Bad Not-Quite-Dreams

December 31, 2008 8:00 AM

After many years of chronic depression I have finally achieved a reasonable facsimile of mental health. Except...

When I close my eyes for sleep I am troubled by visions of killing myself in various gruesome ways. These visions range from flashes to full-blown plans, but they are uniformly gory and highly disturbing. I do not know exactly how long this has been going on, but my guess is for at least half a year.

To be clear: I do not wish to harm myself or anyone else; when I do remember them (because these visions never jump from the pre-sleep stage to full-blown dream) I am disturbed but rarely suicidal. And I know myself well enough to realize when I need to take the necessary steps to ensure I will remain among the living.

I've been on these meds (zoloft and occasional trazadone) for a year and a half. After discussing the pre-sleep visions with my shrink, he doubled the recommended dose of trazadone from 50 to 100mg, and recommended I "try to think about something else." He did not have answers to my concerns about this advice, namely the increased dependency/decreasing effectiveness of trazadone over time. Also I am unsure how to follow the second bit of advice: how does one let one's mind relax while concentrating on something one is trying not to think about? (Don't think of purple anteaters!) (Too late!)

Although the visions of self-harm only occur when I prepare for sleep it is beginning to affect the rest of my life. I realized I was staying up later, and reading far beyond the point of being tired, in order to avoid them. They are that bloody.

Have you ever experienced this? How did you recover, or learn to deal with it?

Is it possible there is another factor at play here? Lack of exercise? Mold spores? Brain tumor?

I am a single mid-thirties male and can be reached at [e-mail].

posted by anonymous to health & fitness (19 comments total)

I don't know about brain tumors or mold spores, but I know that ever since I was first depressed as a teenager I have always entertained highly gruesome fantasies of my own death, mainly right before I fell asleep. It's almost as if they helped me sleep, as crazy as it may sound. It's worth noting that I'm not on any pills and no longer suffer depression though I still see those images from time to time. In short, I don't think you need to worry about it. I simply counted it off as something weird I do and ignored it. It can't actually hurt me, I've never actually gone through with anything (and how would I? I can't actually convince someone to break into my house and kill me while I'm sleeping) and have no desire to. I just let them play out in my mind and didn't worry about it and gradually it's gotten better. These days I hardly ever have such thoughts, and they never concern me.

I think it may be something about wanting to be in control of your own destiny, or perhaps it was my own little pity party inside my head (i.e. "everyone will be so sad if I died right now") but whatever it was, it never did me any harm.
posted by big open mouth at 8:09 AM on December 31, 2008

Not to overlook your history of depression, but can you treat this as just a sleeping problem? Find a book that offers some of the habits and tools you can try to fall asleep peacefully and easily. A friend of mine has an interest in lucid dreaming, and started reading a "how to" book. Though he's not experiencing astral projection or anything, he says that the meditation instructions are helping him fall asleep faster and he wakes up feeling more rested. Perhaps 10 minutes of guided meditation before you climb into bed will help you control your thoughts as you fall asleep?
posted by juliplease at 8:15 AM on December 31, 2008 [1 favorite has favorites]

I can't speak to whether there is a cause other than your depression, but I have experienced this. In my situation, it was oddly comforting, kind of like I'd imagine what cutters feel. In other words, I didn't actually want to do myself harm, but the fantasy was strangely alluring. I knew I wouldn't do anything, so I gave myself permission to think about it. They went away when my doctor upped my dose of Lamictal. (Lamictal + Klonopin before bed = too sleepy and content to think about much of anything.) Another crucial aspect was confronting the things and people in my life that weren't working. Learning to be assertive and feeling in control of my life reduces the need to fantasize about asserting the "ultimate" control (killing myself).

Other than that, I would recommend trying mindfulness meditation before bed, as it trains you to be able to focus your mind and let go of disturbing thoughts. I would also recommend exercise that makes you really tired. Don't watch TV right before bed; let your mind relax and chill. Take a hot bath/shower, drink warm milk, try all the tricks for insomnia and stress relief.
posted by desjardins at 8:17 AM on December 31, 2008

Sounds like some obsessive compulsive disorder. I used to deal with a variant of this.

