Sleep terror disorder
Sleep terror disorder
Sleep terror disorder is defined as repeated temporary arousal from sleep, during which the affected person appears and acts extremely frightened.
Sleep terror disorder is sometimes referred to as pavor nocturnus when it occurs in children, and incubus when it occurs in adults. Sleep terrors are also sometimes called night terrors, though sleep terror is the preferred term, as episodes can occur during daytime naps as well as at night. Sleep terror is a disorder that primarily affects children, although a small number of adults are affected as well.
Causes and symptoms
The causes of sleep terror are for the most part unknown. Some researchers suggest that sleep terrors are caused by a delay in the maturation of the child's central nervous system. Such factors as sleep deprivation, psychological stress , and fever may also trigger episodes of sleep terror.
The symptoms of sleep terror are very similar to the physical symptoms of extreme fear. These include rapid heartbeat, sweating, and rapid breathing (hyperventilation). The heart rate can increase up to two to four times the person's regular rate. Sleep terrors cause people to be jolted into motion, often sitting up suddenly in bed. People sometimes scream or cry. The person's facial expression may be fearful.
People experiencing sleep terror disorder sometimes get out of bed and act as if they are fighting or fleeing something. During this time injuries can occur. Cases have been reported of people falling out of windows or falling down stairs during episodes of sleep terror.
People experiencing sleep terror are not fully awake. They are nearly impossible to bring to consciousness or comfort, and sometimes respond violently to attempts to console or restrain them. In many cases, once the episode is over the person returns to sleep without ever waking fully. People often do not have any recollection of the episode after later awaking normally, although they may recall a sense of fear.
Episodes of sleep terror usually occur during the first third of a person's night sleep, although they can occur even during naps taken in the daytime. The average sleep terror episode lasts less than 15 minutes. Usually only one episode occurs per night, but in some cases terror episodes occur in clusters. It is unusual for a person to have many episodes in a single night, although upwards of 40 have been reported. Most persons with the disorder have only one occurrence per week, or just a few per month.
Sleep terror disorder is much more common in children than it is in adults. It is estimated that approximately 1%–6% of children in the United States experience sleep terror at some point in their childhood. For most children, sleep terrors begin between the ages of four and 12. The problem usually disappears during adolescence. Sleep terror disorder appears to be more common in boys than in girls; some studies have reported that preadolescent boys are the group most commonly affected. No figures are available for the rates of the disorder in different racial or ethnic groups. Sleep terrors in children are not associated with any psychological disorders.
Fewer than 1% of adults have sleep terror disorder. For most adults, sleep terrors begin in their 20s or 30s, although it is possible for someone to suffer from episodes of sleep terror from childhood onward. In the adult population, sleep terrors affect both sexes equally. They are, however, often associated with psychological disorders, most commonly anxiety, personality, or post-traumatic disorders. People who have a family history of sleep terrors or sleepwalking disorder are about 10 times more likely to develop sleep terror disorder than those who do not.
Sleep terror is diagnosed most often in children when parents express concern to the child's pediatrician. A fact sheet from the American Academy of Child and Adolescent Psychiatry suggests that parents consult a child psychiatrist if the child has several episodes of sleep terror each night, if the episodes occur every night for weeks at a time, or if they interfere with the child's daytime activities. The diagnosis is usually made on the basis of the child's and parents' description of the symptoms. There are no laboratory tests for sleep terror disorder. In adults, the disorder is usually self-reported to the patient's family doctor. Again, the diagnosis is usually based on the patient's description of the symptoms.
Sleep terror is characterized by an abrupt arousal from sleep followed by symptoms of extreme fear. The symptoms often include screams, rapid heartbeat, heavy breathing, and sweating, as well as a subjective feeling of terror. According to the Diagnostic and Statistical Manual of Mental Disorders , fourth edition, text revision (DSM-IV-TR ), which is the standard reference work used by mental health professionals to diagnose mental disorders, people with sleep terror disorder do not respond to attempts to comfort or awaken them. In order to meet criteria for the diagnosis, the patients must not be able to recall their dreams, and they must not remember the episode itself. In addition, the episodes may not be attributed to a medical condition or drug use.
