Abstract
In a nutshell, REM behavior disorder (RBD) is a condition wherein a person who is asleep essentially acts out their dreams while they are experiencing the REM parts of their sleep cycles. Unfortunately, a variety of injuries can occur with this behavior leaving the patient and any bed partners injured. This paper will define and discuss the characteristics and treatment of idiopathic and symptomatic rapid eye movement behavior disorders and whom this ailment generally afflicts. This paper will also briefly address the possible relationships between REM behavior disorder and narcolepsy, Parkinson’s disease (PD), and Alzheimer’s disease.
Keywords: Symptomatic REM sleep behavior disorder, Idiopathic REM sleep behavior disorder, Neurodegenerative disorders, Parkinson’s Disease, narcolepsy.
Throughout history man has made attempts to understand how his mind works and exactly how it affects the body. One of these many relational mysteries between body and brain that still remains is the realm of sleep and dreaming. Rapid eye movement behavior disorder exists within this vast domain. This is an affliction wherein a person who is sleeping acts out whatever they are currently dreaming. Since dreams only occur during the rapid eye movement (REM) part of their sleep cycles, they only mimic their dreams during REM sleep. Moreover, as the patient is imitating the dreams while asleep, a wide range of injuries can befall not only the sleeper, but also their bed partner and any other persons or animals in the residence who happen to be in the dreamer’s path. There are only two types of rapid eye movement behavior disorder: Idiopathic and Symptomatic. In the past few decades, researchers have hypothesized that there may be a link between rapid eye movement behavior disorder and some neurological disorders such as narcolepsy, Parkinson’s disease, and Alzheimer’s disease. Treatment of the parasomnia varies widely so that there is no defined course in order to control or eradicate it. Though many details regarding rapid eye movement behavior disorder still elude scientists and researchers alike, perhaps a review of the current information could help to enlighten interested parties.
Types and Symptoms
There are two types of rapid eye movement behavior disorder. These are identified as symptomatic and idiopathic. The main difference seems to be “When no neurological signs or central nervous system lesions are found, rapid eye movement behavior disorder (RBD) is currently defined as idiopathic.” (Fantini & Ferini-Strambi, 2007) The symptoms for both types of the condition, however, are the same. Fantini & Ferini-Strambi’s research stated the following regarding indicators of the condition:
“Typical behaviors include screaming, grasping, punching, kicking and sometimes jumping out of bed, which may cause injuries to the patient or their bed partner. Injuries are reported by more than 75% and may include ecchymoses, lacerations, bone fractures and even subdural haematomas. Arousal from episodes is usually rapid and often accompanied by a dream recall that matches with the observed behavior.” (Fantini & Ferini-Strambi, 2007)
More specifically, Thomas, Bonanni, and Onofrj’s research lists the minimal criteria in diagnosing rapid eye movement behavior disorder as “Limb or body movement is associated with dream mentation. And, at least one of the following occurs: harmful or potentially harmful sleep behavior; dreams appear to be “acted out”; sleep behaviors disrupt sleep continuity.” (Thomas & Bonanni, 2007) And what of the content of these dreams? Fantini and Ferini-Strambi assert that this is also quite relevant in their research.
“Indeed RBD appears to be a disorder involving both behavior and dream synthesis. Dreams of these patients tend to be unpleasant, stereo-typical, mainly action-filled and often violent in nature. The dreamer is often attacked by animals or unfamiliar people and he would either fight back in self-defense or attempt to flee. … The physiopathological mechanism underlying the change in dream content is not completely known, but a close relationship between the excessive phasic muscle activity observed during REM sleep and the action-filled dreams has been postulated.” (Fantini & Ferini-Strambi, 2007) Now that types of the condition and its symptoms have been clearly defined, let us examine who is affected by this affliction.
Demographic
Unfortunately, this disorder can afflict anyone, but it is more prevalent in older males. According to Fantini & Ferini-Strambi,
“RBD affects mostly men over the age of 50 years. The male:female ratio is about 8:1 in the largest series of cases and the reason for the male predominance is unclear. It has been suggested that female subjects may have RBD with less aggressive behaviors that do not call for medical attention. A role of sex hormones in mediating violent and aggressive behaviors has been postulated to explain this gender effect.” (Fantini & Ferini-Strambi, 2007)
Similarly, Ciccarelli reiterates, “Usually seen in men over age 60, [rapid eye movement behavior disorder] can happen in younger men and in women. (Ciccarelli & White, 2015) However, Fantini & Ferini-Strambi propose an interesting characteristic in rapid eye movement behavior disorder patients.
