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ABSTRACT

Nightmare severity correlates with suicidality in PTSD patients

Ali Artar, MD., PG-4 Psychiatry Resident, University of New Mexico Department of Psychiatry, Administrative Chief Resident, Mental Health Center. Dr. Artar is currently co-investigator in a study designed to determine the prevalence of sleep disordered breathing in suicidal patients. Address: University of New Mexico Department of Psychiatry 2400 Tucker NE Albuquerque, NM 87131 email:aoartar8555@earthlink.net

Barry Krakow, MD., Associate Research Professor of Emergency Medicine and Psychiatry at the University of New Mexico Health Sciences Center, Albuquerque, New Mexico, Medical Director, UNM Sleep Research. Address: Barry Krakow, M.D. UNM Sleep Research, 4775 Indian School Rd. NE, ABQ. NM 87110.  mailto:bkrakow@salud.unm.edu 

Background: Dr. Krakow has conducted 10 years of clinical research on the treatment of nightmares including clients with and without posttraumatic stress disorder. He is currently engaged in a program to treat insomnia and nightmares in crime victims.

Suicide is the 9th leading cause of death in the United States. The U.S. Surgeon General has recently called for greater research to study this problem, which accounts for 30,000 annual deaths. While there are many known risks factors for suicidality, such as co-morbid psychiatric
disorders, age and marital status, the relationship between sleep and and suicidal behavior has only recently been explored. A few studies have demonstrated positive correlations between suicidality and sleep quality, most notably in depressed patients. Patients with chronic posttraumatic stress disorder (PTSD) also may exhibit suicidality in addition to their constellation of posttraumatic stress symptoms.

One of the most frequent and distressing symptoms of PTSD are nightmares. Nightmare formation follows the occurrence of the emotional trauma and can persist in PTSD patients. Disruption of previously normal sleep patterns can ensue, resulting in shortened overall sleep time, shifts in sleep-wake time, and in general, decreased quality of sleep. When depression is added to these symptoms, hopelessness can set in, leading to emotional exhaustion, a feeling that one cannot go on living like this anymore, and suicide attempts. Most initial treatments aimed at stopping this progression of worsening symptomatology involve medications targeting symptoms of depression, anxiety, and psychosis, some or all of which may occur in PTSD patients. Psychotherapies frequently cannot be initiated or be tolerated until symptoms are adequately controlled. However, available treatments frequently result in only partial resolution of symptoms, and chronicity of PTSD symptoms such as suicidality, nightmares and sleep disturbances develops. Exacerbations of these and other PTSD symptoms invariably occur, many times after seemingly minor external stressors, and thus PTSD symptoms can persist over time. The result can become chronic impairment of social and occupational functioning, decreasing quality of life, and further or permanent disability in these individuals.

The severity of these and other PTSD symptoms can vary from patient to patient. In order examine possible relationships between suicidality, sleep quality, nightmares and overall PTSD symptom severity, a chart review study was performed. This study was performed utilizing the intake data of female sexual assault survivors with insomnia, nightmares and PTSD symptoms who had enrolled in a nightmare treatment program. Instruments included in the analysis were the Hamilton Depression Rating Scale (Suicide Subscale), Pittsburgh Sleep Quality Index (Component 1: Subjective Sleep Quality), Nightmare Frequency Questionnaire, and Posttraumatic Stress Scale (Total Severity Score). Pearson correlation coefficients were calculated. Significant correlations were obtained in all analyses: sleep quality (r = .25, p = .002); nightmares (r = .26, p = .001); and PTSD (r = .50, p = .000)

Similar to previous studies, this study revealed that sleep quality showed a moderate correlation with suicidality. Nightmares also demonstrated a moderate correlation and overall PTSD severity demonstrated a large correlation. The current study raises the possibility that a patient's exhaustion may be associated with some aspect of their sleep quality.

Sleep quality in PTSD patients would generally be expected to be poor due to nightmares, hyper-arousal symptoms, anxiety and ultimately psycho-physiological insomnia. However, new research suggests that sleep breathing and sleep movement disorders may also be a cause for poor sleep quality in sexual assault survivors with PTSD. All of these conditions may deplete essential energy reserves through chronic sleep deprivation, which, in turn, could degrade coping capacity.