Sleep terror disorder is frequently confused with nightmare disorder . The two are similar in the sense that both are related to bad dreams. Nightmare disorder, however, involves a significantly smaller amount of physical movement than does sleep terror. Normally, people experiencing nightmare disorder do not get out of bed.
Moreover, people experiencing nightmare disorder often have problems going back to sleep because of the nature of their dream. Most people experiencing sleep terrors, however, go back to deep sleep without ever having fully awakened. People experiencing nightmares can generally remember their dreams and some of the events in the dream leading up to their awakening. People often awake from nightmares just as they are about to experience the most frightening part of a disturbing dream. People experiencing sleep terrors, however, can sometimes recall a sense of profound fear, but often do not remember the episode at all.
If sleep terror episodes are infrequent, then treatment may not be necessary as long as the episodes are not interfering significantly with the person's life. Some people may want to rearrange their bedroom furniture to minimize the possibility of hurting themselves or others if they get out of bed during a sleep terror episode. To keep children from becoming overly worried about their sleep terrors, experts suggest that parents avoid placing unnecessary emphasis on the episodes. Psychotherapy is often helpful for adults concerned about the specific triggers of sleep terror episodes.
Several different medications have been used to treat sleep terror disorder, with varying degrees of success. One of the most common is diazepam (Valium). Diazepam is a hypnotic (sleep-inducing medication), and is thought to be useful in the prevention of sleep terror episodes because it acts as a nervous system depressant. There are many different types of hypnotics, and choosing one for a patient depends on other drugs that the patient may be taking, any medical or psychological conditions, and other health factors. Most studies of medications as treatments for sleep terror disorder have been done on adult patients; there is little information available on the use of medications to treat the disorder in children.
In most children, sleep terror disorder resolves before or during adolescence without any treatment. Adults often respond well to diazepam or another hypnotic. Psychotherapy and avoidance of stressors that may precipitate terror episodes may be helpful as well. Episodes of sleep terrors often decrease with age. This decrease is due to the fact that the amount of slow-wave sleep, which is the sleep phase during which terror episodes usually occur, declines with age.
Aldrich, Michael S. Sleep Medicines. New York: Oxford University Press,1999.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. text revised. Washington DC: American Psychiatric Association, 2000.
Chokroverty, Susan, ed. Sleep Disorders Medicine: Basic Science, Technical Considerations, and Clinical Aspects. 2nd ed. Boston: Butterworth-Heinemann, 1999.
Sadock, Benjamin J. and Virginia A. Sadock, eds. Comprehensive Textbook of Psychiatry. 7th ed. Vol. 2. Philadelphia: Lippincott Williams and Wilkins, 2000.
Thorpy, Michael J, ed. Handbook of Sleep Disorders. New York: Marcel Dekker Inc., 1990.
Owens, Judith A., Richard P. Millman, Anthony Spirito. "Sleep Terrors in a 5-Year-Old Girl." Pediatrics & Adolescent Medicine 153, no. 3 (March 1999).
American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891. <www.aacap.org>.
American Academy of Sleep Medicine. 6301 Bandel Road NW, Suite 101, Rochester, MN 55901. (507) 287-6006. <www.asda.org>.
American Academy of Child & Adolescent Psychiatry (AACAP). "Children's Sleep Problems." AACAP Facts For Families Pamphlet #34. Washington, DC: American Academy of Child & Adolescent Psychiatry, 2000.
Tish Davidson, A.M.
