Causes of Night Terrors and Nightmares with Panic Awakening
Night terrors and nightmares are distinct sleep disorders with different causes: night terrors arise from deep non-REM sleep due to developmental, genetic, environmental, or organic factors (most common in children), while nightmares occur during REM sleep and are often triggered by trauma, psychiatric conditions, or serotonergic medications.
Understanding the Two Different Conditions
Night Terrors (Sleep Terrors)
Night terrors are arousal disorders from deep NREM sleep (stage 3-4) that occur within the first three hours of sleep, causing the person to sit upright, scream in terror with a frightened expression, and exhibit autonomic hyperactivity including tachycardia, sweating, and dilated pupils 1. The key distinguishing feature is retrograde amnesia—the person has no memory of the episode the next morning 1.
Causes of night terrors include:
- Developmental factors (peak age 5-7 years, affecting 1-6.5% of children) 1
- Sleep deprivation, which predisposes to episodes 1
- Genetic predisposition 1
- Environmental stressors 1
- In adults, night terrors are strongly linked to psychopathology, with all adult patients in one study showing psychiatric symptoms, most commonly affective and substance use disorders 2
Nightmares with Panic Awakening
Nightmares occur during REM sleep (typically in the latter half of the night) and involve full alertness on awakening with clear, vivid dream recall 3. The person remembers the frightening content, unlike night terrors 3.
Causes of nightmares include:
- Trauma and PTSD: The American Academy of Sleep Medicine notes that nightmares occur in 80% of PTSD patients and can occur during both sleep onset and NREM sleep in trauma patients 4
- Serotonergic medications: The American Academy of Sleep Medicine confirms that drugs affecting serotonin neurotransmitters produce nightmares, typically in the latter half of sleep during REM periods 3
- Psychiatric disorders: The onset of nightmares in adults is often associated with underlying psychiatric conditions 5
- Stress responses: Sporadic nightmares may be normal responses to acute stress 5
- Medical illness: New-onset nightmares in adults can be associated with medical conditions 5
Nocturnal Panic Attacks (A Third Consideration)
If the person is waking fully alert with clear memory and experiencing panic symptoms, this may represent nocturnal panic attacks rather than night terrors, which occur in 44-71% of patients with panic disorder 6. These are non-REM events distinct from sleep terrors, occurring with full awakening and clear recall 6.
Critical Diagnostic Distinctions
To determine the cause, assess these key features:
- Memory of the event: No memory = night terror; clear recall = nightmare or nocturnal panic 1, 3
- Timing in sleep cycle: First third of night = night terror; latter half = nightmare 1, 3
- Age of onset: Childhood onset suggests benign night terrors; adult onset suggests psychiatric illness, medications, or medical conditions 1, 5
- Trauma history: Recent or past trauma points to PTSD-related nightmares requiring trauma-focused treatment 4
- Medication review: Determine which serotonergic medication was started or increased most recently before nightmare onset 3
Common Pitfalls to Avoid
- Do not assume night terrors in adults are benign—they are strongly associated with psychopathology and require psychiatric evaluation 2
- Do not reflexively prescribe antipsychotics for PTSD-related nightmares, as these patients maintain insight and benefit more from trauma-focused therapies 4
- The American Academy of Sleep Medicine advises against assuming successful PTSD treatment will automatically resolve nightmares, as 60% continue having nightmares at least weekly after treatment 7