What's the deal with night terrors?

Tegan Taylor: How'd you sleep last night?

Norman Swan: It wasn't too bad. I'm not a great sleeper.

Tegan Taylor: I know, you've told me that many times. And I also know because you often send me texts at two or three o'clock in the morning. It's like a Lancet paper with no added context, it's just like a link.

Norman Swan: One day I hope that you'll be up at the same time as me and we'll have a little chat and fall asleep chatting to each other.

Tegan Taylor: Chatting about the latest health and medical research.

Norman Swan: Absolutely. That'll put us to sleep in no time at all.

Tegan Taylor: Have you always been a bad sleeper?

Norman Swan: Well, as a child I was a particularly bad sleeper. I had something called night terrors.

Tegan Taylor: Just the name of that sounds terrifying.

Norman Swan: Well, I remember it vividly. Some people would say it wasn't a pure night terror, but we'll come to that later. It was a consistent dream, the dream was always the same. And in fact, I knew as a child when I was going to get it, but I couldn't control it. It was almost like an aura. But I would fall asleep anyway, and sure enough…

Tegan Taylor: Oh, so before you went to sleep you knew that that was going to be one of the nights.

Norman Swan: And I got scared. And I was probably 7, 8, 9. It happened for quite a long period of time. And I would sleepwalk during the dream. So, here's the dream: I'm being chased, and I'm being chased along a tunnel. And I found it very hard to describe the tunnel until those endoscopy pictures emerged, when you were running through…

Tegan Taylor: Someone's colon!

Norman Swan: Exactly, somebody's colon. And in fact, to continue the analogy, it would be like the small bowel, and then it would sort of slowly become the large bowel. But I wasn't running through a bowel because I didn't know what…

Tegan Taylor: Yeah, you were a seven-year-old destined to become a doctor one day.

Norman Swan: But anyway, this kind of spongy tunnel, and there was something behind me and it was chasing me, and it was getting closer and closer. And the tunnel was becoming larger and larger until it was really quite this massive cavern. And up on the edge of the cavern I could see there was a ledge that you could run along, and I thought I got away from this beast, or whatever it was, and it was coming closer, but it was back on the ledge and it was chasing me and chasing me. And then at the edge of this ledge, there was like a ladder leading up to a wooden door, and I was climbing up the ladder and this thing's chasing me up the ladder. And I opened the door and walked onto a street in Paris, where people were having afternoon tea in a pavement cafe. And the dream was over.

Tegan Taylor: Every time? It was the same every time?

Norman Swan: And I would wake up in the dining room of the house. Often there would be people visiting. And apparently I was screaming and yelling, and suddenly I would wake up not really knowing where I was, taking a while to recover.

Tegan Taylor: Oh my gosh.

Norman Swan: And in fact it took until I was an adult to explain where this night terror came from.

Tegan Taylor: Oh, I definitely want to hear the ending of that story. But first, I think we need to do the beginning of What's That Rash?.

Norman Swan: Yep, where you send in your questions to us and we answer them.

Tegan Taylor: I'm health reporter Tegan Taylor, coming to you from Jagera and Turrbal land.

Norman Swan: And I'm physician and journalist Dr Norman Swan, coming to you from Gadigal land.

Tegan Taylor: And wouldn't you know it, Norman, today's question is about night terrors. Liz has sent in asking why do adults experience night terrors, because, as you kind of allude to, kids have them but it's much rarer for adults to have them. So I'm really excited to dig in on this because it's really interesting and slightly terrifying.

Norman Swan: It is. Only about 1% or 2% of adults get…

Tegan Taylor: You say 'only' but that is actually a pretty large proportion.

Norman Swan: I suppose it is. Now, if you look at the research in the area, they call this…so we're talking about adults now rather than children…the children situation is a bit different, we might come back to that…but in adults they call this a parasomnia, and parasomnias are really just about unusual behaviours during sleep.

Tegan Taylor: So other parasomnia things are things like sleepwalking and weird sort of dreams, it's not just one set type of thing, is that right?

