Rapid eye movement (REM) sleep is the phase of sleep closest to awakening. The REM sleep cycle naturally occurs about every 90 minutes and is usually when people dream. Sleep cycles are driven by the body’s circadian rhythms and are easily disrupted by changes to diet, medical conditions, work schedules and substance use. When these disruptions become chronic, people can develop REM sleep disorders.
What Is REM Sleep Behavior Disorder?
Sleep disturbances can have serious consequences. A lack of REM sleep can cause people to become confused, anxious and have problems with physical coordination. In severe cases, lack of time spent in the REM stage of sleep can even trigger psychosis. Non-REM sleep is physically restful but does not have the necessary restorative effects on the mind that REM sleep does.
Many sleep disorders affect REM sleep, including parasomnias, or conditions in which people engage in abnormal behavior while they sleep. The REM sleep definition indicates that people move more during REM sleep than other sleep phases, but usually only subtly. In parasomnias, people move much more during sleep than usual. These disorders occur when people do not experience the paralysis of their arms and legs that usually occurs during REM sleep.
One of the most well-known parasomnias is sleepwalking, but these sleep disorders can affect movement in other ways. In REM sleep behavior disorder, people don’t sleepwalk, but “act out” dreams in ways that can risk injury to themselves or others. They may speak in full sentences as if they were awake, yelling unintelligibly, flail, kick, grab the person next to them or jump up from the bed. These behaviors affect sleep quality and can cause people to exhibit symptoms of a lack of REM sleep the following day.
Symptoms of REM Sleep Behavior Disorder
It’s often easier for a person to know that they have REM sleep behavior disorder when they share the bed with a sleeping partner. Someone who is in the room with them and awake when they are experiencing symptoms may observe them kicking, punching, reaching out or moaning.
A person with REM sleep behavior disorder (RBD) may wake their partner by grabbing them, shouting their name or even talking to them. It may take some time for a person who sleeps next to someone with RBD to realize that their speaking sleeping partner is not awake. The bizarre or unrealistic content of speech may ultimately signal that the person with RBD is speaking in their sleep.
Detecting REM sleep behavior disorder symptoms is a bit more difficult when someone does not share the bed with a sleeping partner, but it is possible. Signs that someone experienced disordered movement during REM sleep include:
- Finding items knocked off or moved from nearby tables or other surfaces
- Seeing sheets, pillows or other bedding items on the floor or far from the bed
- Discovering unexplained bruises, scratches or other physical marks on their body
The risks of REM sleep behavior disorder aren’t necessarily severe in themselves, but people who think they may have this condition should talk to their doctor. Symptoms of RBD can indicate other underlying disorders that are more serious.
Missing REM sleep altogether comes with more severe risks. Lack of REM sleep symptoms include:
- Memory problems
- Difficulty concentrating
- Problems with motor coordination
- Impaired performance on cognitive and motor tasks
Even one night of missed sleep can put a person at increased risk of being in a car accident or getting into serious conflicts at work or home. The effects of chronic REM sleep deprivation are more severe, potentially triggering severe anxiety and depression and even suicide attempts.
Causes of REM Sleep Behavior Disorder
While REM sleep behavior disorder causes can be varied and may include alcohol withdrawal, sedative-hypnotic withdrawal, and the side effects of antidepressants, drug-induced REM sleep behavior disorder tends to be short-lived, ending as soon as people stop using medications or as soon as the withdrawal phase ends.
Most people with chronic RBD are adults over the age of 50 who are in the early stages of a neurodegenerative disease. For people with REM sleep behavior disorder, Parkinson’s is a significant concern that should be evaluated and either diagnosed or eliminated by a qualified physician. Medical research suggests that REM behavior disorder results from synucleinopathy, a condition in which protein accumulates in nerve cells and neurons. This condition is linked to Parkinson’s disease, multiple system atrophy and Lewy body dementia.
Diagnosing REM Sleep Behavior Disorder
Clinical interviews are the first step in diagnosing REM sleep behavior disorder. A physician or mental health professional will ask a person targeted questions to determine if they meet the criteria for diagnosis listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Based on DSM-5 criteria, a person must experience the following to be diagnosed with rapid eye movement sleep behavior disorder:
- Experiencing repeated episodes of arousal during the REM stage of sleep that involve vocalization or complex movement
- Waking from these episodes in a totally alert state with no confusion or disorientation
- Having been observed by clinical professionals or via recording as having REM sleep without atonia (skeletal muscular paralysis) or having a comorbid diagnosis of Parkinson’s disease or multiple system atrophy
- Suffering from significant distress or functional impairment because of these behaviors
Clinicians must also review and eliminate other potential causes of these effects, such as a medical condition or the effects of a substance, before diagnosing someone with REM sleep behavior disorder.
