Despite going to sleep by 10 p.m., Debbie Quinn-Nance has a bustling night life.
Sometimes she sits up in bed and screams like an actress in a bad horror flick. She may even race around the house, fleeing an imagined threat. Last fall, her violent thrashing in the sheets landed her on the floor with a broken tailbone.
These episodes aren't a sign of missing mental marbles: Quinn-Nance has night terrors, episodes of visceral fear in her sleep. About 6 percent of kids and 1 percent of adults suffer from this parasomnia — the word for bizarre sleep behavior — which occurs when there's a glitch between sleep cycles, and the sleeper is stuck in a confusing and frightening state between deep sleep and wakefulness. The disorder has long been a sideshow in sleep science, but new research is shedding light on what makes some people go bump in the night and may help curb the disturbing spells.
Quinn-Nance, a 50-year-old nurse coordinator at Swedish Medical Center's pain clinic, has always chalked these episodes up to a family quirk: "I've had them since I can remember, and my two brothers and dad did it, too — we'd even bump into each other in the hall — so it didn't seem abnormal to me."
But a couple of weeks after she broke her tailbone, Quinn-Nance tripped when hotfooting it from bed and busted her chin and bruised her hip. Seeing a dangerous pattern, she sought the help of Dr. Sarah Stolz, associate medical director of the Swedish Sleep Medicine Institute.
Stolz, who has seen at least 100 night-terror cases, ordered a sleep-lab test to get to the root of Quinn-Nance's nocturnal activities.
More than a bad dream
Night terrors, she explains, are often confused with nightmares, but they are a completely different phenomenon. Night terrors usually occur in the first third of the night. They take place in the deep dreamless cycle before one kicks into REM sleep, the sleep stage characterized by rapid eye movements and vivid dreams as well as nightmares.
A snag can occur when some people are coming up out of very deep non-REM sleep. Instead of moving into REM, they are trapped in a state called confusional arousal. The best-known example of this is sleepwalking. People can get out of bed, navigate a room, even unlock windows and climb out. Their eyes are wide open but seem to see through you.
Sometimes the confusional arousal turns terrifying. No one knows why, but some doctors think it may be underlying anxiety. During a night terror, someone appears to suddenly awaken with a gasp. The person may cower and whimper in fear or scream at the top of his lungs and flee the bed, the room, the house. After a few minutes or as long as a half-hour later, the person will settle down, fall back into normal sleep and remember nothing. Such episodes can occur as often as several times a week — particularly in children — or as sporadically as a few times a year.
Whereas nightmares are like a David Lynch movie, with complicated, confounding plots, night terrors are like B-horror movies: No plot, just a lot of screaming.
"My heart will be pounding, I'll be sweating, I'll be scared but I don't really know of what," Quinn-Nance says.
While nightmares are very personal — starring people and situations from one's real life — Stolz suggests night terrors may offer a glimpse into universal human fears. Primordial concerns like snakes, spiders and wolves may have little to do with our current anxieties, but hallucinations of creepy crawly things play a prominent role in night terrors.
"Night terrors have a caveman mentality," Stolz says. "It's not an elaborate plot, but just a vague sense that you are being chased."
Alcoholics and people who have suffered psychological trauma may be more prone to night terrors, according to Dr. Oneil Bains, a sleep specialist at Virginia Mason Sleep Disorders Center, but the most common triggers appear to be more mundane. Anything that deepens sleep can trigger confusional arousals and night terrors.
Sleep deprivation, fever and heavy exercise can zonk certain people out so deeply they have trouble shifting between sleep cycles. Because children sleep very deeply, they are more likely to have night terrors than adults. It's so common in preschoolers it's almost considered a developmental stage; though most kids grow out of it around puberty.
On the flip side, night terrors can also be caused by anything that fragments sleep — a snoring bed partner, a few drinks, a noisy room.
New findings suggest that sleep apnea — already known to be one of the biggest causes of fragmented sleep — may be a major underlying factor in night terrors. About 10 million Americans suffer from this condition, in which breathing is obstructed during sleep, prompting the sleeper to awaken briefly throughout the night.
In a recent study published in the journal Pediatrics, researchers at Stanford University studied 84 children between ages 2 and 11 with severe night terrors and found a surprisingly large number — 49 — had sleep-disordered breathing.
Children rarely have true sleep apnea, but they may have obstructed nighttime breathing that can sometimes be treated with a tonsillectomy. Surgeons removed the tonsils of 43 of the children in the study, and three months later, another sleep-lab test showed their breathing was normal, and none showed signs of confusional arousals or night terrors.
