Coding Note: Use F51.3 for confirmed sleepwalking and F51.4 for confirmed sleep terrors. G47.50 is appropriate when the specific parasomnia subtype is not yet determined. G47.52 (REM sleep behavior disorder) is a separate entity — see RBD plan.
CPT CODES: 95810 (Video-polysomnography (PSG)), 95717 (Extended EEG monitoring), 95816 (Routine EEG), 70553 (MRI brain with and without contrast), 85025 (CBC), 80053 (CMP), 84443 (TSH), 80307 (Urine drug screen), 82728 (Serum ferritin)
SCOPE: Diagnosis and management of non-REM parasomnias (disorders of arousal) in adults. Covers sleepwalking (somnambulism), sleep terrors (pavor nocturnus), confusional arousals, and related variants including sleep-related eating disorder and sexsomnia. Critical focus on differentiating from nocturnal frontal lobe epilepsy. Includes diagnostic workup, safety interventions, trigger management, and pharmacotherapy. Excludes REM sleep behavior disorder (separate plan), nightmare disorder, and pediatric-specific management.
DEFINITIONS:
- Non-REM Parasomnia (Disorder of Arousal): A group of parasomnias arising from incomplete arousals out of NREM (typically N3/slow-wave) sleep, characterized by complex behaviors with impaired consciousness and subsequent amnesia
- Sleepwalking (Somnambulism): Complex ambulatory behaviors initiated during arousals from NREM sleep, ranging from sitting up in bed to walking, running, eating, or leaving the house
- Sleep Terrors (Pavor Nocturnus): Episodes of abrupt terror arousal from NREM sleep, typically with a piercing scream, intense fear, and autonomic activation (tachycardia, diaphoresis, mydriasis)
- Confusional Arousals (Sleep Drunkenness): Episodes of mental confusion during arousal from NREM (typically slow-wave) sleep; may include inappropriate behavior, slow speech, and reduced alertness without prominent ambulation or terror
- Sexsomnia: A variant of confusional arousal characterized by sexual behaviors during NREM sleep, with complete amnesia for the event
- Sleep-Related Eating Disorder (SRED): Recurrent episodes of involuntary eating during arousals from NREM sleep, often with consumption of unusual or inedible substances
- Overlap Parasomnia: Co-occurrence of NREM parasomnia features with REM sleep behavior disorder in the same patient
- Slow-Wave Sleep (N3): The deepest stage of NREM sleep, characterized by high-amplitude delta waves on EEG; predominates in the first third of the night
DIAGNOSTIC CRITERIA (ICSD-3-TR):
Disorders of Arousal — General Criteria (All of the following):
Recurrent episodes of incomplete awakening from sleep
Inappropriate or absent responsiveness to efforts of others to intervene or redirect the person during the episode
Limited (e.g., a single visual scene) or no associated cognition or dream imagery
Partial or complete amnesia for the episode
The disturbance is not better explained by another sleep disorder, mental disorder, medical condition, medication, or substance use
Sleepwalking — Additional Criteria:
- Complex behaviors arising from arousals during NREM sleep, typically from slow-wave sleep
- Behaviors may include sitting up, walking, running, eating, leaving the house, or driving
- Eyes are typically open with a glassy stare; individual is difficult to awaken
Sleep Terrors — Additional Criteria:
- Episodes of abrupt terror arousal from NREM sleep, usually initiated by a piercing scream or cry
- Intense fear and signs of autonomic arousal including tachycardia, tachypnea, diaphoresis, and mydriasis
- Relative unresponsiveness to efforts of others to comfort the individual during the episode
Confusional Arousals — Additional Criteria:
- Episodes of mental confusion or confusional behavior during arousal from NREM sleep (typically slow-wave sleep)
- May include slow speech, confused thinking, inappropriate behavior, or poor reactivity to external stimuli
- Absence of prominent ambulation (distinguishes from sleepwalking) or prominent terror/autonomic activation (distinguishes from sleep terrors)
Key Epidemiologic Features:
- Sleepwalking: prevalence ~1-4% in adults; ~17% in children
- Sleep terrors: prevalence ~2% in adults; ~3-6% in children
- Confusional arousals: prevalence ~4% in adults
- All disorders of arousal are more common in childhood and typically decrease with age
- Strong genetic predisposition: prevalence increases to ~45% if one parent affected, ~60% if both parents affected
Predisposing and Precipitating Factors:
- Sleep deprivation — strongest documented trigger (increases slow-wave sleep pressure)
- Alcohol — fragmentary arousals from NREM sleep
- Febrile illness — especially in children
- Medications — zolpidem, SSRIs, lithium, quetiapine, sodium oxybate
