Depression and Sleep
“When you are alert and paying attention to something important, your cortex is aroused. When you are drowsy and not focusing on anything, the cortex is in the unaroused state. During sleep, the cortex is in the unaroused state, except during dream sleep when it is highly aroused. In dream sleep, in fact, the cortex is in a state of arousal that is very similar to the alert waking state, except that it has no access to external stimuli and only processes internal events.”
Joseph LeDoux. “The Emotional Brain.”
Disturbed sleep patterns are a distinct characteristic of depressive states. Most commonly
experienced is that of “early morning awakening” where the person has no difficulty falling asleep but springs awake in the early hours and is unable to return to sleep. Ironically, most people report that it is just as they are having to get up that they feel able and ready to sleep again. Very frustrating indeed.
The characteristic of sleep disturbances are:
- Impaired sleep continuity and duration
- Decreased deep sleep
- Decreased latency to the onset of REM sleep
- An increase in the proportion of REM sleep in the early part of the night
Less common than the typical early morning awakening are the other disturbances that affect the person so that he is unable to remain asleep and fails to reach any satisfying depth of sleep. In another form, we see the person who takes an unreasonable length of time to fall asleep, but once there generally sleeps well and the person who has slept excessively but continues to feel exhausted when awake during the daytime.
Sleep deprivation experiments demonstrate that prolonged deprivation results in hallucinations and delusions. Longer studies of sleep deprivation in rats demonstrate a syndrome that features physical debilitation, skin problems, increased food intake, weight loss, lowering of body temperature and eventually death.
Curiously an observation with severely depressed patients suggests that short-term sleep
deprivation temporarily improves their depressive symptoms. We can compare this to a serotonin antagonist, Reserpine (Indian Snakeroot), that over long-term use produces a crashing depression.
This drug also increases REM sleep and dreaming frequency.
Typically, subjects demonstrating severe psychological changes during sleep deprivation
experiments will fully recover after a prolonged period of natural sleep.
If we divide sleep into two major categories, REM sleep and Non-REM sleep we can attribute the following:
REM (Rapid Eye Movement) Sleep.
1. REM begins typically after about 90 minutes into sleep. This is fairly consistent but is typically found to occur earlier in people experiencing depression. It occurs throughout the night
on a 90-100 minute cycle, with the first period of REM sleep lasting less than 10 minutes and subsequent episodes lasting 15-40 minutes each.
2. Polygraph measurements during REM sleep appear very similar to those taken of the person in the waking state. REM sleep is sometimes refered to as paradoxical sleep.
3. Vital signs such as pulse rate, ventilation rate and blood pressure are all comparatively high during REM sleep however their variability from minute to minute is marked.
4. Brain oxygen demand increases above that of supply, suggesting an increased tolerance to carbon dioxide during this time.
5. Body temperature regulation is altered where the body responds to internal stimuli with
regards to temperature control rather than respondiing to external stimuli.
6. The amino acid l-tryptophan (precursor to serotonin) increases the speed of falling asleep and increases REM sleep.
7. Depressed people demonstrate changes in REM sleep. REM occurs earlier (after 60 minutes or so) and mostly occurs to the latter half of the period of sleep.
8. Someone waking from REM sleep will usually do so rapidly and report that they were experiencing dreaming. They will return to baseline consciousness rapidly.
9. As a person gets older the percentage of time spent in REM sleep decreases.
1. The pulse rate typically slows by 5-10 bpm, ventilation and blood pressure also drop and unlike in REM sleep is stable and regular..
2. Episodic, involuntary movements occur – similar to the jumping/falling movements some people will be familair with.
3. Someone waking rapidly from deep non-REM half to one hour into sleep will be disorientated and possess disorganised thinking and will be slow in returning to baseline consciousness/cognition.
4. Thus it is suggested (Kaplan) that awaking from deep non-REM sleep will result in specific disorders resulting from the disorientation experienced, such as bedwetting, somnambulism and nightmares.
5. Cerebral blood flow in non-REM sleep is reduced, as it is too almost all body tissues.
6. In the healthy adult, non-REM sleep accounts for 75 percent of sleep time.
Some Neurological Aspects of Sleep.
– Neurologically speaking, sleep depends on a complex interaction between the cerebral cortex (basically the outer layer/surface of the brain) and the central reticular formation (at the base of the brain, damage to which results in immediate loss of consciousness).
