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Diagnosis information
Core diagnostic criteria, specifiers, differential considerations, and documentation support in one open, scan-friendly view.
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Core criterion A
Repeated episodes of arousal during sleep associated with vocalisation and/or complex motor behaviours
Core criterion B
These behaviours arise during REM sleep and therefore occur usually >90 min after sleep onset; are more frequent during the later portions of the sleep period; and uncommonly occur during daytime naps
Core criterion C
Upon awakening from these episodes, the individual is completely awake, alert, and not confused or disoriented
Core criterion D
Either of: REM sleep without atonia on polysomnographic recording; history of RBD + established synucleinopathy diagnosis
Core criterion E
Not attributable to physiological effects of a substance or medication; not better explained by coexisting mental/medical disorders
Consistent with [REM Sleep Behaviour Disorder] [specifier(s)]. During repeated episodes of arousal during REM sleep, there have been complex motor behaviours; dream-enactment behaviours; vocalisations during sleep; behaviours occurring in association with vivid, action-filled dreams, forming a pattern consistent with loss of the normal REM atonia. The presentation is further characterised by REM sleep without atonia on polysomnography; recall of dream content consistent with enacted behaviours; risk of injury to self or bed partner. These symptoms have resulted in clinically significant distress or impairment, and the disturbance is not better explained by another sleep disorder, substance/medication effect (including antidepressants), or a primary neurological condition, although co-existing neurodegenerative disease is a key consideration and warrants clinical monitoring.
Adapt this supplied template to the assessment. It is not a substitute for diagnostic reasoning or local documentation requirements.