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All humans follow similar sleeping patterns. A typical night’s sleep seems
to consist of the repetition of 90 -110 minute cycles of rapid eye movement
(REM) sleep, and periods when there is no REM (NREM). The first period
of REM usually lasts 5 to 10 minutes, but this tends to lengthen in successive
cycles. There are four main stages of sleep.
Stage One Sleep is the lightest of all the stages where a person’s brain
wave patterns are similar to those when he or she is awake. The body
is very active during this period; brain temperature rises, heart rate and
blood pressure fluctuates, breathing is irregular and the brain uses more
oxygen. A person returns to Stage One several times during the sleep
cycle after going through the first four stages.
Stage Two Sleep begins soon after falling asleep, usually within the first
5 to 10 minutes. This is the period where sleepwalking and sleeptalking
takes place although this is not really a true ‘dream state’. The time
spent in Stage Two tends to get shorter and shorter with each 90 – 110 minute
Stage Three Sleep (REM). Here breathing is slow and even, the heart rate
has slowed down and the body temperature has dropped. This is when a person
is in the ‘Alpha’ brain wave state where images are in colour. During this
period, the brain generates up to five times as much electricity as when a
person is awake. The brain not having to deal with input from the senses can
account for some of this, but there is no understandable reason why the rest
of the increase is necessary.
During Stage Three, a person is often hard to awaken and this is also the
time when most dreaming is done. (NREM dreams have been recorded. Research
indicates that it is possible to have some eye movement during NREM stages
although dreamers awakened at such times have less coherent and non-visual
reports of their dreams) (Rickards).
The rapid eye movement that gives this stage its name involves both eyes
moving quickly from side to side, although research suggests that this movement
has nothing to do with the actual content of the dreams. During this
period the body has shut down to an almost paralysed level as the brain sends
messages to the spinal column to suppress muscle responsiveness. And, as the
brain believes what it sees, this is one of the reasons people often feel
they cannot run or cry out during a nightmare.
The first REM period of sleep is usually the shortest, lasting 10 to 15
minutes, but by the end of the night it can be lasting from 40 to 60 minutes.
With each cycle the REM period grows longer and Stage Four Sleep gets shorter,
or even disappears altogether. A person will tend to have 4 or 5 REM
periods each night and these will range from 5 to 45 minutes each in duration.
The last REM period of the night usually produces the most vivid and easily
remembered dreams, specially if a person wakes just as a Stage Three has been
Stage Four Sleep is the deepest level of sleep. The first cycle of
the sleep period will usually involve 20 minutes or more in this stage, but
the more exhausted the body, the more Stage Four Sleep it needs. Stage Four
Sleep is the only time when growth hormones are released into the body, so
teenagers need more of this than adults. People over 70 might have almost
no Stage Four Sleep in their cycle, which would leave them cranky.
Stage Four becomes shorter and shorter over the progress of the entire sleep
period and by the end of it, as time to wake up comes closer, a person might
not be spending any time in Stage Four at all. Stage Four Sleep is the period
when Sleep Terror Disorder (also known as Night Terrors or pavor nocturnes)
Some research suggests that there are variations within these stages according
to the individual and that these differences may vary again within an individual
from night to night. These patterns may be affected by a person’s mental state
(Rickards). Sleep disorders may be the primary presenting problem or they
may be a response to something else such as an anxiety disorder or depression
Sleep Terror Disorder is an experience of extreme anxiety from which a person
usually awakens screaming. This most often occurs during the first third
of the night and may last for 10 to 20 minutes after which time normal sleep
returns. The sufferer will commonly experience sweating, confusion,
rapid heart rate, be difficult to awaken fully or comfort, be unable to explain
what has happened and have no recall of bad dreams or nightmares if they do
awaken fully or when they awaken the next day. To be diagnosed as a
disorder these episodes must be recurrent and not be the result of drug abuse,
medication or some other medical condition. They must also cause significant
distress or impairment of abilities in social, work or other important areas
of functioning. (DSM-IV). This disorder most often occurs in pre-adolescent
boys, although girls do suffer too, and is fairly common in children between
the ages of 3 and 5. When it occurs in the very young, the incidence usually
reduces greatly after the age of 5, (other research says 10). It can
run in families. When it occurs in adults it could be the result of emotional
tension or stress, and/or excessive use of alcohol. This disorder is not dangerous.
In children, this disorder doesn’t generally point to psychological problems
and they usually outgrow it. It might be eased in an adult by the sufferer
reducing stress levels. Some form of counselling could also be appropriate.
Benzodiazepines are sometimes used to treat the problem although this doesn’t
seem to be a recommendation.
