Clinical features

Sleep terrors appear especially during the first half of the night, mainly in the first NREM sleep cycle, and

Table 9.5 Differential diagnosis of autonomic activation in sleep and on arousal.

Sleep terror Nightmare

REM sleep behaviour disorder Panic attack

Post-traumatic stress disorder

REM, rapid eye movement.

may occur more than once per night. The episodes may last for only a few seconds, or for up to 1020 min which is longer than most epileptic seizures. The child suddenly appears to waken with a gasp, loud scream or cry and with the appearance of extreme fear, agitation and panic (Table 9.5). Sweating, dilated pupils, rapid respiratory and heart rates and an increase in muscle tone are characteristic and enuresis occasionally occurs. The child may sit up or leap out of bed, utter meaningless speech, and occasionally run wildly around the room. This is more common in adolescence than in younger children, but there may be injuries through, for instance, running out of doors or jumping through windows. The child is unresponsive to questions or commands and resists restraint, often causing harm to both the patient and others. The sleep terrors may be followed by an awakening with confusion and incoherent speech, and behaviour which is identical to a confusional arousal. Sleep is then re-entered promptly.

There is no detailed recall of the event or of any dream content but there may be a sensation of intense fear as if the subject is coming out of a faint or a frightening near-death situation. This is similar to what is experienced in nocturnal frontal lobe epilepsy. Recall of this type is more common if alertness is attained before the subsidence of autonomic activation.

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