A SLEEP DISORDER: SLEEP TERROR
Sleep is generally an action that maintains order in human life, isolating the individual from the external environment and allowing for both physical and mental rest. This action, which is especially necessary to enhance the quality of life, is also a crucial requirement for children's brain development. For sleep to occur, several brain regions need to be activated, and chemical hormones like melatonin must be secreted. In fact, sleeping is a burden for the brain. The sleep process consists of two stages: REM (Rapid Eye Movement, characterized by intense dreaming) and NREM (Non-Rapid Eye Movement, where eye movements are absent). NREM itself also occurs in four stages. During sleep, melatonin levels increase (which is also a growth and body balance hormone), while cortisol, known as the stress hormone, decreases. This drop in cortisol helps the person prepare better for the next day. However, this order does not always proceed as it should. Sometimes, your sleep is interrupted by a nightmare, or you may find it difficult to fall asleep. But what if your sleep frequently involves waking up with screams, fear, and self-harming behaviors? Is this just a nightmare?
Sleep is generally an action that maintains order in human life, isolating the individual from the external environment and allowing for both physical and mental rest. This action, which is especially necessary to enhance the quality of life, is also a crucial requirement for children's brain development. For sleep to occur, several brain regions need to be activated, and chemical hormones like melatonin must be secreted. In fact, sleeping is a burden for the brain. The sleep process consists of two stages: REM (Rapid Eye Movement, characterized by intense dreaming) and NREM (Non-Rapid Eye Movement, where eye movements are absent). NREM itself also occurs in four stages. During sleep, melatonin levels increase (which is also a growth and body balance hormone), while cortisol, known as the stress hormone, decreases. This drop in cortisol helps the person prepare better for the next day. However, this order does not always proceed as it should. Sometimes, your sleep is interrupted by a nightmare, or you may find it difficult to fall asleep. But what if your sleep frequently involves waking up with screams, fear, and self-harming behaviors? Is this just a nightmare?
Sleep terror, also known as "night terror" in DSM-5 and "sleep terror disorder" in DSM-IV, is a sleep disorder where a person suddenly wakes up screaming, shouting, engaging in behaviors that may harm themselves or others (like running, jumping out of bed, trying to hit someone nearby), waking up crying, experiencing burning sensations in the face and hands, and increased autonomic responses like heart palpitations and fear. Sleep terror falls under the category of parasomnias, a subgroup of sleep disorders characterized by unwanted behaviors, physical, and neural arousals occurring during the transition from REM to NREM or during the NREM phase of sleep. Emotional, physical, and neural arousals are intensely experienced during sleep terror and can occur in the early stages of sleep or during the transition from REM to NREM. Although someone witnessing the person experiencing sleep terror may think they are awake and fully conscious, the person is not fully awake. They are usually only awakened by someone else forcibly bringing them out of this state. For these reasons, people who experience sleep terror often do not remember the events of the night, or the events may seem distorted and confusing to them. Therefore, those who suffer from sleep terror may experience physical and emotional strain.
Sleep terror typically emerges during childhood and usually ends during adolescence. The prevalence of sleep terror in children aged 4-12 is around 3%, while in adults, this rate drops to 1%. The onset of sleep terror for the first time in adulthood is rare. However, when cases of adult sleep terror are examined in the literature, it is clear that the intensity, prevalence, and development of treatment strategies are of critical importance.
What Causes Sleep Terror?
There is no clear cause of sleep terror. However, research has shown that genetic factors play a role. Individuals with primary relatives who have parasomnias are more likely to experience sleep terror compared to those without a family history of such disorders. Additionally, it is believed that in children, the fact that the central nervous system is not yet fully developed and is still in the process of developing may trigger this disorder. Moreover, if a person has diagnosed mental disorders (such as schizophrenia, bipolar disorder), these can also contribute to the occurrence of sleep terror. As with all psychological disorders, it is important to approach sleep terror from a biopsychosocial perspective.
What is the Differential Diagnosis of Sleep Terror
Sleep terror can often be confused with nightmare disorder, another subtype of parasomnia, due to its characteristic features. Therefore, in cases of sleep disorders like sleep terror, anamnesis should be taken very carefully, details should be noted, and the family history should be examined. In nightmare disorder, the individual is in REM sleep, and there are no issues with consciousness upon awakening. Additionally, the individual can usually recall the content of their nightmares afterward. This is not usually the case with sleep terror, where motor activities are also observed.
It should be noted that a disorder called REM Sleep Behavior Disorder, which is not listed in DSM but is included in ICD-3, can also be confused with sleep terror. However, REM Sleep Behavior Disorder typically occurs in adults and is characterized by disproportionate violent behavior, making it more of a motor sleep disorder. Additionally, there is a possibility of comorbidity in individuals who experienced sleep terror during childhood.
How is Sleep Terror Treated?
There is no definitive treatment for this disorder. Initially, ensuring a safe sleep environment is crucial. The person's room should be free of objects that could cause self-harm, and during a sleep terror episode, they should not be forcibly awakened. The person should be calmed and allowed to regain full consciousness. It is important not to approach someone who is already experiencing intense, involuntary fear with loud noises or fear. Psychological education on sleep-wake cycles can be beneficial, and the individual may seek help from a professional to establish a proper sleep routine. If the frequency of sleep terror episodes is low, the methods mentioned above are commonly applied. However, in cases where sleep terror is frequent and severe, psychopharmacotherapy may be considered. In such cases, antidepressants and selective serotonin reuptake inhibitors (SSRIs) may be prescribed. Although anxiolytic medications, such as benzodiazepines, might seem suitable initially due to the anxiety-inducing nature of the condition, these drugs carry a high risk of dependence because of their pleasant effects on the brain. Consequently, it has been observed that people who stop taking benzodiazepines may experience more severe sleep terror attacks.
References
Algın, D., Akdağ, G., & Erdinç, O. (2016). Quality sleep and sleep disorders. Osmangazi Tıp Dergisi, 38(1), 29-34. https://doi.org/10.20515/otd.40263
Keskin, N., & Tamam, L. (2018). Sleep disorders: Classification and treatment. Arşiv Kaynak Tarama Dergisi, 27(2), 241-260. https://doi.org/10.17827/aktd.346010
Küçük, F., & Eryılmaz, S. E. (2023). Sleep Problems and Evidence-Based Practices. In Sağlık & Bilim 2023: Çocuk Hemşireliğinde Kanıta Dayalı Uygulamalar (pp. 67-81). Efe Akademi. https://books.google.com.tr/books?id=YAW4EAAAQBAJ&lpg=PA67&ots=RsXJj_-J5F&dq=uyku%20ter%C3%B6r%C3%BC&lr&hl=tr&pg=PA70#v=onepage&q=uyku%20ter%C3%B6r%C3%BC&f=false
Tütüncü, M., Şenel, G. B., Zeydan, B., Karadeniz, D., & Apaydın, H. (2018). Relationship Between Sleep-related Violence and NREM Parasomnia: A Case Report. Journal of Turkish Sleep Medicine, 5(2), 46. https://www.researchgate.net/publication/328287590_Relationship_Between_Sleep-related_Violence_and_NREM_Parasomnia_A_Case_Report
Sodan Turan, H., Gündüz, N., Polat Işık, A. Ö., & Tural, Ü. (2015). Sleep Terror and Treatment Approach in Two Cases. Nöropsikiyatri Arşivi, 52(2), 204-206. https://www.researchgate.net/publication/280324401_IKI_OLGU_OZELINDE_UYKU_TERORU_ve_TEDAVI_YAKLASIMI
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