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Sleep terrors.

Also called "night terrors", these episodes are characterized by extreme terror and a temporary inability to attain full consciousness. The person may abruptly exhibit behaviors of fear, panic, confusion, or an apparent desire to escape. There is no response to soothing from others. They may experience gasping, moaning or screaming. However, the person is not fully awake, and once the episode passes, often returns to normal sleep without ever fully waking up. In most cases, there is no recollection of the episode in the morning.

Like  sleepwalking , night terror episodes usually occur during NREM delta (slow wave) sleep. They are most likely to occur during the first part of the night. The timing of the events helps differentiate the episodes from nightmares, which occur during the last third of the sleep period.

While sleep terrors are more common in children, they can occur at any age. Research has shown that a predisposition to night terrors may be hereditary. Emotional stress during the day, fatigue or an irregular routine are thought to trigger episodes. Ensuring a child has the proper amount of sleep, as well as addressing any daytime stresses, will help reduce terrors.

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Night Terrors Resource Guide

• by Rose MacDowell
• Updated: September 7, 2023

Table of Contents

Night terrors, also called sleep terrors, are a type of sleep disorder that disrupts sleep and causes intense fear similar to that caused by nightmares. Unlike nightmares, night terror episodes may involve flailing, screaming, feelings of extreme panic, or sleepwalking.

Night terrors are considered a parasomnia, a classification of sleep disorders characterized by unusual behavior, vocalization, or movement during sleep . Night terrors are more common in children, but adults may suffer from them, as well. Though episodes normally last anywhere from a few seconds to a few minutes, they have been known to last thirty minutes or even longer.

Note: The content on Sleepopolis is meant to be informative in nature, but it shouldn’t take the place of medical advice and supervision from a trained professional. If you feel you may be suffering from any sleep disorder or medical condition, please see your healthcare provider immediately.

What Are Night Terrors?

Night terrors are a sleep disorder that typically occurs during the transition between the deepest stage of sleep, known as N3, and REM sleep , the fourth and final stage of sleep when vivid dreaming occurs. ( 1 ) The disorder results from a partial arousal from sleep, when the sufferer is not fully asleep but not conscious. Night terrors are characterized by a state of heightened fear, but do not typically involve dreams or nightmares .

Night terrors affect only a small percentage of children — approximately one to three percent — and an even smaller percentage of adults. ( 2 ) The disorder is more common in boys, and occurs most often around the age of one and a half.

While frightening for both children and parents, night terrors are not generally a cause for concern. Most children outgrow them by their teens or earlier. Night terrors may require treatment if they cause persistent sleep problems or become a safety risk.

Symptoms of Night Terrors

People who experience night terrors may scream, flail, sit up in bed , run around, or exhibit aggressive behavior. Some sufferers may leave the home, break windows, or damage furniture and other objects. ( 3 )

Other symptoms of night terrors include overwhelming fear and the inability to be awakened . Bedwetting occurs in some children. Sufferers may also experience some or all of the following:

• Rapid breathing
• Elevated heart rate
• Dilated pupils

One of the defining features of night terrors is amnesia, or the complete inability to recall the experience the following day . Even children who are awakened during an episode rarely remember it. ( 4 ) Though amnesia prevents direct recall of the occurrence, sufferers may experience the effects of night terrors after waking, including daytime sleepiness due to disrupted sleep.

Amnesia The short or long-term loss of memories, including experiences and facts.

Causes of Night Terrors

In children, night terrors can be a normal part of nervous system development . Sleep stages may not be clearly defined in young children, making night terrors, sleepwalking, and other parasomnias more likely. ( 5 ) Nervous system immaturity can cause the fight-or-flight system to activate at inappropriate times during sleep, triggering night terrors.

The disorder can also be associated with underlying medical conditions, such as seizure disorders and acid reflux. Other related triggers may include :

• Sleep apnea
• Narcolepsy and other forms of hypersomnia
• Light or noise
• An unfamiliar environment
• Restless legs syndrome

Night terrors may also occur as a side effect of certain medications. Other factors that can contribute to the disorder include stress, sleep deprivation, and fever . ( 6 )

Night terrors tend to run in families, and in adults may be associated with a history of anxiety or depressive disorders. They may also be caused by alcohol or recreational drug use in adults.

Diagnosis of Night Terrors

Night terrors are normally diagnosed by a doctor based on the patient’s or parents’ description of events . Doctors may conduct a psychological or physical exam to identify conditions that could be contributing to night terrors. If the diagnosis is unclear, doctors might recommend a sleep study, known as a polysomnography. ( 7 )

A polysomnography typically involves an overnight stay at a sleep lab. Brain waves, heart rate, and blood pressure are measured using sensors attached to the head and body. Limb movements and breathing are measured, as well. Though a sleep study may be helpful in cases where the diagnosis is less clear, the majority of night terrors sufferers can be diagnosed by symptoms alone.

Treatment of Night Terrors

Infrequent sleep terrors do not generally require treatment . Treatment may be needed if night terrors persist or cause significant sleep disruption. Treatment options include improving sleep habits , treating underlying conditions, and in rare cases, the use of medication. ( 8 ) Reducing stress and vigorous daily exercise may also be recommended.

Scheduled awakenings to avoid long periods spent asleep can also help. ( 9 ) These awakenings may be accomplished by parents, or by a machine designed to vibrate and slightly rouse the sleeper when it senses night terrors beginning.

Some studies show that co-sleeping with very young children may help reduce the incidence of night terrors . ( 10 ) Simply sharing a room with parents can reassure a child and make night terrors less likely.

Co-sleeping The practice of a parent and child sleeping in the same bed.

At-home treatment for night terrors includes the following :

• Do not awaken a child during a night terror. Try to help your child return to normal sleep by holding them or speaking in a soothing tone
• To help prevent injury, protect your child from stairways, windows, or leaving the home
• Explain night terrors and how to respond to them with anyone who stays with your child during naps or overnight
• Avoid triggers whenever possible. A child who is overly tired is more likely to suffer from night terrors. A regular sleep schedule, consistent afternoon naps, and treatment of related medical conditions can help prevent or reduce the frequency of the disorder

Night Terrors Vs. Nightmares

Though night terrors and nightmares share features such as intense fear, elevated heart rate, and sleep disruption, they are distinct entities . Nightmares involve frightening dreams , whereas night terrors do not. People who suffer from nightmares typically know where they are when they wake, and are able to remember specific details of their dreams. People suffering from night terrors remain asleep, and don’t normally remember their experiences in the morning.

Night terrors also differ from nightmares in that they occur during the first half of the night when N3 sleep dominates the sleep cycle. Nightmares normally occur during the last half of the night, when REM sleep cycles are longer. ( 11 )

While it is relatively easy to wake a child or adult from a nightmare, it is very difficult to wake a person suffering from night terrors . Sleep specialists generally warn against trying to wake someone from a night terror, and advise keeping the sleeper as safe and comfortable as possible until the episode passes. If you’re still curious about these differences, please check out our full guide on Nightmares vs Night Terrors .

Last Word From Sleepopolis

Night terrors are a fairly unusual occurrence in children, and quite rare in adults. They are considered a parasomnia, a sleep disorder associated with unusual behavior, dreams, or sensations. When night terrors do happen, they typically occur only on occasion and resolve by themselves by early adolescence. 

Frightening as night terrors can be to outside observers, sufferers do not remember the incidents. A regular sleep schedule, naps, and a dark, quiet sleep environment can help prevent disturbed sleep and night terrors. If the disorder occurs frequently or puts a child at risk of injury, treatments such as medication or scheduled awakenings can help reduce or even eliminate occurrences .

• Megan A. Moreno, Sleep Terrors and Sleepwalking:  Common Parasomnias of Childhood,  JAMA Pediatrics Patient Page , July, 2015
• Theodoros   Mazarakis,  A case of adult night terrors, Tzu Chi Medical Journal , Sept. 2014
• Wills L, Garcia J., Parasomnias: epidemiology and management, CNS Drugs , 2002
• Thornton B.A. Mason, II, MD, PhD., Pediatric Parasomnias, Sleep , Feb. 2007
• Irfan M, Schenck CH, Howell MJ., Non-Rapid Eye Movement Sleep and Overlap Parasomnias, Continuum, Aug. 2017
• Ngoc L. Van Horn; Megan Street, Night Terrors, StatPearls , Mar.2, 2019
• Eve G Spratt, MD, MSc; Chief Editor: Caroly Pataki, MD, Sleep Terrors, Medscape , Mar.14,2019
• DJ Nutt, Adult night terrors and paroxetine, The Lancet , July  19, 1997
•  Eve G Spratt, MD, Carolyn Pataki, MD, Sleep Terrors Treatment & Management, Medscape , Mar. 14, 2019
• Boyden SD, Pott M, Starks PT., An evolutionary perspective on night terrors, Evolution, Medicine, and Public Health , Apr. 14, 2018
• Rochelle Zak, MD, Nightmares and nightmare disorder in adults, UpToDate , Mar. 16, 201

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Rose MacDowell

Related posts.

• Patient Care & Health Information
• Diseases & Conditions
• Sleep terrors (night terrors)

To diagnose sleep terrors, your doctor or other healthcare professional may:

• Talk about your medical history. Your healthcare professional will likely discuss your medical history. You may have a physical exam to identify any conditions that may be part of the reason for your sleep terrors. You may be asked about your family history of sleep problems.
• Talk about your symptoms. Sleep terrors are usually diagnosed based on your description of the events. The health professional also may ask you or your bed partner some questions about your sleep behaviors. A video of a sleep terror episode can be helpful.
• Recommend an overnight sleep study. In some cases, your health professional may recommend an overnight study in a sleep lab. Sensors placed on your body record and monitor brain waves, the oxygen level in your blood, heart rate and breathing during sleep. The sensors also record eye and leg movements while you sleep. You may be videotaped to document your behavior during sleep cycles.