I read some stuff on some OCD support groups that helped a ton. Basically, I think you need to just accept the thoughts as OCD thoughts, they don't have anything to do with you. Once you accept them as just annoyances, they will probably lessen. Mine have diminished to almost nothing, and when they do come up, I can laugh them off.

It's good that you understand that you are not suicidal. So you understand that the thoughts are not manifested by any inner urge. That's 50% of it right there.

I would look online about OCD and cognitive ways to deal with it. I don't think you need to medicate this, unless some thoughtful analysis doesn't help.
posted by sully75 at 8:25 AM on December 31, 2008 [2 favorites has favorites]

PS I'm not an anything. Just have dealt with this myself in the past. YMMV
posted by sully75 at 8:26 AM on December 31, 2008

After discussing the pre-sleep visions with my shrink, he doubled the recommended dose of trazadone from 50 to 100mg, and recommended I "try to think about something else."

(raised eyebrows) Is there any way you can get a second opinion? Because that sounds a little...dismissive.

But if it's any consolation, I did have one night when something like this happened -- I was on vacation driving through the Southwest, and one night right when I was falling asleep I suddenly was plagued with very graphic and detailed flashes of mental images of losing control of the car I was in and soaring headlong off the sides of cliffs and plunging into the Grand Canyon or the like. After a few minutes of wondering why in hell I was so obsessed with that, I realized that I had been driving along those kinds of cliffs for that whole entire day and had been spending all that time supressing the fear that I would lose control of the car, but that fear still had to go someplace, so my brain kept it under lock and key so I could concentrate on my driving -- and once I was finally somewhere safe it unlocked that fear and told my brain, "Okay, go nuts, get this out of your system."

This may be the same thing -- your brain may have been supressing this fear that you would harm yourself, maybe, and it shut it away until it knew you were safe. And then when you were safe, this fear still needed somewhere to go, so it let that fear out now that you were in a place where you wouldn't actually give in to it, and that fear is now just burning itself out.

Issuing the caveat that I'm neither a doctor nor a psychologist, and I'm basing that theory entirely on that one driving-off-cliffs incident from my own life. But if that theory makes sense to you, there it is.
posted by EmpressCallipygos at 9:07 AM on December 31, 2008 [1 favorite has favorites]

Some kind of cognitive OCD (or "thinking OCD", as it is called on some peer support fora) was my first reaction, too. It's possible that your shrink didn't pick up on this because it seems that even some mental health professionals have trouble recognising it, if the obsessive thoughts don't come with some form of compulsive behaviour.

My own symptoms have been much alleviated by learning basic mindfulness meditation. It's not just the practice but the perspective: stepping back and disengaging from the loop. It's just my brain chattering. I am not my thoughts.
posted by sively at 9:15 AM on December 31, 2008

Third with "obsessive only" OCD. Realize that obsessions are often about taboo or guilt-inducing subjects (cleanliness, disease, death).

I remember having a conversation with a friend who deals with schizophrenia about the differences in our disorders. She commented that, with schizophrenia, the voices would be telling her to cut her wrists. I explained the OCD version was to have intrusive fantasies about accidentally cutting my wrists on a broken glass, and then putting on three pairs of leather gloves next time I broke a glass.
posted by lleachie at 9:21 AM on December 31, 2008

You should get more information about the side-effects of Sertraline and Trazodone, both of which are poorly-understood, side-effect-ridden compounds. If they were working as advertised, it is likely that you would have no trouble falling asleep since both are sold as "sleep aids." Talk to someone else about medication adjustment.
posted by Electrius at 9:38 AM on December 31, 2008

Lots of good thoughts and advice here, and yeah, it sounds like OCD and I would try to find coping mechanisms to deal with the "brain chatter", rather than taking it as a sign that you really are a suicide risk. It could be medication that you settle on, but I am also nthing the meditation recommendation, though you may want to take a class, to have someone help you learn the process.

