Tag: parasomnia

Does Your Child Wake Up Screaming? How to understand and treat night terrors

By Dr. Leslie EllisOctober 9, 2021

I used to dread going to bed when we lived in my lovely heritage apartment in Vancouver. Every night, about two hours after falling asleep, I would be startled awake by the most blood-curdling, agonizing screaming from the woman next door. Her window faced ours, and she sounded as though she was being murdered in her sleep almost every night. I wondered why no one would wake her up or help her. I have since learned that this would not have done much good as she was having night terrors.

So many people I’ve spoken with about this have suffered the same thing with their children. Night terrors are fairly common in very young children, affecting 20-40% of children under age 3, and 3-14% of school age children, but just 2% of adults (APA 2013). In a typical episode, parents will put their child quietly to bed only to hear them thrashing and screaming in terror about three hours later. The kids were hard to fully wake up, disoriented and confused, often with little or no memory of the incident in the morning.

Night terrors are often mistaken for nightmares. At a recent talk I gave about nightmares, most of the questions were actually about night terrors – from desperate parents wanting to know if there was something they could do about them. I treat nightmares, not night terrors, but I did some investigation, and there are a few things to know and to do that can help. First and foremost, know that they are generally benign and kids usually grow out of them.

Who Has Night Terrors?

Before I get into some of the ways you can help your child with their night terrors, it helps to understand what they are, who has them and why. A thorough survey of the literature suggests that although the exact cause is not well understood, genetic, developmental, environmental, psychological and organic factors can all play a part.

Night terrors most common in early childhood. A longitudinal study (Petit et al., 2015) of 1,940 children from Quebec found that 34% of children aged 18 months experience night terrors, 13% at age 5, and 5% at age 13. A recent review (Leung et al., 2020) found the peak may be later, at age 5-7 years. Either way, sleep terrors typically start at a very young age and stop at adolescence. It’s rare that the condition continues into adulthood – although for some it can switch to sleepwalking.

Sleep terrors are more common under a number of conditions that can be controlled, at least to some degree, such as: sleep deprivation, going to bed with a full bladder, emotional stress, anxiety (including separation anxiety), bullying, a noisy sleeping environment and excessive alcohol or caffeine. Other factors associated with this parasomnia include: febrile illness (unexplained fever), ADHD, autism, epilepsy, sleep apnea and PTSD. Some medications, especially those that are sedative, can lead to night terrors because they increase the duration of non-REM, the deep sleep stage in which these episodes occur.

It bears repeating the while night terrors are very distressing and can disrupt sleep for both children and their parents, they are not considered dangerous. They warrant clinical attention only if they are severe enough to disrupt daytime functioning. If you are considering consulting a doctor, keep a sleep diary and track BEARS. Not the big furry animal, but the 5-item assessment tool for children with sleep problems (Owens & Dalzell, 2005):

B: bedtime issues
E: excessive daytime sleepiness
A: night awakenings
R: regularity and duration of sleep
S: snoring

What Are Night Terrors?

In a typical episode, the child will sit bolt upright or even jump out of bed, heart racing, screaming in terror. They may speak, but what they say will be confused and incoherent because although they appear to be awake, they are in a hybrid sleep-wake state. They will be difficult to wake fully because these episodes occur during very deep (slow-wave) sleep. It’s best not to wake them up during an episode, and typically they won’t recall a thing in the morning.

Night terrors are distinguished from nightmares because they happen in the first half of the night associated with the deeper (stage 3 and 4) of non-REM sleep, while nightmares mainly occur in the second half, and are associated more with REM sleep and dreaming. Nightmares are clearly recalled in vivid detail, and those who have them tend not to thrash around and scream.

Night terrors are much more common in children. When they continue into adulthood, they look a bit different. While two-thirds of children have no recollection after episodes of night terrors or sleepwalking, the same proportion of adults do recall at least one experience and remember their episodes about half the time (Castelnovo, et al., 2021). For adults, night terrors appear to be more of a dissociative experience, and can be accompanied by hallucinations.

What you can do about night terrors

While none of the suggestions below work all the time, there are a number of things you can try to reduce or even eliminate night terrors. Excellent sleep hygiene (such as regular bedtimes; limiting screen time, no food and drink before bed, especially sugar and caffeine; dark, cool quiet bedroom; and wind-down rituals like story time) can all help reduce night terrors. Parents can also do their best to limit stresses on kids who have night terrors – things like bullying and separation anxiety might be addressed. Interestingly, psychological factors are found to be mostly associated with night terrors in teens and adults, but not children.

Wake-up treatment. One treatment that has met with some success is to wake a person up about half an hour before they would typically have an episode. If you do this for two weeks, it can break the cycle and stop it from recurring. In some cases, however, the episodes simply start occurring later in the night.

Co-sleeping. One interesting paper (Boyden, Pott & Starks, 2018) suggests that sleeping with your child stops night terrors, especially with very young children. The authors say that evolution did not design humans to sleep alone when very young and that “night terrors are the result of an environmental mismatch between evolved behaviour and the modern cultural practice of solitary sleeping.” This solution has not been empirically tested, but anecdotally, it appears to work for many.

