Culebras A
State University of New York, Health Science Center, Syracuse.
Psychiatr Clin North Am. 1992 Jun;15(2):467-89.
Wakefulness and sleep are antagonistic states competing for the domain of brain activity. Non-REM sleep and REM sleep are different states of being, sustained by activity in brainstem nuclei, hypothalamus, basal forebrain, and thalamus. Such complex phenomenology is subject to many alterations grouped in the new International Classification of Sleep Disorders. The insomnias are the result of interacting psychosocial, psychophysiologic, neurodevelopmental, and medical factors. Proper perspective of each factor provides the clinical strategies to approach medically the symptom-complex of insomnia. The most common cause of daytime hypersomnia is chronic sleep deprivation. Obstructive sleep apnea responds to nasal CPAP, but the failure rate approaches 30%. In intolerant patients BiPAP and surgical remedies should be considered. Motor and behavioral abnormalities of sleep may be linked to REM sleep as in the REM sleep behavior disorder. Paroxysmal nocturnal dystonia and nocturnal wanderings may be associated with epilepsy. Intrusions of one state of being (wakefulness, non-REM sleep, and REM sleep) into another result in mixed, poorly defined, or only partially developed states. Dissociation of states may be responsible for confusional arousals, hallucinations, and cateplexy. Senile degeneration of the suprachiasmatic nuclei may underlie the circadian rhythm changes in old age and the "sundown" syndrome in demented patients. Misalignment of the hypothalamic pacemaker causes dysregulation of sleep-related physiologic and behavioral variables. Exposure to bright light retrains the pacemaker in night-shift workers, transmeridian travelers, and in patients with seasonal affective syndrome. Benzodiazepine compounds are very effective hypnotics, but should be used sparingly in the elderly to avoid falls, memory lapses, and aggravation of a preexisting sleep apnea syndrome. Sleep laboratory evaluations are indicated in patients with hypersomnia, suspected sleep apnea syndrome, motor-behavioral disorders of sleep, and in many individuals complaining of insomnia.
觉醒和睡眠是争夺大脑活动领域的拮抗状态。非快速眼动睡眠和快速眼动睡眠是不同的存在状态，由脑干核、下丘脑、基底前脑和丘脑的活动维持。这种复杂的现象学受到新的《国际睡眠障碍分类》中归类的许多改变的影响。失眠是心理社会、心理生理、神经发育和医学因素相互作用的结果。对每个因素的正确认识为从医学角度处理失眠症状复合体提供了临床策略。白天过度嗜睡最常见的原因是慢性睡眠剥夺。阻塞性睡眠呼吸暂停对鼻持续气道正压通气（CPAP）有反应，但失败率接近30%。对于不耐受的患者，应考虑双水平气道正压通气（BiPAP）和手术治疗。睡眠的运动和行为异常可能与快速眼动睡眠有关，如快速眼动睡眠行为障碍。阵发性夜间肌张力障碍和夜间漫游可能与癫痫有关。一种存在状态（觉醒、非快速眼动睡眠和快速眼动睡眠）侵入另一种状态会导致混合的、定义不明确的或仅部分发展的状态。状态解离可能导致混乱觉醒、幻觉和猝倒。视交叉上核的老年变性可能是老年人昼夜节律变化和痴呆患者“日落”综合征的基础。下丘脑起搏器失调会导致与睡眠相关的生理和行为变量失调。夜班工作者、跨子午线旅行者和季节性情感障碍患者暴露于强光下可重新训练起搏器。苯二氮䓬类化合物是非常有效的催眠药，但在老年人中应谨慎使用，以避免跌倒、记忆减退和加重已有的睡眠呼吸暂停综合征。对于过度嗜睡、疑似睡眠呼吸暂停综合征、睡眠运动行为障碍的患者以及许多抱怨失眠的人，需要进行睡眠实验室评估。
