rem sleep behavior disorder ( rbd ) is fundamentally characterized by rem sleep without atonia , dream enactment behavior ( deb ) , and sleep - related injury to self or others . as the atonia , which occurs in normal rem sleep
is absent in rbd the patient exhibits complex motor behavior in response to dream mentation .
its essential clinical features include uncharacteristic abnormal vocalizations ( grunting , shouting , screaming , swearing etc . ) ; abnormal motor behavior in the form of running , jumping from bed , punching , flailing and kicking ; and altered dream mentation , which generally consist of insects or animals or bellicose strangers chasing the dreaming man and he defending against them .
unlike in normal dreams the patient retains memory of the vivid dreams for months or years .
there have been instances of catastrophes like international flights getting redirected for emergency landing and brides getting seriously injured on wedding nights because of rbd .
secondary rbd occurs in conjunction with neurological conditions ( synucleinopathies and narcolepsy ) , drugs such as selective serotonin reuptake inhibitors , tricyclics and serotonin - norepinephrine reuptake inhibitors , and psychoactive substances .
even idiopathic rbd may lead to emergence of synucleinopathies after a lapse of years in 10 - 81% of cases .
a prevalence of 0.38 - 0.5% has been reported in the west , while in the asian population the same is reported as 0.04% .
prevalence of idiopathic rbd in india is not known . in a recent report from india 19.4% of patients with parkinson 's disease ( pd )
were found to be having rbd , which is much less than the figures of 42.6% quoted in the western literature . to the best of our knowledge ,
a doctor aged 68 presented with history of violent dreams of more than 50 years duration and some strange happenings over the years .
anamnesis brought out that he started having vivid dreams of wild animals attacking him at night at 9 years of age .
on one night he attacked a person sleeping beside him with a stout stick when he dreamt of an animal attacking him .
when he was 11 he witnessed a murderous assault on his father and developed symptoms of posttraumatic stress disorder ( ptsd ) .
he would shout and scream at night once in a month or so , but exhibited no violence . at about 17
, he developed sleep attacks and after a year had a single episode of sleep paralysis associated with visual and haptic hypnogogic hallucinations .
sleep attacks resolved spontaneously after his marriage at 22 . after many years , he consulted a psychiatrist for ptsd symptoms and recovered with treatment but overly aggressive vivid dreams continued .
he would now make elaborate plans of defense while actively dreaming but did never act on his plans until he was 55 .
on one night he clobbered his brother when he saw a wild animal attacking him in dream .
he continues to get vivid violent dreams , but while dreaming he knew he was dreaming and learned to dismiss them .
he was satisfied with the knowledge that he had a sleep disorder and declined to get investigated or to take treatment .
a 64-year - old male sought psychiatric consultation for excessive dreams and violent behavior during dreams of 2 years duration .
since then he experienced vivid dreams in profusion at night nearly every day . in the dreams , he would be invariably under attack from strangers . in an effort to drive them away
, he would let out wild screams and throw punches , which invariably would land on his wife .
family members thought he was under the influence of an evil spirit at night as he would be his usual docile self during the day .
some of his friends slept by his bed side for some time but retreated after repeated hits .
his wife bore his incessant assaults stoically until one day when he delivered powerful blows to her face dislodging four of her front teeth .
he felt ashamed and left the house and came for consultation on a friend 's suggestion .
response to treatment with clonazepam 1 mg and melatonin 3 mg at night was quick : by the end of 2 week , he was free from all violent dreams but reported  normal dreams  which he could not recall . at 1 year follow - up
a doctor aged 68 presented with history of violent dreams of more than 50 years duration and some strange happenings over the years .
anamnesis brought out that he started having vivid dreams of wild animals attacking him at night at 9 years of age .
on one night he attacked a person sleeping beside him with a stout stick when he dreamt of an animal attacking him .
when he was 11 he witnessed a murderous assault on his father and developed symptoms of posttraumatic stress disorder ( ptsd ) .
he would shout and scream at night once in a month or so , but exhibited no violence . at about 17
, he developed sleep attacks and after a year had a single episode of sleep paralysis associated with visual and haptic hypnogogic hallucinations .
sleep attacks resolved spontaneously after his marriage at 22 . after many years , he consulted a psychiatrist for ptsd symptoms and recovered with treatment but overly aggressive vivid dreams continued .
