Night Terrors


Article Author:
Ngoc Van Horn


Article Editor:
Megan Street


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
3/2/2019 5:47:45 PM

Introduction

Night terrors are a common preschool-aged sleep disorder in which a child quickly wakes up from sleep in a terrified state. For the majority of these episodes, the child will not have any recollection of this event ever happening.[1][2][3][4]

A night terror is considered a parasomnia due to its characterization of unusual physical and verbal behaviors. Parasomnias can often occur during any stage of sleep; however, night terrors specifically are associated with non-rapid eye movement (REM) sleep stages in which the person or child is in a transitional state in between sleep and wakefulness.

The act of sleeping can be categorically broken down into several stages and states. There are three primary states of sleep consisting of (1) wake, (2) non-REM sleep, and  (3) REM sleep. Within these states, they are further broken down into the separate stages. Sleep stages 1, 2, 3, and 4 are considered non-REM sleep while stage 5 is considered REM sleep. The different sleep stages represent different electrical patterns and frequencies in the brain that can be detected and measured with an electroencephalogram (EEG). These states and stages can overlap each other, and it is during these transition states where parasomnias can occur.[5][6]

Etiology

Because there is no clear transition between the primary sleep states and stages, there are multiple time periods in a single duration of sleep in which a person can be in a combination of both wakefulness and sleep. Herein lies the most accepted theory of parasomnia etiology.

Furthermore, there are theories that there is a genetic component however this has never been proven and remains antidotal. The exact etiology is unknown however there are strong correlations with fever and illness, excessive physical activity, excessive caffeine or alcohol intake, lack of sleep and exhaustion, and emotional stress.

Epidemiology

Night terrors are most often seen between the ages 3 to 7 years of age, and they often subside by 10 years of age. It appears that there is equal prevalence between boys and girls with a prevalence of approximately 30% in children.

Night terrors can occur in adults however it is rare. This may be indicative of underlying neurologic disorders that require more work up and investigation.

History and Physical

Episodes of night terrors most often occur in the first third of the night during slow wave sleep when the child is in the transitional state of being wakeful and sleeping. This particular period is referred to as the arousal state.

Episodes can appear to be very dramatic in presentation with the child screaming and thrashing without realization of his or her surroundings. Children may show signs of excessive autonomic activity such as tachycardia, tachypnea, mydriasis, and excessive sweating. In some cases, enuresis can also occur.

Unfortunately, children often do not respond to verbal cues, being comforted, or attempts to awaken. It is extremely difficult to wake these children in the middle of an episode. These spells can last approximately 10 to 20 minutes and then the child will abruptly return to sleep. Most do not recall the episodes.

Evaluation

No specific test must be done in an emergent clinical setting to make the diagnosis. A night terror is a clinical diagnosis that can be determined by taking a careful history, especially detailing the actual episode from families and witnesses. The only lab work or imaging that needs to be done is to rule out other differential diagnoses that are listed below.[7][8][9]

Treatment / Management

There is no specific treatment for night terrors other than comforting the child. Reassurance and education for the parents or guardians are strongly encouraged especially to ensure the safety of the child during a night terror.

If there is excessive stress or conflict in the child’s life, a combination of therapy and coping techniques can be recommended to help decrease the frequency of episodes. Medication administration is strongly discouraged and not indicated.

Rarely is a sleep study ever indicated since the prognosis of night terrors is good and self-limiting; however, there is developing research involving scheduled awakenings through the night with a vibration machine to help improve quality of life.

