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Are You Acting Out Your Dreams in Your Sleep?

6 min read  |  January 22, 2025  | 

Everyone dreams, some more than others. For most of us, a dream is something we usually forget upon waking. If we remember it, we sometimes wonder at its meaning or laugh at its ludicrous settings.

But for a small group of people who suffer from REM sleep behavior disorder (RBD), a dream can be physically dangerous. That’s because they act out their dreams, sometimes sitting up suddenly or jumping out of bed, kicking, punching or flailing around. They might also yell or scream.  

“Typically the person has no idea they’re doing any of this because they remain asleep,” says Kori Ascher, D.O., a sleep medicine expert at the University of Miami’s Health System.  “It’s usually a partner or spouse, sometimes a roommate, who tells the patient what’s happening.”

About 1% of the population suffer from REM sleep behavior disorder, according to various studies of the rare parasomnia condition.

That said, Dr. Ascher and many other sleep doctors believe the disorder is probably undercounted. 

If a person sleeps alone, the likelihood is that they’re not aware of the condition because there’s no one to tell him about it.

The prevalence of the sleep disorder increases with age and is more common in groups of patients suffering from neurological conditions, such as Parkinson’s and Lewy body dementia. The overwhelming majority are men and the average age of onset is about 61 years old. Dr. Ascher’s patients with the condition, for example, are in their 60s and 70s and they discover they’re enacting their dreams from a bed partner.

“Patients may not perceive their sleep as disrupted, but sleep studies often reveal fragmented sleep or abnormal sleep architecture,” she says, adding that if woken up, “they are alert and clear in their thoughts.” Some even remember the dream itself.

“There seems to be a common theme in those dreams,” she adds. “It’s the patients defending themselves from some outside force. They’re being chased or attacked.”

REM sleep behavior disorder is something of a medical mystery. While the precise cause of RBD is not fully understood, animal studies suggest disruptions in specific brain pathways typically active during REM. These point to a breakdown in certain neural pathways that leads to physical movement during sleep.

One such study, done on cats, showed that injuries in the dorsolateral pontine tegmentum of the brain led to abnormal behaviors during REM sleep, including pouncing, hissing and attacking non-existent prey. Other studies, done on rodents, confirm that lesions in that area of the brain increased physical activity in sleep.

Under normal conditions, a person enters REM (rapid eye movement) within 90 minutes of falling asleep. This is the last stage pof the sleep cycle. During this REM phase, which accounts for about 25% of our sleep hours, the brain is active, with blood pressure rising and eyes moving quickly all around. In turn, the body goes into atonia, which is a temporary muscle paralysis. This state of atonia essentially prevents us from moving about.

Those with RBD, however, enter the REM stage but don’t experience atonia — hence, all that movement and vocalization. The number of episodes a patient experiences can vary greatly, too, from several times a night to only a few times a year.

To get a diagnosis of RBD, a sleep doctor will request an overnight sleep study known as a polysomnogram, which monitors a person’s brain and heart activity as well as eye movements and arm and leg movements. The physician will also review the patient’s medical history to discount potential causes other than RBD that might account for dream reenactment. In certain cased, episodes can be attributed to medications or substance abuse. (Risk factors for RBD include the use of antidepressants or the abuse of drugs or alcohol.)

 Head injuries, sleep deprivation, and narcolepsy are “triggers” for REM sleep behavior disorder.

More recently, studies have reported an association between pesticide exposure and RBD, particularly among farmers who regularly handle such chemicals.

Nevertheless, the studies reporting correlation of RBD to pesticides does not imply causation.  At present, no studies have found a direct relationship, Dr. Ascher says.

RBD has also been linked to the development of various neurodegenerative diseases, such as Parkinson’s, multiple system atrophy, and Lewy body dementia. Studies estimate that between 38% and 81% of men with RBD will develop one of these diseases within years of the sleep disorder diagnosis. The wide range in these studies, she says, is because reports highly depend on patient follow-up duration and characteristics

Dr. Ascher, however, is quick to offer hope: “A diagnosis doesn’t mean you will develop a neurological disease. Also, RBD treatment will slow the frequency of RBD episodes, but further research is needed to determine whether interventions in the prodromal phase (such as in RBD) could alter disease trajectories.”

Treatment for RBD is fairly straightforward and it involves both medications and lifestyle changes. “It involves a frank conversation with the patient about managing the condition,” she says. “Safety is our number one priority.”

This is particularly important to prevent injuries — to both the patient and the bed partner.

The go-to drug is melatonin. It has fewer side effects and is tolerated better by older patients. Sleep doctors may also prescribe clonazepam, which has shown to be very effective in reducing symptoms. It can have some serious side effects, such as forgetfulness and impaired balance, so it must be monitored closely.

These oral treatments work best with a corresponding injury-prevention plan. One study reported that 55% of REM sleep behavior disorder patients reported an injury, 37.8% to self, and 16.7% to the bed partner. These included bruising, fractures, cuts, even blunt trauma. Of those, 11.3% had severe injury, including two (4%) subdural hematomas, the collection of blood outside the brain.

Dr. Ascher suggests patients put padding on the floor, moving furniture away from the bed, and removing sharp or dangerous objects from the bedroom. She also advises the bed partner to sleep in a separate bed or room. 

“While symptoms can often be managed effectively,” she adds, “RBD is typically a chronic condition without a cure, especially when linked to underlying neurological disorders.”


Ana Veciana-Suarez is a regular contributor to the University of Miami Health System. She is an acclaimed author and journalist who has worked at The Miami Herald, The Miami News, and The Palm Beach Post.


Resources

https://pubmed.ncbi.nlm.nih.gov/29216391

https://link.springer.com/chapter/10.1007/978-3-319-90152-7_42

https://pmc.ncbi.nlm.nih.gov/articles/PMC9524747/#:~:text=While%20the%20findings%20are%20not,high%20pesticide%20exposure%20event%2018

https://www.sciencedirect.com/science/article/abs/pii/S1389945714002469

Tags: Dr. Kori Ascher, sleeo conditions, sleep care in Miami, sleep health, sleep movements

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