失眠 Insomnia

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失眠 Insomnia

　　失 眠Charles E. Henley

　　 (卡勞爾·布賴寧)

　　Insomnia is more than just being unable to fall asleep. It is a subjective condition of insufficient or nonrestorative sleep despite an adequate opportunity to sleep. The Institute of Medicine and most current studies place the prevalence of insomnia at 30% to 40% in the general adult population. Although the need for sleep does not necessarily decrease with age, the incidence of sleep disturbances appears to increase with age, particularly among women. Actually, the elderly are more prone to sleep maintenance problems, whereas younger people tend to have trouble falling asleep.

　　失眠并不僅僅是無(wú)法入睡。失眠是在有足夠睡眠機(jī)會(huì)時(shí)睡眠仍不充分或睡后精力無(wú)法恢復(fù)的一種主觀病癥。美國(guó)醫(yī)學(xué)研究院和現(xiàn)有的多數(shù)研究都認(rèn)為，失眠在普通成人中的流行率為30%至40%。雖然睡眠需要未必隨年齡增長(zhǎng)而減少，但睡眠障礙的發(fā)生率似乎是隨年齡而增加的，特別是婦女。事實(shí)上，老年人更容易在睡眠維持方面出問題，而年輕人則往往是難以入睡。

　　I. Approach.

　　I. 診斷思路：

　　Insomnia represents a symptom of an underlying problem and is not in itself a disease entity. Sleep and alertness are regulated by a complex interaction between the body's internal biologic clocks, the reticular activating system, and various influences such as light or anxiety that can interfere with the normal sleep cycles. The approach to diagnosis should recognize the potential for various causes and use history and special studies to determine the cause of the insomnia.

　　失眠是某種潛在疾病的一種癥狀，失眠本身并不是一種病質(zhì)。睡眠和覺醒是眾多復(fù)雜因素相互作用的結(jié)果，如人體內(nèi)生物種、腦干網(wǎng)狀激活體系統(tǒng)及其他各種可以影響正常睡眠周期的因素，如燈光、焦慮等。診斷時(shí)應(yīng)該認(rèn)清各種因素的影響力，并根據(jù)病史及其他特殊檢查確定失眠原因。

　　A. Types of insomnia.

　　A. 失眠類型。

　　Although more than one classification system for insomnia exists, a consensus seems to support dividing insomnia into transient (lasting a few days), short-term (lasting weeks), and long-term or chronic (lasting many weeks to months or years). The Association for the Psychophysiological Study of Sleep has classified insomnia as:

　　失眠分類方法不止一種，但公認(rèn)的是將失眠分為暫時(shí)性（持續(xù)數(shù)天）、短期性（持續(xù)數(shù)周）和長(zhǎng)期性或慢性（持續(xù)數(shù)周、月或年）這幾種。睡眠社會(huì)心理生理研究協(xié)會(huì)將失眠分為以下幾種：

　　1. Psychophysiologic, which covers the transient and short-term problems associated with situational factors such as concern about an ill family member.

　　1. 社會(huì)心理性失眠。該類失眠包括暫時(shí)性和短期性失眠，通常與環(huán)境因素有關(guān)，如對(duì)生病家屬的擔(dān)心。

　　2. Psychiatric, especially depression, which has a very high concordance with insomnia, and which also covers other affective disorders and psychosis.

　　2. 精神病性失眠。尤其是抑郁癥引發(fā)的失眠，抑郁癥與失眠有很高的關(guān)聯(lián)性。其他因素包括情感障礙、精神錯(cuò)亂等。

　　3. Drugs and alcohol, especially chronic alcoholism, and the use of central nervous system stimulants such as caffeine, nicotine, or other drugs.

　　3. 藥物與酒精性失眠。特別是慢性酒精中毒和服用一些中樞神經(jīng)系統(tǒng)興奮劑，如咖啡因、尼古丁或其他藥物。

　　4. Sleep-related movements syndromes. These syndromes comprise a special category related to behavioral or motor problems. Periodic limb movements and restless leg syndrome are the most frequent diagnoses.

　　4. 睡眠相關(guān)運(yùn)動(dòng)綜合癥。這些綜合癥包括與行為或運(yùn)動(dòng)相關(guān)的一些特殊疾病，其中以周期性肢體運(yùn)動(dòng)和下肢不適綜合癥為最常見。

　　5. Sleep-induced respiratory problems (e.g., obstructive sleep apnea). With this condition, the patients usually have no trouble falling asleep initially, but have multiple arousals and awakenings during the night.