Differential Diagnosis

The differential diagnosis for night terrors can include but is not limited to the following:

  • Seizures: An abnormal, excessive synchronous discharge of neurons originating from the cerebral cortex causing a physical disturbance
  • Somnambulism (also known as sleepwalking): A benign, self-limited arousal parasomnia disorder that is characterized either excessive bed movement or walking during sleep
  • Nightmares: A disorder that occurs during REM stage of sleep that is characterized extreme fear, horror, distress or anxiety
  • Narcolepsy: An adolescent age chronic sleep disorder consisting of excessive daytime drowsiness
  • Sleep Apnea Hypersomnia: A sleep disorder in which the feeling of constant, recurrent episodes of extreme sleepiness and sleep deprivation are intertwined with interruptions of breathing 
  • Breath-holding spells: These occur most often between the ages of six to eighteen months in which some irritating stimuli trigger a voluntary episode of apnea or alteration in consciousness. It is not uncommon for these children to become cyanotic during the episodes.
  • Syncope: A brief, sudden loss of consciousness and muscle tone that may be caused by a variety of reasons. 
  • Benign myoclonus: A self-limited episode of sudden jerking of the extremities in the early stages of sleep
  • Shuddering attacks: A whole body attacks that resemble an essential tremor
  • Tics: These are repetitive movements such as twitching, blinking, head shaking or other subtle movements that are done unconsciously by the patient.
  • Gastroesophageal reflux: An arching or dystonic posturing (Sandifer's positioning) due to regurgitated gastric contents or acid into the esophagus
  • Psychogenic Nonepileptic Seizures (PNES): formerly known as “Pseudoseizures”; this is a movement disorder that appears to be seizures however there is no abnormal brain activity, underlying etiology is often psychiatrically associated.

Prognosis

The prognosis for night terror is good with most children outgrowing these episodes by 10 years of age. In contrast, the excessive movement may become a disturbance that alters a family’s or child’s quality of life during an exacerbation. There are developing therapies to encourage scheduled awakenings to prevent further episodes.

Pearls and Other Issues

  • Having night terror does not increase a child’s chance of epilepsy.
  • There is a loose correlation of familial inheritance.

Enhancing Healthcare Team Outcomes

The diagnosis and management of night terrors is complex and requires a multidisciplinary team that includes the pediatrician, nurse practitioner, social worker, primary care provider, and neurologist. Once diagnosed, there is no specific treatment for night terrors other than comforting the child. Reassurance and education for the parents or guardians are strongly encouraged especially to ensure the safety of the child during a night terror.

If there is excessive stress or conflict in the child’s life, a combination of therapy and coping techniques can be recommended to help decrease the frequency of episodes. Medication administration is strongly discouraged and not indicated.

Rarely is a sleep study ever indicated since the prognosis of night terrors is good and self-limiting; however, there is developing research involving scheduled awakenings through the night with a vibration machine to help improve quality of life.

The prognosis for night terror is good with most children outgrowing these episodes by 10 years of age.


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Night Terrors - Questions

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Which of the following findings is considered a normal developmental behavior in young children?



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A 7-year-old previously healthy girl is brought into the emergency department by her father with a concerning episode in the middle of the night. She started screaming and seemed oblivious to her surroundings and parents. The episode abruptly ended and she went back to sleep. She has no recollection of the event. What is the most likely diagnosis?



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A 6-year-old male with a well-established past medical history of attention-deficit/hyperactivity disorder on methylphenidate awoke in the middle of the night screaming "I didn't do it, I promise!" The mother was unable to wake him up or console him. He eventually calms down and goes back to sleep. He does not remember anything about the episode in the morning. What is the most likely diagnosis?



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Night terrors and somnambulism are most likely to occur during which stage of sleep?



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A 5-year-old previously healthy male is brought to the clinic because of severe nighttime episodes. Within one hour of falling asleep his parents hear him screaming and thrashing in his bed. They try to console him and wake him up, but he appears extremely sedated and abruptly falls back to sleep. He does not recall the episodes. What is the best treatment for this disorder?



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Which of the following is not part of REM sleep?



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A 7-year-old previously healthy female has had several awakenings in the middle of the night. During the awakening, she is screaming, tachypneic, tachycardic, and her pupils are dilated. She is unaware of her surroundings and is inconsolable during the episodes. She falls back to sleep after five minutes and has no memory of this in the morning. What is the most probable diagnosis?



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Which of the following is false about night terrors?



