Nevertheless there are two types of nervous depression which can be treated in the same way as anxiety and nervous tension. When we are tense and nervous we are aware that we are not in good health, and that we are not fulfilling our duties at work and in the home with the natural ease which helps us to do a job well. As a result we feel depressed. Things look gloomy, it seems as if a cloud were over us. It is harder to smile, harder to laugh, and harder to see the funny side of things. In fact, everything seems more difficult. Jobs which we have done in the past without effort now seem to be almost too much for us. There is a general loss of interest, and things which we used to enjoy, such as the company of our friends or a visit to the theatre, no longer have any appeal for us. In its place there is a tendency to shun our friends and spend our time by ourselves, perhaps sitting and brooding, perhaps just sitting with an awful inertia hanging over our heads so that we do nothing at all. When in fact we have to do something we often feel overwhelmed by the mental effort of making a start. In lesser degree the depression may show itself as a vague listlessness, a lack of energy, and a general disinclination to get going and do things. We have noted that this type of depression is the result of incapacity arising from our anxiety and nervous tension. Accordingly it is relieved as our anxiety subsides as a result of

self-management.

In the depression that arises from reaction to loss or bereavement we feel a sense of destitution, loss, and aloneness. Normal people are emotionally dependent upon one another in greater or lesser degree. The loss of dependency by death or absence of a loved one produces the normal reaction of depression, similar to the way in which fear is a normal reaction to danger. The depression becomes, abnormal only if it is of undue severity or of prolonged duration. Sometimes, of course, it results from loss in the more material sense in the way of fortune or livelihood. As with the depression caused by anxiety, depression of this nature can be greatly relieved by the same principles of self-management.

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How much sleep?

A statistical survey showed that most people sleep 7.5 hours each night. This survey covered a large group of people, some sleeping 9 hours and some 5 hours. The average was 7.5 hours. It does not mean that everyone sleeps 7.5 hours every night. Also, the older we are the less sleep we need. Hence do not be alarmed if you are 60 years old and sleep less than 5 hours each night, as this is normal for you and is certainly not insomnia.

More sleep does not equal better health

Not sleeping does not normally damage your health. We can function reasonably well with very little sleep. Hence if we are not sleeping well for one or two nights, it does not make us an insomniac. Many people think that to be healthy they must sleep at least eight hours or more. But this is not true. The amount of sleep you have is not proportional to your degree of health. In fact studies indicate that long sleepers (more than ten hours a night) have death rates nearly double those who sleep seven to eight hours a night.

One-quarter of sleep time is normally spent in dreams

Some of us believe that a good sleep means no dreams and no awakenings throughout the night. This has been proven incorrect by research conducted in sleep laboratories. We have at least four or five periods of REM sleep each night, during which we dream, although most of us forget our dreams the next morning. Work in sleep laboratories confirms that dreams are an essential part of healthy sleep. REM sleep occupies about 25 per cent of the time spent in sleep and this percentage stays relatively constant throughout life.

Brief awakenings indicate good sleep

Another observation made in the sleep laboratory is that a few brief awakenings occur during a normal good night’s sleep. Most of these awakenings last a few seconds to a minute only, and we fall back into sleep immediately after and never remember them in the morning. As we grow older, the number of awakenings increases. Hence we should be prepared for these awakenings in the middle of the night, since they are perfectly healthy and normal. With this in mind, if you wake up in the middle of the night, do not panic, just lie back and relax, be confident, and you will always fall back into sleep.

How to stop taking sleeping pills (beware of rebound insomnia)

The myth of sleeping pills needs to be destroyed here. Sleeping pills are useful for two weeks only; after that the body develops a tolerance to the pills and they become less and less effective in inducing sleep. The reason why most people continue to take them beyond two weeks is to avoid rebound insomnia. Rebound insomnia is a withdrawal symptom experienced after sleeping pills are stopped. Rebound insomnia should be distinguished from true insomnia. When the sleeping pills are stopped, rebound insomnia follows immediately, and one must be prepared for not sleeping well for the next few nights. Natural sleep should commence after the rebound insomnia passes. Hence it is most important to stop taking the sleeping pills gradually. The tragedy is that most people stop taking the sleeping pills suddenly, and consequently they cannot sleep because they experience rebound insomnia. They then believe they have lost the innate ability to sleep, and they immediately start taking the sleeping pills again.

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Loss of loved ones, loss of possessions, tragedies of any kind, or any events of similar magnitude are extraordinary and we are expected to feel the stress badly and most of us will be hurt. The normal biological and psychological reaction to stress as outlined earlier still applies, but is of much greater magnitude and lasts much longer. We call this grief reaction.

When we are hit with a stress hammer, there are two phases: the injury phase and the healing phase.

Injury phase

During the injury phase, we feel the pain. This pain can be in our head as headache or in our chest not unlike a heart attack. Of course, the pain is hurting most of all in the mind. It is a normal defence mechanism of the body to protect the psyche, and the immediate reaction is denial. What has happened is not true, we hope we are dreaming. There is a sense of disbelief: ‘Can somebody tell me this is not true’. This is a form of protection for us from the sudden shock of the extraordinary stress.

