lived out. See AbbreviationFinder for abbreviations related to RBD.
After awakening, however, there is no memory. The condition is also known as Schenck syndrome or RBD (Rapid eye movement sleep behavior disorder). More than 90 percent of men are affected. RBD usually occurs between the ages of 40 and 70. In the majority of cases (over 80 percent), the people affected are over 60 years old. Only very rarely do people under the age of 40 suffer from REM sleep behavior disorder.
Causes
A synucleinopathy is assumed to be the cause of the REM sleep behavior disorder. This is a deposit of misfolded alpha-synuclein within nerve cells in the brainstem. The synuclein is responsible for the formation of dopamine. As a result of genetic modification of this protein, misfolding can occur, destroying its secondary structure with the formation of insoluble protein complexes.
On the one hand, this reduces the formation of dopamine and, on the other hand, these deposits block important sections of the brainstem. The processes that inhibit motor activity are switched off in the brain during sleep. This in turn means that the dream content can be lived out with the help of movements. Since the synucleins are also responsible for the formation of dopamine, misfolding leads to a reduction in dopamine production.
This is why REM sleep behavior disorder is often an accompanying symptom of Parkinson’s. This disorder can develop before or during Parkinson’s disease. Since the resulting deposits damage certain areas of the brain, Lewy body dementia often develops as a result of RBD. In rarer cases, multiple system atrophy (MSA) develops.
Symptoms, Ailments & Signs
A REM sleep behavior disorder manifests itself in increased motor activity during the REM sleep phase. Patients experience violent dreams that are primarily about attacks by insects, animals, or humans. The victim defends himself by hitting, kicking and shouting. The movements are carried out because the motor inhibition is removed by the incorrectly folded alpha-synucleins. The movements are complex, not leaving the bed, unlike sleepwalking.
The affected person’s behavior during sleep, including the way he speaks and cries, is not typical of his behavior during the waking phase. The person concerned can no longer remember the dream after waking up. When you wake up, the waking action and the dream are mixed up. The consequences are endangering others and oneself through violent actions. However, the other phases of sleep are quiet and follow the normal rhythm.
The frequency of sleep disturbances ranges from once a week to several times a night. In many cases, RBD is an accompanying symptom of Parkinson’s disease. REM sleep behavior disorder is often idiopathic and is the first symptom of Parkinson’s disease or Lewy body dementia. Sometimes the disorder is also associated with symptoms of cognitive impairment.
Diagnosis & course of disease
REM sleep behavior disorder can be diagnosed using a variety of diagnostic methods. For this purpose, relatives are interviewed as part of a third-party anamnesis. The patient also makes a self-assessment of the symptoms, using various questionnaires. Neurological examinations are performed for comorbidities of RBD. In this way, the REM sleep behavior disorder can be verified in connection with Parkinson’s or Lewy body dementia.
RBD can also be diagnosed by polysomnography. The activity of the mental muscle (chin muscle) during the REM sleep phase is examined using an EMG. If the muscle activity is increased, RBD can be assumed.
Complications
REM sleep behavior disorder primarily increases the risk of accidents and falling out of bed. Since the affected person cannot distinguish between a dream and a waking state for a short time after waking up, there is a risk of endangering themselves and others. If the person suffers from a mental illness, the behavioral disorder can sometimes cause traumatic states, delusional behavior and other complications.
REM sleep behavior disorder often occurs as the first symptom of Parkinson’s disease or Lewy body dementia. As a result, there are further complaints and sometimes an increase in the behavioral disorder. Treatment via clonazepam can cause side effects such as muscle weakness, dizziness, unsteady gait and fatigue.
Headaches, nausea, skin irritation and urinary incontinence rarely occur. In isolated cases, allergic reactions or an allergic shock occur. In children, the drug can provoke premature development of secondary sexual characteristics.
In addition to the typical side effects, melatonin, which is often prescribed as an accompaniment, can also lead to nightmares, hyperactivity and weight gain. Especially at the beginning of the medication, irritability, restlessness, exhaustion and dry mouth can occur, whereby these symptoms disappear after a few days or weeks without further complications in the case of melatonin.
