Parasomnias are a type of sleep disorder that includes unusual behaviors or activities that occur while the person is falling asleep, during sleep, or upon waking from sleep. Parasomnias include those that occur during non-rapid eye movement (NREM) and others that arise during rapid eye movement (REM) sleep. These disorders can lead to challenges such as disrupted sleep, excessive daytime sleepiness (EDS), or even accidental injuries to the person or their bed partner. Some people may also start to feel anxious about going to sleep, especially if these events happen often. Insufficient sleep and other sleep disorders increase the risk of experiencing a parasomnia. We cover the most common parasomnias in this section.

NREM-Related Parasomnias

NREM-related parasomnias typically arise out of our deepest stage of sleep, NREM 3 or N3 sleep. With this stated, recall from our sections on sleep and circadian health that in childhood and adolescence, we spend more time in this stage of sleep. Surprise! These disorders are more common during childhood and become less common in adulthood. 

The three most common forms of NREM-related parasomnias, also called disorders of arousal, are confusional arousals, sleepwalking (also called somnambulism), and sleep terrors. With confusional arousals, you often remain in bed, looking around and appearing dazed or uncomprehending. Sleepwalking is self-explanatory; you walk around, but you’re actually asleep and don’t usually interact with your environment. Sleep terrors often manifest as crying or screaming, rapid heart and breathing rates, profuse sweating, and dilated pupils. There is some overlap among these disorders.¹

As mentioned above, NREM-related parasomnias usually happen during a transitional state from the stage of sleep called NREM stage 3 sleep (N3) to a lighter stage of sleep or waking. N3 sleep is the deepest stage of sleep. For instance, although you might have dreams during this time, you typically don’t remember them. Because we spend more time in N3 sleep in childhood, it is more common for NREM parasomnias to occur in the pediatric population, with about 16% of children and adolescents being affected.² As we get older, the numbers decrease but are still pretty common, affecting about 2-7 out of every 100 adults.² There isn’t a specific gene that has been found to cause NREM-related parasomnias, but there does seem to be a genetic pattern where if someone in your family has had an NREM-related parasomnia, you might be more likely to experience it, too. Because N3 increases in response to insufficient sleep,  you may find that these episodes are more likely to happen during periods of illness and even stress, or if something is fragmenting your sleep, disrupting N3 sleep.

NREM-related Parasomnias General Diagnostic Criteria²

1. Recurrent episodes of incomplete awakening from sleep
2. Inappropriate or absent responsiveness to efforts of others to intervene or redirect the person during the episode
3. Limited (e.g., a single visual scene) or no associated cognition or dream imagery
4. Partial or complete amnesia for the episode
5. The disturbance is not better explained by another current sleep disorder, medical disorder, mental disorder, or medication/substance use.

Confusional Arousal Diagnostic Criteria²

Criteria A-C must be met

1. The disorder meets general criteria for NREM disorders of arousal
2. The episodes are characterized by mental confusion or confused behavior that occurs while the patient is in bed.
3. There is an absence of terror or ambulation outside of bed.

Sleepwalking Diagnostic Criteria²

Criteria A and B must be met

1. The disorder meets general criteria for NREM disorders of arousal.
2. The arousals are associated with ambulation and other complex behaviors out of bed.

Sleep Terrors Diagnostic Criteria²

Criteria A and B must be met

1. The disorder meets general criteria for NREM disorders of arousal.
2. The arousals are characterized by episodes of abrupt terror, typically beginning with an alarming vocalization such as a frightening scream.
3. There is intense fear and signs of autonomic arousal, including mydriasis (dilated pupils), tachycardia (fast heart rate), tachypnea (fast breathing), and diaphoresis (sweating) during an episode.

Sleep-Related Eating Disorders Diagnostic Criteria²

Criteria A-D must be met

1. Recurrent episodes of dysfunctional eating that occur after an arousal during the main sleep period.
2. The presence of at least one of the following in association with the recurrent episodes of involuntary eating:

1. Consumption of peculiar forms or combinations of food or inedible or toxic substances.
2. Sleep-related injurious or potentially injurious behaviors performed while in pursuit of food or while cooking food.
3. Adverse health consequences from recurrent nocturnal eating.

3. There is partial or complete loss of conscious awareness during the eating episode, with subsequent impaired recall.
4. The disturbance is not better explained by another sleep disorder, mental disorder, medical disorder, medication, or substance use.

Recurrent Isolated Sleep Paralysis Diagnostic Criteria

Criteria A-D must be met

1. A recurrent inability to move the trunk and all of the limbs at sleep onset or upon awakening from sleep.
2. Each episode lasts from seconds to a few minutes.
3. The episodes cause clinically significant distress including bedtime anxiety or fear of sleep.
4. The disturbance is not better explained by another sleep disorder, mental disorder, medical disorder, medication, or substance use.