Healing phase

The healing phase starts when the body begins to react. We are angry at what has happened; we may be angry at ourselves or angry at the one we have lost. The biological reaction sets us on a chain of tension, anxiety, and depression all mixed up, until we feel exhausted. We are at battle stations all the time, but there is really no enemy. The enemy is ourselves. Some of us feel guilty and question whether there was anything we did wrong that may have led to this loss. We may cry and feel tired and exhausted. This may go on for days.

We need to let this energy out. Hysterical crying and weeping is common. Sharing this locked up energy with someone is sometimes useful; just talking about it, airing our thoughts can be helpful. Some like taking long walks, some like rearranging and cleaning out their desks, or just doing something that may be purposeful but relaxing.

Unresolved grief reaction

Is there anything we can do to ease the grief reaction? Not really. In fact grieving is to be encouraged, so that the locked up energy generated from the stress reaction can be expressed and shared. A person can be affected in the future if this locked up energy is allowed to remain inside. This is called unresolved grief reaction and can be damaging. One patient who was referred to me, a young lady, had agoraphobia after the death of her father. She was using up all her time to help her grieving mother and did not grieve for herself. Her mother was depressed and suicidal. The patient was young and just married, she moved in with her mother to comfort her, and was afraid to show her own emotion, as she was afraid this could harm her mother. Her mother got better, but the daughter fell ill and this lasted for many years afterwards.

Acceptance

The next phase of healing is acceptance of what has happened. A homeostatic peaceful rearrangement or a new balance of the psyche is reached. The person may be badly scarred, but may find life has a different meaning or that his feelings and experiences may now be in a different level of existence. Extraordinary stress sometimes changes a person for the better. Things that he used to take for granted are now treasured. Happiness is now more like a spice in life, a gift rather than a necessity.

Insomnia

Sleep may be a problem in the initial phase. But most patients do not want any sleeping medication. They want to feel the pain and want the wound to heal in its natural way. There will always be a scar. But they treasure the experience and look back on it occasionally. Once an equilibrium state is reached, most people are able to continue their normal life. They will never forget this kind of extraordinary stress and the loss they can never replace. Somehow life goes on and the sun is always up the next day.

We normally cope adequately with most stresses, but there are occasions when the coping mechanisms fail. We call this a nervous breakdown, and in such cases professional help is called for, as medications and other forms of treatment are sometimes indicated.

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(1) Circadian rhythm

This is the familiar 24 hour rhythm. Chronobiologists have demonstrated that if we lock ourselves underground, away from all time cues and in free running conditions, our natural endogenous biological clock is about 25 hours. Hence we wake and sleep one additional hour later with each subsequent day. Hence if we normally feel sleepy at 10 p.m. at night, after three days we will be feeling sleepy at 1 a.m., which is three hours later. If we still go to bed at 10 p.m. as before, we will be twisting and turning in bed until 1 a.m. For those who suffer from insomnia, it is most important to reset the biological clock to the 24 hour clock. The way to do this is to wake up at the same time every morning. Chronobiologists call this exercise entrainment of the biological clock to a time cue called Zeitgeber (or synchronizer). In this case the Zeitgeber is the alarm clock waking us up at the same time each morning, even on Sundays and public holidays.

(2) Ultradian rhythm

This is the 90 minute cycle mat goes on round the 24 hour clock. There is some practical significance of this rhythm to those who have sleeping problems.

There is a brief period of low arousal about every 90 minutes, and it is during this period, me 90 minute window, that we feel sleepy and fall asleep quite easily. If for any reason we miss this window, for example, because we are watching television and waiting until a program finishes, we may find it difficult to sleep. We have to wait until the next window, which is 90 minutes later. Hence if you feel sleepy at night, do not wait, go to sleep immediately, or else you may have to wait until the arrival of the next window. It does not follow that if we feel sleepy, say, at 10 p.m. we will feel even more sleepy at 10.30 p.m. In fact, for some people, having passed their 90 minute window at 10 p.m., they will feel wide awake at 10.30 p.m.

Some sleep experts suggest that if you miss the 90 minute window and feel distressed in bed and not sleepy, it may be a good idea to do something relaxing in another room and come back to bed once you feel sleepy again. Remember, the 90 minutes is an average of cycles varying from 60 minutes to 130 minutes.

If you are really very sleepy, you will fall asleep at any time, irrespective of the 90 minute window. This is because, in sleep deprived individuals, the ultradian rhythm disappears.

People who do not work or take any exercise during the day will have too much time on their hands. They will tend to have frequent naps during the day and will not need as much sleep at night. For them there is not much difference between the activities during the day and those at night. These people do not accept the fact that they have already had too much sleep in the day and do not need much more sleep at night. They believe they are suffering from insomnia. A good day is normally a busy active day, so that in the evening you feel tired, as if you have achieved a lot and have earned a good night’s rest. Regular exercise will keep your body healthy, keep your muscles strong, your heart and circulation in good shape, and also let off any tension that has accumulated in your body. It has been shown that exercise increases the amount of NREM sleep. However, if strenuous exercise is undertaken too close to sleep time, it may delay sleep onset. Exercise should be finished at least three hours before bedtime. Exercise and activities like aerobics, jogging, tennis, swimming, golf, gardening, and fishing are all very good for health. After all, sleeping well is a sign of good health, and good health starts with good hygiene.

