A 7-year-old girl is brought to the office by her mother, who is concerned about her behavior. Over the past month, the girl has awakened almost every night, come into her parents' room, and insisted on sleeping the remainder of the night in their bed. The girl wakes up abruptly in a panicky sweat, crying and screaming, "I'm so scared; monsters are chasing me." She breathes rapidly and shakes but is able to calm down after being consoled by her parents and hugging a favorite stuffed animal. She started a new school 2 months ago. Although the girl is shy, she enjoys school and has several good friends. She is eating normally and plays on a soccer team. Examination shows no abnormalities. Which of the following is the most likely diagnosis?

Question

A 7-year-old girl is brought to the office by her mother, who is concerned about her behavior.  Over the past month, the girl has awakened almost every night, come into her parents' room, and insisted on sleeping the remainder of the night in their bed.  The girl wakes up abruptly in a panicky sweat, crying and screaming, "I'm so scared; monsters are chasing me."  She breathes rapidly and shakes but is able to calm down after being consoled by her parents and hugging a favorite stuffed animal.  She started a new school 2 months ago.  Although the girl is shy, she enjoys school and has several good friends.  She is eating normally and plays on a soccer team.  Examination shows no abnormalities.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This girl's recurrent awakenings with associated dream content and ability to be consoled are most consistent with nightmare disorder. Diagnosis requires recurrent episodes of awakening from sleep with recall of highly disturbing and frightening dream content. On awakening, the child is fully alert, remembers the dream, and can usually be consoled. Although frightening, nightmares are typically transient and developmentally normal for most children. Nightmares occur during rapid eye movement (REM) sleep and are more frequent in the second half of the night. Sleep terror disorder, in contrast, is a non-REM arousal disorder characterized by incomplete awakenings, unresponsiveness to comfort, and no recall of dream content (Choice G). Sleep terrors typically occur in the first third of the night and are characterized by marked autonomic arousal and amnesia for the episode in the morning. (Choice A) Nightmares are common in acute stress disorder, but there is no history of trauma exposure or characteristic symptoms of hyperarousal or intrusive symptoms while awake. (Choice B) Although starting a new school can sometimes be stressful, this girl is not displaying any emotional or behavioral problems apart from nightmares (she enjoys school, has friends, eats well), making an adjustment disorder unlikely. (Choice D) Although panic attacks can occur during sleep and produce abrupt awakenings, they are not typically associated with nightmares. (Choice E) REM sleep behavior disorder involves repeated episodes of complex motor behaviors or vocalization during REM sleep. (Choice F) Separation anxiety disorder is characterized by excessive fear or anxiety concerning separation from home or attachment figures. Although this girl turns to her parents for comfort following a nightmare, there is no evidence that she has difficulty separating in general. Educational objective: Nightmare disorder involves recurrent awakenings from REM sleep associated with full alertness and dream recall. It should be differentiated from non-REM sleep terrors, which are characterized by partial arousals, unresponsiveness, and lack of dream content. References: Just a scary dream? A brief review of sleep terrors, nightmares, and rapid eye movement sleep behavior disorder. (http://www.ncbi.nlm.nih.gov/pubmed/24126984) Prevalence and correlates of disturbed dreaming in children. (http://www.ncbi.nlm.nih.gov/pubmed/25108315)

A 7-Year-Old Girl Is Brought to the Office by Her