When It's Not Just a Bad Dream

Long before I knew there was a condition called REM (rapid eye movement) sleep behavior disorder, I experienced a mild form of it as my spouse's sleep partner. He acted out dreams verbally and physically. In our younger days it was something we laughed about the next day, but with age, the enactments became more pronounced.

When he landed on the floor multiple times, we had to take action. One railing went up on the side of the bed to no avail, leading to a second rail. The flailing and kicking became a danger to him and me. That's when I did an Internet search and found an exact match simply typing in "violent sleep movements." REM sleep behavior disorder (RBD for short) pops up.

REM is the phase associated with our dream state that comprises 20% of our sleep, primarily during the second half of the night. For most of the population, our body provides a temporary paralysis of our muscles, called sleep atonia, that prevents us from dream enactment. In the case of an individual with RBD, atonia doesn't kick in and the individuals may find themselves kicking, flailing arms and vocalizing.

My husband's dream enactment was usually preceded with guttural vocalizations. I began to sleep lightly so that I could awaken him at the first sign of enactment. The situation was unsustainable, so he found an effective treatment, melatonin, which works by enhancing the action of hormones that promote sleep. 

Louis Saffran, M.D. director of the Mount Sinai South Nassau Center for Sleep Wellness, has studied pulmonary, critical care and sleep medicine for more than 25 years. He acknowledges that some individuals with RBD may want to begin with melatonin, a mild treatment not known to have significant side effects, but says his preference is a long-acting tranquilizer. "The most effective treatment for RBD is clonazepam," he says.

A third potential treatment was identified by a team of researchers from Mount Sinai Hospital and published in May 2023, suggesting the use of insomnia medication to treat RBD. Andrew Varga, M.D., is a neuroscientist and physician at the Mount Sinai Integrative Sleep Center and associate professor of medicine at the Icahn School of Medicine at Mount Sinai, who worked on the study. Varga explains his reason for looking for an alternative treatment for RBD is because "the most common RBD treatment — the sedative clonazepam — has a potential for addiction and withdrawal. [And] melatonin, sold over the counter, may not be strong enough to reduce symptoms."

The study demonstrated that insomnia medications, known as DORAs (dual orexin receptor antagonists), can reduce RBD symptoms and with further development, may be the right level of intervention. Plus they are already approved by the FDA for insomnia treatment.

"The goal in RBD treatment is not to cure the disorder, because there is no known cure," Varga says. "But movements can be made less vigorous and less frequent." Even when treated, patients and their partners may still experience some degree of dream enactment and vocalization.

Saffran advocates putting safeguards in place, such as barriers and cushions, but adds, "The only way to gain 100% prevention of harm caused by RBD to a sleep partner is for the couple to sleep separately."

Reducing symptoms is the first step in addressing RBD, but it is important to identify potential underlying causes. Saffran says, "RBD is a degenerative nerve condition that can be an early indicator of other neurological disorders including Parkinson's disease or dementia."

Saffran continues, "Individuals usually do not remember the incidents unless they are awakened at the time." Observation at a sleep clinic may help: Patients who stay overnight for monitoring at the sleep clinic where Saffran is the director are often referred to a neurologist.

Saffran and Varga both emphasize the importance of seeking early diagnosis of underlying pathologies and viewing RBD as a literal wakeup call. The disorder is progressive and can get worse with time. "The medical community has become increasingly more interested in detecting RBD not only to alleviate the symptoms of those experiencing it, but also as a path to early intervention in detecting and treating other conditions," Varga explains.

RBD is still considered a rare occurrence, affecting about 3 million Americans, with most over age 50, or about 2% of the population in that age range. However, I asked if the condition is underreported.

Saffran says he believes the number of individuals affected by RBD is a reliable estimate, adding, "Anyone who is experiencing these violent dream enactments will at some point bring it to the attention of a doctor." This disregards the segment of the population that may not recognize the sleep disorder as a medical problem, or if they do, presupposes that they have access to a physician and health insurance.

Varga, on the other hand, says he "absolutely believes it is underreported." Individuals living alone are either not aware they are dream enacting or ignore it because they aren't bothering anyone. In the case of couples facing this challenge, they may simply decide to sleep separately so they can each get a good night's rest.

In a social conversation, a friend confided to me that her husband often had violent movements in his sleep, sometimes at her peril, which he didn't remember unless she woke him up. When I asked if either of them had brought the subject up with their doctor, she answered that they had not. Is RBD more common than the medical community reports? Perhaps, only the sleep partners know for sure.

Linda Goor Nanos is a practicing attorney, author, wife, mother and grandmother. Her writing credits include a memoir "Forty Years of PMS," professional articles and published essays on life lessons. Read More