"Sleep terror disorder." Gale Encyclopedia of Mental Disorders. . Encyclopedia.com. (June 26, 2017). http://www.encyclopedia.com/psychology/encyclopedias-almanacs-transcripts-and-maps/sleep-terror-disorder
"Sleep terror disorder." Gale Encyclopedia of Mental Disorders. . Retrieved June 26, 2017 from Encyclopedia.com: http://www.encyclopedia.com/psychology/encyclopedias-almanacs-transcripts-and-maps/sleep-terror-disorder
Childhood night terrors are a parasomnia, or partial-sleep disorder, common in young children. They occur in the deepest stage of sleep and are characterized by an abrupt arousal, usually within the first hour of sleep. The child may sit bolt upright in acute terror, screaming inconsolably. Night terrors are a confusional arousal resulting from immature sleep patterns with an intense activation of the flight or fight emotion.
Night terrors are not a dream or typical nightmare. They occur in non-REM, slow-wave sleep. The panicked screaming, kicking, thrashing, and flailing is alarming in its intensity. Sleepwalking, another parasomnia disorder, may also occur in as many as one third of children with night terrors. While experiencing the night terror the child is extremely disoriented and may stare straight ahead, eyes wide open, with the dark centers (pupils) enlarged. There is profuse sweating, the heartbeat is rapid, the breathing fast, and the blood pressure is elevated. As the child is not fully awake, she is unable to see or recognize her parent or caretaker and cannot be easily awakened. The night terror may last from one to 15 minutes or more and is usually followed by a return to deep sleep. Afterwards the child may have no memory of the experience.
Night terrors appear to run in families, though there is no scientific evidence of genetic factors. They are a developmental process and not typically a result of mental or physical illness.
Childhood night terrors occur more frequently in boys. Children between the ages of three and five years of age are most likely to experience such nocturnal episodes. Such confusional arousals rarely persist beyond childhood, and they are significantly less frequent or cease entirely after age 12.
Causes and symptoms
Childhood night terrors appear to be a normal physiological process of the immature and developing nervous system. These confusional arousals can be triggered by stressful circumstances such as when a child is overly tired, when there is a loud noise or other unusual disruption, a change in the child's regular sleep-wake schedule, or even a full bladder. Night terrors occurring in adolescence and adult life may be more severe and are often linked with trauma and post-traumatic stress disorders.
When to call the doctor
Consult a pediatrician for night terrors if any of the following occur:
- Episodes occur more than once a week.
- Episodes persist after a schedule of preventive awakenings.
- Episodes last more than 45 minutes.
- The child exhibits drooling, jerking, and stiffening of the body.
- The child is physically endangered during an episode.
- Episodes occur later during the sleep cycle, more than two hours after going to sleep.
- The child has fears that persist throughout the day.
Diagnosis is based on observation of the following characteristic symptoms:
- recurring episodes of abrupt and partial awakening from deep sleep with panicked screaming and disorientation
- increased heart rate, rapid breathing, and profuse sweating during an episode
- child is unresponsive to efforts to arouse or console during an episode
- child has little or no memory of the event after a full awakening
Parents should not attempt to awaken a child experiencing a night terror. Efforts to console may be futile, though holding the child firmly and speaking with soothing words may facilitate the return to deep sleep. The primary effort should be to protect the child from possible harm to herself and others and ease them back to sleep.
In some severe cases, a pediatrician may prescribe a benzodiazepine tranquilizer, such as diazepam, known to suppress the stage four level of deep sleep. Though tranquilizers may be used for short-term control of night terrors, the result is uncertain and not generally advised.
Hypnosis, biofeedback, and various relaxation techniques have been used with some success to reduce or eliminate occurrence of childhood night terrors. Calming music or bedtime stories can help lull a child into deep sleep. Maintaining a quiet home without sudden disruptive noise will minimize some of the external stimuli that may trigger night terrors.
Unusually heavy or spicy meals should be avoided before bedtime as indigestion might act as a trigger for night terror arousals.
Childhood night terrors are usually outgrown by the age of seven and rarely persist beyond adolescence.
Some pediatricians suggest that parents maintain a sleep diary and observe the child throughout several night terror episodes, noting the amount of time following sleep when the night terror begins. After the sleep-wake pattern is determined, a series of 15–20 minutes prior to the usual occurrence of the night terror and keep the child awake and out of bed for a full five minutes. This may help to break the disruptive sleep pattern that has resulted in the night terrors.