“It has been observed that the aggressiveness in dreams often contrasts with the often placid and mild-mannered daytime temperament. A recent study quantified the dream content in RBD and found a very high proportion of aggressive interactions and animals characters, with a reduced sexual content in RBD patients, besides normal or even reduced levels of daytime aggressiveness. (Fantini & Ferini-Strambi, 2007)
There are a few famous examples of people who have suffered or allegedly suffered from rapid eye movement behavior disorder. One of these is comedian Mike Birbiglia who through his many appearances on National Public Radio, his off-Broadway play, his book, and his comedy in general has raised awareness about this sleeping disorder. Birbiglia tells of a recurring dream during the onset of his condition where he dreamed that there was an insect-like jackal in his bedroom. He did not seek help for his condition until he realized the severity of it. The catalyst for this was an incident wherein he jumped through a second story hotel window and kept running until he awoke, realizing that he was asleep throughout the entire event. He was also in his underwear, and would need 30 stitches for his many injuries. Now Birbiglia sleeps in a sleeping bag and wears mittens so that he is not able to open the bag whilst asleep. He also urges audiences to seek help for sleep-related problems. (Birbiglia, 2003) Another less positive example of someone who suffered from rapid eye movement behavior disorder is Kenneth Parks of Toronto, Canada who was acquitted of murder in 1987.
Parks “drove 23 kilometers to the home of his wife’s parents. He stabbed his mother-in-law to death, attacked his father-in-law, and then drove to the police … [and said] he thought he has killed some people. He had no motive and had been suffering from severe insomnia. He did have a history of sleepwalking and his defense team, which included sleep experts and psychiatrists, concluded that he was indeed unaware of his actions at the time of the crime.” (Ciccarelli & White, 2015)
Similarly, Brian Thomas of South Wales of South Wales “killed his wife while dreaming of intruders breaking into their camper. [He] had a history of sleepwalking and normally slept apart from his wife. Experts found that he suffered from night terrors, and he was acquitted of her murder by reason of temporary insanity.” (Ciccarelli & White, 2015) These three men are all excellent examples of the type of people who suffer from this disorder.
Treatment
While treatment for rapid eye movement behavior disorder has not been completely standardized, researchers have had good results with a variety of therapy options. For example, “Clonazepam, a benzodiazepine with some serotoninergic properties, administered at bedtime in doses ranging from .5 to 2 mg, significantly controls both the behavioral manifestations of RBD and the disturbed dream content, and therefore is considered the first-choice treatment.” (Fantini & Ferini-Strambi, 2007) Moreover, “its efficacy and safety has been reported in about 90% of patients. However, possible loss of efficacy over time may sometimes require an increase in the dose with important daytime sedation residual effects.” (Fantini & Ferini-Strambi, 2007) On the other hand, other researchers stress more common sense approaches,
“Good sleep hygiene should be encouraged, emphasizing in particular the behavioral rules; maintenance of a regular sleep-wake cycle; bedtime sleep restriction; avoidance of frequent naps during the day; moderate daytime physical exercise… Melatonin in low dosages may also be used to rest the sleep-wake schedule.” (Manni, Terzaghi, & Pacchetti, 2007)
Interestingly, the use of melatonin is found in most researchers’ recommended course of therapy. “It seems that melatonin exerts its therapeutic effect by restoring REM atonia rather than suppressing excessive phasic motor activity.” (Fantini & Ferini-Strambi, 2007) Then again, “Levodopa was reported to improve subjective symptoms of RBD in three patients with Parkinson’s disease.” (Fantini & Ferini-Strambi, 2007) And, “Pramipexole, at a dose ranging from .5 to 1 mg at bedtime, induced a sustained reduction in sleep motor behaviors in five out of eight idiopathic RBD patients.” (Fantini & Ferini-Strambi, 2007) And yet, “Pramipexole does not seem to change either the percentage of REM sleep phasic EMG activity or the percentage of REM sleep muscle atonia.” (Fantini & Ferini-Strambi, 2007) So, though there has been some success in treating rapid eye movement behavior disorder, there is still no singular cure or course of therapy in order to eradicate the condition.
