Night terrors and nightmares
Parents arrive with one of two stories. Either the child sits bolt upright in the middle of the night and screams loud enough for the whole house to hear…
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Parents arrive with one of two stories. Either the child sits bolt upright in the middle of the night and screams loud enough for the whole house to hear, eyes wide open, pushing away every attempt to pick them up and seeming not to recognise a parent at all. Or the child wakes in tears, clings on and gives a detailed account of being chased. These are two different things and they call for two different responses: the first usually fades with age on its own, the second can stay with a person into adult life. What follows is how to tell them apart, what to do at night, what to change during the day, and when something else is hiding behind a night-time episode.
Two different night-time events
Sleep comes in waves. The deepest part of it falls in the first hours after falling asleep, while dreaming belongs to the hours before dawn. That is where the difference comes from.
A night terror erupts out of deep sleep, usually one to three hours after the child has gone to sleep. The person is asleep throughout, however awake they look. In the morning they remember nothing: asking "what did you dream about" gets nowhere, because there was no dream. It is mostly children of roughly three to eight, and there is almost always someone in the family who screamed at night or walked in their sleep as a child.
A nightmare is a real dream that a person genuinely wakes from. It comes closer to morning, the child recognises you, is frightened, asks you to stay, and can retell the story the next day. Nightmares happen at any age, adults included.
One thing often confused with a night terror is sleep paralysis: the person has woken, understands and hears everything, but for a few seconds or minutes cannot move or speak. Frightening, but harmless, and unrelated to night terrors.
What an episode looks like from the outside
A night terror frightens the parents far more than the child, for the simple reason that the child is not living through it consciously.
- A sudden scream with nothing leading up to it: quiet one moment, not the next.
- Eyes open, the gaze seemingly going straight through you. The child sits up, leaps out, thrashes about, tries to run from the room.
- Flushed face, damp skin, racing heart, heavy breathing.
- No reply when spoken to, or a reply that makes no sense; hands pushed away; comforting only makes matters worse.
- It lasts anywhere from seconds to a quarter of an hour and sometimes happens twice in a night. It ends with the child lying down and sleeping on.
A nightmare looks like the opposite: the child is fully awake, reaches out to you, settles with a hug and a familiar voice, and then takes a long time to fall asleep again, because of the fear of seeing the same thing.
What sets episodes off
Night terrors do not come from "nerves" in the everyday sense. What provokes them is anything that stops the brain moving smoothly through deep sleep.
- Lost sleep and a broken routine. By far the commonest reason. Episodes cluster after a missed daytime nap, late bedtimes, a house move, school holidays or a change of time zone.
- Illness and fever. During a feverish cold, night terrors turn up even in children who have never had one.
- A full bladder, a stuffy room, a sudden noise, light. Anything that nudges the brain towards a partial waking.
- Stress and fright. A new nursery, arguments, exams, being apart from a parent, a frightening film or video clip before bed, an adult conversation the child overheard. This weighs more heavily on nightmares than on night terrors.
- Medicines. Vivid, heavy dreams come with some antidepressants, some blood pressure medicines and stop-smoking treatments. Coming off sleeping tablets or alcohol also brings a surge of dreaming.
- Disturbed breathing and movement in sleep: snoring with pauses in breathing, restless legs syndrome. These are not background noise but causes in their own right, and they are treated separately.
What to do while an episode is happening
The main rule during a night terror is not to wake the person. Someone woken out of it has no idea where they are or who is in front of them, becomes more frightened, and then takes far longer to settle.
- Stay nearby, say nothing, and wait. It usually ends by itself within a few minutes.
- Do not talk to them, shake them or hold them down, unless there is real danger.
- Remove the danger instead of wrestling with the child: move them back from the edge of the bed, shut the door to the stairs, stand between them and the window.
- Do not describe the episode to the child in the morning. They remember nothing, and the account will create a fear where there was none.
With a nightmare it is the reverse: go in, hold them, put on a dim light, let them talk it out, stay until they are asleep. The story itself is best unpicked during the day, and you can even invent a different ending for the dream — from school age that works better than insisting "it wasn't real".
If episodes are frequent, make the room safe in advance: clear cables and small objects off the floor, keep the child off the top bunk, and shut windows and the front door with a catch that does not open at the first attempt.
What makes episodes less frequent
In an ordinary case no medicine is needed for night terrors. What works is putting order into sleep, and the result shows within two or three weeks.
- The same bedtime and waking time, weekends included, and enough sleep overall for the child's age: a child short of sleep screams at night more often.