- Comorbid sleep disorders — OSA, restless legs syndrome, periodic limb movements (increase arousal frequency)
- Stress and anxiety — increase NREM instability
- Noise or environmental disruption — forced arousals from N3
PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting
3A. Safety and Environmental Interventions (First Priority — All Patients)¶
Treatment
Route
Indication
Dosing
Contraindications
Monitoring
ED
HOSP
OPD
ICU
Bedroom safety modifications
-
Injury prevention during sleepwalking/sleep terror episodes
N/A :: - :: ongoing :: Lock windows and exterior doors; install door alarms or motion-sensor alarms; remove sharp objects and breakable items from bedroom; place mattress on floor or use bed rails; lock away weapons and car keys; install gates on stairways; secure glass doors and windows
None
Compliance; injury log
ROUTINE
ROUTINE
ROUTINE
-
Sleep partner safety plan
-
Prevent injury to bed partner during violent episodes
N/A :: - :: ongoing :: Consider separate sleeping arrangements if episodes involve violent or sexual behaviors; educate partner not to forcefully restrain (may worsen agitation); gently redirect patient back to bed without attempting to wake
None
Partner injury assessment
ROUTINE
ROUTINE
ROUTINE
-
Floor-level sleeping arrangement
-
Reduce fall risk during ambulatory parasomnias
N/A :: - :: ongoing :: Place mattress directly on floor; remove bedframe; clear area around bed of obstacles and hard furniture
None
Adherence; fall history
-
ROUTINE
ROUTINE
-
Home video monitoring
-
Capture events for diagnostic characterization; assess safety of environment
N/A :: - :: ongoing :: Infrared/night-vision camera in bedroom; record events for clinical review; assists in differentiating from seizures (stereotypy vs. variable behavior)
OSA-triggered arousals precipitate parasomnia episodes; treating OSA reduces NREM arousal frequency
N/A :: - :: nightly :: Initiate CPAP per titration study; compliance target >=4 hours/night; resolution of arousal-triggered parasomnias documented in literature
CPAP intolerance (consider alternatives)
CPAP compliance; AHI on therapy; parasomnia frequency
-
ROUTINE
ROUTINE
-
Treat restless legs syndrome / PLMD
PO/device
RLS/PLMD increases NREM arousals which trigger parasomnia episodes
N/A :: - :: per RLS protocol :: Iron supplementation if ferritin <75; dopamine agonists or alpha-2-delta ligands per RLS guidelines
Per individual RLS treatments
Ferritin; PLMS index; parasomnia frequency
-
ROUTINE
ROUTINE
-
Sleep hygiene optimization
-
Sleep deprivation is the single strongest trigger for NREM parasomnias
N/A :: - :: daily :: Regular sleep-wake schedule 7 days/week; target 7-9 hours nightly; avoid sleep deprivation; cool, dark, quiet sleeping environment; limit screen time 1 hour before bed; avoid shift work if possible
None
Sleep diary; adherence
ROUTINE
ROUTINE
ROUTINE
-
Scheduled awakenings
-
Preemptive disruption of N3 sleep before typical event timing
N/A :: - :: nightly :: Wake patient 15-30 minutes before typical event time; maintain wakefulness for 5 minutes; most effective when events are predictable in timing; typically used for 4-6 weeks
None; may cause sleep deprivation if overused
Event log; timing adjustment
-
-
ROUTINE
-
Stress management / CBT
-
Psychological stress increases NREM sleep instability and arousal frequency
First-line when parasomnia episodes pose safety risk; suppresses arousals from slow-wave sleep; most evidence for NREM parasomnias
0.25 mg qHS; 0.5 mg qHS; 1 mg qHS; 2 mg qHS :: PO :: qHS :: Start 0.25 mg at bedtime; titrate by 0.25 mg every 1-2 weeks based on response; effective range 0.25-2 mg; max 2 mg qHS; taper slowly to discontinue (rebound parasomnias possible)
Severe hepatic impairment; untreated OSA (respiratory depression risk); pregnancy (teratogenic); concurrent opioids or heavy alcohol use; myasthenia gravis
Safe first-line option; consolidates NREM sleep architecture; preferred in elderly or when benzodiazepines contraindicated
3 mg qHS; 6 mg qHS; 9 mg qHS :: PO :: qHS :: Start 3 mg 30 minutes before bedtime; may increase by 3 mg every 1-2 weeks; max 9 mg; extended-release formulation may be more effective for maintaining consolidated sleep
Autoimmune conditions (theoretical); may exacerbate depression (rare)
Daytime sedation; headache; vivid dreams; next-day grogginess at higher doses
10 mg qHS; 20 mg qHS :: PO :: qHS :: Start 10 mg at bedtime; may increase to 20 mg after 2 weeks; evidence primarily for sleep terrors
Concurrent MAOIs; concurrent pimozide or thioridazine; first trimester pregnancy
