研究目的 失眠的過度激發假說是目前最廣為接受的失眠病因之一，失眠者通常可觀察到具有身心過度激發的狀態，其中認知神經過度激發假說更由中樞神經的角度探討失眠者的過度激發現象，且已有許多證據支持此觀點。然而過度激發因素在失眠病程上的影響仍不明確，不論在前置因子或是持續因子的層面，激發因素皆經常被提及與討論。本研究以未失眠但具有高睡眠脆弱特質之族群作為研究對象，企圖模擬失眠者在失眠初發之前的狀態，另加入睡前及早晨的自主神經系統與主觀激發狀態之測量，比較其與低睡眠脆弱特質組在有無壓力誘發狀態下，兩組的睡眠中訊息處理程度、睡前及早晨的自主神經系統激發程度與主觀激發狀態，藉以了解（1）壓力是否會引發個體進入較高的主、客觀激發狀態；(2)睡眠脆弱特質在不同的激發程度下，是否會對於個體的睡前、睡眠中及早晨的激發程度造成影響，以初步推論激發狀態因素在失眠病程中所扮演之角色。 方法 以壓力下失眠反應量表（Ford Insomnia Response to Stress Test, FIRST）區分出高睡眠脆弱特質組（HV）13位（6男、7女）、低睡眠脆弱特質組（LV）14位（6男、8女），年齡為19-32歲之健康成人。每位受試者均需在睡眠實驗室進行3個夜晚之夜間睡眠記錄，包含第一晚的PSG測量以排除個案有其他睡眠疾患，並讓受試者習慣實驗環境；第二晚及第三晚則交互平衡操弄基礎情境或壓力情境，在壓力情境下，受試者被告知將進行即席演講，需在睡前抽出演講題目，並於隔天早晨喚醒後10分鐘內發表一篇內容充實、呼應主題之演說，隨後測量心跳變異率（heart rate variability，HRV）、平均心跳間距（r-r interval，RRI）、主觀身心激發狀態（Pre sleep arousal scale，PSAS）等主客觀激發程度，入睡後進行整夜的ERP（事件相關電位[Event-related potential，ERP]）測量，誘發ERPs之實驗流程以oddball典範為主，並於早晨起床後再次進行HRV、RRI及PSAS之測量。 結果 以2（組別）x 2（情境）之混和設計二因子變異數分析比較各組在不同情境下的主客觀激發程度指標是否有所不同。結果顯示壓力確實能引發受試者進入較高的主客觀激發狀態，包含睡前及早晨有較快的平均心跳速率、較高的主觀身心激發程度，而在NREM睡眠中可發現HV在有壓力的情境下，對外界的訊息處理程度顯著較LV組增加，包含較快的N1與較慢的N350出現，但HV在壓力下亦有較快的P2與較強的P900，顯示對外界訊息的抑制功能上升，且隨著睡眠更深，進入慢波睡眠時，P2及P900亦顯著較LV強，表現出更多的抑制外界訊息能力。 結論 本研究探討睡眠脆弱特質在不同激發狀態下對於睡眠的影響，結果顯示壓力能引發個體較高的激發狀態，然而在未失眠族群中，高睡眠脆弱特質對於認知激發狀態下的睡眠中訊息處理程度雖有提高，但可發現高睡眠脆弱特質組亦有較高的抑制外界訊息能力，而不致於使得激發狀態過度影響其睡眠，此結果部分支持失眠的認知神經過度激發假說，過度激發因素可能在持續因子的部分影響性較大，造成個體產生對睡眠的抱怨。另一方面，本研究結果亦彰顯失眠的高危險群的及早介入預防之重要性。 / Introduction: Conditioned hyperarousal has been theorized to be a major etiological factor in chronic insomnia patients. It has been suggested that insomniacs showed more arousal than non-insomniacs in many psychological and physiological measures, including enhanced information processing during sleep as measured by NREM ERPs. However, the role of hyperarousal on the course of development of insomnia remained unclear, it has been considered as a predisposing trait and/or perpetuating factor in the cause of insomnia. The present study compared arousal levels around sleep onset, during sleep and in the morning between non-insomniac individuals with low and high vulnerability to stress-related sleep disturbance, as high vulnerable individuals were proposed to be predisposed to chronic insomnia. The objectives of the study are therefore to investigate: 1) the effect of an acute stressor on arousal level prior, after, and during sleep, and 2) the differences in stress reactivity between individual with high and low vulnerability to stress-related sleep disturbances. Method: Fourteen healthy individuals scoring low (LV) and thirteen healthy individuals scoring high (HV) on the Ford Insomnia Response to Stress Test (FIRST) were studied. All subjects had to sleep in the lab for three nights: a screening/ adaptation night, then a baseline night and a stress night. The sequences of the later two nights were counterbalanced across subjects. During the stress night, subjects were informed that they would be required to give a speech immediately after waking up. Heart rate variability (HRV), r-r interval (RRI) of EKG and subjective arousal level (Pre sleep arousal scale, [PSAS]) was accessed before lights off and in the morning. Then sleep ERP was recorded during the night. An odd-ball paradigm was conducted to evoke ERPs throughout the night. Result: Mixed two-way ANOVAs were used to compare