Medication Summary
Medications rarely are indicated for sleep terrors and usually provide no long-term help to patients. They should be prescribed only for severe symptoms that affect waking behavior (eg, school performance and peer or family relations) and only after behavioral interventions have failed. Pharmacologic therapy should be administered only as a temporary measure.
Tricyclic Antidepressants
Class Summary
Tricyclic antidepressants decrease deep delta sleep and arousal between sleep stages.
Imipramine (Tofranil, Tofranil-PM)
Imipramine hydrochloride inhibits reuptake of norepinephrine or serotonin at the presynaptic neuron. This agent is an antagonist at histamine H1 and alpha1 adrenoceptors, as well as at M2 muscarinic acetylcholine receptors. In limited studies, imipramine has stopped the disorder when administered at bedtime for 8 weeks.
Amitriptyline
Amitriptyline is a tricyclic antidepressant (TCA) with sedative effects. It inhibits reuptake of serotonin and/or norepinephrine at the presynaptic neuronal membrane, which increases concentration in the central nervous system (CNS). Amitriptyline has been effective in the treatment of REM sleep disorder behaviors.
Benzodiazepines
Class Summary
Some studies suggest that long-term management with low dose clonazepam is effective for adults with severe sleep terrors involving violence or self-injurious behaviors. [28, 6]
Clonazepam (Klonopin)
Long-acting benzodiazepine that increases the presynaptic GABA inhibition and reduces the monosynaptic and polysynaptic reflexes. It has been used off-label for REM and nonREM sleep behavior disorders.
Antidepressants, selective serotonin reuptake inhibitors (SSRIs)
Class Summary
SSRIs are antidepressant agents that inhibit the central nervous system (CNS) neuronal uptake of serotonin and may also have a weak effect on norepinephrine and dopamine neuronal reuptake. SSRIs are used effectively to treat panic attacks. The overlap in symptoms between nocturnal panic attacks and night terrors could suggest a role for SSRIs in the treatment of night terrors.
Paroxetine (Pexeva, Paxil, Paxil CR)
Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake, but it has a weak effect on norepinephrine and dopamine neuronal reuptake. This agent is a low-affinity antagonist at some subtypes of muscarinic acetylcholine receptors and is a nitric oxide synthase inhibitor. The anticholinergic effects of paroxetine may result in sedation or cardiovascular effects. Patients suffering from night terrors have been shown to respond to paroxetine therapy.
Tables
| 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 |
| 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 |
