Treatment of Night Terrors in Adults
For adult night terrors, prioritize safety measures and sleep hygiene optimization first, followed by benzodiazepines (clonazepam) for severe cases, recognizing that night terrors are fundamentally different from nightmares and require distinct management. 1
Critical Distinction: Night Terrors vs. Nightmares
Night terrors are NREM sleep parasomnias occurring during slow-wave sleep in the first third of the night, characterized by confusion, screaming, autonomic hyperactivity, and complete amnesia for the event. 1, 2 This is fundamentally different from nightmares, which occur during REM sleep and are recalled upon awakening. 1 The provided nightmare treatment guidelines (imagery rehearsal therapy, systematic desensitization) are not appropriate for night terrors. 3
First-Line Approach: Non-Pharmacological Management
Safety Measures (Essential)
- Remove dangerous objects from the bedroom environment 4
- Consider door alarms if wandering occurs during episodes 4
- Ensure the sleeping area is secure to prevent injury during confused arousal states 5
Sleep Hygiene Optimization
- Establish a consistent sleep-wake schedule with adequate total sleep duration 4
- Avoid sleep-fragmenting substances including caffeine and excessive screen time before bed 4
- Address any underlying sleep disorders that may trigger arousals from slow-wave sleep, particularly sleep apnea 4, 2
Stress Reduction
- Implement stress management strategies, as night terrors in adults are often related to stressful life events 5
- Consider counseling to address underlying psychopathology, as adult night terrors are frequently associated with psychiatric symptoms including affective and substance use disorders 5, 2
Pharmacological Treatment for Severe Cases
Benzodiazepines (Short-Term Use Only)
- Clonazepam at bedtime is the medication of choice for severe, persistent night terrors 4, 5
- Limit use to 3-6 weeks to avoid dependence risk 4
- Benzodiazepines suppress slow-wave sleep, reducing the substrate for night terror episodes 5
Alternative Pharmacological Options
- Serotonin reuptake inhibitors may be considered, particularly if comorbid depression or anxiety is present 5
- Avoid prazosin and clonidine, as these are indicated for nightmares (not night terrors) and can cause problematic blood pressure effects 1
Specialized Interventions
Hypnotherapy
- Hypnosis may be considered for refractory cases, with case reports showing sustained improvement in night terrors 6
- Technique involves suggestions for gradual sleep onset and regular cycling through sleep stages without dropping too quickly into deep slow-wave sleep 6
Important Clinical Pitfalls
Common mistake: Treating night terrors with nightmare-focused therapies like imagery rehearsal therapy, which target REM sleep phenomena rather than NREM arousal disorders. 1
Psychiatric comorbidity: All adult patients with night terrors in clinical studies reported psychiatric symptoms, most commonly affective and substance use disorders. 2 Screen for and address these conditions concurrently.
Polysomnographic confirmation: If diagnosis is uncertain or episodes persist despite treatment, consider sleep study to document arousals from slow-wave sleep and rule out other parasomnias or nocturnal seizures. 2