Original ArticleSleep disturbances in a clinical forensic psychiatric population
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.
References (40)
- et al.
Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders
Clin Psychol Rev
(2005) - et al.
Short-term cotherapy with clonazepam and fluoxetine: anxiety, sleep disturbance and core symptoms of depression
J Affect Disord
(2000) - et al.
Eszopiclone co-administered with fluoxetine in patients with insomnia co-existing with major depressive disorder
Biol Psychiatry
(2006) - et al.
Poor sleep as potential causal factor in aggression and violence
Sleep Med
(2012) - et al.
Reduced aggression in two inpatient children with the treatment of their sleep disorder
J Am Acad Child Adolesc Psychiatry
(2002) - et al.
The validity of the Dutch sleep disorders questionnaire (SDQ)
J Psychosom Res
(1998) - et al.
The Pittsburgh sleep quality index: a new instrument for psychiatric practice and research
Psychiatry Res
(1989) - et al.
Restless legs syndrome as side effect of second generation antidepressants
J Psychiatry Res
(2008) - et al.
Periodic leg movements in sleep and periodic limb movement disorder: prevalence, clinical significance and treatment
Sleep Med Rev
(2006) - et al.
Prevalence of restless legs syndrome in North American and Western European populations: a systematic review
Sleep Med
(2011)
Prevalence of self-reported clinically diagnosed sleep apnea according to obesity status in men and woman: National Health and Nutrition Examination Survey, 2005–2006
Prev Med
A behavioral perspective on insomnia treatment
Psychiatr Clin North Am
The treatments of chronic insomnia: a review of benzodiazepine receptor agonists and psychological and behavioral therapies
Sleep Med Rev
Sleep and psychiatry
Dialogues Clin Neurosci
Sleep and depression
J Clin Psychiatry
Sleep disturbances in patients with schizophrenia: impact and effect of antipsychotics
CNS Drugs
Sleep disorders in substance abusers. How common are they?
Psychiatry
Sleeping problems among Chinese heroin-dependent individuals
Am J Drug Alcohol Abuse
Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial
JAMA
The effects of music relaxation on sleep quality and emotional measures in people living with schizophrenia
J Music Ther
Cited by (30)
Associations of sleep problems with non-physical bullying perpetration and victimization among adolescents: A cross-lagged panel study
2023, Sleep HealthCitation Excerpt :On the other hand, several studies have declared that aggressive behaviors might increase sleep problems. For example, Kamphuis and colleagues discovered that more than half of the patients with aggressive traits suffered from sleep problems.17 Another research focused on the community people (64% Caucasian, 32% African American, and 4% Hispanic), revealing that the association between interpersonal conflict and sleep disturbance was higher among people with aggressive traits.18
Insomnia in personality disorders and substance use disorders
2020, Current Opinion in PsychologyCitation Excerpt :A growing field of research focuses on the relationship between insomnia and PDs. Studies show that 50% to 93% of individuals with a PD experience at least one sleep problem or self-identify as insomnia sufferers [6,7,8]. Conversely, more than 50% of individuals with insomnia received at least one PD diagnosis [9•].
Recent advances in understanding physical health problems in personality disorders
2018, Current Opinion in PsychologyCitation Excerpt :For instance, patients with sleep disturbance screened positive for Cluster C PDs at high rates (50%) [13]. In addition, forensic patients with (versus without) antisocial PD reported higher sleep dissatisfaction [14]. An epidemiological study focused on borderline PD found that PD symptoms were associated with poorer subjective sleep quality [15], comparable to that of individuals with other mental health problems.
Prevalence of sleep disorders and severity of insomnia in psychiatric outpatients attending a tertiary level mental health care facility in Punjab, India
2018, Asian Journal of PsychiatryCitation Excerpt :Kaufmann et al. (2011), found 78% of their study population to have some sleep problem. In a study of forensic psychiatric population, the prevalence was found to be 30% (Kamphuis et al., 2013). As recorded by Berlin et al. (1984), out of 100 consecutive psychiatric outpatients, 80 had sleep disorder of which 72 had insomnia.