Norman Swan: Yeah, they tend to classify it into non-REM sleep (so non rapid eye movement sleep which tends to be non-dreaming sleep), and rapid eye movement sleep (which tends to be dreaming sleep). Sleepwalking is really probably a behaviour associated with night terrors and non-REM sleep, which tends to happen early in the sleep process. And the REM type activities tend to be things like acting out dreams, sleep paralysis, where you wake up and you can't move, because during REM sleep your muscles are a bit paralysed. And you get nightmares as well, frank nightmares during REM sleep. And what I just described to you, what I experienced was kind of a mix, I got a nightmare…but night terrors, you wake up really confused, not knowing where you are, you can be screaming and so on, but you don't necessarily remember a nightmare that caused it, you wake up in terror.

Tegan Taylor: Right, so you're distressed but it's not from a specific dream. The other type of parasomnia that I think we are going to have to come back to and talk about another time is something called exploding head syndrome, which is very intriguing. But today we're going to talk just about night terrors. So why are they common in kids and not in adults? Or I suppose a step back from that is what are they? How do they even happen?

Norman Swan: Short answer for a very short What's That Rash? is nobody knows.

Tegan Taylor: Case closed.

Norman Swan: But we can sort of pad for time. But I think it's better understood with adults than in children, I think children…three things could be going on, and none of them are inevitable. One is probably developmental, it's just literally a stage you go through. Not every child goes through it, and nobody knows why. It used to be thought that it was a form of epilepsy that results in abnormal behaviour, but it's very hard to unpick that. And it doesn't really go along with the fact that it tends to disappear in childhood and become very rare in adulthood. Both adults and children are associated with trauma and mental health issues. So there's obviously an overlap, but usually there's something else going on in adults to produce night terrors. And it's harder to unpick that in children because in children there may not be any mental health issues going on and they've just got night terrors.

Tegan Taylor: You sort of touched on it before, but I'm really interested to know what the difference is between nightmares, something that is terrifying, and a night terror, as in a state of being when you first wake up.

Norman Swan: So why they classify night terrors within non-REM is that people wake up and they can't remember a nightmare and it's not clearly associated with a nightmare, and they're very confused. It's more associated with…it can be associated with stress, with fever. Sleep deprivation, by the way, in both situations can cause both nightmare disorder and night terrors, as well as mental health issues. So you're right, that's where it sits, and that's why they say it's non-REM, whereas REM is much more…you've got a nightmare and if you get a failure of sleep paralysis, that's when you can act out and move in your dream which can be quite a dangerous situation.

And sometimes people with nightmares can sleepwalk, but that's less usual than in people who've got night terrors, and you can get sleepwalking with unusual behaviours. In fact, I know of someone who must have been having a dream looking for a bathroom, but ended up peeing in a closet. So it's a pretty dysfunctional form of sleepwalking. And some people can hurt themselves sleepwalking because they're in another world when they're doing it.

Tegan Taylor: It is pretty weird. You think about nightmares, you sort of wake up, you realise you're fine, or you wake up and you're confused, and then you kind of go, no, I'm okay. But actually, like you say, it is dangerous, there's potential danger in this. And it's also really distressing. So what kinds of treatments are there?

Norman Swan: So let's take night terrors. You look for causes. So are you particularly stressed, have you had a fever when it happens and it's only when you've actually got a fever when it happens, are you sleep deprived and you're going through a period of quite extreme fatigue? In which case, paradoxically, sleep is the treatment, to make sure that you're getting enough sleep.

Tegan Taylor: Are people often worried about falling asleep because they're scared it's going to happen?

Norman Swan: They can be. So the other form of…when I was (before time began) treating children, we actually used to give a sleeping pill to some of these children to get them beyond that. That's not recommended anymore, which is one of the reasons why I don't practice anymore because I'd just be dangerous. But what they do is they say because night terrors tend to happen early in the sleep cycle, if parents start to recognise or adults start to recognise with their partners when it occurs after you fall asleep, whether it happens after 40 minutes, an hour or whatever it is, if you're by yourself, you set an alarm for 40 minutes after you put your head on the pillow to wake you up before you actually enter that period of night terrors. And if you're a parent, you wake the child up. And the people who deploy this kind of treatment say that it can take four or six weeks, but it often extinguishes the night terrors. I don't think there's been a randomised trial to know whether or not the night terrors would have gone away anyway. So that's one.

