Confusional arousal

Raman Malhotra MD (Dr. Malhotra of Washington University School of Medicine in St. Louis has no relevant financial relationships to disclose.)
Alon Avidan MD MPH (

Dr. Avidan of the University of California, Los Angeles, received consulting fees and honorariums from Harmony Bioscience for speaking engagements and service on a review panel, and from Eisai for speaking engagements.

Antonio Culebras MD, editor. (

Dr. Culebras of SUNY Upstate Medical University at Syracuse received an honorariums from Jazz Pharmaceuticals for a speaking engagements.

Originally released April 22, 1994; last updated August 2, 2020; expires August 2, 2023


Confusional arousals are non-REM sleep parasomnias that are fairly common in children and adults. The International Classification of Sleep Disorders (3rd Edition) categorizes confusional arousals as a “disorder of arousal from NREM sleep.” The episodes arise out of sleep and consist of confusion, disorientation, and amnesia for the event. The behaviors that arise from sleep occasionally may be complex, such as having conversations, dressing oneself, or even participating in sexual activity (sleep sex or sexsomnia). Confusional arousals may be comorbid in idiopathic hypersomnia, shift-work sleep disorder, or obstructive sleep apnea, or in patients recovering from sleep deprivation or taking hypnotics. Clinical presentations of confusional arousals can share many characteristics with other abnormal motor activities during sleep (such as seizures), making it difficult to correctly identify them without the aid of an in-lab polysomnogram. A study has demonstrated that certain behaviors during spells such as eye opening, raising your head, visually exploring the environment, expression of fear or surprise, talking, or interacting with the environment are more likely to occur in disorders of arousal such as confusional arousals as compared to controls (Barros et al 2020). Investigations into the pathophysiology of the condition demonstrate an immature or developing brain, which leads to sleep state instability as a major component of the pathophysiology of this condition. Studies demonstrate that patients with NREM sleep parasomnias seem to have more sleep pressure (shorter sleep latency and more total sleep time), which may lead to incomplete arousal from stage N3 sleep. Management is typically avoiding triggers, treating underlying sleep disorders (sleep apnea, restless legs syndrome), and, rarely, pharmacological treatment, especially if there is a concern about injury to self or others.

Key points


• Confusional arousals are common in both pediatric and adult populations.


• Common behaviors that arise from sleep include confusion, disorientation, and loss of memory and conversing.


• Differential diagnosis includes other non-REM and REM sleep parasomnias as well as seizures.


• Confusional arousals are seen in patients with idiopathic hypersomnia, obstructive sleep apnea, shift-work sleep disorder, or recovery sleep after sleep deprivation.

Historical note and terminology

Confusional arousals following awakenings have been recognized for centuries. In the early French literature they were referred to as l'ivresse du sommeil (Marc 1840) and in the German literature as Schlaftrunkenheit (Gudden 1905). Both translate literally as "sleep drunkenness." More recent work links them to an intensification of the normal phenomenon of transitory impaired cognition following awakenings referred to as "sleep inertia." Historically, the literature also describes cases of violence occurring when the individual is suddenly awakened. A study of normal subjects shows their decision-making performance is impaired following abrupt awakenings from slow wave sleep to the level of only 51% of baseline performance levels during the first 3 minutes; even after 30 minutes performance was still impaired as much as 20% below baseline (Bruck and Pisani 1999).

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