Nightmares and Hallucinations as Precursors of Rheumatic Autoimmune Diseases

Survey Among Hundreds of Patients and Doctors

The recently published British study was based on a survey involving 676 patients with systemic lupus erythematosus (SLE) and 400 doctors. Subsequently, in-depth interviews were conducted with 69 people living with a systemic autoimmune rheumatic disease, including 27 SLE patients, and 50 doctors who regularly encounter these diagnoses in clinical practice.

The focus was on neuropsychiatric (NP) symptoms, which present significant challenges in diagnosing and managing SLE and other SARDs, particularly in terms of their timing relative to disease onset. The researchers tested the hypothesis that NP symptoms might be prodromal to both the onset and flares of SARDs.

The study examined the timing of 29 neurological and mental symptoms, such as depression, hallucinations, or loss of balance. Patients were asked if they could identify the order in which these symptoms appeared. Clinical reports documenting the first episodes of NP symptoms and the onset of the disease were also analyzed.

Interrupted Dreaming as the Most Common Symptom

Among NP symptoms associated with SARDs, interrupted dreaming was reported most frequently. However, according to respondents, most cases occurred after disease onset. Nevertheless, following interviews with patients, researchers found that three out of five (61%) SLE patients and one in three (34%) individuals diagnosed with another SARD reported increased rates of interrupted dreaming, usually in the form of vivid and disturbing nightmares. Patients described dreams where they were physically attacked, such as being kidnapped.

Nightmares were found to precede hallucinations. When a less stigmatizing term like "daydreaming with open eyes" was used during research, it improved the acceptance of this experience. One British participant described their state as disorientation, comparing it to "Alice in Wonderland." In half (54%) of the cases, the first occurrence of hallucinations took place more than a year after disease onset.

Initial surveys suggested that, contrary to the assumptions of many rheumatologists and data from available literature, most NP symptoms did not appear before the documented onset of SARDs. However, in-depth interviews revealed that the entire spectrum of NP symptoms could indeed be prodromal to both disease onset and later flares. It was also shown that the progression of symptoms during disease onset varied significantly between patients, yet they closely resembled each other during individual flares for specific patients.

Do Not Overlook NP Symptoms

Patients who experienced daydreaming with open eyes were often reluctant to share their experiences. Conversely, many doctors admitted they had never considered nightmares and hallucinations as symptoms of SARD flares. Lead study author Melanie Sloan from the University of Cambridge emphasized the importance of doctors not only discussing NP symptoms with patients but also recording their individual development.

The importance of not overlooking NP symptoms is further underscored by the finding that some patients were initially misdiagnosed or even hospitalized for psychotic episodes or suicidal thoughts—later revealed to be early signs of SARDs. Therefore, consideration should be given not only to the timing of diagnosis but also to NP symptoms, as this may accelerate the identification and treatment of disease flares.

Editorial Team, Medscope.pro

Source: Sloan M., Burgeois J. A., Leschziner G. et al. Neuropsychiatric prodromes and symptom timings in relation to disease onset and/or flares in SLE: results from the mixed methods international INSPIRE study. eClinicalMedicine 2024 May 20; 73: 102634, doi: 10.1016/J.eclinm.2024.102634.