From Confusional Arousal to Automatic Behaviors during Sleep

Scope of the Meeting

Sleep drunkenness, or Confusional Arousal, or Excessive Sleep Inertia is a sleep disorder characterized by periods of mental confusion occurring upon wakening at night or in the morning or during the day after a nap.

The individual presents an alteration of cerebral reactivity to external stimuli which occurs in the transitional period from NREM sleep to wakefulness (Broughton, 1968). The affected subject appears awake but behavior may be very inappropriate, with memory deficits, disorientation in time and space and slow mentation and speech.

Laboratory studies have shown it exists a period of sleep inertia that occurs upon the awakening (Achermann et al., 1995; Balkin & Badia, 1988; Jewett et al., 1999). This period is characterized by a reduced vigilance and impaired cognitive response which return to normal within 30 minutes to more than one hour. The severity of sleep inertia or the time course of its dissipation is not related to the sleep stage when the awakening occurs (Jewett et al., 1999). In animals, sudden awakenings by an external stimuli from non-REM sleep, provoke a reduction of the pre-pulse inhibition of the startle reflex which is not observed in spontaneous arousals. This mechanism would play a protective role for the survival of the animal that needs to response quickly to potential threats when it is suddenly aroused (Horner et al., 1997).

From an epidemiological perspective:

  1. In a representative sample from the United Kingdom, Germany and Italy (13057 subjects - Ohayon et al, 2000)
    • Confusional Arousals were reported by 2.9% of the sample;
    • 1% of the sample also presented memory deficits (53.9%), disorientation in time and/or space (71%) or slow mentation and speech (54.4%);
    • 1.9% (1.7% to 2.1%) reported confusional arousals without associated features.
    • Younger subjects (< 35 years) and shift or night workers were at higher risk of reporting confusional arousals.
    • These arousals were strongly associated with:
      • A mental disorder with odd ratios ranging from 2.4 to 13.5: Bipolar and anxiety disorders were the most frequently associated mental disorders.
      • Obstructive Sleep Apnea Syndrome (OSAS)
      • Hypnagogic or hypnopompic hallucinations
      • Violent or injurious behaviors
      • Insomnia and hypersomnia
      • Shift or night workers have a high occurrence of confusional arousals which may increase the likelihood of inappropriate response by employees sleeping at work
  2. In a U.S. representative sample (15929 subjects, Ohayon 2011), we confirmed the results of our previous epidemiological study: Confusional Arousals are associated with hallucinatory phenomena that could be responsible for Automatic Behaviors or Violent Behaviors (Ohayon & Schenk, 2010).

This Symposium will address the issue of Confusional Arousals and the place of Automatic Behaviors in Sleep Medicine (Disorder of Sleep or Disorder of Arousal or Dissociative Disorder). Participants will discuss biological, genetic, clinical, pharmacological evidences and implications.


Saturday, August 27th, 2011

08:15 - 08:30 Maurice Ohayon, MD, DSc, PhD, Chair
Welcome / Overview of the meeting
08:30 - 09:10 Maurice Ohayon, MD, DSc, PhD
From Confusional Arousals to Automatic Behaviors in the US General Population
09:10 - 09:50 Yun Kwok Wing, MD, PhD
Automatic Behaviors During Sleep Among Psychiatric Populations
09:50 - 10:05 Discussion Are longitudinal and familial surveys able to identify predictive factors and/or vulnerability factors of Automatic Behaviors during Sleep ?
Confusional Arousals and Automatic Behaviors: Prevalence and risk factors. Are Mental Disorders a risk factor?
Confusional Arousals, Sleep Inertia, Automatic Behaviors: a same entity?
10:05 - 10:20 Break
10:20 - 11:00 Christina Gurnett, MD, PhD
Sleepwalking And Genetics
11:00 - 11:40 David Spiegel, MD
Unwelcome Arousal: Parasomnias and PTSD
11:40 - 12:20 Andrew Krystal, MD, MSc
Are Psychotropic Drugs Triggers for Automatic Behaviors During Sleep?
12:20 - 12:35 Discussion
Genetic, mental and iatrogenic vulnerability for Automatic Behaviors during Sleep
Is Automatic Behavior a Dissociative Disorder?
Psychotropic Drugs: Therapeutic agents or Automatic Behavior triggers?
12:35 - 13:45 Lunch
13:45 - 14:25 Phyllis Zee, MD, Ph.D.
14:25 - 15:05 Yves Dauvilliers, MD, PhD
Clinical aspects and pathogenesis of sleepwalking
15:05 - 15:45 Jacques Montplaisir, MD, PhD
Sleepwalking: sleep disorder or disorder of arousal?
15:45 - 16:05 Discussion
How to explain Sleepwalking and other Automatic Behaviors during Sleep?
Automatic Behaviors: Sleep Disorder or Arousal Disorder?
Sleepwalking and its treatment - Sleepwalking as an effect of the medications
16:05 - 16:25 Break
16:25 - 17:05 Christian Guilleminault, MD
Sexual Behavior During Sleep
17:05 - 17:45 Michael Vitiello, PhD
Confusional Arousals and Automatic Behaviors during Sleep: Risk Factors in the older adult population
17:45 - 18:05 Discussion
Sexual Behaviors during Sleep and their association with Mental Disorders?
Are Sexual Disorders during sleep, Eating Disorders during sleep similar to Sleepwalking?
How to characterize the Confusional Arousals of Elderly people? Role of the medications?
18:05 - 18:40 Associate participants
Report about their presentations
18:40 - 19:10 Maurice Ohayon, MD, DSc, PhD, Chair
General Discussion
Place of Confusional Arousals and Automatic Behaviors in the DSM-5
From Confusional Arousals to Automatic Behaviors: future directions


Sunday, August 28th, 2011

08:00 - 08:15 Overview of the Symposium
08:15 - 10:00 General Discussion
10:00 - 10:30 Closing Statements


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This activity is supported by an Educational Grant from Neurocrine Biosciences to Stanford University.