Table 3.

Psychological and psychiatric causes of dream enactment behavior.

Cause	DSM-5 Category	Associated Features	Frequency of DEB	Reported Correlates	References
Anxiety	Anxiety disorders	(This section does not refer to anticipatory nocturnal anxiety or “sleep phobia”) DEB may persist after treatment of daytime anxiety; Antidepressants may trigger early clinical presentation of an RBD due to underlying neurodegeneration Note: Experiencing DEBs does not indicate high daytime anxiety and depression scores.	No information	Taking SSRIs Taking SNRIs Taking tricyclic antidepressants Depression Insomnia Signs of neurodegeneration	5,49,53
Autistic disorder, Asperger disorder, or pervasive developmental disorder not otherwise specified	Autism spectrum disorder	Disorders of initiation and maintenance of sleep are almost universal Clonazepam is effective in treating abnormal motor control in sleep SSRIs may cause or contribute to lack of muscle atonia during REM sleep Children who are not medicated may not experience REM sleep without atonia 54% of children experience parasomnias Younger children experience more parasomnias	May occur nightly	Dysregulation of melatonin synthesis Sensitization to environmental stimuli Insomnia OSA Periodic limb movements Bruxism Delayed sleep phase Anxiety Depression Epilepsy	54–59
Bereavement	Major depressive disorder and depressive episodes	Occurs mostly within 5 years of loss; Dream/reality confusion; Dreams produce intensely real endings, which produce awakenings.	No information	Anxiety dreams Existential dreams Nightmares Experiencing a range of distressing emotions	60
Depression	Major depressive disorder and depressive episodes	Antidepressant medication use is associated with more frequent DEBs RBD-associated laughter is associated with depression REMREEA was associated with BDI and HADS scores (mood symptoms) and use of antidepressants Antidepressants may trigger early clinical presentation of an RBD due to underlying neurodegeneration Failure to recall enacted dreams Note: Experiencing DEBs is not indicative of high daytime anxiety and depression scores.	At least once weekly	Taking SSRIs Taking SNRIs Taking tricyclic antidepressants Taking dopaminergic drugs Insomnia Anxiety Signs of neurodegeneration	5,33,49,61–65
Postpartum state	Not applicable	63% of new mothers report some form of DEB (including expressing emotions, motor activity and speaking) Dream-associated motor activity increases postpartum Dreams mostly involve infants The propensity to enact nightmares is possibly due to an increase in their emotional intensity REM sleep deprivation may produce more intense dreams when sleep recovery occurs	At least once in the 12 weeks postpartum	Frequent sleep interruption Fluctuation in hormones such as oxytocin, prolactin, and vasopressin Insecure attachment Global symptom severity Postpartum somniloquy or somnambulism Dream anxiety Nightmares	38,60
Posttraumatic stress disorder	Trauma-associated sleep disorder (trauma- and stressor-related disorders)	Nightmare theme specifically linked to the personally experienced traumatic event (“flashbacks”) Nightmares occur both in NREM and REM sleep Excessive movements Complex vocal and motor behaviors during sleep Presents at a considerably younger age than is typical for RBD	1 Event every 4–6 weeks	RBD General REM sleep disturbances Taking SSRIs Reduction in locus coeruleus neuronal activity History of TBI Insomnia Nightmares Parasomnias	52,66–69
Sleep-related dissociative disorder	Dissociative disorders	Symptom criteria include the diagnosis of a dissociative disorder based on DSM criteria, with dissociative episodes arising during the main sleep period Vivid dreams, nightmares, dissociation and symptoms of schizotypy Potentially harmful behaviors during episodes, including walking, self-mutilation, and driving, with subsequent amnesia for these events Occur either during the transition from wake to sleep or during awakenings at night 5.3% of individuals who experience sleep-related injury, were identified as having sleep related dissociative disorder	No information	Abnormal nocturnal behaviors, such as dream enactments Schizotypal Personality; Disorder PTSD Narcolepsy Nightmare disorder	70–73

BDI = Beck Depression Inventory, DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, 5th ed., BDS = Behavior Dimensions Scale, HADS = Hospital Anxiety and Depression Scale, OSA = obstructive sleep apnea, RBD = REM sleep behavior disorder, REMREEA = sREM-related EMG activity, SSRI = selective serotonin reuptake inhibitor, SNRI = serotonin-norepinephrine reuptake inhibitor, TBI = traumatic brain injury.