Cases That Test Your Skills A veteran who is suicidal while sleeping Piyush Das, MD, and Taru Dutt, MBBS Mr. R, age 28, is a veteran with major depressive disorder and How would you PTSD. One night while asleep, he puts an unloaded gun in his handle this case? mouth and pulls the trigger. What could be causing this behavior? Answer the challenge questions throughout this article CASE Suicidal while asleep The authors’ observations Mr. R, age 28, an Iraq and Afghanistan veteran Parasomnias are sleep-wake transition with major depressive disorder and posttrau­ disorders classified by the sleep stage matic stress disorder (PTSD), is awoken by his from which they arise, either NREM or wife to check on their daughter approximately rapid eye movement (REM). NREM para- 30 minutes after he takes his nightly regimen of somnias could result from incomplete zolpidem, 10 mg, melatonin, 6 mg, and hydroxy­ awakening from NREM sleep, typically zine, 20 mg. When Mr. R returns to the bed­ in Stage N3 (slow-wave) sleep.1 DSM-5 room, he appears to be confused. Mr. R grabs describes NREM parasomnias as arousal an unloaded gun from under the mattress, disorders in which the disturbance is not puts it in his mouth, and pulls the trigger. Then attributable to the physiological effects of Mr. R holds the gun to his head and pulls the substance; substance/medication-induced trigger while saying that his wife and children sleep disorder, parasomnia type, is when will be better off without him. His wife takes the disturbance can be attributed to a sub- the gun away, but he grabs another gun from stance.2 The latter also can occur during his gun box and loads it. His wife convinces him REM sleep. to remove the ammunition; however, Mr. R gets NREM parasomnias are characterized the other unloaded gun and pulls the trigger by abnormal behaviors during sleep with on himself again. After his wife takes this gun significant harm potential.3 Somnambulism away, he tries cutting himself with a pocket­ or sleepwalking and sleep terrors are the knife, causing superficial cuts. Eventually, 2 types of NREM parasomnias in DSM-5. Mr. R goes back to bed. He does not remember Sleepwalking could involve complex behav- these events in the morning. iors, including: • eating What could have caused Mr. R’s nighttime • talking suicidal behavior? Dr. Das is Staff Psychiatrist and Somnologist, VA Medical Center, a) severe depression with suicidal ideations Grand Island, Nebraska, and Assistant Clinical Professor of b) personality disorder Psychiatry, Creighton University School of Medicine, Omaha, Nebraska. Dr. Dutt is Research Fellow, Department of Neurology, c) non­rapid eye movement (NREM) sleep Mayo Clinic College of Medicine, Rochester, Minnesota. arousal disorder/NREM parasomnia Disclosures The authors report no financial relationships with any company d) substance/medication­induced sleep whose products are mentioned in this article or with manufacturers Current Psychiatry disorder, parasomnia type of competing products. Vol. 16, No. 4 43 Cases That Test Your Skills • cooking initial 20 mg.9 Because the patient remem- • shopping bered the suicidal thoughts, the authors • driving believed that the patient attempted suicide • sexual activity. while under the influence of zolpidem. The Zolpidem, a benzodiazepine receptor authors did not believe the incident to be agonist, is a preferred hypnotic agent for sleep-related suicidal behavior, because it insomnia because of its low risk for abuse was uncertain if he attempted suicide while and daytime sedation.4 However, the drug asleep. has been associated with NREM parasom- Mr. R does not remember the events nias, namely somnambulism or sleepwalk- his wife witnessed while he was asleep. ing, and its variants including sleep-driving, To our knowledge, Mr. R’s case is the first sleep-related eating disorder, and rarely sleep-related pseudo-suicidal behavior case Clinical Point sexsomnia (sleep-sex), with anterograde resulting from zolpidem, 10 mg/d, with- amnesia for the event.5 Suicidal behavior out concurrent alcohol use in an adult male Zolpidem is preferred that occurs while the patient is asleep with veteran with PTSD and no suicidal ideation for insomnia because next-day amnesia is another variant of som- while awake. of its low risk for nambulism. There are several reports of abuse and daytime suicidal behavior during sleep,6,7 but to our HISTORY sedation; however, knowledge, there are only 2 previous cases Further details revealed implicating zolpidem as the cause: Mr. R says that in the days leading to the it is associated with • Gibson et al8 described a 49-year-old incident he was not sleep­deprived and was NREM parasomnias man who sustained a self-inflicted gunshot getting at least 6 hours of restful sleep every wound to his head while asleep. He just had night. He had been taking zolpidem every started taking zolpidem, and in the weeks night. He has no childhood or family history of before