More Information

• Polysomnography (sleep study)

Treatment usually isn't needed for sleep terrors that happen rarely. Children typically outgrow sleep terrors.

Treatment may be needed if the sleep terrors cause a safety risk, interfere with sleep, don't go away with time or happen more often. Being embarrassed or disrupting the sleep of others may lead some people to seek treatment.

Treatment generally focuses on plans for safety and getting rid of causes or triggers for sleep terrors.

Treatment options may include:

• Treating any underlying condition. If the sleep terrors are linked with a medical or mental health condition or another sleep disorder, such as obstructive sleep apnea, treatment is aimed at the underlying problem.
• Addressing stress. If stress or anxiety seems to be part of the cause of the sleep terrors, your healthcare professional may suggest meeting with a sleep specialist. Cognitive behavioral therapy, hypnosis or relaxation therapy may help.
• Anticipatory awakening. This involves waking the person who has sleep terrors about 15 minutes before the person usually has the event. Then the person stays awake for a few minutes before falling asleep again.
• Medicine. Medicine is rarely used to treat sleep terrors, especially for children. But if needed, the healthcare professional may prescribe medicines that help with sleep, such as benzodiazepines or certain antidepressants.
• Biofeedback
• Cognitive behavioral therapy

Lifestyle and home remedies

If sleep terrors are a problem for you or your child, here are some tips:

• Get enough sleep. Extreme tiredness can contribute to sleep terrors. If you're not getting enough sleep, try an earlier bedtime and a more regular sleep schedule. Sometimes a short nap may help. If possible, avoid noises or other stimuli that could interrupt sleep.
• Establish a regular, relaxing routine before bedtime. Do quiet, calming activities before bed. Read books, do puzzles or soak in a warm bath. Meditation or relaxation exercises may help too. Make the bedroom comfortable and quiet for sleep. Avoid caffeine close to bedtime.
• Make the area safe. To help prevent injury, close and lock all windows and outside doors at night. You might even lock inside doors or put alarms or bells on them. Block doorways or stairways with a gate. Move electrical cords or other objects that might be a tripping hazard. Don't use bunk beds, if possible. Place any sharp or fragile objects out of reach. Also, lock up all weapons.
• Put stress in its place. Identify the things that cause stress. Think of ways to handle the stress. If your child seems anxious or stressed, talk about what's bothering your child. A mental health professional can help.
• Offer comfort. If your child has a sleep terror, consider simply waiting it out. It may be upsetting to watch, but it won't harm your child. You might cuddle and gently soothe your child. Then try to get your child back into bed. Speak softly and calmly. Don't shout. Trying to wake your child or keep your child from moving may make things worse. Usually the event will shortly stop on its own.
• Look for a pattern. If your child has sleep terrors, keep a sleep diary. For a few weeks, note how many minutes after bedtime a sleep terror occurs. If the timing is fairly consistent, anticipatory awakenings may help.

Preparing for your appointment

Sleep terrors in children tend to go away by the time they're teenagers. But if you have concerns about safety or underlying conditions for you or your child, talk to your healthcare professional. Your health professional may refer you to a sleep specialist.

Keep a sleep diary for two weeks before the appointment. A sleep diary can help the healthcare professional understand more about the sleep schedule, issues that affect sleep and when sleep terrors happen. In the morning, record bedtime rituals, quality of sleep, and anything else you think is important. At the end of the day, record behaviors that may affect sleep, such as sleep schedule changes and any medicine taken.

You may want to take a family member or friend along, if possible, to provide more information.

What you can do

Before your appointment, make a list of:

• Any symptoms, including any that may not seem related to the reason for the appointment. Bring a sleep diary to the appointment, if possible. A video recording of the sleep terror can be helpful.
• Key personal information, including any major stresses or recent life changes.
• All medicines, vitamins, herbs or other supplements being taken, and the doses.
• Questions to ask the healthcare professional to help make the most of your time together.

Some questions to ask include:

• What is likely causing these symptoms?
• What are other possible causes?
• What kinds of tests are needed?
• Is the condition likely to last a short time or a long time?
• What's the best course of action?
• What are other options to the primary actions you're suggesting?
• Do you recommend seeing a specialist?
• Are there any brochures or other printed material that I can have? What websites do you recommend?

Don't hesitate to ask other questions during your appointment.

What to expect from your doctor

Your doctor or other healthcare professional is likely to ask several questions, for example:

• When did the sleep terrors begin?
• How often do the sleep terrors occur?
• When during the night do the episodes occur?
• Can you describe a typical episode?
• Have there been sleep problems in the past?
• Does anyone else in your family have sleep problems?
• Have the episodes resulted in any injuries.

Be ready to answer questions so you have time to go over information you want to spend more time on.

• Sateia M. Sleep terrors. In: International Classification of Sleep Disorders. 3rd ed. American Academy of Sleep Medicine; 2014. https://learn.aasm.org/Listing/a1341000002XmRvAAK. Accessed March 1, 2023.
• Kryger M, et al., eds. Disorders of arousal. In: Principles and Practice of Sleep Medicine. 7th ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed March 1, 2023.
• Parasomnias. Merck Manual Professional Version. https://www.merckmanuals.com/professional/neurologic-disorders/sleep-and-wakefulness-disorders/parasomnias. March 3, 2023.
• Sleep-wake disorders. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5-TR. 5th ed. American Psychiatric Association; 2022. https://dsm.psychiatryonline.org. Accessed. March 2, 2023.
• Leung AKC, et al. Sleep terrors: An updated review. Current Pediatric Reviews. 2020; doi:10.2174/1573396315666191014152136.
• Bruni O, et al. The parasomnias. Child and Adolescent Psychiatric Clinics of North America. 2021; doi:10.1016/j.chc.2020.08.007.
• Olson EJ (expert opinion). Mayo Clinic. March 10, 2023.

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Sleep terror …

Federica Provini MD

• Updated 06.03.2023
• Released 04.07.1994
• Expires For CME 06.03.2026

Sleep terror

• In This Article
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Introduction

Sleep terror is one of the manifestations of disorders of arousal and consists of abrupt arousals out of sleep stage 3 NREM, primarily in the first third of the night, with disordered motor agitation, screaming, fear, and autonomic activation. Sleep terrors affect between 1% to 6% of prepubertal children, with a peak incidence between 5 and 7 years of age and a strong familial clustering. Sleep terrors are usually benign and tend to spontaneously decrease in frequency or cease during adolescence. However, since the early 2000s, it has been shown that sleep terrors can persist in adulthood in predisposed individuals or even appear de novo in some cases, often causing excessive daytime sleepiness and altered quality of life. In this update, the author addresses the latest clinical and polygraphic criteria for the differential diagnosis between sleep terrors and other motor phenomena occurring during sleep, focusing on sleep-related hypermotor epilepsy in which the differential diagnosis poses particular problems. In addition, the author provides the results of the new extensive research on the link between sleep terrors and the concept of local arousal.

Historical note and terminology

Sleep terrors (also called "pavor nocturnus" in children and "incubus" in adults) have commanded attention for centuries. It was not until 1949, when Jones wrote On The Nightmare , that sleep terrors were differentiated from terrifying dreams ( 21 ).

Gastaut described sleep terrors in a single subject, which originated in slow-wave sleep ( 15 ). Broughton first suggested that sleep terror is a "disorder of arousal" rather than an epileptic phenomenon ( 05 ). Fisher confirmed that sleep terrors begin in stage 3 or 4 sleep (now N3), generally in the first cycle ( 14 ). In the International Classification of Sleep Disorders, sleep terrors are classified as a disorder of arousal (from NREM sleep) within the class of parasomnias ( 01 ).

Clinical manifestations

Presentation and course.

Other clinical features consist of marked autonomic activation, including flushing of the skin, diaphoresis, and mydriasis. The heart rate rises; tachypnea and increased respiratory amplitude are common ( 50 ; 02 ; 39 ).

The patient may feel anxious, fearful, or terrified and is generally inconsolable until the intense agitation dissipates. A sense of respiratory oppression or of doom or impending death may accompany the episode. As the patient calms down at the end of the episode, sleep follows easily, and the episodes usually do not occur more than once per night ( 50 ). Sleep-related violence during disorders of arousal episodes or potentially harmful behaviors, which are rare in childhood, could appear in adults ( 31 ).

Recall of the episode either immediately after or the next morning is usually absent or limited to a single, unpleasant frightening visual scene, and patients, especially children, usually do not remember them in the morning ( 05 ). In contrast with REM sleep behavior disorder, disorders of arousal, including sleep terrors are often considered as nondreaming states as they emerge from N3 sleep; however, recent studies have challenged this view ( 48 ; 19 ). If children usually could not recall any mental activity associated with their episodes, many adults recalled at least one mental experience. The content of the collected reports was dominated by dynamic actions acted out from a self-perspective, often with apprehension and in response to misfortune and danger, in a home-setting environment ( 09 ).

Sleep terror episodes can be precipitated by fever, sleep deprivation, unusual circadian rhythms, or the use of central nervous system depressant medications ( 39 ; 16 ). Attacks can often be triggered by forced arousals in slow-wave sleep. Young children with poorly controlled sleep disorders (eg, obstructive sleep apnea) or medical conditions, such as esophageal reflux or asthma, had more sleep disruptions, including more frequent sleep terrors, than children without ( 38 ; 16 ).

Prognosis and complications

In children, sleep terrors are usually benign and become less frequent with age, tending to resolve spontaneously during adolescence, perhaps because the amount of time spent in delta-wave sleep decreases with age ( 39 ). When sleep terror episodes include sleepwalking activity, the risk of injuries to oneself or to others is increased due to the lack of control on the behavior and on the real environment and transient indifference to pain ( 19 ).

In children and adolescents with disorders of arousal, behavioral and emotional problems are surprisingly common, and the severity of emotional or behavioral problems is positively correlated with the severity of the nocturnal episodes ( 12 ).

