Clinical Experience
Dr. D’Cruz has spent approximately 30 years seeing patients with lupus. “The patients are not just reporting dreams,” he says. “They frequently report severe nightmares that are terrifying.”
These nightmares include people trying to kill them or life-threatening events directed at the patient or family. They can also include alarming experiences, such as relatives dying in car or airplane accidents or large objects hurtling toward the dreamer. Taken together, repeated nightmares can be classified as nightmare disorder.
Although Dr. D’Cruz acknowledges that neuropsychiatric lupus “is still a big black box in rheumatology,” he considers these nightmares to be the telltale sign of neuropsychiatric lupus. Unfortunately, says Dr. D’Cruz, patients who report nightmares often also have suicidal ideation that they haven’t mentioned to anyone.
Dr. D’Cruz explains that although depressive and anxiety symptoms are commonly experienced as a reaction to increased disease activity, experiencing these symptoms, as well as nightmares, before a flare is potentially more suggestive of the direct impact of an incipient lupus flare on the brain, as opposed to the brain’s reaction to a flare.
Dr. D’Cruz and Dr. Sloan propose that these nightmares and disrupted sleep patterns may indicate heightened cerebral arousal related to the immunological inflammation associated with systemic lupus erythematosus (SLE). The hypothesis is consistent with research suggesting neuropsychiatric lupus is associated with autoantibody, cytokine production within the central nervous system and blood-brain barrier disruption. Consistent with this, Dr. D’Cruz has found nightmares often subside as the lupus flare is treated.
Neuropsychiatric lupus involves cerebral inflammation, says Dr. D’Cruz, but brain scans and cerebrospinal fluid analysis are often normal and, therefore, not diagnostic. Moreover, while an electroencephalogram (EEG) can sometimes be abnormal in patients with neuropsychiatric lupus, an EEG is rarely helpful for diagnosis. Neuropsychiatric lupus must be diagnosed clinically.
A comparison of a patient with schizophrenia to a patient with lupus and neuropsychiatric symptoms, explains Dr. D’Cruz, reveals that patients with lupus and psychosis can differ in several ways. For example, patients with neuropsychiatric lupus who experience hallucinations often have some insight into realizing these symptoms are part of their lupus. Patients with neuropsychiatric lupus may also experience seizures. Neuropsychiatric symptoms can first present at any stage in the SLE disease course. Dr. D’Cruz and his colleagues recommend that, when attributing neuropsychiatric symptoms to lupus, rheumatologists consider the timing of those symptoms relative to the timing of SLE symptom onset.
