There is a well-established link in the sleep research literature between nightmares and suicide. Nightmares have been firmly established as a predictor of both suicidal ideation and suicide. However, too few clinicians ask about nightmares, and too few people who suffer from nightmares talk about them. This is despite the presence of several empirically-supported, effective treatments available to therapists.
It is important to distinguish between those who experience occasional nightmares and those with a diagnosis of nightmare disorder because it is only those whose nightmares cause clinically significant distress and impairment in functioning that fall into the danger zone. This is about 5% of the general population and about one-third of those suffering from some form of psychopathology.
Avoiding talking about nightmares could be a clinical oversight
The sad fact is that very many people suffering from a dangerous level of nightmare distress do not get the help they need. They don’t talk about their distressing dreams, and too often, no one asks about them. If you, as a clinician, are reticent to discuss your client’s nightmares for fear of retraumatizing them, your good intentions may in fact do more harm than good. Colluding with the tendency traumatized individuals have to avoid talking about their symptoms could in fact be viewed as a clinical oversight. Given the positive clinical results in the research for even the most direct and prolonged exposure to the worst of the nightmare material, it appears to be much better to face than avoid nightmares.
According to a recent article in the Journal of Clinical Sleep Medicine (Nadorff et al., 2015), “Nightmares are a robust and modifiable predictor of increased suicidality and poor psychiatric outcomes, yet nightmare screening and treatment remain rare.” They conducted two studies into what proportion of nightmare sufferers report them to a health care provider and also looked into reasons for low reporting.
In a student sample of 747 student participants, they found that as few as 11 percent reported their nightmares to a health care provider. They also found that less than one-third of these believed nightmares are treatable, and those with the highest nightmare distress were less likely to believe treatment is possible. The researchers also studied a more general sample, and although more (29.6%) had reported their nightmares to a health care professional, only 20 to 30 percent of those who sought treatment felt they were helped by it.
Nightmares can be effectively treated
However, there are effective treatment for nightmares, and they are accessible to clinicians.
Many recent studies that have attempted to isolate the key active ingredients in psychotherapeutic nightmare treatments have failed to do so, because it appears that everything that has been developed to treat nightmares works, and with few, if any adverse effects.
The list of effective ingredients in the most well-established nightmare treatments include a sub-set of the following: rescripting a new dream ending, psycho-education about nightmares and trauma, relaxation techniques, imagining a safe place, imaginal and prolonged exposure, and writing about the dream (something that can be helpful even without a therapist). In several recent studies, researchers could find no different between nightmare treatment protocols with multiple elements and those that were stripped down for research purposes in an attempt to isolate the key active ingredient. All conditions, even an active waitlist control (imagining a safe place) had significant positive effects on those suffering from nightmares. This is an interesting and challenging problem for researchers, but at the same time, good news for clinicians. There appear to be many effective ways to help those with nightmares, and fewer risks than you might imagine.
Therapists who treat those with sleep problems, post-traumatic stress disorder, depression, anxiety and/or nightmares need to be aware of the link between suicide and nightmares. In addition, for those with nightmare disorder, there is an increased risk of suicide if the nightmares continue over time. To conclude, ask your clients about nightmares and if they are a problem, treat them as soon as possible. Time is of the essence.
If you are interested in learning more about nightmares and their treatment, sign up for my short, focused online course. Because I feel this material is important to disseminate, the course is always open, is self-paced, and currently discounted during the virus crisis. Please ask your clients if they have nightmares, and let them know they are treatable. CLICK HERE for a free PDF for clients: What You Can Do About Your Nightmares. Or check out our Short Focused Course on Nightmare Treatment using THIS LINK.