Nightmares & Night Terrors

Nightmares & Night Terrors

Summary

Nightmares are emotionally disturbing dreams that occur during rapid eye movement (REM) sleep and provoke feelings of fear, terror, distress or extreme anxiety.

Night terrors, or sleep terrors, are frightening dreams that occur during deep sleep and are sometimes accompanied by screaming, crying or yelling. Patients may also run around and throw items.

Nightmares usually involve a complex plot that the patient remembers after awakening. Night terrors are more primitive, involving simple plots such as fire or a monster.

Both nightmares and night terrors are most common in children, beginning around the age of 4 years. They can be extremely frightening for a child, but are not usually a serious problem.

Most people experience nightmares at some point in their lives, usually after a period of emotional or physical stress. Symptoms of nightmares include abrupt awakening from sleep with a lingering sense of fear or anxiety and immediate recall of the frightening dream. Nightmares are common in children, but decrease in frequency as children age. Among adults, nightmares can be caused by a variety of psychiatric disorders (e.g., post-traumatic stress disorder[PTSD]), sleep disorders (e.g., arousal disorders) and medications (e.g., antidepressants).

According to the American Academy of Family Physicians, night terrors are most common in children between the ages of 4 and 12 and affect 1 to 4 percent of all children. Symptoms of night terrors include confusion or disorientation upon waking and profuse sweating with little memory of any frightening dream. The cause of night terrors is unknown, but they are commonly associated with periods of emotional tension, stress and/or conflict.

Night terrors decline in frequency as children age. They are rare in adults and most commonly occur in people with other sleep disorders or substance abuse problems.

Many patients, especially children, respond well to reassurance and support and do not require special treatment for nightmares and night terrors. In persistent cases, patients may be referred to a physician or mental health professional for further evaluation. Some patients may be referred to a sleep center where a sleep study (test that measures physiological aspects of sleep) will be conducted to help identify the presence of a sleep disorder.

Many patients, both children and adults, are treated effectively with reassurance and support. To reassure children, parents may minimize children’s exposure to frightening images and ensure that bedtime is safe and comfortable for youngsters.

Patients whose nightmares or night terrors are caused by underlying conditions (e.g., PTSD) may require therapy, such as cognitive behavioral therapy, or medication, such as antidepressants.

About nightmares

Nightmares are frightening dreams that occur later in the sleep period and cause a person to awaken with a lingering sense of fear or anxiety. They are lengthy sequences during which a person dreams of imminent physical danger (e.g., pursuit, attack, injury). In some cases, dreams involve personal failure or embarrassment. Nightmares may occur at night or during the day while napping.

Sleep is divided into five stages: stages 1 through 4, which range from the lightest sleep to deep sleep, and the fifth stage, which is known as rapid eye movement (REM) sleep. During a typical night’s sleep, a person cycles through these stages approximately every 90 minutes.

Dreams and nightmares occur during REM sleep. During this stage, breathing becomes more rapid, irregular and shallow and the eyes jerk rapidly. People experience longer cycles of REM sleep more frequently as the night progresses. This intensifies dreams in the second half of the night, and increases the likelihood of nightmares later in the night or close to morning.

Nightmares may occur after a traumatic event and mimic aspects of the trauma. However, most nightmares do not recount actual events. Some patients may have multiple nightmares with a similar theme during the night. People who have post-traumatic stress disorder (PTSD) frequently have nightmares related to the stressful event they have experienced, such as combat, abuse or disaster (e.g., fire, hurricane). Children commonly have nightmares about real or fantasy creatures, such as animals, insects or monsters.

After waking up, patients usually have a lingering sense of fear or anxiety and can often remember the nightmare in detail. Nightmares do not usually cause significant distress, but in some cases may cause disruption in daytime functioning. This is particularly true if nightmares are frequent and sleep is avoided. Patients who avoid sleep may experience excessive sleepiness, poor concentration, depression, anxiety or irritability. In addition, recent research suggests that nightmares may be associated with suicidality.

According to the American Academy of Family Physicians, nightmares affect 20 to 39 percent of children aged 5 to 12. Among adults, 5 to 8 percent experience ongoing problems with nightmares.

According to the American Psychiatric Association, 10 to 50 percent of children aged 3 to 5 have nightmares that are intense enough to wake their parents. As many as 50 percent of adults report having occasional nightmares.

More women than men report having nightmares. However, it is not known whether women experience nightmares more often than men or whether the discrepancy reflects an increased tendency among women to report nightmares.

About night terrors

Night terrors, or sleep terrors, are frightening dreams that occur early in the sleep period during deep sleep and cause a person to awaken, usually with screaming, crying or yelling. Patients may also run around and throw items.

Night terrors may occur at night or during the day while napping. It is the most extreme form of an arousal disorder (parasomnia disorder presumed to be due to an abnormal arousal mechanism).

