Night Terrors

Night terrors, also known as sleep terrors, are an early childhood parasomnia characterized by screams or cries, behavioral manifestations of extreme fear, difficulty waking and inconsolability upon awakening^[1].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.Most episodes last 45-90 minutes and are most common as the individual passes through stages 3 and 4 non-rapid eye movement sleep. Night terrors are most common in between ages 4 until puberty.

The three main stages of sleep are (1) wakefulness, (2) non-rapid eye movement (non-REM) sleep, and (3) rapid eye movement (REM) sleep. These states are subsequently subdivided into distinct stages. Stages 1, 2, 3, and 4 of sleep are classified as non-rapid eye movement (non-REM) sleep, and stage 5 is classified as REM sleep. The states and stages mentioned may exhibit overlapping characteristics, and it is during these transitional states that parasomnias may manifest^[2].

Episodes of night terrors typically occur during the early part of the night when the child is in a state between wakefulness and sleep. This specific period is known as the arousal state. Episodes may seem quite intense, with the child screaming and thrashing without being aware of their surroundings. Children may exhibit symptoms of heightened autonomic activity, including rapid heart rate, rapid breathing, dilated pupils, and excessive perspiration. In certain instances, enuresis may also manifest.It is common for children to not respond to verbal cues, attempts to comfort them, or efforts to awaken them. Waking these children during an episode can be quite challenging. These episodes typically last for about 10 to 20 minutes before the child suddenly goes back to sleep. Many children do not remember the episodes.

The precise cause is uncertain, however there are significant associations with fever and illness, extreme physical exertion, excessive use of coffee or alcohol, sleep deprivation and fatigue, and emotional strain.

The peak incidence of night terrors occurs between the ages of three and seven, and they frequently subside by the time a child reaches ten. There seems to be an equivalent prevalence rate among males and girls, with an estimated prevalence of around 30% among children.

• Recurrent episodes
• Sudden arousal from sleep
• Maybe unresponsive during the attack
• Often there is no recall of the nightmare
• When fully awake, there is complete amnesia of the terror
• Causes significant distress in interpersonal life, academics, work, and social interaction
• Individual may scream or be distressed during the attack
• Autonomic symptoms are common (tachycardia, diaphoresis)
• Symptoms are not explained by any other condition

• Sleep studies are not usually necessary as night terrors generally have a positive outlook and resolve on their own.
• Comforting the child is the primary approach for addressing night terrors, as there is no targeted treatment available.
• Provide reassurance and education to the parents or guardians, particularly to ensure the child's safety during a night terror.
• If a child is experiencing high levels of stress or conflict, a combination of therapy and coping techniques can be suggested to help reduce the frequency of episodes.
• Medications are not necessary and avoiding their use is highly recommended.
• Clonazepam may be considered on a short-term basis at bedtime if sleep terrors are frequent and severe or are associated with functional impairment, such as fatigue, daytime sleepiness, and distress^[3].
• Anticipatory awakening, performed approximately half an hour before the child is most likely to experience a sleep terror episode, is often effective for the treatment of frequently occurring sleep terrors.
• L-5 Hydroxy Tryptophan (L -5-HTP) administered (2 mg/kg per day) at bedtime has been reported to modulate the arousal level in children and to induce a long-term improvement of sleep terrors^[4].
• There are also sporadic case reports of melatonin use in night terrors^[5][6].
• there is ongoing research on using scheduled awakenings and vibration machines during the night to enhance quality of life

The differential diagnosis for night terrors can include:

• Seizures. Patients with nocturnal frontal lobe epilepsy can present in a similar fashion.
• 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 characterized by recurring episodes of excessive sleepiness and sleep deprivation that are accompanied by episodes of breathing interruptions.
• 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
• Benign sleep 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
• Gastroesophageal reflux: An arching or dystonic posturing (Sandifer's positioning) due to regurgitated gastric contents or acid into the esophagus
• Psychogenic Nonepileptic Seizures (PNES)