Night Terrors Research Articles

Diagnosis and treatment of sleep disorders: a brief review for clinicians

Sleep disorders encompass a wide spectrum of diseases with significant individual health consequences and high economic costs to society. To facilitate the diagnosis and treatment of sleep disorders, this review provides a framework using the International Classification of Sleep Disorders, Primary and secondary insomnia are differentiated, and pharmacological and nonpharmacological treatments are discussed. Common circadian rhythm disorders are described in conjunction with interventions, including chronotherapy and light therapy. The diagnosis and treatment of restless legs syndrome/periodic limb movement disorder is addressed. Attention is focused on obstructive sleep apnea and upper airway resistance syndrome, and their treatment. The constellation of symptoms and findings in narcolepsy are reviewed together with diagnostic testing and therapy, Parasomnias, including sleep terrors, somnambulism, and rapid eye movement (REM) behavior sleep disorders are described, together with associated laboratory testing results and treatment.

Nocturnal frontal lobe epilepsy

The paroxysmal motor events during sleep are certainly common.The systematic use of nocturnal video-polysomnography has largely improved the diagnostic yield in patients with clusters of nocturnal motor events. Two broad nosological categories have been identified: parasomnias (sleep terror and sleep-walking), which are thought to represent disorders of arousal during sleep, and the epileptic seizures arising from sleep (nocturnal epilepsy). In recent years, particular attention has been devoted to those seizures arising from epileptic foci located within the frontal lobe or within the temporal lobe with early involvement of the frontal lobe: so-called nocturnal frontal lobe epilepsy (NFLE). Also in recent years the clinical, neuroradiological and neurophysiological profile of NFLE has clearly been delineated: up to 40% of patients with NFLE had at least one first-degree relative with a probable primary parasomnia: about 20% of patients had a family history of epilepsy; 5 to 10% had NFLE, with nocturnal seizures quite similar to those of the proband; the age at onset of seizures ranged from 1 to 65 years; the mean frequency of seizures was 15-20 per month; patients often complained of nocturnal sleep disruption (about one half of them reported excessive daytime sleepiness); one third of patients also had occasional seizures during wakefulness, usually in childhood; the seizures had a stereotypic motor pattern, of various complexity; traditional neuroradiological examinations showed abnormalities in about 10% of cases; there was a wide intra-familial variation in the severity of seizure disorder. There was also considerable intra-individual variation in severity during the different periods of life, with an age-dependent degree of severity; ictal EEG abnormalities were found in 30 to 60% of patients; the EEG during sleep showed interictal focal epileptiform abnormalities in about 50% of patients; in about two third of patients carbamazepine, clonazepam or their association were able to greatly reduce nocturnal seizures in frequency and complexity and, in some cases, to completely control them. The differential diagnosis between sporadic (and familial) NFLE from benign parasomnias is difficult from the history alone. A full video-polysomnographic study should be proposed to all the patients complaining of repeated nocturnal motor, autonomic and behavioural episodes, in order to provide a correct diagnosis.

Leading US academic tells Student BMJ Ritalin use in students is acceptable

A leading US academic, Professor Martha Farah, told the Student BMJ that it is acceptable for students to take the prescription medicine Ritalin to get a study boost. Illegal use of Ritalin is on the rise across US campuses, with more and more students reporting taking the stimulant. The drug, best known for treating people with attention deficit hyperactivity disorder (ADHD), enhances attention and increases the ability to focus and ignore distractions. Possible side effects include insomnia, night terrors, and tremors, as well as dependence and tolerance. But Professor Farah, director of the …

