Rapid eye movement (REM) sleep behavior disorder (RBD) is characterized by intermittent loss of REM sleep–related atonia, with the appearance of elaborate motor activity associated with dream mentation. RBD was predicted by Jouvet in 1965, when he showed in cats that loss of the atonia that normally occurs during REM sleep could be produced experimentally by specific pontine tegmental lesions.41 In 1986, Schenck and Mahowald described RBD in humans.42

The behaviors in RBD can include punching, kicking, leaping, running, talking, yelling, and any behavior that could occur during a dream. Bed partners are frequently injured, and patients may go to great lengths to prevent injury to themselves or to bed partners. Patients usually have a vivid recall of the actual dreams that correlate to the witnessed behavior. (Dream recall is not uniformly noted, and patients may not be willing to talk about the dream that led them to seek medical attention.) These events occur more commonly in the latter half of the night but can occur any time the patient enters REM sleep.

Most cases begin in late adulthood, but children as young as age 2 years have presented with symptoms of RBD. It occurs most often in men.43

Causes

RBD can be induced by medication, and cases of tricyclic antidepressants, monoamine oxidase inhibitors, and serotonin reuptake inhibitors causing RBD-like behavior have been reported. Acute forms of RBD can also occur during alcohol withdrawal and, potentially, benzodiazepine withdrawal.

About 60% of patients have no clear identifiable cause for the disorder. In 40%, an identifiable neurologic disorder such as stroke, posterior fossa tumor, demyelination, or a degenerative disorder may prevent the induction of REM sleep–related atonia.44,45

Diagnosis

The diagnosis of RBD is made by a combination of history and polysomnography.43 Patients or witnesses should give the history of sleep behaviors that are disruptive, potentially harmful, or annoying, or there should be videotape documentation of excessive limb or body jerks, complex movements, or vigorous movements during REM sleep.

The polysomnogram should demonstrate excessive EMG tone in the chin or excessive twitching of the chin or limb leads during REM sleep. The addition of an extended EEG montage is important, to exclude epileptic seizures. The events in RBD are longer and less stereotyped than seizures.

Treatment

Patients with this disorder generally respond well to clonazepam. Dopaminergic compounds, antiepileptic drugs, clonidine, and even tricyclic antidepressants may be helpful in intractable cases.

Adapted from: Malow, BA, and Vaughn BV. Sleep disorders and epilepsy. In: Ettinger AB and Devinsky O, eds. Managing epilepsy and co-existing disorders. Boston: Butterworth-Heinemann; 2002;255–267.
With permission from Elsevier (www.elsevier.com).
Reviewed and revised April 2004 by Steven C. Schachter, MD, epilepsy.com Editorial Board.