When all else fails, the thing that seems to help me with intrusive thoughts when I am trying to go to sleep (YMMV, of course), is to make up and tell myself stories. They may be inspired by movies, favorite books, or just something that pops into my head, but usually when I am trying to go to sleep I have a continuing narrative that has a fairly dramatic storyline that I dip back into, and that is usually enough to distract me long enough to fall asleep.
posted by gudrun at 9:47 AM on December 31, 2008

I've always been wary of Trazadone's use as a long term sleep aid. At what point of use frequency and duration does one also start to experience the tricyclic anti-depressant effect of the drug, and how does that interact with the other anti-depressants and assorted psychoactives that it's often bundled with? Doctors are doing this more and more with Seroquel, too, I've had a lot of clients without psychotic disorder histories using it just to get to sleep. What are the long term effects of using an antipsychotic as a sleep aid? I think it's definitely worth getting another medical opinion about the trazadone if your psychiatrist's flip answer doesn't satisfy you.
posted by The Straightener at 9:52 AM on December 31, 2008

One really helpful and sort of sad thing I remember about the OCD was people who were obsessed with the idea that they might harm their children. The idea was, if you are OCD, you worry about harming your children, even though you never would (unless maybe I guess if you somehow freaked yourself out enough to sort of fulfill your fear). But you torture yourself about it. But an actual psychopath would take pleasure in fantasizing about killing their children. It would excite them. Not disgust them.

Anyway. That was meaningful to me because the thoughts I was having were really disturbing to me, and ultimately I realized that they were not a part of me. Or at least, they were not a meangnful and significant part of me, if I didn't let them be.

Good luck!
posted by sully75 at 10:20 AM on December 31, 2008

Some individuals experience suicidal thoughts when taking trazadone, or when undergoing dosage changes. "If taken carelessly, Trazadone, like almost all other antidepressants, may aggravate depression and increase the intensity of suicidal thoughts or attempts."

Also, the FDA issued a warning that antidepressants such as trazadone may increase risk of suicidal thoughts and behaviors in teens and children.

If you continue to experience these thoughts, contact your doctor again and ask that he reevaluate you to determine whether another pharmaceutical therapy might be more prudent. If he ignores your concerns, please seek a second opinion.
posted by terranova at 10:20 AM on December 31, 2008

When I first started Zoloft (sertraline) every night I would have extremely vivid, extremely bizarre, frequently disturbing, dreams. Even worse, from my perspective, was that I remembered them in exquisite detail the next morning. My guess is you're experiencing some kind of side effect from your meds.

Oddly, since I switched to the generic sertraline, the dreams come only rarely. Anyway, definitely get a second opinion if you keep having this problem.
posted by orrnyereg at 11:20 AM on December 31, 2008

I've had the exact same thing, intermittently, for several years now, including the changed sleep habits. Sometimes, like you, it can take a while to for me to acknowledge to myself that the reason I'm staying up unreasonably late is that I want to be dead tired, so tired I'll just conk out within minutes, before I even try to sleep. I think of it as one of those things, like the viruses that never leave your body; a persistent meme, if you like. I don't think it's OCD, really; it's more like I'm trying to say something to myself (often something simple like 'this new job is a bit stressful') and the only way it can be said is in this ridiculously crude language. I think the thoughts happen when preparing for sleep because that's when they aren't able to be drowned out by anything else. It's a vicious communication breakdown between one part of me and another, I think - as if someone were raising their voice because another person wasn't listening to them, and the other person then made a special effort to avoid the nasty shouting.

In your case, I'd say that the fact that the feeling part of you is shouting loudly rather than beating you up till you can't move (depression) is an improvement, of sorts.

