矛盾性失眠脑电特征及治疗的研究进展

doi:10.3969/j.issn.1674-8115.2024.05.016

摘要/Abstract

摘要：

矛盾性失眠（paradoxical insomnia，Para-I）又被称为假性失眠（pseudoinsomnia）或失眠状态错觉（sleep state misperception，SSM）。这类患者通常主诉患有严重失眠，但缺乏睡眠紊乱的客观证据，日间功能受损情况与患者所述的睡眠缺失程度不成比例。高估睡眠潜伏时间（sleep latency，SL）、低估总睡眠时间（total sleep time，TST）是Para-I的主要特征。这种睡眠质量的错误评价妨碍了对睡眠障碍的诊断、严重程度及临床疗效的评估。Para-I的发病机制仍不清楚，可能与抑郁水平、焦虑水平、人格特征、社会关系质量、大脑结构和功能的特殊改变有关。基于多导睡眠监测（polysomnography，PSG）的失眠相关研究发现，非快速眼动睡眠（non-rapid eye movement sleep，NREM睡眠）和快速眼动睡眠（rapid eye movement sleep，REM睡眠）的改变可能与失眠患者的主客观睡眠不一致程度有关。PSG是诊断睡眠障碍的重要手段。它可以通过同步监测脑电图（electroencephalogram，EEG）、肌电图（electromyogram，EMG）、眼动电图（electrooculogram，EOG）、口鼻气流、胸腹呼吸运动、血氧饱和度、心电图（electrocardiogram，ECG）、鼾声等多项参数对睡眠结构及相关的生理行为变化进行分析。近年来，越来越多的研究开始借助PSG对Para-I的睡眠EEG及治疗进行探索并取得了一定的进展。该文就Para-I的脑电特征和治疗的最新进展做一综述，以期为Para-I的精准治疗提供新的思路。

关键词: 矛盾性失眠, 主客观睡眠不一致, 多导睡眠监测, 失眠认知行为治疗

Abstract:

Paradoxical insomnia (Para-I), also known as pseudoinsomnia or sleep state misperception, is a condition in which the patient complains of severe insomnia but has no objective evidence of sleep disorder, and daytime functioning may be disrupted disproportionately to the degree of patient-reported sleep loss. Para-I is characterized by overestimation of sleep latency (SL) and underestimation of total sleep time (TST). Incorrect assessment of sleep quality hinders the diagnosis, evaluation of severity, and assessment of clinical efficacy of sleep disorders. The pathogenesis of Para-I remains unclear, but may be related to factors such as depression, anxiety, personality traits, social relationships and specific changes in brain structure and function. Studies on the polysomnography (PSG) of the patients with insomnia have found that changes in non-rapid eye movement (NREM) and rapid eye movement (REM) sleep may be related to the degree of subjective-objective sleep discrepancy. PSG is a valuable diagnostic tool for sleep disorders. It allows for the analysis of sleep structure and related physiological and behavioral changes by monitoring various parameters, including electroencephalogram (EEG), electromyogram (EMG), electrooculogram (EOG), oro-nasal airflow, thoracic and abdominal respiratory motions, oxygen saturation, electrocardiogram (ECG) and snoring. In recent years, studies have increasingly explored the sleep EEG and treatment of Para-I with PSG, resulting in significant progress. This article reviews the latest advances in the electroencephalographic characteristics and treatment of Para-I, providing new ideas for precise treatment.

Key words: paradoxical insomnia (Para-I), subjective-objective sleep discrepancy, polysomnography (PSG), cognitive behavioral therapy for insomnia

中图分类号:

R749

张毓, 苑成梅, 肖泽萍. 矛盾性失眠脑电特征及治疗的研究进展[J]. 上海交通大学学报（医学版）, 2024, 44(5): 658-662.

ZHANG Yu, YUAN Chengmei, XIAO Zeping. Research advances in the electroencephalographic characteristics and treatment of paradoxical insomnia[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2024, 44(5): 658-662.

