What are the treatments for night terrors?

Treatments for Night Terrors

Imagery Rehearsal Therapy (IRT) is the most strongly recommended first-line non-pharmacological treatment for night terrors, with Level A evidence showing 60-72% reduction in nightmare frequency with maintained effects at follow-up. 1

Non-Pharmacological Treatments (First-Line)

Imagery Rehearsal Therapy (IRT) - Level A Evidence

• Involves recalling the nightmare, writing it down, changing any part to a more positive one, and rehearsing the rewritten dream scenario for 10-20 minutes daily 2
• Reduces nightmare frequency by 60-72% with maintained effects at 3,6, and 30-month follow-ups 1
• Acts to inhibit the original nightmare by providing a cognitive shift that empirically refutes the original premise 2

Progressive Deep Muscle Relaxation (PDMR) - Level B Evidence

• Involves tensing and releasing muscles, one body part at a time, to induce physical relaxation and reduce anxiety 2
• One Level 1 study showed 80% reduction in nightmare frequency in treated subjects, with complete elimination in over half of participants 2
• Particularly effective when combined with systematic desensitization for reducing nightmare intensity 2

Systematic Desensitization - Level B Evidence

• Uses graduated exposure therapy to help patients cope with and manage stressors gradually 2
• More effective than relaxation therapy alone for reducing nightmare intensity at 25-week follow-up 2
• Combines well with PDMR for comprehensive treatment 2

Anticipatory Awakening

• Effective for frequently occurring sleep terrors 3
• Parents wake the child approximately 30 minutes before the typical time of night terror episodes 3
• Helps prevent the partial arousal from deep sleep that triggers episodes 3

Other Non-Pharmacological Approaches - Level C Evidence

Sleep Hygiene and Environment

• Ensuring adequate sleep and avoiding sleep deprivation is crucial as it can predispose to sleep terrors 3
• Maintain consistent sleep schedule and appropriate sleeping environment 3
• Address any factors that might disrupt normal sleep patterns 3

Hypnosis

• May be considered for PTSD-associated nightmares 2
• Case studies show effectiveness in treating night terrors in children 4
• Techniques include suggestions for gradual sleep onset and regular sleep cycles 4

Exposure, Relaxation and Rescripting Therapy (ERRT)

• Combines psychoeducation, sleep hygiene, and progressive muscle relaxation training 2
• Similar to IRT but with different exposure techniques 2
• Shown to decrease frequency and severity of trauma-related nightmares 2

Sleep Dynamic Therapy

• Integrates sleep medicine instructions with psychotherapeutic interventions 2
• Combines sleep quality assessment, sleep hygiene, stimulus control, and IRT 2
• One pilot study showed significant reduction in Nightmare Severity Index 2

Pharmacological Treatments

For Severe and Frequent Cases

• Clonazepam may be considered on a short-term basis at bedtime if:
  • Sleep terrors are frequent and severe 3
  • Episodes are associated with functional impairment (fatigue, daytime sleepiness, distress) 3
  • Non-pharmacological approaches have been ineffective 3

For PTSD-Associated Nightmares

• Prazosin is recommended as first-line pharmacological treatment with Level A evidence 1
  • Starting dose: 1 mg at bedtime, gradually titrating by 1-2 mg every 3-7 days 1
  • Typical effective dose: ~3 mg (range 1-10+ mg) 1
  • Women typically respond to lower doses than men 1

Treatment Algorithm

1. Initial Approach:

   • Reassurance and parental education 3
   • Implement good sleep hygiene and appropriate sleeping environment 3

2. For Persistent Night Terrors:

   • Implement Imagery Rehearsal Therapy (IRT) as first-line treatment 2, 1
   • Add Progressive Deep Muscle Relaxation (PDMR) for additional benefit 2
   • Consider anticipatory awakening for predictable episodes 3

3. For Severe Cases with Functional Impairment:

   • Consider short-term clonazepam at bedtime 3
   • For PTSD-related night terrors, consider prazosin 1

Important Considerations and Pitfalls

• Avoid interrupting episodes: Attempts to wake or console during a night terror episode should be avoided as this may prolong or worsen the episode 3

• Differential diagnosis: Night terrors differ from nightmares - patients with night terrors typically don't fully awaken, show autonomic hyperactivity (tachycardia, tachypnea, diaphoresis), and have amnesia for the episode 3

• Natural history: Most children outgrow night terrors by late adolescence, with 50% stopping by age 8 years 5

• Precipitating factors: Address any underlying conditions or triggers that may contribute to night terrors 3

• Monitoring: For pharmacological treatments, monitor side effects and efficacy regularly 1

• Common mistake: Using medications not specifically recommended for night terrors or nightmare disorder 1