Practice Essentials
Sleep terrors (also referred to as night terrors or
pavor nocturnus) are a specific sleep disruption
most remarkable for their intensity and anxiety-
inducing nature. Several precipitating factors have
been suggested, but no consistent structural or
biochemical abnormality has been identified to
account for all cases of sleep terrors.
Background
Sleep disruption in childhood is a common and
frequently upsetting occurrence; sleep terrors (also
known as night terrors or pavor nocturnus) are a
specific sleep disruption most remarkable for their
intensity and anxiety-inducing nature. Most
episodes begin within the first 1-2 hours of sleep,
during stages 3 and 4 of non–rapid eye movement
(REM) sleep, though episodes may occur later or
during naps.
Affected individuals typically appear to wake from
sleep with a sudden intense distress (often
indicated by a loud cry or scream), followed by
poorly controlled panic and a lack of
responsiveness or normal interaction with other
individuals. The episodes generally last for 1-10
minutes, at which point the agitation abruptly ends,
and the individual resumes normal sleep. The
affected individual typically has no memory or only
vague recall of the event the following day. If the
individual is successfully roused during the event,
the period of distress and confusion can be
prolonged.
Diagnostic criteria (DSM-5)
Parasomnias are sleep-wake disorders
characterized by undesirable motor, verbal, or
experiential phenomena occurring in association
with sleep, specific stages of sleep, or sleep-awake
transition phases. In the American Psychiatric
Association (APA) Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5),
one common parasomnia, non-REM (NREM) sleep
arousal disorder, is described as being
characterized by either somnambulism (ie,
sleepwalking) or sleep terror. [1]
The specific DSM-5 criteria for NREM sleep arousal
disorder, sleep terror type, are as follows [1] :
 Recurrent episodes of abrupt terror arousals
from sleep, usually beginning with a panicked
scream; intense fear and signs of autonomic
arousal (eg, mydriasis, tachycardia, rapid
breathing, and sweating)
 Relative unresponsiveness to efforts of others
to comfort the individual during the episode
 Little or no recall of dream imagery
 Amnesia for the episode
 The episodes cause significant distress or
impairment in social, occupational or other
areas of functioning
 The symptoms cannot be explained by
another mental disorder, medical condition, or
the effects of a drug of abuse or medication
Pathophysiology
Several precipitating factors for sleep terrors have
been suggested, but no consistent structural or
biochemical abnormality has been identified to
account for all cases of sleep terrors. A dysfunction
in the serotoninergic system has been suggested,
owing to an association found between adolescents
with migraines and a history of sleep
terrors. [2] Additionally, some evidence has
suggested that the serotonin precursor L-5-
hydroxytryptophan can help reduce the frequency
of sleep terrors. [3]
Sleep studies demonstrate that sleep terrors occur
during stage 3 and 4 NREM sleep. The occurrence
of sleep terrors is increased in some families,
suggesting a genetic predilection; however, to date,
no genetic marker has been clearly identified. [4]
A strong correlation between sleep terrors and
sleepwalking is noted, with a high frequency of
either process in first-degree family members of
individuals who experience sleep
terrors. [5] Sleepwalking has been associated
with HLADQB1. [6] An association of sleep terrors
and sleepwalking in family members of individuals
with nocturnal frontal lobe epilepsy has also been
reported. [7] One study also found evidence that
many young children with sleep terrors went on to
develop sleepwalking later in childhood, suggesting
similar underlying pathophysiology. [8]
Etiology
No specific cause has been identified for sleep
terrors. Suggested triggers have included the
following [9, 10, 11]:
 Inadequate or irregular sleep schedule
 Unfamiliar or disruptive sleep environment
 Concurrent fever or illness
 Certain medications, including central nervous
system (CNS) depressants (eg, sedative-
hypnotics and alcohol) and some stimulants
 A full bladder during sleep
 Generalized stress
 Obstructive sleep disorders
No trigger is uniformly or consistently seen in most
individuals who experience sleep terrors. These
triggers do not appear to cause sleep terrors but
may lower the threshold for sleep terror events.
