How the link between REM sleep and depression affects the treatment of Bipolar Disorder

Psychotherapy is a specialised branch of education and feartheseeds has hit the nail on the head by asking a question on the comments for this post about how knowledge of the link between REM sleep (the brain state in which dreaming occurs) and depression can be used to help treat and manage bipolar disorder, in which a (most likely genetic) predisposition for mania precedes and follows intensely depressive episodes in a destructive swinging pattern.

Rather than reply further in a comment, I thought I would consider this in a post by itself because it’s an interesting and valid topic that we haven’t yet addressed on this blog.

feartheseeds asks:

“Essentially: If I have a disease that prevents me from either wanting to get better (mania) or being able to actually seek treatment (depression), and then causes long lasting natural depressions via lack of sleep, how can I (or: can I) modify my sleeping patterns without medications specifically prescribed to do so?”

Firstly it’s important to stress that we really don’t advocate treating bipolar disorder without medication. Having said that however, we know people who have developed ways of managing their bipolar disorder without drugs. It obviously depends on the individual state of the sufferer and their access to support and resources that they can use to help them.

In order to organise what I want to say about how the human givens approach and knowledge about the importance of sleep can help someone manage bipolar disorder, I’m going to descend into bullet points:

1) Sleep and depression.

For the reasons described in Ivan’s youtube video, and detailed in this article, we now know why depressed people dream more than non depressed people. It is because dreaming evolved to dearouse the autonomic nervous system from unacted out emotions and worrying during the day produces an enormous amount of arousals that the brain has to dream about. By doing more dreaming in the REM state, which burns up energy, than having recuperative slow wave sleep, which energises the brain and mind/body system, the sleep pattern becomes distorted. This is the reason why depressed people, however much they sleep, always wake up feeling exhausted.

In addition, the orientation response, which fires continually during dreaming, is firing excessively because of the extra amount and intensity of a depressed persons dreaming, and so it gets tired out too. This is the same neuronal pathway we also need to focus and motivate ourselves to do anything during the daytime. Since it is doing things that make our lives feel meaningful, this lack of motivational energy (the orientation response drives motivation) makes life seem meaningless. This should not be underestimated, human suffering cannot get any worse that severe depression: it can even lead people to take their own life.

2) Sleep and Mania

Mania can be seen as the opposite to depression with regards to REM sleep. Someone in a manic phase sleeps less and therefore has less REM sleep to dearouse the autonomic nervous system. In depression they do too much REM sleep. Staying awake all night, intense euphoria, all the symptoms of mania, are not conducive to healthy sleeping patterns.

Just as ordinary sleep deprivation leads to hallucinations (as in the case of Peter Tripp, the radio DJ who in 1959 stayed awake for 8 days as a sponsored “wake-a-thon” stunt before the truly dangerous effects of sleep deprivation were widely known. Tripp suffered severely disturbing hallucinations and delusions and was thought to have suffered more long-term side effects.) Sleeping less through a manic phase can quickly create a severe psychotic state.

Perception distortions occur in waking life because, quite literally, the distinct difference between waking reality and dreaming reality has been blurred, the person literally is dreaming during waking to compensate for the lack of good quality dreaming at night, which we all need a certain amount of to survive…

3) Managing sleep.

So while it is generally agreed now that bipolar disorder has a genetic component, it is obvious that individual sleeping patterns (brought on by the disorder or not) do play a part in the severity of the depression and mania, and my point is, that by managing sleep patterns (and by managing I mean trying hard in a depressive phase to limit your sleep to a healthy amount, waking up at a healthy time every morning, not sleeping in when you feel tired etc, and in a manic phase, doing everything you can to get the REM sleep you need) at the very least reduce symptoms of both bipolar moods and improve your quality of life. Drugs are not the only way of regulating REM sleep, although some of them do, and this is why they work.

Doing this on your own may be hard work, so making sure you and everyone around you knows the signs of when you might be slipping into depression or rising into mania and learns how to help you manage your sleep and also meet your emotional needs (this needs a whole bullet point to itself!) will help a lot.

4) The importance of meeting essential emotional needs.

When someone with bipolar disorder starts swinging towards a depressive phase, they start over compensating for the REM sleep they have missed out of during the manic phase.

A depressive phase is a sign for themselves and people around them to look at what is causing them to worry, boost emotional support and get help to get the emotional needs met (see here for a list of essential emotional needs, or “human givens”). This is so obvious but is incredibly important and can’t be said enough times. Anything to do with not meeting an innate emotional need will trigger anxiety and a depressive episodes and more REM sleep, and bipolar people obviously have a particular sensitivity for this. People do not have mental health problems when their innate emotional needs are met so ensuring they are is the best therapy anyone could have.

