Does the duration of sleep disturbance increase suicide risk?
Article in Review: Nadorff, M, Nazem, S & Fiske, A. (2013) Insomnia symptoms, nightmares, and suicide risk: Duration of sleep disturbance matters. Suicide and Life Threatening Behaviour, 43(2), 139-149.
Summary: Exploring the role of sleep disturbance in suicidality and what clinicians should consider when working with clients experiencing ongoing sleep disturbance.
Investigating the factors that increase risk of suicide is important, for practitioners and researchers alike. In past studies , it was determined that there is an association between insomnia symptoms, nightmares, and suicidal ideation. However, it remained unclear how suicidal behaviour is connected with sleep disturbance. The research completed by Nadorff, Nazem, and Fiske (2013) will be specifically considered herein, as it seeks to further explain this association by investigating the effect of insomnia symptoms and nightmare duration on suicidality. (For in depth consideration, please refer directly to the research, reference provided below) In order to determine if the duration of these sleep disturbances were independently associated to suicide risk, the research controlled for anxiety symptoms, depressive symptoms and posttraumatic symptoms.
One consideration postulated the relationship between insomnia and suicidality was due to the negative social and emotional impacts that result from unrelenting experiences of insomnia symptoms. Insomnia can leave individuals feeling unmotivated and fatigued, leading to a decrease in life aspirations. The latter can co-occur with feelings of isolation, resulting in a cumulative negative effect that may cause the individual to believe that they are a burden.
As discussed previously in ‘What factors influence the disclosure of suicidal ideation?’ (28 January 2016) perceived burdensomeness can be an inhibiting factor for suicidal disclosure, and thus can decrease our ability to help individuals who are at risk of suicide.
In relation to the impact of nightmares on suicidality, previous research noted that individuals who experience persistent nightmares may often feel “unable to escape the distress and impairment” that they cause. This can lead to feelings of despair, which has been closely associated with suicidal behaviour. Not surprisingly, the longer these sleep disturbances last, the more severe the negative effects become, and the greater the risk of death by suicide.
What was Nardorff and colleagues investigating?
The aim of the study was to characterise the relationship between insomnia, nightmares and suicidality. It was hypothesised that the duration of persistent insomnia (months/years) would correlate with increased suicidality.
Secondly, Nardorff and colleagues postulated that the duration of nightmares would correlate with increased risk for suicide, irrespective of the current severity of nightmares.
Finally, it was hypothesised that after controlling for psychiatric symptoms (depression, anxiety, PTSD) that insomnia and nightmare duration would be predictive of increased risk for suicidality.
Does the duration of sleep disturbance and nightmare matter?
It was confirmed that the duration of insomnia symptoms is significantly associated with suicide risk (Nardorff et al. 2013). This was reported to be an interesting finding, as the insomnia and suicidality had previously been attributed psychological (primarily depressive) symptoms. As such, these findings are suggestive of differing underlying mechanisms leading to suicidality for sleep disorders versus other psychological disorders.
Similarly, the research found that there is a connection between the duration of nightmares and suicide risk (Nardorff et al. 2013). This finding is consistent with previous research. Of note, the research confirmed that the nature and severity of a person’s nightmare history was correlated with suicide risk, regardless of psychological or psychiatric symptoms.
Finally, there appears to be a combined effect of duration of insomnia and nightmares on suicidality, independent of psychiatric symptoms.
What does this mean for intervention and safety planning?
Past research has instructed clinicians to not use nightmare treatments with suicidal clients due to the concern that it may cause the symptoms to worsen before they decrease in severity, increasing the imminent risk of suicide. However, this research provides a different perspective, suggesting that the longer the symptoms last, the more sever they become. From this, it is clear that how you work is extremely important and as we should never undertake a process without clear knowledge of the risks, always seeking to keep our clients safe.
Further research is required before clear practice recommendations are made with respect to working with nightmares and suicidality. However, it is suggested that when working with clients experiencing persistent insomnia and nightmares the following should be considered:
For the client
- Do they have adequate grounding techniques for managing distress upon awaking from a nightmare
- Can they establish their safety upon waking (extended from grounding strategies)
- Ask them how they conceptualise their insomnia/nightmares – what does it mean for them?
- Do they follow recommended sleep hygiene practices? (ie. stop sleeping during the day)
- Are they doing anything before sleep that may be sabotaging the quality of their sleep?
For the clinician
- Aim to understand the origins of the nightmares. For example, if they are trauma based, a best practice trauma therapy may alleviate insomnia/nightmares indirectly without working directly with the nightmare
- Review whether medications are impacting on their sleep patterns – sleeping pills should not be used for extended periods of time – if this is relevant, talk to them about it, refer them back to the prescriber or suggest they take a second opinion
- Do they need a referral to a sleep disorder clinic or specialist?
- If pain is involved in insomnia, do they need a referral to a pain clinic/specialist?
- Do not make assumptions of risk based on psychiatric/psychological symptoms alone. Risk for suicide is not a function of the severity of psychiatric symptoms
There are likely multiple other useful strategies and considerations!
Through the finding that insomnia duration is connected to suicide risk independent of depression, it is recommended that treatment for sleep disturbance (whether due to a sleep disorder or psychiatric disorder) may reduce risk for suicide.
Limitations are observed in that this research utilised a collage population as its sample, future studies should conduct such research on different age groups and particularly a clinical sample, to determine the validity of the findings.
Ultimately, this research paves the way for further research into the association between insomnia symptoms, nightmare duration and suicide risk to enhance our capacity to detect and intervene on high risk suicidal individuals.
Nadorff, M, Nazem, S & Fiske, A. (2013) Insomnia symptoms, nightmares, and suicide risk: Duration of sleep disturbance matters. Suicide and Life Threatening Behaviour, 43(2), 139-149.
First published 25 February 2016
By Carmen Betterridge