Sleep terrors most often affect children between 4 and 12 years of age, but adults can experience these episodes as well. Patients may seek medical attention if they have multiple episodes that do not seem to be resolving on their own or if the episodes are especially upsetting. Other persons who sleep in the same room or in a nearby room where they can hear the associated sounds or movements may become concerned about the symptoms. This can prompt a medical evaluation if patients do not seek help owing to their own distress about the experience.
Factors associated with an increased risk for sleep terrors include fever, stress, a traumatic life event, sleep deprivation, medications, alcohol abuse, obstructive sleep apnea, and restless legs syndrome. The medications that are most commonly associated with this adverse effect are antihistamines, neuroleptics, antidepressants, sedatives, and stimulants. In addition to alcohol, cocaine and other drugs of abuse are potential risk factors.
Sleep terrors occur during non–rapid eye movement (NREM) sleep, between arousal from stage 3 or 4 of sleep (Figure 1). The episodes tend to occur during the first third of a standard 7- to 9-hour sleep period, and the autonomic symptoms could be associated with the hormonal variations that occur during the first part of a sleep episode (Figure 2). The medications that are associated with sleep terrors have the potential to increase the amount of stage 3 and 4 sleep.
Although sleep terrors are not a sign of psychiatric disorders and are not a criterion for a diagnosis of any specific mental health condition, the prevalence of parasomnias, including sleep terrors, may be higher among persons who have psychiatric conditions. The different parasomnias are not identical in their symptom pattern, but they share biologic characteristics. A predisposition to parasomnias is thought to be associated with developmental or genetic risk factors; however, specific genetic links or physiological changes have not been identified.
Sleep terrors are described in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) as recurrent episodes of partial, abrupt awakening from deep NREM sleep, usually during the first third of the major sleep episode, accompanied by panicky and/or inconsolable screaming, intense fear, relative unresponsiveness, and signs of autonomic arousal such as tachycardia, tachypnea, diaphoresis, and dilated pupils during each episode.
The diagnosis of sleep terrors is based on a clinical history. The patient's description of symptoms, as well as the description provided by any witnesses, may point to characteristic features of this parasomnia. Patients are described as not being easily awakened during the event, and they fall asleep immediately after the behavioral symptoms. Additionally, the effects of autonomic hyperactivity may be noted. Some of these autonomic symptoms may be described by the patient's parents, spouse, or others who witness the event.
Some patients may be better able to identify precipitating factors or the frequency of events if they are encouraged to keep a sleep diary. If the patient has a sleep partner, that person can also provide helpful information for a sleep diary.
During the diagnostic evaluation, potential medical problems that could contribute to the symptoms must be considered, including sleep deprivation due to obstructive sleep apnea or restless legs syndrome. A review of medications is advised, especially for adult patients.
Because stress and PTSD are known risk factors, patients may benefit from screening for these issues. Researchers suggest that patients who have sleep terrors should have a "basic mental health examination to possibly identify underlying issues."
Sleep hygiene, including maintaining a consistent bedtime, is important for all patients who have sleep terrors. Patients who exhibit agitated behavior during the episodes should also make practical modifications, such as moving any potentially dangerous objects away from where they could reach them during sleep. This includes items that could injure the patient or others.
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