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  • Print publication year: 2010
  • Online publication date: November 2010

Chapter 29 - Sleep panic arousals

from Section 5 - Sleep-related movement disorders and other variants


Sleep enuresis (SE) is characterized by recurrent involuntary voiding of urine during sleep that occurs at least twice a week, for at least 3 consecutive months, in a child of 5 years age. The assessment of SE is based on history (familial predisposition and emotional standpoint), sleep habits, and also on physical examination. There is a strong genetic influence in SE; when both parents suffer from SE, almost 75% of their children are expected to be also enuretic, while the prevalence of SE in the offspring of two parents who were not enuretic during childhood is only 15%. Several polysomnographic studies reported that children with SE have normal sleep architecture, in terms of proportion and distribution of sleep stages during night. The management of primary enuresis starts from the education of the patient and family including: supportive approach, evening fluid restriction, and sleep hygiene rules.


1. American Psychiatric Association. Diagnostic Statistical Manual of Mental Disorders, 4th rev. ed. Washington, DC: American Psychiatric Association, 2000.
2. SingareddyR, UhdeTW. Nocturnal sleep panic and depression: Relationship to subjective sleep in panic disorder. J Affect Disord 2009; 112: 262–6.
3. UhdeTW. The anxiety disorders. In KrygerMH, RothT, DementW (Eds), Principles and Practice in Sleep Medicine, third edition. Philadelphia, PA: W.B. Saunders, 2000; 1123–39.
4. FreedS, CraskeMG, GreherMR. Nocturnal panic and trauma. Depress Anxiety 1999; 9: 141–5.
5. MellmanTA, Kulick-BellR, AshlockLE, NolanB. Sleep events among veterans with combat-related post-traumatic stress disorder. Am J Psychiatry 1995; 152: 110–5.
6. HauriPJ, FriedmanM, RavarisCL. Sleep in patients with spontaneous panic attacks. Sleep 1989; 12: 323–37.
7. MellmanTA, UhdeTW. Sleep panic attacks: New clinical findings and theoretical implications. Am J Psychiatry 1989; 146: 1204–07.
8. MellmanTA, UhdeTW. Electroencephalographic sleep in panic disorder. A focus on sleep-related panic attacks. Arch Gen Psychiatry 1989; 46: 178–84.
9. UhdeTW, Roy-ByrneP, GillinJC, et al. The sleep of patients with panic disorders: A preliminary report. Psychiatr Res 1984; 12: 251–9.
10. CrakeMG, BarlowDH. Nocturnal panic. J Nerv Ment Dis 1989; 177: 160–8.
11. Roy-ByrnePP, UhdeTW, PostRM. Effects of one night's sleep deprivation on mood and behavior in panic disorder. Arch Gen Psychiatry 1986; 43: 895–9.
12. OverbeekT, DiestR, SchruersK, KruizingaF, GriezE. Sleep complaints in panic disorder. J Nerv Ment Disord 2005; 193: 488–93.
13. SchredlM, KronenbergG, NonellP, HeuserI. Sleep quality in patient with panic disorder: Relationship to nocturnal panic attacks. Somnologie 2002; 6: 149–53.
14. CraskeMG, KreugerM. Prevalence of nocturnal panic in a college population. J Anxiety Disord 1990; 4: 125–39.
15. NortonGR, DorwardJ, CoxBJ. Factors associated with panic attacks in nonclinical subjects. Behav Ther 1986; 17: 239–52.
16. AlbertU, MainaG, BergesioC, BogettoF. Nocturnal panic and recent life events. Depress Anxiety 2005; 22: 52–8.
17. AgaragunMY, KaraH. Recurrent sleep panic, insomnia, and suicidal behavior in patients with panic disorder. Compr Psychiatry 1998; 39: 149–51.
18. LabbateLA, PollackMH, OttoMW, LamgenauerS, RosenbaumJF. Sleep panic attacks: An association with childhood anxiety and adult psychopathology. Biol Psychiatry 1994; 36: 57–60.
19. SteinMB, TancerME, UhdeTW. Major depression in patients with panic disorder: Factors associated with course and recurrence. J Anxiety Disord 1990; 19: 287–96.