the differences between vulnerabilities and conditions. Both HV ans LV showed higher subjective arousal level and smaller RRI under the stress condition than the baseline condition. During NREM sleep, HV showed increased information processing under stress condition than LV as shown by faster N1, slower N350. Also, HV showed increased inhibition under stress condition than LV, with faster P2 and higher P900. Stronger P2 and P900 were also observed in HV when reached slow-wave sleep stage, comparing to LV. Conclusion: Both groups showed more arousal under stress condition than baseline condition, indicating an acute stress can lead to a higher arousal level. Moreover, high vulnerable individuals showed increased information processing during NREM sleep than low vulnerable individuals, but also showed more inhibition to prevent sleep from being disturbed by external stimulus. The results suggest that increased information processing in reacting to stress may be a predisposing trait for sleep disturbances. However, sleep may be protected by a compensatory inhibitory process in those who have not developed a long-term insomnia.

研究背景與目的：大學生睡眠型態呈現睡眠時相延遲、睡眠不足、睡眠品質不佳的狀況，造成身心健康與學業問題。此種睡眠型態，一方面受到生理發展的影響因素，形成內在日夜節律型態偏向夜貓型的情形，二方面為社會與心理的影響因素，隨著年齡增加，家長對於孩子生活監控程度降低，特別是邁入大學以後，生活自主權增加，大學生有更多的自由安排自己的生活與睡眠時間，而大學生生活時間的安排與規劃，影響著夜晚的睡眠。現今科技可日新月異，科技產品的使用，包括看電視、打電腦與使用手機，成為大學生生活中不可或缺的活動之一。其中，電腦與上網為休閒活動時重要的角色。過去研究發現大學生一天使用電腦約3至5小時以上，國外調查睡前活動的研究發現約42.4％的大學生睡前使用電腦，而睡前使用電腦使得就寢時間延遲，形成總睡眠時數減少，睡眠不足造成白天的疲倦感增加，除此之外也有可能影響入睡時間與睡眠品質，因此本研究目的希望找出電腦使用對於睡眠影響的因素，減少電腦使用對大學生睡眠作息造成的影響。本研究根據訪談的結果及過去的文獻彙整，假設電腦使用使得沈浸狀態（flow）與激發狀態（arousal）較高，進而影響睡眠，包括就寢時間較晚、入睡時間較長、睡眠品質不佳、總睡眠時數不足、週末較晚起床補眠的狀況。 研究方法：本研究為瞭解個體電腦使用的沈浸與激發狀態變化對睡眠的影響，採受試者內設計，以重複測量的方式進行研究，測量受試者一週使用電腦的型態與睡眠之關係。受試者需符合睡前4小時內使用電腦1小時以上的習慣，排除任何生理、心理、睡眠疾患與極端日夜型態者（circadian type），並排除使用非法或影響睡眠的藥物。研究共募集國立與私立大學共76名學生，研究一週間請受試者於睡前填寫電腦使用型態問卷與與沈浸量表、激發狀態量表與睡眠日誌。資料回收後進行階層線性分析。階層一分析個人內每天電腦使用的沈浸程度、生理激發程度與認知激發程度是否可預測各睡眠變項，階層二分析個人間的日夜節律型態與焦慮特質調節沉浸、生理激發與認知激發程度與睡眠變項的關係。 研究結果：本研究發現每人每天睡前4小時電腦使用的內容，包括遊戲類、人際互動類與娛樂活動類的沈浸程度皆比文書作業的沈浸程度來得高，就受試者內的比較而言，當晚上電腦使用的沈浸程度越高，當晚的就寢時間提早、入睡時間減少、總睡眠時數增加與提升睡眠品質。而睡前4小時電腦使用時間長度可預測認知激發程度，但認知激發並無法預測睡眠變項；另外，不論睡前電腦使用內容或總時間無法預測生理激發，但晚上電腦使用後的生理激發程度越高，當晚的就寢時間越晚且總睡眠時數越少。此外，認知激發與生理激發的關係為正相關。在階層二個人間調節變項的分析，由於沈浸程度對睡眠變項的預測，以及生理激發程度對就寢時間與總睡眠時數的預測，皆未有尚未解釋的部分，因此在研究模型中無需再加入調節變項。 研究討論：研究結果發現沈浸程度在睡前電腦使用對睡眠影響的過程中扮演正向角色，但若睡前從事虛擬角色的線上遊戲，雖然沈浸程度偏高，但就寢時間偏晚且總睡眠時數較少；此外睡前的電腦使用時間越長，認知激發越高，而認知激發與生理激發呈現正相關，因此有可能認知激發程度提高，使生理激發程度也越高，而生理激發程度越高，導致就寢時間較晚，總睡眠時數較少。建議睡前選擇電腦使用內容並控制使用時間，以減少電腦使用對睡眠的不良影響。 / OBJECTIVE: College students tend to delay their sleep phase and have high prevalence of sleep problems, such as poor sleep quality and insufficient sleep. Many factors may be associated with the sleep patterns. First, delay sleep phase in college students may be affected by a natural tendency of delayed endogenous circadian phase in during puberty. Second, psychosocial and behavioral factors, such as late evening social events and computer use, may also contribute to these sleep patterns. Among these, computer use has been shown to be associated with poor sleep in previous studies. However, it’s unclear that what mechanisms through which computer use has an impact on sleep in college students. The goal of this study is to