阻塞型睡眠呼吸中止症患者伴隨失眠之非藥物處置：個案報告

Nonpharmacological Interventions for Obstructive Sleep Apnea Cormorbid with Insomnia: Case Report

10.6550/ACP.200612_3(2).0005

陳明輝(Ming-Hui Chen)；楊建銘(Chien-Ming Yang)；陳濘宏(Ning-Hung Chen)

睡眠呼吸中止症 ； 失眠 ； 側睡治療法 ； 認知行為治療法 ； Obstructive sleep apnea ； insomnia ； positional therapy ； cognitive-behavior therapy

臨床心理學刊

3卷2期（2006 / 12 / 01）

93 - 105

繁體中文

目的：本個案報告係呈現以側睡治療法及認知行為治療法來治療阻塞型睡眠呼吸中止症伴隨失眠患者之效果。 方法：病人為47歲，男性，主訴為失眠及打鼾，且被診斷為重度睡眠呼吸中止症。在側睡治療法方面，教導個案睡衣背部縫高爾夫球，維持側睡姿勢，以減少睡眠呼吸中止症的發生。在認知行為治療法方面，包括使用刺激控制法、睡眠限制法、教導放鬆技巧及修正睡眠衛生習慣，以改善個案失眠困擾。在睡眠評估方面，則以睡眠日誌及睡眠多頻道檢查(polysomnography, PSG)進行評估。 結果：個案共進行9次的個別心理治療，每週一次，每次50分鐘。在客觀評估方面，睡眠多頻道檢查結果顯示，個案治療前與治療後的呼吸障礙指數(respiratory disturbance index, RDI)從每小時34.3次降到7.6次，入睡時間則從12.5分鐘降到4分鐘。在主觀評估方面，睡眠日誌記錄結果顯示，個案入眠時間從55分鐘降到15分鐘，平均睡眠時間從4.9小時增加到6.9小時，平均睡眠品質及平均白天清醒度兩者均從3.67分增加到4分。 結論：側睡治療合併認知行為治療法可以有效地改善與睡姿有關的阻塞型睡眠呼吸中止症伴隨失眠的問題，加上這些治療法具經濟且實施容易的特性，更適合於臨床上的應用。

Objective: The present case report demonstrates the efficacy of non-pharmacological strategies, namely positional therapy and cognitive behavior therapy (CBT), in the management of insomnia and sleep apnea symptoms in patients with obstructive sleep apnea comorbid with insomnia. Method: The patient was a 47-year-old male with a chief complain of insomnia and snoring, and was diagnosed with a severe sleep apnea syndrome. Positional therapy was introduced to reduce sleep apnea by having the patient wear night clothes with two golf balls stitched on its back, in order to keep a lateral sleep position. In addition, CBT for insomnia was applied with the following components: stimulus control instruction, sleep restriction therapy, relaxation training, and sleep hygiene education to eliminate his insomnia. Sleep diary and polysomnography (PSG) were used to evaluate the patient's progress and treatment effects. Results: The treatment consisted of nine weekly 50-minutes individual sessions. The patient's sleep apnea and insomnia symptoms were improved significantly after treatment. Respiratory disturbance index decreased from 34.3/hr to 7.6/hr, PSG sleep onset latency decreased from 12.5min. to 4 min., subjective sleep latency decreased from 55min. to 15min., and average sleep time increased from 4.9hrs to 6.9hrs. The ratings on both quality of sleep and daytime alertness improved from 3.67 points to 4 points. Conclusion: Positional therapy in combination with CBT for insomnia can improve position-related obstructive sleep apnea symptoms and associated insomnia. Because these non-pharmacological strategies are safe, inexpensive, and can be conducted relatively easily, they could be the treatment of choice for patients with insomnia complaints associated with position-related sleep apnea.

