The Comprehensive Toolkit Understanding the Mental Health Continuum

Contents The Mental Health Continuum

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The REM state

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The REM state and mental health

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A good night’s sleep

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What stops us getting the sleep we need?

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Creating positive sleep patterns

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Relaxation exercises

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Muscle tension relaxation

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Mindful breathing

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Mental health conditions

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Stress and anxiety

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Phobias, panic attacks and post-traumatic stress disorder (PTSD)

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Obsessive compulsive disorder

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Anger

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Depression

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Bipolar or manic-depressive disorder

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Autistic spectrum disorder

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Schizophrenia and psychosis

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Understanding the Mental Health Continuum reflection sheet

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References

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Understanding the Mental Health Continuum In this unit we will look at mental health conditions, the Mental Health Continuum and the relationship between mental ill health and a brain state known as REM (rapid eye movement). By the end of the unit, we will have an understanding of: the Mental Health Continuum, how mental health conditions arise and how and why addressing sleep hygiene can reduce the risk of mental health conditions arising. The Mental Health Continuum Mental health conditions used to be thought of as discrete illnesses. However, most experts now agree that they exist on a continuum. This advance in our understanding enables us to recognise these important insights: •

We are all on the Mental Health Continuum

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Stress is the crossover point between wellness and mental ill health, so if we address stress before it becomes prolonged, by teaching people about emotional needs and coping skills, we reduce the likelihood of more serious mental ill health arising

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Stress is not random; it comes from unmet needs

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Recovery from mental ill health is possible and likely

So to reiterate, stress, which all of us will experience at some time in our lives, is the crossover point where the risk of developing more serious mental ill health is greater. Exposure to stress or experiencing feelings of distress over a lengthy period of time can leave us vulnerable to developing more serious mental health conditions, such as anxiety disorders and depression; it can also negatively affect our physical health. If anxiety disorders or severe depression are not addressed, there is a greater risk of developing the symptoms of psychotic illnesses, particularly if the sufferer has a genetic disposition towards chronic mental illnesses. Descriptions of specific mental ill health and conditions are included at the end of this unit. But before looking at these, we shall explore the role of the REM state in keeping us emotionally healthy.

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The REM State REM is the name given to a phase of sleep that is accompanied by the twitching of the eye muscles; REM stands for rapid eye movement. It was first identified by sleep researchers Eugene Aserinsky and Nathaniel Kleitman in 1953. Up until their observations, it had been assumed that all sleep was the same. In the course of their laboratory research, Aserinsky and Kleitman discovered that phases of rapid eye movements during sleep could last between three and 35 minutes, and that when people exhibiting rapid eye movements were woken and questioned, they reported that they had been dreaming. We now know that 80% of dreaming occurs during REM sleep. Further research by William Dement identified that there is a pattern to REM sleep: in a typical sleep pattern, the first REM phase occurs 90 minutes after we fall asleep and in an eight-hour sleep cycle there are a further four phases of REM sleep, the final one occurring before we wake. The neurobiologist, Michel Jouvet described the characteristics of two different kinds of sleep; REM sleep (which he called paradoxical sleep) and non-REM or slow wave sleep. He demonstrated that the major muscle groups are paralysed during REM sleep (sleep atonia). In experiments carried out in the 1960s, when the

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part of the brain that inhibits muscle movement in cats was removed, during REM sleep the cats behaved as if they were hunting or chasing prey. Jouvet proposed that they were acting out instinctive behaviours common to cats, and that one of the roles of REM sleep is to maintain the integrity of our instincts. REM state activity also occurs in unborn foetuses; during the final trimester of pregnancy the foetus spends 99% of the time in REM sleep. Newborn babies can spend 16-20 hours asleep; infants between the ages of one and four can spend 10-14 hours a day sleeping; an adolescent needs about nine to 10 hours, and adults seven to eight hours. In the later stages of our life we spend about six hours asleep although whether this is because we need less sleep or because the ageing process makes it harder to sustain sleep is not known.

