Definition

Night terrors are a condition characterized by episodes of screaming, intense fear, and thrashing while asleep. Unlike nightmares, those who experience night terrors do not remember the event the next morning, whereas individuals with nightmares can usually recall their dreams in detail.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), by the American Psychiatric Association, night terrors are classified alongside sleepwalking under a category called parasomnias. Parasomnias refer to undesirable events that occur during sleep.

Causes

During sleep, the human body goes through several stages, including the wakeful state, rapid eye movement (REM) sleep, and non-rapid eye movement (NREM) sleep. The stages are distinguished by eye movement. NREM sleep is the deep sleep stage, which is further divided into several depths of sleep. The transition between NREM and REM sleep occurs every 2-3 hours.

Typically, these transitions happen smoothly. However, in night terrors, there is a disruption during this sleep transition, placing the individual between sleeping and waking states, a condition known as arousal. Night terrors occur during the transition from the deepest stage of NREM sleep to a lighter REM stage.

Several factors can contribute to night terrors, including fever and illness, excessive physical activity, excessive intake of caffeine or alcohol, lack of sleep, fatigue, and emotional stress. Sleep disturbances such as obstructive sleep apnea (OSA), restless legs syndrome (RLS), medications, mood disorders like depression and anxiety, and alcohol use can also trigger night terrors.

Risk Factor

Night terrors typically occur in children aged 3-7 years and usually resolve by age 10. Both boys and girls are equally affected by this condition. Statistics show that 80% of children with night terrors have a family history of the condition. While night terrors can occur in adults, their presence may indicate a neurological disorder that warrants further investigation.

Symptoms

Night terrors can occur independently or in conjunction with sleepwalking. During an episode of night terror, an individual may exhibit the following symptoms:

• Begin with a frightening scream
• Sit up in bed and appear terrified
• Wide-eyed staring
• Excessive sweating, heavy breathing, increased heart rate, flushed face, and dilated pupils
• Continuous kicking and thrashing
• Difficult to wake up, and if awakened, may be confused
• Unable to be calmed
• Little to no memory of the event the next morning
• May get out of bed, run around the house, and behave aggressively if restrained

Typically, an episode lasts a few seconds to a few minutes. Afterward, the individual usually calms down.

Diagnosis

Diagnosing night terrors does not require immediate action. The condition can be diagnosed clinically, meaning it can be identified by obtaining a complete history and conducting a thorough physical examination. Your doctor will ask about any family history of night terrors. Laboratory tests and imaging are generally conducted to rule out other conditions with similar symptoms, such as seizures, sleepwalking, nightmares, narcolepsy (excessive daytime sleepiness), sleep apnea (pauses in breathing during sleep), breath-holding spells, fainting, myoclonus (sudden muscle jerks during early sleep), and tics (repetitive, involuntary movements).

Examinations that can be performed include an electroencephalogram (EEG) and polysomnography. An EEG measures the brain's electrical activity and is used to detect abnormal brain waves that may cause seizures. Polysomnography is a sleep study that observes a child during sleep to identify disorders such as breathing disturbances.

Management

There is no specific treatment for managing night terrors. However, parents or caregivers need support and education to ensure the child's safety during an episode. It is best not to wake the child during a night terror episode, as this can cause confusion and make it harder for them to fall back asleep. If your child experiences night terrors, ensure they are safe and free from injuries caused by thrashing or stumbling over objects.

In some cases, these episodes can disrupt a child's daily activities, such as learning and socializing at home or school. Doctors may prescribe medications to help with sleep or antidepressants.

If a child is under significant stress or experiencing emotional conflict, a doctor may recommend a combination of therapies, including psychotherapy and training in coping mechanisms to help the child better manage their issues. This combination of therapies can help reduce the frequency of night terrors in children with such challenges. Medication is usually not needed in these cases.

Complications

Night terrors typically resolve on their own by age 10. However, complications can arise from these episodes, such as:

• Daytime sleepiness, which can cause issues at school (or work for adults) and make it difficult to complete daily tasks
• The individual may feel like their sleep is not restful or adequate
• Knowing they have night terrors may cause embarrassment and even lead to relationship problems with those around them. The person may also injure themselves or others nearby

Prevention

As a parent or caregiver, there are several steps you can take:

• Ensure your child's room is safe so they do not get injured during an episode of night terror
• Remove items that could disrupt the child's sleep, such as electronics or noisy objects.
• Try to reduce your child's stress levels
• Make sure the child gets enough sleep. Encourage them not to become overly tired or stay up late
• Establish a regular sleep schedule and stick to it with your child
• Ensure a consistent wake-up time each day

Another prevention method for night terrors is interrupting the child's sleep pattern, which can be done as follows:

• Firstly, record the time interval between when the child falls asleep and when a night terror typically starts
• Wake the child 15 minutes before the expected time of the night terror, ensuring they get out of bed for about 5 minutes. This is a good time for a bathroom break if needed
• Continue this routine for a week

When to See a Doctor?

Occasional night terrors are generally not a cause for concern. If you regularly take your child to the doctor, you can mention if they are experiencing night terrors. However, you should be vigilant and consult a doctor if night terrors become more frequent, severely disrupt the child’s or others' sleep, pose a safety risk or cause injury, result in daytime sleepiness or difficulty with daily activities, or persist into adolescence or begin in adulthood.