20. VollrathM, AngstA. Outcome of panic and depression in a 7-year follow up: Results of the Zurich Study. Acta Psychiatr Scand 1989; 80: 591–9.
21. UhdeTW, BoulengerJ-P, Roy-ByrnePP, GeraciMF, VittoneBJ, PostRM. Longitudinal course of panic disorder: Clinical and biological considerations. Prog Neuro-Psychopharmacol Biol Psychiatry 1985; 9: 39–51.
22. ScupiBS, MaserJD, UhdeTW. The National Institute of Mental Health Panic Questionnaire (NIMH-PQ): An instrument for assessing clinical characteristics of panic disorder. J Nerv Men Dis 1992; 180: 566–72.
23. AkiskalHS, LemmiH, DicksonH, KingD, YerevanianB, Van Valkenburg, C. Chronic depressions. Part 2. Sleep EEG differentiation of primary dysthymic disorders from anxious depressions. J Affect Disord 1984; 6: 287–95.
24. SarisoyE, BokeO, ArikAC, SahinAR. Panic disorder with nocturnal panic attacks: Symptoms and comorbidities. Eur Psychiatry 2008; 23: 195–200.
25. MatzaLS, RevickiDA, DavidsonJR, StewartJW. Depression with atypical features in the National Comorbidity Survey: Classification, description, and consequences. Arch Gen Psychiatry 2003; 60: 817–26.
26. LandryP, MarchandL, MainguyN, MarchandA, MontplaisirJ. Electroencephalography during sleep of patients with nocturnal panic disorder. J Nerv Ment Disord 2002; 190: 559–62.
27. GormanJM, FyerMR, GoetzR, et al. Ventilatory physiology of patients with panic disorder. Arch Gen Psychiatry 1988; 45: 31–9.
28. HegelMT, FergusonRJ. Psychophysiological assessment of respiratory function in panic disorder: Evidence for a hyperventilation subtype. Psychosom Med 1997; 59: 224–30.
29. PappLA, MartinezJM, KleinDF, et al. Respiratory psychophysiology of panic disorder: three respiratory challenges in 98 subjects. Am J Psychiatry 1997; 154: 1557–65.
30. WilhelmFH, TrabertW, RothWT. Physiologic instability in panic disorder and generalized anxiety disorder. Biol Psychiatry 2001; 49: 596–605.
31. GormanJM, BrowneST, PappLA, et al. Effects of antipanic treatment on response to carbon dioxide. Biol Psychiatry 1997; 42: 982–91.
32. GriezI, LousbergH, Van Den HoutMA, ZandbergenJ. CO2 vulnerability in panic disorder. Psychiatry Res 1987; 20: 87–95.
33. PernaG, BattagliaM, GarberiA, ArancioC, BertaniA, BellodiL. Carbon dioxide/oxygen challenge test in panic disorder. Psychiatry Res 1994; 52: 159–71.
34. SandersonWC, WeltzerS. Five percent carbon dioxide challenge: Valid analogue and marker of panic disorder?Biol Psychiatry 1990; 27: 689–701.
35. BulowK. Respiration and wakefulness in man. Acta Physiol Scand Suppl 1963; 209: 1–110.
36. MeadowsGE, DunroyHMA, MorrellMJ, CorfieldDR. Hypercapnic cerebral vascular reactivity is decreased, in humans, during sleep compared to wakefulness. J Appl Physiol 2003; 94: 2197–202.
37. MorrellMJ, HartyHR, AdamsL, GuzA. Changes in total pulmonary resistance and PCO2 between wakefulness and sleep in normal human subjects. J Appl Physiol 1995; 78: 1339–49.
38. Roy-ByrnePP, MellmanTA, UhdeTW. Biologic findings in panic disorder. J Anxiety Disord 1988; 2: 17–29.
39. UhdeTW, MellmanTA. Commentary on “Relaxation-induced panic (RIP): When resting isn't peaceful”. Integr Psychiatry 1988; 6: 147–9.