The bottom line is that while night terrors can seem extreme, they are usually benign and your child will experience them less and less over time. There are a number of things you can try, such as good sleep hygiene, limiting stress, waking them prior to an episode and co-sleeping. To all those exhausted parents reading this, I hope it has been of some help.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Davey, M. (2009). Kids that go bump in the night. Australian Family Physician, 30, 290- 294.

Ekambaram, V., & Maski, K. (2017). Non- rapid eye movement arousal parasomnias in children. Pediatric Annals, 46, e327-e331. doi:10.3928/19382359-20170814-01

Golbin, A.Z., Guseva, V.E., & Shepovalnikov, A.N. (2013). Unusual behaviors in sleep as “compensatory” reactions aimed at normalizing the sleep–wake cycle. Human Physiology, 39, 635-641. doi:10.1134/ S0362119713060042

Ivanenko, A., & Johnson, K.P. (2016). Sleep disorders. In M.K. Dulcan (Ed.), Dulcan’s textbook of child and adolescent psychiatry (2nd ed.). Arlington, VA: American Psychiatric Publishing.

Laberge, L., Tremblay, R.E., Vitaro, F., & Montplaisir, J. (2000). Development of parasomnias from childhood to early adoles- cence. Pediatrics, 106, 67-74. doi:10.1542/ peds.106.1.67

Leung, A. K. C., Leung, A. A. M., Wong, A. H. C., & Lun Hon, K. (2020). Sleep terrors: an updated review. Current Pediatric Reviews, 16(3), 176-182.

Murphy, P.J., Frei, M.G., & Papolos, D. (2014). Alterations in skin temperature and sleep in the fear of harm phenotype of pediatric bi- polar disorder. Journal of Clinical Medicine, 3, 959-971. doi:10.3390/jcm3030959

Nguyen, B.H., Pérusse, D., Paquet, J., Petit, D., Boivin, M., Tremblay, R.E., & Montplaisir, J. (2008). Sleep terrors in children: A prospective study of twins. Pediatrics, 122, e1164- e1167. doi:10.1542/peds.2008-1303

Petit, D., Pennestri, M.H., Paquet, J., Desautels, A., Zadra, A., Vitaro, F.,…Montplaisir, J. (2015). Childhood sleepwalking and sleep terrors: A longitudinal study of prevalence and familial aggregation. JAMA Pediatrics, 169, 653-658. doi:10.1001/ jamapediatrics.2015.127

Salazar, F., Baird, G., Chandler, S., Tseng, E., O’Sullivan, T., Howlin, P.,…Simonoff, E. (2015). Co-occurring psychiatric disorders in preschool and elementary school-aged chil- dren with autism spectrum disorder. Journal of Autism and Developmental Disorder, 45, 2283- 2294. doi:10.1007/s10803-015-2361-5

Silvestri, R., Gagliano, A., Aricò, I., Calarese, T., Cedro, C., Bruni, O.,…Bramanti, P. (2009). Sleep disorders in children with attention- deficit/hyperactivity disorder (ADHD) re- corded overnight by video-polysomnography. Sleep Medicine, 10, 1132-1138. doi:10.1016/ j.sleep.2009.04.003

Wolke, D., & Lereya, S.T. (2014). Bullying and parasomnias: A longitudinal cohort study. Pediatrics, 134, e1040-e1048. doi:10.1542/ peds.2014-1295

Are you a parent concerned about the frequency and intensity of your child’s bad dreams? Should you be concerned?
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No need to fear the Old Hag: Sleep Paralysis briefly explained

By Dr. Leslie EllisJuly 5, 2020

Locals will warn you never to sleep on your back in Newfoundland, or risk a visit from the Old Hag. She steals in on the night fog just as you are falling asleep. She is an apparition that crawls up from the foot of your bed and sits on your chest so heavily you can’t breathe or move. Sometimes she may try to seduce you, other times, to kill you. These terrifying experiences are so common in Newfoundland, they have become the subject of a tv series aptly called Hag. They are also the subject of research into the relationship between sleep paralysis and folklore.

There is a physiological explanation for sleep paralysis. And there are good reasons these peculiar events feel like visitations by the Old Hag or some other kind of apparition. Sleep paralysis episodes are not limited to Newfoundland and in fact, are fairly common worldwide and throughout human history: roughly 8 percent of us will experience one in our lifetime, and some will have recurrent episodes. Students and psychiatric patients have a much higher prevalence of about 30 percent, likely because it is more common in people who are sleep-deprived and stressed. Sleep paralysis is not a nightmare, but rather a form of sleep disturbance, a parasomnia.

Sleep Paralysis is normal: terrifying but harmless

The most important thing to know is that sleep paralysis is normal. Having an episode doesn’t mean you are losing touch with reality or being visited by the ghost of an old sea witch. These legends, in various guises, have been around since Sumerian times as a way to make sense of those frightening occasions when we wake up paralyzed, unable to move from the neck down. What you may not realize is that we all experience sleep paralysis every night, but for the most part we dream our way right through it.