When should you go to the doctor?
REM sleep behavior disorder should always be treated by a doctor. Self-healing usually does not occur, and the disease usually cannot be treated by self-help. Treatment by a doctor is therefore essential. Usually, REM sleep behavior disorder needs treatment when the sufferer has persistent dreams about insects or other animals chasing them while they sleep. The patient usually has to defend himself against these animals in order not to die in his sleep.
The condition can also lead to sleepwalking, which should also be treated to prevent further complications and symptoms. In most cases, the symptoms of REM sleep behavior disorder are registered by outsiders, so they should make those affected aware of the disorder. In many cases, the disease can be treated by a psychologist. However, how long the treatment will last cannot generally be predicted.
Treatment & Therapy
The drug clonanzepam is currently the main drug used to treat idiopathic REM sleep behavior disorder. This drug belongs to the benzodiazepines and has a sedative and muscle relaxant effect. It is taken before bed to reduce muscle activity during REM sleep. Even with its long-term use, there is no loss of effectiveness. Some patients also respond positively to melatonin.
So far, however, there is unfortunately no prospect of a cure for RBD. The symptoms of the idiopathic form of the disease can be improved. Unfortunately, this has no influence on the development of Parkinson’s disease or Lewy body dementia. For the therapy of RBD as a concomitant symptom of neurodegenerative diseases, there are still no adequate studies. Although increasing the dopaminergic dose improves the symptoms of Parkinson’s disease, it does not change the frequency and intensity of an existing REM sleep behavior disorder.
Prevention
There are no known preventive measures against REM sleep behavior disorder. With a corresponding genetic predisposition, RBD can occur from the age of forty. At the same time, their occurrence can be interpreted as a sign of a predisposition to neurodegenerative diseases. It has not yet been clarified whether particular stressful situations can trigger the disease.
According to a Swedish study, physical activity can reduce the onset of Parkinson’s disease. To what extent this also applies to REM sleep behavior disorder requires further investigation.
Aftercare
REM behavior disorder is a sleep disorder, a parasomy. REM means Rapid Eye Movement. These movements often occur when falling asleep or when waking up. NREM is light sleep and deep sleep and is shown by a drop in temperature, changes in breathing, a drop and increase in heart rate and lower blood pressure.
Symptoms associated with NREM include sleepwalking and anxiety disorders. When people sleepwalk, they often don’t remember it. It is also difficult for relatives to wake you up. Disturbing with REM is the lack of muscle activity, an uneven heartbeat and nightmares. It is therefore a sleep behavior disorder. The dreams that occur often frighten the dreaming with their aggressive thoughts.
The diagnosis is made in the sleep laboratory with the help of the medical history and questionnaires to secure the clinical diagnosis. A video check can also be carried out. During follow-up care, attention must be paid to whether changes in the brain and Parkinson’s disease occur within a few years. Sensory perception, attention and memory are tested. An ultrasound and a CT show the condition of the brain. How the REM behavior disorder develops also depends on the patient’s compliance.
You can do that yourself
If a patient is diagnosed with a REM sleep behavior disorder, it is important to clarify whether this disorder is a concomitant disease and/or heralds the onset of other diseases. Only then can appropriate therapies be initiated.
There is no cure for REM sleep behavior disorder. It can only be improved with medication. The mostly male patients should learn relaxation techniques to support them before going to bed. Jacobson ‘s progressive muscle relaxation is easy to learn. Alternatively, yoga, qigong and tai chi are also available. Even music therapy or EFT tapping therapy could bring relief to the patient.
With REM sleep behavior disorder, the patient puts themselves and others at risk. On the one hand, the risk of accidents is greatly increased because the patient acts out the content of his dream. In addition, there may be the effects of the medication that he is taking to treat other diseases and can lead to unsteady gait or dizziness. Therefore, the bed should be as secure as possible. Sharp objects, loose carpets and other tripping hazards should be removed from the bedroom. A bed safety rail would also be recommended so that the patient does not accidentally fall out of bed.
In patients with REM sleep behavior disorder, spouses are also at risk at night. Housing permitting, this partner should sleep in another room, or at least in another, distant bed.