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The mother of a 5-year-old previously healthy male heard the screams of her son who she put to bed approximately an hour ago. She entered the room to find his thrashing around in bed and screaming. She tried to yell at him but, he would not respond to verbal cues. What should she do next?



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A 5-year-old previously healthy male is brought in by emergency medical services (EMS) for a concerning episode. Mom states that she was awakened by the child’s screams. Mom found the patient rolling around thrashing and screaming. The whole episode lasted about ten minutes, and the patient appeared to be sleeping again. He has never done this before. He was afebrile, and there were no apparent injuries. By the time EMS arrived at the house, the patient was back to neurologic baseline. On further history taking, mom does admit that there has been a lot of stress in the house with an impending divorce. What should be done next?



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A 2-year-old boy who is previously healthy presents to the emergency department with an episode where he sat up in bed, screamed, was inconsolable and went back to sleep. The patient has been napping inconsistently for the past few days and has been having trouble sleeping. In the ED, he is back to normal, smiling and playing with the stethoscope. He has stable vital signs with a normal physical exam. What should be done next?



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A 4-year-old boy who is previously healthy presents to the Emergency Department with an episode where mom was awakened by the boy screaming in bed. He had no episode of enuresis or complete body shaking. The episode lasted about five minutes and he promptly returned back to sleep. Here, he is baseline with stable vital signs and a completely normal physical exam. He denies any trauma or stressors, but cannot recall the episode. Which statement is true about this disorder?



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In the middle of the night, a mother hears her 4-year-old daughter screaming. She runs into the room and sees her daughter sitting straight up, screaming with her eyes open. The mother tries to get her attention, but the daughter doesn't notice mom waving her hands. She continues like this for the next 4 minutes. When mom is about to call emergency medical services, the daughter abruptly falls back to sleep. The next morning, the daughter does not recall the episode. What is the diagnosis?



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A 4-year-old boy who is previously healthy presents to the emergency department with an episode where mom was awaked with the boy screaming in bed. He had no episode of enuresis or complete body shaking. The episode lasted about five minutes, and he promptly returned to sleep. Here, he is baseline with stable vital signs and a completely normal physical exam. He denies any trauma or stressors, but cannot recall the episode. What abnormal findings will be revealed with work up?



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Night Terrors - References

References

Kaur H,Jahngir MU,Siddiqui JH, Sleep-related Eating Disorder in a Patient with Parkinson's Disease. Cureus. 2018 Sep 22;     [PubMed]
Ellington E, It's Not a Nightmare: Understanding Sleep Terrors. Journal of psychosocial nursing and mental health services. 2018 Aug 1;     [PubMed]
Boyden SD,Pott M,Starks PT, An evolutionary perspective on night terrors. Evolution, medicine, and public health. 2018;     [PubMed]
Cimolai N, Night terrors associated with celiac disease. European journal of gastroenterology     [PubMed]
Kabel AM,Al Thumali AM,Aldowiala KA,Habib RD,Aljuaid SS,Alharthi HA, Sleep disorders in adolescents and young adults: Insights into types, relationship to obesity and high altitude and possible lines of management. Diabetes     [PubMed]
Lopez R,Shen Y,Chenini S,Rassu AL,Evangelista E,Barateau L,Jaussent I,Dauvilliers Y, Diagnostic criteria for disorders of arousal: A video-polysomnographic assessment. Annals of neurology. 2018 Feb;     [PubMed]
Kim DS,Lee CL,Ahn YM, Sleep problems in children and adolescents at pediatric clinics. Korean journal of pediatrics. 2017 May;     [PubMed]
Beisang D,Forlenza GP,Luquette M,Sarafoglou K, Sporadic Insulinoma Presenting as Early Morning Night Terrors. Pediatrics. 2017 Jun;     [PubMed]
Ennis CR,Short NA,Moltisanti AJ,Smith CE,Joiner TE,Taylor J, Nightmares and nonsuicidal self-injury: The mediating role of emotional dysregulation. Comprehensive psychiatry. 2017 Jul;     [PubMed]

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