identify the underlying factors that mediate the effect of computer use to sleep. According to our pilot study in which college students were interviewed for their computer-use habits and sleep pattern, we hypothesize that mental flow, physical arousal and cognitive arousal are the factors mediating the impacts of computer use to sleep patterns characterize college students, including delayed sleep phase, longer sleep onset latency, insufficient sleep and poor sleep quality. METHOD: Seventy-six college students who are habitual computer users (using computer at least one hour before sleep every day) participated in the study. They were required to complete a set of questionnaires everyday for one week, including the computer-use questionnaire, the Flow Scale, and the Pre-Sleep Arousal Scale. Hieratical Linear Model was conducted to analyze within-individual level (level one) and between- individual level (level two). In our study, within-individual levels were mental flow, physical arousal and cognitive arousal that mediated the impacts of computer use to sleep patterns when college students used computer before sleep every night. In addition, between- individual levels in our study were various circadian types and anxious trait between college students. They may moderate the impacts of mental flow, physical arousal and cognitive arousal to sleep patterns in college students. RESULT: The results showed within-individual level that contents of computer using, including play on-line games, interpersonal interaction, and entertainment, could predict increased flow level. Higher flow level in turn predicted earlier bedtime, shorter sleep latency, more sleep duration and better sleep quality. In addition, physical arousal was not affected by computer use, but had a negative impact on sleep. Higher physical arousal level was able to predict later bedtime and shorter sleep duration. Computer-use time during the four hours prior to bedtime was associated with pre-sleep cognitive arousal. Cognitive arousal did not show significant association with any sleep variables, however. Furthermore, there was a positive relationship between cognitive arousal and physical arousal. In addition, because the results of between- individual levels showed that the mental flow, physical arousal and cognitive arousal completely explained sleep patterns, there was no need to add between- individual moderations. CONCLUSION: Our study showed that flow level while engaging in computer use may have positive effect on sleep. However, playing on-line games before sleep, although may lead to higher flow level, were associated with later bedtime and shorter sleep duration. Also, the more time spending on computer before sleep, the higher the cognitive arousal. Higher cognitive arousal level may be associated with higher physical arousal level. And, higher physical arousal level lead to later bedtime and shorter sleep duration. The results suggested that in order to prevent the negative impacts of computer-use among college students, they should reduce computer using time and avoid on-line games before sleep. Future study can develop intervention program based on current findings to prevent college students from the negative impacts of computer.

