Diagnostic Criteria

A. Repeated episodes of abrupt awakening (lasting 1-10 minutes) from sleep, usually occurring between 30 and 200 minutes after onset of sleep (the interval of sleep that typically contains EEG delta activity, sleep stages 3 or 4) and usually beginning with a panicky scream.

B. Intense anxiety during the episode and at least three of the following signs of autonomic arousal:

  1. tachycardia
  2. rapid breathing
  3. dilated pupils
  4. sweating
  5. piloerection

C. Relative unresponsiveness to efforts of others to comfort the individual during the episode and, almost invariably, confusion, disorientation, and perseverative motor movements (e.g., picking at pillow).

D. No evidence that the episode occurred during REM sleep or of abnormal electrical brain activity during sleep.

Differential Diagnosis

REM sleep nightmares

REM sleep nightmares are distinguished from Sleep Terror Disorder by their appearance in the middle and latter thirds of the night, the milder anxiety experience, the absence of a panicky scream upon awakening, and the distinct recall of a detailed dream sequence in which a growing threat leads to awakening. Parents may misinterpret the fearfulness and fragmentary imagery reports of Sleep Terror Disorder as indicative of a REM sleep nightmare.

Hypnagogic hallucinations

Hypnagogic hallucinations may be associated with anxiety, but occur at onset of sleep and are vivid images at the transition from wakefulness to sleep.

Epileptic seizures

Epileptic seizures during sleep with postictal confusion may present a clinical picture similar to Sleep Terror Disorder, but the presence of epileptic seizures in the waking state or the presence of an abnormal sleep EEG rules out a diagnosis of Sleep Terror Disorder.


Diagnostic Criteria

A. Recurrent episodes of abrupt awakenings from sleep, usually occurring during the first third of the major sleep episode and beginning with a panicky scream.

B. Intense fear and signs of autonomic arousal, such as tachycardia, rapid breathing, and sweating, during each episode.

C. Relative unresponsiveness to efforts of others to comfort the person during the episode.

D. No detailed dream is recalled and there is amnesia for the episode.

E. The episodes cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Differential Diagnosis

Many individuals suffer from isolated episodes of sleep terrors at some time in their lives. The distinction between individual episodes of sleep terrors and Sleep Terror Disorder rests on repeated occurrence, intensity, clinically significant impairment or distress, and the potential for injury to self or others.

Nightmare Disorder

Sleep Terror Disorder must be differentiated from other disorders that produce complete or partial awakenings at night or unusual behavior during sleep. The most important differential diagnoses for Sleep Terror Disorder include Nightmare Disorder, Sleepwalking Disorder, other parasomnias (see Parasomnia Not Otherwise Specified), Breathing-Related Sleep Disorder, and seizures occurring during sleep. In contast to individuals with Sleep Terror Disorder, individuals with Nightmare Disorder typically awaken easily and completely, report vivid storylike dreams accompanying the episodes, and tend to have episodes later in the night. The degree of autonomic arousal and motor activity is not as great as that in Sleep Terror Disorder, and recall is more complete. Sleep terrors usually occur during slow-wave sleep, whereas nightmares occur during REM sleep. Parents of children with Sleep Terror Disorder may misinterpret reports of fearfulness and fragmentary imagery reports as nightmares.

Sleepwalking Disorder

Sleepwalking Disorder may be difficulty to differentiate from cases of Sleep Terror Disorder that involve prominent motor activity. In fact, the two disorders frequently occur together, and family history commonly involves both disorders. The prototypical case of Sleep Terror Disorder involves a predominance of autonomic arousal and fear, with a lesser degree of motor activity that tends to be abrupt and disorganized. The prototypical case of Sleepwalking Disorder involves little autonomic arousal of fear and a greater degree of organized motor activity.

Parasomnia Not Otherwise Specified

Parasomnias Not Otherwise Specified include several presentations that can resemble Sleep Terror Disorder. The most common example is "REM sleep behavior disorder," which also produces subjective fear, violent motor activity, and the potential for injury. Because this occurs during REM sleep, it involves vivid storylike dreams, more immediate and complete awakening, and motor activity that clearly follows dream content. "Nocturnal paroxysmal dystonia" also includes awakenings from sleep with motor activity, but this activity is longer in duration, more rhythmic and stereotyped, and not associated with subjective reports or signs of fear.

Hypnagogic hallucinations and Narcolepsy

Hypnagogic hallucinations, experienced sporadically by many otherwise-asymptomatic individuals, as well as more regularly by those with Narcolepsy, may be associated with anxiety. Their occurrence at sleep onset, vivid images, and subjective sensation of wakefulness differentiate these episodes from sleep terrors.

Breathing-Related Sleep Disorder

Rarely, an individual with a Breathing-Related Sleep Disorder may have episodes of awakenings associated with fear and panic that resemble those in Sleep Terror Disorder. The association with snoring, obesity, and respiratory symptoms such as witnessed apneas, an inability to breathe, or choking episodes distinguishes Breathing-Related Sleep Disorder. A single episode of sleep terror can also occur during the slow-wave sleep rebound that follows the abrupt treatment of obstructive sleep apnea syndrome (e.g., following nasal continuous positive airway pressure [CPAP] therapy).

Seizures and Sleep Disorder Due to a General Medical Condition

Seizures that occur during sleep can produce subjective sensations of fear and stereotyped behaviors, following by confusion and difficulty awakening. Most nocturnal seizures occur at sleep-wake transitions, but they may occur during slow-wave sleep. Incontinence and tonic-clonic movements suggest a seizure disorder, but frontal and temporal love seizures can produce more complex behaviors as well. An EEG often reveals interictal findings in individuals with sleep-related seizures, but EEG monitoring during nocturnal sleep may be needed for definite differential diagnosis. Sleep disruption related to seizures should be diagnosed as Sleep Disorder Due to a General Medical Condition, Parasomnia Type. Sleep Disorders Due to a General Medical Condition other than sleep-related seizures may rarely cause unusual behavioral episodes at night. The new onset of abnormal behavior during sleep in a middle-aged or older adult should prompt consideration of a closed head injury or central nervous system pathology such as tumor or infection.

Substance-Induced Sleep Disorder

Sleep terror episodes also may be exacerbated or induced by medications such as central nervous system depressants. If episodes are judged to be a direct physiological effect of taking a medication or substance, the disorder should be classified as a Substance-Induced Sleep Disorder, Parasomnia Type.

Panic Disorder

Panic Disorder may also cause abrupt awakenings from deep NREM sleep accompanied by fearfulness, but these episodes produce rapid and complete awakenings without the confusion, amnesia, or motor activity typical of Sleep Terror Disorder. Individuals who have Panic Attacks during sleep report that these symptoms are virtually identical to those of Panic Attacks that occur during the day. The presence of Agoraphobia may also help differentiate the two disorders.


See Non-Rapid Eye Movement Sleep Arousal Disorders

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