Sleep Terrors

Sleep Terrors

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Sleep terrors (also referred to as night terrors or pavor nocturnus) are a specific sleep disruption most remarkable for their intensity and anxiety-inducing nature. Several precipitating factors have been suggested, but no consistent structural or biochemical abnormality has been identified to account for all cases of sleep terrors.

Symptoms of sleep terrors include the following:

Sudden arousal from non–rapid eye movement (NREM) sleep, usually occurring in the first third of the night

Associated autonomic and behavioral manifestations of fear, including crying, screaming, or thrashing

Agitation (more commonly seen in adults)

Significant autonomic hyperactivity, including tachycardia, tachypnea, and diaphoresis

No or minimal response to external stimuli during the event

Upon wakening: Confusion, disorientation, and amnesia regarding the event

There are no specific physical findings or signs found on routine physical examination when the individual is awake.

See Presentation for more detail.

The diagnosis is made primarily based on a history that identifies the classic symptoms of sleep terror and by excluding other possible etiologies for the sleep disturbance based on the clinical presentation. There have been no identified irregularities in laboratory evaluation, and no additional workup is required in a classic sleep terror presentation. Further evaluation may be useful as follows:

Sleep diary to help identify sleep patterns and triggers for sleep terrors

Investigation of comorbidities

Assessment for significant daytime somnolence, violent behavior during episodes, or severe distress on the part of family members

Polysomnography for a suspected respiratory disturbance

Routine electroencephalography (EEG) or sleep-deprived EEG if nocturnal seizures are suspected

The specific DSM-5 criteria for NREM sleep arousal disorder, sleep terror type, are as follows^[1]:

Recurrent episodes of abrupt terror arousals from sleep, usually beginning with a panicked scream; intense fear and signs of autonomic arousal

Relative unresponsiveness to efforts to comfort the individual during the episode

Little or no recall of dream imagery

Amnesia for the episode

Significant distress or impairment in social, occupational or other areas of functioning

The symptoms cannot be explained by another mental disorder, medical condition, or the effects of a drug of abuse or medication

See Workup for more detail.

Because sleep terrors are typically benign and self-limited, most affected individuals require no specific medical intervention other than reassurance and education.

Measures that may be helpful include the following:

Appropriate treatment of associated comorbid conditions

Promoting a stable environment with adequate regular sleep habits

Routine follow-up and developmental assessment for affected children

Continued support and reassurance for affected families

Surveillance for deviation from classic sleep terror characteristics or increasing severity of behavior during episodes

Efforts to keep affected individuals from harming themselves or others during episodes

Scheduled awakenings

See Treatment and Medication for more detail.

Sleep disruption in childhood is a common and frequently upsetting occurrence; sleep terrors (also known as night terrors or pavor nocturnus) are a specific sleep disruption most remarkable for their intensity and anxiety-inducing nature. Most episodes begin within the first 1-2 hours of sleep, during stages 3 and 4 of non–rapid eye movement (REM) sleep, though episodes may occur later or during naps.

Affected individuals typically appear to wake from sleep with a sudden intense distress (often indicated by a loud cry or scream), followed by poorly controlled panic and a lack of responsiveness or normal interaction with other individuals. The episodes generally last for 1-10 minutes, at which point the agitation abruptly ends, and the individual resumes normal sleep. The affected individual typically has no memory or only vague recall of the event the following day. If the individual is successfully roused during the event, the period of distress and confusion can be prolonged.

Parasomnias are sleep-wake disorders characterized by undesirable motor, verbal, or experiential phenomena occurring in association with sleep, specific stages of sleep, or sleep-awake transition phases. In the American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), one common parasomnia, non-REM (NREM) sleep arousal disorder, is described as being characterized by either somnambulism (ie, sleepwalking) or sleep terror.^[1]

The specific DSM-5 criteria for NREM sleep arousal disorder, sleep terror type, are as follows^[1]:

Recurrent episodes of abrupt terror arousals from sleep, usually beginning with a panicked scream; intense fear and signs of autonomic arousal (eg, mydriasis, tachycardia, rapid breathing, and sweating)

Relative unresponsiveness to efforts of others to comfort the individual during the episode

Little or no recall of dream imagery

Amnesia for the episode

The episodes cause significant distress or impairment in social, occupational or other areas of functioning

The symptoms cannot be explained by another mental disorder, medical condition, or the effects of a drug of abuse or medication

Several precipitating factors for sleep terrors have been suggested, but no consistent structural or biochemical abnormality has been identified to account for all cases of sleep terrors. A dysfunction in the serotoninergic system has been suggested, owing to an association found between adolescents with migraines and a history of sleep terrors.^[2]Additionally, some evidence has suggested that the serotonin precursor L-5-hydroxytryptophan can help reduce the frequency of sleep terrors.^[3]

