Nightmares and Suicide: Assessing and Managing Patients with Sleep Disturbance

If you haven’t had a good night’s sleep, you’re just not yourself the next day. And you also know that sleep impacts the immune system and your ability to stay focused during the day.

In addition to being associated with a decreased ability to manage one’s emotions, a pattern of sleep disturbance is a risk factor for depression and also increases the risk of cancer, infection, hypertension, weight gain, heart disease, diabetes, inflammation, osteoporosis, chronic pain, and arrhythmias. It can also have a significant negative impact on cognition and creativity. Insomnia symptom duration is significantly associated with suicide risk independent of severity of current insomnia symptoms.

But in people with psychiatric symptoms, how do nightmares influence suicidality? Nightmare duration is significantly associated with suicide risk independent of severity of current nightmares. Insomnia symptoms and nightmare duration are significantly related to suicide risk after controlling for depressive symptoms, anxiety symptoms, and PTSD symptoms, current insomnia and current nightmares.

Significant changes in sleep are now listed among the top 10 warning signs of suicide, according to the Substance Abuse and Mental Health Services Administration. People who have a history of suicide attempts show lower sleep efficiency (the ratio of time asleep over time in bed trying to go to sleep).

What is the most effective approach to managing sleep disturbance and disruption in patients? According to the Best Practice Guide for the Treatment of Nightmare Disorder in Adults by Aurora, et al. in 2010, medication options include Prazosin and Clonidine. One non-pharmacologic cognitive behavioral therapy option is having the patient remember the nightmare, write it down, then rewrite the outcome. Another option is progressive muscle relaxation, in which the patient is instructed to tense and relax muscles, one body part at a time.

At the American Psychiatric Nurses Association (APNA) 28th Annual Conference, October 22-25, 2014, Jane S. Mahoney, PhD, RN, PMHCNS-BC, associate professor at Baylor College of Medicine and director of Nursing Practice & Research, The Menninger Clinic, Houston, TX, shared information and insight on what clinicians can do to help their patients with sleep disturbance.

Simply taking a look at patients who look like they’re sleeping, then assuming they are sleeping is a useless assessment. Mahoney said it is important to teach nurses how important sleep is and instruct them to tell patients:

“I want you to know that your sleep really matters to us! Sleep is as important as food and air and water. So let’s talk about how you slept last night. Did you feel like you slept as well as you could of? Did you wake up periodically? Did you lay in bed worrying about things? Did you have a nightmare?” said Mahoney. So the assessment has to probe and educate the patient, too, that sleep is important.

With patients who have been diagnosed with PTSD, Mahoney suggested normalizing nightmares. For example, it’s been her experience that people who have the anxiety issues often times have sleep disturbances and nightmares. She suggested telling the patient, “I would like to explore with you if that is one of the things that is happening to you because we have a very effective, noninvasive, nonmedical treatment that we can offer you, where we change those dreams. Now knowing that, would you be willing to tell me if this is happening to you?” It’s all in the way you engage the patient, where they are, said Mahoney.