Epidemiology
It is estimated that between 1% and 6% of children
experience sleep terrors although prevalence is
difficult to accurately assess for numerous reasons,
including variations in the definition of sleep terrors
in studies as well as age groups with much different
rates of sleep terrors being assessed in studies.
This condition is much less common in adults,
occurring in less than 1%. In children younger than
3.5 years, the peak frequency is at least 1 episode
per week; among older children, the peak
frequency is 1-2 episodes per month. [12] The course
in adults is more chronic, with significant variability
in both the frequency and the severity of episodes
among affected individuals. [1]
Night terrors can occur from infancy through
adulthood. [13] The age range of peak frequency is
4-12 years for children and 20-30 years for adults.
However, one study found peak prevalence in
children at 18 months of age, indicating that
previous thoughts on prevalence might be affected
by lack of studies in children under two years
old. [8] Most childhood-onset sleep terrors resolve
by adolescence. Most sources indicate that the
genders experience sleep terrors at an equal
frequency; however, the APA (in DSM-5) states
that the incidence is increased in male
children.[1] Sleep terrors are experienced equally
across racial categories.
Prognosis
Most children with sleep terrors experience
resolution before adolescence. No increased
occurrence of psychiatric diagnoses is found in
children. Adults who experience sleep terrors have
an increased occurrence of other psychiatric
conditions, particularly posttraumatic stress
disorder (PTSD), generalized anxiety, and
dependent, schizoid, and borderline personality
disorders. [1, 14, 15]
Sleep terrors are fundamentally benign, but some
affected individuals may experience trauma from
interactions with their surroundings or may injure
others attending them. Attempts to awaken an
affected individual during an episode are generally
unsuccessful and increase the potential of harm to
persons offering support. [16]
Patient Education
Families and individuals must understand that
sleep terrors are fundamentally benign, self-limited
events. Safety measures including modifying the
sleep environment to afford increased patient
protection, securing windows, and limiting access
to potentially harmful situations. Because the
affected individual is generally unresponsive to
outside interventions, aggressive attempts to
intervene should be discouraged. Improvement of
sleep hygiene and avoidance of potential triggers
may reduce the frequency or severity of events. [10]
For patient education resources, see the Sleep
Disorders Center, as well as Night
Terrors, Disorders That Disrupt Sleep
(Parasomnias), and REM Sleep Behavior Disorder.
Healthy Sleep
In 2016, the American Academy of Sleep Medicine
(AASM) issued consensus recommendations for
the amount of sleep needed to promote optimal
health in children and teenagers and to avoid the
health risks of insufficient sleep. [17]
To promote optimal health, the recommendations
advise the following amount of sleep (per 24 hours)
on a regular basis:
 Infants 4 to 12 months: 12 to 16 hours of
sleep (including naps);
 Children 1 to 2 years of age: 11 to 14 hours
(including naps);
 Children 3 to 5 years of age: 10 to 13 hours
(including naps);
 Children 6 to 12 years of age: 9 to 12 hours;
and
 Teenagers 13 to 18 years of age: 8 to 10
hours.
Signs and symptoms
Symptoms of sleep terrors include the following:
 Sudden arousal from non–rapid eye
movement (NREM) sleep, usually occurring in
the first third of the night
 Associated autonomic and behavioral
manifestations of fear, including crying,
screaming, or thrashing
 Agitation (more commonly seen in adults)
 Significant autonomic hyperactivity, including
tachycardia, tachypnea, and diaphoresis
 No or minimal response to external stimuli
during the event
 Upon wakening: Confusion, disorientation,
and amnesia regarding the event
There are no specific physical findings or signs
found on routine physical examination when the
individual is awake.
See Presentation for more detail.
History
Sleep terror is characterized by a sudden arousal
from non–rapid eye movement (NREM) sleep
(usually from slow-wave sleep) and associated
autonomic and behavioral manifestations of fear.
Commonly, patients let out a piercing scream,
followed by fear, crying and inconsolability. In
adults, agitation is often seen. Significant
autonomic hyperactivity is present, with
tachycardia, tachypnea, flushing, diaphoresis, and
increased muscle tone.