参考文献 46

1	American Academy of Sleep Medicine. International classification of sleep disorders[M]. 2nd edtion. Westchester: American Academy of Sleep Medicine, 2005.
2	American Academy of Sleep Medicine. International classification of sleep disorders[M]. 3rd edition. Darien: American Academy of Sleep Medicine, 2014.
3	Diagnostic Classification Steering Committee. International classification of sleep disorders: diagnostic and coding manual (ICSD)[M]. Rochester: American Sleep Disorders Association, 1990.
4	EDINGER J D, KRYSTAL A D. Subtyping primary insomnia: is sleep state misperception a distinct clinical entity?[J]. Sleep Med Rev, 2003, 7(3): 203-214.
5	ST-JEAN G, BASTIEN C H. Classification of insomnia sufferers based on laboratory PSG recordings and subjective sleep reports[J]. Sleep, 2009, 32: A284.
6	ST-JEAN G, TURCOTTE I, BASTIEN C H. Cerebral asymmetry in insomnia sufferers[J]. Front Neurol, 2012, 3: 47.
7	MA Y, GOLDSTEIN M R, DAVIS R B, et al. Profile of subjective-objective sleep discrepancy in patients with insomnia and sleep apnea[J]. J Clin Sleep Med, 2021, 17(11): 2155-2163.
8	LEE S A, IM K, YANG H R. Factors associated with sleep state misperception in patients with obstructive sleep apnea[J]. Sleep Breath, 2022, 26(4): 1921-1930.
9	ARDITTE HALL K A, WERNER K B, GRIFFIN M G, et al. Exploring predictors of sleep state misperception in women with posttraumatic stress disorder[J]. Behav Sleep Med, 2023, 21(1): 22-32.
10	JENKINS C A, THOMPSON K N, CHANEN A M, et al. Subjective and objective sleep in young people with borderline personality disorder features[J]. J Sleep Res, 2022, 31(2): e13463.
11	LAVIN-GONZALEZ P, BOURGUIGNON C, CRESCENZI O, et al. Inactograms and objective sleep measures as means to capture subjective sleep problems in patients with a bipolar disorder[J]. Bipolar Disord, 2020, 22(7): 722-730.
12	KAWAI K, IWAMOTO K, MIYATA S, et al. A study of factors causing sleep state misperception in patients with depression[J]. Nat Sci Sleep, 2022, 14: 1273-1283.
13	LIAO J P, ZHU S C, LI X L. Anxiety and depression in paradoxical insomnia: a case-control study[J]. Neuropsychiatr Dis Treat, 2018, 14: 231-238.
14	LEE J, JUNG H Y, LEE S I, et al. Smartphone addiction proneness is associated with subjective-objective sleep discrepancy in patients with insomnia disorder[J]. Psychiatry Investig, 2021, 18(11): 1035-1043.
15	LEE J Y, JOO E Y, CHOI S J, et al. The mediating effect of depression in the relationship between sleep misperception and insomnia severity among insomnia patients[J]. J Sleep Med, 2020, 17(2): 159-166.
16	徐碧云. 矛盾性失眠患者个性特征与心理症状分析[J]. 脑与神经疾病杂志, 2019, 27(1): 20-24.
	XU B Y. Analysis of personality and psychological symptoms of paradoxical insomnias[J]. Journal of Brain and Nervous Diseases, 2019, 27(1): 20-24.
17	CASTELNOVO A, FERRI R, GALBIATI A, et al. Extreme sleep state misperception: from psychopathology to objective-subjective sleep measures[J]. Int J Psychophysiol, 2021, 167: 77-85.
18	PARK S, PARK K, SHIM J S, et al. Psychosocial factors affecting sleep misperception in middle-aged community-dwelling adults[J]. PLoS One, 2020, 15(10): e0241237.
19	EMAMIAN F, MAHDIPOUR M, NOORI K, et al. Alterations of subcortical brain structures in paradoxical and psychophysiological insomnia disorder[J]. Front Psychiatry, 2021, 12: 661286.
20	YOON G, LEE M H, OH S M, et al. Negative and positive sleep state misperception in patients with insomnia: factors associated with sleep perception[J]. J Clin Sleep Med, 2022, 18(7): 1789-1795.
21	STEPHAN A M, LECCI S, CATALDI J, et al. Conscious experiences and high-density EEG patterns predicting subjective sleep depth[J]. Curr Biol, 2021, 31(24): 5487-5500.e3.
22	REN W J, ZHANG N, SUN Y L, et al. The REM microarousal and REM duration as the potential indicator in paradoxical insomnia[J]. Sleep Med, 2023, 109: 110-117.
23	OHAYON M M, CARSKADON M A, GUILLEMINAULT C, et al. Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: developing normative sleep values across the human lifespan[J]. Sleep, 2004, 27(7): 1255-1273.