研究目的 失眠的過度激發是目前最廣為接受的失眠病因之一。無論在生理、認知、行為三不同層面上，多可觀察到失眠者有身心過度激發的狀態。根據失眠三因子模式，不同失眠病程階段，影響過度激發的背後成因有所差異。在慢性失眠部分，過 去累積了相當多的實證研究證實其過度激發的現象，但尚未進入慢性病程前之過度激發相關機轉，仍有待研究進一步探討。本研究嘗試以橫斷式的研究方法，並依據過去失眠病因發展推導，選擇從壓力反應特性 (包含壓力操弄後的壓力反應強度和 消退速度)、注意力偏誤 (包含警覺性注意力和注意力移除困難)、與睡前的睡眠監控行為三個面向切入，探討不同病程階段個體過度激發的背後機轉，並進一步檢驗上述之差異是否可用以預測在壓力操弄情境下，不同病程個體睡前的激發反應變化，藉此檢驗失眠病程發展之病因假說，並希望未來可據此發展有效之失眠防治與介入策略。 研究方法 本研究共計招募受試者 58 人，年齡介於 24-48 歲，包含符合 ICSD-3 慢性失眠者 18 人，以及以壓力下失眠反應量表( Ford Insomnia Response to Stress Test; FIRST)區分出急性失眠高危險組 19 人與低危險組 21 人。每位受試者皆需到睡眠實驗室進行兩階段的實驗，第一階段包含晤談評估、問卷填答、壓力反應的生理測量(以指溫與膚電為指標)、與包含威脅與睡眠刺激之點偵測注意力作業，之後需配戴腕錶與記錄睡眠日誌配合充足且規律作息一週後，再到睡眠實驗室進行第二階段的評量，包含睡前 2 小時、1 小時、關燈前生理指標 (指溫、膚電) 與腦波的測量和主觀身心激發狀態 (Pre-Sleep Arousal Scale, 簡稱 PSAS) 評量，於睡前填寫睡眠相關監測指標 (Sleep Associated Monitoring Index，簡稱 SAMI)，並完成一晚的 PSG 測量以排除其他睡眠相關疾患。 研究結果 首先，以單因子變異數分析比較不同組別間在壓力反應與回復和二因子變異數分析注意力警覺/移除困難指標的差異。在壓力生理反應表現上，慢性失眠組與高危險組在接受壓力操弄後的激發消退時間較低危險組來得長。在注意力層面，高危險組對壓力(威脅圖片) 刺激有顯著的警覺與移除困難注意力偏誤，慢性失眠組則是對睡眠刺激有顯著的移除困難注意力偏誤。在行為層面，慢性失眠組與高危險組睡前的注意力監控行為 (包含監測自身身體感覺訊息是否與入睡狀態不一致、鬧鐘 時間、環境) 均顯著較低危險組來得多。再者，以皮爾森相關探討注意力偏誤與睡前激發反應之關聯性，結果顯示高危險組的注意力偏誤現象與睡前高頻腦波與主觀生理激發的降幅呈現顯著負相關; 而慢性失眠組的注意力偏誤指標卻與膚電、主觀認知激發的降幅呈顯著正相關。 結論 本研究結果支持不同失眠病程背後的過度激發影響機制有所差異，生理層面較慢的激發消退能力與對壓力源的認知偏誤的前置因子，可能為急性失眠者易受日常壓力源誘發睡眠困擾之原因；而影響慢性失眠族群的持續因子主要在於其將睡眠視 為壓力源的認知歷程與行為轉變。此外，研究更進一步發現兩組分別對於壓力與睡眠的注意力轉移困難，使其在覺察壓力後易持續表現出過度激發現象。本研究結果除支持失眠過度激發理論之外，更釐清不同階段失眠的認知歷程的機制，並彰顯不 同失眠病程介入策略應有所差異，和急性失眠高危險族群及早介入預防之重要性。 / Introduction Hyperarousal has been recognized to be a major etiological factor of chronic insomnia. Cumulated research evidences have demonstrated that chronic insomnia patients are hyperaroused in somatic, cognitive, and behavioral aspects. According to Spielman’s 3P Model of Insomnia, there were different factors are involved at different points during the course of insomnia. However, there are seldom study to investigate the difference mechanism of hyperarousal in the course of the development of insomnia. The present study used cross-sectional design to compare the difference of good sleeper (low sleep vulnerability, LV), acute insomnia (high sleep vulnerability, HV), and chronic insomnia (CI) in stress reaction (eg. reactivity and recovery), attentional bias (eg. vigilance and disengagement), and sleep associated monitoring behaviors to investigate the underlying mechanism of hyperarousal. Furthermore, the study examined the correlation between attentional bias indices and subsequent pre-sleep arousal to investigate the impact of attentional bias