In the short term, I have found listening with speech radio or audiobooks playing low in the background all night was very helpful. So was talking to a friend, who is now able to point out to me that it will eventually go, will probably come back again, and is more to do with various banal forms of stress than with mortal danger. In the long term, this is probably just a stage in your recovery from depression, and will respond well to the increased self-knowledge and self-care that depression responds to. It might, however, always be around in some form, because 'the unconscious, that irritating moron' can be very recalcitrant, and persuading it to communicate with nuance rather than just screaming and throwing stuff is pretty difficult sometimes. Respond like a good parent: resist being drawn into the drama, and instead try to work out if there's something going on that you can fix.
posted by Acheman at 11:24 AM on December 31, 2008 [2 favorites has favorites]

Been there. Nthing cognitive OCD. Mine used to start as soon as I woke up in the morning and were more intense just before bed when it's dark and the brain shuts down some of its natural inhibitory mechanisms. Believe it or not, I actually started going to bed at daybreak instead to reduce some of the misery. Not the best idea, but at the time I had no other way out of it.

A lot of people have been talking about pills in this thread. You should certainly look into the possibility that your problems are med-triggered or at least med-exacerbated. (Your psychiatrist absolutely needs to be responsive to what you tell her/him, by the way. If they're not, you need to either tell them so or look for a new pdoc.) But there's a chance that switching or altering dosage won't change anything, and in the meantime you need a way to improve your quality of life. So if you're not already, you need to start thinking about therapy.

I don't mean psychoanalysis. Look for a psychologist who specializes in cognitive behavioral therapy for OCD. CBT is often the gold standard for treating OCD. The goal of CBT applied to OCD is to give you tried-and-tested methods for coping with, and eventually turning off, the distressing thoughts. And as I've said in other threads, CBT along with medication (whether for OCD or for depression or another disorder) is known to be more effective than therapy alone or medication alone.

If you can't afford therapy or insurance doesn't cover it, then your best bet is to look for books on OCD coping strategies. I wish I could recommend some, but this one, The OCD Workbook, is the only one I know that other people actually use.

By the way, it's sometimes tempting to start romanticizing dark thoughts. Sometimes you can't get rid of them, so you start to try to milk whatever enjoyment you can from them. I don't mean that you'd actually enjoy the images, just that you might use them to convince yourself that you're a dark, tortured, terribly special soul. Don't fall into this trap. The relief it provides is false at best, feeble, temporary, and can lead to a rebound effect. Brains try to derive dopamine from whatever they can. I know it's difficult, but do your damnedest not to allow yours to get much from this.
posted by jeeves at 12:25 PM on December 31, 2008

you should probably ask for a referral to cognitive-behavioral psychologist. they can help you break those thought patterns (what to do when you have those thoughts) and replace them with more restful, relaxing thoughts (i.e. give you a mental routine to go through when you are trying to sleep).
posted by thinkingwoman at 2:06 PM on December 31, 2008

My guess is this is chemical and related to your meds. You shouldn't have to bend yourself into contortions and do a tremendous amount of work just to get yourself to sleep.

I have had something somewhat similar on nights where I have had bad dreams, often those involving delusions I had years ago. I just chalk it up to my inherent mental state (bipolar) breaking through my meds and take another one of my antipsychotic pills (Geodon) and go back to sleep.

This reminds me of those particularly bad times where it was very unpleasant to go to the kitchen to get the pills. Seeing knives around just was very, very scary. I couldn't stop thinking of the damage a knife could do. My brain wanted to fly off on all sorts of tangents involving cutting and general gruesomeness. I just got out of there as fast as I could.

Sometimes the brain just goes really wonky and adjusting the chemical mix can be all you need. (Not always, I am not an expert, etc. I just don't think that extended and arduous mental machinations are superior to popping the right pill, or avoiding popping the wrong pill.)

You might need a new psychiatrist. I realize it can be so very uncomfortable shopping for another but if you get a good one who will listen and work with you to get you the meds you really need for relief, it is like being given your life back. It is worth everything.
posted by marble at 5:40 PM on December 31, 2008

I agree w/ marble it's probably a chemical issue...getting a Psych doc who is curious and relentless in working with you and your meds till the problem is resolved is the direction I would go. I think docs are there to find the answers, not to tell you to work around the problem.
posted by mumstheword at 11:59 PM on December 31, 2008