Once potential REM sleep behavior disorder is confirmed in a clinical interview, a primary care physician or mental health professional will typically refer a person to a sleep specialist for a polysomnogram, a type of overnight sleep study. Sleep studies allow physicians to confirm that a person has the disorder definitively.
Who Is at Risk for REM Sleep Behavior Disorder?
Risk factors for RBD and related conditions include:
- Being sleep-deprived
- Being older than 50 and male
- Taking antidepressant medications
- Using alcohol or other drugs, especially sedatives
- Having Parkinson’s disease or Lewy body dementia
- Having other sleep disorders, especially narcolepsy
- Having a family history of these or other related conditions
It is important for physicians to evaluate people with RBD for short-term risk factors like substance use as well as screen them for chronic neurodegenerative conditions.
Rapid Eye Movement Sleep Behavior Disorder Statistics
Rapid eye movement sleep behavior disorder is relatively rare and usually responds well to treatment. Improved public awareness about the condition will help more people get diagnosed and treated. Facts about REM sleep behavior disorder include:
- Over 60 percent of people with RBD are 50 years of age or older.
- Anywhere from 60 percent to 89 percent of people who have RBD are male.
- Rapid eye movement sleep behavior disorder occurs in 0.5 to 1 percent of the general population and 2 percent of older adults.
- From 35 to 92 percent of people diagnosed with RBD later develop a neurodegenerative disease.
People with RBD symptoms may be experiencing effects from a medication or substance, but people with prolonged symptoms should be evaluated for related conditions.
Rapid Eye Movement Sleep Behavior Disorder Treatment
Because the symptoms of RBD only occur when people are asleep, behavioral interventions for RBD are limited to actions like moving objects away from the bed, placing a pad on the floor next to the bed or putting adult safety rails on the bed.
Some lifestyle changes like avoiding caffeine or alcohol can improve sleep and work well as general REM sleep disorder treatment. However, these changes cannot address the factors underlying REM sleep behavior disorder. Some clinicians recommend general sleep hygiene tasks like keeping a regular sleep schedule as RBD sleep disorder treatment not because they can cure the disorder, but they can reduce the frequency and severity of REM sleep behavior episodes. The main element of REM sleep behavior disorder treatment is always medication.
Medications for Treating REM Sleep Behavior Disorder
Clonazepam (Klonopin) is the most effective medication for REM sleep behavior disorder. However, it is not recommended for people with substance use disorders or people who are at risk of drug interactions. Melatonin is nearly as effective as clonazepam for RBD and has fewer risks and side effects. It works well as a general REM sleep medication for people with a variety of conditions that affect REM sleep including jet lag, shift work, and insomnia.
People who have RBD have to work carefully with treating professionals to make sure that the medications they are taking for other conditions do not interfere with their sleep or cause their RBD symptoms to worsen. Medications that suppress REM sleep include the following:
- Stimulant drugs and medications
- Tricyclic antidepressants (TCAs)
- Monoamine oxidase inhibitor (MAOI) antidepressants
- Selective serotonin reuptake inhibitor (SSRI) antidepressants
The reason that antidepressants affect REM sleep is not fully understood, though it is most likely due to their effects on levels of serotonin and natural sleep hormones. All classes of stimulants cause surges of adrenaline and dopamine that interfere with sleep. Though the reasons are different, all of these drugs and medications have the same result: people spend less time in REM sleep and therefore wake up feeling less rested.
Over time, this can cause symptoms of depression to get worse. Because of these side effects, people with comorbid RBD and depressive disorders may need to work with physicians to find alternatives to common antidepressants or use other treatment strategies.
Rapid Eye Movement Sleep Behavior Disorder and Substance Abuse
While RBD most commonly occurs in older adults in the early stages of Parkinson’s or other neurodegenerative diseases, it can also be present in different contexts. People with alcohol or sedative dependence sometimes develop REM sleep behavior disorder symptoms during the withdrawal period from these substances. Other people may experience RBD or its symptoms when they are using substances that suppress REM sleep like caffeine, alcohol, marijuana and opioids. These drugs can significantly increase the risks associated with a lack of REM sleep.
Effects of Substance Abuse on REM Sleep Behavior Disorder Symptoms
People who already have RBD are likely to experience more severe sleep disturbances when they use substances, especially alcohol, marijuana and stimulants. The way the brain regulates REM sleep is still not fully understood and researchers continue to find that different drugs can trigger a wide range of sleep-related symptoms. For example, while benzodiazepines are often used to treat REM sleep behavior disorder, they may make it worse in some individuals.