The REM state and mental health Many of the theories that support this course draw upon ideas first proposed and written about by social psychologist Joe Griffin, the originator of the expectation fulfillment theory of dreaming, and his collaborator, Ivan Tyrrell. The expectation fulfillment theory of dreaming draws upon the findings of researchers looking at the biology of dreaming to ascertain its function in maintaining the brain’s health. The

theory postulates that: •

Dreams are metaphorical translations of waking introspections

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Introspections that cause emotional arousal and that are not acted upon during the day become dreams

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Dreaming deactivates that emotional arousal by completing the expectation pattern metaphorically, freeing the brain respond fresh to each new day

This theory also explains a number of other phenomena associated with dreaming: •

We dream in metaphor in order to complete the pattern of emotional arousal and also so as not to confuse the content of dreaming with waking reality

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We forget the content of most of our dreams, so that the content of our memory remains intact and allows us to maintain a coherent model of reality

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Depressed people have more intensive phases of REM sleep, precisely because the emotional arousal which comes with worrying about unmet needs requires more REM sleep to discharge

The rapid eye movements which give REM sleep its name also occur during waking phases. For example, when the memory of an event or an activity which arouses strong emotion is recalled, rapid eye movements occur as the

REM state gives us access to our instincts. Rapid eye movements have also been observed in patients experiencing psychotic episodes and, since this initial observation was made, it has been captured in a large number of filmed therapy sessions. Rapid eye movement can also be seen when people undergo hypnosis or practise visualisation, and when they daydream – consciously accessing the REM state during wakefulness. What do these observations suggest about mental health? Tyrrell and Griffin propose the following: as Jouvet demonstrated, the REM state is involved with maintaining the integrity of our instincts. It does this by discharging emotional arousal at night, so that our instincts can be restored to their baseline setting, ready to serve us the next day. When we enter the REM state to daydream, or during visualisation, learning is added to our instinctive knowledge; withdrawing attention from external reality allows connections to be formed with what we already know. However, not all learning expands our understanding of the world. If we are involved in an accident or witness violence, the perceived threat throws attention into the REM state to access our instinctive knowledge and find out how best to respond. While we are in the REM state, we are highly suggestible, and the memory of threatening

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experiences can become hardwired into our instinctive knowledge about the world and encoded with strong emotions like fear and anxiety. This is how harmful conditioning like traumas and phobias are laid down. The REM state works through metaphorical pattern matching – finding an approximate match between our instinctive knowledge and the constantly changing events in our environment. This patternmatching process allows us to respond flexibly to what is going on around us, which we need to do for our survival. However, there is scope for things to go awry. When a pattern match is made between an event and our instincts for security, it can trigger a strong emotional response. When our instincts have been conditioned by trauma, the emotional response can be inappropriate, giving rise to angry outbursts in social situations; fear or anxiety about leaving the house to meet with friends or go to work; associating being in bed with lying awake at night and being unable to go to sleep; returning to obsessive or compulsive behaviours to control stress levels; and avoiding developing new relationships that meet needs for emotional connection and attention. So, understanding the REM state gives us an insight into how all anxiety disorders – insomnia, phobias, post-traumatic stress

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disorder (PTSD), obsessive compulsive disorder (OCD) etc – can be generated. It has also been speculated that there is a link between psychotic illness and the REM state. It is suggested that if a person’s physical and emotional needs are so poorly met that REM sleep phases are insufficient to discharge the resulting emotional arousal, the pressure causes the REM state to override waking consciousness. Waking reality is then experienced as a waking dream, the contents of which are indistinguishable from concrete reality. People who have suffered with psychotic illness and who have heard this explanation have said that it has been useful in helping them to make sense of their experiences. If the links made between mental ill health and REM sleep phases are correct, it suggests that we can do a lot to help recovery from mental ill health and preservation of wellbeing by promoting healthy sleep routines. How we can do this is what we shall look at next.

