Sleep (Night) Terrors DSM-5 307.46 (F51.4)
DSM-5 Category: Sleep- Wake Disorders
Introduction
Sleep Terrors, also known as Night Terrors, or pavor nocturnus., are classified as one of two non-Rapid Eye Movement sleep arousal disorder in the DSM -5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition). The other NREM sleep arousal disorder is somnambulism. NREM sleep arousal disorders are characterized by partial awakening from Deep sleep. In the case of Sleep terrors, the person, usually a child, will awaken abruptly, and scream and cry inconsolably up to 10-30 minutes. These episodes are accompanied with autonomic arousal- e.g. tachycardia, hyperventilation, and pupillary dilation, and tend to be nocturnal, rather than occurring while napping in the daytime. (American Psychiatric Association, 2013). Sleep terrors are not the same phenomena that will occur when a sleeper awakens from a nightmare. Although there are similarities, Sleep terrors have many contrasting features, compared to wakening from a nightmare. Upon awakening from a nightmare, one will rapidly fully awaken, and the nightmare may be recalled in detail. Dream fragments may be recalled from a Sleep Terror episode, but they are not as complete as the recall of a nightmare, and also tend to be qualitatively different ( Uguccioni, Golmard, Fontréaux, Leu-Semenescu, & Brion, 2013). One will typically rapidly orient themselves, sympathetic activation will decrease, they will return to sleep, and may recall the nightmare in the morning. Nightmares can occur at any stage in the lifespan, and occur during REM sleep, while Sleep terrors are an NREM ( Non-Rapid Eye Movement) parasomnia or a disorder of arousal (Tinuper, Bisulli, & Provini, 2012) Sleep terrors are much more common in childhood, and rare in adults. Sleep terrors are described as one of the benign parasomnias which occur as neural circuits, synapses, and receptors develop in the child (Nevsimalova, Prihodova, Kemlink, & Skibova, 2013). Although they are defined as benign, they are very distressing to a parent trying to comfort their hysterical child. The child themselves will not have recall of the event the following morning (American Psychiatric Association, 2013). An isolated event of a Sleep terror is not defined as Sleep terror disorder. See the diagnostic criteria in Symptoms.
Symptoms of Sleep Terrors
According to the DSM-5, Sleep terrors are episodes of partial, abrupt awakening from Deep sleep, during the first third of the night, or the first third of the major sleep episode, accompanied by inconsolable screaming and crying, and autonomic arousal. There are similarities with a daytime panic attack, in that these symptoms are accompanied by feelings of dread and a desperate desire to escape. There will typically be a single episode of Sleep terror per night, though multiple episodes can occur. Other features include: minimal if any recall of dreams, retrograde amnesia of the event, and marked distress or impairment in social, academic, or occupational functioning, The episodes cannot be accounted for by use of illicit drugs, a prescribed medication, or another psychological or medical condition. Episodes of sleep terrors are differentiated from Sleep Terror Disorder, in that there is distress and impairment (American Psychiatric Association, 2013).and it is likely the episodes occur regularly
Onset
Sleep Terror disorder is typically first seen in early childhood, and resolves with as the child ages. (American Psychiatric Association, 2013) Although there are adults who experience Sleep Terrors.
Prevalence
The DSM-5 indicates that the prevalence of Sleep terror disorder is unknown (American Psychiatric Association, 2013). However episodes of Sleep terrors occur in about 37% of children at 18 months, and about 20% at age two and a half. About 2.2. % of adults will experience sleep terror episodes (American Psychiatric Association, 2013). Other sources indicate Sleep terror disorder occurs in 3% of children, and have a <1% prevalence in adults, (Fialho, Pinho, Lin, Minett, Vitalle, Fisberg, Peres, Vilanova, & Masruha, 2013).In adults, the Sleep terrors can be viewed as nocturnal versions of a panic attack (Linton, 2013).
Risk Factors
The DSM-5 notes there is an increased risk of an episode of night terror occurring if the person has taken a CNS (Central Nervous System) Depressant. Fatigue, sleep deprivation, and stress are also factors that can precipitate Sleep Terrors in susceptible individuals. (American Psychiatric Association, 2013).
Comorbidity
The DSM-5 notes that major depressive disorder is comorbid with Sleep Terrors (American Psychiatric Association, 2013). OCD “ tendencies”, anxiety, and other phobias are comorbid in adults with Sleep Terrors (Luca, Luca,& Calandra (2013). Migraine headaches are also noted to occur co-morbidly in children and teens with Sleep terrors. In one study, about one third of a sample of n=158 10-19 year- olds with Sleep Terrors also reported migraine headaches. (Fialho, et al 2013).
