Nightmares: Just a part of childhood?
Your heart is pounding, your eyes fly open wide and you sit up so fast you startle the shadows. Pulse of 116 and you’re definitely hyperventilating. Reality no longer exists. You’re not seeing the dark walls of your bedroom; you’re still seeing the dark images of your dreams.
Are you plagued by nightmares? Nightmares are often thought of as a childhood problem but this isn’t always the case. And I don’t just mean a small annoyance that happens once in a blue moon. This can be a very persistent problem and one that is related to an increased risk of suicide. How is this?
Before we get into the details, here are some quick facts:
Severe nightmares can lead to sleep avoidance [1].
Disturbed sleep patterns can lead to suicidality [2].
Severe nightmares are correlated with increased risk of suicide even after accounting for mental illness [1,3–7].
People with frequent nightmares have a 105% higher risk of suicide [8].
Frequent nightmares are a predictor for a repeat suicide attempt [3].
In naturopathic medicine, we routinely ask patients about their sleep. In fact just last week we addressed sleep as the primary concern for one of our patients. Do you have trouble falling or staying asleep? Do you grind your teeth at night? Are you tired when you wake up? Do you have nightmares?
We address decreased sleep quantity and a lack of sleep quality in order to improve fatigue and physical health. However, these factors are important for another reason: their association with suicidal ideation [2].
If you’re sleep is poor, you probably don’t feel all that fabulous to begin with, but it’s not just poor sleep that is involved in this relationship. It appears that the presence or absence of nightmares (nightmares both decreasing sleep quantity and quality) better explain the links between poor sleep and suicide.
This connection between nightmares and suicide risk remains strong even after taking mental illness into consideration [1,9]. Furthermore, amongst those with mental illnesses, experiencing frequent nightmares increases risk of suicide in patients with depression, worsens symptoms in patients with psychosis (55% of whom experience frequent nightmares) and increases subsyndromal psychiatric symptoms in students [10–12].
Nerd note: You may be wondering about the content of these dreams. There actually has been research into this and depressed suicidal patients (compared to depressed non-suicidal patients) are more likely to dream of self-harm, dying or being dead – in addition to themes of vulnerability, hopelessness, and helplessness [13].
In children, difficulty maintaining sleep, increased REM sleep, and nightmares are each independently associated with increased self-harm behaviours [14]. It has been suggested this may be explained by reduced activity in the serotonergic system, hyperarousal, or HPA dysfunction [14–16]. This is a complicated picture, but consider that SSRI drugs also have a negative effect on sleep and are independently associated with nightmares [14,15,17].
It is of note that the duration of nightmares is significantly related to suicide risk, while current nightmares are not [1,5,6,18]. Perhaps defeat, entrapment and hopelessness help to explain these findings, as it could be argued that these would build up over time with duration of nightmares [4].
Insomnia also has a role, however this role is independent of nightmares and changes depending on the population studied. In older adults, current insomnia has a stronger link to suicide risk, but in college populations duration of insomnia was more indicative [5,6].
Regardless, there persists a direct relationship between nightmares and suicidal behaviours.
Final Thoughts
It is important for us to consider the role of sleep in health – and by this I mean not just the duration but also the quality. In clinic we can ask about sleep or tell the patient about “sleep hygiene” but how often do we really, truly evaluate just how much impact our sleep quality is having on our health?
Sleep itself is connected to health in numerous ways, but nightmares in particular are an aspect of the sleep experience that needs to be addressed in pursuit of health.
Keep an eye out for my next post on addressing nightmares.
References
Nadorff, M. R., Pearson, M. D. & Golding, S. Explaining the Relation between Nightmares and Suicide. J. Clin. Sleep Med. 12, 289–90 (2016).
Matsumoto, Y. et al. Day workers suffering from a wider range of sleep problems are more likely to experience suicidality. Sleep Biol. Rhythms 14, 369–376 (2016).
Sjöström, N., Hetta, J. & Waern, M. Persistent nightmares are associated with repeat suicide attempt. Psychiatry Res. 170, 208–211 (2009).
Littlewood, D. L., Gooding, P. A., Panagioti, M. & Kyle, S. D. Nightmares and Suicide in Posttraumatic Stress Disorder: The Mediating Role of Defeat, Entrapment, and Hopelessness. J. Clin. Sleep Med. 12, 393–9 (2016).
Golding, S., Nadorff, M. R., Winer, E. S. & Ward, K. C. Unpacking Sleep and Suicide in Older Adults in a Combined Online Sample. J. Clin. Sleep Med. 11, 1385–92 (2015).
Nadorff, M. R., Nazem, S. & Fiske, A. Insomnia symptoms, nightmares, and suicide risk: duration of sleep disturbance matters. Suicide Life. Threat. Behav. 43, 139–49 (2013).
McCall, W. V. et al. Nightmares and dysfunctional beliefs about sleep mediate the effect of insomnia symptoms on suicidal ideation. J. Clin. Sleep Med. 9, 135–40 (2013).
Tanskanen, A. et al. Nightmares as predictors of suicide. Sleep 24, 844–7 (2001).
Nadorff, M. R., Nazem, S. & Fiske, A. Insomnia symptoms, nightmares, and suicidal ideation in a college student sample. Sleep 34, 93–8 (2011).
Sheaves, B. et al. Insomnia, Nightmares, and Chronotype as Markers of Risk for Severe Mental Illness: Results from a Student Population. Sleep 39, 173–181 (2016).
Sheaves, B., Onwumere, J., Keen, N., Stahl, D. & Kuipers, E. Nightmares in Patients With Psychosis: The Relation With Sleep, Psychotic, Affective, and Cognitive Symptoms. Can. J. Psychiatry. 60, 354–61 (2015).
Bernert, R. A. & Nadorff, M. R. Sleep Disturbances and Suicide Risk. Sleep Med. Clin. 10, 35–39 (2015).
Glucksman, M. L. Manifest Dream Content as a Possible Predictor of Suicidality. Psychodyn. Psychiatry 42, 657–670 (2014).
Singareddy, R. et al. Subjective and objective sleep and self-harm behaviors in young children: a general population study. Psychiatry Res. 209, 549–53 (2013).
McCall, W. V. & Black, C. G. The link between suicide and insomnia: theoretical mechanisms. Curr. Psychiatry Rep. 15, 389 (2013).
Nagy, T. et al. Frequent nightmares are associated with blunted cortisol awakening response in women. Physiol. Behav. 147, 233–237 (2015).
Kaplan, S. G., Ali, S. K., Simpson, B., Britt, V. & McCall, W. V. Associations between sleep disturbance and suicidal ideation in adolescents admitted to an inpatient psychiatric unit. Int. J. Adolesc. Med. Health 26, (2014).
Bernert, R. A. & Joiner, T. E. Sleep disturbances and suicide risk: A review of the literature. Neuropsychiatr. Dis. Treat. 3, 735–43 (2007).
Photo credit: Matthew Henry