REM-Related Parasomnias

The primary difference between REM- and NREM-related parasomnias is the stage of sleep from which the disorders arise. REM-related parasomnias usually happen in the second half of the night, when REM sleep is more common. During these episodes, people may act out their dreams, sometimes in vivid or intense ways. Unlike other types of parasomnias, people with REM-related parasomnias are usually fully alert and aware when they wake up. The most common REM-related parasomnias are REM sleep behavior disorder (RBD) and nightmares.³

REM Sleep Behavior Disorder

As discussed in the section on sleep stages, most people don’t move much during REM sleep—even though that’s when most dreaming happens. This stillness is called REM atonia, and it’s your brain’s way of keeping you safe while you dream. But for people with RBD, that protective stillness doesn’t happen. Instead, they may physically act out their dreams—sometimes talking, kicking, punching, or even jumping out of bed. These episodes can be intense and may lead to accidental injuries, either to the person experiencing them or their bed partner. RBD is rare in children, usually only occurring in children with a central disorder of hypersomnolence, like narcolepsy, or who have a neurodevelopmental disorder. Starting, but more often soon after stopping, a  REM-suppressing medication, such as a selective serotonin-reuptake inhibitor or other antidepressants or REM-suppressing medicines, is associated with an increased risk of having RBD.¹In adults, RBD is more common in people who have a neurodegenerative condition such as Parkinson disease, dementia with Lewy bodies, Alzheimer disease, and others. In fact, RBD can precede the development of a neurodegenerative disorder by more than a decade. There is some evidence of an association between RBD and traumatic brain injury, posttraumatic stress disorder (PTSD), and stroke.⁴

RBD Diagnostic Criteria²

Criteria A-D must be met

1. Repeated episodes of sleep-related vocalization or complex motor behaviors.
2. The behaviors are documented by video-polysomnography to occur during REM sleep or, based on clinical history of dream enactment, are presumed to occur during REM sleep.
3. Polysomnographic recording demonstrates REM sleep without atonia.
4. The disturbance is not better explained by another current sleep disorder or mental disorder.

Nightmare Disorder

Nightmares can be more than just unsettling dreams—they can deeply affect how you feel during the day and how well you sleep at night. Nightmares are actually the most common type of parasomnia, affecting 4% of adults, many of whom have PTSD. Some people confuse nightmares with night terrors, however, they are very distinct (see table below). When nightmares happen often, they can start to wear you down. You might find yourself dreading bedtime or avoiding sleep altogether, which can lead to exhaustion and make things feel even harder. Nightmares can also make mental health challenges like depression or anxiety worse. And as the night goes on, these dreams often become more intense and disturbing. Nightmares typically include negative emotions such as anger, fear, anxiety, and terror.²

Nightmare Disorder Diagnostic Criteria²

Criteria A-C must be met

1. Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve threats to survival, security or physical integrity.
2. On awakening from the dysphoric dreams, the person rapidly becomes oriented and alert.
3. The dream experience, or the sleep disturbance produced by awakening from it, causes clinically significant distress or impairment in social, occupational, or other important areas of functioning as indicated by the report of at least one of the following:

• 1. Mood disturbance (eg, persistence of nightmare affect, anxiety, dysphoria)
• 2. Sleep resistance (eg, bedtime anxiety, fear of sleep/subsequent nightmares)
• 3. Negative impact on caregiver or family functioning (eg, nighttime disruption)
• 4. Behavioral problems (eg, bedtime avoidance, fear of the dark)
• 5. Daytime sleepiness
• 6. Fatigue or low energy
• 7. Impaired occupational or educational function
• 8. Impaired interpersonal/social function

The Treatment of Parasomnias

If you or someone you care about is struggling with unusual or disruptive behaviors during sleep, you’re not alone—and you’re not without options. Treating parasomnias isn’t one-size-fits-all because each person’s experience is unique. Because parasomnias include a wide range of sleep behaviors, the best treatment often depends on the specific type you’re dealing with. That said, there are some helpful steps that can make a big difference for many people.