Sleep disturbances in Angelman syndrome: a questionnaire study

Only few studies are available on sleep disorders in Angelman syndrome (AS), a neurodevelopmental disorder with several behavior disturbances. The aim of this study was to determine the prevalence of sleep disorders in a relatively large group of AS subjects, compared to that of age-matched controls. Fourty-nine consecutive parents of patients with AS (26 males and 23 females aged 2.3–26.2 years) were interviewed and filled out a comprehensive sleep questionnaire. Based on their genetic etiology, four groups were defined: deletion of chromosome 15q11–13 (25 subjects); methylation imprinting mutation (six subjects), UBE3A mutations (seven subjects) and paternal uniparental disomy (five subjects). In the remaining cases genetic testings were negative. A significantly high frequency of disorders of initiating and maintaining sleep, prolonged sleep latency, prolonged wakefulness after sleep onset, high number of night awakenings and reduced total sleep time were found in our AS patients, as compared to age-matched controls. We also found other types of sleep disorders, never reported before, such as enuresis, bruxism, sleep terrors, somnambulism, nocturnal hyperkinesia, and snoring. No differences were found between the four genetic aetiology groups. Moreover, we did not find important improvement of sleep disturbances from pre-pubertal to post-pubertal ages. Our data confirm the significant presence of sleep/wake rhythms fragmentation, peculiar of AS, and also demonstrate the presence of several other types of sleep disturbances in this syndrome.

Drug-Induced Dissociative States of a Sleep Terror Patient

ABSTRACT Frightening negative hallucinations as a side effect of fencamfamine (a central nervous system stimulant), aggressive behavior and amnesia due to interactions between metoprolol (a beta adrenergic blocking agent) and alcohol, chronic and severe sleep terrors and conversion disorder are described in a middle-aged man with high social status and no personality disorder. Rare mental side effects should draw attention to the possibility of a latent dissociative disorder. The relationship between beta-blocker induced disturbing dreams, dissociative disorders and sleep terrors is discussed.

Treatment efficacy in behavioral pediatric sleep medicine

Behavioral interventions have been identified as the treatment of choice for many forms of pediatric sleep disturbance. We adopt criteria established by the Task Force on Promotion and Dissemination of Psychological Procedures (1996) to evaluate the literature base describing behavioral interventions for pediatric sleep disturbance. Three well-established interventions, one promising intervention and one probably efficacious intervention, have emerged for bedtime refusal and frequent nighttime awakenings. Only one intervention for sleep terrors and sleepwalking has sufficient empirical support to be considered promising. Behavioral interventions targeting circadian rhythm disorders (e.g., delayed sleep phase), nightmares and rhythmic movement disorder (RMD) have not been researched sufficiently to be considered empirically supported.

Sleepwalking and Sleep Terrors in Prepubertal Children: What Triggers Them?

Sleepwalking and Sleep Terrors in Prepubertal Children: What Triggers Them?

A Return to Spirituality

This paper describes how family therapy was used by an Asian social worker in working with an Asian family who believes and practices Buddhism. The family came to treatment concerned about their 7-year-old son who was experiencing school refusal, night terrors, and increasing “hyperactivity.” Since the family perceived the origin of these problems to be spiritual, the author gave special attention to the family's spiritual beliefs in order to join with them and work within their worldview. This paper discusses the case in detail and also illustrates how there can be a meeting of eastern and western worldviews when family therapy is translated into culturally relevant practice.

Posttraumatic stress disorder in the spouse of a patient with sleep terrors

A 27-year-old woman who developed posttraumatic stress disorder (PTSD) as a consequence of her husband's severe sleep terror episode is reported. A 29-year-old man suddenly aroused from sleep and jumped through the closed second-story window of the room he shared with his wife, sustaining major lacerations to his arms. He hung onto the roof as his wife screamed at him from the window, and eventually climbed back inside. He was evaluated with polysomnography and was given the diagnosis of sleep terrors, which was effectively treated with behavioral and pharmacologic interventions. During a routine follow-up visit with the patient, his wife's PTSD symptoms came to clinical attention and she was referred for treatment. She demonstrated marked improvement in her condition after an 8 week course of cognitive-behavioral therapy. We conclude that family members of patients with sleep disorders manifesting as violent behaviors during sleep can suffer psychological trauma even if they are not physically injured.