the incident he had several episodes NREM parasomnias. He says he did not engage of sleepwalking and sleep-eating. He had in intense exercise that evening or have a fever consumed alcohol the night of the self- the night of the incident and has abstained inflicted gunshot wound, but had no other from alcohol for 2 years. psychiatric history. His wife says that after he took zolpidem, • Chopra et al4 described a 37-year-old when he was woken up, “He was not there; man, with no prior episodes of sleepwalk- his eyes were glazed and glossy, and it’s like ing or associated complex behaviors, who he was in another world,” and his speech and was taking zolpidem, 10 mg/d, for chronic behavior were bizarre. She also reports that insomnia. He shot a gun in the basement of his eyes were open when he engaged in this his home, and then held the loaded gun to behavior that appeared suicidal. his neck while asleep. The authors attrib- Three months before the incident, Mr. R had uted the event to zolpidem in combination reported nightmares with dream enactment with other predisposing factors, including behaviors, hypervigilance on awakening and dehydration after intense exercise and alco- during the daytime, irritability, and anxious and hol use. The authors categorized this type of depressed mood with neurovegetative symp­ Discuss this article at event as “para-suicidal amnestic behavior,” toms, and was referred to our clinic for medica­ www.facebook.com/ although “sleep-related pseudo-suicidal tion management. He also reported no prior or CurrentPsychiatry behavior” might be a better term for this current manic or psychotic symptoms, denied type of parasomnia because of its occurrence suicidal thoughts, and had no history of suicide during sleep and non-deliberate nature. attempts. Mr. R’s medication regimen included In another case report, a 27-year-old man tramadol, 400 mg/d, for chronic knee pain; took additional zolpidem after he did not fluoxetine, 60 mg/d, for depression and PTSD; Current Psychiatry 44 April 2017 experience desired sedative effects from an and propranolol ER, 60 mg/d, and propranolol, Cases That Test Your Skills 10 mg/d as needed, for anxiety. He was started sleep-related suicidal behavior related to on prazosin, 2 mg/d, titrated to 4 mg/d, for zolpidem, 10 mg at bedtime, concomitant medication management of nightmares. dehydration and alcohol use were impli- Mr. R also was referred to the sleep labora­ cated as facilitating factors. Dehydration tory for a polysomnogram (PSG) because of could increase serum levels of zolpidem reported loud snoring and witnessed apneas, resulting in greater CNS effects. Alcohol especially because sleep apnea can cause use was implicated in the Gibson et al8 nightmares and dream enactment behav­ case report as well, and the patient had iors. The PSG was negative for sleep apnea or multiple episodes of sleepwalking and excessive periodic limb movements of sleep, sleep-related eating. However, Mr. R was but showed increased electromyographic not dehydrated or using alcohol. (EMG) activity during REM sleep, which was An interesting feature of Mr. R’s consistent with his report of dream enactment case is that he was taking fluoxetine. Clinical Point behaviors. Two months later, he reported Cytochrome P450 (CYP) 3A4 is involved improvement in nightmares and depres­ in metabolizing zolpidem, and norfluox- Gabapentin, which sion, but not in dream enactment behaviors. etine, a metabolite of fluoxetine, inhib- is known to increase Because of prominent anxiety and irritabil­ its CYP3A4. Although studies have not the depth of sleep, ity, he was started on gabapentin, 300 mg, 3 found pharmacokinetic interactions was added to Mr. R’s times a day. between fluoxetine and zolpidem, these regimen a month studies did not investigate fluoxetine before the event What increased the likelihood of parasomnia dosages >20 mg/d.11 The inhibition of in Mr. R? CYP enzymes by fluoxetine likely is dose- a) high zolpidem dosage dependent,12 and therefore concomitant b) concomitant use of other sedating agents administration of high-dosage fluoxetine c) sleep deprivation (>20 mg/d) with zolpidem might result in d) dehydration higher serum levels of zolpidem. Mr. R also was taking several sedating agents (gabapentin, hydroxyzine, melato- The authors’ observations nin, and tramadol). The concomitant use of Factors that increase the likelihood of para- these sedative-hypnotic agents could have somnias include: increased his risk of parasomnia. A review • zolpidem >10 mg at bedtime of the literature did not reveal any reports • concomitant use of other CNS depres- of gabapentin, hydroxyzine, melatonin, sants, including sedative hypnotic or tramadol causing parasomnias. This agents and alcohol observation, as well as the well-known • female sex role of zolpidem5 in etiopathogenesis of • not falling asleep immediately after parasomnias, indicates that the pseudo- taking zolpidem suicidal behavior Mr.