🌙 Night Terrors vs Nightmares – A Comprehensive Guide for PLAB 2
- Ann Augustin
- Jul 8
- 4 min read
✨ Introduction
Sleep disturbances like night terrors (sleep terrors) and nightmares are common paediatric presentations. Differentiating them, understanding their pathophysiology, and counselling parents effectively are vital skills for PLAB 2 and clinical practice.
🛌 Night Terrors (Sleep Terrors)
Presentation
Occur in the first third of the night, during non-REM (N3/deep sleep).
Child sits up, screams, looks terrified, with autonomic signs (tachycardia, sweating, dilated pupils).
Unresponsive and inconsolable during the episode.
No memory of the event in the morning.
Lasts a few minutes up to 15-20 minutes, then returns to sleep.
Age of Onset
Most common in children aged 3-8 years, peak at 4-7 years.
Rare in adults.
Risk Factors
Sleep deprivation
Stress or anxiety
Fever or illness
Family history of parasomnias (e.g. sleepwalking)
Disrupted sleep schedule
Obstructive sleep apnoea (OSA) (less common trigger)
Pathophysiology
Parasomnia of non-REM sleep due to incomplete arousal from deep sleep, activating autonomic and motor systems without full cortical awareness.
Linked to immature CNS sleep-wake regulation pathways, usually resolves with age.
💊 Management and Treatment Plan for Night Terrors
✅ 1. Reassurance and Education (First-line)
Explain to parents that night terrors are benign and self-limiting.
Advise not to wake the child during episodes as this may prolong confusion and distress.
✅ 2. Optimise Sleep Hygiene
Ensure adequate sleep duration for age.
Maintain a consistent bedtime routine and avoid late bedtimes.
✅ 3. Address Triggers
Reduce stress or anxiety.
Monitor and treat any intercurrent illness or fever.
✅ 4. Safety Measures
Ensure a safe sleep environment:
Remove sharp or dangerous objects nearby.
Use safety gates if sleepwalking coexists.
✅ 5. Scheduled Awakening (if frequent and predictable)
If episodes occur at a similar time nightly, gently wake the child ~15-30 minutes before expected episodes for a few nights to weeks to disrupt the sleep cycle.
✅ 6. Medications (rarely needed)
For severe, persistent, or injurious cases, refer to a sleep specialist.
Clonazepam (a benzodiazepine) may be used under specialist supervision to suppress deep sleep.
😨 Nightmares
Presentation
Occur during REM sleep, usually in the second half of the night.
Child wakes up fully, frightened, often crying, and seeks comfort.
Vivid recall of the dream content.
May resist going back to sleep due to fear.
Risk Factors
Stress or anxiety
Trauma (PTSD-related nightmares)
Watching frightening content before bed
Fever
Certain medications (e.g. SSRIs, beta blockers)
Pathophysiology
Occur during REM sleep when dreaming is vivid.
Often related to emotional processing during sleep.
💊 Management and Treatment Plan for Nightmares
✅ 1. Reassurance and Comfort
Explain that nightmares are common and harmless.
Comfort the child and allow them to talk about their dream if they wish.
✅ 2. Optimise Sleep Hygiene
Maintain a regular bedtime routine with calming activities.
Avoid scary TV shows, movies, or games before bed.
✅ 3. Address Underlying Stress or Anxiety
Explore emotional or psychological stressors.
If persistent, consider referral for psychological therapy (e.g. CBT for anxiety or trauma).
✅ 4. For PTSD-Related Nightmares
Imagery Rehearsal Therapy (IRT):
The child/adult rewrites the nightmare with a positive ending and rehearses it while awake.
Medication options (in severe adult PTSD cases):
Prazosin (an alpha-1 blocker) may reduce nightmares under specialist care.
✅ 5. Medical Management
Generally not required for typical childhood nightmares.
🔬 Differential Diagnoses
Condition | Presentation |
Night Terrors | First third of night, non-REM sleep, screaming, autonomic arousal, unresponsive, no recall. |
Nightmares | Second half of night, REM sleep, wakes fully, frightened, vivid recall. |
Nocturnal seizures | Stereotyped tonic-clonic or focal movements, any time, possible tongue biting, post-ictal confusion. |
Sleepwalking | Non-REM sleep, gets out of bed, walks around with blank stare, no fear or screaming unless combined with night terrors. |
Confusional arousals | Child wakes confused and disoriented, no fear or autonomic signs. |
OSA | Snoring, gasping, frequent awakenings, daytime sleepiness. |
Nocturnal panic attacks | Sudden awakening with intense fear and autonomic symptoms, often no dream recall. |
Sleep paralysis | Occurs on waking or falling asleep, awareness with inability to move, may have hallucinations. |
📝 Data Gathering Questions
Night Terrors
What happens during these episodes?
At what time of night do they occur?
How long do they last?
Can you wake or comfort them during the episode?
Do they remember it in the morning?
Any recent illness, fever, or stress?
How is their sleep routine?
Any family history of similar events?
Any snoring or breathing difficulties?
Nightmares
Can you describe the dream?
What time of night does it occur?
How often do they happen?
Do they wake up fully and seek comfort?
Any recent stress, trauma, or worries?
Any exposure to frightening content before bed?
Do they remember the dream in the morning?
How is their general mood and anxiety during the day?
🔑 Key Differences
Feature | Night Terrors | Nightmares |
Sleep stage | Non-REM (N3) | REM |
Timing | First third of night | Second half |
Awareness | Unresponsive during episode | Fully awake after |
Recall | None | Vivid recall |
Behaviour | Screaming, autonomic signs, inconsolable | Frightened, seeks comfort |
📌 Final Takeaway
✅ Night terrors: Disorder of arousal from deep sleep, no recall, resolves with age.
✅ Nightmares: Distressing dreams during REM sleep with full recall and awareness.
📚 References
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