Accordingly, someone swinging towards a phase of mania is (among other things) not doing enough dreaming – and everything must be done to remedy that and get enough sleep, or the manic person will reach a stage where the balance will tip, and to compensate they will fall back into REM sleep and depression again.

Meeting emotional needs also reduces arousal levels, which is crucial for arousal levels (which need to be de-aroused nightly during dreaming) in waking life.

So, if emotional needs are met and the importance of REM sleep is understood and managed, bipolar mood cycles become less intense and more manageable, as someone who has experienced years passing before a bipolar episode begins again, can affirm.

Therapists, GP’s and anyone who works, lives with, suffers from or knows someone with bipolar disorder need to be aware of, and learn to work with, this information. I see a great deficit in the knowledge of how to treat bipolar disorder and depression, and a severe lack of services in the NHS that provide this information to people who need it.

Thanks so much to feartheseeds for bringing this subject to attention on this blog.

Comments, questions, personal experience, criticisms, suggestions are welcome.

Posted by: Eleanor

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21 responses to “How the link between REM sleep and depression affects the treatment of Bipolar Disorder

  1. Great post! This has certainly given me more to consider, on top of the information that I have been reading recently on the Human Givens movement.

    Regards,
    Sisiphus

  2. Having read more about the Human Givens, and putting it aside for the moment to have a break, I am now wondering why it is not more well known. I merely stumbled across it whilst researching something else and was curious enough to try and find out more. The wide applicability of the premises contained within (the movement, not referring to this post), are very valuable. I have always read widely and I cannot understand why I have not come across it before now.

    Sisiphus

  3. I am pleased that you recognise the value of the human givens approach. We get asked why it’s not better known 100’s of times (which is a paradox in itself since, clearly, the people asking us have heard of it) but I think it’s a matter of time. In the UK it is being applied by schools, Mental Health Trusts and Primary Care Trusts. Tens of thousands of copies of the HG book have sold, many to individuals in countries outside the UK.

  4. I agree with the general premise of bad sleep = increased levels of depression.

    But I have a hard time accepting that treatment of those erratic sleeping patterns must be left to the people who have BiPolar Disease and the family / friends they may or may not have in their lives. Someone with a BiPolar Disease is automatically guaranteed of having a sleeping disorder, whether it’s because their brain won’t shut off at appropriate times, or their mania and depression will not allow for proper sleep.
    Should it not be standard policy that on diagnosis, and when first prescribed a mood stabilizer, the patient should also be automatically prescribed a mild anti-psychotic to assist in beginning the management of that sleeping disorder?

    “…and by managing I mean trying hard in a depressive phase to limit your sleep to a healthy amount, waking up at a healthy time every morning, not sleeping in when you feel tired etc, and in a manic phase, doing everything you can to get the REM sleep you need…”

    I have difficulties with leaving the initial treatment of the sleeping patterns of people suffering from BiPolar Disease to those people whose reasoning has been corrupted by the disease. In today’s psychiatric reasoning the patient must convince a doctor of their level of sickness, then the patient is handed a prescription for a mood stabilizer and given a time for the next appointment. It seems as though everything else regarding recovery is left to the patient, including fixing their sleeping patterns. I’ve had several people leave questions on my blog regarding these issues, so much so that I’ve created a “FAQ” page with the most common ones, I’d be interested in your comments on them, Eleanor:
    http://saltedlithium.wordpress.com/about/eight_questions_nine_answers/
    When it comes to reasoning and focus, BiPolar Disease leaves very little room for either. I agree, 100%, that during our Lucid Moments we must prepare for our diseased moments. But the lucid moments of people with BiPolar Disease are most often entirely spent recovering from our diseased moments.

    “A depressive phase is a sign for themselves and people around them to look at what is causing them to worry, boost emotional support and get help to get the emotional needs met (see here for a list of essential emotional needs, or “human givens”). This is so obvious but is incredibly important and can’t be said enough times.””