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REM Sleep Behaviour Disorder
The brain has mechanisms that protect us from hurting others or ourselves
during sleep; however, if someone with sleep problems is coming close to causing
such injuries, this might be a feature of another problem, such as a brain
stem dysfunction, and professional help should be sought. This is called
REM Sleep Behaviour Disorder (acting out dreams). Here, sufferers can have
violent behaviour during sleep. The person may punch, kick, leap out of bed;
even run from the bed as he or she tries to enact the dream. This might occur
3 or 4 times a night on consecutive nights. This disorder can start
at any age, but is more common in male adults (NSDC). The NSDC site suggests
that this disorder often has no known cause, but might also occur due to
withdrawal from alcohol, sedatives or anti-depressant medication, or be due
to neurological conditions such as dementia or a previous stroke. Short
acting benzodiazepines seem to be the treatment of choice.
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This problem involves sudden jerks, which occur at the beginning of sleep
and can be considered normal as it affect 60-70% of the population.
‘Severe increased exertion’, emotional stress and too much caffeine can increase
the frequency of sleep starts. These movements can involve the arms
or the legs or the whole body and there might also be feelings of falling
or imbalance (newcastle).
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Nightmare Disorder varies from Sleep Terror Disorder in a number of ways:
it occurs during REM sleep, it will involve an extended and extremely frightening
dream, usually including threats to personal survival, security or self-esteem.
It generally occurs during the second part of the night and the person wakes
with vivid recall of the dream and quickly becomes alert. It can affect people
at any age. To be classed as a disorder the problem must involve clinically
significant distress or impairment in social, work or other important areas
of function. The problem must also not be generated by another mental disorder,
drug abuse, medication or a general medical condition (DSM-IV). Other research
suggests that to be classed at disorder level it has to last at least six
months and the disturbing dream has to occur at least once a week. Research
also suggests that people do not necessarily awaken so often as a response
to the nightmare if they have had the problem for a long time.
The ‘Nightmare Quiz’ site says that if all the following situations apply,
a Chronic Nightmare Disorder is likely.
- I experience disturbing
or unpleasant dreams on a regular basis – that is, at least every week or
- I’m certain that
my nightmares were caused by bad things that happened to me in the past.
- My sleep is disturbed
by my bad dreams.
- Occasionally or
more often, I sense some anxiety and fear about going to sleep because I am
concerned I will have a bad dream.
The NQ site further suggests that if any three of the following are true
and the dreams have been occurring for six months or longer, there is a strong
possibility of Chronic Nightmare Disorder.
- If I think about
these nightmares, I sometimes re-experience the disturbing emotions in the
dreams, and these emotions linger during the day.
- During my waking
hours, I have noticed on several occasions that I will suddenly recall some
part or the whole of a bad dream that I may have experienced the night before,
or some other bad dream from a time in the past.
- My bad dreams almost
always include some emotion which disturbs me, for example, fear, anxiety,
anger, sadness, guilt, shame, frustration, confusion.
- Upon awakening
from these unpleasant dreams, I may not remember the whole dream, but I can
usually remember some part of it.
- Occasionally or
more often, I will actually delay my bedtime because I am sure I’m going to
have a bad dream.
- If I wake up in
the night because of a bad dream, I will sometimes feel anxious or fearful
about going back to sleep.
- Occasionally or
more often, if I have had a disturbing dream, I feel unrested upon awakening
in the morning.
- During the daytime
I feel fatigued, sleepiness, or low energy if I’ve had bad dreams or nightmares
the night before.
The NQ site makes it clear that the sufferer is the best judge of this condition
and that if a person is not bothered by his or her nightmares then it obviously
isn’t so much of a problem.
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Panic attacks, as described elsewhere on this site, can occur while a person
is asleep. As described by Mufson; ‘The attacks occur suddenly, rousing
the person from sleep, and can be associated with a feeling of impending doom.
When awakening, the symptoms of rapid heart beat, shortness of breath, dizziness
and sweating may continue for several minutes. Dream recall is often
minimal and the panic is not associated as a rule with bad dreams or nightmares.
A common problem that arises in this disorder is ‘sleep avoidance’. Individuals
become worried about going to sleep and insomnia sets in.’ The treatment
is the same as for panic disorder without sleep panic. Research suggests
that over three-quarters of those suffering from Panic Disorder have had
attacks while asleep (P and AH).
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Insomnia, hypersomnia, anxiety and depression
Not getting enough sleep is the most common sleep disturbance of people
who are clinically depressed (All About Depression). This might involve waking
early in the morning, or during the night and then finding it difficult to
get back to sleep; or it might involve a general difficulty in falling asleep
at night. These are variations of insomnia. Hypersomnia is when a person
sleeps too much, which might be at night or involve increased daytime sleeping,
but where the person still feels sluggish and tired. Hypersomnia can cause
much social and work difficulty as the drive for sleep exceeds the drive to
succeed in those areas (Adams).
The AAD site suggests that insomnia is generally associated with a ‘melancholic’
type of depression and hypersomnia with an ‘atypical’ depression.
