What is Confusional Arousal?
Confusional arousals are episodes in which a person appears to awake from a sleeping state and exhibits strange, confused, or disoriented behavior. They may talk or open their eyes, but they are unlikely to get out of bed. Episodes usually last for only a few minutes but may last longer in some cases. Unlike other sleep disorders like sleep terrors or nightmare disorders, people who experience confusional arousals typically don’t feel intense fear or terror.
Confusional arousals typically occur during a phase of sleep called the slow-wave phase. This phase usually occurs relatively early in the sleep period, just as the person is slipping into the deepest sleep of the night. This differentiates them from other sleep disorders which occur during a sleep stage called rapid eye movement (REM) sleep.
Although someone experiencing confusional arousal may appear to be awake, they typically will not truly wake up during the episode. As a result, they will generally have no memory of the event the next day.
Symptoms of Confusional Arousal
Common symptoms of confusional arousals include:
- Sudden arousal from sleep without fully awakening
- Lack of responsiveness to other people
- Irrational responses
- Staring blankly
- Mumbling or making incoherent noises
- Lack of memory of the episode the next day
What Causes Confusional Arousal?
The exact cause of confusional arousals is unknown, but they are often associated with medical conditions, stress, and other external situations.
Some potential risk factors for confusional arousals include:
- Lack of adequate sleep
- Too much sleep
- Bad sleep environment (e.g., an unfamiliar place or one that is too noisy or bright)
- Ongoing emotional stress
- Sleep apnea
- Other sleep disorders
- Restless legs syndrome
- Antidepressant medications
Confusional arousals in adults may be associated with mental health-related issues such as bipolar disorder, anxiety disorders, or depression.
Is Confusional Arousal Hereditary?
Research suggests a strong genetic component to confusional arousals and other similar sleep disorders. Most people who experience these types of disorders, called non-REM parasomnias, also have a close family member who has experienced them.
Scientists have not yet identified a gene or genetic mutation specifically associated with confusional arousals. Likely, some people are genetically predisposed to experiencing the disorder, but some external environmental factor usually triggers the episodes.
How Is Confusional Arousal Detected?
Confusional arousals, especially those experienced by children, may not require any intervention by a doctor, therapist, or sleep specialist. However, you should seek professional help if the episodes are severe or frequent.
How Is Confusional Arousal Diagnosed?
Doctors may take several diagnostic steps when a patient is experiencing confusional arousal.
- Physical exam. A basic physical exam will screen for indications of medical conditions that could be causing the episodes.
- Blood tests. The doctor may order laboratory blood tests to rule out conditions, such as thyroid dysfunction, that may be causing the problems.
- Sleep diary. Your doctor may ask you to keep a log of your sleep over two weeks or so to look for patterns in your sleep behavior. You may also be asked to track other habits impacting your sleep, such as caffeine use.
- Sleep study. A study of your sleep patterns, which may be conducted at a sleep center, may be recommended if your doctor suspects that a condition such as sleep apnea could cause confusional arousal.
To be diagnosed with confusional arousal, which is distinct from sleep terrors or sleepwalking, a person must experience disoriented arousal from sleep in which they remain in bed and do not experience a feeling of terror.
PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.
How Is Confusional Arousal Treated?
Most cases of confusional arousals do not require treatment. Symptoms usually begin early in childhood and decrease in frequency later in childhood, often by age five. In adults and children with underlying sleep or mental health disorders, treating the underlying condition may help relieve the symptoms of confusional arousal. Treatment may also be necessary if the episodes are frequent.
Parents and caregivers of people experiencing confusional arousals can take steps to minimize the likelihood of episodes and prevent potentially harmful situations during the events.
- Ensure the person is practicing good sleep hygiene, including keeping to a regular sleep schedule and maintaining a sleep space conducive to a good night’s sleep.
- Ensure the bedroom is free of hazards, such as sharp-edged furniture.
- Stay with the person until the episode is over.
In some cases that do not respond to other interventions, doctors may recommend medications such as sedatives or antidepressants.
How Does Confusional Arousal Progress?
Confusional arousals usually do not have long-term complications. Children who experience them typically grow out of them by late childhood.
However, confusional arousal in adults may be a sign of underlying mental health conditions that require treatment. Untreated chronic confusional arousals and other sleep disturbances can lead to a wide variety of medical problems, quality-of-life complications, and mental health-related issues, including:
- Problems at work or school
- Relationship difficulties
- Accidents caused by fatigue or mental fogginess
- Anxiety or depression
- Substance abuse
- Weight gain
- High blood pressure
- Heart disease
How Is Confusional Arousal Prevented?
Good sleep habits and a healthy lifestyle can help prevent confusional arousal and other sleep disorders. Steps you can take to ensure better sleep include:
- Stick to a regular sleep schedule (even on weekends)
- Don’t eat or drink close to bedtime
- Avoid stimulating activities (e.g., watching TV, using electronics) 30 minutes before bedtime
- Use your bedroom only for sleep
- Keep your bedroom dark and cool
- Get plenty of exercise
- Limit consumption of caffeine and alcohol
- Quit smoking
- Don’t take naps
- Try meditation or relaxation techniques
Confusional Arousal Caregiver Tips
Some people with confusional arousal and other parasomnias also suffer from other brain and mental health-related issues, a condition called co-morbidity. Here are a few of the disorders commonly associated with parasomnias:
- Depression is more common in adults who experience parasomnias.
