Continuing Education Activity

Night terrors are a common sleep disorder in young children and describe a condition in which a child 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. A night terror is considered a parasomnia due to its characterization of unusual physical and verbal behaviors. This activity illustrates the etiology, evaluation, and treatment of night terrors and the importance of an interprofessional team approach to management.

Objectives:

• Describe the history and physical exam findings typically seen in patients with night terrors.
• Identify the population in which night terrors typically occur.
• Review the management of night terrors.
• Explain a well-coordinated interprofessional team approach to provide effective care to patients affected by night terrors.

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]

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 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.

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.

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 V 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. Individual may scream or be distressed during the attack
8. Autonomic symptoms are common (tachycardia, diaphoresis)
9. Symptoms are not explained by any other condition

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 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]

In some children, EEG studies may be required to rule out seizures. Patients with nocturnal frontal lobe epilepsy can present in a similar fashion.

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, excessive movements 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 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 the parents or guardians are strongly encouraged especially to ensure the safety of the child during a night terror. Parents should be educated about safety measures including secure windows. Limiting access to the potentially harmful location in the home and outside.

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. To avoid night terrors, it is vital that a sleep nurse 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.