People with RBD sometimes experience initial symptom relief from substances that suppress REM sleep. At other times, they may have an immediate negative reaction to them. In general, substance use degrades the quality of sleep and can cause insomnia or other sleep disorders. Sleep deprivation can trigger symptoms of anxiety, depression and even psychosis.
Rapid Eye Movement Sleep Behavior Disorder and Alcohol
Sleep disruptions are a frequent side effect of alcohol use even for people who only drink on rare occasions. Sleep problems can become chronic and pronounced for people who consume alcohol regularly, especially people who meet diagnostic criteria for alcohol dependence.
One common experience associated with alcohol use is rapidly falling asleep, only to wake up a couple of hours later and not be able to return to sleep for several hours. The effect is more pronounced for people who are over 50 who naturally wake up more often during the night compared to those that don’t.
Alcohol affects different neurotransmitters and systems in the brain that regulate sleep. It can suppress REM sleep, causing people to wake up from a full night of sleep feeling like they hardly slept at all. It can also make people restless during sleep, more prone to vivid nightmares and symptoms of RBD. People often act out their dreams in ways that meet criteria for REM sleep behavior disorder when they experience alcohol withdrawal.
REM Sleep Behavior Disorder and Marijuana
Like alcohol, many people use marijuana to relax and even to help them go to sleep. Some people prefer cannabis because they perceive it as having fewer risks and adverse health consequences than alcohol. However, for people with sleep disorders, marijuana can cause similar severe sleep disruptions. Research shows cannabis suppresses REM sleep and reduces sleep quality in general. Reduced sleep quality can cause it to have a backlash effect for people with REM sleep behavior disorder, initially reducing episodes of acting out dreams, then causing them to become more severe over time.
Rapid Eye Movement Sleep Behavior Disorder and Stimulants
While people use different stimulants in different contexts, and while each one works slightly differently, they all trigger similar effects in the brain and body. The sleep-suppressing effects of stimulant drugs are well-known and are why many people take them. In addition to caffeine, the stimulants people use most often include the following:
- MDMA (Ecstasy)
- Prescription stimulant drugs like Adderall
- Synthetic stimulant drugs like “bath salts“
Students sometimes abuse stimulants to help them stay up all night to complete a paper. Many overnight workers take them to support their bodies fight against the instinct to be asleep at night and awake during the day. These uses are especially common for illegal or over-the-counter amphetamines, Adderall and other prescription stimulants. People are more likely to take stimulants like cocaine, Ecstasy, bath salts and methamphetamines in social contexts or for entertainment or pleasure.
All stimulants activate the sympathetic nervous system and increase levels of dopamine and adrenaline. People who use stimulants can force themselves to feel more alert and function without sleep on a short-term basis. Unfortunately, over time, these effects are lessened and can lead to chronic fatigue and insomnia.
People with insomnia, RBD or other sleep disorders may resort to abusing stimulants to help them stay awake and alert the day after a poor night’s sleep. Unfortunately, this quickly leads to a negative cycle in which the stimulants they take to counter the effects of poor sleep cause the quality of their sleep to worsen steadily.
Drug Abuse as a Cause of REM Sleep Behavior Disorder
People who develop REM sleep behavior disorder may already have abnormalities in brain function that are linked to genetic factors. Substance use can’t cause the neurodegenerative diseases related to these differences, but it can hasten their onset and worsen their symptoms. It can also cause shorter-term RBD associated with substance-induced changes to the brain. Changes to neurotransmitters and sleep hormones can interfere with the quality and frequency of REM sleep as well as natural processes like the suppression of movement during REM sleep.
Treatment for REM Sleep Disorder with Co-Occurring Substance Abuse
Unlike other DSM-5 disorders, REM sleep behavior disorder is primarily biological and does not require psychotherapy to treat. Coordinating its treatment with substance abuse treatment is as simple as making sure physicians communicate with clinicians providing addiction treatment to make sure that medications for RBD are not interfering with treatment goals.
Integrated treatment becomes more complicated when people with RBD and substance use disorders have other mental health conditions. Most antidepressants suppress REM sleep, especially in people with sleep disorders. This can make it hard to control depressive symptoms without triggering worse RBD symptoms or a recurrence of substance use. It is essential that people receiving treatment for REM sleep disorders and other mental health conditions work closely with clinicians to ensure that treatment for one condition does not make another worse.
The Recovery Village operates rehab facilities across the United States with qualified staff who understand the needs of people with co-occurring conditions. Contact a representative at the Recovery Village today to learn more about integrated treatment options that can meet your needs.