40. CraskeMG, BarlowDH. Nocturnal panic: Response to hyperventilation and CO2 challenges. J Abnorm Psychol 1990; 99: 302–07.
41. SingareddyR, UhdeTW. Sleep deprivation in nocturnal panic attacks. Biol Psych 2005; 57: S8.
42. BrownTM, UhdeTW. Sleep panic attacks: A micromovement analysis. Depress Anxiety 2003; 18: 214–20.
43. SloanEP, NatarajanM, BakerB, et al. Nocturnal and daytime panic attacks – comparison of sleep architecture, heart rate variability, and response to sodium lactate challenge. Biol Psychiatry 1999; 45: 1313–20.
44. AikinsDE, CraskeMG. Sleep-based heart period variability in panic disorder with and without nocturnal panic attacks. J Anxiety Disord 2008; 22: 453–63.
45. KoenigsbergHW, PollakCP, FerroD. Can panic be induced in deep sleep? Examining the necessity of cognitive processing for panic. Depress Anxiety 1998; 8: 126–30.
46. KronenbergG, SchredlM, FiedlerK, HeuserI. In healthy volunteers responses to challenge with cholecystokinin tetrapeptide differ between administration during REM and delta sleep. Depress Anxiety 2001; 14: 141–4.
47. GeraciM, AndersonTS, Slate-CothrenS, PostR, McCannU. Pentagastrin-induced sleep panic attacks: Panic in the absence of elevated baseline arousal. Biol Psychiatry 2002; 52: 1189–93.
48. McCannUD, ShiyokoO, SlateSO, GeraciM, Roscow-Terrill D, UhdeTW. A comparison of the effects of intravenous pentagastrin on patients with social phobia, panic disorder and healthy controls. Neuropsychopharmacology 1997; 16: 229–37.
49. UhdeTW. Caffeine-induced anxiety: An ideal chemical model of panic disorder. In AsnisGM, van PraagHM (Eds), Einstein Monograph Series in Psychiatry. New York: Wiley-Liss, 1995; 181–205.
50. BalonR, PohlR, YeraganiVK, SingareddyRK. Provocation of anxiety states in humans and its possible significance for the pathogenesis of these disorders. In KasperS, den BoerJA, SitsenJMA (Eds), Handbook of Depression and Anxiety, second edition. New York: Marcel Dekker, 2007; 703–32.
51. NickellPV, UhdeTW. Anxiety disorders and epilepsy. In DevinskyO, TheodoreWH (Eds), Epilepsy and Behavior. New York: Wiley-Liss, 1991; 67–84.
52. MellmanTA, UhdeTW. Patients with frequent sleep panic: Clinical findings and response to medication treatment. J Clin Psychiatry 1990; 51: 513–6.
53. MendezM, RadtkeRA. Interactions between sleep and epilepsy. J Clin Neurophysiology 2001; 18: 106–27.
54. BilliardM. Epilepsies and the sleep–wake cycle. In StermanMB, ShouseMN, PassouantP (Eds), Sleep and Epilepsy. New York: Academic Press.
55. JanzD. Epilepsy and the sleeping–waking cycle. In VinckenPJ, BruynGW (Eds), Handbook of Clinical Neurology. The Epilepsies. Amsterdam: North-Holland Biomedical Press, 1974; 457–90.
56. SteinMB, UhdeTW. Infrequent occurrence of EEG abnormalities in panic disorder. Am J Psychiatry 1989; 146: 517–20.
57. EdlundMJ, SwannAC, ClothierJ. Patients with panic attacks and abnormal EEG results. Am J Psychiatry 1987; 144: 508–09.
58. SazgarM, CarlenPL, WennbergR. Panic attack semiology in right temporal lobe epilepsy. Epileptic Disord 2003; 5: 93–100.
59. GambardellaA, MessinaD, Le PianeE, et al. Familial temporal lobe epilepsy autosomal dominant inheritance in a large pedigree from southern Italy. Epilepsy Res 2000; 38: 127–32.
60. WallM, TuchmanM, MielkeD. Panic attacks and temporal lobe seizures associated with a right temporal lobe arteriovenous malformation: Case report. J Clin Psychiatry 1985; 46: 143–5.