- Anxiety disorders are also commonly co-morbid with parasomnias in adults.
- People with bipolar disorder are at increased risk of confusional arousal.
Confusional Arousal Brain Science
Confusional arousals usually occur when a person is transitioning to deep sleep. Some scientists believe these episodes result from a mixed state in which part of the brain is asleep, and another part is awake. It’s possible that parts of the brain that control rational thought and memory, such as the neocortex and the hippocampus, are asleep while other parts are awake.
The mixed-state theory would help explain why people generally don’t remember their confusional arousal episodes. During dreams, which typically occur during REM sleep, the brain’s higher-level functions are more active, allowing for the creation of vivid dream narratives and memories. However, those parts of the brain are inactive during non-REM sleep, when confusional arousals usually occur, resulting in a period of apparent wakefulness that leaves no lasting impression.
Confusional Arousal Research
Title: Feasibility Study of Personalized Trials to Improve Sleep Quality
Principal investigator: Karina Davidson, PhD, MASc
New Hyde Park, NY
This pilot study aims to assess the feasibility of using N-of-1 methods in a virtual research study of melatonin intervention for poor sleep quality. Participants (N=60) will be sent a Fitbit device and three smart pill bottles, with one containing 3 mg of melatonin, one containing 0.5 mg of melatonin, and the final bottle containing a placebo pill. The first two weeks will be a baseline period, where no supplement is assigned, but data are collected, including self-report of sleep quality and duration and accelerometer-derived sleep and activity data. After successfully completing the baseline period, participants will be randomized to six 2-week intervention blocks of a 3 mg dose of melatonin, a 0.5 mg dose of melatonin, and a placebo. At the end of the trial, participants will be asked to complete the System Usability Scale, a satisfaction survey (electronic or phone/video call if they are non-responders), and participate in a virtual interview (such as over Microsoft Teams or a phone call) to inform feasibility and acceptability of protocol requirements, study materials, and personalized reports.
Title: Parents Advancing Toddler Health (PATH)
Principal investigator: Amanda R. Tarullo, PhD
Children living in poverty have a high incidence of early-developing sleep and behavior problems, which are often co-morbid. Early sleep and behavior problems are prevalent and persistent risk factors for lifelong poor mental and physical health outcomes. They may be key mechanisms underlying early and enduring socioeconomic health disparities. While effective interventions exist, low-income families have low enrollment and retention in these interventions. The stigma of treating behavior problems creates an additional barrier to treatment. This RCT aims to address these barriers to treatment for low-income children with co-morbid sleep and behavior problems. Sleep and behavior problems and family dysfunction transact across time, increasing in severity, while healthy sleep, positive child behaviors, and effective parenting can support each other across development. Thus we posit that intervention in one domain, either sleep or behavior, may improve outcomes both within and across domains.
Although early interventions can improve health equity in young children living in poverty, this promise often is not realized because of barriers to family engagement. The proposed study will target co-morbid behavior and sleep problems in early childhood, comparing child outcomes and family response to sleep and behavior interventions and investigating the novel strategy of letting families select their intervention. We will enroll 500 low-income toddlers with co-morbid sleep and behavior problems, randomized to 4 parent coaching interventions: sleep, behavior, family choice (sleep or behavior), and an active control. At baseline and 1, 5, and 9 months post-intervention, researchers will assess the child’s sleep and behavior, and family functioning. In addition, researchers will measure family preference, engagement, and perceived value of each intervention. The goals of the study are: (1) to examine the effects of evidence-based sleep and behavior interventions in young low-income children with co-morbid sleep and behavior problems on child sleep and behavior and family functioning; (2) to determine whether parents prefer, engage with, and value a sleep or behavior intervention more; and (3) to examine if giving families a choice of intervention results in higher engagement, higher perceived value and better family and child outcomes than assignment to intervention. By informing best practices for engaging low-income families to treat co-morbid sleep and behavior problems, results will be critical to reducing health disparities for children living in poverty.
Title: Telehealth Delivery of Treatment for Sleep Disturbances in Young Children With Autism Spectrum Disorder
Principal investigator: Cynthia Johnson, PhD
The Cleveland Clinic
Ninety children with Autism Spectrum Disorder (ASD), between the ages of 2 and 7 years, and their parents will be recruited for this ten-week randomized clinical trial. Participants will be randomized to five individually delivered sessions of Sleep Parent Training (SPT) or five individually delivered sessions of Sleep Parent Education (SPE). Delivery of the programs will be via a telehealth platform that includes parent-child coaching in real-time. In addition to baseline, outcome measures will be collected at week 5 (midpoint of trial) and week 10 (endpoint of trial), as well as follow-up at week 16, to determine the durability of the treatment.
This study will deliver an already initially tested manualized parent training program especially targeting bedtime and sleep disturbances, but delivered via a telehealth platform and enhancing the program using live parent coaching at bedtime. Utilizing REDCap automated survey invitations feature, investigators will provide reminders of the intervention recommendations and data collection requirements. In a randomized clinical trial of 90 children with ASD, ages 2 to less than seven years, a parent training program targeting sleep disturbance (Sleep Parent Training; SPT) will be compared to Sleep Parent Education (SPE). The investigators hypothesize that SPT will be superior in improving child sleep, child daytime functioning as well as parent well-being compared to SPE.