Night terrors usually occur during deep sleep (stages 3 and 4 of sleep) in the first third of the sleep period. They last between one and 10 minutes and are accompanied by signs of intense anxiety, such as increased heart rate, rapid breathing and dilation of the pupils.

People experiencing night terrors are difficult to arouse. When awakened, they are disoriented for several minutes and remember a vague sense of terror but do not remember the contents of a dream. Children waking from night terrors may thrash about or jump out of bed and may fight restraint. In most cases, people awaken briefly after a night terror and then fall back to sleep. The next morning, they may vaguely recall the episode, but are unable to recall specific details. People usually have only one night terror during a sleep period.

Night terrors usually cause significant distress and may impair social relationships due to embarrassment. People may avoid situations in which others may become aware of the problem, such as visiting friends overnight or sleeping with a bed partner.

Night terrors can be related to other disorders associated with deep sleep, including periodic limb movement disorder (disorder characterized by periodic episodes of repetitive jerking and kicking during sleep) and sleepwalking (disorder marked by walking or other activity during sleep).

Adults who have night terrors are more likely than children to experience substance abuse problems and mental disorders, such as mood disorders (mental disorders that affect mood and interfere with the ability to function).

According to the American Academy of Family Physicians, night terrors are most common in children between ages 4 and 12 and affect 1 to 4 percent of all children

Potential causes of nightmares & night terrors

There are many possible causes of nightmares. For instance, exposure to frightening images, such as those found in movies, books or video games, may cause nightmares, especially in children. Periods of emotional tension, stress or conflict can also induce nightmares. Sleep deprivation and changes in sleep schedules are also potential causes.

Other possible causes of nightmares may include:

  • Psychiatric and sleep disorders, including:
    • Post-traumatic stress disorder (PTSD). Psychiatric illness that occurs after a traumatic event in which the threat of injury or death was present (e.g., combat, abuse, natural disaster). It may occur soon after the trauma or be delayed for months.

    • Depression. Mood disorder marked by sadness, anger or frustration that lasts for long periods of time and interferes with a person’s ability to enjoy daily life.

    • Schizophrenia. A serious thought disorder that makes it difficult to distinguish between real and unreal experiences, think logically, have normal emotional responses to others and behave appropriately in social situations.

    • Dissociative disorders. Disorders characterized by the sudden, temporary separation of thoughts, emotions, sensation or memories from the rest of the identity or sense of self.

    • Panic disorder. Repeated, sudden attacks of intense fear that cause severe anxiety symptoms in the body. It is more likely to begin in adolescence than in childhood.

    • REM sleep behavior disorder. Sleep disorder characterized by altered dreams and violent behavior that often leads to self-injury during rapid eye movement (REM) sleep.

    • Arousal disorders. Disorders that cause a person to awaken during sleep. One example is sleepwalking (disorder marked by walking or other activity during sleep).

  • Medications, including:
    • Antidepressants. Medications primarily used to prevent or treat depression, anxiety and obsessional problems.

    • Antihypertensives. Medications to treat high blood pressure.

    • Anti-parkinsonian medications. Medications to treat Parkinson’s disease (progressive disorder of the nervous system).

  • Withdrawal from medications and substances, including:
    • Alcohol.

    • Barbiturates. A class of drugs that slow the central nervous system and produce relaxation.

    • Benzodiazepines. Medications that slow down the central nervous system. They are used to produce sedation, induce sleep, relieve anxiety and muscle spasms and prevent seizures.

The cause of night terrors is unknown, but, like nightmares, they are commonly associated with periods of emotional tension, stress or conflict. They may also be caused by:

  • Arousal disorders.

  • Family history. Some studies indicate an increased likelihood of night terrors among people who have a close relative (parent, sibling, child) with night terrors or who sleepwalks.

  • Alcohol or sedative use. Withdrawal from alcohol or sedatives during the night can cause night terrors.

  • Sleep deprivation/fatigue. These can disrupt sleep patterns and cause night terrors.

  • Disruptions in sleep/wake schedules. Working the night shift can disrupt normal sleeping patterns and result in night terrors.

Signs and symptoms of nightmares & night terrors

Nightmares and night terrors are similar in that they both involve abrupt awakenings from sleep. However, there are important differences that distinguish the two disorders from one another.

Signs and symptoms of nightmares and night terrors include:

NightmaresNight Terrors
Sudden awakening from sleep with intense fear, anxiety and feeling of impending harmSudden awakening from sleep often accompanied by screaming, crying or yelling
Occurs later in sleepOccurs earlier in sleep
Immediate recall of frightening dream upon wakingMay experience a vague sense of frightening images, but no specific recall of frightening dream upon waking
Little confusion or disorientation upon wakingConfusion or disorientation upon waking
Mild increase in heart rate, breathing rate or sweatingRapid heart rate (tachycardia) and breathing rate (tachypnea) and profuse sweating
Patients generally awaken on their ownOthers have difficulty waking and/or comforting patient


Individuals who experience nightmares may also suffer from anxiety or depression.