A significant bidirectional association between depressive symptoms and disturbed sleep in children and adolescents was found ( 37 ). If disturbed sleep is associated with the consolidation of depressive symptoms starting in childhood, which, in turn, is associated with ongoing sleep problems, timely and appropriate interventions could prevent spiraling effects on both domains.

Clinical vignette

A 7-year-old child presented with a 3-year history of sudden awakenings, usually 1 hour after sleep onset. The child’s medical history was unremarkable. Family history revealed that a maternal cousin had experienced sleep terror episodes in the past. During the episodes the patient sat up with a fearful expression and glassy eyes, vocalized, screamed, and shook; his body seemed fighting against an unknown danger. He was usually inconsolable, unresponsive to external stimuli, and was difficult to waken and calm. He had tachycardia, tachypnea, flushing of the skin, and mydriasis. The patient was confused and disoriented if awakened. Often the child might be able to provide only an indication of fear, but return to sleep might occur without achieving full waking consciousness, and morning amnesia for the whole event was the rule. The episodes occurred twice monthly, lasting 3 to 5 minutes; during febrile illness, they were more frequent and prolonged. Neurologic examination was negative. Based on the characteristic history, he was diagnosed with sleep terrors. No pharmacologic treatment was begun because the attacks did not produce harm or injury; parents and child were reassured that the episodes are generally self-limiting, decreasing in frequency, and cease during adolescence or young adulthood.

Biological basis

Etiology and pathogenesis.

A number of genetic, developmental, psychological, and organic risk factors have been identified for sleep terrors.

Genetic factors. There is clear evidence that many patients with sleep terrors have a family history of sleep terrors, sleepwalking, or both, supporting the hypothesis that sleepwalking and night terrors share a common strong genetic predisposition ( 41 ; 33 ). Still, no genes have been identified in family pedigrees, and the most probable mode of inheritance is considered to be multifactorial ( 33 ). Studies of twins strongly support the heritability of sleep terrors, with a higher correlation between monozygotic rather than dizygotic twins of patients with sleep terrors. In addition, it has been proposed that the human leukocyte antigen (HLA) DQB1*04 and HLA DQB1*05:01 alleles might explain at least part of this genetic susceptibility to NREM parasomnias ( 16 ), suggesting a possible involvement of immune-related mechanisms in motor control during sleep.

Developmental factors. The common pattern of onset is in childhood, and termination by late adolescence implicates a developmental factor. An immature form of some cortical GABAergic and cholinergic inhibitory circuits might be ineffective in stopping movements during sleep ( 16 ). It has also been suggested that disorders of arousal, including sleep terrors, may be associated with a dysfunction in the serotoninergic system, which plays a crucial role in generating slow wave sleep, arousal, and control of motor activity.

Psychological factors. Sleep terrors are common in patients with posttraumatic stress disorder and are probably increased in children raised in violent, abusive families. Some studies reported a significant association between anxiety level and sleep terror episodes. Children and adolescents with disorders of arousal exhibit specific psychobiological personality traits compared to age- and gender-matched control subjects ( 47 ), but psychopathology is extremely rare in children despite the impressive intensity of the attacks.

Finally, Boyden and colleagues proposed that sleep terrors might be an extreme response to the evolutionary–environmental mismatch that has resulted from changes in sleeping behavior, from co-sleeping, with decreased risk of predation of children having parents nearby, to sleeping separately ( 04 ; 16 ).

Organic factors. Sleep terrors occur more often in children with sleep-disordered breathing than in normal children and are increased in patients with obstructive sleep apnea, especially during nasal continuous positive airway pressure therapy, and in those who consume alcohol at bedtime or enjoy intense evening physical activities that promote increased slow wave sleep and NREM sleep instability. The prevalence of parasomnias, including sleep terrors, is greater among children with neurodevelopmental disorders, such as Down syndrome and cerebral palsy. These patients are more vulnerable to upper airway obstruction that can cause repeated arousals from sleep, triggering arousal disorders. Nevsimalova and colleagues suggested that childhood parasomnias, including sleep terror, can be regarded as a disorder of sleep maturation because they are frequently associated with perinatal risk factors and developmental comorbidities ( 40 ).

Sleep terrors starting in adulthood can be symptomatic of neurologic diseases. There are isolated documented cases of sleep terrors caused by a brainstem lesion or a thalamic tumor.

The pathogenesis of sleep terrors is unknown. Sleep terror is classified as a disorder of arousal based on the concept that disordered arousal mechanisms lead to behavioral and emotional activation but not to a full awakening ( 10 ; 39 ; 08 ; 32 ). Sleep disorders that are known to trigger arousals, like sleep-disordered breathing, may cause sleep terror in children. Sleep terrors usually occur during deep non-REM sleep (stage 3). High-voltage slow-wave activity may be seen immediately prior to the episode, and the EEG during an episode may show diffuse, hypersynchronous rhythmic delta, diffuse delta with intermixed faster frequencies in the theta and alpha range, or prominent alpha and beta activity.

Some authors failed to find a “delta wave build-up” prior to an arousal disorder, suggesting that this EEG pattern does not appear to be specific for an arousal disorder episode ( 45 ). Intracerebral EEG studies suggest that arousal disorders could be dissociated arousal states due to the coexistence of different, local, cerebral states of being ( 45 ; 02 ). Scalp EEG analysis reveals a localized decrease in slow wave activity over centro-parietal regions relative to the rest of the brain in patients with arousal disorders compared to good-sleeping healthy controls; also, these differences in local sleep were present in the absence of any detectable clinical or electrophysiological signs of arousal ( 11 ). These topographical changes in local EEG power persist during REM sleep and wakefulness, suggesting a trait-like functional change that crosses the boundaries of NREM sleep. Spectral analysis over 325 episodes of disorders of arousal showed an absolute significant increase in all frequency bands prior to episodes of disorders of arousal, excluding sigma, which displayed the opposite effect. In normalized maps, the increase was relatively higher over the central/anterior areas for both slow and fast frequency bands. Taken together, these results show that deep sleep and wake-like EEG rhythms coexist over overlapping areas before episodes of disorders of arousal, suggesting an alteration of local sleep mechanisms. Episodes of different complexity are preceded by a similar EEG activation, implying that they possibly share a similar pathophysiology ( 32 ).

Studies on adults suggest that an abnormal deep sleep associated with a high slow-wave sleep fragmentation might be responsible for the occurrence of sleep terror episodes ( 30 ). A video-polysomnographic (V-PSG) assessment to quantify slow-wave sleep interruptions (slow-wave sleep fragmentation index, slow/mixed and fast arousal ratios, and indexes per hour) and the associated behaviors in 60 adult patients with disorder of arousal showed that slow-wave sleep fragmentation index and the mixed, slow, and slow/mixed arousal indexes and ratios were higher in patients with disorders of arousal than controls ( 30 ). Usually, the increased slow-wave sleep fragmentation observed in patients with sleep terrors is not associated with the level of daytime sleepiness ( 29 ). In fact, daytime sleepiness in adult patients with sleep terrors and sleepwalking episodes seems to be associated with a specific polygraphic phenotype (rapid sleep onset, long sleep time, lower numbers of awakenings on N3), which is suggestive of a higher sleep propensity that may contribute to incomplete awakening from deep sleep ( 07 ).

Evaluating autonomic reactions in a small group of adult patients with sleepwalking and sleep terrors, Ledard and colleagues found an autonomic arousal occurring 4 seconds before motor arousal from N3 sleep (with a higher adrenergic reaction than in controls), suggesting that an alarming event during sleep (possibly a worrying sleep mentation or a local subcortical arousal) causes the motor arousal ( 22 ).

Epidemiology

Approximately 1% to 6% of prepubertal children have recurrent sleep terrors, with a peak incidence between 5 and 7 years of age ( 23 ). Episodes tend to decrease in frequency or cease during early adolescence such that 50% of children no longer have attacks by the age of 8, suggesting a disorder of maturation of the nervous system. The high amount of slow wave sleep in preschool and school aged children could be a predisposing factor for the occurrence of disorders of arousal. The decrease of delta sleep due to synaptic pruning during adolescence may also account for the disappearance of sleep terrors at this age ( 16 ). However, in some patients, episodes begin in adolescence or early adulthood ( 02 ; 39 ). The prevalence of disorders of arousal was 7.1% among boys and 7.7% among girls in a nationwide survey conducted among Japanese adolescents ( 20 ). The prevalence in adults is about 1%. Sex and racial or cultural differences do not appear to affect prevalence, although some sources indicate that boys seem to be more frequently affected than girls ( 16 ).

Many individuals share the condition with one or more family members, and the increased prevalence in first-degree relatives suggests an autosomal dominant pattern of inheritance. Again, these findings predate the discovery of autosomal-dominant nocturnal frontal lobe epilepsy and may refer to misdiagnosed seizures.

Sleep deprivation, a big delay in sleep/wake schedule such as that of confinement due to COVID-19, emotional stress, alcohol use at bedtime, and febrile illness can influence the frequency and severity of episodes in susceptible individuals ( 33 ; 06 ). Avoidance of these precipitants may help to prevent sleep terrors. In some patients, the premenstrual period may be associated with more frequent episodes ( 35 ; 39 ).

Poorer sleep quality in children is often associated with maternal depressive symptoms, and parasomnias are more prevalent among children of mothers with chronic symptoms of depression ( 17 ).

Differential diagnosis

Confusing conditions.