A good night’s sleep Sleep is a both a physical and an emotional need. The right kind of sleep is vital for our wellbeing – a healthy adult needs about seven to eight hours sleep a night. The amount of sleep we need varies from person to person; age, lifestyle, diet and environment all have an influence on the amount of sleep a

person needs. As we have seen, there are broadly two different kinds of sleep: deep sleep (sometimes also known as slow wave sleep) and REM (rapid eye movement) sleep. Both are vital to our health. Deep sleep, when the brain is least active, is the phase of sleep when hormones are released to repair body tissue and maintain our vital organs. At least four hours of deep sleep every night is required to maintain physical health. During REM sleep the brain flushes away neurotoxins from the previous day to keep our brains emotionally healthy. REM sleep discharges the emotions that we have not acted upon in the previous day – stress, anger or desire for example. In this way our emotions are restored to their usual level.

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Difficulty concentrating or functioning during the day

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Feelings of irritability

One cause for us not getting the sleep we need may be that we have not established patterns and routines that support good sleep. If we do not stick to a regular bedtime, don’t have a cool, calm quiet bedroom free from distractions (such as screens) or if we drink caffeine late in the day we are not setting ourselves up for a good night’s sleep. Our habits and routines around sleep engage our pattern matching resource. If our brain learns to associate going to bed with being wide awake it is unlikely that we will go to sleep easily. Poor sleep patterns include: •

Not having (and sticking to a regular time to go to bed and to get up

Lack of sleep or poor-quality sleep can affect your mood, cause tiredness and fatigue. One in three people in the UK at some time during the year experience some of the following symptoms:

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Watching television, internet surfing or playing games consoles in bed

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Not having curtains that block out early morning sunlight during the summer months

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Spending a long time lying awake before falling asleep

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Drinking too much caffeine during the day

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Broken or interrupted sleep, waking several times during the night

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Difficulty getting back to sleep after waking up early

Drinking too much alcohol, which inhibits REM sleep – the right amount of which is needed to keep our brain’s emotionally healthy

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Waking up feeling tired, lacking in energy and not refreshed

What stops us getting the sleep we need?

Another cause of sleep problems can be related more to what is happening during our waking hours.

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Not getting the sleep we need can be caused by all sorts of stressful life events which compromise our ability to meet our physical or emotional needs. We need to be stretched, and nature gives us the fuel to help us stretch to meet and overcome challenges. However, when this builds up to become overwhelming or unbearable this turns into stress and becomes unhealthy. Our imaginations are powerful problem-solving tools that try to predict the best course of action for the future. However, too much stress can stop us thinking clearly and cause the imagination to become overactive in trying to find a solution. In other words, we begin to worry. If we become stuck in the habit of worrying, it can be hard to relax enough to go to sleep, giving rise to insomnia. We process our worries about unmet needs through dreaming in the REM stage of sleep. This means that when we are worried, we will get more REM sleep and less deep sleep, which can in turn leave us feeling unrefreshed after our sleep. In addition, REM sleep uses up more energy; dreaming lots can cause us to wake up feeling tired and lacking in motivation. Not surprisingly, if we are spending a lot of time dreaming and not getting enough deep sleep, we are likely to feel worse in the mornings. Some things we can do to help get

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better sleep are:

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Creating the right environment… •

Make the bedroom a ‘temple’ to sleep – no screens, piles of laundry or other distractions

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Have blackout curtains so that we are not woken up earlier than we need to be

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Keep the bedroom cool

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Have a good firm mattress and appropriate pillows

Meeting our needs during the day… •

Get our needs met in a healthy way – so there is less to worry about!

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Go to bed and get up at regular times

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Take exercise to burn cortisol and tire the body

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Make sure we get privacy so we can actively reflect on the day before we go to bed

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Get good strong light at the beginning of the day to activate us. Natural blue morning light stimulates cortisol which helps wake us up

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Avoid watching TV or internet surfing in the two hours before bed. Just as morning light helps wake us up, when we use blue light devices at night, it makes the body thinks it’s time to be awake

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If you are having trouble going off to sleep, DO NOT stay in bed for longer than 20 minutes. Get up and do a task you find REALLY BORING for 20 minutes then go back to bed. If you are still awake after another 20 minutes, get up and repeat the task

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Have a notepad by the bed to jot down worries and thereby release them until the morning

Create a routine or ritual that tells the body it’s time to sleep (using our pattern match resource)

During the night… •

your phone (or a daylight alarm that helps you wake up more naturally too)

No mobile phones in bed – use an alarm clock instead of

Creating positive sleep patterns Change 1: creating the right environment What can I change about my sleep environment?