In sum, these findings, coupled with our current understanding of sleep complaints in PTSD, indicate the need for a deeper exploration of the relationship between nightmares, poor sleep quality, and suicidal ideation and behavior.

Nightmare treatments utilized at the UNM Sleep Center include a cognitive behavioral technique involving daytime imagery rehearsal of disturbing dreams. This has shown to not only reduce nightmares, but overall PTSD distress as well.

Another finding of interest that has been shown to decrease nightmares involves new research that suggests PTSD patients-a high-risk group for suicidality- may suffer a disproportionately higher rate of physical sleep disorders, such as sleep disordered breathing (SDB). The two common types of SDB are obstructive sleep apnea (OSA) and upper airway resistance syndrome (UARS). Both produce a final common pathway of multiple awakenings or micro-arousals from sleep, which leads to sleep fragmentation, poor sleep quality and subjective complaints of daytime fatigue and sleepiness as well as numerous cognitive and mood disturbances.

In a recent study at UNM Sleep Research, a potential diagnosis of SDB was made in 52% of sexual assault survivors with nightmares and PTSD. In this sample, poor sleep quality correlated with increased suicidality. And, PTSD patients who were diagnosed with and treated for SDB had decreased nightmares and PTSD symptoms without additional psychiatric or pharmacological intervention. Thus, the role of sleep breathing disturbances may play an integral role in development of sleep complaints in some psychiatric patients and may, in turn, impact upon suicidality.

Moreover, in a study (8) involving a group of 22 chronic nightmare sufferers (14 of whom met criteria for PTSD, and 15 of whom had OSA, and 7 of whom had UARS), CPAP (continuous positive airway pressure), the current treatment of choice for obstructive apneas, resulted in a median improvement of 80% in nightmares and a median 68% improvement in PTSD symptoms in the treatment group without additional psychiatric or pharmacological interventions. In this study, all participants in the non-treatment group had median 5% worsening in nightmares and 6 of this group had a median 43% worsening in PTSD symptoms.

Suicide is the 9th leading cause of death in the United States. The U.S. Surgeon General has recently called for greater research to study this
problem, which accounts for 30,000 annual deaths. While there are many known risks factors for suicidality, such as co-morbid psychiatric
disorders, age and marital status, the relationship between sleep and and suicidal behavior has only recently been explored. A few studies have demonstrated positive correlations between suicidality and sleep quality, most notably in depressed patients. Patients with chronic posttraumatic stress disorder (PTSD) also may exhibit suicidality in addition to their constellation of posttraumatic stress symptoms. The current study examined the relationship between suicidality, sleep quality, nightmares and PTSD.

Method

A chart review was performed from the intake data of female sexual assault survivors with insomnia, nightmares and PTSD symptoms who had enrolled in a nightmare treatment program. Instruments included in the analysis were the Hamilton Depression Rating Scale (Suicide Subscale), Pittsburgh Sleep Quality Index (Component 1: Subjective Sleep Quality), Nightmare Frequency Questionnaire, and Posttraumatic Stress Scale (Total Severity Score). Higher scores reflect greater severity of each measured item.

Results

Pearson correlation coefficients were calculated. Significant correlations were obtained in all analyses: sleep quality (r = .25, p = .002); nightmares (r = .26, p = .001); and PTSD (r = .50, p = .000)

Conclusions

Similar to previous studies, sleep quality showed a moderate correlation with suicidality. Nightmares also demonstrated a moderate correlation and PTSD demonstrated a large correlation. These findings may be of considerable interest to sleep researchers because it is well know that suicidal patients (both completers and non-completers ) often described the phenomenon of "emotional exhaustion" either in notes or following
unsuccesful attempts. The current study raises the possibility that a patient's exhaustion may be associated with some aspect of their sleep
quality. Sleep quality in PTSD patients would generally be expected to be poor due to nightmares, hyper-arousal symptoms, anxiety and ultimately psycho-physiological insomnia. New research suggests that sleep breathing and sleep movement disorders may also be a cause for poor sleep quality in sexual assault survivors with PTSD. All of these conditions may deplete essential energy reserves through chronic sleep deprivation, which, in turn, could degrade coping capacity. In sum, these findings, coupled with our current understanding of sleep complaints in PTSD, indicate the need for a deeper exploration of the relationship between poor sleep quality and suicidal ideation and behavior.