The differential diagnosis includes sleep-related epilepsy, REM sleep behavior disorder, nightmares, confusional arousals, nocturnal panic attacks, nocturnal delirium, and other sleep disorders that produce anxiety, including obstructive sleep apnea and nocturnal cardiac ischemia. Sleep terrors pose particular problems in their differential diagnosis with the sleep-related epileptic seizures, particularly sleep-related hypermotor epilepsy in which attacks commonly occur without scalp EEG epileptic abnormalities ( 46 ; 25 ; 39 ). Generally, the distinction between sleep terrors and epileptic seizures is based on clinical criteria. Features favoring the diagnosis of sleep-related hypermotor epilepsy rather than sleep terrors are a high rate of same-night recurrence, the presence of dystonic-dyskinetic motor pattern during the attacks, their stereotypical motor behavior, their response to antiepileptic medication, and onset or persistence into adulthood ( 43 ; 46 ; 39 ). Sleep terrors typically occur within the first few hours of sleep, whereas seizures may occur throughout the night (see Table 1). Nocturnal complex partial seizures may also be associated with fearful appearance, screaming, running, tachycardia, and vague frightening perceptions. However, it is not always possible to distinguish sleep terrors from seizures on the basis of history alone, and video-polysomnographic recording is mandatory in cases in which episodes are frequent and persisting in young adulthood with a violent motor behavior ( 39 ). In association with the episodes’ semiological features, sleep stage and the relative time of occurrence of minor and major motor manifestations during sleep represent useful criteria to discriminate sleep-related hypermotor epilepsy and disorders of arousal ( 42 ; 25 ). Analyzing the "event distribution index" during video-polysomnography recordings of 89 patients with a definite diagnosis of disorders of arousal (59) or sleep-related hypermotor epilepsy (30), the occurrence of at least one major event outside N3 was highly suggestive for sleep-related hypermotor epilepsy. The occurrence of at least one minor event during N3 was highly suggestive for disorders of arousal ( 42 ).

Sleep terrors usually occur within the first few hours of sleep and arise out of NREM sleep stages 3 (N3), whereas nightmares occur out of REM sleep during the middle or latter half of the night. Nightmares are not usually accompanied by major motor activity or severe anxiety, vocalization, and autonomic discharge, and they are less likely to begin with an intense scream than sleep terrors. The sleeper is more easily aroused and, when awakened from a nightmare, exhibits good intellectual function. Afterward, dream content can be recalled in vivid detail (see Table 1). Some patients, however, have clinical features that overlap between nightmares and sleep terrors.

Table 1. Differential Diagnosis of Sleep Terror

Confusional arousals are awakenings from slow-wave sleep without terror or ambulation. Patients may fumble with bedclothes and mumble incoherently but do not exhibit intense autonomic arousal or flight reactions. The features of sleep terrors, sleepwalking, and confusional arousals often overlap. For example, sleepwalking episodes and confusional arousals may be associated with whimpering or crying, fearful behavior, and mild autonomic arousal.

In nocturnal dissociative disorder, the patient is awake when the episode begins and behavior is purposeful, more complex, and longer lasting. The EEG is consistent with wakefulness.

REM sleep behavior disorder may be associated with violent behavior, running, or screaming; however, autonomic activation is usually absent or mild with, for example, little or no tachycardia. Episodes tend to occur later in the night and are often associated with dream recall. Observers often report that patients seem to be "acting out" their dreams. In some patients, however, behavior may be similar to that observed with sleep terrors, and some patients have an "overlap syndrome” (parasomnia overlap disorder) with elements of sleep terrors, somnambulism, and REM sleep behavior disorder ( 49 ).

It is, however, important to remember that disorders of arousal may begin in adulthood and also persist or arise in older adults. Motor patterns of disorders of arousal in older adults are similar to those in younger patients. A combined clinical examination and video polysomnography recording are crucial in establishing a definitive diagnosis of nocturnal motor behavior in all older adults and especially in those affected by neurodegenerative diseases ( 26 ).

Nocturnal panic attacks may at times clinically resemble sleep terrors, and episodes may arise out of NREM sleep, usually stage 2 or 3. Psychopathology is common, and there are always similar episodes in daytime wakefulness, which is not true in patients with sleep terrors.

In a single case, screaming/yelling episodes were due to a sporadic insulinoma, suggesting the inclusion of hypoglycemia in the differential diagnosis of new-onset or worsening seizures or night terrors ( 03 ).

Associated or underlying disorders

Comorbidities include obstructive sleep apnea, periodic limb movements during sleep, insomnia, restless legs syndrome, REM sleep behavior disorder (considered parasomnia overlap), and epilepsy ( 24 ).

Diagnostic workup

An accurate clinical interview is theoretically sufficient to confirm a diagnosis of disorders of arousal according to standard international criteria ( 34 ).

(Contributed by Dr. Federica Provini.)

For otherwise normal children with typical behaviors occurring during the first third of the night, the diagnosis can usually be made based on clinical criteria. The International Classification of Sleep Disorders, third edition, criteria are adequate for a reliable diagnosis of disorders of arousal in adulthood, too ( 27 ). When the diagnosis is uncertain, video-polygraphic monitoring is indicated, particularly if the events are occurring several times per week. If nocturnal seizures are a diagnostic consideration, multiple EEG channels should be included in the recording montage, and the paper speed could be sufficient to identify epileptiform and ictal EEG activity (15 to 30 mm per second). A synchronized video recording of the patient is useful to observe the clinical manifestations of the motor attacks and their stereotypy if more than one episode is recorded ( 43 ; 39 ). Standard polysomnographic recording techniques used for identifying sleep apnea are generally insufficient when complex partial seizures are a consideration.

Polysomnographic monitoring usually demonstrates that sleep terrors consist of sudden and incomplete arousal from deep sleep. The onset of sleep terror episodes is usually within the first few hours of sleep, during stage 3 sleep. Prior to a sleep terror episode, the EEG may show high-voltage, generalized symmetrical, hypersynchronous slow-wave activity. During the episode, it often shows a regular, rhythmic delta activity pattern, associated with a marked increase in muscle tone and change in respiratory and heart rate. In these patients beyond full sleep terrors, partial arousals from slow-wave sleep without full terror are also common, and tachycardia usually occurs during both clinical episodes of sleep terror and partial arousals. Psychogenic dissociative episodes are associated with a waking EEG pattern.

In addition, the analysis of homemade video recordings of nocturnal episodes may be an important supportive diagnostic tool for disorders of arousal ( 34 ). Homemade video offers multiple advantages: wide availability, low cost, the possibility of recording patients in their usual sleep environment, and repeated recordings ( 31 ). Lopez and colleagues documented how home nocturnal infrared video recording has good feasibility and acceptability and may improve the evaluation of the phenotype and severity of nonrapid eye movement parasomnias and of treatment response in an ecological setting ( 28 ).

Psychiatric or psychological evaluation may be indicated in selected patients.

As frightening as they are, parents and children usually only need to be reassured that the episodes are generally self-limiting and that the attacks rarely produce harm or injury. Attempts should be made to alleviate whatever stress may be going on in the child’s environment and to ensure that the child is getting adequate rest. When the behavior has the potential of injury or causes major disruption of family life, the pharmacological treatment most commonly includes melatonin and benzodiazepines; imipramine, mirtazapine, or ramelteon may be beneficial ( 18 ; 44 ; 13 ; 36 ).

Melatonin was reported to be efficacious and may serve as an initial pharmacological treatment strategy for patients with various phenotypes. Melatonin could improve the underlying circadian misalignment, which is usually a potential component to the development of NREM parasomnias ( 24 ). In other cases, melatonin may have been effective via partial treatment of sleep deprivation or insomnia, which could function as a precipitating factor for NREM episodes. Benzodiazepines are also helpful and can be used for long intervals with few complications in most patients; however, when the drug is withdrawn, the relapse rate is high. Among benzodiazepines, the most frequently used is clonazepam (0.5 to 2 mg at bedtime), which was reported to be effective in 40% of those treated ( 24 ). Diazepam (5 to 10 mg before retiring) could be useful, but to avoid daytime sedation due to the long half-life of diazepam and its metabolites, better results have been reported with shorter-acting benzodiazepines such as midazolam and oxazepam at the usual evening doses of 10 to 20 mg. The proposed mechanism of benzodiazepines in the treatment of disorders of arousal is reducing slow wave sleep, which NREM parasomnias generally arise from, or by increasing the arousal threshold, decreasing arousal, and stabilizing sleep. Appropriate caution in the use of benzodiazepines is recommended for patients with concurrent disorders, including advanced age, fall risks, abuse potential, and sleep-disordered breathing, as these outcomes could worsen respiratory depression and may result in the worsening of apnea and NREM parasomnia events ( 24 ).

Imipramine 50 to 100 mg at bedtime is sometimes effective, and hypnosis or other behavioral treatment may be helpful for some patients. A 6-month course of medication, followed by gradual withdrawal, is a typical program. In the wake of the hypothesis that manifestations of arousal disorders such as sleep terrors may be due to a conflict between the mechanisms generating slow-wave sleep and arousal, dependent on a dysfunction in the serotoninergic system, L-5-hydroxytryptophan, a precursor of serotonin, (2 mg/Kg at bedtime) has been proposed as highly effective in reducing the number of sleep terror episodes.

Treating comorbid conditions (eg, obstructive sleep apnea) is a recommended treatment strategy that is often associated with symptom improvement.

For adults, stress reduction through psychotherapy may be helpful when the disorder is linked to significant psychopathology, although studies evaluating the efficacy of different psychological approaches in adults (hypnosis, relaxation therapy, or cognitive behavioral therapy) provided contrasting results ( 36 ).

Special considerations

The incidence of NREM parasomnias in pregnancy has not been systematically investigated ( 19 ). Few papers describe a decrease or an exacerbation of sleepwalking or sleep terrors during pregnancy. Studies comparing pregnant with nonpregnant women found no significant changes in the prevalence of NREM parasomnias in pregnancy. A survey of 325 women, using an online questionnaire and focusing on the prevalence of parasomnias 3 months before pregnancy, during pregnancy, and 3 months after delivery, documented a significant increase in the severity and frequency of sleepwalking, night terrors, vivid dreams, and nightmares during pregnancy ( 19 ). Although it could be difficult to distinguish NREM or REM parasomnia episodes without a video-polysomnographic recording of an episode, the increased prevalence of parasomnias during pregnancy needs to be targeted, especially by nonpharmacological approaches. The increased psychosocial stress associated with pregnancy as well as the impaired sleep quality and the increased incidence of sleep disorders, in particular sleep-disordered breathing, may be the cause of the parasomnia episodes among pregnant women.