    Again, this disease actively fights to exclude everyone from the life of the host. People with BiPolar Disease fall into themselves either through their depression by isolation, or through their mania by grandeur. The social effects of this disease more resembles those of addiction, as opposed to cancer or diabetes. By the time most people with PiPolar Disease seek help they have already lost most or all of their social network because of the disease. And even if they still have a network, the diagnosis and first mood stabilizer prescription, in a great many cases, is enough so that the patient believes either they’re cured or fully treated.
    If sleep is crucial to recovery from BiPolar Disease, should it not be incumbent upon the psychiatrist, upon first diagnosis, to also prescribe a sleep aid (not a sleeping pill) to treat the BiPolar sleeping habits? To me the sleeping aid, along with the mood stabilizer and a large daily dose of Vitamin D should be the first line of attack against BiPolar Disease, then followed up with psychotherapy (if warranted) and an anti-depressant after some stability has been achieved. It seems to me that this would be the best way for the patient to regain some control over their sleeping pattern.

    “I see a great deficit in the knowledge of how to treat bipolar disorder and depression, and a severe lack of services in the NHS that provide this information to people who need it.”

    As you might see from my link above I believe you’re right beyond a shadow of a doubt. We are the first generation of humanity to actually watch the brain function. There have already, within the past five years of FMRI, CAT and MRI imaging in the United States, been incredible advances in studying mood diseases. Psychiatry is moving away, albeit too slowly, from relying upon the patient to describe her disease to being able to use diagnostic tools to determine cause and effect.

    Thanks for responding to my questions.

  5. feartheseeds: I see what you mean now – and I think what you are looking for is confirmation of this: [which I probably haven’t made clear enough]

    You are right in everything you have said in your reply about the nature of bipolar disorder being to directly work against the particular managing techniques I describe.

    In my post I was almost describing a sort of ‘ideal world’ scenario – assuming that a bipolar suffer would have a strong network of support, the time and inclination to learn about the importance of sleep and other fundamentals about their illness, an unprejudiced and knowledgeable doctor etc etc etc. Obviously this isn’t the case for everyone, and a human givens therapist would do everything they could to get needs met (as this is what they are) using the resources the client has available at that time.

    Confusion may arise when I state that bipolar can be treated without drugs. I say that [in some cases] managing bipolar can be achieved without drugs by regulating sleep and meeting emotional needs because I personally know people who do this, but I would obviously never claim to generalise or recommend this to every bipolar sufferer without understanding their circumstances or situation.

    I looked at your eight questions, nine answers page with interest and what immediately leapt out at me was how you make clear that everyone is different and it’s what works that should be used to treat bipolar. As long as needs are being met healthily and sleep patterns are kept track of, this should be the approach to take.

    So, what this post was all about was to further get information about REM sleep and moods (depression and mania) available for anyone to use to help themselves as much as they can, in whatever circumstance they are currently in – as this information is not used to the right degree in the NHS. This is where knowledge of emotional needs and being trained to recognise the extent of the individual’s resources which are available to fulfill them becomes most useful – and is why MindFields College exists.

    ALSO – I found it very interesting what you mention how the patient has to convice the doctor about their level of sickness and fend for yourself. So many people don’t get diagnosed or given enough help. (I feel like I’m being patronising as obviously you have experience of all this first hand.) The solution lies in the correct information being available – and implemented in the right way, at the right time. Filling in this gap.

    The need for a bigger organising idea behind the treatment of mental illness is what is required in order for us to progress.

    Hope I haven’t rambled on too incoherently and that you’ve got a clearer idea of where we are coming from.

    Take care and thanks for your insightful comments :) could I put you on my blogroll?

  6. “Hope I haven’t rambled on too incoherently and that you’ve got a clearer idea of where we are coming from.”

    You haven’t rambled, and you certainly haven’t been incoherent. Thanks again, Eleanor, for your responses. If you see some value in my site, please feel free to add it to your blogroll. I might also suggest this site: http://puddlejumper.wordpress.com and, for an American perspective on BiPolar Disease: http://www.furiousseasons.com

    There is still this question, however:

    Above everything else, in my opinion, the initial contact between doctor and BiPolar patient — when the diagnosis of Manic Depression is made — is the critical time for how the patient will decide on what is and is not important to their recovery. I do believe that there are several methods of recovery from BiPolar Disease, however, if sleep management is to be part of that recovery — and it must be — then a sleep aid must be part of the initial medication cycle, otherwise wouldn’t the patient be left to the whims of the disease? So… last question:

    Until it can be proven that a patient can be treated in an “alternative” fashion should it not be standard policy that on diagnosis, and when first prescribed a mood stabilizer, the patient should also be automatically prescribed a mild anti-psychotic to assist in beginning the management of that sleeping disorder?

    Thanks again. You’ve been very patient.

    Gabriel.

  7. I’m not a Doctor, nor have I enough knowledge or experience in this area – so I can’t really comment on policy – but I agree that medication to help regulate sleep is beneficial if someone clearly needs help to do that and this can’t be attained in any other way.

