A bed partner or parent who tries to calm or restrain the patient by grabbing him or her may trigger a violent reaction as with sleepwalkers. In case of a confusional arousal triggered by an attempt of awakening the patient, violent behaviours may occur almost spontaneously. Unlike confusional arousals and sleep walking, patients experiencing night terrors seem to react to some type of frightening image. Therefore, the violent reaction may occur if another individual is encountered or is in proximity. Classification
International Classification of Sleep Disorders (ICSD)
According to the 2nd edition of the International Classification of Sleep Disorders (ICSD-2), confusional arousals are classified in NREM parasomnias embedded in the non-epileptic paroxysmal motor events during sleep, which include (1) Parasomnia, (2) Sleep-related movement disorders and (3) Isolated symptoms, apparently normal variants and unresolved issues. NREM parasomnias (or disorders of arousal) also include sleep terrors (see night terror) and sleepwalking. Confusional arousals are characterised by more or less complex movements without leaving bed with whimpering, sitting up in bed and some articulation without walking or terror. In comparison of other arousal parasomnias the age onset of sleep walking is generally between 5 and 10 years whereas confusional arousals and sleep terror may occur 3 years earlier. Sleep terrors are mainly characterised by screaming, agitation, flushed face, sweating and only share the inconsolability with confusional arousals. The current 3rd edition of the International Classification of Sleep Disorders (ICSD-3) added the sleep-related eating disorders in the disorders of arousal from NREM sleep.
Confusional arousals are classified as “partial awakenings in which the state of consciousness remains impaired for several minutes without any accompanying major behavioural disorders or severe autonomic responses”. Complete or partial amnesia of the episodes may be present. Signs and symptoms
Confusional arousals are accompanied by mental confusion and disorientation, relative lack of response to environmental stimuli, and difficulty of awakening the subject. Vocalisation accompanied with coherent speech is common. Patients may appear upset, and some of them become aggressive or agitated. As well as for children, attempting to awaken or console an adult patient may increase agitation. Confusional arousals can occur during or following an arousal of deep sleep (see slow-wave sleep) and upon an attempt of awakening the subject from sleep in the morning.In children, confusional arousals can often be reproduced artificially by awakening the child during deep sleep. However, it doesn’t have any clinical significance without deeper investigation. Children living an episode of confusional arousal typically sit up in bed, whimper, cry, moan, and may utter words like “no” or “go away”. They remain distressed and inconsolable despite all parental efforts. Paradoxically, parental efforts can rather increase agitation of the child. The onset of symptoms is usually within 2 and 3 hours of sleep onset (at the time of transition from slow-wave sleep to a lighter sleep stage) and those events can last from 10 to 30 minutes. Patients generally wake up without any recollection of the event. It is necessary to distinguish confusional arousals in adults from children.