Arousal Reactions in Sleepwalking and Night Terrors in Adults: The Role of Respiratory Events

The aim of the study was to determine the role of respiratory events, assessed by means of esophageal pressure monitoring, during arousals from slow wave sleep in adult patients with parasomnias. N/A. N/A. Ten patients with parasomnias (sleepwalking, night terrors, or both) and 10 control subjects matched for gender and age underwent 3 consecutive nights of polysomnography. N/A. By increasing sleep fragmentation, esophageal pressure monitoring has a deleterious effect on sleep architecture in patients with parasomnias and in control subjects. Respiratory events occur more frequently in parasomniacs than in controls. Respiratory effort seems to be responsible for the occurrence of a great number of arousal reactions in parasomniacs and is involved in triggering the parasomnia episodes. Sleep-disordered breathing seems to be frequently associated with parasomnias during slow wave sleep, emphasizing the utility of performing esophageal pressure monitoring in cases of sleep walking or night terrors.

Self-reported organic and nonorganic sleep problems in schoolchildren aged 11 to 15 years in Vienna.

To estimate the prevalence of self-reported sleep problems, to examine associations among demographic characteristics, familial factors, and sleep problems, and to investigate the association between the symptoms of obstructive sleep apnea (OSA) and nonorganic sleep disorders. An anonymous questionnaire with 22 questions was designed. 332 schoolchildren (aged 11-15 years, mean age 12 years and 9 months; median, 12 years; 56% female, 44% male) from two high schools in Vienna were investigated with regard to self-reported symptoms characteristic for obstructive sleep apnea and for parasomnia/insomnia. Data were analyzed by definition of three groups (problem, occasional problem, and nonproblem sleepers, and by calculation of an insomnia/parasomnia sum score). Statistical analysis included nonparametric tests (Mann Whitney-U and Kruskal), Pearson correlation test, and multiple regression analysis. Twelve percent reported at least one sleep problem every night, 76% reported occasional sleep problems, and 12% had no sleep problems. Girls were affected more frequently than boys (p <.01). Children with sleep problems suffered more often from concentration difficulties (p <.05), daytime fatigue (p <.001), and daytime naps (p <.05). Children who snored had nightmares (10% vs. 2%, p <.01), night terrors (4% vs. 1.5%, p <.001), sleepwalking (1.4% vs. 1%, p <.05), and nocturnal awakening (16% vs. 5%, p <.01) more frequently. On multiple regression analysis, 23% of the variability of a defined parasomnia/insomnia sum score had the characteristic OSA symptoms of nocturnal sweating, dryness of the mouth, snoring, hyperactivity, and daytime fatigue. 12% of schoolchildren aged 11-15 years reported sleep problems almost every night. The children suffer from daytime fatigue, naps, and concentration difficulties. Nearly one-fourth of the symptoms of parasomnia/insomnia were associated with characteristic signs of OSA, suggesting the importance of a routine clinical investigation in children with so-called nonorganic sleep disorders.

Ritual behavior in children and mothers’ perceptions of family patterns

This study examined the relationships between family patterns and the characteristics of rituality and fears in children. The study assessed mothers’ perceptions of two family characteristics: adaptability, which refers to the ability of the family system to change its power structure, role relationships and relationship rules, and cohesion, which refers to the emotional bonding of family members. Data were collected from 108 mothers of children aged 5–7, drawn from kindergartens in Northern Israel. Participants completed the Adaptability and Cohesion Scale, the Childhood Rituality Inventory (CRI), and the Fear Scale for Children. Family cohesion was positively related to “Just Right” and to Repetitive Behaviors. In addition, children’s “Just Right” behaviors were highly correlated with fears of harm and death, and children’s Repetitive Behaviors were highly correlated with fears of noises and night terrors, fear of strangers, and fears of harm and death.

Cluster headaches simulating parasomnias

Nocturnal episodes of agitated arousal in otherwise healthy young children are often related to nonrapid eye movement parasomnias (night terrors). However, in patients with acute onset or increased frequency of parasomnias, organic causes of discomfort must be excluded. We report four young children whose parasomnias were caused by nocturnal cluster headaches and who responded to indomethacin dramatically.

Arousability and dreaming.

