DDx
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
-
Separation anxiety
-
Sleep breathing disorders
-
Sleep paralysis
It is especially important to distinguish sleep terrors from nightmares. The table below compares features of both.
Table 2. Comparison of sleep terrors and nightmares. (Open Table in a new window)
| Feature | Sleep Terror | Nightmare |
|---|---|---|
| Categorization | Disorder of arousal | REM parasomnia |
| Timing | Usually occurs during the first half of the night and typically out of stage N3 slow-wave sleep | Begins out of REM sleep and typically occurs in the last third of the night |
| Family history | Frequently positive | May be positive |
| Behavior semiology | Sudden arousal with intense screaming, inconsolable crying, agitation, heightened autonomic discharge | Paroxysmal awakenings with anxiety dream recall |
| Event duration | Few seconds to minutes | Few seconds to minutes |
| Age at onset | Typically < 10 years old | Typically < 10 years old |
| Triggers | Sleep deprivation, febrile illness, anxiety, stress, sleep apnea, motor disorders of sleep | Sleep deprivation, febrile illness |
| Frequency | Few times per month/week; very rarely >1 episode in a single night | Few times per month/week; very rarely >1 episode in a single night |
| Post-spell | Limited to no recall of the events with confusion | Recall is typical at times with vivid detail |
| PSG changes | Abrupt arousal from slow-wave sleep (stage N3) with expression of confusion/ambulation/intense fright in all three arousal types, followed by return to sleep; increased cyclic alternating pattern | Dense eye(phasic) movements during REM sleep |
Differential Diagnoses
-
Panic Attacks
-
Sleep Walking
-
Sleep-related Epilepsy
Media Gallery
of
0
Tables
Table 1. Diagnostic criteria for sleep terrors
| Features | DSM-5 | ICSD-3 |
|---|---|---|
| Frequency | Recurrent episodes | Recurrent episodes |
| Awakening | Abrupt arousal from sleep | Incomplete awakening from sleep |
| Responsiveness | Relative unresponsiveness | Inappropriate or absent responsiveness |
| Recall | Little or no recall of dream imagery | Little or no associated cognition or dream imagery |
| Amnesia | Amnesia of the episode | Partial or complete amnesia of the episode |
| Functional Impact | Significant distress or impairment in social, occupational, or other areas of functioning | |
| Differential | Symptoms cannot be explained by another mental disorder, medical condition, or the effects of drugs of abuse or medication | Symptoms cannot be explained by another mental disorder, medical condition, or the effects of drugs of abuse or medication |
| Initial Expression of Fear | Panicked scream | Alarming vocalization, such as a frightened scream |
| Autonomic Symptoms | Autonomic arousal | Mydriasis, tachycardia, tachypnea, diaphoresis during an episode |
Table 2. Comparison of sleep terrors and nightmares.
| Feature | Sleep Terror | Nightmare |
|---|---|---|
| Categorization | Disorder of arousal | REM parasomnia |
| Timing | Usually occurs during the first half of the night and typically out of stage N3 slow-wave sleep | Begins out of REM sleep and typically occurs in the last third of the night |
| Family history | Frequently positive | May be positive |
| Behavior semiology | Sudden arousal with intense screaming, inconsolable crying, agitation, heightened autonomic discharge | Paroxysmal awakenings with anxiety dream recall |
| Event duration | Few seconds to minutes | Few seconds to minutes |
| Age at onset | Typically < 10 years old | Typically < 10 years old |
| Triggers | Sleep deprivation, febrile illness, anxiety, stress, sleep apnea, motor disorders of sleep | Sleep deprivation, febrile illness |
| Frequency | Few times per month/week; very rarely >1 episode in a single night | Few times per month/week; very rarely >1 episode in a single night |
| Post-spell | Limited to no recall of the events with confusion | Recall is typical at times with vivid detail |
| PSG changes | Abrupt arousal from slow-wave sleep (stage N3) with expression of confusion/ambulation/intense fright in all three arousal types, followed by return to sleep; increased cyclic alternating pattern | Dense eye(phasic) movements during REM sleep |