24	RIEMANN D, SPIEGELHALDER K, NISSEN C, et al. REM sleep instability: a new pathway for insomnia?[J]. Pharmacopsychiatry, 2012, 45(5): 167-176.
25	KOKKINOS V, VULLIÉMOZ S, KOUPPARIS A M, et al. A hemodynamic network involving the insula, the cingulate, and the basal forebrain correlates with EEG synchronization phases of sleep instability[J]. Sleep, 2019, 42(4): zsy259.
26	PARRINO L, FERRI R, BRUNI O, et al. Cyclic alternating pattern (CAP): the marker of sleep instability[J]. Sleep Med Rev, 2012, 16(1): 27-45.
27	TERZANO M G, PARRINO L. Origin and significance of the cyclic alternating pattern (CAP)[J]. Sleep Med Rev, 2000, 4(1): 101-123.
28	PARRINO L, MILIOLI G, DE PAOLIS F, et al. Paradoxical insomnia: the role of CAP and arousals in sleep misperception[J]. Sleep Med, 2009, 10(10): 1139-1145.
29	BENBIR ŞENEL G, AYDıN Ö, TANRıÖVER AYDıN E, et al. Changes in sleep structure and sleep spindles are associated with the neuropsychiatric profile in paradoxical insomnia[J]. Int J Psychophysiol, 2021, 168: 27-32.
30	FERNANDEZ L M J, LÜTHI A. Sleep spindles: mechanisms and functions[J]. Physiol Rev, 2020, 100(2): 805-868.
31	LECCI S, CATALDI J, BETTA M, et al. Electroencephalographic changes associated with subjective under- and overestimation of sleep duration[J]. Sleep, 2020, 43(11): zsaa094.
32	XU B Y, CAI Q H, MAI R R, et al. Sleep EEG characteristics associated with total sleep time misperception in young adults: an exploratory study[J]. Behav Brain Funct, 2022, 18(1): 2.
33	ZHAO W R, VAN SOMEREN E J W, LI C Y, et al. EEG spectral analysis in insomnia disorder: a systematic review and meta-analysis[J]. Sleep Med Rev, 2021, 59: 101457.
34	PROVENCHER T, FECTEAU S, BASTIEN C H. Patterns of intrahemispheric EEG asymmetry in insomnia sufferers: an exploratory study[J]. Brain Sci, 2020, 10(12): 1014.
35	GAO R. Interpreting the electrophysiological power spectrum[J]. J Neurophysiol, 2016, 115(2): 628-630.
36	ANDRILLON T, SOLELHAC G, BOUCHEQUET P, et al. Revisiting the value of polysomnographic data in insomnia: more than meets the eye[J]. Sleep Med, 2020, 66: 184-200.
37	HARVEY A G, TANG N K Y. (Mis)perception of sleep in insomnia: a puzzle and a resolution[J]. Psychol Bull, 2012, 138(1): 77-101.
38	HARTMANN S, PARRINO L, ENSRUD K, et al. Association between psychotropic medication and sleep microstructure: evidence from large population studies[J]. J Clin Sleep Med, 2023, 19(3): 581-589.
39	İNALTEKİN A, YAĞCI İ, KIVRAK Y. Paradoxical insomnia: a case report[J]. Noro Psikiyatr Ars, 2020, 57(4): 338-339.
40	KHAZAIE H, REZAIE L, DARVISHI F, et al. Treatment of paradoxical insomnia with atypical antipsychotic drugs. A comparison of olanzapine and risperidone[J]. Neurosciences (Riyadh), 2013, 18(1): 64-69.
41	NISHIKAWA K, KURIYAMA K, YOSHIIKE T, et al. Effects of cognitive behavioral therapy for insomnia on subjective-objective sleep discrepancy in patients with primary insomnia: a small-scale cohort pilot study[J]. Int J Behav Med, 2021, 28(6): 715-726.
42	AHN J S, BANG Y R, JEON H J, et al. Effects of subjective-objective sleep discrepancy on the response to cognitive behavior therapy for insomnia[J]. J Psychosom Res, 2021, 152: 110682.
43	PERRAULT A A, POMARES F B, SMITH D, et al. Effects of cognitive behavioral therapy for insomnia on subjective and objective measures of sleep and cognition[J]. Sleep Med, 2022, 97: 13-26.
44	JANKŮ K, ŠMOTEK M, FÁRKOVÁ E, et al. Subjective-objective sleep discrepancy in patients with insomnia during and after cognitive behavioural therapy: an actigraphy study[J]. J Sleep Res, 2020, 29(4): e13064.
45	SHAIF N A S, DOSHI K, LIM J. Effects of mindfulness-based therapy for insomnia and a sleep hygiene/exercise programme on subjective-objective sleep discrepancy in older adults with sleep disturbances: exploratory secondary analysis of a randomised clinical trial[J]. J Sleep Res, 2022, 31(6): e13700.
46	LEE S A, IM K, YANG H R. Effects of continuous positive airway pressure on sleep state misperception in patients with obstructive sleep apnea[J]. J Korean Med Sci, 2023, 38(8): e54.

