Diagnostic Criteria

A. Recurrent episodes of incomplete awakening from sleep, usually occurring during the first third of the major sleep episode, accompanied by either one of the following:

  1. Sleepwalking: Repeated episodes of rising from bed during sleep and walking about. While sleepwalking, the individual has a blank, staring face; is relatively unresponsive to the efforts of others to communicate with him or her; and can be awakened only with great difficulty.
  2. Sleep terrors: Recurrent episodes of abrupt terror arousals from sleep, usually beginning with a panicky scream. There is intense fear and signs of autonomic arousal, such as mydriasis, tachycardia, rapid breathing, and sweating, during each episode. There is relative unresponsiveness to efforts of others to comfort the individual during the episodes.

B. No or little (e.g., only a single visual scene) dream imagery is recalled.

C. Amnesia for the episodes is present.

D. The episodes cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).

F. Coexisting mental and medical disorders do not explain the episodes of sleepwalking or sleep terrors.

Specify whether:

  • Sleepwalking type
    • With sleep-related eating
    • With sleep-related sexual behavior (sexsomnia)
  • Sleep terror type

Differential Diagnosis

Nightmare disorder

In contrast to individuals with NREM sleep arousal disorders, individuals with nightmare disorder typically awaken easily and completely, report vivid storylike dreams accompanying the episodes, and tend to have episodes later in the night. NREM sleep arousal disorders occur during NREM sleep, whereas nightmares usually occur during REM sleep. Parents of children with NREM sleep arousal disorders may misinterpret reports of fragmentary imagery as nightmares.

Breathing-related sleep disorders

Breathing disorders during sleep can also produce confusional arousals with subsequent amnesia. However, breathing-related sleep disorders are also characterized by characteristic symptoms of snoring, breathing pauses, and daytime sleepiness. In some individuals, a breathing-related sleep disorder may precipitate episodes of sleepwalking.

REM sleep behavior disorder

REM sleep behavior disorder may be difficult to distinguish from NREM sleep arousal disorders. REM sleep behavior disorder is characterized by episodes of prominent, complex movements, often involving personal injury arising from sleep. In contrast to NREM sleep arousal disorders, REM sleep behavior disorder occurs during REM sleep. Individuals with REM sleep behavior disorder awaken easily and report more detailed and vivid dream content than do individuals with NREM sleep arousal disorders. They often report that they "act out dreams."

Parasomnia overlap syndrome

Parasomnia overlap syndrome consists of clinical and polysomnographic features of both sleepwalking and REM sleep behavior disorder.

Sleep-related seizures

Some type of seizures can produce episodes of very unusual behaviors that occur predominantly or exclusively during sleep. Nocturnal seizures may closely mimic NREM sleep arousal disorders but tend to be more stereotypic in nature, occur multiple times nightly, and be more likely to occur from daytime naps. The presence of sleep-related seizures does not preclude the presence of NREM sleep arousal disorders. Sleep-related seizures should be classified as a form of epilepsy.

Alcohol-induced blackouts

Alcohol-induced blackouts may be associated with extremely complex behaviors in the absence of other suggestions of intoxication. They do not involve the loss of consciousness but rather reflect an isolated disruption of memory for events during a drinking episode. By history, these behaviors may be indistinguishable from those seen in NREM sleep arousal disorders.

Dissociative amnesia, with dissociative fugue

Dissociative fugue may be extremely difficult to distinguish from sleepwalking. Unlike all other parasomnias, nocturnal dissociative fugue arises from a period of wakefulness during sleep, rather than precipitously from sleep without intervening wakefulness. A history of recurrent childhood physical or sexual abuse is usually present (but may be difficult to obtain).

Malingering or other voluntary behavior occurring during wakefulness

As with dissociative fugue, malingering or other voluntary behavior during wakefulness arises from wakefulness.

Panic disorder

Panic attacks may also cause abrupt awakenings from deep NREM sleep accompanied by fearfulness, but these episodes produce rapid and complete awakening without the confusion, amnesia, or motor activity typical of NREM sleep arousal disorders.

Medication-induced complex behaviors

Behaviors similar to those in NREM sleep arousal disorders can be induced by use of, or withdrawal from, substances or medications (e.g., benzodiazepines, nonbenzodiazepine sedative-hypnotics, opiates, cocaine, nicotine, antipsychotics, tricyclic antidepressants, chloral hydrate). Such behaviors may arise from the sleep period and may be extremely complex. The underlying pathophysiology appears to be a relatively isolated amnesia. In such cases, substance/medication-induced sleep disorder, parasomnia type, should be diagnosed.

Night eating syndrome

The sleep-related eating disorder form of sleepwalking is to be differentiated from night eating syndrome, in which there is a delay in the circadian rhythm of food ingestion and an association with insomnia and/or depression.

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