Discussion
Now that management of the condition is as clear as current research allows, there is yet one more question to ask: does rapid eye movement behavior disorder herald other disorders? In their research Thomas et al. state that “65% of the investigated patients developed a neurodegenerative disorder or symptoms.” (Thomas & Bonanni, 2007) The same researchers further concluded that
“close follow-up of patients with idiopathic RBD could result in early detection of an underlying neurodegenerative disorder. This finding may be of great interest whenever early effective therapeutic strategies that slow disease progression become available. Neuroprotective drugs could be tested in patients with idiopathic RBD.” (Thomas & Bonanni, 2007)
Other researchers concur with this finding, “Increasing evidence indicates that chronic iRBD is associated with various neural dysfunctions and may represent, at least in a proportion of cases, an early marker of a neurodegenerative disease.” (Fantini & Ferini-Strambi, 2007) Other researchers have even gone a step further in specifying which neurodegenerative disease are associated with rapid eye movement behavior disorder. “Sleep disorders are now regarded as important among the non-motor symptoms of Parkinson’s disease (PD) and as a significant variable of PD-related quality of life. Furthermore some sleeping disorders, namely REM behavior disorder, have been hypothesized to herald PD.” (Manni, Terzaghi, & Pacchetti, 2007) Other researchers have found other connections.
“The first neuropathological report of RBD in 1997 showed neuropathological aspects of Alzheimer’s disease (AD) but successive neuropathological re-evaluations evidenced a Lewy-body variant of AD. A recent study found that four out of 14 patients with probable AD showed excessive muscle activity during REM sleep and one manifested complex movements consistent with the diagnosis of RBD, suggesting that RBD and excessive muscle activity during REM sleep could be observed in probable AD.” (Thomas & Bonanni, 2007)
Lastly, Nightingale et al. hypothesized a relation between RBD and narcolepsy.
“This study suggests that 36% of narcoleptics experience symptoms of RBD… The fact that those with RBD, a loss of atonia in sleep, are more likely to suffer from cataplexy, a loss of tone when awake, demonstrates the dissociation of wakefulness and REM sleep that occurs in these disorders.” (Nightingale, et al., 2005)
In short, these researchers’ conclusions implied “a stronger relationship between these disorders than a previously published figure of 7-12%. This is clinically significant as RBD is a potentially distressing but readily treatable disorder.” (Nightingale, et al., 2005)
Conclusion
Though there are still aspects of rapid eye movement behavior disorder that are not yet clear, what is undeniable is that persons who are experiencing symptoms should seek medical help as soon as possible for their safety and the safety of their loved ones. Furthermore, patients who are already at risk for neurological disorders should look for signs of RBD. Lastly, those who have already been diagnosed with RBD should participate in research to further understand this vexing condition, and they should monitor their own prognoses for signs of future more serious conditions such as the ones mentioned.
References
Birbiglia, M. (2003). Sleepwalk with Me. (M. Birbiglia, Performer) The Moth, New York, New York, USA.
Ciccarelli, S. K., & White, J. N. (2015). Psychology Fourth Edition. Pearson Education, Inc.
Fantini, M., & Ferini-Strambi, L. (2007). Idiopathic Rapid Eye Movement Sleep Behavior Disorder. Neurological Sciences Volume 28 Supplement, 15-20.
Manni, R., Terzaghi, M., & Pacchetti, C. &. (2007). Sleep disorders in Parkinson’s Disease: facts and new perspectives. Neurlogical Sciences Volume 28 Supplement, 1-5.
Nightingale, S., Orgill, J., Ebrahim, I., de Lacy, S., Agrawal, S., & Williams, A. J. (2005). The Association between Narcoleps and REM behavior disorder (RBD). Sleep Medicine Volume 6 Issue 3, 253-258.
Thomas, A., & Bonanni, L. &. (2007). Symptomatic REM Sleep Behavior Disorder. Neurological Sciences Volume 28 Supplement, 21-36.
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