[1]	宋毅杰, 陈天真, 钟娜, 赵敏. 生成式人工智能在精神医学中的应用与挑战[J]. 上海交通大学学报（医学版）, 2025, 45(10): 1271-1278.
[2]	程菲, 陈天真, 游旭, 薛保双, 杨云斌, 杜江. 情绪调节能力对酒精使用障碍患者抑制控制功能的影响[J]. 上海交通大学学报（医学版）, 2025, 45(7): 883-891.
[3]	张玥, 张丽珊, 丁肖媛, 沈植旻, 卞邹吉, 余晓丹. 维生素D联合DHA补充干预学龄前注意缺陷多动障碍的疗效研究[J]. 上海交通大学学报（医学版）, 2025, 45(5): 570-577.
[4]	邢雨茜, 程影, 陈剑华. 精神分裂症视网膜特征及潜在机制的研究进展[J]. 上海交通大学学报（医学版）, 2025, 45(5): 639-645.
[5]	王思睿, 孔盖, 李惠, 钱禛颖, 崔慧茹, 唐莺莹. 经颅磁刺激治疗对抑郁症患者杏仁核及海马亚区体积的影响[J]. 上海交通大学学报（医学版）, 2025, 45(4): 434-442.
[6]	周金静, 张晨, 杨桂萍, 沈辉, 张宗凤, 高睿, 陈永军, 曹璇, 范青. 共病强迫型人格障碍对强迫症患者行为抑制/激活系统的影响[J]. 上海交通大学学报（医学版）, 2025, 45(3): 335-341.
[7]	王海红, 袁辰馨, 甘鸿, 江海峰, 赵燕, 杜江, 张毅. 间歇性θ短阵快速脉冲刺激对戒断期酒精依赖患者渴求、情绪和认知功能影响的随机对照研究[J]. 上海交通大学学报（医学版）, 2025, 45(3): 349-356.
[8]	周金静, 张晨, 杨桂萍, 沈辉, 张宗凤, 高睿, 陈永军, 曹璇, 范青. 共病强迫型人格障碍对强迫症患者行为抑制/激活系统的影响[J]. 上海交通大学学报（医学版）, 2025, (): 1-7.
[9]	曹思瑶, 刘洁琼, 王广帅, 王广海. 孤独症谱系障碍婴儿期超早筛查和干预的研究进展[J]. 上海交通大学学报（医学版）, 2025, 45(2): 222-227.
[10]	王偲佳, 魏燕燕, 钱禛颖, 李清伟, 王继军. 精神障碍患者视网膜结构变化的研究进展[J]. 上海交通大学学报（医学版）, 2025, 45(2): 247-252.
[11]	王晓红, 方贻儒. 双相障碍神经炎症机制的研究进展[J]. 上海交通大学学报（医学版）, 2025, 45(1): 107-112.
[12]	蔡蔷薇, 孙锋, 吴文玉, 邵付明, 高正良, 金盛凯. 多发性硬化症小胶质细胞转录调控网络分析[J]. 上海交通大学学报（医学版）, 2025, 45(1): 29-41.
[13]	高雨燕, 李伟, 王书婷, 岸本鹏子, 张洳源. 戒毒人员精神病理症状与药物成瘾的关系及心理痛苦的中介作用[J]. 上海交通大学学报（医学版）, 2025, 45(1): 51-59.
[14]	张迎迎, 张俊瑶, 宋际伟, 王声杰, 姚俊岩. 空气污染与阿尔茨海默病因果关联的两样本孟德尔随机化研究[J]. 上海交通大学学报（医学版）, 2025, 45(1): 87-94.
[15]	牟凡, 黄志伟, 程渝, 赵雪, 李华芳, 禹顺英. 基于生理药物代谢动力学模型预测氯氮平联合用药的药物相互作用[J]. 上海交通大学学报（医学版）, 2024, 44(11): 1414-1421.