on sleep in different groups. Method The present study recruited fifty-eight subjects, aged between 24-48. They included eighteen chronic insomniacs (CI) diagnosed ICSD-3, nineteen healthy individuals scoring high (HV) and twenty-one healthy individuals scoring low (LV) on the Ford Insomnia Response to Stress Test (FIRST). All subjects visited sleep lab twice. During the first visit, the subjects filled in a package of questionnaires, and went through psychophysiological recording (including) of stress reaction, and a visual dot-probe task. They then were required to keep a sleep log and wear actigraphy at home for one-week to make sure they followed a regular sleep schedule. During the second visit, subjects went through a pre-sleep physiological recording (including peripheral temperature, skin conductance, and EEG) and filled in two questionnaires (Pre Sleep Arousal Scale [PSAS] and Sleep Associated Monitoring Index[SAMI]) at three time points and had a PSG recording to screen for sleep disorders. Result One-way ANOVAs were conducted to compare the differences of stress reaction/recovery among three groups. Two-way ANOVAs were used to compare the differences in attentional bias (vigilance/ disengagement) of threatening and sleep-related stimulus among three groups. In stress related physiological activity, CI and HV showed slower recovery rate than LV. Considering attentional bias, HV had significant vigilance and disengagement bias to threatening pictures, and CI had significant disengagement bias to sleep-related pictures. CI and HV also showed more prevalent sleep-associated monitoring behaviors than LV. Furthermore, Spearman’s correlation was used to examine the association between attentional bias and pre-sleep arousal. The result shows the attentional bias of HV had negative correlation with reduction of high frequency EEG and somatic sub-score on the PSAS. In contrast to our prediction, CI showed positive correlation between decrease of skin conductance and the cognitive sub-score on the PSAS. Conclusion The study showed that stress recovery ability and stress-related attentional bias were the major differences between individuals with low and high sleep vulnerability, indicating that increased information processing to threats and stress-related stimulus as well as decreased recovery ability of autonomic arousal in reacting to stress may predisposed an individual to stress-related sleep disturbances. On the other hand, the