1. Albarrak, M.,Banno, K.,Sabbagh, A. A.,Delaive, K.,Walld, R.,Manfreda, J.,Kryger, M. H.(2005).Utilization of healthcare resources in obstructive sleep apnea syndrome: a 5-year follow-up study in men using CPAP.Sleep,28(10),1306-1311.
2. American Academy of Sleep Medicine Task Force(1999).Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research.The Report of an American Sleep,22(5),667-689.
3. Bootzin, R. R.(1972).A stimulus control treatment for insomnia.Proceedings of The American Psychological Association
4. Bootzin, R. R. ,Epstein, D. R.(2000).Stimulus control.Treament of late-life insomnia,Thousand Oaks, Ca.:
5. Brown, D. L.(2006).Sleep disorders and stroke.Seminars in Neurology,26(1),117-122.
6. Cannici, J.,Malcolm, R.,Peek, L. A.(1983).Treatment of insomnia in cancer patients using muscle relaxation training.Journal of Behavior Theray and Experimental Psychiatry,14(3),251-256.
7. Cartwright(2003).Sleep apnea: a challenge for behavioral medicine.Treating sleep disorder-principles and practice of behavioral sleep medicine,New Jersey:
8. Cartwright, R. D.,Lloyd, S.,Lilie, J.,Kravitz, H.(1985).Sleep position training as treatment for sleep apnea syndrome: a preliminary study.Sleep,8(2),87-94.
9. Cartwright, R.,Ristanovic, R.,Diaz, F.,Caldarelli, D.,Alder, G.(1991).A comparative study of treatments for positional sleep apnea.Sleep,14(6),546-552.
10. Chung, K. F.(2005).Insomnia subtypes and their relationships to daytime sleepiness in patients with obstructive sleep apnea.Respiration,72(5),460-465.
11. Coates, T. J.,Killen, J. D.,George, J.,Marchini, E.,Silverman, S.,Thoresen, C.(1982).Estimating sleep parameters: a multitrait--multimethod analysis.Journal of Consulting and Clinical Psychology,50(3),345-352.
12. Currie, S. R.,Wilson, K. G.,Pontefract, A. J.,deLaplante, L.(2000).Cognitive-behavioral treatment of insomnia secondary to chronic pain.Journal of Consulting and Clinical Psychology,68(3),407-416.
13. Dashevsky, B. A.,Kramer, M.(1998).Behavioral treatment of chronic insomnia in psychiatrically ill patients.Journal of Clinical Psychiatry,59(12),693-699+700-691.
14. Doghramji, K.(2006).The epidemiology and diagnosis of insomnia.American Journal of Managed Care,12(8 Suppl),214-220.
15. Engleman, H. M.,Wild, M. R.(2003).Improving CPAP use by patients with the sleep apnoea/hypopnoea syndrome (SAHS).Sleep Medicine Review,7(1),81-99.
16. Hauri, P.(ed.)(1991).Case studies in insomnia.New York:Plenum Press.
17. Haynes, P. L.(2005).The role of behavioral sleep medicine in the assessment and treatment of sleep disordered breathing.Clinical Psychology Review,25(5),673-705.
18. Jacobs, G. D.,Pace-Schott, E. F.,Stickgold, R., Otto, M. W.(2004).Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison.Archives of Internal Medicine,164(17),1888-1896.
19. Jokic, R.,Klimaszewski, A.,Crossley, M.,Sridhar, G.,Fitzpatrick, M. F.(1999).Positional treatment vs continuous positive airway pressure in patients with positional obstructive sleep apnea syndrome.Chest,115(3),771-781.
20. Krakow, B.,Melendrez, D.,Ferreira, E.,Clark, J.,Warner, T. D.,Sisley, B.(2001).Prevalence of insomnia symptoms in patients with sleep-disordered breathing.Chest,120(6),1923-1929.
21. Krell, S. B.,Kapur, V. K.(2005).Insomni a complaints in patients evaluated for obstructive sleep apnea.Sleep Breath,9(3),104-110.