Sleep studies demonstrate that sleep terrors occur during stage 3 and 4 NREM sleep. The occurrence of sleep terrors is increased in some families, suggesting a genetic predilection; however, to date, no genetic marker has been clearly identified.^[4]

A strong correlation between sleep terrors and sleepwalking is noted, with a high frequency of either process in first-degree family members of individuals who experience sleep terrors.^[5]Sleepwalking has been associated with HLADQB1.^[6]An association of sleep terrors and sleepwalking in family members of individuals with nocturnal frontal lobe epilepsy has also been reported.^[7] One study also found evidence that many young children with sleep terrors went on to develop sleepwalking later in childhood, suggesting similar underlying pathophysiology.^[8]

No specific cause has been identified for sleep terrors. Suggested triggers have included the following^{[9, 10, 11]}:

Inadequate or irregular sleep schedule

Unfamiliar or disruptive sleep environment

Concurrent fever or illness

Certain medications, including central nervous system (CNS) depressants (eg, sedative-hypnotics and alcohol) and some stimulants

A full bladder during sleep

Generalized stress

Obstructive sleep disorders

No trigger is uniformly or consistently seen in most individuals who experience sleep terrors. These triggers do not appear to cause sleep terrors but may lower the threshold for sleep terror events.

It is estimated that between 1% and 6% of children experience sleep terrors although prevalence is difficult to accurately assess for numerous reasons, including variations in the definition of sleep terrors in studies as well as age groups with much different rates of sleep terrors being assessed in studies. This condition is much less common in adults, occurring in less than 1%. In children younger than 3.5 years, the peak frequency is at least 1 episode per week; among older children, the peak frequency is 1-2 episodes per month.^[12]The course in adults is more chronic, with significant variability in both the frequency and the severity of episodes among affected individuals.^[1]

Night terrors can occur from infancy through adulthood.^[13]The age range of peak frequency is 4-12 years for children and 20-30 years for adults. However, one study found peak prevalence in children at 18 months of age, indicating that previous thoughts on prevalence might be affected by lack of studies in children under two years old.^[8] Most childhood-onset sleep terrors resolve by adolescence. Most sources indicate that the genders experience sleep terrors at an equal frequency; however, the APA (in DSM-5) states that the incidence is increased in male children.^[1]Sleep terrors are experienced equally across racial categories.

Most children with sleep terrors experience resolution before adolescence. No increased occurrence of psychiatric diagnoses is found in children. Adults who experience sleep terrors have an increased occurrence of other psychiatric conditions, particularly posttraumatic stress disorder (PTSD), generalized anxiety, and dependent, schizoid, and borderline personality disorders.^{[1, 14, 15]}

Sleep terrors are fundamentally benign, but some affected individuals may experience trauma from interactions with their surroundings or may injure others attending them. Attempts to awaken an affected individual during an episode are generally unsuccessful and increase the potential of harm to persons offering support.^[16]

Families and individuals must understand that sleep terrors are fundamentally benign, self-limited events. Safety measures including modifying the sleep environment to afford increased patient protection, securing windows, and limiting access to potentially harmful situations. Because the affected individual is generally unresponsive to outside interventions, aggressive attempts to intervene should be discouraged. Improvement of sleep hygiene and avoidance of potential triggers may reduce the frequency or severity of events.^[10]

For patient education resources, see the Sleep Disorders Center, as well as Night Terrors, Disorders That Disrupt Sleep (Parasomnias), and REM Sleep Behavior Disorder.

In 2016, the American Academy of Sleep Medicine (AASM) issued consensus recommendations for the amount of sleep needed to promote optimal health in children and teenagers and to avoid the health risks of insufficient sleep.^[17]

To promote optimal health, the recommendations advise the following amount of sleep (per 24 hours) on a regular basis:

Infants 4 to 12 months: 12 to 16 hours of sleep (including naps);

Children 1 to 2 years of age: 11 to 14 hours (including naps);

Children 3 to 5 years of age: 10 to 13 hours (including naps);

Children 6 to 12 years of age: 9 to 12 hours; and

Teenagers 13 to 18 years of age: 8 to 10 hours.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.

Fialho LM, Pinho RS, Lin J, et al. Sleep terrors antecedent is common in adolescents with migraine. Arq Neuropsiquiatr. 2013 Feb. 71(2):83-6. [Medline].

Bruni O, Ferri R, Miano S, Verrillo E. L -5-Hydroxytryptophan treatment of sleep terrors in children. Eur J Pediatr. 2004 Jul. 163(7):402-7. [Medline].

Nguyen BH, Perusse D, Paquet J, et al. Sleep terrors in children: a prospective study of twins. Pediatrics. 2008. 122(6):e1164-e1167.

Hublin C, Kaprio J. Genetic aspects and genetic epidemiology of parasomnias. Sleep Medicine Reviews. 2003. 7(5):413-421.

