Diagnostic Criteria

A. Repeated episodes of arousal during sleep associated with vocalization and/or complex motor behaviors.

B. These behaviors arise during rapid eye movement (REM) sleep and therefore usually occur more than 90 minutes after sleep onset, are more frequent during the later portions of the sleep period, and uncommonly occur during daytime naps.

C. Upon awakening from these episodes, the individual is completely awake, alert, and not confused or disoriented.

D. Either of the following:

  1. REM sleep without atonia on polysomnographic recording.
  2. A history suggestive of REM sleep behavior disorder and an established synucleinopathy diagnosis (e.g., Parkinson's disease, multiple system atrophy.)

E. The behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (which may include injury to self or the bed partner).

F. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

G. Coexisting mental and medical disorders do not explain the episodes.

Differential Diagnosis

Other parasomnias

Confusional arousals, sleepwalking, and sleep terrors can easily be confused with REM sleep behavior disorder. In general, these disorders occur in younger individuals. Unlike REM sleep behavior disorder, they arise from deep NREM sleep and therefore tend to occur in the early portion of the sleep period. Awakening from a confusional arousal is associated with confusion, disorientation, and incomplete recall of dream mentation accompanying the behavior. Polysomnographic monitoring in the disorders of arousal reveals normal REM atonia.

Nocturnal seizures

Nocturnal seizures may perfectly mimic REM sleep behavior disorder, but the behaviors are generally more stereotyped. Polysomnographic monitoring employing a full electroencephalographic seizure montage may differentiate the two. REM sleep without atonia is not present on polysomnographic monitoring.

Obstructive sleep apnea

Obstructive sleep apnea may result in behaviors indistinguishable from REM sleep behavior disorder. Polysomnographic monitoring is necessary to differentiate between the two. In this case, the symptoms resolve following effective treatment of the obstructive sleep apnea, and REM sleep without atonia is not present on polysomnography monitoring.

Other specified dissociative disorder

Unlike virtually all other parasomnias, which arise precipitously from NREM or REM sleep, psychogenic dissociative behaviors arise from a period of well-defined wakefulness during the sleep period. Unlike REM sleep behavior disorder, this condition is more prevalent in young females.


Many cases of malingering in which the individual reports problematic sleep movements perfectly mimic the clinical features of REM sleep behavior disorder, and polysomnographic documentation is mandatory.

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