Nightmares and night terrors do not usually require a visit to a physician. However, a physician should be consulted if nightmares or night terrors:

  • Are frequent or persistent
  • Disrupt sleep enough to cause problems during the day
  • Are accompanied by other psychiatric symptoms (e.g., depression, anxiety)
  • Cause injury

Diagnosis of nightmares & night terrors

Nightmares and night terrors are usually easily identified by an adult experiencing them or by a child’s parent. If the nightmares or night terrors occur frequently or interfere with waking life, professional help may be sought. A physician may examine a patient for underlying physical causes. In some cases, patients who experience frequent nightmares or night terrors may be referred to a mental health professional for further evaluation.

Patients may be asked to describe the episode to help determine whether they are experiencing nightmares or night terrors. Some questions that a patient may be asked include:

  • How long after falling asleep do the episodes occur?
  • Do they scream, cry or yell upon wakening?
  • Do they recall the episode after waking?
  • Do they experience daytime dysfunction due to episodes?
  • Have they experienced any physical or emotional stress lately?

For most children, nightmares and night terrors do not require further investigation. Adult patients may be referred to a sleep center where sleep patterns are analyzed in depth by health professionals who specialize in sleep disorders. At the sleep center, a polysomnogram (sleep study) will typically be performed. This painless test is conducted overnight while patients are sleeping. Electrodes are placed on the face and scalp before sleep. The test monitors electrical activity of the brain (electroencephalogram) and heart (electrocardiogram), movements of the muscles (electromyogram) and eye movements (electro-oculogram). These are measured as patients move through the different stages of sleep.

Mental health professionals have created specific criteria for determining whether patients experience occasional nightmares or night terrors or have chronic disorders. To meet the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for diagnosis of nightmare disorder, a patient must:

  • Have multiple frightening dreams that lead to awakening
  • Become fully alert after waking up
  • Experience social or occupational dysfunction or significant distress as a result of frightening dreams
  • Not experience frightening dreams as a result of a mental disorder, substance abuse or medication

To be diagnosed with night terror disorder, a patient must:

  • Have multiple abrupt awakenings usually beginning with screaming or crying
  • Exhibit signs of intense fear, such as rapid heart rate and breathing
  • Be difficult to awaken or comfort during an episode
  • Have scant or no recollection of the episode
  • Experience significant distress or impairment in social, occupational or other areas of functioning

Treatment options for nightmares & night terrors

Treatment of nightmares and night terrors depends on the age of the patient and the cause of the sleep disturbance.

The frequency of nightmares and night terrors decreases in most children as they age. Because nightmares rarely indicate an underlying disorder in children, most respond well to reassurance and support. Children are rarely treated with medication.

To reassure children, parents or guardians may want to:

  • Minimize the child’s exposure to frightening images, such as violence on television and in video games

  • Read, talk and relax with children

  • Ensure that bedtime is safe and comfortable for children

  • Help the child imagine a happy ending to nightmares if they occur frequently

  • Encourage older children to keep a dream journal

Patients experiencing night terrors should never be awoken because they are not rational and may lash out at the person awakening them.

Adults who experience occasional nightmares may also respond well to reassurance and support. However, adults who experience chronic nightmares that disrupt daytime functioning may require therapy. Behavior therapy, which may consist of group or individual counseling with a mental health professional, has proven especially beneficial.

Therapy may be required for patients whose nightmares are associated with post-traumatic stress disorder (PTSD), a psychiatric illness that occurs after a traumatic event in which the threat of injury or death was present. Some types of therapy used to treat patients with PTSD include:

  • Cognitive restructuring. Therapy technique during which a patient identifies negative, irrational beliefs and replaces them with truthful, rational statements.

  • Exposure therapy. Involves exposing patients to prolonged and repeated images of trauma until the images no longer cause severe anxiety.

Some patients with PTSD are treated with antidepressant medications. Patients should be aware that a physician may need to adjust the dosage or change medications to achieve the best results with minimal side effects. In addition, the U.S. Food and Drug Administration(FDA) has advised that antidepressants may increase the risk of suicidal thinking in some patients and all people being treated with them – especially children – should be monitored closely for unusual changes in behavior.

Patients with REM sleep behavior disorder may be treated with benzodiazepines (medications that slow down the central nervous system) or antidepressants.

Questions for your doctor

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to nightmares and night terrors:

  1. How can I determine whether my child is experiencing a nightmare or a night terror?
  2. How common are nightmares and night terrors among children?
  3. How common are nightmares and night terrors among adults?
  4. What are some of the causes of nightmares and night terrors?
  5. My child is afraid to go to sleep because of nightmares. What should I do?
  6. What is the best way to cope with my child’s nightmares?
  7. Will my child outgrow having nightmares?
  8. Does having night terrors mean that I have a sleep disorder?
  9. Will I ever be cured of my night terrors?
  10. Do you recommend any medication treatment or therapy for me?
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