Treatment for Sleep Terrors
The DSM-5 does not describe any specific treatment options, (American Psychiatric Association, 2013). although sleep hygiene may reduce the incidence of occurrence. Sleep Terrors are typically outgrown by children, and no treatment is required. For a case of an adult with severe Sleep Terrors, CBT (Cognitive Behavioral Therapy) utilizing exposure reduced the incidence of Sleep Terrors, and improved quality and duration of sleep, and overall quality of daytime functioning (Linton, 2013).
Impact on Functioning
Sleep terrors are described as benign regarding their impact on most children, but the impact on the parent must also be considered. A parent may feel anxious about putting their child to bed if they experience sleep terrors, and this may disrupt bedtime routines (American Psychiatric Association, 2013).It is also very distressing for a parent to be unable to comfort their child when they are experiencing a Night terror. In adults, Sleep terrors are disturbing to one's sleeping partner, (Linton, 2013).and over time could potentially strain a relationship.
Differential Diagnosis
The clinician should rule out PTSD ( Post-traumatic Stress Disorder) in both adults and children with Sleep Terrors. Individuals with PTSD frequently experience repetitive nightmares. One study indicated that 71-92% of people with PTSD may have nightmares (US. Dept of Veteran's Affairs, 2014) People with PTSD may awaken from a nightmare in distress, and act out violently. These episodes are qualitatively different from Night Terrors, though they may be reported as such by the individual or their cohorts.
References:
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th Edition). Washington, DC.
Fialho, L.M.N., Pinho, R.S. Lin, J., Minett T.S.C. , Vitalle, M.S. S., Fisberg, M. Peres, M.F.P., Vilanova,L.C.P., Masruha, M.R. (2013). Sleep terrors antecedent is common in adolescents with migraine. Archives Neuropsychiatry. 13;71(2):83-86. Retrieved March 1, 2014 from http://www.scielo.br/pdf/anp/v71n2/aop_0002122_13.pdf
Haupt M, Sheldon SH, Loghmanee D. ( 2013). A brief review of sleep terrors, nightmares, and rapid eye movement sleep behavior disorder.. Pediatric Annals. 42(10):211-216. (PMID:24126984) DOI: 10.3928/00904481-20130924-12 Retrieved March 1, 2014 from http://europepmc.org/abstract/MED/24126984/reload=0;jsessionid=GgZXeOQoIibcMO7WtFHq.10
Linton, S.J. (2013). A Cognitive-Behavioral treatment package for sleep terrors: A Case Study. The Open Sleep Journal. 6. 8-11. Retreived March 2, 2014, from http://benthamscience.com/open/toslpj/articles/V006/8TOSLPJ.pdf
Luca, A., Luca,M., and Calandra, C. (2013) Sleep disorders and depression: brief review of the literature, case report, and nonpharmacologic interventions for depression. Clinical Interventions in Aging. 8:1033–1039.doi: 10.2147/CIA.S47230 PMCID: PMC3760296
Nevsimalova, S, Prihodova, I., Kemlink, d., Skibova. J. (2013). Childhood parasomnia – A disorder of sleep maturation? European Journal of Paediatric Neurology. (Abstract).(17), 6. 615-619. Retrieved March 1, 2014 from http://www.ejpn-journal.com/article/S1090-3798%2813%2900072-X/fulltext
Tinuper, P., Bisulli, F., Provini, F. (2012). THE BORDERLAND OF EPILEPSY: The parasomnias: Mechanisms and treatment. DOI: 10.1111/j.1528-1167.2012.03710.x Retrieved March 1, 2014 from http://onlinelibrary.wiley.com/doi/10.1111/j.1528-1167.2012.03710.x/full
Uguccioni, G. Golmard, J.L. Fontréaux, A.N., Leu-Semenescu, S Brion, A. .(2013). Fight or flight? Dream content during sleepwalking/sleep terrors vs rapid eye movement sleep behavior disorder Sleep Medicine (14), 5. 391-398
US. Dept of Veteran's Affairs, (2014). Nightmares and PTSD. PTSD: National Center for PTSD. Retrieved March 2, 2014 from http://disadvantageous/public/problems/nightmares.asp
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