目的： 探索矛盾性失眠患者的临床特征和觉醒程度的特点及关系。
方法： 2017 年 10 月至 2018 年 3 月在北京大学第六医院门诊、 附近社区及网络平台招募符合 DSM-5 慢性失眠障碍诊断标准的患者 37 例， 年龄、性别、受教育年限相匹配的健康对照 21 例。所有受试者在研究第一天完成一般资料的采集、 匹兹堡睡眠质量指数量表（PSQI） 、 疲劳严重程度量表（FSS） 、 Epworth 嗜睡量表（ESS）、 明尼苏达多项个性测查表（MMPI） 等； 连续记录 1 周睡眠日志；于第 7 天完成多导睡眠监测（PSG）， 根据 PSG 及主观睡眠记录， 将总睡眠时间（TST）≥6.5 h，且睡眠效率（SE）≥85%； 主客观 TST 相差≥60 min 或主客观 SE 相差≥15%作为矛盾性失眠诊断标准，将失眠患者分为矛盾性失眠组（9 例） 和非矛盾性失眠组（28 例）； 评估主客观睡眠差异的指标： ①睡眠知觉（%） （主观 TST/客观 TST×100%） ； ②总睡眠时间（TST）
估计误差（客观 TST-主观 TST）； ③睡眠效率（SE）估计误差（客观 SE-主观 SE）；睡眠监测结束后完成唾液皮质醇采集（醒后 0min、 15min、 30min、 45min、 60min），用放射免疫方法检测唾液皮质醇浓度。

结果：（1） 相关分析显示， 矛盾性失眠组觉醒时皮质醇水平与主观入睡潜伏期（r= 0.84； P＜0.05）、 TST 估计误差（r = 0.78； P ＜0.05）、 SE 估计误差（r = 0.81； P＜0.05）之间存在正相关，与主观 TST（r = -0.80； P＜0.05） 之间存在负相关；（2）相关分析显示， 失眠组睡眠知觉和 PSQI 评分（r = -0.45； P＜0.01）、 主观睡眠潜伏期（r = -0.38； P＜0.05）、 MMPI 癔病（Hy） 量表分（r = -0.41； P＜0.05） 之间呈负相关， 与 FSS 评分（r = 0.35； P＜0.05）、 MMPI 控制力（Cn） 量表分（r = 0.42；P＜0.05） 之间呈正相关； PSQI、 ESS、 FSS 评分、 MMPI 中疑病（Hs）、 Hy、 Cn 量表分对睡眠知觉（R2 = 0.65， P＜0.001）及 SE 估计误差（R2 = 0.66， P＜0.001）有预测作用，PSQI、FSS 评分、Hy、Cn 对 TST 估计误差有预测作用（R2 = 0.53，P＜0.001）。
结论：（1） 矛盾性失眠患者觉醒水平与主观入睡潜伏期、 主客观睡眠差异之间存在正相关；（2） 主观睡眠质量、日间症状、 人格特征与睡眠主客观差异之间存在相关性，并对其有预测作用。