The patient is routinely unresponsive to external
stimuli and, when awakened, is confused,
disoriented, and amnestic regarding the event. It
should be cautioned that confrontation of an
individual during an episode may be dangerous, in
that the individual may become violent. Incoherent
vocalizations or micturition have been reported to
accompany the event.
Because sleep terror events are relatively common
and many affected individuals have family
members with similar experiences, many families
may not seek medical attention. When the episodes
cause clinically significant distress or impairment in
social, occupational, or other important areas of
functioning, the diagnosis of sleep terrors advances
to the diagnosis of NREM sleep arousal disorder,
sleep terror type. [1]
Physical Examination
No specific physical findings or signs are expected
during a routine physical examination when the
individual is awake. Several conditions that may be
associated with sleep terror occurrence may
demonstrate distinct physical abnormalities (eg,
tonsillar enlargement). These findings are not
consistent for all individuals who experience sleep
terrors and are frequently noted in individuals with
no recognized sleep terror occurrences.
Diagnostic Considerations
In addition to the conditions listed in the differential
diagnosis, other medical conditions that interrupt
sleep and can distress an individual should be
considered, including the following:
 Acute stress disorder
 Gastroesophageal reflux
 Hypnagogic hallucinations
 Nocturnal frontal lobe epilepsy (NFLE)
 Noncturnal panic attacks
 Noncturnal seizures
 Pinworms
 Separation anxiety
 Sleep breathing disorders
 Sleep paralysis
Differential Diagnoses
 Breathing-Related Sleep Disorder
 Nightmare Disorder
 Nightmares and REM Sleep Behavior
Disorder
 Panic Attacks
 Periodic Limb Movement Disorder
 Posttraumatic Stress Disorder
 Posttraumatic Stress Disorder in Children
 Restless Legs Syndrome
 Sleep Disorders
 Sleep Walking
Approach Considerations
No consistent irregularities in laboratory evaluation
have been identified, and no additional workup is
required in a classic sleep terror presentation. No
specific imaging is indicated with normal
development and no focal neurologic abnormalities.
If trauma during an episode has been sustained,
appropriate imaging should be sought to evaluate
the injury.
A sleep diary may help families identify particular
triggers for sleep terror events. Comorbidities
should be investigated independently of their
association with sleep terrors.
Further evaluation and intervention may be
required for individuals with significant daytime
somnolence, for those who exhibit violent behavior
during the episodes that threatens harm to self or
others, or in situations where the sleep terrors
generate severe distress to family members.
Polysomnography is useful if a respiratory
disturbance is suspected.
Physicians should also ask about specific
symptoms that might suggest nocturnal seizures,
including repetitive stereotypic behaviors or
abnormal posturing during the episodes. [18] When
nocturnal seizures are a possibility, routine
electroencephalography (EEG) or sleep-deprived
EEG may be helpful. [19, 20] EEG findings are often
similar with sleep terrors and nocturnal seizures,
especially nocturnal frontal lobe epilepsy (NFLE),
making diagnosis difficult. Additionally, a normal
awake EEG or interictal sleep EEG may not rule
out a seizure disorder. [21] Findings on EEG that
suggest parasomnias rather than NFLE include the
presence of vertex waves, sleep spindles,
nonrhythmic theta activity, or evidence of EEG
state dissociation with a posterior dominant alpha
rhythm. Additionally, NFLE most often presents in
stages 1 and 2 of sleep as opposed to
parasomnias, which most often present in stages 3
and 4. [22]
Approach Considerations
In view of the benign and self-limited nature of
sleep terrors, most affected individuals require no
specific medical intervention other than
reassurance and education.
The use of scheduled awakenings has been
suggested as a possible means of reducing sleep
terror occurrences. [23] This involves noting what
time the episodes usually occur for five nights in a
row, then waking the child up 10 to 15 minutes
before that time, keeping the child awake for 4 to 5
minutes, then allowing the child to resume sleep. [24]
During episodes, efforts should be made to keep
affected individuals from harming themselves or
others. These efforts can be supported by removing
hazardous objects from the sleep area, securing
windows, and impeding exit from the sleep area.