61. DantendorferK, FreyR, MaierhoferD, SaletuB. Sudden arousals from slow wave sleep and panic disorder: Successful treatment with anticonvulsants – a case report. Sleep 1996; 19: 744–6.
62. GallinatJ, Stotz-IngenlathG, LangUE, HegerlU. Panic attacks, spike-wave activity, and limbic dysfunction. A case report. Pharmacopsychiatry 2003, 36: 123–6.
63. PicardiA, Di GennaroG, MeldolesiGN, GrammaldoLG, EspositoV, QuaratoPP. Partial seizures due to sclerosis of the right amygdala presenting as panic disorder. Psychopathology 2007; 40: 178–83.
64. ScaliseA, PlacidiF, DiomediM, De SimoneR, GigliGL. Panic disorder or epilepsy? A case report. J Neurol Sci 2006; 246: 173–5.
65. UhdeTW, Merritt-DavisO, YaroslavskyY, GlitzD, SingareddyRK, CorteseBM. Sleep paralysis: Overlooked fearful arousal. 159th Annual Meeting of the American Psychiatric Association, Toronto, Canada, May 20–25, 2006 in Syllabus & Proceedings Summary, 2006; Abstract #96D: 250–1.
66. TakeuchiT, MiyasitaA, SasakiY, et al. Isolated sleep paralysis elicited by sleep interruption. Sleep 1992; 15: 217–25.
67. RolandMMS, BaranAS, RichertAC. Sleep-related laryngospasm caused by gastroesophageal reflux. Sleep Med 2008; 9: 451–3.
68. BroughtonRJ. NREM arousal parasomnias. In KrygerM, RothT, DementW (Eds), Principles and Practice of Sleep Medicine, 3rd ed. Philadelphia: Saunders, 2000; 693–706.
69. MoldJW, MathewMK, BelgoreS, DeHavenM. Prevalence of night sweats in primary care patients: An OKPRN and TAFP-Net collaborative study. J Fam Pract 2002; 51: 452–6.
70. LopesFL, NardiAE, NascimentoI, ValencaAM, ZinWA. Nocturnal panic attacks. Arq Neuropsiquiatr 2002; 60: 717–20.
71. CraskeMG, LangAJ, AikinsD, MystokowskiJL. Cognitive behavioral therapy for nocturnal panic. Behav Ther 2005; 36: 43–54.
72. CraskeMG, TsaoJCI. Assessment and treatment of nocturnal panic attacks. Sleep Med Rev 2005; 9: 173–84.
73. KrahnLE, BlackJL, SilberMH. Narcolepsy: New understanding of irresistible sleep. Mayo Clin Proc 2001; 76: 185–94.
74. Anic-LabatS, GuilleminaultC, KraemerHC, MeehanJ, ArrigoniJ, MignotE. Validation of a cataplexy questionnaire in 983 sleep-disorders patients. Sleep 1999; 22: 77–87.
75. DauvilliersY, ArnulfI, MignotE. Narcolepsy with cataplexy. Lancet 2007; 369: 499–511.
76. HaslerG, BuysseDJ, GammaA, AjdacicV, EichD, RösslerW, AngstJ. Excessive daytime sleepiness in young adults: A 20-year prospective community study. J Clin Psychiatry 2005; 66: 521–9.
77. Theorell-HaglöwJ, LindbergE, JansonC. What are the important risk factors for daytime sleepiness and fatigue in women?Sleep 2006; 29: 751–7.
78. SingareddyRK, UhdeTW. Nocturnal panic and depression: Relationship to sleep in panic disorder. 45th Annual Meeting of the American College of Neuropsychopharmacology, Hollywood, Florida, December 3–7, 2006 in Neuropsychopharmacology 2006; 31: S228.
79. FlosnikDL, CorteseBM, UhdeTW. Cataplexy in anxious patients: Is sub-clinical narcolepsy under-recognized in anxiety disorders?J Clin Psychiatry 2009; in press.
80. CorteseBM, UhdeTW. Immobilization panic. Am J Psychiatry 2006; 163: 1453–4.