　　5. 睡眠誘發(fā)的呼吸系統(tǒng)疾?。ㄈ缱枞运吆粑鼤和＃??；加羞@類疾病的病人通常無(wú)入睡困難，但在夜間醒來次數(shù)多。

　　6. Medical and environmental causes such as repeated rapid eye movement (REM) interruptions from outside noise.

　　6. 醫(yī)源及環(huán)境性失眠。如外界噪聲多次打斷快速眼球運(yùn)動(dòng)睡眠相。

　　7. Unknown causes--the patient may just be a short sleeper.

　　7. 原因不明性失眠。也許病人本來就睡眠少。

　　B. Special concerns.

　　B. 特別注意問題。

　　Potentially, the most serious problem associated with insomnia is related to obstructive sleep apnea. If left untreated, it is associated with oxygen desaturation, hypercapnia, and hypopnea, which can lead to significant cardiovascular problems (e.g., systemic and pulmonary hyper tension, cor pulmonale, and right ventricular failure).

　　與失眠相關(guān)的最嚴(yán)重的潛在問題是阻塞性睡眠呼吸暫時(shí)。如不治療，會(huì)并發(fā)血氧飽和度下降、高碳釀血癥和呼吸減慢，從而導(dǎo)致嚴(yán)重的心血管疾?。ㄈ缦到y(tǒng)性和肺動(dòng)脈高壓、肺心病和右心室衰竭）。

　　II. History

　　病史：

　　A. Characteristics of insomnia.

　　A. 失眠的特點(diǎn)：

　　Insomnia cannot be diagnosed by the amount of time a person sleeps. Rather, it is distinguished by the daytime consequences of unsatisfactory sleep. A pertinent history for insomnia would include:

　　不能根據(jù)病人睡眠時(shí)間長(zhǎng)短來診斷失眠。應(yīng)根據(jù)睡眠不足是否影響生活加以鑒別。與失眠相關(guān)的病史包括：

　　1. A history of restlessness, irritability, daytime somnolence, and impaired work or social functioning, which can lead to situational stress. This may be a transient problem, but it can lead to difficulties with initiation of sleep and early awakenings.

　　1. 不安、易怒、晝間困倦及工作與社會(huì)職能障礙，均可導(dǎo)致環(huán)境壓力。問題可能是暫時(shí)性的，但會(huì)造成入睡困難和早醒。

　　2. Use of caffeine or other stimulants, especially over-the-counter medications (e.g., decongestants) that may contain ephedrine or phenylpropanolamine. Late evening exercise can also be a stimulant. Alcohol may help induce sleep, but it interferes with REM sleep and leads to nonrestorative sleep and early awakenings.

　　2. 服用咖啡因或其他興奮劑，特別是含有麻黃堿或鹽酸基丙醇胺的非處方藥（如堿充血?jiǎng)?。晚間鍛煉也有興奮作用。酒精有助入睡，但干擾快速眼球運(yùn)動(dòng)睡眠相，導(dǎo)致早醒和睡后精力未恢復(fù)。

　　3. Affect changes, sadness, hopelessness, and vegetative signs such as weight loss should suggest depression, the most common psychiatric disorder associated with insomnia (Chapter 3.3). This is especially true if the insomnia persists for weeks. Anxiety disorders cause difficulty with getting to sleep, whereas patients with depression may fall asleep more readily but have early awakening.

　　3. 情感變化、悲傷、無(wú)助和營(yíng)養(yǎng)機(jī)能變化引發(fā)的一些體征，如體重減輕，可提示抑郁癥，它是最常見的失眠相關(guān)精神病。如果失眠持續(xù)數(shù)周，其診斷就更確鑿無(wú)疑。焦慮癥導(dǎo)致入睡困難，抑郁癥病人則容易入睡，也易早醒。

　　4. Medical problems such as peptic ulcer disease and heart failure have been implicated in insomnia (Chapters 7.5 and 9.6). A history of frequent nocturnal urinations can also disrupt sleep and may indicate benign prostate hyperplasia or other prostate problems. Hyperthyroidism can cause irritability and insomnia, as can thyroid replacement therapy for hypothyroidism. Other problems such as asthma, angina, back pain, and sinusitis can also cause sleep disorders.

　　4. 內(nèi)科疾病。如消化性潰瘍病和心力衰竭，都跟失眠有牽連。夜間尿頻中斷睡眠，多見于良性前列腺增生或其他前列腺疾病。甲狀腺功能亢進(jìn)可導(dǎo)致易怒和失眠，用甲狀腺素替代療法治療甲狀腺功能減退癥時(shí)也會(huì)出現(xiàn)上述現(xiàn)象。其他疾病如哮喘、心絞痛、背痛和鼻竇炎等也可引起睡眠障礙。

　　5. Loud snoring, daytime somnolence, forgetfulness, difficulty concentrating, and a history from the bed partner of periods of discontinuation of breathing during sleep of 10 seconds or more should suggest a more thorough evaluation for obstructive sleep apnea. Daytime napping, associated findings of gastrointestinal reflux disease, and hypertension are also suggestive associations for sleep apnea.

