Cases That Test Your Skills

A veteran who is suicidal while sleeping

Current Psychiatry. 2017 April;16(4):43-49

Mr. R, age 28, is a veteran with major depressive disorder and PTSD. One night while asleep, he puts an unloaded gun in his mouth and pulls the trigger. What could be causing this behavior?

PDF Download

References

1. Howell MJ. Parasomnias: an updated review. Neurotherapeutics. 2012;9(4):753-775.
2. Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: American Psychiatric Association; 2013.
3. Zadra A, Desautels A, Petit D, et al. Somnambulism: clinical aspects and pathophysiological hypotheses. Lancet Neurol. 2013;12(3):285-294.
4. Chopra A, Selim B, Silber MH, et al. Para-suicidal amnestic behavior associated with chronic zolpidem use: implications for patient safety. Psychosomatics. 2013;54(5):498-501.
5. Hwang TJ, Ni HC, Chen HC, et al. Risk predictors for hypnosedative-related complex sleep behaviors: a retrospective, cross-sectional pilot study. J Clin Psychiatry. 2010;71(10):1331-1335.
6. Shatkin JP, Feinfield K, Strober M. The misinterpretation of a non-REM sleep parasomnia as suicidal behavior in an adolescent. Sleep Breath. 2002;6(4):175-179.
7. Mahowald MW, Schenck CH, Goldner M, et al. Parasomnia pseudo-suicide. J Forensic Sci. 2003;48(5):1158-1162.
8. Gibson CE, Caplan JP. Zolpidem-associated parasomnia with serious self-injury: a shot in the dark. Psychosomatics. 2011;52(1):88-91.
9. Mortaz Hejri S, Faizi M, Babaeian M. Zolpidem-induced suicide attempt: a case report. Daru. 2013;20;21(1):77.
10. Poceta JS. Zolpidem ingestion, automatisms, and sleep driving: a clinical and legal case series. J Clin Sleep Med. 2011;7(6):632-638.
11. Hesse LM, von Moltke LL, Greenblatt DJ. Clinically important drug interactions with zopiclone, zolpidem and zaleplon. CNS Drugs. 2003;17(7):513-532.
12. Catterson ML, Preskorn SH. Pharmacokinetics of selective serotonin reuptake inhibitors: clinical relevance. Pharmacol Toxicol. 1996;78(4):203-208.
13. Rosenberg RP, Hull SG, Lankford DA, et al. A randomized, double-blind, single-dose, placebo-controlled, multicenter, polysomnographic study of gabapentin in transient insomnia induced by sleep phase advance. J Clin Sleep Med. 2014;10(10):1093-1100.
14. Kato T, Montplaisir JY, Lavigne GJ. Experimentally induced arousals during sleep: a cross-modality matching paradigm. J Sleep Res. 2004;13(3):229-238.
15. Siclari F, Khatami R, Urbaniok F, et al. Violence in sleep. Brain. 2010;133(pt 12):3494-3509.
16. Husain AM, Miller PP, Carwile ST. Rem sleep behavior disorder: potential relationship to post-traumatic stress disorder. J Clin Neurophysiol. 2001;18(2):148-157.
17. Bernardy NC, Lund BC, Alexander B, et al. Increased polysedative use in veterans with posttraumatic stress disorder. Pain Med. 2014;15(7):1083-1090.
18. Lam SP, Fong SY, Ho CK, et al. Parasomnia among psychiatric outpatients: a clinical, epidemiologic, cross-sectional study. J Clin Psychiatry. 2008;69(9):1374-1382.
19. Freeman TW, Roca V, Kimbrell T. A survey of gun collection and use among three groups of veteran patients admitted to veterans affairs hospital treatment programs. South Med J. 2003;96(3):240-243.

CASE Suicidal while asleep

Mr. R, age 28, an Iraq and Afghanistan veteran with major depressive disorder and posttraumatic stress disorder (PTSD), is awoken by his wife to check on their daughter approximately 30 minutes after he takes his nightly regimen of zolpidem, 10 mg, melatonin, 6 mg, and hydroxyzine, 20 mg. When Mr. R returns to the bedroom, he appears to be confused. Mr. R grabs an unloaded gun from under the mattress, puts it in his mouth, and pulls the trigger. Then Mr. R holds the gun to his head and pulls the trigger while saying that his wife and children will be better off without him. His wife takes the gun away, but he grabs another gun from his gun box and loads it. His wife convinces him to remove the ammunition; however, Mr. R gets the other unloaded gun and pulls the trigger on himself again. After his wife takes this gun away, he tries cutting himself with a pocketknife, causing superficial cuts. Eventually, Mr. R goes back to bed. He does not remember these events in the morning.

What increased the likelihood of parasomnia in Mr. R?
a) high zolpidem dosage
b) concomitant use of other sedating agents
c) sleep deprivation
d) dehydration

The authors’ observations

Parasomnias are sleep-wake transition disorders classified by the sleep stage from which they arise, either NREM or rapid eye movement (REM). NREM parasomnias could result from incomplete awakening from NREM sleep, typically in Stage N3 (slow-wave) sleep.¹ DSM-5 describes NREM parasomnias as arousal disorders in which the disturbance is not attributable to the physiological effects of substance; substance/medication-induced sleep disorder, parasomnia type, is when the disturbance can be attributed to a substance.² The latter also can occur during REM sleep.

NREM parasomnias are characterized by abnormal behaviors during sleep with significant harm potential.³ Somnambulism or sleepwalking and sleep terrors are the 2 types of NREM parasomnias in DSM-5. Sleepwalking could involve complex behaviors, including:

eating
talking
cooking
shopping
driving
sexual activity.

A veteran who is suicidal while sleeping

References

CASE Suicidal while asleep

The authors’ observations

Pages

Recommended Reading