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Dr. Provini of the University of Bologna and IRCCS Institute of Neurological Sciences of Bologna received speakers' fees from Idorsia, Italfarmaco, and NeoPharmed Gentili Spa.

Antonio Culebras MD FAAN FAHA FAASM

Dr. Culebras of SUNY Upstate Medical University at Syracuse has no relevant financial relationships to disclose.

Former Authors

• Michael Aldrich MD (original author) and Gabriele Barthlen MD

Patient Profile

• 2 to 44 years
• No sex preponderance
• heredity may be a factor
• No occupation group selectively affected
• none selectively affected

ICD & OMIM codes

• Sleep terror disorder: 307.46
• Sleep terrors (night terrors): F51.4

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Managing Nightmares

Reviewed by Psychology Today Staff

Not every dream is pleasant; many are disconcerting or even terrifying. Unpleasant dreams—particularly those that are frightening or deeply upsetting—are referred to as “nightmares,” and are experienced by most people from time to time. Certain mental health disorders, as well as traumatic life events, may make someone more likely to experience more frequent nightmares.

Having scary dreams night after night can severely disrupt sleep and ultimately decrease quality of life. Luckily, many cases of persistent nightmares appear to respond to treatment, improving sleep quality and mental well-being for many with trauma, depression, or other challenges.

On This Page

• Understanding Nightmares
• Common Nightmares
• Treating Nightmares

Nightmares, though upsetting, are a normal (if infrequent) occurrence for the vast majority of people. Like dreams, nightmares often involve people, places, or other elements from an individual’s real life that are made distorted, frightening, or otherwise unpleasant; also like dreams, they are theorized to help humans process memories or come to terms with difficult feelings from their waking life.

Nightmares may be more likely to occur when an individual is stressed, anxious, or struggling with other difficult emotions in daily life; they may also occur seemingly randomly. In some cases, they may be triggered (or exacerbated) by mental health disorders.

According to the DSM, nightmares are generally thought to be caused by anxiety or stress; trauma or an upsetting event; sleep disorders; a fluctuating sleep schedule; or medication or drug use. (For more on the causes of nightmares, see our Diagnosis Dictionary. )

In some cases, yes. Chronic nightmares have been associated with depression , schizophrenia, PTSD, and some personality disorders, like borderline personality disorder. Some researchers believe that assessing the frequency and content of nightmares may help clinicians determine the progression and severity of mental health disorders; more frequent dreams of death, for instance, may reveal the presence of suicidal thoughts.

Yes; approximately half of patients with diagnosed PTSD report experiencing nightmares in the wake of the traumatic event . Post-traumatic nightmares may contain detailed memories of the traumatic event itself, but they don’t always; some incorporate themes or a sense of danger from the trauma but don’t replay the event verbatim. Regardless of themes, nightmares are associated with more severe symptoms overall; on the other hand, targeting nightmares with treatment has been linked to improvement on all symptoms.

The phrase “night terrors” refers to a kind of sleep disturbance in which an individual screams, cries, or otherwise appears consumed by intense fear during sleep; the individual may also flail wildly or even walk around. While night terrors can be quite alarming for family members or other witnesses, the person who experienced them will most likely not recall the episode in the morning. Night terrors are a normal part of development for many children; they are significantly less common in adulthood but are experienced by approximately 2 percent of adults.

No. Night terrors involve physical movement and crying out, and typically occur during non-REM sleep; because they occur in a deeper, slow-wave phase of sleep, upon waking, the individual will usually have no memory of what occurred. Nightmares are unpleasant dreams that occur during REM sleep. Screaming, thrashing, and other forms of extreme movement are not common during nightmares. In addition, because they occur during REM sleep (when brain activity is highest) the individual will usually have some memories of the nightmare when they wake up.

Nightmares often feel like one-of-a-kind horror shows to the individual experiencing them. But in reality, like dreams, there actually exist myriad “universal” nightmare themes that have been reported across cultures, genders, and ages.

In general, nightmares of any kind are thought to be related to stress, sadness, or anxiety. Some people believe that particular nightmare themes are indicative of particular real-world problems, dilemmas, or fears, but these exact connections have not tended to hold up consistently in research. Knowing that an upsetting nightmare theme is not uncommon, though, may help someone deal with any anxiety, shame, or sadness that the nightmare triggers.

Common nightmare themes include physical aggression, interpersonal conflicts, or experiences in which the dreamer feels helpless or unable to escape a particular situation, according to one large study that analyzed approximately 10,000 dreams. Nightmares may also feature large-scale calamities like war or natural disasters. Fear, guilt, sadness, and disgust are emotions that often characterize nightmares.

Dreams involving teeth falling out , rotting, or breaking are common around the world. Some evidence suggests that they may be related to real-life dental irritation, though this relationship is inconclusive. Other researchers hypothesize that such dreams are triggered by psychological distress like anxiety or nervousness, though this has also not been definitively proven. Ultimately, the nightmare may not mean anything; many neurologists argue that dreams are merely random collections of images generated by the human brain.

Some evidence has found that dreams of falling are associated with periods of heightened daytime stress or anxiety. But this research is inconclusive. Ultimately, even those who argue that falling dreams have a specific meaning are divided on what that meaning is; thus, it’s best left to the individual to determine the meaning of their own dream, if they so choose.

Nightmares that occur only occasionally are often not cause for concern. But persistent nightmares could be indicative of a larger problem—like depression or trauma—or may themselves interfere with well-being by disrupting sleep or triggering daytime anxiety.

Fortunately, there are several options for treating nightmares; strategies range from self-help (i.e. practicing relaxation techniques before bed) to improved sleep hygiene to formal therapy. If frequent nightmares came on suddenly with no discernible psychological trigger, it may be best to talk to a doctor; certain medications or physical disorders like sleep apnea may be causing persistent nightmares.

The best place to start is by improving sleep hygiene; sticking to a more consistent sleep schedule, engaging in a relaxing bedtime routine, limiting caffeine and alcohol, and exercising consistently may help curb nightmares in many cases. The next step may be to explore the issue with a doctor to determine if the nightmares have any medical causes.

If no medical causes are found, certain types of psychotherapy—including cognitive behavioral therapy and image reversal therapy—have been found to be effective at reducing the frequency of nightmares by helping an individual navigate the stress, anxiety, or trauma that may be responsible for the bad dreams. (For more on treating nightmares, visit our Diagnosis Dictionary. )

Yes; medications that are used to treat PTSD, depression, or anxiety have also shown some efficacy in treating nightmares. Some possible medications that a doctor may prescribe for nightmares include olanzapine, clonidine, trazodone, and tricyclic antidepressants, among others.

Many people hold the lay belief that eating certain foods—such as dairy products or spicy food—too close to bedtime is responsible for nightmares. Some research has found an association between people’s self-reported eating habits and nightmares, but the researchers warn that such results should be interpreted with caution. While it’s possible that particular foods do trigger digestive upset or influence mood—and may indeed lead to nightmares as a result—such findings may also be the result of confirmation bias or mere coincidence. Ultimately, whether certain foods actually cause nightmares remains to be seen.

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What Are Night Terrors?

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Steven Gans, MD is board-certified in psychiatry and is an active supervisor, teacher, and mentor at Massachusetts General Hospital.

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Night Terrors vs. Nightmares

How parents can help kids.

Night terrors, also known as sleep terrors, are episodes of intense fear that occur during sleep and are often characterized by agitated movements and vocalizations. They tend to be more common in young children, but they can also be experienced by adults.

During a night terror, a person may yell, scream , thrash, or show other signs of fear. These episodes may last for several minutes, but people usually do not fully awaken.

Night terrors often last between one to 10 minutes, but can last longer. They also tend to occur most frequently at night and not during daytime napping. While they can be very upsetting for the person who experiences the night terror as well as family members who witness such episodes, they are usually considered relatively benign. 

Signs of a night terror can include:

• Screaming or yelling
• Rapid breathing
• Racing heartbeat
• Excessive sweating
• Sitting up or getting out of bed
• Being difficult to wake
• Open, staring eyes but lack of response to environmental stimuli
• Confusion upon waking
• No memory of the night terror upon waking
• Aggressive behavior

Night terrors are a type of non-rapid eye movement sleep arousal disorder in which a person who is sleeping appears to wake in a terrified state. A person's eyes may be open, they may cry out or scream, and make agitated or aggressive movements.

While a person might appear to be awake, they will be confused and not able to communicate with others. Just as people often do not remember their dreams once they wake up, people usually do not have any memory of these night terror episodes.

Night terrors are known as sleep terrors in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) . The DSM-5 is the manual that is used by most doctors and mental health professionals to diagnose different types of mental health conditions.

Sleep Arousal Disorder

Sleep terrors are one of the two types of non-rapid eye movement sleep arousal disorders that are recognized in the DSM-5. The DSM-5 defines a sleep terror as a repeated sudden, partial awakening from a deep sleep that is accompanied by autonomic arousal and behaviors reflecting intense fear.  

Difficult to Diagnose

Night terrors can be difficult to diagnose for a number of reasons, particularly when it comes to receiving a diagnosis as an adult for two main reasons:

• Night terrors can come and go and tend to occur irregularly.
• People rarely remember having them. In some cases, you may only know that you are experiencing if someone else happens to witness a night terror.

If there is a reason to suspect that you might be having night terrors, your doctor may perform a physical exam, ask you a number of different questions, and ask you or a loved one to keep a sleep diary.

