Elsevier

Sleep Medicine

Volume 14, Issue 11, November 2013, Pages 1164-1169
Sleep Medicine

Original Article
Sleep disturbances in a clinical forensic psychiatric population

https://doi.org/10.1016/j.sleep.2013.03.008Get rights and content

Abstract

Objective

Poor sleep is known to cause detrimental effects on the course of diverse psychiatric disorders and is a putative risk factor for hostility and aggression. Thus, sleep may be crucial in forensic psychiatric practice. However, little is known about the prevalence of sleep disturbances in these complex psychiatric patients.

Methods

In this study we investigated the presence of sleep disorders and subjective sleep quality using the Sleep Diagnosis List (SDL), the Pittsburgh Sleep Quality Index (PSQI), interviews addressing the causes of sleep complaints, and file information on sleep medications in 110 patients admitted to a forensic psychiatric hospital.

Results

Almost 30% of the participants suffered from one or more sleep disorders, especially insomnia. An even larger proportion of the participants (49.1%) experienced poor sleep quality. Interestingly, patients with an antisocial personality disorder or traits were particularly dissatisfied with their sleep. The most common causes of sleep problems were suboptimal sleep hygiene, stress or ruminating, negative sleep conditioning, and side effects of psychotropic medication. Of the poor sleepers, 40.7% received a hypnotic drug.

Conclusion

Despite intensive clinical treatment, sleep problems are experienced by a large number of forensic psychiatric patients. It would be worthwhile to examine the effects of pharmacological and non-pharmacological sleep interventions on both psychiatric symptoms and reactive aggressive behavior in forensic patients.

Introduction

Sleep disturbances are common in individuals with psychiatric disorders [1]. For example, sleep problems are present in approximately 80% of patients with a major depressive disorder (MDD) [2], in 30% to 80% of patients with schizophrenia [3], and in at least 55% of individuals with active substance abuse [4], [5]. Although these sleep disturbances often are secondary to the psychiatric illness, recent observations strongly suggest that sleep disorders should be actively treated parallel to the psychiatric disorder. The few studies regarding this matter indicate that separate treatment of comorbid sleep disturbances exerts positive effects on the course of the psychiatric disorder and may prevent relapses [6]. For instance in female sexual assault survivors, imagery rehearsal therapy with a focus on nightmares was found to alleviate both insomnia and other symptoms of a posttraumatic stress disorder (PTSD) [7]. In schizophrenic patients, music relaxation played at bedtime has been shown to reduce subjective and objective insomnia complaints as well as total psychopathology score on the Positive and Negative Syndrome Scale [8]. Moreover, studies in patients with MDD showed that pharmacological and cognitive behavioral treatment of sleep disturbances may enhance the antidepressant response to psychopharmacologic drugs [9], [10], [11].

Because a lack of sleep is associated with emotional instability, short temperedness, hostility, and aggression [12], sleep disturbances may be particularly detrimental for aggressive populations, such as forensic psychiatric patients. Anecdotal evidence suggests that treatment of sleep disturbances can reduce aggression [13], [14], [15]. Although clinical observations suggest that sleep problems are common in forensic psychiatric patients, epidemiologic studies on this topic are lacking. The aims of this study, therefore, were to examine in a clinical forensic psychiatric population i) the prevalence of sleep disorders, ii) sleep quality and sleep problems, iii) the association between poor sleep and psychiatric disorders, iv) perceived causal and perpetuating factors of sleep difficulties, including sleep hygiene behavior and v) the treatment of sleep disturbances.

Section snippets

Participants and procedure

Participants were recruited from two forensic psychiatric hospitals in the Netherlands, the Forensic Psychiatric Centre (Dr. S. Van Mesdag) in Groningen and the Forensic Psychiatric Hospital in Assen. Patients who were present at the weekly group meetings on their unit received written and oral information from the first author. It was made clear to them that they had the right to refuse participation and that this would not affect future treatment. After 2 weeks of consideration, participating

Participant characteristics

Characteristics of the participants are shown in Table 1. The majority of the sample were men (97.3%). The mean age of the sample was 36.6 ± 10.2 (standard deviation) years, ranging from 21 to 77 years. Nearly all participants were sentenced by the criminal court for a violent offence. More than 40% of participants did not enter or finish high school. At the time of the investigation, the average duration of admission in the hospital was 28.9 ± 32.1 months, ranging from a few days to over 14 years.

Discussion

The goal of our study was to determine the prevalence of sleep problems in a clinical forensic psychiatric population. We found that close to 30% of the forensic psychiatric patients had a sleep disorder, with insomnia being the most frequent. Because the instrument used to assess insomnia focuses on relatively severe and chronic insomnia, the finding that approximately 20% of the forensic psychiatric patients had insomnia is considerable. For comparison, a prevalence rate of only 4% was found

Conclusion

Our study shows that sleep disorders and poor sleep quality are experienced by a large part of clinical forensic psychiatric patients. This is highly relevant, as poor sleep may exacerbate psychiatric symptoms and aggressive reactivity, which in turn may increase the risk for recidivism. Patients with antisocial traits or PD seem to be especially at risk for poor sleep quality. Precipitating and perpetuating factors of sleep problems in forensic psychiatric patients are diverse, but clinicians

Conflict of interest

The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2013.03.008.

. ICMJE Form for Disclosure of Potential Conflicts of Interest form.

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