Children often experience night terrors during the toilet-training years. The night terror might be triggered by a full bladder. Assisting the child to the toilet prior to bedtime and even during the course of a night-terror might be beneficial in reducing reoccurrence.
Childhood night terrors are alarming to witness. Parents may find it particularly difficult when efforts to console the child fail and the child does not recognize them even though his or her eyes may be wide open. The screaming, flailing, and kicking that accompany a night terror may frighten parents who fear the child is having a seizure. It is not a seizure unless the behavior includes eyes rolling back in the head, stiffening of the body, and drooling. Most childhood night terrors will last about 10 minutes.
Benzodiazepine —One of a class of drugs that have a hypnotic and sedative action, used mainly as tranquilizers to control symptoms of anxiety. Diazepam (Valium), alprazolam (Xanax), and chlordiazepoxide (Librium) are all benzodiazepines.
Confusional arousal —A partial arousal state occurring during the fourth stage of deepest sleep. Childhood night terrors are a form of confusional arousal.
Parasomnia —A type of sleep disorder characterized by abnormal changes in behavior or body functions during sleep, specific stages of sleep, or the transition from sleeping to waking.
Rapid eye movement (REM) sleep —A phase of sleep during which the person's eyes move rapidly beneath the lids. It accounts for 20–25% of sleep time. Dreaming occurs during REM sleep.
Schroeder, Carolyn S., and Betty N. Gordon. Assessment & Treatment of Childhood Problems, 2nd ed. New York: Guilford Press, 2002.
National Sleep Foundation. 1522 K Street, NW, Suite 500, Washington, DC 20005. Web site: <www.livingwithillness.com/id174.htm>.
Driver, Helen. "Parasomnias." Canadian Sleep Society. Available online at <www.css.to/sleep/disorders/parasomnia.htm> (accessed October 12, 2004).
Harvie, Jeni. "Disorders: A Wake-up Call for Parents." Sydney Morning Herald, January 29, 2004. Available online at <www.smh.com.au/articles/2004/01/29/10750881124899.html> (accessed October 7, 2004).
"Nightmares and Night Terrors." Cincinnati Children's Hospital Medical Center. Available online at <www.cincinnatichildrens.org/health/info/growth/diagnose/nightmares.htm> (accessed October 12, 2004).
"Nightmares and Night Terrors in Children." American Academy of Family Physicians. Available online at <http://familydoctor.org/566.xml> (accessed October 12, 2004).
Night Terror Resource Center. Available online at <www.nightterrors.org> (accessed October 12, 2004).
"Sleep Behavior Problems (Parasomnias)." Kids Health for Parents. Available online at <www.kidshealth.org/parent/general/sleep/parasomnia.html> (accessed October 12, 2004).
"Sleep Problems in Children." Sleep Matters, March 31, 2004. Available online at <www.sleepfoundation.org/features/children_sleep_problems.cfm#nightmares> (accessed October 12, 2004).
"Night Terrors." Gale Encyclopedia of Children's Health: Infancy through Adolescence. . Encyclopedia.com. (June 26, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/night-terrors
"Night Terrors." Gale Encyclopedia of Children's Health: Infancy through Adolescence. . Retrieved June 26, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/night-terrors
Night terrors are a sleep disorder characterized by anxiety episodes with extreme panic, often accompanied by screaming, flailing, fast breathing, and sweating and that usually occur within a few hours after going to sleep.
Night terrors occur most commonly in children between the ages of four and 12 but can also occur at all ages. Affected individuals usually suffer these episodes within a few hours after going to sleep. They appear to bolt up suddenly, and wake up screaming, sweating and panicked. The episode may last anywhere from five to 20 minutes. During this time, the individual is actually asleep, although the eyes may open. Quite often, nothing can be done to comfort the affected person. Very often, the person has no memory of the episode upon waking the next day.
