REM Sleep Behavior Disorder: What to Know About This Rare Condition

You may be familiar with common sleeping disorders, like obstructive sleep apnea or insomnia. But parasomnias are less well-known. One in particular, REM sleep behavior disorder (RBD), affects an estimated 1% of the population. 

This sleep disorder is different from others. That’s because it has the potential to affect both the individual and their bed partner. Learn more here about RBD, including how to recognize it and how it’s diagnosed.

What is REM sleep behavior disorder (RBD)?

RBD is exactly as it sounds: a sleep disorder that affects behavior during rapid eye movement (REM) sleep. Dreaming is common during REM sleep, one of the two stages of our sleep. Most people experience paralysis of their muscles in this phase. This prevents them from acting out their dreams. 

But in RBD, that muscle paralysis does not occur, allowing the person to act out their dreams. Most often, they dream of being attacked in some way and having to defend themselves. This results in:

• Jerking

• Repetitive movements

• Kicking

• Punching

• Flailing

Because these actions are all physical, people with RBD can easily injure themselves and/or bed partners. 

Shouting, grunting, and swearing are also common. Most people with RBD can be awoken easily during these episodes, and they usually recall their dreams. 

What causes it?

RBD can occur in three situations:

• Due to a neurological disorder 

• Due to medication(s) 

• Isolated RBD (not due to something else)

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The most common cause of RBD is another neurologic condition such as Parkinson’s disease, multiple system atrophy (MSA), or Lewy body dementia (LBD). These conditions cause degenerative changes in the central nervous system, including the areas of the brain that control REM sleep. 

RBD can also occur with use of antidepressant medications. These medications include selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). This is the most common cause of RBD in younger people (less than 50 years old). It’s not clear why only some people who take these medications go on to have RBD while others don’t. 

Isolated RBD occurs when there is no other medical condition or medication to blame. It’s not exactly clear what the cause is. But many experts believe isolated RBD is a precursor to another neurologic diagnosis. Data suggests over 70% of people with isolated RBD go on to develop Parkinson’s, LBD, or other condition. This is especially the case if they are over 50 at the time of diagnosis. 

Risk factors associated with REM sleep behavior disorder

RBD tends to be more common in men of older age (greater than 60 years). Another risk factor is narcolepsy, a sleep disorder that causes people to unwillingly fall asleep during the day. Up to 70% of people with narcolepsy also experience RBD. 

How is RBD diagnosed?

Usually, the first person who recognizes the problem is the bed partner of someone with RBD. The next step is to see a healthcare provider. It helps to see a sleep specialist, who can help rule out other sleep disorders or conditions. This often involves answering several questions about sleep habits and a brief physical exam.

Diagnosis requires a sleep study — called polysomnography — in a lab (not a home test). Specifically, the sleep study looks for elevated muscle tone during REM sleep. The study is also helpful for ruling out other sleep disorders, such as obstructive sleep apnea and periodic limb movement disorder.

The following are required for diagnosis of RBD:

• Repeated sleep-related behavior episodes

• Episodes of physical movements in the REM sleep phase, confirmed by the sleep study

• Lack of muscle paralysis in REM sleep, confirmed by the sleep study

• Findings not explained by any other medical or sleep disorder

Imaging studies are not required for a diagnosis of RBD. They may be helpful in looking for other neurologic conditions, however.

How is REM sleep behavior disorder treated?

Depending on the situation, preventing sleep-related injury is often the most important first step. If you act out your dreams, anything or anyone nearby could be hurt, as well as yourself. 

Here are some tips to make your sleeping area safe:

• Sleep separately from other people when possible. If that’s not possible, place pillows between you and your bed partner.

• Remove anything from the bedside that can be harmed or cause harm if struck. Examples include bedside tables, windows, or lamps. If the items can’t be moved, cushion sharp edges and hard surfaces.

• Sleep as low to the ground as possible. This is in case you fall out of bed.

• Put away any potential weapons. Anything that could be a weapon — like a gun or knife — should be hidden and kept out of reach.

There isn’t a cure for RBD. Treatment can depend on whether your provider suspects it’s due to another condition. For example, stopping your SSRI or SNRI may help if it is contributing to your sleep problems. But that’s often not possible for many people, so it’s important to speak with your healthcare provider if and when you make that decision. Also note that it’s not safe to stop taking these medications suddenly. 

Medication can help if you have isolated RBD or RBD due to a medical condition. According to the American Academy of Sleep Medicine clinical practice guidelines, the following medications may help:

• Clonazepam

• Melatonin

• Rivastigmine

• Pramipexole

Note that the FDA has not approved these medications for treatment of RBD. This means their use is considered “off-label.” That said, your healthcare provider will be familiar with their use and can help you decide which is the best option for your situation. 

When should I see a doctor about my sleep?

If you suspect RBD, it’s never too early to get help. A healthcare provider can help you figure out what’s going on and refer you to a specialist when needed. The thought of a sleep study might not be appealing. But it’s important to get a diagnosis and/or rule out other conditions. Be sure to stay safe while you sleep in the meantime. 

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Written by:

Mandy Armitage, MD

Mandy Armitage, MD, has combined clinical medicine with her passion for education and content development for many years. She served as medical director for the health technology companies HealthLoop (now Get Well) and Doximity.

Reviewed by:

Patricia Pinto-Garcia, MD, MPH

Patricia Pinto-Garcia, MD, MPH, is a medical editor at GoodRx. She is a licensed, board-certified pediatrician with more than a decade of experience in academic medicine.

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