Exams and Lab Tests

In addition to a physical exam, lab tests may be performed to help rule out any potential medical conditions that might be causing or contributing to your symptoms.

Your doctor may also order other tests if health problems or a sleep disorder are suspected. Such tests might include a sleep study (polysomnography) or an electroencephalogram (EEG) to look at electrical activity in the brain.

Your doctor will also ask you a number of questions. For example, you might be asked:

• Whether you currently take any medications
• How often you consume alcohol
• Whether you take any other substances
• What your stress levels are like
• Whether you have been diagnosed with another mental health condition
• What mental health symptoms you might be experiencing
• Whether you take any sleep medications or natural sleep aids
• If you have ever had another type of sleep disorder
• Whether any of your family members have had symptoms or been diagnosed with a sleep disorder
• If you have symptoms of a breathing-related sleep problem

In order to diagnose sleep terrors, your doctor will have to rule out any other medical causes or sleep disorders.

During sleep, the brain goes through a series of stages that are marked by different patterns of activity. The first three stages of sleep are known as non-rapid eye movement (NREM) sleep and the fourth is known as rapid eye movement (REM) sleep.

Night terrors most commonly occur as people move from one stage of sleep to the next. During this time, they may awaken slightly, which may contribute to the arousal that is seen during a night terror.

The exact causes of night terrors are not known, although there is evidence that the condition tends to run in families, although further research is needed to better understand possible genetic links. 

Some factors may increase the risk of night terrors in adults. These factors include:

• Sleep disruptions
• Medications including antidepressants
• Restless leg syndrome
• Stressful events
• Alcohol use or the use of another central nervous system (CNS) depressant
• Mental health conditions, particularly in adults
• Underlying neurological conditions  

Research also suggests that children and teens who experience night terrors are also more likely to report experiencing migraine headaches.

In one study looking at kids between the ages of 10 and 19, those who experienced sleep terrors were significantly more likely to experience either episodic or chronic migraines.  

Night terrors typically begin during early childhood and usually resolve on their own as children age, although some adults may continue to experience sleep terrors.

Night terrors are not uncommon in children between the ages of four and 12. Night terrors affect approximately 2% to 7% of children and tend to occur most frequently between the ages of four and seven.

The condition is also believed to occur in approximately 3% of adults, although exact numbers are difficult to estimate since many people do not remember these episodes after waking. Sleep terrors in adults often seem similar to the experience of a daytime panic attack.

Bad nightmares may sometimes seem similar to a night terror, but there are differences between the two. Some of these key differences include:

• People usually waken fully and quickly from a nightmare. During a night terror, people do not fully wake—they seem confused and unable to communicate.
• People usually remember at least part of their nightmare once they wake. In some cases, they may recall the nightmare in vivid detail. Night terrors are not frequently remembered. When they are recalled, people may only remember incomplete fragments.

Nightmares can occur during any stage of sleep, including REM sleep. Night terrors, on the other hand, only occur during NREM sleep.

While night terrors can be distressing, they usually resolve on their own without intervention and have no lasting effects. However, there might be times when it is appropriate to seek treatment:

• If you or your child's night terrors are causing other family members significant distress
• If agitation or aggression experienced during a night terror, such as kicking, thrashing, or jumping out of bed, poses a risk of injury
• If the night terrors are making it difficult to function normally during the day
• If you or your child are experiencing signs of fatigue or sleep deprivation
• If night terrors are putting a strain on your relationship with your partner or other members of your household
• If the episodes are frequent
• If they are accompanied by other sleep issues
• If they begin in adolescence or adulthood

Some approaches that might be recommended as treatment for sleep terrors include one or a combination of the following options.

Psychotherapy

Approaches such as cognitive-behavioral therapy (CBT) may be helpful for improving sleep hygiene.   While the available research is limited, some evidence suggests that psychotherapy may be helpful for reducing or eliminating night terrors in children and adults.  

Stress Management

Because people are more likely to experience night terrors when they are overstressed, a therapy that addresses stress may be helpful. Relaxation therapy may help reduce symptoms, but other techniques such as hypnosis or biofeedback might also be recommended.

Treating Other Conditions

If there are any related conditions that may be contributing to night terrors, treating these underlying disorders may be beneficial. Depression, anxiety, and other sleep disorders may also play a role in contributing to night terrors, so seeking treatment for those other conditions may help reduce or eliminate night terror symptoms. 

Medications

There is no medication specifically indicated for night terrors, but sometimes certain prescription drugs may be helpful. Antidepressants and anti-anxiety medications may be helpful in some cases.

There are also things that you can do that may help manage night terrors. Treatments for night terrors are often centered on improving sleep hygiene and reducing stress, so positive changes in your daily habits may help reduce or even eliminate symptoms of this condition.

Some steps you can take to cope with night terrors:

Establish Good Sleep Habits

Sleep deprivation and fatigue can increase the likelihood of experiencing a sleep terror, so getting on a regular sleep schedule can help improve the quality and amount of sleep that you are getting. 

• Go to bed at the same time each night and wake up at the same time each morning
• Avoid eating in the evening
• Avoid caffeine in the afternoon and evening
• Avoid looking at your phone or devices in bed
• Make sure your sleep environment is comfortable

Use Relaxation Strategies

Because stress can increase the risk of having a night terror, finding ways to get your stress levels under control can be an effective self-help strategy. This might involve identifying sources of stress and then finding ways to relax, whether that involves something like yoga, massage, deep breathing, or meditation.

It can sometimes be difficult for kids to identify or articulate their worries, so focus on making sure that your child has plenty of reassurance, support, and opportunity to talk about their concerns.

Try Scheduled Wakening

Look for patterns and try to notice if night terrors occur around the same time each night. If you spot any discernible patterns, you can try a technique that relies on waking someone up at a scheduled time each night.

You can have your partner wake you or set an alarm to rouse you from sleep. Parents can try waking their child briefly at a specific time before night terrors typically occur, usually around 10 to 15 minutes before the sleep terrors usually take place. 

Research has shown that this approach can significantly reduce or even completely eliminate sleep terrors.   While scheduled wakening is considered low-risk, it may be difficult to use if the individual or if other members of the household are struggling with sleep deprivation.

If your partner experiences night terrors, you can help by providing reassurance and keeping them safe. Remove hard or sharp objects from the bedroom to prevent accidental injuries. Avoid trying to wake someone when they are experiencing a night terror, which can make the episode worse and even result in physical injuries if the other person is confused, upset, or agitated.

If your child is experiencing night terrors, there are a number of steps you can take to help:

• Don't try to interrupt the sleep terror. While it can be distressing, trying to awaken your child in the middle of a disturbance can actually make the night terror last longer.
• Make sure your child's sleep environment is safe and comfortable. Remove any sharp, hard, or dangerous objects from their immediate environment. Try surrounding your child with soft pillows or blankets to prevent cuts or bruises if they thrash or kick during an episode.
• Close and lock windows. Some children may get out of bed and move around during a night terror. 
• Lock doors securely. Because some kids may sleepwalk during a night terror, it is also possible that they might open doors and wander outside of the house. Make sure your doors are locked each night. You may find it helpful to put an alarm on your child's bedroom door, windows, or any outside doors.

Van Horn NL, Street M. Night Terrors . In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. (5th Edition). Washington, DC.;2013.

Fialho LM, Pinho RS, Lin J, et al. Sleep terrors antecedent is common in adolescents with migraine . Arq Neuropsiquiatr . 2013;71(2):83-86. doi:10.1590/s0004-282x2013005000006

Cleveland Clinic. Nightmares in children .

Linton, S.J. (2013). A cognitive-behavioral treatment package for sleep terrors: a case study . The Open Sleep Journal. 6. 8-11.

Galbiati A, Rinaldi F, Giora E, Ferini-Strambi L, Marelli S. Behavioural and cognitive-behavioural treatments of parasomnias . Behav Neurol . 2015;2015:786928. doi:10.1155/2015/786928

Cleveland Clinic. Are night terrors disturbing your child's sleep? Tips for parents .

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

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Hypnosis and guided imagery.

This chapter overviews hypnosis and guided imagery, describing similarities and differences in their application to sleep disorders. It includes an introduction to hypnosis, and provides a definition and, history of the method, as well as a, guide to using hypnosis interventions and their utility and applications for sleep disorders. Some of the sleep disorders found to be effectively treated by hypnosis include nightmares, sleep walking, night terrors, and parasomnia overlap disorder. The chapter also overviews guided imagery and, provides an example and various uses for guided imagery in sleep disorders. The chapter concludes by reviewing the various differences and uses of hypnosis and guided imagery, including the greater research and wider use of guided imagery in its application to sleep disorders.

Avoiding the night terrors: the effect of circadian rhythm on post-operative urine output and blood pressure in free flap patients

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DeSanto-Shinawi syndrome is a rare genetic condition caused by loss-of-function mutation in WAC. It is characterized by dysmorphic features, intellectual disability, and behavioral abnormalities. In this case report, we describe the clinical features and genotype of a patient with a novel mutation 1346C > A in WAC. This patient’s dysmorphic features include a prominent forehead, bulbous nasal tip, macroglossia, deep-set eyes, and malar hypoplasia. This patient also showed signs of intellectual disability and behavioral abnormalities such as night terrors. These findings are consistent with those described in earlier reports. Here, we report new findings of epilepsy and recurrent skin infections which had not been reported in prior studies.

The Search for Peace and the Bald Eagle

In this chapter Patrick details his time in the wilderness. He conquers his night terrors, becomes less anxious, and revels in the experience of nature and being alone. Patrick focuses on healing in the Canadian wilderness.