With nightmare disorder, antidepressants can cause it, so it may be a drug that you're on. It may be unrecognised PTSD, which needs to be treated and treated properly and well. There's also a treatment called image rehearsal, that if you've actually got the same nightmare, it's almost like exposure therapy for post traumatic stress disorder or a phobia where you actually visualise the dream and actually learn to relax after that visualisation so that it's not causing the stress that it otherwise would. And you extinguish the nightmare that way. So those are the kinds of things, as well as safety, so that if there's possibility of danger, you try and make the path for the sleepwalking safe, and if you're in an apartment, the balcony is locked and all sorts of things like that, so people can't get into trouble.

Tegan Taylor: So when you were talking about adults before, because we're specifically answering Liz's question, she's asking about why adults get it, and you mentioned things like depression and anxiety being correlated with people being more likely to have them, so is a treatment for adults getting those disorders under control, does that often help resolve the night terrors too?

Norman Swan: People assume that to be the case. But there haven't been randomised trials which say, yep, definitely this is the way…you know, if you get your anxiety and depression treated, whether it's going to help the night terrors or the nightmare disorder. The assumption is that it will, and the experience of clinical psychologists who deal with this and sleep experts do indeed tend to help doing that sort of treatment.

Tegan Taylor: So you promised before that you would tell me that you've realised something about your childhood night terrors as an adult. What's the resolution?

Norman Swan: So I could never work out where this dream came from, I just thought it was in my imagination, but it was just totally weird that it was the same dream every night. And I can remember it today with a vividness that I could remember it at the age of nine, and I had no idea where it came from.

One day, my kids were watching television and I walked into the room, and they were watching Walt Disney's Alice in Wonderland. It's the last scene from Walt Disney's…with modifications…of Walt Disney's Alice in Wonderland.

Tegan Taylor: What happens in the last scene?

Norman Swan: Well, she's being chased by…it's not the rabbit, she's been chased by something, I can't remember actually what it is in the Walt Disney movie, in the cartoon…

Tegan Taylor: Oh, because there's a door…

Norman Swan: And there's a door. And that's when she goes back to the real world.

Tegan Taylor: Oh, wow.

Norman Swan: And I must have watched that as a little kid, and got terrified by it, and it went into my head.

Tegan Taylor: So we need to write a strongly worded letter to Lewis Carroll and Walt Disney.

Norman Swan: I blame Walt, myself.

Tegan Taylor: I'm glad you got your resolution. What did it feel like when you realised that that was what it was?

Norman Swan: I was amazed. I mean, I sat down on the couch and looked at it…I mean, I didn't get an anxiety attack or anything like that. I thought, bloody hell, that's where it comes from. I was just gobsmacked.

Tegan Taylor: So what do we tell Liz then? Because if she doesn't have a Walt Disney movie she can pin it to, what do we say to her about why adults get night terrors and maybe what to do about them?

Norman Swan: Well, I think what to do about them is if you're getting them and it's disturbing, you probably should see a clinical psychologist and go through some issues to see whether or not you have untreated anxiety and depression, whether…you don't want to force a diagnosis when one isn't there, but if you've got it…and are you under stress at the moment? Do you only get it when you've got fever? Are you particularly sleep deprived? So, just going through a routine set of causes, but you're probably better doing it with somebody who's an expert in the area, and it'll be a clinical psychologist, particularly one that deals with asleep and parasomnias. And that's something to talk to your GP about, if they know of a psychologist like that. They can just simply walk through it, take a proper history, and work out where the vulnerability points might be.

Tegan Taylor: Yes, definitely talk to a GP or clinical psychologist, don't get your health advice from a pair of podcasters. But perhaps you would like to share this episode with a friend, maybe a friend who pops up in your nightmares every now and again.

Norman Swan: Yep, just share it with your manager probably.

Tegan Taylor: But how can people get in contact with us, Norman?

Norman Swan: They can do that by emailing us at thatrash@abc.net.au.

Tegan Taylor: Or of course, if you're on Instagram, we're @ABChealth. You can send us a DM. We love to get your questions.

Norman Swan: And they are fantastic questions and, like this one, they open up a huge area for discussion which you never imagined existed.

Tegan Taylor: It's like running joyfully down a long dark tunnel together.

Norman Swan: Exactly. But the great thing about What's That Rash? is there's a door at the top with a good cup of coffee at the end of it.

Tegan Taylor: We'll catch you next time.

Norman Swan: See you then.