- A calm hour before bed. Dim light, no screens, no boisterous games, and the same short sequence every evening: bath, teeth, a book.
- A sleep diary for a fortnight: when the child went to bed, when the episode happened, what the day held, whether they were unwell. The pattern is usually visible straight away, and for the doctor such a record saves an entire appointment.
- A trip to the toilet before bed and not much to drink late in the evening.
- Scheduled waking. If episodes come at roughly the same time, try waking the child about fifteen minutes beforehand: rouse them lightly, wait for them to mumble something, then let them fall asleep again. This is done for a week or two. It is a simple trick and it often breaks the chain.
- Talking about what is worrying them. Not in bed and not as "tell me what's bothering you", but during ordinary shared activities, when children start talking of their own accord.
When something else lies behind a night-time episode
This is the most important part. Several conditions look similar but need an entirely different approach.
- A night-time epileptic seizure. What should raise concern: short episodes several times a night, almost identical each time — the same movements, the same posture; stiff or cycling movements; episodes not only in the first hours of sleep but also towards morning; a bitten tongue, a wet bed, blood-stained saliva; a memory of the episode surviving. A description alone will not separate this from a parasomnia, so record an episode on a phone and see a neurologist.
- Pauses in breathing during sleep. Loud snoring, mouth breathing, pauses followed by a snort, sweating, restless positions, daytime sleepiness or, on the contrary, over-excitability. In children the usual cause is enlarged adenoids and tonsils, and once these are treated the night terrors often disappear by themselves.
- Restless legs syndrome. The child complains of "creepy-crawlies" or of feeling ticklish inside, cannot lie still in the evening, jerks the legs. Here it is worth checking iron stores: where they are low, symptoms ease once the shortfall has been made up.
- Acting out dreams in an adult. If someone flails, punches, leaps out of bed, injures themselves or their partner, and on waking recalls a dream that matched those movements exactly, this is not a night terror. Such behaviour arises during dreaming sleep and in older people can be an early sign of a disease of the nervous system, so it needs a neurologist rather than being put down to stress.
When to see a doctor
Make an appointment if:
- episodes happen almost every night, or several times in one night;
- during an episode the child has already hurt themselves, fallen, left the room or tried to leave the house;
- night terrors have started for the first time in a teenager or an adult — at that age they are unusual and need explaining;
- a child dreams the same thing repeatedly and is afraid to go to bed;
- an adult has nightmares regularly and they are spoiling both nights and days;
- you notice snoring with pauses, mouth breathing or daytime sleepiness;
- episodes began soon after starting a new medicine.
An ambulance is needed if, during a night-time episode: a convulsion of the whole body starts and does not stop within a few minutes; the person does not come round afterwards; the lips turn blue or breathing stops; there has been a head injury with loss of consciousness or vomiting. In Spain, Italy, Portugal, Poland and Ukraine the ambulance is called on the single number 112.
Nightmares in teenagers and adults
An occasional nightmare after a hard day is ordinary in an adult and needs no treatment. It is worth looking into when they keep returning, wake the person every night, and going to bed starts to feel like something to dread.
The first move is to look for a cause rather than a remedy. The medicine list is reviewed: some antidepressants, some blood pressure treatments and stop-smoking medicines produce vivid, heavy dreams, and the matter is often settled by changing the drug or the time it is taken. Alcohol is looked at separately: it cuts dreaming sleep short and towards morning that sleep returns in excess, which is where nightmares at the end of the night come from. Snoring with pauses in breathing is checked too.
Where nightmares follow something a person has lived through, psychological therapy helps. There is a method in which, during the day and in calm surroundings, the person rewrites the dream in detail with a new, safe ending and rehearses that version in their mind: it was designed precisely for recurring nightmares and works without medicines. In post-traumatic stress disorder a doctor sometimes adds a medicine that damps down the night-time activity of the stress system — that is a specialist's decision. Sleeping tablets settle nothing: they do not remove the dreams, and they do create dependence.
Online consultation
Night-time episodes are exactly the case where the account and the record matter more to a doctor than an examination. In an online appointment you can go through the sleep diary calmly, show the video filmed on a phone at night, and get an answer to the main question: is this something the child will grow out of, or a cause that needs finding. The doctor will also look over the medicine list, weigh up the signs of disturbed breathing in sleep, and say whether a neurologist, an ear, nose and throat doctor or a sleep specialist is needed.
What an online appointment does not replace: examination of the nose and throat, sleep studies, and investigation where seizures are suspected. And with the emergency signs listed above, the place to start is not a consultation but an ambulance.
This material is for information only and does not replace medical advice.
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