Terror at Northfield

This chapter discusses the relationship between a commonly misdiagnosed parasomnia and various precipitating factors. Expertise in differentiating a benign parasomnia from significant medical disorders in adults and children is important, as is the ability to correctly identify and modify predisposing and precipitating factors. The case presented in this chapter illustrates how making a premature decision based on a small piece of information delayed an important diagnosis and increased the risk of further morbidity. The peak prevalence of sleep terrors is 18 months of age, but they may be seen at any age during childhood. When recurrent sleep terrors recur or develop in adults, evaluation for other primary sleep disorders, including sleep apnea, restless legs, shift work, and sleep deprivation, is warranted, and polysomnography is usually indicated. Identifying and correcting precipitating factors may minimize the recurrence of sleep terrors. Treatment of sleep apnea may greatly reduce the frequency of night terrors and other parasomnias.

Treatment and management of seven children with fractured femurs experiencing night terrors in hospital: a case study

Effects of acupuncture therapy on 83 cases of infants with night terrors, export citation format, share document.

What a Terror Attack in Israel Might Reveal About Psychedelics and Trauma

Thousands of Israelis were using mind-altering substances when Hamas-led fighters attacked a desert festival on Oct. 7. Now, scientists are studying the ravers to determine the effects of such drugs at a moment of extreme trauma.

This photo of Yuval Tapuhi was taken at the Tribe of Nova festival on Oct. 7, before the Hamas-led terrorist attack. Credit... Avishag Shaar-Yashuv for The New York Times

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By Natan Odenheimer ,  Aaron Boxerman and Gal Koplewitz

• April 11, 2024

One Israeli said that being high on LSD during the Hamas-led attack on Oct. 7 prompted a spiritual revelation that helped him escape the carnage at a desert rave. Another is certain the drug MDMA made him more decisive and gave him the strength to carry his girlfriend as they fled the scene. A third said that experiencing the assault during a psychedelic trip has helped him more fully process the trauma.

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Some 4,000 revelers gathered on the night of Oct. 6 at a field in southern Israel, mere miles from the Gaza border, for the Tribe of Nova music festival. At dawn, thousands of Hamas-led terrorists stormed Israel’s defenses under the cover of a rocket barrage.

About 1,200 people were killed that day, the deadliest in Israeli history according to the Israeli authorities, including 360 at the rave alone. Many of the ravers were under the influence of mind-altering substances like LSD, MDMA and ketamine as they witnessed the carnage or fled for their lives.

For a group of Israeli researchers at the University of Haifa, the attack has created a rare opportunity to study the intersection of trauma and psychedelics, a field that has drawn increased interest from scientists in recent years.

The survivors of the Nova festival present a case study that would be impossible to replicate in a lab: a large group of people who endured trauma while under the influence of substances that render the brain more receptive and malleable.

Illegal in most countries, including Israel, these substances are now on the cusp of entering the psychiatric mainstream. Recent research suggests that careful doses of drugs like MDMA and psilocybin , the active ingredient in “magic mushrooms,” might be useful in treating post-traumatic stress disorder.

The festival participants were under the influence during their trauma, not in a controlled clinical setting, but researchers say studying them could help scientists better understand how psychedelics might be used to treat patients after a traumatic event.

The researchers surveyed more than 650 Nova survivors. Roughly 23 percent said they took hallucinogens like LSD, also known as acid, and about 27 percent used MDMA, a stimulant and psychedelic commonly called molly or ecstasy. Many attendees used more than one substance.

Participants in the survey described a variety of experiences while using drugs on Oct. 7, ranging from hallucinations to extreme clarity, from panic to resolve and from paralysis to action.

“Even though people were dropping on the ground screaming next to me, I felt a growing sense of confidence, that I was invincible,” said Yarin Reichenthal, 26, a judo coach who experienced the attack while on LSD. “I felt enlightened. I felt no fear at all.”

In many instances, according to preliminary results of the researchers’ survey, even festivalgoers using the same drugs experienced the attack in different ways — variances that might have meant the difference between life and death.

The scientists cautioned that the study was not a comprehensive review of how every participant at the rave fared because so many were killed.

“We only hear the stories of those who made it out alive,” said Roy Salomon, a cognitive science professor at the University of Haifa and a co-author of the study. “So our understanding is influenced by survivors’ bias.”

Witnesses said that for many attendees, drug use appeared to hamper their ability to flee for safety. Some ravers were too zoned out on psychedelics to realize what was happening and escape. The researchers said that those experiences were also important to their findings.

“There are two main questions,” said Roee Admon, a University of Haifa psychology professor and a co-author of the study. “How is the traumatic event experienced under different psychedelics, and what might the long-term clinical impact be?”

Professor Admon and Professor Salomon, who are leading the survey, are studying the survivors in the hopes of gleaning information about how drug use affected their experience of trauma. They are also studying how the attendees appear to be recovering and coping. A graduate student, Ophir Netzer, also helped write the study.

Of those who made it out alive, some survivors appeared to be recovering well and others reported feeling numb and detached. Some said they had increased their drug use since the attack to cope.

“We were all in such a heightened emotional state, which made us all the more vulnerable when the attack began,” said Tal Avneri, 18, who said he stayed relatively lucid on Oct. 7 after taking MDMA. “And when you’re hurt at your most fragile, you can later become numb.”

For devotees of Israel’s trance scene, a festival like Nova is more than just a way to let loose. Many view the raves — often held in forests and deserts, with pounding electronic beats and mind-altering substances — as spiritual journeys amid a like-minded community.

“The love I felt on the dance floor, the raves, the psychedelics — they helped me cope with my mother’s death,” said Yuval Tapuhi, a 27-year-old Nova survivor from Tel Aviv.

Around 6:30 a.m. on Oct. 7, as the sky turned pink and many revelers were beginning the most intense part of their trips, rockets from Gaza suddenly streaked through the sky. Air-raid sirens and loud explosions cut through the music.

Some people fell to the ground and burst out crying, multiple survivors said. Some attendees scrambled to evade the terrorists by hiding in bushes, behind trees or in riverbeds. Others sprinted through open fields, running for hours before reaching safety.

Still others fled in their cars, creating a huge traffic jam at the rave’s main exit, where they became easy targets for Palestinian gunmen swarming across the border.

Amid the gunfire and rocket barrage, Mr. Reichenthal, the judo coach, had what he describes as a transcendent experience, which he credits with his survival. The LSD trip, he said, made it feel as if his fear had been stripped away, and he murmured Bible verses as he ran to safety.

Many survivors described their initial panic being replaced with a coolheaded resolve — a function, one expert said, of stress counteracting the effects of the drugs.

Sebastian Podzamczer, 28, attributed his survival, at least in part, to a huge rush of energy and clarity he experienced while using MDMA. The drug’s influence, he said, gave him what he believes was the strength to carry his girlfriend, who had been paralyzed by fear.

Mr. Podzamczer, a former combat medic in the Israeli military, had PTSD after his service. Taking psychedelics recreationally, he said, helped him unravel some of that pain, allowing him to speak about his military service without shaking and panicking.

“But I always thought that if I was caught in an extreme situation like that, I’d be paralyzed by panic from my PTSD,” Mr. Podzamczer said. Instead, he found that the MDMA he took at the rave “helped me stay afloat, to act more quickly and decisively.”

High levels of stress can almost “overwhelm” the effects of a drug and jolt people back to reality, said Rick Doblin, the founder of the Multidisciplinary Association for Psychedelic Studies, a nonprofit organization in California that finances scientific research but is not involved in the Nova survivor study.

Almog Arad, 28, said that her acid trip kicked in after the attack began but that the circumstances quickly “minimized” the drug’s effects. While she continued to see intense colors and patterns as she fled, her decision-making remained relatively sound, she said.

“Adrenaline was the strongest drug I took that day,” she said.

The University of Haifa researchers plan to follow the survivors for years, tracking their neural activity with functional magnetic resonance imaging, or fMRI.

They have presented their preliminary findings in a preprint paper , a scientific manuscript undergoing peer review.

Compared with survivors who used other substances, attendees who used MDMA are recovering better and showing less severe symptoms of PTSD, according to the study’s preliminary conclusions.

Many MDMA users in particular, the researchers said, believe that using the drug helped them survive. That perception, the scientists added, could have influenced their ability to cope with their trauma.

“The way in which we remember the trauma has a great impact on how we process it,” Professor Admon said. “So even if a victim’s perception is subjective, it will still have a great impact on their recovery.”

The researchers said it was difficult to assess the exact doses that the festivalgoers used, making it hard to analyze how different quantities of drugs affected people.

Mr. Reichental said he witnessed one man at the rave who appeared to be so out of it that as gunfire sounded and another raver tried to help him escape, the man instead began to flirt with her. “How lucky it is that destiny brought us together,” Mr. Reichenthal recalled the man saying. He does not believe the man survived the attack.

Psychologists and survivors said those ravers who took ketamine, a psychedelic with an intense tranquilizing and dissociative effect, appeared to be one of the groups hit hardest.

Immediately after the Nova massacre, a group of therapists and experts established a volunteer relief network for survivors, known as Safe Heart, that provided psychological support for more than 2,200 people. The group has collaborated with the University of Haifa researchers as well as with a separate , qualitative study led by Guy Simon, a psychotherapist and doctoral candidate at Bar-Ilan University.

“Most people who undergo a traumatic experience do not develop PTSD,” Professor Admon said. “Identifying those who do and treating them as early as possible is critical to their healing.”

Read by Natan Odenheimer

Audio produced by Adrienne Hurst .

Aaron Boxerman is a Times reporting fellow with a focus on international news. More about Aaron Boxerman

Our Coverage of the Israel-Hamas War

News and Analysis

The Israeli military announced what it called a precise operation to kill members of Hamas in Gaza , a day after a strike there killed three sons  of one of the most senior leaders of the group.

Hamas said that it did not have 40 living hostages in Gaza  who met specific criteria for an exchange with Israel under a proposed cease-fire deal, raising fears that more hostages may be dead than previously believed.

