Rapid Eye Movement Sleep Behavior Disorder DSM-5 327.42 (G47.52)
DSM-5 Category: Sleep-Wake Disorders
Introduction
The DSM-5 provides a comprehensive explanation of Rapid Eye Movement Sleep Behavior Disorder (RBD). It is described as a parasomnia; or excessive motor activity during dreaming in association with loss of skeletal muscle atonia of REM sleep (Dauvilliers, Jennum, & Plazzi, 2013). During normal REM sleep the individual experiences a sense of paralysis; a phenomenon that is weakened with RBD (Boeve, 2010); allowing the sufferer to act out their dreams and perhaps cause injury to themselves or a bed partner. Behaviors may manifest once or more during sleep and occur along a continuum of mild (muscle twitching) to severe (reaching, grabbing, and complex motor behaviors). It is thought that the latter are reactions to events that are occurring in the RBD patient’s dream state. The disorder is rare; occurring in on 0.5 percent of the population.
Symptoms of Rapid Eye Movement Sleep Behavior Disorder
The DSM-5 offers a comprehensive iteration of symptoms of RBD. The majority of RBD patients are male, middle-aged to elderly, who are often experiencing concurrent neurodegenerative disorder such as multiple system atrophy, Parkinson’s disease or dementia. There has been conjecture that RBD might be an early symptom of these disorders (American Psychiatric Association, 2013); although this hypothesis has yet to be confirmed through research.
Any or all of these determinants may be noted by a physician or sleep expert. First, while sleeping; the patient will probably experience repeated episodes of arousal evidenced by vocalization and/or complex motor behaviors. This occurs during REM (rapid eye movement) which may be ninety minutes after the onset of sleep has begun; this may also be more frequent later in the sleep session. Too, it is not common to daytime napping; and upon awakening there is no sense of disorientation or confusion.
Further delineations to the disorder include a lack of coexisting physiological or mental disorders; with no evidence of substance abuse. RBD is also characterized by significant social or occupational distress or functioning and establishment of certain comorbid illnesses. Beyond this general explanation, there is no exact cause of this disorder.
In order to diagnose Rapid Eye Movement Sleep Behavior Disorder a neurological exam may be required. Conversely, the presence of symptoms of a neurological cause such as Parkinson’s disease could be deciding factors as well. When RBD is suspected a Polysomnographic video recording may be advised by a physician. These tests occur at sleep study centers where the patient is expected to sleep while the electrical activity of their heart, brain, respiration and muscles are being monitored. If a patient does not show symptoms of movement during REM then the illness is most likely not RBD.
Daily Life
Aside from the suggested treatments there are a number of home remedies that have been offered to minimize the risk to the RBD patient and others. This begins by ensuring that the sleep environment is devoid of potentially harmful materials. Removal of dangerous objects from the bedroom and clearing the floor and immediate area around the bed are both excellent measures. Padded rails could also be added. It may actually be necessary to place the mattress on the floor itself or cushion the area around the bed to minimize the impact of falling out of bed should that occur. It is also better that the bedroom be on the ground floor against the possibility of the RBD individual leaving the bed during an episode. It may require the bedmate to actually sleep separately for a time.
All sleep disorders left untreated can affect the health of the person who is ill as well as the sleep partner. Poor sleep can impact all other aspects of one’s life –socially, emotionally and professionally. Therefore, at the first sign of sleep problems medical intervention is advised. A full physical is usually the first order of business; and this will uncover any related physiological problems that could be causing disturbed sleep. If a sleep disorder is diagnosed; some common steps that will help everyone sleep better include embracing a healthier lifestyle. That means to stop smoking and/or drinking. These introduce substances into the body that may interrupt a good night’s sleep. Exercise is also important and keeping a normal sleep schedule will help create a routine that encourages sleep. Finally, the sleep environment itself should be absent of noise – such as a television, that may subconsciously prevent the individual from getting the proper rest.
Treatment of Rapid Eye Movement Sleep Behavior Disorder
Experts who have studied the symptoms for RBD explained in the DSM-5 have developed a series of pharmaceutical treatments in response.
The most common medication recommended for the treatment of RBD is Clonazepam. This drug is considered the single most highly effective for treating RBD; and it has a success rate of 90% in relieving symptoms while showing almost no signs of side-effects. Moreover, symptoms can begin to subside as quickly as the first dose; but often no longer than a week (Aurora, Zak, Maganti, et. al., 2010). Unfortunately, it has been found that pharmacological treatment must be on going and there has been evidence that the symptoms can reoccur after some time on the medication; perhaps as long as several years. Too, when medication is halted a return of these symptoms is almost immediate. An alternative to Clonazepam has been tricyclic antidepressants in limited cases. These and a few other medications have been shown to be much less effective; however, and may actually instigate RBD in certain patients.
RBD is one of the rare instances of a disorder found in the DSM-5 for which there are few if any suggestions for psychotherapy as well (Chen, Yu, Huang, & Lu, 2013). As the single medication, Clonazepam, has been proven to be so highly successful few alternatives have been given much consideration. However, sleep disorders are serious physical ailments and could result in the presentation of mood disorder symptoms such as depression. In that case, or with signs of comorbidity, talk therapy for both the RBD patient and/or the bed partner could prove helpful. It is not unusual for a person who may have otherwise been healthy to struggle when learning of an illness that is, for all practical purposes, life-long. A physician should be consulted who will be able to suggest additional treatment alternatives.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Aurora R., Zak R., Maganti R., Auerbach S., Casey K., Chowdhuri S, Karippot A, Ramar K, Kristo D., Morgenthaler T. (2010). Best practice guide for the treatment of REM sleep behavior disorder (RBD). J Clin Sleep Med. 2010 Feb 15;6(1):85-95.
Boeve, B. (2010). REM sleep behavior disorder: Updated review of the core features, the RBD-neurodegenerative disease association, evolving concepts, controversies, and future direction. Ann N Y Acad Sci;1184:15-54.
Chen, M.; Yu, H.; Huang, Z.; & Lu, J. (2013). Rapid eye movement sleep behavior disorder. Current opinion in neurobiology; Vol. 23, Iss. 5, p. 795.
Dauvilliers, Y.; Jennum, P.; Plazzi, G. (2013). Rapid eye movement sleep behavior disorder and rapid eye movement sleep without atonia in narcolepsy. Sleep medicine: Vol. 14, Iss; 8, p. 775.
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