Serotonin syndrome; sexual dysfunction; weight gain; discontinuation symptoms if stopped abruptly; suicidality monitoring in young adults; paradoxical worsening of parasomnias (rare)
-
-
EXT
-
Trazodone
PO
Concurrent insomnia with parasomnia; reduces NREM arousals; sedating antidepressant
25 mg qHS; 50 mg qHS; 100 mg qHS :: PO :: qHS :: Start 25 mg at bedtime; titrate by 25 mg every 1-2 weeks; max 100 mg qHS for parasomnia indication
Concurrent MAOIs; severe hepatic impairment; concurrent QT-prolonging drugs
Priapism (rare but serious); orthostatic hypotension; next-day sedation; cardiac arrhythmia at higher doses
-
ROUTINE
ROUTINE
-
Imipramine
PO
Refractory sleep terrors; tricyclic antidepressant with evidence for sleep terrors
10 mg qHS; 25 mg qHS; 50 mg qHS :: PO :: qHS :: Start 10 mg at bedtime; titrate by 10-25 mg every 1-2 weeks; max 50 mg qHS; avoid in elderly (anticholinergic burden, falls risk)
Sleep medicine specialist for video-PSG scheduling, diagnosis confirmation, identification of comorbid sleep disorders (OSA, RLS/PLMD), and long-term pharmacotherapy management
-
ROUTINE
ROUTINE
-
Neurology / epilepsy specialist to differentiate from nocturnal frontal lobe epilepsy (sleep-related hypermotor epilepsy) when events are stereotyped, brief, frequent, or occur multiple times per night
ROUTINE
ROUTINE
ROUTINE
-
Psychiatry referral if significant psychological stress, trauma, anxiety, or comorbid mood disorder is contributing to parasomnia frequency or severity
-
ROUTINE
ROUTINE
-
Forensic sleep medicine evaluation if parasomnia events have medicolegal implications (violence during sleep, sexsomnia, injury to others, sleep-driving)
-
-
EXT
-
ENT / pulmonology if obstructive sleep apnea identified as arousal trigger requiring CPAP titration or surgical evaluation
NREM parasomnias are a neurological condition caused by incomplete arousals from deep sleep; they are not a psychiatric disorder or sign of emotional disturbance
ROUTINE
ROUTINE
ROUTINE
-
Safety-proof the sleeping environment immediately: lock doors and windows, install alarms, remove sharp objects, place mattress on floor, secure weapons and car keys
ROUTINE
ROUTINE
ROUTINE
-
Do NOT forcefully restrain or attempt to aggressively wake someone during an episode; this may worsen agitation and risk injury; instead, gently guide the person back to bed and speak calmly
ROUTINE
ROUTINE
ROUTINE
-
Report any injuries to self or others occurring during episodes; escalating frequency, increasing violence, or new behaviors require urgent medical reassessment
ROUTINE
ROUTINE
ROUTINE
-
Avoid sleep deprivation — this is the single strongest trigger; maintain a consistent sleep schedule even on weekends and holidays
ROUTINE
ROUTINE
ROUTINE
-
Avoid alcohol within 3 hours of bedtime; alcohol is a potent trigger for NREM parasomnias
ROUTINE
ROUTINE
ROUTINE
-
Bed partners should sleep in a separate room if episodes involve violent or sexual behaviors until treatment is effective
-
ROUTINE
ROUTINE
-
Record events on video (smartphone with night vision or infrared camera) whenever safely possible; video recordings are extremely valuable for diagnosis
KEY DIFFERENTIAL: highly stereotyped events; brief duration (typically <2 min); multiple events per night possible; hypermotor semiology (kicking, pedaling, thrashing); may retain awareness; can occur at any time of night; events cluster in NREM stage 2
Video-PSG with extended EEG montage; routine EEG (may show frontal spikes/sharp waves); MRI brain (frontal cortical dysplasia); trial of carbamazepine (positive response supports epilepsy)
REM sleep behavior disorder (RBD)
Occurs during REM sleep (second half of night); dream enactment with recall of vivid/violent dreams; typically older males >50; REM without atonia on PSG; associated with alpha-synucleinopathies (Parkinson, DLB, MSA)
Video-PSG showing REM without atonia; clinical history of dream recall and REM-timing events
Obstructive sleep apnea with confusional arousals
Pseudo-parasomnia triggered by respiratory arousals; snoring, witnessed apneas, obesity; events resolve with CPAP treatment
PSG with respiratory scoring (AHI >5); trial of CPAP with resolution of events
Nocturnal panic attacks
Full awakening with complete recall; subjective terror with palpitations, dyspnea, chest pain; daytime panic attacks also present; occurs from NREM stage 2-3 but patient is fully alert after
Psychiatric evaluation; presence of daytime panic disorder; full recall of event (vs. amnesia in parasomnias)
PTSD nightmares
Dream recall present; REM-associated; history of trauma; nightmares with thematic content related to traumatic experiences; full arousal with emotional recall