Lecendreux M, Mayer G, Bassetti C, et al. HLA association in sleepwalking. Mol Psychiatry. 2003. 8:114-7.

Bisulli F, Vignatelli L, Naldi I, et al. Increased frequency of arousal parasomnias in families with nocturnal frontal lobe epilepsy: A common mechanism?. Epilepsia. 2010. 51(9):1852-1860.

Petit D, Pennestri MH, Paquet J, Desautels A, Zadra A, Vitaro F, et al. Childhood Sleepwalking and Sleep Terrors: A Longitudinal Study of Prevalence and Familial Aggregation. JAMA Pediatr. 2015 Jul. 169 (7):653-8. [Medline].

Guilleminault C, Palombini L, Pelayo R, Chervin RD. Sleepwalking and sleep terrors in prepubertal children: what triggers them?. Pediatrics. 2003 Jan. 111(1):e17-25. [Medline].

Mindell JA & Owens JA. A Clinical Guide to Pediatric Sleep: Diagnosis and Management ofSleep Problems. Philadelphia: Lippincott Williams & Wilkins; 2003.

Pressman, M. Factors that predispose, prime and precipitate NREM parasomnias in adults: clinical and forensic implications. Sleep Med. Rev. 2007. 11:5-30.

DiMario FJ Jr, Emery ES 3rd. The natural history of night terrors. Clin Pediatr (Phila). 1987 Oct. 26(10):505-11. [Medline].

Byars KC, Yolton K, Rausch J, Lanphear B, Beebe DW. Prevalence, patterns, and persistence of sleep problems in the first 3 years of life. Pediatrics. 2012 Feb. 129(2):e276-84. [Medline]. [Full Text].

Ohayon MM, Guilleminault C, Priest RG. Night terrors, sleepwalking, and confusional arousals in the general population: their frequency and relationship to other sleep and mental disorders. J Clin Psychiatry. Apr 1999. 60(4):268-76.

Thünker J, Pietrowsky R. Effectiveness of a manualized imagery rehearsal therapy for patients suffering from nightmare disorders with and without a comorbidity of depression or PTSD. Behav Res Ther. 2012 Sep. 50(9):558-64. [Medline].

Pressman MR. Disorders of arousal from sleep and violent behavior: the role of physical contact and proximity. SLEEP. 2007. 30(8):1039-1047.

[Guideline] Paruthi S, Brooks LJ, D’Ambrosio C, Hall W, Kotagal S, Lloyd RM, et al. Recommended Amount of Sleep for Pediatric Populations: A Statement of the American Academy of Sleep Medicine. J Clin Sleep Med. 2016 May 25. [Medline]. [Full Text].

Carter KA, Hathaway NE, Lettieri CF. Common sleep disorders in children. Am Fam Physician. 2014 Mar 1. 89 (5):368-77. [Medline].

Moore M, Allison A, and Rosen CL. A review of pediatric nonrespiratory sleep disorders. Chest. 2006. 130(4):1252-1262.

Cornaggia CM, Beghi M, Giovannini S, Boni A, Gobbi G. Partial seizures with affective semiology versus pavor nocturnus. Epileptic Disord. 2010 Mar. 12 (1):65-8. [Medline].

Weber P, Jüngling F, Datta AN. Differential diagnoses of nocturnal fear and movement paroxysm: a case report. Eur J Pediatr. 2012 Sep. 171 (9):1309-15. [Medline].

Williams SG, Correa D, Lesage S, Lettieri C. Electroencephalographic hypersynchrony in a child with night terrors. Sleep Breath. 2013 May. 17 (2):465-7. [Medline].

Frank NC, Spirito A, Stark L, and Owens-Stively A. The use of scheduled awakenings to eliminate childhood sleep walking. Journal of Pediatric Psychology. 1997. 22:345-353.

Lask B. Novel and non-toxic treatment for night terrors. BMJ. 1988 Sep 3. 297 (6648):592. [Medline].

Ferri R, Zucconi M, Marelli S, Plazzi G, Schenck CH, Ferini-Strambi L. Effects of long-term use of clonazepam on nonrapid eye movement sleep patterns in rapid eye movement sleep behavior disorder. Sleep Med. 2013 May. 14 (5):399-406. [Medline].

Schenck CH, Mahowald MW. Long-term, nightly benzodiazepine treatment of injurious parasomnias and other disorders of disrupted nocturnal sleep in 170 adults. Am J Med. 1996 Mar. 100 (3):333-7. [Medline].

Eve G Spratt, MD, MSc Professor of Pediatrics and Psychiatry, Division of Developmental Pediatrics, Medical University of South Carolina; Director, Pediatric Consultation Liaison Psychiatry, Medical University of South Carolina Children’s Hospital at Charleston

Eve G Spratt, MD, MSc is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry