Confusional Arousals & Automatic Behaviors

Confusional Arousals Category in DSM 5

Confusional arousals (CA) are awakenings, usually from N3, marked by disorientation and amnesia with blunted affect, cognition, and behavior, but sometimes punctuated by violent or sexually aggressive behavior. A PubMed Title/Abstract search of "confusional arousal" and "confusional arousals" (with no time restriction) only found 43 articles, suggesting there is muted research/clinical interest in this topic. Prevalence is estimated at 17% in children, declining to 6% in young adults, and continuing to decline to 1% in older adults. There is a strong genetic influence and environmental precipitants include abrupt awakening, irregular sleep schedule (e.g., shiftwork), obstructive sleep apnea, psychiatric disorder (e.g., bipolar disorder, anxiety, depression), alcohol abuse, and hypnotic use. Elevated CA, along with numerous other sleep disorders, are common to ADHD.

Benign manifestation of CA does not merit treatment, but when disruptive or dangerous, benzodiazepines are the treatment of choice. Anticipatory scheduled awakening or treatment of precipitants (e.g., sleep apnea, psychiatric disorder) may be effective. Recommendations for future research include:

  1. Though plausibly related to accidental injury or nonrestorative sleep, there is no systematic evidence to confirm CA contribute to accidents and little research to connect confusional arousals to nonrestorative sleep;
  2. The role of alcohol in CA has garnered conflicting data and speculation. This is needing clarification;
  3. It is not clear if CA occurring upon morning awakening or after naps is the same disorder as those occurring in the first third of the night and arising from N3;
  4. It is not known how the risk of CA is distributed among the classes of hypnotics.

From Confusional Arousals to Automatic Behaviors in the US General Population

Confusional Arousals and Automatic Behaviors during Sleep: Risk Factors in the Older Adult Population

Confusional Arousal (CA), a phenomenon also referred to as sleep drunkenness, or, or excessive sleep inertia is a fairly common sleep disorder occurring in approximately three percent of the general population. CA is characterized by a period of mental confusion, including lack of judgment and spatial/temporal disorientation, which may occur upon nighttime or morning awakening from sleep or following a daytime nap. Individuals with sleep disorders, such as sleep apnea and insomnia, are more likely to experience CA, as are those with psychiatric illnesses and memory deficits (Ohayon, 2000). Medical illness and psychoactive prescription medications may also predispose to CA.

While in the general population CA occurs most frequently in younger (< 35 yrs) individuals and those on shift and night work, its prevalence and associated risk factors within the older adult population is unclear. Many of the factors associated with CA occur with increasing prevalence in older adults suggesting that older adults may be at increasing risk for CA. Indeed, CA may itself be a risk factor for nighttime, and possibly post-nap, falls, a significant cause of morbidity and mortality in the older adult population.

Unwelcome Arousal: Parasomnias and PTSD

Parasomnias, including nightmares, poor sleep efficiency, and sleepwalking, are common symptoms of Post-Traumatic Stress Disorder (PTSD). The symptoms of PTSD as they will likely be defined in DSM-5 will be reviewed, along with the typical abnormalities in the two major stress responses systems in the body, the hypothalamic-pituitary-adrenal axis, and the sympathomedullary axis. Sleep is characterized by dominance of parasympathetic activity, so the adrenergic hyperarousal and abnormal cortisol levels typical of PTSD tend to disrupt it, triggering parasomnias. Treatments for them will be reviewed, including antidepressants and benzodiazepines. Promising evidence that prazosin, an alpha-1 adrenoreceptor antagonist, reduces nightmares and other PTSD-related parasomnias, will be presented. These treatments in the context of overall psychotherapeutic treatment for PTSD will be examined.

Confusional Arousals and Sleep Inertia

Disorders of Arousal

  • Confusional arousals,
  • Sleepwalking
  • Sleep terrors

Common features:

  • Tend to arise from slow wave sleep
  • Common in childhood
  • Cluster in families
  • Decrease with increasing age
  • Amnesia for event

NREM Sleep Arousals -Determinants

Specialized Forms

  • Sleep-related eating disorder
  • Sleepsex

How Can These Things Happen?
3 Concepts:

  1. Central pattern generators / locomotor centers
  2. State dissociation
  3. Sleep inertia

Concept #1: Central Pattern Generators / Locomotor Centers
Central Pattern Generators (CPGs) are present throughout the nervous system.Earliest movement patterns originate in the spinal cord. With maturation, come under control of brainstem pattern generators.Descending systems suppress spinal pattern generators. (Do they come out during sleep ? )The brainstem is capable of a wide variety of extremely complex behaviors in the absence of more rostral input.Decorticate experimental and barnyard animals are capable of performing very complex, integrated motor acts.

A wide variety of complex behaviors may be elicited by hypothalamic/limbic stimulation

  • Standing/walking
  • Predatory attack
  • Sham rage
  • Threat
  • Eating/drinking
  • Gnawing, grooming
  • Sexual, maternal

The brainstem contains innate determined patterns of extremely complex behaviors which may occur in the absence of higher input.(Much of sleep-generation originates in the brainstem - which remains very active during sleep.)

Concept #2: State Dissociation
State determination is the result of a large number of physiologic variables, which usually cycle in concert. The incomplete (combined) occurrence of, or rapid oscillation of, state - determining variables results in fascinating symptoms, which explain many unusual human experiences.The tonic and phasic components of the three physiologic states (W, NREM, REM) may become dissociated and recombined across states.

Concept #3: Sleep Inertia (Sleep Drunkenness)
A period of impaired performance and reduced vigilance following awakening from the regular sleep episode or from a nap. May be severe, and last minutes to hours. May be associated with polygraphically documented "microsleep" episodes

Varies greatly on an individual basisMay be thought of as the "confusional arousal" potential in all of us. Possibly disorders of arousal represent an extreme form of sleep inertia