    Why do you ask?

    Thanks for the links

  8. You’re very welcome for the links. If you’re looking for another devestatingly honest discussion of BiPolar Disease (and, really, who isn’t?), ‘Spin Me I Pulsate’ by “thordora” is wonderfully written: http://vomitcomit.wordpress.com/.

    Maybe this specific question would have been better posted as a response to: https://mindsalot.wordpress.com/2006/12/04/what-do-doctors-do-when-faced-with-depression/

    I am intrigued by the idea of a “New” medical philosophy and I was/am trying to find out how people with BiPolar Disease fit into that philosophy. Most methods of “dealing with” people with BiPolar Disease rely, in my opinion, far too heavily on the “Best Picture” method where the assumption is that the patient will automatically have the necessary networks and understanding of the disease to carry them through their initial treatment.

    To me, there is a great need for BiPolar Disease to be treated as a cancer or diabetes: go hard and deep. We’re not naturally or even clinically depressed, we have issues that need to be dealt with fine, but treating our disease always seems to take a back seat to the psychotherepy and hand holding.

    I found this in a UK based publication which fits:
    “Most of [people with BiPolar Disease] are best treated not by charismatic psychoanalysts who carefully excavate the early, repressed trauma that has “led” to their illness, but by doctors who administer psychotropic drugs of one kind of another.”
    Tim Lott, “Losing The Plot”, Guardian Unlimited, 12/12/06

    You can find a link to it here:
    http://saltedlithium.wordpress.com/2006/12/29/manic_depression_gives_us_no_special_abilities_or_insights/

    So… what is the (or: is there a) philosophy for treating people who are afflicted with BiPolar Disease within the Human Givens approach to mental health, beyond what you have discussed earlier?

    And forgive me if it seems as though we ‘BiPolar People’ have recently escaped from our bedrooms and have taken over the ISP’s of the world so we can inundate you with bizarre requests and half-baked ideas… well, actually that’s exactly what’s happened. Take Us to your leader.

    Thanks again for your patience.

    Gabriel.

  9. Here is a quote (which I have actually already paraphrased from in my first reply to you – I thought i’d better warn you of this incase you noticed – I didn’t think you’d come back for more! :p ) about the human givens view of bipolar disorder.

    It was published in Ivan Tyrrell and Joe Griffin’s first book ‘Human Givens: a new approach to emotional health and clear thinking.’ – which I know is on Amazon and also here:
    http://www.hgonline.co.uk/FMPro?-db=HG_Orders.fp5&-format=hgonline/shop/findbook.htm&ReqID=106&-new

    This best summarises our ‘philosophy’ on bipolar – direct from the horses mouth, as it were.

    “Severe depression is known as a unipolar affective disorder (from the Latin affectus or feeling). It is unipolar because the emotional disturbance takes just one direction – downward into depression. The condition commonly known as manic depression is called by psychiatrists bipolar affective disorder because a sufferer oscillates between highs and lows – periods of mania followed by periods of deep depression.

    It is generally agreed that there is a significant genetic contribution to the genesis of manic depression. It occurs with equal frequency in men and women and is usually treated with drugs, particularly lithium, which can help regulate the emotional seesaw that propels the sufferer from mania – extreme excitement and sometimes even violence – to depression – pure inertia and lassitude.

    Manic depression occurs in a variety of profiles with some people visiting the depressed pole more frequently, and others spending more time in the manic pole. Some may cycle through both poles with dizzying rapidity; others can spend years at the depressed end before experiencing mania, which is why it can take many years to diagnose accurately. Whilst in the depression phase people, as we have seen, are overusing the REM state, dreaming excessively. In mania, by contrast, people typically do not dream enough – working or playing hard, day and night, with minimal time set aside for sleep and rest because they feel they don’t need it. By staying up all night every night they become starved of the vital REM sleep that would reduce the arousal (mania). So arousal levels build and build, till the inevitable point when there is a crash down into excessive REM sleep to make up for the lack … and the consequent depression.

    It is increasingly recognised that self-management of the disorder, combined with medication, is the most effective treatment for the majority of patients. In the depression phase, the psychotherapeutic skills needed to treat depression are apposite. When the manic pole is threatening, it is important for a person to reduce stimulation – cut down on caffeine for example – and apply relaxation techniques. What is especially vital is getting a good night’s sleep. However exciting life may seem to an individual during the manic phase, unless they get enough REM sleep they will heighten their arousal levels, accelerating the onset of mania.

