The symptoms of REM sleep behavior disorder (RBD) can vary in severity. While they’re asleep, a person with RBD looks as if they’re acting out a bad dream and may:
About 8 in 10 people with RBD experience sleep-related injuries.
An episode may happen once during a sleeping period or several times. Episodes can also happen every time you sleep or just once in a while. The symptoms tend to be more severe if a person is acting out a violent nightmare.
People who have RBD aren’t aware of their behaviors during sleep. Many people only find out they have RBD when their bed partner or roommate tells them about their behavior or when they wake up with an injury.
When a person is having an episode, you can typically wake them up easily. When they wake up, they’re usually alert and can remember details of the dream. This is different from night terrors, in which people are typically difficult to wake up and are confused once they’re awake.
Obstructive sleep apnea (OSA) can mimic symptoms of RBD. This is called “pseudo RBD.” In this case, treatment of OSA can eliminate the behaviors.
Normally, most of your body’s muscles (mainly skeletal muscles) are temporarily paralyzed during REM sleep while you’re dreaming so you can dream safely. This is called muscle atonia.
For people with REM sleep behavior disorder, temporary paralysis doesn’t happen. Because of this, they can unknowingly act out their dreams and speak while they sleep. Researchers don’t know why exactly this happens, as many complex neural pathways are involved in REM sleep.
One theory for isolated (idiopathic) RBD is that an issue in the part of your brainstem called the pons leads to REM sleep without atonia. Certain cells in the pons control muscle paralysis during REM sleep. Lesions (damaged tissue) in the pons are also associated with Parkinson’s disease, Lewy body dementia or multiple system atrophy (MSA). As isolated RBD and these conditions are closely linked, researchers believe an issue in the pons may be the cause.
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One study showed that 97% of people with isolated RBD had one of these conditions within 14 years of their RBD diagnosis, with Parkinson’s disease being the most likely.
People with narcolepsy lack orexin (hypocretin), a brain chemical that regulates sleep, wakefulness and appetite. This lack may fail to stabilize REM sleep, leading to RBD.
Researchers think that certain antidepressants can cause RBD due to imbalances in dopamine and serotonin (neurotransmitters), which are involved in REM sleep.
If you have symptoms of REM sleep behavior disorder (RBD), it’s important to see a healthcare provider. They’ll ask you questions about your symptoms and medical history. If you have a bed partner or housemates, your provider will likely want to ask them questions about your sleeping behavior.
Your provider will also perform a physical exam and a neurological exam. They may refer you to a sleep specialist.
To receive a diagnosis of REM sleep behavior disorder, you’ll undergo an in-lab video sleep study — or polysomnogram (PSG). Sleep studies are tests that record specific body functions during sleep, such as your:
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According to the International Classification of Sleep Disorders, a diagnosis of RBD requires all of the following:
The main goal of treatment for REM sleep behavior disorder (RBD) is to create a safe sleeping environment for you and your bed partner. This can involve certain strategies and medications.
Steps to create a safer sleeping environment include:
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If the symptoms are severe, it may be safest for your bed partner if you sleep alone in a different room.
You should also try to avoid drinking alcohol, as this can trigger an RBD episode and make the condition worse.
If your symptoms are severe and safety measures aren’t enough to prevent injury, your healthcare provider may prescribe medication to manage your symptoms. While there aren’t any U.S. Food and Drug Administration (FDA)-approved medications specifically for RBD, studies have shown that melatonin, clonazepam and pramipexole can reduce symptoms in some cases.
Melatonin is a hormone your pineal gland naturally makes that’s essential for regulating your sleep cycle. However, there are also synthetic forms of melatonin. It’s considered the first-line medication for treating RBD, as it rarely causes side effects. Your provider will likely recommend starting at a baseline dose and then increasing the dose until your symptoms improve.
Clonazepam is a sedative. Researchers aren’t sure why it helps treat RBD. Most people with RBD who take a low dose of clonazepam before they sleep have few or no nightmares, vocalizations or dream enactment behaviors. Clonazepam can cause unpleasant side effects. Because of this, your provider may only prescribe it if melatonin doesn’t help.
Pramipexole is a dopamine agonist. Providers primarily prescribe it to treat Parkinson’s disease and restless leg syndrome, but recent research shows that it can help treat the symptoms of RBD. Researchers think this medication works because RBD may be a dopaminergic deficiency disorder.
The prognosis (outlook) of REM sleep behavior disorder depends on a few factors, including:
The most important implication of RBD is its association with neurological conditions, particularly Parkinson’s disease, multiple system atrophy and Lewy body dementia. More and more research suggests that RBD can be one of the earliest warning signs of these conditions. This is the case when RBD develops spontaneously and isn’t due to narcolepsy or taking medications.
RBD can cause serious injury to you and/or your bed partner, so it’s important to seek treatment.
People who have RBD in addition to a neurological condition often have a poor prognosis. For example, quality of life is worse in people who have early Parkinson’s disease and RBD than in people who have early Parkinson’s disease without RBD.
Due to the potentially violent nature of their movements, people with REM sleep behavior disorder can put themselves — and their bed partner — at risk of injury. It can also cause frequent sleep disruptions, which can affect your overall quality of sleep.
Injuries can include:
In some cases, these injuries can be life-threatening.
Up to 90% of partners of people with RBD have sleep issues. Over 60% have experienced a physical injury.
Because of this, it’s important to seek treatment for RBD — or at the very least create a safer sleeping environment.
In most cases, there’s nothing you can do to prevent RBD. This is because the condition has risk factors that you can’t prevent or change, such as your age or having narcolepsy or a neurodegenerative condition.
If substances like alcohol cause RBD or make it worse, stopping the use of these substances can make RBD go away.
If you’ve received a diagnosis of isolated RBD, you’ll likely need to see your healthcare provider regularly to check for signs of the neurological conditions that are strongly associated with it.
If you develop any other symptoms, such as issues with movement or cognitive changes, see your provider.
If you or your bedpartner are injured as a result of RBD, see your provider.
REM sleep behavior disorder (RBD) isn’t a mental health condition, such as a mood disorder or an anxiety disorder. RBD is a sleep disorder — specifically, a parasomnia.
Unknowingly causing injury to yourself or your bed partner while you’re asleep can be distressing. If your partner has told you that you act out your dreams, talk to a healthcare provider. They can recommend a sleep study to diagnose REM sleep behavior disorder (RBD) and suggest treatment options. More than anything, it’s essential to create a safe sleeping environment to prevent injuries.
Yelling, kicking, walking and even eating in your sleep can be serious. When you have parasomnias, Cleveland Clinic’s sleep experts can help.
Last reviewed on 11/22/2022.
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