Night terrors are differentiated from nightmares in that they have been shown to occur during Stage 4 of sleep, or in REM sleep, while nightmares can occur anytime throughout the sleep cycle.
Causes and symptoms
Suffering from night terrors seems to run in families. Extreme tension or stress can increase the incidence of the episodes. In adults, the use of alcohol also contributes to an increased incidence of night terrors. Episodes sometimes occur after an accident involving head injury. Other factors thought to contribute to episodic night terrors, but not actually cause them, include:
- excessive tiredness at bedtime
- eating a heavy meal prior to bedtime
- drug abuse
Night terrors are primarily diagnosed by observing the person suffering from an episode. The following symptoms are characteristic of a person suffering from a night terror:
- gasping, moaning, crying or screaming during sleep
- little or no recollection of the episode upon awakening
In most cases, the individual will still be asleep as the night terror episode happens and will prove difficult to awaken. The goal should be to help the affected person go back into a calm state of sleep. The lights should be turned on, and soothing comments should be directed at the person, avoiding brusque gestures such as shaking the person or shouting to startle them out of the episode. Any form of stress should be avoided.
Individuals affected by night terrors should be evaluated by a physician if they are really severe and occur frequently. A physician can recommend the best treatment for the particular circumstances of the night terrors. In some severe cases, the physician may prescribe a benzodiazepine tranquilizer, such as Diazepam, known to suppress Stage 4 of sleep. The physician may also refer the affected person for further evaluation by a sleep disorder specialist. It should be noted that episodic night terrors in children are normal and do not suggest the presence of psychological problems. In adults, night terrors are more likely to be related to a significant stress-related or emotional problem.
In children, night terror episodes in children usually end by the age of 12.
If a child seems to have a regular pattern of night terror episodes, he should be gently awakened about 15 minutes before the episode usually happens. The child should be kept awake and out of the bed for a short period of time and then allowed to return to bed.
Since sleep deprivation is a strong trigger for night terror episodes, children should not be allowed to become overtired. Having children take a nap during the day may be useful.
Adults affected by night terror episodes should avoid stress, the consumption of alcohol and stimulants before going to sleep.
American Academy of Family Physicians. "Nightmares and Night Terrors in Children." October 2000.
Laberge, Luc, et al. "Development of Parasomnias from Childhood to Early Adolescence." Pediatrics July 2000: 67-74.
American Sleep Disorders Association, 6301 Bandel Road Suite 101, Rochester, MN 55901. (507) 287-6008. 〈http://www.asda.org〉.
National Foundation for Sleep and Related Disorders in Children. 4200 W. Peterson Suite 109, Chicago, IL 60646. (708) 971-1086.
Benzodiazepines— A class of drugs that suppresses Stage 4 of sleep.
REM sleep— Rapid Eye Movement phase of sleep, a mentally active period during which dreaming occurs.
Sleep disorder— Any disorder that keep a person from falling asleep or staying asleep.
"Night Terrors." Gale Encyclopedia of Medicine, 3rd ed.. . Encyclopedia.com. (June 26, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/night-terrors-0
"Night Terrors." Gale Encyclopedia of Medicine, 3rd ed.. . Retrieved June 26, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/night-terrors-0
Night terrors are pathological phenomena that begin around three or four years of age. The child suddenly wakes up at the beginning of the night; he or she is terrified, screams in bed, and seems to be in the grip of hallucinations. When the worried parents arrive, the child does not recognize them and they are unable to calm the child. This state persists for a few minutes, at most, and brings with it neurovegetative manifestations (sweating, tachycardia, and polypnea). Once he or she has calmed down, the child goes back to sleep. The next day the child has no memory of the episode. Night terrors can be recurrent, but in general they disappear around the age of five or six.