Objective: To explore the clinical characteristics, features of alertness and the relationship between the two in patients with paradoxical insomnia (PI).
Methods: 37 patients meeting DSM-5 chronic insomnia (CI) were recruited in Peking University Sixth Hospital, nearby communities and by an internet social platform from
October 2017 to March 2018, and 21 good sleepers matched with their age, gender, and years of education were included as control (GS). All subjects completed the scales on the
first day, including general demographic surveys, Pittsburgh Sleep Quality Index (PSQI), Fatigue Severity Scale (FSS), Epworth sleepiness scale (ESS), Minnesota Multiphasic Personality Inventory (MMPI), and then recorded one consecutive week of sleep diaries.Subjects received polysomnography (PSG) on the seventh day to assess subjective-objective sleep differences, using the measures including sleep perception (subjective TST/ objective
TST), total sleep time (TST) estimation error (objective TST-subjective TST), sleep efficiency(SE) estimation error(objective SE-subjective SE). According to PSG and subjective sleep record, total sleep time (TST) ≥ 6.5 h and sleep efficiency (SE) ≥ 85%, subjective and objective TST difference ≥ 60 min or subjective and objective SE difference ≥15% as paradoxical insomnia diagnostic criteria. All insomnia patients were divided into paradoxical insomnia group (PI, n = 9) and non-paradoxical insomnia group (NPI, n = 28).Saliva cortisol was collected on the second day after waking (0 min, 15 min, 30 min, 45 min and 60 min after waking), using radioimmunoassay to test saliva cortisol concentration.
Results: (1)Correlation analysis results show that in PI group, cortisol level at awakening positively correlated with subjective sleep latency (r = 0.84; P < 0.05), TST estimation error
(r = 0.78; P < 0.05) and SE estimation error (r = 0.81; P < 0.05), and negatively correlated with subjective total sleep time (r = -0.80; P < 0.05). (2)Correlation analysis results show that in CI group (including PI and NPI) sleep perception negatively correlated with PSQI scores (r = -0.45; P < 0.01), subjective sleep latency (r = -0.38; P < 0.05), (Hy) scores of MMPI (r = -0.41; P < 0.05), and positively correlated with FSS scores (r = 0.35; P < 0.05), and control (Cn) scores of MMPI (r = 0.42; P < 0.05). PSQI, ESS, FSS scores, Hs, Hy, and Cn of MMPI have a predictive effect on sleep perception (R2 = 0.65, P < 0.001) and SE estimation error (R2 = 0.66, P < 0.001), PSQI, FSS scores, Hy, Cn have a predictive effect on TST estimation error (R2 = 0.53, P < 0.001).
Conclusions: (1) The alertness level of PI patients positively correlated with subjective sleep latency, subjective-objective differences, and negatively correlated with subjective total sleep time. (2) The subjective-objective differences correlates with subjective sleep quality, daytime symptoms, and personality traits; subjective sleep quality, daytime symptoms, and personality traits have a predictive effect on subjective-objective differences.
 

第一章 文献综述 .................................................... 1
1.1 失眠概述................................................... 1
1.2 失眠的分类................................................... 1
1.3 失眠及矛盾性失眠的临床特征.................................... 4
1.3.1 失眠的临床特征............................................ 4
1.3.2 矛盾性失眠的临床特征...................................... 5
1.4 失眠及矛盾性失眠的过度觉醒的研究进展.......................... 6
1.4.1 失眠的过度觉醒机制........................................ 6
1.4.2 失眠的过度觉醒的研究进展.................................. 7
1.4.3 矛盾性失眠的过度觉醒的研究进展........................... 10
第二章 引言 ....................................................... 13
第三章 对象与方法 ................................................. 15
3.1 研究对象................................................15
3.2 研究工具和设备............................................... 16
3.2.1 睡眠测评工具及设备....................................... 16
3.2.2 皮质醇采集及检测设备..................................... 19
3.3 研究流程................................................. 19
3.4 统计学分析..................................................20
第四章 结果 ................................................... 21
4.1 人口学资料及临床特征......................................... 21
4.1.1 失眠组、非矛盾性失眠组和健康对照组的人口学资料及临床特征比较
................................................... 21
4.1.2 矛盾性失眠组、非失眠组和健康对照组的 MMPI 比较............ 25
4.1.3 矛盾性失眠组、非矛盾性失眠组和健康对照组的主客观睡眠差异比较
.................................................... 26
4.1.4 与失眠患者睡眠知觉、 TST 估计误差、 SE 估计误差相关的因素... 29
4.1.5 临床特征及睡眠参数对主客观差异的预测作用................. 30
4.2 觉醒程度及与临床特征的关系................................... 32
4.2.1 非失眠组、矛盾性失眠组和健康对照组的皮质醇浓度比较....... 32
4.2.2 矛盾性失眠组、非矛盾性失眠组和健康对照组的觉醒时皮质醇浓度相关性分析...................................................33
第五章 讨论 ................................................. 35
5.1 矛盾性失眠患者临床特征....................................... 35
5.2 矛盾性失眠患者人格特征 ....................................... 36
5.3 主客观睡眠差异与临床特征的相关性 ............................. 37
5.4 矛盾性失眠患者生理性觉醒程度 ................................. 38
第六章 结论及展望 ................................................. 41
参考文献 ....................................................43
附录 A 正常睡眠的标准.............................................. 52
致谢 ...................................................53
北京大学学位论文原创性声明和使用授权说明 ........................... 55
个人简历 .................................................. 56

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