Night Terrors
Episodes of intense fear, screaming, and apparent terror during deep sleep, typically with no memory of the event upon awakening.
What is Night Terrors?
Night terrors (sleep terrors) are a parasomnia characterized by episodes of intense fear, screaming, and physical agitation during partial arousal from deep non-REM sleep. The person appears terrified and may sit up, scream, cry, thrash, or attempt to flee, but is actually in a state of incomplete awakening and is unresponsive to comfort. Episodes typically last 1-10 minutes and are followed by return to sleep with no memory of the event. Night terrors are most common in children ages 4-12 and usually resolve by adolescence. They are distinct from nightmares, which occur during REM sleep and are remembered.
Prevalence
Night terrors affect approximately 3-6% of children, with peak prevalence between ages 4-12. Most children outgrow them by adolescence. In adults, prevalence is less than 1%. There is a strong genetic component, with occurrence much more likely if parents had night terrors or sleepwalking. Night terrors and sleepwalking are closely related and often co-occur.
Causes
Night terrors occur when the brain becomes stuck between deep sleep and wakefulness. The same factors that trigger sleepwalking can trigger night terrors: genetics (strong family history), sleep deprivation, irregular sleep schedules, fever, stress and emotional conflict, certain medications, sleeping in unfamiliar places, and conditions that cause arousal from deep sleep (sleep apnea, restless legs, noise). The immature nervous system in children makes them more susceptible.
Symptoms
Screaming or crying out
Episodes typically begin with a sudden, piercing scream or shout, often terrifying to parents or bed partners.
Appearance of intense fear
The person appears extremely frightened with wide eyes, racing heart, rapid breathing, sweating, and flushed skin.
Unresponsive to comfort
Unlike nightmares, the person cannot be consoled during a night terror. They don't recognize caregivers and may become more agitated if restrained.
Physical agitation
Sitting up, thrashing, kicking, running, or bolting from bed may occur. Injury is possible during violent episodes.
No memory of the event
Upon awakening (either after the episode or the next morning), there is no recollection of the event or only fragmentary, confused memories.
Timing in first third of night
Most night terrors occur in the first few hours of sleep when deep (slow-wave) sleep predominates.
Return to sleep
After the episode (typically 1-10 minutes), the person calms and returns to sleep, usually with no lingering effects.
Diagnosis
Self-Assessment Questions
If you answer yes to any of these questions, consider consulting a sleep specialist:
- 1Does the person scream, appear terrified, or bolt upright during sleep?
- 2Are they unresponsive to attempts at comfort during episodes?
- 3Do they have no memory of the episode the next morning?
- 4Do episodes occur in the first few hours after falling asleep?
- 5Is there a family history of night terrors or sleepwalking?
- 6Does sleep deprivation, stress, or fever seem to trigger episodes?
Night terrors are diagnosed clinically based on the characteristic features: sudden arousal from deep sleep with intense fear, unresponsiveness, and amnesia. Polysomnography is rarely needed unless episodes are atypical or frequent.
Clinical History
Detailed description of episodes from observers, including timing, behaviors, responsiveness, and aftermath. History distinguishes night terrors from nightmares and seizures.
Sleep Diary
Tracking sleep patterns and episodes helps identify triggers such as sleep deprivation or irregular schedules.
Polysomnography with Video
May be performed if episodes are very frequent, atypical, or if nocturnal seizures need to be excluded.
Treatment
Most children outgrow night terrors without treatment. Management focuses on safety, addressing triggers, and reassuring parents. Medication is rarely needed but may be considered for severe or dangerous episodes.
Parental Reassurance and Education
Understanding that night terrors are common, not harmful to the child, and usually resolve with age helps reduce parental anxiety.
Safety Measures
Ensuring a safe sleep environment to prevent injury during episodes: remove hazards, lock doors and windows, consider bedroom alarms.
Address Triggers
Ensuring adequate sleep, consistent sleep schedules, and reduced stress can significantly decrease episode frequency.
Scheduled Awakenings
For children with predictable episode timing, briefly waking them 15-30 minutes before usual episode time can prevent night terrors.
Treat Underlying Sleep Disorders
If sleep apnea, restless legs, or other disorders are fragmenting sleep, treating them can reduce night terrors.
Benzodiazepines
Clonazepam or diazepam at bedtime may be used short-term for severe, dangerous, or extremely frequent episodes.
Lifestyle Adjustments
- •Ensure adequate sleep time for age
- •Maintain very consistent sleep schedules
- •Create a calming bedtime routine
- •Reduce stressors in the child's life
- •Keep the sleep environment safe
- •Don't try to wake the child during an episode; gently guide them back to bed
- •Don't discuss the episode extensively the next day, which may increase anxiety
- •Consider a brief scheduled awakening if episodes occur at predictable times
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