The behaviors of RBD widely vary from night to night and over time in the same individual and between patients. Contrary to the classic descriptions of RBD necessarily causing complex, dangerous dream-enactment episodes, the majority of movements in RBD are discrete and seemingly benign and may thus remain unnoticed for months to years. These movements are small twitches and brief jerks primarily affecting the extremities, occurring every few seconds to every few minutes, and they may not be related to specific dream contents. However, complex and potentially dangerous behaviors related to dream enactment can occur at any time on a given night or during the course of the disorder, which can be distressing and difficult to explain to bed partners, family, and clinicians. It is not unusual for patients with RBD to wonder whether they may be dealing with a psychological condition. On the contrary, research has shown that RBD manifestations and the dream mentation that patients may recall are largely independent of the individual’s daytime personality. For individuals without RBD, bizarre dream mentation is masked by the REM sleep atonia. Notably, RBD is common, afflicting 80 million patients worldwide, with age being the greatest risk factor. Community survey data suggest that approximately 1 in 20 older individuals may have RBD.
Helping patients to understand the nature of REM sleep and how dream enactment can be unleashed is a critical first step. Insight helps patients address the distress that can occur on awakening from a dream enactment episode and explain the nature of their condition to concerned family members, maintain treatment strategies even when dangerous dream enactment is sporadic, and adhere to long-term neurologic disease monitoring.
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