　　5. 嚴(yán)重打鼾、白天困倦、健忘、注意力難以集中、及睡伴對(duì)其睡眠呼吸中斷10秒種或以上的描述等，這些現(xiàn)象都提示應(yīng)進(jìn)行更徹底的檢查，以確定其是否有阻塞性睡眠呼吸暫停。晝間瞌睡、胃腸反流疾病相關(guān)檢查結(jié)果和高血壓等也提示與睡眠呼吸暫停有關(guān)。

　　6. The bed partner is also a good person to ask about leg movements during sleep. This could be suggestive of a periodic limb movement disorder. A similar syndrome, restless legs, is associated with a history of unpleasant sensations in the legs and a persistent desire to move them. Both conditions cause a delay in sleep onset and nocturnal awakenings.

　　6. 睡伴也是病人睡眠時(shí)腿部運(yùn)動(dòng)的良好詢問對(duì)象，提供情況對(duì)周期性肢體運(yùn)動(dòng)障礙有提示作用。類似的還有不安腿綜合癥，它通常伴有腿部不適感，并使患者想要不斷地移動(dòng)兩腿。這兩種疾病都導(dǎo)致入睡推遲和夜間覺醒。

　　7. Sleep phase disturbances caused by jet lag or shift work can be characterized by early awakening or by awakening later in the day.

　　7. 時(shí)差或倒班引起睡眠相混亂，其特征是早醒或白天晚醒。

　　III. Physical examination.

　　III. 體格檢查：

　　The physical examination for insomnia is more a search for other underlying disease states than for any specific signs for insomnia, although hypertension, obesity, and thick neck suggest consideration of sleep apnea.

　　雖然高血壓、肥胖癥、短頸都可考慮有睡眠呼吸暫停，但失眠患者的體格檢查更多的是檢查其有否其他潛在疾病，而非檢查失眠的特殊體征。

　　IV. Testing.

　　IV. 實(shí)驗(yàn)室檢查：

　　The diagnosis of unexplained insomnia may involve testing in a sleep laboratory using polysomnography. This provides the opportunity to monitor such parameters as the electroencephalogram (EEG),'breathing, oxygen saturation, and body movements during sleep. Polysomnography can determine the disturbances in chronobiologic rhythms and loss of normal sleep-awake patterns associated with circadian rhythm disorders. The EEG results from the sleep laboratory will demonstrate a patient's ability to progress through the five cycles of normal sleep and where in the process any disturbances may be located. For instance, a short REM sleep latency period from initiation of sleep to actual REM sleep, along with increased REM sleep, and reduced total sleep time with frequent awakenings are all associated with depression.

　　原因不明性失眠的診斷，應(yīng)采用睡眠實(shí)驗(yàn)室多相睡眠描記儀進(jìn)行檢查，其監(jiān)測(cè)參數(shù)包括：腦電波、呼吸、血氧飽和度及睡眠時(shí)的軀體運(yùn)動(dòng)等。多相睡眠描記儀可確診時(shí)間生物節(jié)律紊亂和晝夜生理節(jié)律異常導(dǎo)致的正常睡眠—覺醒方式的喪失。睡眠實(shí)驗(yàn)室獲得的腦電波可證明病人是否經(jīng)歷五個(gè)正常睡眠周期和異常出現(xiàn)的位置。如，初入睡至實(shí)際快速眼球運(yùn)動(dòng)睡眠之間快速眼球運(yùn)動(dòng)睡眠期的縮短，快速眼球運(yùn)動(dòng)睡眠延長(zhǎng)、頻繁覺醒導(dǎo)致總睡眠時(shí)間減少等，都與抑郁癥有關(guān)。

　　V. Diagnostic assessment.

　　診斷評(píng)價(jià)：

　　The key to diagnosing insomnia and other sleep disorders is history and sleep laboratory monitoring. Short-term problems related to difficulty with initiating sleep may be situational or environmental. Long-term problems with sleep_, lasting weeks to months, may be more psychophysiologic such as with chronic anxiety or depression. A thorough history of personalor job-related issues, caffeine, alcohol and other drug use, related medical problems, abnormal leg and body movements at night, problems with daytime napping and somnolence as well as night time snoring, and apnea spells will all direct the practitioner to the cause of most problems. A good sleep study often confirms the diagnosis and leads to specific interventions.

　　診斷失眠及其他睡眠障礙的關(guān)鍵是病史和睡眠實(shí)驗(yàn)室監(jiān)測(cè)。與入睡困難相關(guān)的短期失眠一般是由環(huán)境因素引起的。持續(xù)數(shù)周甚至數(shù)月的長(zhǎng)期睡眠問題更多的是由心理生理因素引起，如長(zhǎng)期患有焦慮癥或抑郁癥。詳細(xì)的病史檢查，包括個(gè)人及工作情況問題，咖啡因、酒精及其他藥物服用史，相關(guān)內(nèi)科疾病，夜間腿部及軀體異常運(yùn)動(dòng)，晝間瞌睡，夜間打鼾及呼吸暫停時(shí)間等情況，都可以引導(dǎo)醫(yī)生找到多數(shù)失眠的原因。對(duì)睡眠情況進(jìn)行認(rèn)真檢查通常可以確診失眠，進(jìn)而采取特定的治療措施。