22. Kuo, T. F.,Kushida, C. A.(2003).Treatment efficacy of behavioral interventions for obstructive sleep apnea, restless legs syndrome, periodic leg movement disorder, and narcolepsy.Treating sleep disorders
23. Lanfranchi, P. A.,Somers, V. K.(2003).Sleepdisordered breathing in heart failure: characteristics and implications.Respiratory Physiology ＆ neurobiology,136(2-3),153-165.
24. Lichstein, K. L.,Wilson, N. M.,Johnson, C. T.(2000).Psychological treatment of secondary insomnia.Psychology and Aging,15(2),232-240.
25. Morin, C. M.,Culbert, J. P.,Schwartz, S. M.(1994).Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy.American Journal of Psychiatry,151(8),1172-1180.
26. Morin, C. M.,Espie, C. A.(2003).Insomnia: A Clinical Guide to Asseessment and Treatment.New York:Kluwer Academic/ Plenum Publishers.
27. Morin, C. M.,LeBlanc, M.,Daley, M.,Gregoire, J. P.,Merette, C.(2006).Epidemiology of insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors.Sleep Med,7(2),123-130.
28. Murtagh, D. R.,Greenwood, K. M.(1995).Identifying effective psychological treatments for insomnia: a meta-analysis.Journal of Consulting and Clinical Psychology,63(1),79-89.
29. Oksenberg, A.,Silverberg, D. S.,Arons, E.,Radwan, H.(1997).Positional vs nonpositional obstructive sleep apnea patients: anthropomorphic, nocturnal polysomnographic, and multiple sleep latency test data.Chest,112(3),629-639.
30. Ong, K. C.,Clerk, A. A.(1998).Comparison of the severity of sleep-disordered breathing in Asian and Caucasian patients seen at a sleep disorders center.Respiratory Medicine,92(6),843-848.
31. Peppard, P. E.,Young, T.,Palta, M.,Dempsey, J.,Skatrud, J.(2000).Longitudinal study of moderate weight change and sleep-disordered breathing.Jama,284(23),3015-3021.
32. Peppard, P. E.,Young, T.,Palta, M.,Skatrud, J.(2000).Prospective study of the association between sleep disordered breathing and hypertension.The New England Journal of Medicine,342(19),1378-1384.
33. Perlis, M. L.(ed.),Lichstein, K. L.(ed.)(2003).Treating Sleep Disorder-Principles and practice of behavioral sleep medicine.
34. Phillips, B. A.,Okeson, J.,Paesani, D.,Gilmore, R.(1986).Effect of sleep position on sleep apnea and parafunctional activity.Chest,90(3),424-429.
35. Puvanendran, K.,Goh, K. L.(1999).From snoring to sleep apnea in a Singapore population.Sleep Research Online,2(1),11-14.
36. Richard, W.,Kox, D.,den Herder, C.,Laman, M.,van Tinteren, H.,de Vries, N.(2006).The role of sleep position in obstructive sleep apnea syndrome.European archives of oto-rhino-laryngology: official journal of the European Federation of Oto-Rhino- Laryngology Societies (EUFOS): affiliated with the German Society for Oto-Rhino-Laryngology-Head and Neck Surgery,263(10),946-950.
37. Sullivan, C. E.,Issa, F. G.,Berthon-Jones, M.,Eves, L.(1981).Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares.Lancet,1(8225),862-865.
38. Weaver, T. E.,George, C. F. P.(2005).Cognition and performance in patients with obstructive sleep apnea.Principles and Practice of Sleep Medicine,Saunders:
39. Young, T.,Blustein, J.,Finn, L.,Palta, M.(1997).Sleep-disordered breathing and motor vehicle accidents in a population-based sample of employed adults.Sleep,20(8),608-613.
40. Young, T.,Palta, M.,Dempsey, J.,Skatrud, J.,Weber, S.,Badr, S.(1993).The occurrence of sleepdisordered breathing among middle-aged adults.The New England Journal of Medicine,328(17),1230-1235.

1. 楊建銘(2009)。臨床心理學在睡眠醫學的應用：過去、現在與未來。應用心理研究，41，77-92。