In a related study, the results of treatment of sleep disordered breathing in a group of 22 chronic nightmare sufferers (14 of whom met criteria for PTSD, and 15 of whom had Obstructive sleep apnea (OSA), and 7 of whom had upper airway resistance syndrome (UARS).

The complaint of insomnia is common in psychiatric patients, and has usually been regarded as psychophysiological insomnia, i.e., insomnia as a function of the psychiatric illness itself as well as a learned behavior (9), rather than as a physical sleep disorder, i.e., as a type of SDB. However, it has been shown in a group of sexual assault victims who suffered from insomnia, nightmares, and met criteria for PTSD (10), that 2 out of 4 participants in the sample, 90% of whom had clinically diagnosable insomnia, endorsed specific sleep symptoms at a frequency highly indicative of a potential SDB. This group comprised 52% of the overall sample. This percentage (52%) of potential SDB is at least 10 times greater than the current estimated prevalence of SDB in the general population, which is 1-5%.

Furthermore, in another study of crime victims with insomnia, nightmares and PTSD (11), UARS manifested more commonly than OSA by a ratio of 2 to 1, and either type of SDB was diagnosed in 85% of polysomnogram cases and 70% of home airflow monitoring cases (the latter utilizing the Autoset device, ResMed Ltd, North Ryde, Australia).

Moreover, in a study (8) involving a group of 22 chronic nightmare sufferers (14 of whom met criteria for PTSD, and 15 of whom had OSA, and 7 of whom had UARS), CPAP (continuous positive airway pressure), the current treatment of choice for obstructive apneas, resulted in a median improvement of 80% in nightmares and a median 68% improvement in PTSD symptoms in the treatment group without additional psychiatric or pharmacological interventions. In this study, all participants in the non-treatment group had median 5% worsening in nightmares and 6 of this group had a median 43% worsening in PTSD symptoms.

Suicide is the ninth leading cause of death in the U.S. (30,000 deaths/year). Recent research has demonstrated correlations between suicidality and sleep disturbance. Subjective reports of poor sleep quality in sexual assault survivors correlated with suicidality, nightmares and PTSD. Worse sleep has been demonstrated in suicidal vs. nonsuicidal depressed patients. Higher suicidal "scores" have been observed in psychiatric patients with insomnia or hypersomnia compared to those without sleep disturbances. Also sleep disturbances and depression (a major suicidal risk) are often co-morbid.

Sleep complaints, common in psychiatric patients, are usually attributed to psychiatric distress. However, new research suggests that PTSD patients-a high-risk group for suicidality- may suffer a disproportionately higher rate of physical sleep disorders, such as sleep disordered breathing (SDB). The two common types of SDB are obstructive sleep apnea (OSA) and upper airway resistance syndrome (UARS). Both produce a final common pathway of multiple awakenings or micro-arousals from sleep, which leads to sleep fragmentation, poor sleep quality and subjective complaints of daytime fatigue and sleepiness as well as numerous cognitive and mood disturbances.
In a recent study at UNM Sleep Research, a potential diagnosis of SDB was made in 52% of sexual assault survivors with nightmares and PTSD. In this sample, poor sleep quality correlated with increased suicidality. And, in a retrospective chart review study, PTSD patients who were diagnosed with and treated for SDB had decreased nightmares and PTSD symptoms without additional psychiatric or pharmacological intervention. Thus, the role of sleep breathing disturbances may play an integral role in development of sleep complaints in some psychiatric patients and may, in turn, impact upon suicidality.

In this pilot study of SDB prevalence, 50-75 suicidal patients admitted to UNM MHC will be recruited. Patients will be interviewed for type and degree of suicidality, depression and sleep complaints. They will also be thoroughly assessed for any potential risks in utilizing the portable Autoset sleep-breathing monitor (due to the electrical cord required to operate it). Participants will be assessed with one overnight sleep study and prevalence of SDB will be determined. Objective sleep parameters, including snoring, oxygenation, apneas and hypopneas, and nasal pressure recorded airflow limitation will serve as independent variables. These will be correlated with depression, suicide, and sleep scores from relevant instruments. Demographic variables will serve as covariates.

The current study aims at developing pilot data for a larger RO1 grant submission to NIMH. While the current proposal does not include a control group, there is substantial prevalence data on SDB in the general population that will yield some comparisons to the suicide patients studied in this protocol.