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 have no recollection of the 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 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: (1) wake, (2) non-REM sleep, and  (3) REM sleep. Within these states, they are further broken down into 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, and it is during these transitional states that parasomnias can occur.[5][6]

Night terrors can cause severe distress, followed by a state of panic and a sensation of helplessness. Most episodes last 45-90 minutes and are most common during stages 3 and 4 of non-rapid eye movement sleep. Night terrors are most common between the ages of 4 and puberty.

Etiology

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

Furthermore, there are theories that a genetic component exists; however, this has never been proven and remains anecdotal. 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 common between ages 3 and 7 and often subside by age 10. There appears to be equal prevalence between boys and girls, with approximately 30% in children.

Night terrors can occur in adults; however, it is rare. This may indicate underlying neurologic disorders that require further workup and investigation.

Pathophysiology

No consistent reason to explain night terror is available. No biochemical or structural abnormality is found in the brain. It has been suggested that levels of serotonin or its precursor may be linked. Thus, SSRIs are often prescribed for night terrors. There is a strong association between sleepwalking and night terrors; in addition, there is a high familial risk.

DSM 5 Criteria

1. Recurrent episodes
2. Sudden arousal from sleep
3. Maybe unresponsive during the attack
4. Often, there is no recall of the nightmare
5. When fully awake, there is complete amnesia of the terror
6. Causes significant distress in interpersonal life, academics, work, and social interaction
7. Individuals may scream or be distressed during the attack
8. Autonomic symptoms are common (tachycardia, diaphoresis)
9. Any other condition does not explain symptoms

History and Physical

Episodes of night terrors most often occur in the first third of the night during slow non-rapid eye movement 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 very dramatic in presentation, with the child screaming and thrashing without awareness of their 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 is required in an emergent clinical setting to make the diagnosis. A night terror is a clinical diagnosis that can be made based on a careful history, especially one that details the actual episode from family members and witnesses. The only lab work or imaging needed is to rule out the differential diagnoses listed below.[7][8][9] In some children, EEG studies or polysomnography may be required to rule out seizures. Patients with nocturnal frontal lobe epilepsy can present similarly.

Treatment / Management

There is no specific treatment for night terrors other than comforting the child. Reassurance and education for parents or guardians are strongly encouraged, especially to ensure the child's safety during a night terror. If there is excessive stress or conflict in the child’s life, a combination of therapy and coping techniques may be recommended to reduce the frequency of episodes. Medication administration is strongly discouraged and not indicated.

A sleep study is rarely indicated, as the prognosis for night terrors is good and self-limiting; however, there is emerging research involving scheduled awakenings throughout the night with a vibration device to improve quality of life.

Differential Diagnosis

The differential diagnosis for night terrors can include, but is not limited t,o the following:

• Seizures: An abnormal, excessive synchronous discharge of neurons originating from the cerebral cort,ex causing a physical disturbance
• Somnambulism (also known as sleepwalking): A benign, self-limited arousal parasomnia disorder that is characterized by either excessive bed movement or walking during sleep
• Nightmares: A disorder that occurs during the REM stage of sleep, characterized by 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 is intertwined with interruptions of breathing. 
• Breath-holding spells: These occur most often between the ages of six and 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 a variety of reasons may cause. 
• Benign myoclonus: A self-limited episode of sudden jerking of the extremities in the early stages of sleep
• Shuddering attacks: A whole-body attack that resembles an essential tremor
• Tics: These are repetitive movements, such as twitching, blinking, head shaking, or other subtle movements, performed 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, and the 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, excessive movements may become a disturbance that alters a family’s or a child’s quality of life during an exacerbation—therapies are being developed to encourage scheduled awakenings to prevent further episodes.

Pearls and Other Issues

Thoughts to consider regarding night terrors:

• 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 an interprofessional 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 parents or guardians are strongly encouraged, especially to ensure the child's safety during a night terror. Parents should be educated about safety measures, including the use of secure windows. Limiting access to potentially harmful locations in and outside the home. If there is excessive stress or conflict in the child’s life, a combination of therapy and coping techniques may be recommended to reduce the frequency of episodes. Medication administration is strongly discouraged and not indicated.

A sleep study is rarely indicated, as the prognosis for night terrors is good and self-limiting; however, there is emerging research involving scheduled awakenings throughout the night with a vibration device to improve quality of life. To avoid night terrors, a sleep nurse must educate the parents on the importance of good sleep hygiene. The prognosis for night terror is good, with most children outgrowing these episodes by 10 years of age.

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References

1.

Kaur H, Jahngir MU, Siddiqui JH. Sleep-related Eating Disorder in a Patient with Parkinson's Disease. Cureus. 2018 Sep 22;10(9):e3345. [PMC free article: PMC6248845] [PubMed: 30473978]

2.

Ellington E. It's Not a Nightmare: Understanding Sleep Terrors. J Psychosoc Nurs Ment Health Serv. 2018 Aug 01;56(8):11-14. [PubMed: 30071122]

3.

Boyden SD, Pott M, Starks PT. An evolutionary perspective on night terrors. Evol Med Public Health. 2018;2018(1):100-105. [PMC free article: PMC5941156] [PubMed: 29765596]

4.

Cimolai N. Night terrors associated with celiac disease. Eur J Gastroenterol Hepatol. 2018 Jun;30(6):687-688. [PubMed: 29697525]

5.

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 Metab Syndr. 2018 Sep;12(5):777-781. [PubMed: 29673929]

6.

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. Ann Neurol. 2018 Feb;83(2):341-351. [PubMed: 29360192]

7.

Kim DS, Lee CL, Ahn YM. Sleep problems in children and adolescents at pediatric clinics. Korean J Pediatr. 2017 May;60(5):158-165. [PMC free article: PMC5461280] [PubMed: 28592979]

8.

Beisang D, Forlenza GP, Luquette M, Sarafoglou K. Sporadic Insulinoma Presenting as Early Morning Night Terrors. Pediatrics. 2017 Jun;139(6) [PMC free article: PMC5996761] [PubMed: 28562256]

9.

Ennis CR, Short NA, Moltisanti AJ, Smith CE, Joiner TE, Taylor J. Nightmares and nonsuicidal self-injury: The mediating role of emotional dysregulation. Compr Psychiatry. 2017 Jul;76:104-112. [PubMed: 28456054]

Disclosure: Ngoc Van Horn declares no relevant financial relationships with ineligible companies.

Disclosure: Megan Street declares no relevant financial relationships with ineligible companies.