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Nocturnal Awakenings (NA); Difficulty Maintaining Sleep (DMS); Non Restorative Sleep (NRS); Global Sleep Dissatisfaction (GSD); Automatic Behaviors during Sleep (ABS)


Lady Macbeth, Sleepwalking - Henri Fuseli (1784)

From Confusional  Arousal to Automatic Behaviors during Sleep

August 27th, 2011

Stanford Sleep Epidemiology Research Center (SSERC)


Scope of the Meeting

Last edited | 10/12/2015 | by Maurice M. Ohayon, MD, DSc, PhD
Additional Information | Confusional Arousals | Sleep Violence | Sleepwalking | Sleep Driving | SleepSex | Sleep Eating | Publications


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


  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



  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



  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.



Yves Dauvilliers, MD, PhD
Professor of Neurology
Director, Sleep Center
University of Montpellier, France

Christina Gurnett, MD, PhD
Department of Neurology
Division Pediatric Neurology
Washington University, St-Louis
Christian Guilleminault, MD
Professor of Psychiatry & Behavioral Sciences
Stanford Sleep Clinic, Redwood City
Stanford University, Palo Alto
Andrew Krystal, MD, MS
Professor of Psychiatry & Behavioral Sciences
Director, Sleep Res. Laboratory
Duke University, Durham

Jacques Montplaisir, MD, PhD
Professor of Psychiatry
Chair, Sleep Medicine
University of Montreal

Ohayon, MD, DSc, PhD
Professor of Psychiatry & Behavioral Sciences
Director, Stanford Sleep Epidemiology Ctr
Stanford University, Palo Alto
David Spiegel, MD
Professor & Associate Chair of Psychiatry & Behavioral Sciences
Stanford University, Palo Alto
Michael Vitiello, Ph.D.
Professor of Psychiatry and Behavioral Sciences
Senior Scientist, Sleep Res. Group
University of Washington, Seattle
Yun Kwok Wing, MD, PhD
Professor of Psychiatry
Chinese University of Hong-Kong, China
Phyllis Zee, MD, Ph.D.
Professor of Neurology
Director, Sleep Disorders Program
Northwestern University, Chicago

Associate Participants


Julia Stingl/Kirchheiner, MD, PhD
Professor of Clinical Pharmacology
University of Ulm, Germany
Damien Leger, MD, PhD
Professor of Neurology
Centre du Sommeil et de la vigilance
Hotel-Dieu Hospital
University Paris-Descartes, Paris

Mark Mahowald, MD

Professor of Neurology
Chair, Hennepin County Medical Ctr
Director, Minnesota Regional Sleep Disorders Ctr
University of Minnesota, Minneapolis

Mark Pressman, PhD

Associate Professor
Director, Sleep Medicine Services
Lankenau Institute for Medical Res.
Jefferson Medical College

Carlos Schenck, MD
Professor of Psychiatry
Minnesota Regional Sleep Disorders Ctr, Hennepin County Medical Ctr
University of Minnesota, Minneapolis