Events arise from established wakefulness (not from sleep); normal EEG during events; prolonged episodes; history of trauma/abuse; events may occur with eyes open during wakefulness in bed
Majority of patients; established parasomnia with no acute injury; safety modifications and trigger counseling provided; outpatient sleep medicine follow-up arranged
Outpatient management
Newly suspected or established NREM parasomnia for diagnostic workup, trigger management, and chronic medication management
Admit for diagnostic video-PSG/EEG
Patients requiring in-lab video-polysomnography with extended EEG montage to differentiate parasomnia from nocturnal seizures; frequent events amenable to capture
Admit to floor
Serious injury sustained during parasomnia episode (falls, lacerations, fractures); unclear diagnosis requiring extended video-EEG monitoring; initiation of treatment requiring observation
Admit for extended video-EEG monitoring
Diagnostic uncertainty between parasomnia and epilepsy; events not captured on initial PSG; stereotyped events raising epilepsy concern
ICU admission
Not typically applicable for parasomnias; consider only if significant trauma-related injury (head injury, internal injury from falls or sleepwalking through windows)
Sleep medicine referral
All patients with suspected NREM parasomnia for diagnostic confirmation, comorbid sleep disorder identification, and treatment optimization
Neurology / epilepsy referral
Any patient with stereotyped events, events multiple times per night, brief duration events, retained awareness during events, or failure to respond to standard parasomnia treatment
Follow-up frequency
Every 2-4 weeks during initial treatment titration; every 3-6 months once stable; sooner if new safety concerns arise
NREM parasomnias arise from incomplete arousals out of slow-wave (N3) sleep, resulting in a dissociated state with motor activation but impaired consciousness and subsequent amnesia
Events characteristically occur in the first third of the night when slow-wave sleep predominates
Sleep deprivation is the single most potent and well-documented trigger — any factor that increases slow-wave sleep rebound (sleep deprivation, prior sleep disruption, recovery sleep) increases risk
The critical clinical distinction is between NREM parasomnia and nocturnal frontal lobe epilepsy (sleep-related hypermotor epilepsy); stereotyped brief events occurring multiple times per night strongly favor epilepsy
Video-PSG with extended EEG montage is the diagnostic gold standard; capturing an event during the study provides definitive classification
Normal interictal EEG does NOT exclude nocturnal frontal lobe epilepsy; scalp EEG may miss deep frontal epileptiform activity in up to 40% of cases
OSA is an underrecognized trigger: respiratory arousal events can trigger parasomnia episodes, and treating OSA with CPAP may completely resolve the parasomnia
Restless legs syndrome and periodic limb movement disorder similarly increase NREM arousal frequency and should be aggressively treated
Clonazepam has the longest track record for NREM parasomnias but carries risks of tolerance, daytime sedation, and respiratory depression (particularly concerning if comorbid OSA)
Melatonin is increasingly used as a safer first-line option, particularly in elderly patients or those with OSA, though evidence remains limited to case series
Anti-IgLON5 disease is a rare autoimmune condition that should be considered in patients with NREM parasomnia plus additional neurological features (gait instability, bulbar dysfunction, cognitive decline)
Sexsomnia and sleep-related violence carry significant medicolegal implications; forensic sleep medicine evaluation is indicated when events have legal consequences
Overlap parasomnia (coexistence of NREM parasomnia with RBD) may suggest underlying neurodegenerative pathology and warrants longitudinal monitoring
Medication-induced parasomnia is common and reversible: zolpidem is the most frequently implicated agent, but SSRIs, lithium, quetiapine, and sodium oxybate are also documented triggers
v1.0 (February 7, 2026)
- Initial template creation
- ICSD-3-TR diagnostic criteria for disorders of arousal (sleepwalking, sleep terrors, confusional arousals)
- Comprehensive differential diagnosis with detailed parasomnia vs. epilepsy differentiation table
- Safety and environmental interventions as first-priority treatment
- Trigger management including OSA treatment, sleep hygiene, and scheduled awakenings
- First-line pharmacotherapy (clonazepam, melatonin) and second-line options (paroxetine, trazodone, imipramine, topiramate, gabapentin)
- PubMed citations for all major evidence sources
- Structured dosing format with :: delimiters for all medications