Melancholic depression involves a loss of pleasure in most activities or
an inability to feel better, even for short periods even when something pleasant
happens. It should also include three of the following: the depressed
mood is distinct (i.e. unlike feelings of bereavement), it is worse in the
mornings, the person wakes too early in the mornings, there is distinct agitation
or movements are slowed down, substantial weight loss, or extreme feelings
of guilt. Melancholic depression might involve something specific happening
Atypical features are: during the last two weeks of major depression or
the last two years of dysthymia, the person is able to enjoy brighter moods
when pleasant things occur. (Dysthmia is a long-standing depression of mood
that does not fulfil the criteria for recurrent depressive disorder, lasting
more days than not for two years or more. It included a general ability
to function but at far less than optimum level) Two of the following must
also be present for atypical features: substantial gain in weight or substantial
increased appetite, sleeping too much (at least ten hours a day, including
daytime naps), the body feels heavy or weighted down, persistent sensitivity
to rejection by others which is related to personal or social difficulties.
Atypical features are two or three times more common in women than men, tend
to occur at an earlier age and sufferers are more likely to develop anxiety
From Anxiety Care’s experience, sleep problems will aggravate anxiety disorders
and depression whatever their basic cause. Anyone who worries excessively
or is very focused on his or her health, is going to be alarmed by insomnia.
Once a person begins to fear not sleeping as bedtime approaches, he or she
is no longer in a mood that is relaxed enough to sleep and therefore doesn’t.
Fearing not sleeping then becomes a self-fulfilling prophesy.
Research suggest that it is the quality rather than the quantity of sleep
which is important, and that we should get adequate stage 3 and stage 4 sleep:
the deep sleeps. Stage 2 sleep leaves us moderately refreshed but inadequate
deep sleep leaves us tired however long we have actually been asleep. ‘Sleep
Disorders’ reports the Harvard Health Letter as saying that aerobic exercise
is the only known way for adults to boost deep sleep. Becker states that late
afternoon exercise is best as this slightly raises body temperature, which
is already at its highest point of the day between five and seven pm. Then,
the lowering of body temperature during sleep, improves sleep quality.
Anxiety Care clients report more fatigue (mental tiredness), than physical
tiredness and this might be a long-standing problem, affecting them well before
they were aware of any anxiety or depressive disorder. This might be
a ‘chicken and egg’ situation as discussed by Becker. That is, whether a
person is predisposed to anxiety and/or depressive problems might affect their
responses, their fatigue and physical tiredness levels and how they respond
to outside stressors; also, one assumes, how they respond to loss of sleep
or their perceived drop in ability to function ‘normally’. Within the
charity, there are a number of clients, predominantly male, who are employed
in manual occupations where a drop in concentration could be lethal.
This obviously aggravates any worries about sleep problems. This might
also colour the responses to how far the sleep problem interferes with normal
functioning, which is one of the yard-sticks of diagnosing a clinical disorder.
Becker reports on a study by Ford and Kamerow which tended to show that
people, when questioned, who expressed sleep problems (not depression) during
a two-week period in the six months prior to the questioning had a ‘forty
times greater chance’ of having clinical depression if they reported a continuing
poor sleep record when questioned a year later. Becker also states that 15-35%
of patients taking SRI medication (a common treatment for OCD) reported insomnia
problems; while the ‘About’ site states that tricyclic medication, (clomipramine,
often used with OCD is a tricyclic), reduces the time it takes to fall asleep
and also seems to improve the overall quality of sleep.
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Source material and references
The first page and a half of the above article was taken, in greater part,
from an online rendering of a lecture by Kalina Christoff: ‘Brain Behaviour,
Psychology 112, August 3, 1999, Stanford University, Department of Psychology’.
Lecture 12. ‘Internally Manifested Mind States: Sleep and Dreams. Neurotransmitters.’
David B. Adams, Ph.D., FAClinP, Sleep Disorders
All About Depression, ‘Sleeping Problems’
Philip Becker M.D., Depression and Sleep, (Interview)
DSM-IV: Sleep Terror Disorder, in Behavenet Clinical Capsule,
Phillip W. Long M.D., Dysthymic Disorder, European Description, The ICD-10
Classification of Mental and Behavioural Disorders, World Health organization,
Geneva, 1992. http://www.meantlhealth.com/icd/p22-md04.html
Dr. Michael Mufson, ‘panic anxiety and sleep.’
‘Nightmare Disorder’, http://www.grohol.com/disorders/sx48.htm
‘Nightmare Quiz’, http://www.nightmaretreatment.com/quiz.html
‘Night Terror’, Medical Encyclopedia. http://medilineplus.adam.com/ency/article/000809sym.htm
‘Sleep and Movement Disorders’ NSDC
Panic and Anxiety Hub-panic attacks, anxiety attacks
‘Sleeping Patterns’, http://students.usm.maine.edu/kelly.rickards/sleep.htm
UMHS Department Page, Sleep Disorders Clinic
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Any authors or organisations believing that the above article has cited
their work inaccurately or inappropriately, should contact Anxiety Care with
the required changes, which will be made as soon as possible. This is a non-profit