attention shift from threat toward sleep can differentiate chronic insomnia from those individual with frequent acute insomnia. Moreover, the difficulty in disengagement from sleep-related stimulus, rather the vigilance, might explain the cause of hyperarousal that perpetuate insomnia. The results support the transition of arousal from general treat to sleep-related stimulus in the development of chronic insomnia. The study not only further the understanding of the etiological mechanism of insomnia, but also imply that different strategies should be applied in the treatment of acute and chronic insomnia. It also highlights the importance of preventive intervention for individuals with high sleep vulnerability

研究目的：在現今高壓力與忙碌的社會中，失眠是很常見的問題。在國外的失眠的相關調查結果顯示，失眠的盛行率會受對於失眠定義之嚴謹程度影響，而有大範圍的變異，其範圍約落在6~48%。當定義符合臨床上之診斷標準時，失眠盛行率約降至6~15%。因此，受失眠之苦的個體中，有一大部分可能未達診斷標準，而為暫時性或急性失眠之患者。然而過去的研究大多將重點聚焦在符合失眠疾患診斷的失眠族群上，針對剩下雖未符合失眠疾患診斷標準，但又飽受失眠症狀困擾之群體，卻是缺乏探討。此外，失眠的縱貫研究中也發現，暫時性失眠個體到最後會有一部份會發展成為慢性失眠。因此，針對這群為數不少，且容易經歷暫時性失眠之個體，若能更加了解其暫時性失眠發生的成因與相關機制，便能及早介入，協助個體不落入慢性失眠的惡性循環中。過去研究發現，暫時性失眠的發生，最常見的促發因素為壓力事件。Drake、Richardson、Roehrs、Scofield與Roth（2004）便發展出福特壓力失眠反應量表（Ford Insomnia Response to Stress Test, FIRST）來測量個體特質上遭遇壓力情境的睡眠脆弱程度；且研究結果也發現個體身心激發程度是和睡眠脆弱特質息息相關的因素之一。由於過去在失眠的相關研究中，少有研究探討暫時性失眠的相關機制，因此，本研究從和暫時性失眠相關的壓力下睡眠脆弱特質出發，探討此脆弱特質與過度激發的關聯性，並欲探討其他會提升激發程度的相關認知與情緒因子，如：失功能信念、情緒反應性、反芻特質、情緒遲惰特質和此特質間的關係。本研究假設個體對於睡眠的失功能信念與對負向事件的情緒反應性可能會透過提高睡前身心的激發程度，而使個體容易經歷壓力下的急性失眠，增加睡眠的脆弱性；即睡前身心激發程度在睡眠的失功能信念與情緒反應性對睡眠脆弱性的關係間扮演一中介作用之角色。另外，也假設睡眠的失功能信念與情緒反應性與睡前身心激發程度間的關係，會分別受反芻特質與情緒遲惰特質調節，即具有高反芻特質與高情緒遲惰特質者，其睡眠的失功能信念與情緒反應性與睡前身心激發程度間的關係更強烈，因此在壓力下，其有較高的睡眠脆弱性，容易經歷暫時性失眠。 研究方法：本研究於大學中招募60位20~35歲之受試者（男：22位；女：38位），經晤談以確認受試者符合收案標準後，將請受試者填寫研究相關問卷（包含：壓力下失眠反應量表、反芻型反應風格短版量表、睡前激發程度量表、睡眠失功能信念及態度簡式量表、情緒反應量表、失眠嚴重度量表、貝克憂鬱量表第二版與貝克焦慮量表）；並在詳細解釋情緒經驗取樣流程後，請受試者回到日常生活環境中進行連續三天的情緒遲惰經驗取樣紀錄。 研究結果：根據執行檢驗中介效果步驟的階層迴歸與Sobel test的分析結果，睡前認知激發程度對擔憂的失功能信念與情緒持續性和睡眠脆弱性間的關係具中介的作用；即對睡眠有過度擔憂的失功能信念、情緒持續性較久皆可能會提高睡前認知激發程度而增加壓力下的睡眠脆弱性。其他失功能信念之向度，如：知覺失眠造成的影響、對睡眠的期待、藥物使用，以及情緒反應性之其他向度，如：情緒敏感度與情緒激發度對睡前認知過度激發狀態無顯著的預測力。另外，根據執行檢驗調節效果步驟的階層迴歸分析結果，反芻特質與情緒遲惰特質分別在失功能信念與情緒反應性對認知激發程度的關係上，皆未有顯著的調節效果。 研究結論：研究結果部分支持身心激發程度為對睡眠的失功能信念與情緒反應性影響壓力下睡眠脆弱性的中介因子之假設。本研究發現過度擔憂睡眠的信念以及情緒持續度較久這兩個因子會分別獨立地提高睡前認知激發程度，顯示睡前認知激發程度分別受認知與情緒因素影響；且相較與睡前的生理激發狀態，睡前的認知激發對於壓力下的失眠反應之影響具有顯著的預測力，顯示認知激發在失眠的前置因子中可能扮演較重要的角色。另外，反芻特質與情緒遲惰特質分別在失功能信念與情緒反應性對認知激發程度的關係上，皆未有顯著的調節效果，此部份不符合研究預期。基於本研究結果，在臨床上對於容易經歷失眠之個體，若能及早調整對於睡眠的擔憂相關的信念，並學習有效調節情緒的方式，皆可有效降低個體睡前的認知激發活動，減少失眠的發生率與改善失眠症狀，避免使其落入失眠慢性化的惡性循環中。