This study finds that dream valence and the frequency with which several types of dreams were experienced are related to arousability. Specifically, compared to 214 university students who were classified as low in arousability, 182 university students who were high in arousability reported more frequent dreams for all seven types of dreams measured. This relationship between arousability and dreaming was especially salient for the three types of nightmares, (i.e., Fantastic Nightmares, Posttraumatic Nightmares, and Night Terrors) that were measured.

Treating Sleep Terrors in Children with Autism

Sleep terrors manifest themselves as a sudden arousal from slow wave sleep accompanied by screaming, crying, and other signs of intense fear. Children with autism spectrum disorders may be more likely to display problems with sleep, and some children experience such sleep difficulties as sleep terrors on a chronic basis. This nighttime disruption can lead to a great deal of concern, as well as disruption in sleep for other family members. In this first study of the treatment of sleep terrors among children with autism, the effectiveness of one behavioral intervention (scheduled awakenings) was evaluated. Scheduled awakenings involved arousing the child from sleep approximately 30 minutes before an expected sleep terror episode. Results through a 12-month follow-up using a multiple baseline across three children indicated that this intervention quickly and durably reduced the frequency of their nighttime difficulties. Scheduled awakenings is a potentially useful nonmedical intervention for chronic sleep terrors among children with autism.

Hypnosis treatment of sleeping problems in children experiencing loss

AbstractThere is considerable research and clinical evidence that children who experience loss become traumatized. The results of traumatization include sleeping problems, for example difficulties in initiating sleep and sleep terrors. Psychological intervention programmes, including hypnotherapy, have been shown to have some success in helping children to overcome their sleeping problems. In the present study, a new paradigm qualitative methodology was used in which a small group of children were taught self‐hypnosis to manage their sleep difficulties. Within the group, the children's experiences of utilizing self‐hypnosis at home were discussed, and a consensus reached concerning its effects. Complementary data were collected through interviews with caregivers and by completion of the Southampton Sleep Management Schedule (Bartlet and Beaumont, 1998). From the study it was concluded that young children can be taught self‐hypnosis in order to manage their sleeping problems effectively. Furthermore, the present study demonstrated that children can be involved in a collaborative research group. Copyright © 2002 British Society of Experimental and Clinical Hypnosis

Parasomnias: epidemiology and management.

The category of common sleep disorders known as parasomnias includes disorders of arousal, rapid eye movement (REM) sleep behaviour disorder (RBD), nocturnal seizures, rhythmic movement disorder, and tooth grinding or 'bruxism'. Parasomnias are all characterised as undesirable physical or behavioural phenomena occurring during the sleep period. Although these conditions can be distressing and, in some cases, hazardous to the sleeper and his or her bed partner, it is important to recognise that parasomnias are diagnosable and treatable in the vast majority of patients. Evaluation begins with a careful clinical interview with the sleeper and a family member to elucidate the frequency, duration, description and timing after sleep onset of these behavioural events. Disorders of arousal are the most common type of parasomnia and cover a spectrum from calm sleepwalking to emotionally agitated or complex behaviours, such as dressing or driving, for which the patient usually has no memory upon awaking. 'Sleep terrors' are quite common in young children and are often outgrown. Disorders of arousal represent a partial, as opposed to a full, awakening from deep non-REM sleep, typically occurring within the first 60 to 90 minutes after sleep onset. RBD is characterised clinically by a history of dream-enacting behaviour, and the patient may recall dream content. REM sleep periods typically occur in the latter half of the night. Physiologically, RBD results from a lack of the normal muscle atonia that is associated with REM sleep. RBD has been linked to a number of other neurological conditions; thus, a careful review of systems and a physical examination are crucial. A formal laboratory sleep study or polysomnogram with an expanded electroencephalographic montage can help distinguish among non-REM and REM parasomnias and nocturnal seizures. The latter may manifest clinically as arousals from sleep associated with vocalisation and/or complex behaviours. Rhythmic movement disorder can include head banging or body rocking at sleep onset or during the night. Tooth grinding is a common sleep-related behaviour that, when severe, can result in dental injury. Hypnagogic hallucinations (experience of dream imagery at sleep onset) and sleep-onset paralysis (experience of muscle/body paralysis as one is falling asleep) are symptoms rather than diagnostic categories. These phenomena classically occur in many individuals with narcolepsy, but also may occur in healthy sleep-deprived individuals. Safety precautions and good general sleep hygiene measures are recommended for individuals with a parasomnia, as the disorder can be exacerbated by sleep deprivation and various other factors. When the events are frequent or particularly dramatic, medication with a long- or medium-acting benzodiazepine, such as clonazepam, at bedtime is effective therapy in most cases of non-REM disorders of arousal and RBD. A dental guard may be helpful in tooth grinders. Relaxation training and guided imagery may be helpful strategies for some patients, especially those with disorders of arousal or rhythm movement disorders. There is no evidence of any association between parasomnias and psychiatric illness. Demystification of these conditions and reassurance, particularly for parents of paediatric patients, is an important aspect of clinical intervention.