What do I need to do first?

In the one to two hours before bedtime… •

Learn and practise relaxation techniques

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Avoid caffeine in the second half of the day and limit alcohol

When will I do it?

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How I often will I do it to make sure that it works?

What have I noticed since making the change?

What have I noticed since making the change?

Change 3: one to two hours before bed What can I do during this time to improve my sleep?

Change 2: meeting emotional needs during the day

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What can I do during the day to meet my needs better?

What do I need to do first?

What do I need to do first?

When will I do it?

When will I do it?

How I often will I do it to make sure that it works?

How I often will I do it to make sure that it works?

What have I noticed since making the change?

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Change 4: during the night

Relaxation exercises

What strategies can I use during the night to improve my sleep?

Being able to relax is an important skill we all need to help us manage stressful events and balance strong emotions. Being able to relax helps us to think more clearly; when we are relaxed, we can imagine changes to the way we react and focus our minds on meeting our needs in healthy ways.

What do I need to do first?

When will I do it?

How I often will I do it to make sure that it works?

As with anything worthwhile, it is important that we practise relaxation skills on a regular basis – not just after or during an event which has triggered strong emotions. By building opportunities to relax into your lifestyle, you will feel calmer, improve your ability to cope with stress, place less stress on your immune system and help you sleep better. Here are two relaxation exercises you can begin to practise and make a regular part of a healthier lifestyle.

Muscle tension relaxation What have I noticed since making the change?

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The important principle behind this exercise is that if we tense our muscles and then let them go slack, they must relax - and if the body relaxes (because it is connected to the brain), the mind must relax too! Here are the stages of this simple exercise: •

Choose part of your body that you are easily able to control, perhaps your hands or feet

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Then, when you know which part of the body you will start

with, begin to tense the muscles in that part of the body. For example, forming tight fists with your hands and squeezing all of the air out •

Hold that part of your body tensed for 10 seconds, and then allow to it to relax and focus on allowing any tension to pass

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Repeat this exercise for as many times as you need to until you begin to feel calmer and more relaxed

Mindful breathing Our brain communicates with our body both to alert us physically when needed and to relax us. This works by changing the pattern of our breathing; when we need to be alert, our breathing speeds up and gets shallower, preparing us for flight or fight; when we need to relax, our breathing slows down and the outbreath becomes longer. The good news is that we can take control of our breathing pattern to help us: •

Start by placing your hands on your stomach and breathe in filling your stomach up with air and hold it (many of us tend to shallow breathe most of the time)

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Then breathe out more slowly than when you were breathing in. It is the out-breath which stimulates the relaxation response

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Repeat this process, counting to seven in your mind when

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breathing in, and to 11 when breathing out. The number doesn’t really matter so long as the out-breath is longer than the in-breath

When people are exposed to stress over a long period of time and become stuck worrying, it can give rise to anxiety which can also affect our physical health.

For really effective relaxation, when you know how to do both exercises, try to combine the two; tightening your muscles when breathing in and relaxing them when you are breathing out. Remember, practice makes perfect! (But if it works, it’s good enough…)

Symptoms of stress and anxiety can include:

Mental health conditions It is important to keep in mind that medical labels, while useful as a shorthand for psychiatrists and GPs, do not capture every aspect of mental health. These definitions are provided as a guide to help you understand what psychiatrists and GPs mean when they use these terms. As ever, we should be listening out for people’s needs and resources.

Stress and anxiety Stress is any pressure or accumulated pressure that is too much to cope with comfortably. It is important to remember that being stretched and being stressed are not the same thing. Being stretched by, for example, learning a new skill, getting better at our job or studying a language is an important part of a healthy life which then meets our innate need for achievement.

