Integrative insights on nightmares and suicide

Photo Cred: Bekah Russom/Unsplash

By Catherine Darley, ND

Suicide is a tragedy that took the lives of 48,344 Americans in 2018, and an emerging body of evidence is showing that nightmares may be a harbinger of suicide.  

The suicide rate has increased 31 percent since 2001, according to the National Institute of Mental Health. Men are at four times the risk of suicide than women. The cost of suicide is enormous between the devastating emotional toll on family, friends, and community, along with the financial toll due to medical expense and work loss.

A nightmare is an extended, extremely dysphoric, and well-remembered dream that usually involves threats to survival, security, or physical injury. Many of us have had a nightmare. They are more common during times of stress, illness, and sleep deprivation. Up to half of preschoolers may have nightmares, and frequency declines over the lifespan to 4 percent of adults, though a majority of people with post-traumatic stress disorder (PTSD) have nightmares.

According to the International Classification of Sleep Disorders, nightmare disorder is a rapid eye movement (REM) parasomnia, diagnosed when the nightmares are repeated, the person rapidly becomes oriented and alert upon waking, or the dream or sleep disturbance produced causes clinically significant distress or impairment in social, occupational, or other areas of functioning.

Anyone who has had a nightmare knows how very real they can seem, and how distressing. Over the last ten years, researchers and practitioners have learned more about nightmares, and now know that they can be an indicator of suicidality.

This connection between sleep and suicidality first came to my attention in clinic, as I was seeing severely sleep-restricted teens who had had suicidal ideation. As their sleep quantity improved, their depression and suicidality lifted. More than one parent told me they wished they had addressed sleep when the mood problems first began and suspect they could have avoided much of the problem.

Research bears this out, showing that there is an increase in serious suicidal thoughts with sleep restriction, and that for every hour of increased sleep, there is an 11 percent decrease in suicide plans in adolescents. A new presentation of nightmares is indicative of new suicidality. Among people with PTSD, the relationship between nightmares and suicidality is quite strong, with 62 percent of those with nightmares being suicidal, as compared to 20 percent of those without nightmares. Although the mechanism is still being clarified, it appears that part of the connection is due to feelings of defeat, entrapment and hopelessness. Surprisingly, this was independent of depression and insomnia.  

When establishing the foundations of health with patients, in addition to asking about sleep total, quality, regularity, and any complaints, be sure to also ask them about nightmares. Good questions would be:

• “Do you ever have nightmares?”
• “How often is this happening?”
• “Is this more often than in the past?”
• “How are these nightmares impacting you?”

If the person indicates a new experience or increasing frequency of nightmares, or significant distress, then the practitioner should conduct a suicide assessment and treatment protocol as necessary. Note that some medications increase nightmares, namely those which impact norepinephrine, serotonin, and dopamine, as can withdrawal from REM suppressing drugs, GABA, and acetylcholine.

Treatment for nightmare disorder, as outlined by the American Association of Sleep Medicine in their clinical guideline of 2018, is broken into therapies for those suffering from PTSD-related nightmares, or those for whom the nightmares are not associated with PTSD. They evaluate behavioral, psychological, and pharmacologic treatment options, giving those with the most evidence a “recommended” rating, and those with less evidence a “may be used” rating.

For PTSD-related nightmares and disorder, image rehearsal therapy is recommended. Other therapies that can be used for PTSD-related nightmares include cognitive behavioral therapy, exposure relaxation, and rescripting therapy, eye movement desensitization and reprocessing, or cognitive behavioral therapy for insomnia. There are many medications to consider, some of which are tricyclic antidepressants, trazadone, and atypical antidepressants olanzapine, risperidone, and arip. Note that clonazepam and venlafaxine are not recommended.

For treatment of non-PTSD related nightmare disorder, practitioners could use therapies including lucid dreaming therapy, sleep dynamic therapy, exposure relaxation and rescripting therapy, self-exposure therapy, systematic desensitization, and cognitive behavioral therapy. Medications which may be used include nitrazepam, prazosin, and triazolam. Note that clonazepam and venlafaxine are not recommended for this group either.

The task force points out that there is no recommendation of which treatment, or even modality, should be used first—that is up to the clinicians’ discretion based on the patient’s presentation. One resource to consider if a practitioner does not provide these therapies themselves is to refer to a behavioral sleep medicine specialist.

With this insight into the connection between nightmares and suicidality, and how to treat nightmares effectively, we can decrease the number of tragic deaths and spare the emotional toll it takes on so many.

References

American Foundation for Suicide Prevention. Retrieved from: https://afsp.org/about-suicide/suicide-statistics/

Chiu H. Lee H, Chen P, Lai Y, Tu Y. (2018). Associations between sleep duration and suicidality in adolescents: a systematic review and dose-response meta-analysis. Sleep Medicine Review. Retrieved from: https://www. ncbi.nlm.nih.gov/m/pubmed/30093362.

Littlewood C, Gooding P, Panagioti M, Kyle S. Nightmares and suicide in posttraumatic stress disorder:the mediating role of defeat, entrapment, and hopelessness. (2016). Journal of Clinical Sleep Medicine. Retrieved from: https://jcsm.aasm.org/doi/10.5664/jcsm.5592.

The International Classification of Sleep Disorders, 3^rd Edition. (2014). American Academy of Sleep Medicine.

Morgenthaler T, Auerbach S, Casey K, Kristo D, Maganti R, Ramar K, Zak R, Karthe R. (2018). Position paper for the treatmet of nightmare disorder in adults: an American Academy of Sleep medicine position paper. Journal of Clinical Sleep Medicine. Retrieved from: https://jcsm.aasm.org/doi/10.5664/jcsm.7178

National Institute of Mental Health. Retrieved from: https://www.nimh.nih.gov/health/statistics/suicide.shtml