Psychological impact of traumatic injuries: what the surgeon can do.

In their treatment of accident and assault victims, plastic surgeons have unique opportunities to identify and refer patients with posttraumatic stress symptoms. This article describes brief assessments that surgeons or their clinic staff can use to evaluate traumatically injured adults and children for trauma-related psychological symptoms. An immediate postinjury evaluation (within 10 days of the trauma) consists of 11 questions to determine the presence of the following risk factors for posttrauma maladjustment: panic during or immediately after the trauma, reexperiencing symptoms, avoidance, sleep disturbance, injury from an assault, previous trauma and psychiatric history, and blaming someone else for the injury. The seven follow-up interview questions assess reexperiencing symptoms, avoidance, trauma-related phobias, depression, irritability, and increased substance use, all of which, if present, suggest psychological impairment. Questions recommended for the evaluation of younger children assess changes in play and recreational activity, sleep disturbance, night terror, aggression, irritability, avoidance, emergence of new fears, and loss of recently acquired developmental skills. The assessments require less than 2 minutes and are easily integrated into the hospital or clinic examinations of these patients.

Symptoms of sleep disturbances among children at two general pediatric clinics

Objective: We assessed the frequency of childhood sleep problems at 2 general pediatric clinics. Study design: Parents of 1038 unselected children (554 boys) aged 2.0 to 13.9 years completed a validated Pediatric Sleep Questionnaire while waiting for appointments. Results: Habitual snoring was reported in 176 (17%) of the children. Criterion scores suggestive of sleep-disordered breathing were found in 115 (11%) of the children, in 29% of children at the clinic for neurologic indications, and in 21% of children at the clinic for noninfectious respiratory indications. Insomnia (ie, unrefreshing sleep or difficulty with sleep onset, sleep maintenance, or early morning awakening from sleep) was reported in 430 (41%) of the children; ≥2 symptoms were present in 191 (18%) of the children. Excessive daytime sleepiness was suggested in 148 (14%) of the children, and 390 (38%) had symptoms of sleep terrors, sleepwalking, or nocturnal bruxism. Conclusions: Sleep problems such as sleep-disordered breathing, insomnia, excessive sleepiness, and parasomnias are frequent among children seen at general pediatric practices. (J Pediatr 2002;140:97-102)

Epidemiologic study of sleep disorders in Kuwaiti adolescents.

A sample of 2,574 volunteer Kuwaiti boys (n = 1,309) and girls (n = 1,265) in secondary schools were recruited. Their ages ranged from 14 to 18 years. 13 items were used to assess prevalence of insomnia, hypersomnia, nightmares, sleepwalking, sleep terror, and narcolepsy. Participants were requested to respond according to the past month on a 5-point scale. The summation of responses in the last two options, i.e., "Much" and "Very much" was considered as the point prevalence rates. Girls had significantly higher mean ratings than boys on the following items: difficulty initiating sleep, fitful and disturbed sleep, waking up several times, nightmares, and sleep terror, while boys had significantly higher mean ratings on sleepwalking and "watching TV causes naps or sleep." The point prevalence on all the items for boys ranged from 4.6% to 35.2%, and that for girls ranged between 1.0% and 37.5%. One should keep in mind that the present sample was not a clinical one.