– Stimulation of the area of the brain known as the locus ceruleus (implicated in attention and the so called hyperactivity disorders) produces profound alteration in the persons ability to sleep.
– Patients with Alzheimer’s disease (involving a loss of the transmitter/hormone acetylcholine, especially from the areas of the hippocampus (memory)) demonstrate a marked reduction in REM sleep.
– “process S” is an as yet unqualified and unquantified brain substance that is suggested to accumulate late in the waking day to produce tiredness and sleep. This is as yet purely hypothetical.
(Scroll forward to 2.25)
It has been well documented within psychiatric literature that it is the restoration of normal sleep activity that many of the older, sedating anti-depressant drugs exerted their greatest benefits. Given the bizarre behaviours and experiences engaged in by the subjects in one sleep deprivation study, it is important to consider a lack of sleep as being primary to some of the experiences and difficulties reported by your clients.
Similarly, this is an important area of consideration for the NLP Practitioner when designing hypnotic intervention for the depressed client. In particular, as recommended by RB, pay attention to the insomniacs internal tonality and other auditory submodalities. Teach these people a hypnotic voice to use on the inside. As yet, i have been unable to find any research from psychiatry or neurology refering to activity in the verbal/auditory areas of the brain in relation to sleep/wakefulness.
It is also important to discover what the client does when he cannot sleep – does he just lie
there and get more frustrated? See this as a good time for some interesting sexual experiences? Do the ironing or another mundane task? What does the client actually do?
Also, if the depressed client wakes early and is frustrated because they do so, then elicit the
strategy for the early morning awakening. Typically, the client wakes up to a feeling of guilt and begins to ruminate on guilty thoughts. Elicit this strategy, explore how they do this and begin to set the client new strategies and activities to do instead of lying in bed and feeling bad.
It is also worth exploring what strategies the client is using to achieve sleep (although
having said this, most depressed clients I have seen have been long since medicated prior to seeking a consultation with me). Some people have interesting ideas and will use all sorts of chemical crutches to try to sleep. For example, I had one client (who very nearly died from liver failure) who was consuming 2-4 grams of paracetamol at night in an attempt to sedate himself and reduce his emotional pain (paracetamol does neither of these things chemically), other clients drink alcohol for sleep purposes (thus actually exacerbating their depression), others consume illicit drugs whilst others consume over the counter remedies by the bucketload. You need to know what these drugs are and how
It is important to consider which substances are being used by the client because much of the work you do may well end up as a state-dependent learning, where the resources can only be accessed within the drugged state. It might be worth having the client go clean for a few days and night prior to working with them.
Also, consider the use of caffeine – from observation, a great many depressives are serious
caffeine users in the form of tea and coffee. I have seen one jittery chap who was consuming caffeine tablets at the rate of about a gram a day – this gentleman had some serious physical side effects that necessitated urgent medical treatment (cardiac arrhythmia). Since most people appear to rarely drink enough water, encourage the client to begin to make shifts in their drinking habits to reduce caffeine consumption (which as well as being a stimulant stimulating it is also an effective diuretic) toward the latter part of the day.
Other considerations that are so obvious that they can easily be missed are in relation to the actual bed, bedding and bedroom behaviours. Has the client ever considered these aspects? Is their mattress comfortable? Do they actually like the colour and material from which their bedding is made? Investigate things like is the bedding appropriate. For example is the thickness of their duvet too high, is the central heating on too high? Is there a TV in the bedroom? Does the client use the bed for working on office work problems, watching the news, talking on the telephone or waiting in case someone might call?
Researchers have indicated that for some people, simply changing the bedroom into a place for sleep and sex and only those things can have a profound effect in a great many insomniacs. When we think in terms of contextual anchoring, this makes good sense.
Other aspects that are worth considering but I won’t cover in depth here are conditions such as sleep apnea (temporary cessation of breathing owing to obstruction or other cause) and other physical factors concerning sleep. For example, it isn’t unusual to find some [typically elderly] people who need to sleep in a sitting/upright position for various cardiac/pulmonary disorders. When it concerns depression as the presenting complaint, the therapist needs to consider possible side effects of medication that may be taken that might be the primary cause of the depression and may need to involve orthodox practitioners such as occupational therapists and their prescribing physician.