One of the most important things you can do is take care of your sleep hygiene—this means building healthy sleep habits and creating a calming bedtime routine. Making your sleep environment safer is also key. That might include locking doors and windows, removing sharp or heavy objects from the bedroom, or using door alarms to help prevent wandering during the night. These changes can help reduce the risk of injury and bring peace of mind to you and your loved ones. It’s also important to look at what might be triggering the parasomnia—like stress, sleep deprivation, or certain medications—and work with a healthcare provider to address those factors. And just as important as any treatment is knowledge and reassurance: knowing that you’re not alone, that these experiences are real and valid, and that support is available can be incredibly comforting for you, your family, and your bed partner. For some people, cognitive behavioral therapy can be a helpful tool, especially when anxiety or trauma is involved.²

The Treatment of NREM-Related Parasomnias

Scheduled awakenings are a way to treat disorders of arousal such as confusional arousals, sleep terrors, sleep talking, and sleepwalking that usually happen at the same time every night.⁵ This technique is particularly helpful for children who have many events–at least several per week– that occur at about the same time night after night. If during the baseline monitoring, you find that your child’s parasomnias don’t occur at a fairly predictable time, this technique may be less helpful. A couple of tips to help as you consider implementing this treatment: (1) If your child has an event before or during the scheduled awakening, move the scheduled awakening 15 minutes earlier. (2) Keep in mind that this isn’t a quick fix! It may take 2-4 weeks for the parasomnias to decrease or go away–and you may have to wake up to an alarm in the middle of the night to awaken your child. In the long run, however, your hard work will pay off with more restful and restorative sleep for the whole family! 

The Treatment of Sleepwalking

Although the US Food and Drug Administration (FDA) has not approved any specific drugs for the treatment of sleepwalking, a thorough evaluation of provoking factors and implementation of safety strategies should always be performed. Focusing on good sleep habits, creating a safe sleep environment, and understanding what might be triggering the episodes can be helpful. If there is a concern of safety, such as falling downstairs, eloping, or doing other complex behaviors while still asleep, like driving, medications are commonly used. The use of scheduled awakenings, as noted above, may be helpful for people who experience sleepwalking at a similar time a few nights a week or more. Medications that are used off-label can include certain antiseizure medications, antidepressants, benzodiazepines, and even melatonin. 

The Treatment of Sleep Terrors

There isn’t currently a specific medication for sleepwalking. Focusing on good sleep habits, creating a safe sleep environment, and understanding what might be triggering the episodes can be helpful. The use of scheduled awakenings, as noted above, may be helpful for people who experience sleep terrors at a similar time a few nights a week or more.

The Treatment of REM-Related Parasomnias

The Treatment of RBD

If you’re living with RBD, one of the most important first steps is making sure your sleep environment is as safe as possible. That might mean removing sharp or heavy objects from the bedroom, securing doors and windows, or even sleeping separately from a partner in more severe cases. These changes can feel overwhelming at first, but they’re meant to protect you and those you care about—and they can bring real peace of mind. 

The American Academy of Sleep Medicine (AASM) offers several evidence-based suggestions, but they’re considered “conditional,” meaning they may work well for many people, but not everyone.⁶ For adults with isolated RBD, treatments like clonazepam, immediate-release melatonin, or pramipexole may be helpful. If RBD is linked to mild cognitive impairment, transdermal rivastigmine might be considered. For those with RBD related to Parkinson disease or other medical conditions, similar treatments may apply. If a medication is causing the RBD, stopping or changing that medication is often the first step. 

The Treatment of Nightmare Disorder

Because nightmares can affect people in different ways, the AASM separates its treatment recommendations based on whether or not someone is also living with PTSD.⁷ The highest level of evidence supports the use of prazosin for the treatment of nightmares associated with PTSD.

Living with a parasomnia can feel confusing, aggravating, or even frightening at times, but you’re not alone, and there is help. Understanding what’s happening during your sleep is the first step toward finding relief. With the right diagnosis, a supportive care team, and a treatment plan tailored to your needs, restful nights and brighter days are possible. Whether you’re just beginning to seek answers or already on your journey to better sleep, we’re here to support you.

References

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2. American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed, Text Revision. American Academy of Sleep Medicine; 2023.
3. Bruni O, DelRosso LM, Melegari MG, Ferri R. The parasomnias. Psychiatr Clin North Am. 2024;47(1):135-146.
4. Aurora RN, Zak RS, Maganti RK, et al. Best practice guide for the treatment of REM sleep behavior disorder (RBD). J Clin Sleep Med. 2010;6(1):85-95.
5. Meltzer LJ, Crabtree VM. Pediatric Sleep Problems: A Clinician’s Guide to Behavioral Interventions. American Psychological Association; 2015.
6. Howell M, Avidan AY, Foldvary-Schaefer N, et al. Management of REM sleep behavior disorder: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2023;19(4):759-768.
7. Morgenthaler TI, Auerbach S, Casey KR, et al. Position paper for the treatment of nightmare disorder in adults: an American Academy of Sleep Medicine position paper. J Clin Sleep Med. 2018;14(6):1041-1055.