There has been no apparent work done yet on increasing aid to Gaza  by opening an additional border crossing from Israel and accepting shipments at a nearby Israeli port, but Israel said that both changes remain in the works.

Psychedelics and Trauma: Thousands of festival-goers were using mind-altering substances when Hamas-led fighters attacked on Oct 7. Now, scientists are studying the effects of such drugs at a moment of trauma .

Turmoil at J Street: The war in Gaza has raised serious concerns within the Jewish political advocacy group about its ability to hold a middle position  without being pulled apart by forces on the right and the left.

Challenging Democratic Leaders: Protests over the Biden administration’s handling of the war in Gaza are disrupting the activities of Democratic officials, complicating their ability to campaign during a pivotal election year .

Germany’s Upended Arts Scene: Berlin, the home of boundary-pushing artists from around the world, has been turned upside down by debates about what can and can’t be said about Israel and the war in Gaza .

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A case report of sleep terrors exacerbated by cetirizine

Sleep terrors are a type of sleep disorder that is classified as parasomnias and is more common in children than in adults. Cetirizine is a histamine H1 antagonist that is US Food and Drug Administration approved for the treatment of allergic rhinitis and urticaria and has common adverse effects of drowsiness and headaches. We present a case of an adult man with a history of chronic sleep terror disorder and allergic rhinitis who developed worsening of his sleep terrors after initiation of cetirizine that subsequently resolved after discontinuing cetirizine and starting paroxetine.

Hussain S, Aziz SG. A case report of sleep terrors exacerbated by cetirizine. J Clin Sleep Med . 2021;17(1):99–101.

INTRODUCTION

Sleep terrors, also called night terrors, are a type of sleep disorder that is classified under parasomnias. The prevalence of non–rapid eye movement sleep (NREM) parasomnias in the general population varies with age, and both children and adults can have these behaviors. 1 They are more common in pediatric populations, with a prevalence of 14.7% in children 3–10 years of age. 2 The peak of prevalence was observed at age 1.5 years for sleep terrors (34.4%) and at age 10 years for sleepwalking (13.4%). 3 The prevalence of night terrors in adults ranges from 1% to 4% in the adult general population. 4 Cetirizine is a histamine H1 antagonist that is US Food and Drug Administration approved for the treatment of allergic rhinitis and urticaria. Common side effects of cetirizine include drowsiness and headaches. Sleep terrors are a very rare side effect of this medication. We present a case of a 20-year-old man who developed an acute exacerbation of his chronic sleep terrors and parasomnias after initiating cetirizine for allergic rhinitis, which subsequently improved after discontinuation of cetirizine.

REPORT OF CASE

A 20-year-old man with a history of chronic sleep terror, allergic rhinitis, gastroesophageal reflux disease, and obesity presented for evaluation of worsening night terrors associated with sleepwalking. He has a long history of sleepwalking and night terrors since around age 12, but more recently over the past several weeks, he had been having increased frequency and intensity of his sleep terrors.

He would sleepwalk sporadically on average about once a month associated with night terrors. It could occur on consecutive nights and then not occur for several weeks. The patient's mother described that during his usual episodes, he yells and screams in his sleep, and it takes about 5 minutes for her to be able to wake him up. After awakening, he cannot recall the event. Most of his sleep terrors occurred during the first few hours of sleep, suggesting an underlying NREM-related parasomnia.

He was recently started on cetirizine for allergic rhinitis. Since then, he noticed that the episode of sleep terrors were more frequent (2–3 times per week) and were more intense. In 1 of the recent episodes, he was sleepwalking and yelling and smashed the mirror attached to the back of his door. He had several cuts to his upper and lower extremities, and there was blood on the wall and floor. His parents were unable to wake him up; thus, his father essentially had to restrain him by tackling him to the floor. He then woke up and was confused and had no recollection of the event.

The patient had a normal vaginal birth with no complications. History was negative for trauma, seizures, tobacco use, and alcohol use. There was no family history of parasomnias. His current medications included ranitidine 75 mg daily and cetirizine 10 mg daily, which he began taking 3 weeks before for allergic rhinitis.

Review of systems was negative for behavioral disturbances, sleep deprivation, excessive daytime sleepiness, seizures, snoring, postnasal drip, and restless legs syndrome.

Physical examination revealed an adult male in no distress with a body mass index of 33.5 kg/m 2 . Nasal mucosa was erythematous with enlarged turbinate. Oral airway examination revealed a Mallampati score of IV with normal tonsils. The remainder of the physical and neurologic examination was unremarkable. The radioallergosorbent test was positive for dust mites.

Diagnostic polysomnogram revealed a sleep latency of 49 minutes and a sleep efficiency of 84.7%. The sleep architecture demonstrated 6.0% of stage 1 sleep, 68.8% of stage 2 sleep, 12.7% of stage 3 sleep, and 12.6% of stage R sleep. The apnea-hypopnea index was 0.2 events/h. The minimum oxygen desaturation was 92%. There was no evidence of snoring, hypoventilation, periodic leg movement, seizure, or arrhythmias. Polysomnography was done while he was on cetirizine. Sleep diaries revealed an average nocturnal sleep time of 9 hours with no daytime napping.

After a review of his medications, cetirizine was discontinued, and the patient was started on fexofenadine for his allergic rhinitis. The frequency of his sleep terrors returned to his baseline. He was subsequently started on paroxetine, and his sleep terrors completely resolved. He did miss paroxetine for a week, and his sleep terrors returned but then resolved when he restarted his paroxetine.

Parasomnias represent abnormal behaviors that arise from sleep. They range from subclinical events only noticed by a wakeful bed partner to violent, potentially life-threatening dream enactment. They are classified by the sleep state from which they arise: NREM sleep and rapid eye movement sleep. 1

NREM parasomnias include confused arousals, sleepwalking, and sleep terrors. NREM parasomnias are characterized by abnormal nocturnal behavior, impaired consciousness, and autonomic nervous system activation because of impaired arousal. They typically arise from slow-wave (N3) NREM sleep. 1 Sleep terrors that may sometime be confused with nightmares are episodes of intense fear initiated by a sudden cry or scream and accompanied by increased autonomic nervous system activity.

Most commonly sleep terrors occur in preadolescent children. Parents describe the patient as being inconsolable during events. In adults, sleep terrors can involve impulsively bolting out of bed without proper judgment in response to an imminent threatening image or dream fragment. 1 Severe injury or even death may result from leaping out of bed or jumping through a window. Sleep terrors can last for more than 5 minutes, and attempts to abort an episode frequently result in even greater agitation. Children are more likely to have a memory of the sleep terror episode compared with adults. 5

Several factors may contribute to sleep terrors, such as fever, stress, a traumatic life event, sleep deprivation, medications, alcohol abuse, and any disruptive factor during the N3 stage, such as obstructive sleep apnea and restless legs syndrome.

Parasomnias are typically diagnosed by obtaining a careful clinical history that assesses the timing, expression, and form of the behavior in the home environment. A sleep diary (to exclude sleep deprivation as a precipitant) and a partner's log of the events are useful tools. Referral to a specialist in sleep disorders should be considered for patients whose activities are potentially harmful or very disturbing to others or if polysomnography is required.

The first steps in the management of parasomnia are severity assessment, identifying and treating comorbid sleep disorders, eliminating presumed inducing agents, and maximizing environmental safety.

Most sleep terror episodes are benign and limited in duration. In these cases, patients may be given reassurance and are advised to avoid sleep deprivation and sedating agents. Situations that deserve more thorough investigation include violent behavior, nonviolent dangerous behavior (such as leaving the house), dream enactment behavior, or if the parasomnia is associated with symptoms suggestive of another sleep disorder or neuropsychiatric condition. 6

Environmental safety is critical in treating parasomnia cases with the potential for sleep-related injury. The patient should be advised to remove any bedside furniture, firearms, and sharp objects (knife) and to keep windows locked with curtains drawn to prevent lacerations.

If NREM parasomnia persists despite the resolution of exacerbating disorders and removal of inducing agents, pharmacologic interventions may be considered. The most commonly prescribed agents include benzodiazepines and antidepressants. Benzodiazepine acts by increasing the chloride conductance through gamma aminobutyric acid receptors. 7 Clonazepam is commonly used as first-line pharmacotherapy; however, studies show conflicting results. Selective serotonin reuptake inhibitors are effective in the treatment of some NREM parasomnia, most commonly sleep terrors. Paroxetine appears to be particularly effective in the treatment of sleep terrors. In 1 report, 6 patients had a significant reduction if not outright elimination of sleep terrors. The authors suggested that selective serotonin reuptake inhibitors may be uniquely effective for sleep terrors through serotonin effects on terror centers in the midbrain peri-aquaductal gray matter. 8 The evidence for all therapies is currently based on a small number of studies, which are typically case reports and case series.

Cetirizine is a second-generation antihistamine that crosses the blood–brain barrier, has been previously associated with insomnia and nocturnal awakenings, and can cause tolerance with long-term use. 9 Cetirizine has very rarely been associated with either the onset or exacerbation of sleep terrors. In 1 previous case report, a 4-year-old patient with a 2-year history of sleep terrors had complete resolution of the sleep terrors after discontinuation of cetirizine and subsequent recurrence of sleep terrors after another reintroduction of cetirizine. 10 Although sleep terrors are a rare side effect of cetirizine, the exacerbation of this disorder can occur in patients taking cetirizine. In such cases, cetirizine should be discontinued.

CONCLUSIONS

Acute exacerbation of sleep terrors in our patient was attributed to cetirizine because of the significant improvement in the frequency of symptoms after discontinuation of cetirizine. Our case highlights the importance of reviewing the patient medication list for possible side effects with acute worsening of parasomnias.

DISCLOSURE STATEMENT

All authors have seen and approved the manuscript. Work for this study was performed at Roanoke Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, VA. The authors report no conflicts of interest.

ABBREVIATIONS