Dream enactment behavior: review for the clinician

Dream enactment behavior—physically acting out dreams—occurs occasionally in normal children and adults, but disruptive or frequent episodes warrant clinical attention. The behavior often begins with emotionally charged dream content that breaks through normal REM sleep muscle paralysis. Temporary disruption of REM motor suppression can arise from circadian disruption, sleep apnea, or medications. Chronic, severe dream enactment results from neurological damage in degenerative, autoimmune, or infectious disorders. Evaluation requires a structured sleep history, physical exam, and selected testing. Understanding the context and cause guides effective therapy.

Study at a glance

Abstract

Dream enactment behavior commonly occurs on occasion in normal children and adults. Disruptive and frequent dream enactment behavior may come to the attention of the clinician either as the primary reason for consultation or as a prominent characteristic of a patient with other sleep disorders. Questioning patients with chronic neurologic and psychiatric disorders may also reveal previously unrecognized behavior. In the absence of sleep pathology, process of dream enactment likely begins with active, often emotionally charged dream content that may occasionally break through the normal REM sleep motor suppressive activity. Disrupted sleep resulting from many possible causes, such as circadian disruption, sleep apnea, or medications, may also disrupt at least temporarily the motor-suppressive activity in REM sleep, allowing dream enactment to occur. Finally, pathological neurological damage in the context of degenerative, autoimmune, and infectious neurological disorders may lead to chronic recurrent and severe dream enactment behavior. Evaluating the context, frequency, and severity of dream enactment behavior is guided first and foremost by a structured approach to the sleep history. Physical exam and selected testing support the clinical diagnosis. Understanding the context and the likely cause is essential to effective therapy. Baltzan M, Yao C, Rao C, Rizzo D, Postuma R. Dream enactment behavior: review for the clinician. J Clin Sleep Med. 2020;16(11):1949–1969.