Pavor Nocturnus

PAVOR NOCTURNUS, night fright, a relatively common condition in children aged 2-8 years, is a distinctive sleep disorder. A child who has fallen asleep peacefully in the evening suddenly jumps up after several hours, with more or less an expression of fear on his face, screams, cries, often defends himself or fights off someone, hides; usually at this time he is in a semi-sleep state; as if seeking protection from those around him from the frightening experience in his dream, however he recognizes no one, does not hear what is said to him, does not calm down, even if a light is turned on. Based on the fragmentary words he utters at this time, one can guess that he is frightened by some terrible dream. After some time - from several minutes to half an hour - he gradually calms down and falls asleep, and in the morning usually remembers nothing of what happened at night. Such attacks may occur more or less frequently. With age they usually pass; although older children still sometimes have 'frightening dreams', they react to them differently. In more severe and significantly rarer cases, the experience of fear is accompanied by significant involvement of the motor sphere: the child not only jumps out of bed but walks, runs away, hides. In these cases, R. p. is combined with somnambulism. The child walks in a semi-sleep state; his eyes are open, he avoids obstacles, properly uses his limbs, but does not hear, does not react to words and shouts. The 'nightmares' occurring in adults, which are also accompanied by the experience of fear during sleep, apparently cannot be considered on the same plane as R. p., although this question is not entirely clear to this day. As for the pathogenesis of R. p., it is difficult to say at present time. Apparently it can be different. In a certain number of cases, a change in intracranial pressure may play a role. A number of authors, in terms of pathogenesis, equate R. p. with epilepsy, considering R. p. as an equivalent of a seizure. In any case, pathogenetically R. p. can be considered one of the diagnostic stigmas of psychopathy. Finally, P. nocturnus is interpreted in this direction as a particular manifestation of hysterical reactions with their characteristic 'thirst for evaluation', corresponding to a certain age. In this latter direction, the psychoanalytic school (Freud, Ferenczi, Abraham and others) has gone particularly far, considering R. p. from the point of view of 'depth psychology'. With such consideration, any sociogenic origin of R. p. is eliminated, and the latter becomes the exclusive property of the dark 'biological', subconscious, with sadistic-masochistic drives predominating in it (for details see Psychoanalysis). Strohmayer attaches great importance to the premature awakening of sexual feeling. Children who are too caressed, stroked, kissed often experience feelings close to sexual ones, and they may develop insomnia, fearfulness and pavor nocturnus, but apparently this does not happen so often. The same must be said in relation to corporal punishment. As for the etiology of R. p., first of all it must be said that in determining the cause of its development, one must take into account the combination of endogenous and exogenous factors. The endogenous factor is, first of all, the elements of psychoneuropathy (in the broad sense) observed in such children, more often hereditary, but often of a reactive type, arising in connection with and due to unfavorable environmental conditions and disappearing under the influence of a change in the latter. The character of such children can be characterized by the following traits: timidity, impressionability, passivity, instability. Often such children suffer from fear of darkness, insects, etc. When studying the child's environment, we almost always encounter incorrect, and sometimes perverted upbringing, one-sided upbringing of the intellect (cult of prodigies), indulgence (especially in families with only one child) with neglect of physical training and hardening, suppression of independence and initiative. Here one often encounters the fascination of even very small children with fairy tales, circus, cinema, predominantly with frightening plots; frightening the child with a witch, wolf, dog, etc., especially at night. In some cases, certain somatic causes (difficulty in breathing, developing especially when lying on the back, in children with chronic runny nose and adenoids) may be of importance, but in most cases the significance of these factors recedes into the background. In any case, it is difficult to reduce the entire pathogenesis of R. p. to a breathing disorder, since on the one hand, not all children with breathing disorders have R. p., and on the other hand, removal of adenoids and other measures to restore nasal breathing do not always lead to the disappearance of R. p. And the fright itself, which is sometimes observed in such children, usually does not have such a violent and strong character, but rather resembles an adult's nightmare. The same must be said regarding some other external factors: overfilling of the stomach or rectum, more rarely overfilling of the bladder; sometimes apparently the heat and stuffiness in the bedroom is of importance. As can be seen from the above, R. p. is not an independent nosological unit, but represents a special symptom (analogous for example to teeth grinding), a special distinctive sleep disorder, the etiology and pathogenesis of which may not always be the same. As for the differential diagnosis, in general it is not difficult, if one takes into account the characteristic picture of this phenomenon. It is more difficult to determine its etiology in each individual case. In this respect, it is most important to single out cases of R. p. that are equivalent to an epileptic seizure, which sometimes can be determined only after longer observation and study of the child. With sufficient attention from those around, it is relatively easy to distinguish from R. p. the sudden cry of a child at night in the case of development of some painful process (awkward turn when injured, abscess, etc.). Sometimes even flatulence can cause an experience of fear in a child. But in this case the child's behavior is completely different; the same can be said about night cries that are sometimes observed in meningitis, especially tuberculous. Febrile delirium sometimes can manifest in the form of R. p., but in these cases the presence of fever decides the matter. The prognosis is usually good, except for rare cases of epileptic etiology, since usually the attacks of P. nocturnus cease with age, and children develop into fully socially adequate workers. Treatment should in the main be directed toward changing the child's environment, interests and impressions, while simultaneously fighting against indulgence. Attention should be paid to exogenous factors (adenoids, bedroom, dinner, reading - especially exciting fantasy frightening fairy tales and stories at night), to avoid everything that can awaken the sexual instinct too early, to avoid overfatigue. Often a walk before sleep is beneficial. In severe cases, it is necessary to give the child sedatives at night, and it is always necessary to reassure the parents and advise them to pay less attention to these attacks and in general to change their attitude toward the child, since excessive tenderness and anxiety have a very bad effect on the child.