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https://ah.lib.nccu.edu.tw/handle/140.119/136479| 題名: | 睡不著還是太清醒？ 失眠患者的過度激發及恆定驅力與主客觀睡眠的關係 Can`t sleep or too aroused? Hyperarousal and homeostatic drive with the objective and subjective discrepancy phenomenon in insomnia |
作者: | 高幼萱 Kao, Yu-Hsuan |
貢獻者: | 楊建銘 Yang, Chien-Ming 高幼萱 Kao, Yu-Hsuan |
關鍵詞: | 睡眠狀態錯估 自律神經激發 皮質激發 客觀短睡眠時數失眠患者 睡眠恆定系統 Sleep state misperception Autonomic nerve arousal Cortical arousal Objective short-sleep duration insomnia Homeostatic system |
日期: | 2021 | 上傳時間: | 4-Aug-2021 | 摘要: | 研究目的：失眠患者的分類從ICSD-3之後就取消了失眠亞型的診斷，並以自陳描述作為診斷參考依據。然而在失眠病理的討論中，大多數研究者可使用客觀量測工具發現失眠患者確實比好眠者有有明顯的生理激發狀態。Vgontzas的研究團隊（2009）則是宣稱使用客觀睡眠時數作為失眠患者的分組依據，可分出生理症狀為主的短睡眠時數組及心理症狀為主的正常睡眠時數組兩種失眠患者種類。本研究試圖以不同的分組方式，探討以單純客觀因素分組或是加入主觀因素分組，是否可以看到組間有不同的生理變化，藉以回推背後睡眠機制如何影響失眠患者的主觀評估及客觀量測結果。\n\n研究方法：本研究分析35位達ICSD-3慢性失眠診斷標準之參與者，排除嚴重精神疾病、慢性心血管疾病及共病睡眠生理相關疾病者，全部參與者年齡介於20-59歲。使用多頻道睡眠檢測儀收集睡前靜坐及整夜睡眠之腦波與心律資料做為客觀資料，並在檢測後隔天早上填寫自陳睡眠品質量表作為主觀資料。參與者使用主客觀睡眠時數差異程度分成人數相等的三組，分別為相對低估組（12人）、相對正確評估組（12人）及相對高估組（11人）；使用客觀睡眠時數六個小時分成兩組，睡少於六小時的為短睡眠時數組（9人），其餘的為正常睡眠時數組（27人）。\n\n研究結果：在以客觀睡眠時數分組的組別中觀察到短睡眠時數組在整個晚上的清醒期與快速動眼期皆有顯著較高的生理激發，且即使有睡得較少和有較差的睡眠品質，在睡前靜坐及整夜清醒期中短睡眠時數組都出現低頻腦波活動較少。除此之外，短睡眠時數組的皮質激發比起自律神經激發更加顯著，這與過去學者所假設的不完全一致。最後，在以主客觀睡眠差異的組別中則是觀察到低估睡眠時數組在半夜的清醒期的低頻腦波顯著較低，表示在睡後清醒時的腦波活躍程度可能會影響自評的睡眠品質。\n\n結論：從主客觀程度差異分組中觀察到睡眠的低估程度與入睡後清醒時期嗜睡程度有關，而不同睡眠階段的腦波則沒有組間差異，這顯示在入睡後醒來的狀態較少的睡眠驅力可能使個體有低估睡眠的傾向。而使用客觀時數分組方式觀察到短睡眠時數組除了高激發之外，可能也有較低的睡眠需求。綜上所述，使用不同分組方式，觀察到兩種分組所劃出的失眠族群特性有所不同。此結果顯示失眠疾患有許多不同的病理因素，而客觀睡眠檢測可增加失眠患者生理機制的資訊量的觀點。此外，本研究的結果亦支持睡眠恆定系統對失眠疾患的影響，故建議未來在失眠病理的討論能夠對此議題多加探討。 Introduction\nThe International Classification of Sleep Disorders-Third Edition has removed the subtyping from the diagnosis of insomnia disorder. The diagnosis of insomnia is based on subjective report only. However, in the studies of the etiology of insomnia, insomnia based on objective measure were found to have significantly higher physiological arousal in insomnia patients. Vgontzas and colleagues (2009) had proposed that insomnia phenotypes could be classified with objective sleep measurement. They found the insomnia with objective short sleep duration had more cardiovascular and metabolic comorbidity, and the insomnia with objective normal sleep duration was characterized by more psychological symptoms. The current study aims to compare different ways of subtyping insomnia, the classification based on objective sleep duration versus the classification based on the discrepancy between subjective and objective sleep measures, in order to explore the sleep mechanisms that are associated with the different subtypes of insomnia.\n\nMethod\nThirty-five participants who met the ICSD-3 criteria of insomnia disorder were recruited from community. Potential participants with severe psychological, metabolic, or cardiovascular disorders, or comorbid with other sleep disorders were excluded. Their age ranged from 20 to 59 years old. One night of polysomnography (PSG) was conducted to collect EEG and heart rate data before sleep and during sleep. Subjective ratings of sleep duration and sleep quality were obtained after the PSG night. For the subtyping based on discrepancy between subjective and objective sleep measures, participants were divided into three groups: related over-estimation group (11 person), related correct-estimation group (12 person) and related under-estimation group (12 person). For the subtyping based on PSG-measured objective sleep duration, participants were categorized into a short-objective-sleep-duration group (<6 h) and a normal-objective-sleep-duration group (≧6h).\nResult\nThe short-objective-sleep-duration group was found to have higher level of physiological arousal during waking and NREM sleep throughout of the night. Although having less sleep, they were found to have lower theta and alpha power before sleep and during waking after sleep onset, suggesting the possibility of lower sleep needs in these patients. However, inconsistent with the finding by Vgontzas and colleagues, we found more significant results in cortical hyperarousal autonomic hyperarousal. Lastly, the underestimation group has significantly lower theta power at waking during the night.\n\nConclusion\nWhen comparing the groups with different level of subjective and objective sleep discrepancy, the results showed association between theta activity during waking in the night and underestimation of sleep, but no difference among the groups during NREM and REM sleep. The findings suggested that their sleep may be underestimated due to less sleep pressure during waking after sleep onset. By comparing the groups with short and normal objective sleep duration, evidence showed both hyper arousal and decreased sleep drive in short sleep duration group. These two different ways of subtyping can demonstrate different clinical characteristics in patients with insomnia disorder. The findings suggest that insomnia is a disorder with multiple etiological factors. PSG can provide additional information for the etiological factors for insomnia. In addition, abnormality in the homeostatic system may play a role in insomnia that needs more investigation in future studies. |
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