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Disturbed sleep

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Depression

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Persistent anxious thoughts or worries

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Burnout – becoming overly involved in work

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Alcohol consumption or the taking of drugs to cope with stress

Physical symptoms can be exacerbated or triggered by stress, and we should always seek medical help if we are experiencing: •

Asthma

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Angina and heart disease

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Headaches and migraines

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Skin complaints

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High blood pressure

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Irritable bowel

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Peptic ulcer

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Rheumatoid arthritis

Medical professionals may use terms like anxiety disorder, or other diagnostic labels to describe the symptoms of anxiety that persist over time. They may use terms like panic attacks, phobias, obsessive compulsive behaviours or post-

traumatic stress disorder. An explanation for each of these terms follows.

Phobias, panic attacks and posttraumatic stress disorder (PTSD) The brain has an emotional alarm system designed to keep us safe. When people experience panic attacks, phobias or post-traumatic stress, it is because the alarm system has gone into overdrive. There is a small structure in the brain, known as the amygdala (Greek for almond, which is its shape), that has access to our emotional memories and learned responses. We can think of this as our security officer. Our security officer is thought to keep us safe by matching new circumstances to existing memories so as to alert us to anything that previously represented a risk and might do so again. Because the security officer does not have independent access to the rational thinking of the higher cortex. It may form associations which cause it to react inappropriately to things or events that are not relevant, and before we become consciously aware of those reactions. In this way, the security officer may trigger panic attacks or phobic responses, causing us to freeze to risk assess danger, or to run away or lash out. This reaction is known as the fight-orflight response. In the case of posttraumatic stress disorder, a person may re-experience the memory of a trauma, accompanied by emotional

distress, irritability, hyper-vigilance, outbursts of anger, difficulty in concentrating or an exaggerated startle response.

Obsessive compulsive disorder (OCD) OCD is a condition in which the person affected experiences intrusive and distressing thoughts or images, usually connected with an imagined future event, and devises one or many rituals to reduce or ward off that event or make reparations for having the ‘bad’ thought. Usually, the more the rituals are carried out, the more the thoughts recur, requiring yet more rituals. The condition first occurs because of raised stress levels, perhaps when emotional needs for security and control go unmet at a time of physical illness, worry, fear, lack of sleep, bereavement or some other personal setback or crisis. Rituals can be extremely varied and numerous, have set patterns or follow a sequence and may be in some way connected with a generalised anxiety i.e. compulsive hand washing following a fear about health and safety. Anger The ability to get angry is natural and part of the ancient fight-orflight survival mechanism, which evolved to help our long-distant ancestors survive when faced with physical or psychological danger. It is accompanied by an increase in pulse

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rate, adrenalin release and faster and shallower breathing. Excessive anger can have an obvious trigger or else seem to occur out of the blue and always results from stress caused by essential emotional needs not being met.

Depression People experiencing depression may appear to be down and flat. However, depression is a highly emotional state. When we become emotional, we are less able to think clearly, which is why people experiencing strong depression often find concentrating on tasks or making decisions difficult. Worrying about emotional needs is the reason that people become emotional and find themselves stuck in the cycle of depression. A first step towards lifting depression is to learn and practise relaxation exercises. When we are relaxed, we can regain control of our imagination, so that it can be used to plan how we get our emotional needs met. The high emotional arousal caused by worrying prevents us from getting the right quality of sleep and exhausts the parts of the brain which focus our attention. This is why people suffering with depression often wake up feeling tired and lacking in motivation. Learning deep relaxation exercises and addressing unmet emotional needs can improve the quality of

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our sleep. Signs and symptoms of depression include: •

Sadness that doesn’t go away

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Tiredness and a lack of energy

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Difficulty in concentrating

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Not enjoying things that are usually pleasurable or interesting

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Feeling anxious all or some of the time

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Avoiding other people, sometimes even close family and friends

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Feelings of helplessness and a lack of hope

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Sleeping problems: difficulties in getting off to sleep or waking up much earlier than usual

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Finding it hard to function at work, college or school

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Loss of appetite

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Self-harming behaviour

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The loss of a sense of meaning & purpose to life

If somebody is experiencing four or more of these symptoms for most of the day, every day for more than two weeks, they should seek help from their GP.