    Manic depression in many ways highlights the role of black and white thinking in the genesis of depression. In the depressive phase the world is seen from a very black, pessimistic perspective indeed, whilst the opposite is true in the manic phase. Optimism and pessimism are two sides of the same coin. Just as runaway inflation is followed by recession in the world of economics, unbridled optimism is likely to trigger a pessimistic, depressive fallout when the unrealistic dreams turn into the ashes of disappointment.

    For whatever reason it arises (and there appears to be a genetic contribution to the condition), the extremes of black and white thinking can be more starkly observed in manic depression. Black and white thinking is, as we have seen, the primitive thinking style of the emotional brain. The neocortex evolved to enable us to refine that dichotomous style of thought so that we can perceive the myriad shades of grey between these two poles and thus chart a more flexible and realistic way through life’s difficulties, giving us along the way the bonus of the possibility for ever higher development. Again we can see that the pre-condition for the ability to see and understand the complexity of life, and to navigate our way safely through it, is almost always less emotional arousal.

    From this understanding we can see that the therapeutic techniques deriving from an understanding of the human givens will be useful in the treatment of bipolar disorder. We have ourselves encountered a number of clients who are now successfully managing their condition using such techniques, without needing drug treatment. But we would wish to emphasise that the majority of sufferers of manic depression are likely to benefit most from a combination of drugs and human givens therapy.”

    So – This is how human givens therapists deal with bipolar disorder. You might be interested to look at our archive of old Human Givens Journal articles, which goes into detail about the people and organisations who successfully use these techniques to treat depression, schizophrenia and also bipolar. Here are some links to the most relevant off the top of my head:
    http://www.hgi.org.uk/archive/road-recovery.htm
    http://www.hgi.org.uk/archive/chrisdyas.htm
    http://www.hgi.org.uk/archive/doctrinesofpsychology.htm
    http://www.hgi.org.uk/archive/newlook-psychosis.htm

    There is a very definite distinction between psychotherapeutic handholding (possibly by those charismatic but ultimately useless psychoanalysists) and treating bipolar with clear and practical information like that of the importance of sleep, meeting emotional needs, lowering emotional arousal and the correct use of medication. I appreciate your need for bipolar to be treated in a less “wooly” fashion.

    You bipolar lot are very welcome :) – bring on the bizarre requests!

  10. I was diagnosed with BiPolar about 18 months ago (had suffered without knowing for 16 years prior to that) Have medication (Citalopram) as the depressive states are far more long lasting than the manic. Have also started to see a therapist/counsellor one hour a week. I am currently just coming out of a deep depressive state (I am also pregnant which has sent my hormones into overtime causing some interesting fireworks!) and feeling good and balanced now. To my point… I learnt more about my condition from the entries and links that you all have posted here than I have in the past 18 months. We really don’t get told anything and are left to manage our condition as best we can. I had accessed a few websites but they were full of ‘book facts’ and medication information. I am very grateful to you all for opening my eyes as I had become somewhat focussed on my medication being the guiding light.
    Regarding the psychiatrist/therapist question, I have found the 15 or so, sessions that I have attended absolutely invaluable. They may not be of long term benefit towards managing my BiPolar but there are areas of my thinking and behaviour which had/have become slightly ‘off’ partly due to the coping mechanisms I unknowingly developed during my undiagnosed years. It could be likened to sweeping the whole room clean before refurnishing it.
    Thanks for listening!

  11. Vikki thank you so much for your positive comment – I’m so glad the links I and others provided helped you understand your BiPolar further – Best wishes for the future and thanks again :)

    Eleanor

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  13. GOOD ARTICLE. In the UK at least, Depression is now the third biggest reason to visit a GP and yet, outside of the medical field, very few people understand what Depression is all about.

    Please forgive the ‘sales pitch’ but you might just be interested in a brand new DVD just released by my company called EVERYTHING YOU ALWAYS WANTED TO KNOW ABOUT DEPRESSION and presented by UK Consultant Psychiatrist Dr Darryl Britto, who made the DVD especially for Depression patients and those training in the medical field. He discusses the myths about Depression, as well as its causes, symptoms, diagnosis, the various treatment including antidepressants, Cognitive Behaviour Therapy, and Social Intervention, and then goes on to discuss prognosis (outcomes of treatment.) MORE INFO AT: http://www.TimeTrappers.co.uk

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  14. I finally checked this discussion out after being recommended by feartheseeds. Thank you for posting all of this.

    All of these issues are so vital to talk about. It is the first step in bringing awareness.

  15. Thank you aikaterine for your comment.

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