There is no reference to night terrors in the works of Sigmund Freud. The phenomenon is difficult to apprehend from a psychoanalytic point of view; because of the amnesia that follows them, night terrors are not accessible, as dreams are, to any secondary revision. This sleep disorder probably reflects a failure in the dreaming function—a weakness in figuration and the binding of affects with mental representations.
We can refer to the work of Didier Houzel, who used electrophysiological observations as the starting point for a physiological explanation for night terrors. They occur during the phases of slow wave sleep (phase IV), outside of the phases of paradoxical sleep in which dreams occur. Phase IV sleep includes physiological aspects that herald the paradoxical sleep phase. Slow wave sleep is a reparatory phase of dream activity; night terrors suggest a blocking of the dream, which cannot begin during this slow sleep phase and, therefore, cannot proceed with the work of psychically binding instinctual energy.
As for the etiology of night terrors, which coincide with the arrival of oedipal conflict, different factors have been identified: libidinal conflicts proper to this period of emotional life, traumatic events, and, finally, disturbances in the child's affective relationships with people close to him or her. The persistence of night terrors beyond the oedipal period is a sign that the child is incapable of elaborating better psychic defenses. They can mark a return to preoedipal positions.
See also: Combined parent figure; Paranoid position; Phobias in children; Somnambulism.
Houzel, Didier. (1980). Rêve et psychopathologie de l'enfant. Neuropsychiatrie de l'Enfance et de l'Adolescence, 28, 155-164.
Sperling, Melitta. (1958). Pavor nocturnus. Journal of the American Psychoanalytic Association, 1, 79-94.
"Night Terrors." International Dictionary of Psychoanalysis. . Encyclopedia.com. (June 26, 2017). http://www.encyclopedia.com/psychology/dictionaries-thesauruses-pictures-and-press-releases/night-terrors
"Night Terrors." International Dictionary of Psychoanalysis. . Retrieved June 26, 2017 from Encyclopedia.com: http://www.encyclopedia.com/psychology/dictionaries-thesauruses-pictures-and-press-releases/night-terrors
Also referred to as pavor nocturnus, a childhood sleep disorder featuring behavior that appears to be intense fear.
Night terrors, known medically as pavor nocturnus, are episodes that apparently occur during the non-dreaming stages of sleep in some children. Episodes of night terrors are most common in the preschool and early school years. Night terrors usually occur within an hour or two after the child has fallen asleep, and generally do not recur with any frequency or regularity. Many children experience only one episode of night terrors, and few experience more than three or four such episodes over the whole course of childhood . A parent or caregiver witnessing an episode of night terrors, which usually lasts from ten to thirty minutes, will find the behavior unsettling. The child sits up abruptly in bed, appears to be extremely upset, cries out or screams, breathes heavily, and perspires. He or she might also thrash about, kicking, and his or her eyes may bulge out, seemingly in fear of something. The child does not wake during the episode, although his or her eyes will be open, and he or she will be unresponsive to any offers of comfort. The child falls back to sleep, and will have no memory of the occurrence. Night terrors have not been shown to have any link to personality or emotional disorders, although they may be related to a specific feeling of fear that the child has experienced, such as being startled by someone leaping at him or her from behind a chair, or the sight of someone fainting or having an accident.
Beaudet, Denise. Encountering the Monster: Pathways in Children's Dreams. New York: CrossroadContinuum, 1990.
Lansky, Vicki. Getting Your Child to Sleep—and Back to Sleep: Tips for Parents of Infants, Toddlers, and Preschoolers. Deephaven, MN: Book Peddlers, 1991.
Thorpy, Michael. The Encyclopedia of Sleep and Sleep Disorders. New York: Facts of File, 1990.
Association of Sleep Disorders Centers (ASDC). 602 Second Street, SW, Rochester, MN 55902 (Professional organization of specialists in sleep disorders; publishes the journal Sleep. )
"Night Terrors." Gale Encyclopedia of Psychology. . Encyclopedia.com. (June 26, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/night-terrors-1
"Night Terrors." Gale Encyclopedia of Psychology. . Retrieved June 26, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/night-terrors-1