Bipolar or manic-depressive disorder People diagnosed with bipolar disorder – formerly known as manic

depression – experience swings in mood from periods of overactive, excited behaviour known as mania to deep depression. Everybody experiences mood shifts in daily life, but with bipolar disorder these changes are extreme. Between the severe highs and lows, people can experience stability and during the mania phase can sometimes be very productive as a result of the energy and creativity that comes with it. In some instances, people experiencing bipolar may experience visual or auditory hallucinations or have strange, unshared, beliefs or delusions.

Autistic spectrum disorder Autistic spectrum disorder (ASD), formerly referred to as Asperger’s syndrome, is the term used to describe presentations of autism, which, unlike autism, do not prevent a person from functioning and living their lives without support. ASD may shape how a person makes sense of the world, processes information and relates to others. ASD is often described as a ‘spectrum disorder’ because the condition affects people in many different ways and to varying degrees. People diagnosed with ASD may experience difficulty with interacting and communicating in the way that wider society expects them to. They may also empathise with other people through reasoned

construction of other people, rather than matching to, and experiencing other people’s feelings emotionally. More recently, there have been efforts to destigmatise ASD by describing those with the label as neurodivergent, which sees neural and behavioural differences in terms of their strengths, rather than as abnormal.

Schizophrenia and psychosis Views on schizophrenia have changed over the years and there is still not agreement on whether schizophrenia is one condition or more than one syndrome with related features. Symptoms include hallucinations and delusional beliefs alien to the person’s cultural upbringing. Delusions may be categorised by psychiatrists as paranoid, grandiose or nihilistic. Hallucinations may be visual, auditory or touch and smell hallucinations. A large percentage of auditory hallucinations take the form of hearing a voice which may be unkind and persecutory, or give out commands to the person experiencing them. Voices may not always be unpleasant, however. The so-called negative symptoms of schizophrenia include a lack of emotional responsiveness and motivation, difficulty with thought processes and concentration, which can result in a neglect of self-care. However, these symptoms may also

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result from the side-effects of antipsychotic medication.   Experiences of hallucinations and delusions may also be referred to as psychosis or psychotic episodes. As well as their association with schizophrenia, hallucinations and delusions may accompany severe depression and bipolar disorder.

Understand the Mental Health Continuum reflection sheet Describe either: How you or your service supports people to get better quality sleep

References Regularly Occurring Periods of Eye Mobility and Concomitant Phenomena During Sleep Aserinsky, E & Kleitman, N | science.org 1953 The Biological Role of REM Sleep in Sleep: Physiology & Pathology Dement, W | Lippincott 1969 Emotional Intelligence Goleman, D | Bloomsbury 1996 Human Givens: A New Approach to Emotional Health and Clear Thinking Griffin, J & Tyrrell, I | HG Publishing 2003 & 2013 Why We Dream Griffin, J & Tyrrell, I | HG Publishing 2013

How you have used your understanding of the REM state to help somebody make sense of depression

The Paradox of Sleep Jouvet, M | MIT Press 2001 The Emotional Brain Ledoux, J | W&N 1999 Strong Imagination Nettle, D | Oxford University Press 2001 In Search of Solutions O’Hanlon, B & Weiner-Davis, M | WW Norton 2003 The Optimistic Child Seligman, M | Random House 1995 An Idea in Practice Tyrrell, I | HG Publishing 2007

Does Genetic Programming of the Brain Occur During Paradoxical Sleep? in Cerebral Correlates of Conscious Experience Jouvet, M | Elsevier 1978

The Mental Health Toolkit’s website, thementalhealthtoolkit.co.uk provides a range of resources on available support and advice

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Want to know more about The Mental Health Toolkit? To find out more about the support which The Mental Health Toolkit provides people experiencing mental ill health, please visit thementalhealthtoolkit.co.uk or call

0300 111 6000

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