"Sleep apnea causes brief awakenings and anything that causes arousals during deep sleep can predispose you to having a night terror, so it makes a lot of sense," Bains says.
More studies are needed to draw a conclusive link, he adds, but for now, the finding offers doctors a trigger to look for in the sleep lab and a possible treatment avenue.
In adults, sleep apnea can be treated with weight loss, oral mouth devices, some surgical procedures or, most commonly, a C-PAP, a continuous positive airway pressure machine that blows air into the nose through a mask.
Sleep apnea has been increasing in recent years along with obesity, a main risk factor for the breathing problem. This could in turn fuel an upsurge in scary nights for Americans. Experts already say the true frequency of night terrors is likely much higher than its estimated rate of between 1 percent and 6 percent because few people ever report the problem to their doctors.
Bains urges people who may suffer from recurring night terrors to see a physician, partially to pinpoint sleep apnea — a serious condition in its own right — and also to rule out other disorders.
"We want to make sure they aren't really having a seizure," he says. "With certain types of seizures you can have confusional behaviors at night." He also wants to rule out another rare, serious sleep condition known as REM behavior disorder, in which people act out their dreams and can hurt themselves or others.
Families suffer, too
What people say and do during confusional arousals can give bystanders a waking version of a night terror.
The first few times Tom Nance shared a bed with his wife, Debbie Quinn-Nance, he was nearly startled out of his skin when she howled and bolted from bed.
Stolz recalls a patient of hers who once sat up in the middle of the first night she spent with a fellow and said, "I've murdered 20 men in my sleep." The poor guy didn't sleep the rest of the night.
Besides petrified partners, the primary concern is safety. "When people start hurting themselves or getting in dangerous situations, you ought to start doing something about it," Stolz says.
That's why Damon Gibson's parents recently took him to see Stolz.
The 18-year-old senior at Bothell High School has been having night terrors since childhood, often yelling "No! No! No!" and running out of his room.
He twisted his ankle on the stairs and bumped and bruised himself a few times, but nothing really scared his parents until a couple of months ago when he fled the house.
"I heard him bumping around, so I got up to look for him, then saw the front door was open," his mother, Tina Gibson, recalls. She found him — with bruised legs and a scraped elbow — just about 10 feet out the door. "When we realized he could go outside, that really scared us. What if we didn't hear him?"
Damon Gibson is about to graduate from high school and plans to move out on his own this summer. It's a step that worries most parents, but his mother is extra concerned because of his nocturnal roaming.
He doesn't show signs of sleep apnea, so he has a choice of medication or trying to identify and manage his own night-terror triggers.
Benzodiazepines, sleeping pills such as Klonopin often used to treat anxiety disorders, can help halt night terrors, but many doctors and patients are hesitant to use them when night terrors are sporadic because the medication is potentially addictive.
The Gibsons don't want drug treatment, so Stolz has instructed them to keep a detailed sleep log to try to identify triggers for Damon's night terrors. Do they occur when he is overtired, eats late or sleeps at odd hours, for instance? Improved sleep hygiene — going to bed at the same time every night and not allowing himself to get over-tired — may help reduce their frequency, she says.
A night in a sleep lab
It's rare to catch a night terror in the sleep-lab setting — the surest cure for sleep disorder is a night in the clinic, Stolz jokes — but she did see some interesting things when Quinn-Nance slept in the lab for two nights last month. Shortly after midnight the first night, she sat up, eyes wide open, and said, "Huh? Yes. Actually, all of those," as she pointed around the empty room. Then her eyes seemed to register confusion and she lay back in bed.
Watching the grainy video later, Quinn-Nance said, "It's pretty unsettling to see yourself sleeping and then startle awake and sit up and talk and not remember anything about it; it would have been really creepy to see myself in a night terror."
The confusional arousal was a strong clue to Stolz that Quinn-Nance does, indeed, suffer from night terrors. The polysomnograph — a recording of brain activity, muscle movement and breathing during sleep — also uncovered something Stolz hadn't suspected, because this patient isn't overweight and doesn't snore: sleep apnea. Quinn-Nance stops breathing and wakes up 10 to 13 times per hour.
Now Quinn-Nance will try sleeping with the C-PAP machine in hopes it will help curb her nightly activities and prevent future bumps, bruises and broken bones.
"I'm willing to try anything," she says. "After all this time, I really could use some rest."
Julia Sommerfeld: 206-464-2708 or firstname.lastname@example.org