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The first sleeping pills

For many years, opium and alcohol were the only remedies for helping insomnia. In 1869, chloral hydrate was discovered and became the first synthetic hypnotic drug. This was widely used at that time and is still used even now. Choral hydrate is relatively short acting; it is marketed in Australia as Noctec, Dormel, and Chloralix.

Barbiturates

Barbiturates were manufactured in 1912 and were used extensively for the next 60 years as a tranquillizer to calm the anxious. In a moderate dose they can be used as a hypnotic for sleeping. In an even higher dose they can be used in general anaesthesia, knocking people out completely for surgical operation.

After many years it became apparent that a lot of people abused barbiturates, becoming addicted to them. There were serious withdrawal symptoms. People who were on high doses of these pills could not stop taking them and needed a higher and higher dose to have the same desirable effect. People who were on high doses for a long time and stopped suddenly experienced serious withdrawal symptoms. Not only could they not sleep, but also they could go into convulsion and could even develop temporary psychotic illness. These pills have a narrow safety margin, and people have overdosed either accidentally or on purpose. Remember the sad cases of Marilyn Monroe and Elvis Presley?

What about a natural body clock? Do we have one that is not under the influence of the sun? In one experiment, conducted in 1972, a French cave explorer, Michel Siffre, lived underground in a Texas cave for seven months, away from all noises and civilization. He was not permitted to have any watches, clocks, radios, or televisions. In other words, his external cues for time were removed completely. Under these experimental conditions, without an external time cue, the body clock was free running. After a period of days the natural body clock would emerge. It was found that under free running conditions the human body clock was about 25 hours.

However, once he returned to the natural environment, the body clock was reset to 24 hours again. This resetting of the biological clock depends on external cues, the strongest being the change from dark to light.

Experiments have also shown that if we are placed in an artificially lit day of 19 hours and an artificially dark night of 9 hours, we can be trained to live in a 28 hour clock. In this case the biological clock gradually becomes a 28 hour clock instead of a 24 hour clock, and the phase map of temperature shows a maximum once every 28 hours instead of once every 24.

Understanding the biological clock is important for people who have sleep problems. If we wake up every morning at the same time and sleep at about the same time every night, we are helping to keep the biological clock accurate. If we sometimes read, watch television, or have wild parties late into the night, this irregular life style disturbs the accuracy of the biological clock, so that when we want to sleep we may not feel sleepy. By keeping irregular hours of sleeping and waking, we cause ourselves to experience a mini jet lag all the time. To help the biological clock work in our favour, we should wake up at the same time each day. We know that under free running experimental conditions, without any outside time cue, our natural biological clock is about 25 hours. Were we to let nature take its course, we would sleep about one hour late each day. After a few days, we would be sleeping a few hours later than our normal sleep time. To reset the biological clock to 24 hours, we must ensure that we wake at the same hour each day. Although we think we have little control over sleeping, we do have full control over waking up. Waking up at the same time each morning is now one of the most important disciplines recommended by most sleep experts for treating insomnia.

The study of biological clocks and rhythms has now evolved into a special science called chronobiology. Chronobiologists are not only interested in the biological rhythm of sleep but also in other biological functions such as the rhythm of hormonal secretion, urinary excretion, gastric function, body temperature, and the periodical fluctuation of human performance during the 24 hour cycle. Some chronobiologists are even interested in the biological rhythms in animals and plants.

Franz Halberg, a US chronobiologist, divided biological rhythms into three types. In 1959 he described the familiar circadian rhythm— its period is about a day. Then, in 1967, he described ultradian rhythms, which are biological rhythms with periods of less than a day. These include the 90 minute sleep cycle, also known as the REM/NREM cycle or Kleitman’s basic rest activity cycle (BRAC). Rhythms of the third type are called infradian rhythms. These rhythms have periods in excess of a day; the most familiar is the monthly menstrual period. These biological rhythms can be summarised as follows:

(1) Ultradian rhythms: less than a day

(2) Circadian rhythms: about a day

(3) Infradian rhythms: more than a day

The ultradian rhythm with its periodicity of about 90 minutes determines human performance and arousal state both day and night throughout the 24 hour period. This 90 minute cycle has also been found to operate in other human biological activities; for example, urinary volume and concentration, gastric contraction activity, pupil size under constant illumination, respiratory rate, and even heart rate. This rhythm exerts its influence both in the awake and in the sleeping state.

The periodicity of the ultradian rhythm varies from species to species. In man, it is about 90 minutes; in cats, 20 minutes; in rhesus monkeys, 60 minutes. The significance of this ultradian rhythm and the reason for its existence is still a mystery.

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