During the REM sleep cycle most rich in dreaming, our body releases a chemical that makes our voluntary muscles go limp. It’s our body’s way of protecting us from thrashing around as we fight our dream dragons. In fact, it’s more of a problem if the paralysis doesn’t happen – this leads to REM sleep behaviour disorder, the dangerous propensity to physically act out one’s dreams, and it can be a precursor to Parkinson’s disease.

If you suffer from sleep paralysis, it helps to know that this is just your mind waking up from the state of dreaming before your body, when it should be the other way around. Or your body drifting right into REM sleep, and your muscles going lax before your mind has truly shut down for the night. This can happen for various reasons, mostly to do with insufficient or irregular sleep, and most often it is a benign physiological event. Terrifying but harmless.

It also helps to know that sleep paralysis episodes are short, typically lasting about 20 seconds. It may feel like much longer if you are frozen in fear as the Old Hag bears down on your chest. If something like this happens again, try to take some long deep breaths and wait for the images and sensations to subside. Remind yourself that it won’t take long. If you also experience banging noises or flashes of light, this is another parasomnia with the colorful name of exploding head syndrome. This is equally harmless and tends to last just a few seconds, so wait it out and try not to be alarmed!

Not everyone experiences sleep paralysis as an evil old hag. There are many variations of experience, and these fall into three main categories. First is the experience of an intruder, a malevolent felt presence that is sometimes visible and/or audible, but not always. The second type is called incubus, and this is experienced as a supernatural assault, a sense of being smothered, or of a great weight on the chest. These two types are well-known and often combined.

A third kind of sleep paralysis involves unusual bodily experiences (or vestibulo-motor phenomena) such as flying, out-of-body experiences or false awakenings, and some of these can be experienced as blissful. However, the vast majority of reported episodes of all three types of sleep paralysis are terrifying. Understandably, most people who wake up unable to move, and with a sensation of being trapped in their own body, react with fear. The fear itself may exacerbate the sensations of shortness of breath and chest pressure, as these are common features of panic.

What can you do about sleep paralysis

This is an area that has not been studied very well; there have been no formal clinical trials testing treatment. However, since sleep paralysis is correlated with disrupted or insufficient sleep, an obvious step is to observe good sleep hygiene: go to sleep and wake up at consistent times, no caffeine before bed, and avoid sleeping on your back. Sleep paralysis is also associated with hypertension, hypersomnia, sleep apnea and alcohol use. Not surprisingly, it is common in shift workers and others with disrupted sleep schedules.

Therapeutic interventions may be warranted if sleep paralysis is frequent and distressing enough to warrant the diagnosis of recurrent isolated sleep paralysis (RISP). Some anti-depressant medications can help, as can psychotherapy and psychoeducation, especially if it is underlying anxiety or depression that is contributing to the condition. Having a basic understanding of sleep paralysis can help; the knowledge that such episodes are normal and will end soon can make the event itself less scary.

Taking control

During an episode, you might be able to take charge of the dream state as one would in lucid dreaming. It is possible to realize that while you may not be in control of your body at the moment, you do have some control over your subjective experience. Try to remain calm and as curious as you can – this is a chance to observe yourself in the dream state. After an episode, or as a way to lessen the intensity of a future episode, you can try a version of imagery rescripting. This can set you up for a better experience should the Old Hag revisit. The idea is simply to re-imagine the experience, letting it become a different story, possibly with a different character or ending, and this may seed a more benign future encounter.

A caveat: much of the above is based on clinical literature. There are many other ways that people make sense of ‘Old Hag’ experiences that differ from this view. Some are culturally determined, and others are based on the beliefs formed through direct experience. There are those who welcome this altered state of consciousness. My desire in writing this is simply to help and inform, so use what you find valuable and leave the rest.

If you are interested in learning more about nightmares and their treatment, sign up for my short, focused online course. Because I feel this material is important to disseminate, the course is always open, is self-paced, and currently discounted during the virus crisis. Please ask your clients if they have nightmares, and let them know they are treatable. CLICK HERE for a free PDF for clients: What You Can Do About Your Nightmares. Or check out our Short Focused Course on Nightmare Treatment using THIS LINK.

References

Cheyne, J.A. (2005), Sleep paralysis episode frequency and number, types, and structure of associated hallucinations. Journal of Sleep Research, 14: 319-324. doi:10.1111/j.1365-2869.2005.00477.x

Cox A. M. (2015). Sleep paralysis and folklore. JRSM open, 6(7), 2054270415598091. https://doi.org/10.1177/2054270415598091

Sharpless B. A. (2016). A clinician’s guide to recurrent isolated sleep paralysis. Neuropsychiatric disease and treatment, 12, 1761–1767. https://doi.org/10.2147/NDT.S100307

Solomonova, E. (2018). Sleep Paralysis: phenomenology, neurophysiology and treatment. In: Fox, K & Christoff, K. (Eds). The Oxford Handbook of Spontaneous Thought: Mind-Wandering, Creativity, Dreaming, and Clinical Conditions. New York: Oxford University Press.