he would now make elaborate plans of defense while actively dreaming but did never act on his plans until he was 55 .
on one night he clobbered his brother when he saw a wild animal attacking him in dream .
he continues to get vivid violent dreams , but while dreaming he knew he was dreaming and learned to dismiss them .
he was satisfied with the knowledge that he had a sleep disorder and declined to get investigated or to take treatment .
a 64-year - old male sought psychiatric consultation for excessive dreams and violent behavior during dreams of 2 years duration .
since then he experienced vivid dreams in profusion at night nearly every day . in the dreams , he would be invariably under attack from strangers . in an effort to drive them away
, he would let out wild screams and throw punches , which invariably would land on his wife .
family members thought he was under the influence of an evil spirit at night as he would be his usual docile self during the day .
some of his friends slept by his bed side for some time but retreated after repeated hits .
his wife bore his incessant assaults stoically until one day when he delivered powerful blows to her face dislodging four of her front teeth .
he felt ashamed and left the house and came for consultation on a friend 's suggestion .
response to treatment with clonazepam 1 mg and melatonin 3 mg at night was quick : by the end of 2 week , he was free from all violent dreams but reported  normal dreams  which he could not recall . at 1 year follow - up
though rbd is a disorder of the elderly male and generally associated with frequent deb , widely variable frequency of deb and child hood onset with narcolepsy is not unknown .
the first case had onset in child hood and violent dreams continued for over 50 years with sparse deb .
the disease appears to have made him vulnerable to ptsd as two of his siblings exposed to the same traumatic scene did not suffer from ptsd .
the longest period of conversion to any synucleinopathy after the onset of rbd that is reported in literature is 29 years ; narcolepsy in this case occurred after a lapse of nearly 10 years and resolved spontaneously ; the man himself is 68 now , endured rbd for well over 50 years and enjoying robust health .
the long period of dreaming appears to have enabled the individual to adapt to rbd .
the second case presented with classical features and responded well to pharmacotherapy . as conversion to any of the synucleinopathies ( pd , corticobasal degeneration , lewy body dementia , and multiple system atrophy ) can occur even very late ( mean age 71.9  6.6 ) in 81% of cases the diagnosis of idiopathic rbd in the second case may well have to be revised later .
the only advantage of the large gap between onset of rbd and onset of synucleionopathies is that it offers a window for proactive neuroprotective interventions to prevent synucleinopathies .
neurobiology of rbd is not yet elucidated well . in normal sleep motor tone and elaborate motor activity
is known to be inhibited by the activity of the cholinergic pedunculo pontine nucleus ( ppn ) , which through the medullary magnocellular reticular formation and ventrolateral reticulospinal tract influence the anterior horn cells of spinal cord .
recently , albin et al . demonstrated , by dtbz - pet , reduced dopamine binding in substantia nigra ( sn ) in idiopathic rbd patients .
this lends further support to the view that rbd is a marker for emerging synucleinopathies .
clonazepam up to 4 mg at bed time or melatonin up to 12 mg 30 min before bed time is recommended along with protective security measures and psychoeducation to treat this condition .
sodium oxybate 3 g at bed time and 3 g after 6 h was reported to be effective .
going by the lack of reports , rbd in general and idiopathic rbd in particular appear to be extremely rare in india , but considering the recent report from india rbd may not be as uncommon as it appears to be but apparently escaping notice because of infrequent deb
. however , deb when it does occur can be extremely dangerous as brought out in the cases illustrated here .
it is also possible that deb is more common in idiopathic rbd than secondary rbd . due to lack of awareness some cases
screening instruments are now available to identify the disease . the natural history of various forms of rbd , its clinical features and epidemiology merit serious study .
 rem sleep behavior disorder ( rbd ) is a rare parasomnia in which persons exhibit uncharacteristic violent behavior , while dreaming . 
 secondary rbd occurs due to some neurological conditions , psychoactive substance or psychotropic drug use . 
 there are no case reports on idiopathic rbd in india . 
 we report here two cases to underscore the importance of identifying the disease as behavior associated with rbd may be quite serious in nature and might lead to catastrophic consequences . 
INTRODUCTION
CASE REPORTS
Case 1
Case 2
DISCUSSION