Affected children are typically resistant to
interference in the midst of a sleep terror event, but
patient surveillance to avert injury as permitted may
be all that is required.
When the episode has terminated, parents should
assist the child back to bed. Discussion of the event
immediately or the following day is usually not
helpful, because the experience either is not
remembered or is only vaguely recalled.Associated
comorbid conditions, particularly sleep breathing
disorders, should be appropriately treated; this may
or may not affect the frequency of sleep
terrors. [9] General efforts to promote a stable
environment with adequate regular sleep habits are
encouraged but may not alter the occurrence of
sleep terrors.
Long-Term Monitoring
Routine follow-up and developmental assessment
are indicated for all children, including those
affected by sleep terrors.
Continued support and reassurance can be helpful
for affected families. Surveillance for deviation from
classic sleep terror characteristics or increasing
severity of behavior during episodes may prompt
reconsideration of the diagnosis or increased
protective interventions.
Medication Summary
Medications rarely are indicated for sleep terrors
and usually provide no long-term help to patients.
They should be prescribed only for severe
symptoms that affect waking behavior (eg, school
performance and peer or family relations) and only
after behavioral interventions have failed.
Pharmacologic therapy should be administered
only as a temporary measure.
Tricyclic Antidepressants
Class Summary
Tricyclic antidepressants decrease deep delta
sleep and arousal between sleep stages.
Imipramine (Tofranil, Tofranil-PM)
 View full drug information
In limited studies, imipramine has stopped the
disorder when administered at bedtime for 8 weeks.
Amitriptyline
 View full drug information
Amitriptyline has been effective in the treatment of
REM sleep disorder behaviors.
Benzodiazepines
Class Summary
Some studies suggest that long-term management
with low dose clonazepam is effective for adults
with severe sleep terrors involving violence or self-
injurious behaviors. [25, 26]
Clonazepam (Klonopin)
 View full drug information
Long-acting benzodiazepine that increases the
presynaptic GABA inhibition and reduces the
monosynaptic and polysynaptic reflexes. It has
been used off-label for REM and nonREM sleep
behavior disorders.
Diagnosis
The diagnosis is made primarily based on a history
that identifies the classic symptoms of sleep terror
and by excluding other possible etiologies for the
sleep disturbance based on the clinical
presentation. There have been no identified
irregularities in laboratory evaluation, and no
additional workup is required in a classic sleep
terror presentation. Further evaluation may be
useful as follows:
 Sleep diary to help identify sleep patterns and
triggers for sleep terrors
 Investigation of comorbidities
 Assessment for significant daytime
somnolence, violent behavior during
episodes, or severe distress on the part of
family members
 Polysomnography for a suspected respiratory
disturbance
 Routine electroencephalography (EEG) or
sleep-deprived EEG if nocturnal seizures are
suspected
The specific DSM-5 criteria for NREM sleep arousal
disorder, sleep terror type, are as follows [1] :
 Recurrent episodes of abrupt terror arousals
from sleep, usually beginning with a panicked
scream; intense fear and signs of autonomic
arousal
 Relative unresponsiveness to efforts to
comfort the individual during the episode
 Little or no recall of dream imagery
 Amnesia for the episode
  Significant distress or impairment in social,
occupational or other areas of functioning
 The symptoms cannot be explained by
another mental disorder, medical condition, or
the effects of a drug of abuse or medication
See Workup for more detail.
Management
Because sleep terrors are typically benign and self-
limited, most affected individuals require no specific
medical intervention other than reassurance and
education.
Measures that may be helpful include the following:
 Appropriate treatment of associated comorbid
conditions
 Promoting a stable environment with
adequate regular sleep habits
 Routine follow-up and developmental
assessment for affected children
 Continued support and reassurance for
affected families
 Surveillance for deviation from classic sleep
terror characteristics or increasing severity of
behavior during episodes
 Efforts to keep affected individuals from
harming themselves or others during
episodes
 Scheduled awakenings
See Treatment and Medication for more detail.