背景及目的:偶爾發惡夢通常被認為是普遍以及自限性的現象，然而頻繁的惡夢困擾也許代表睡眠問題的一種臨床症狀，或者是具有預測自殺傾向的潛在精神病理學病症。在這項研究中，我們的目標是：1) 瞭解頻繁惡夢在普通人群中的流行性以及與之相關的因素; 2) 調查頻繁惡夢在臨床人口中的流行性以及長期病程; 3) 探討在抑鬱症病人中與頻繁惡夢相關的各種社會心理學的和臨床的因素以及有關的潛在生物學標誌。 / 方法:第一部分研究: 這是一項在社區內分兩個階段進行的研究。在第一階段, 我們對8558 個成人進行睡眠問卷的調查; 在第二階段, 我們對其中252 位研究對象進行詳細的精神病理學臨床評估和人格個性的剖析。 / 第二部分研究: 這是一項在社區內進行的橫斷面研究。受訪者包括6359 個孩童 (年齡9.2 ± 1.8 歲, 女孩49.9%) 和他們的親生父母 (n=9855), 研究中收集的數據包括社會人口統計學的資料、與睡眠、行為以及家庭環境相關的資訊。 / 第三部分研究: 這一項研究訪問了在香港一間大學的附屬公共精神科門診的1231 位病人(年齡42.5±11.3 歲，女性68.2%)。在基線時, 受訪者完成一份詳細的睡眠問卷調查。我們全面追溯了受訪者過往的臨床病歷。此外, 我們在問卷調查完成1 年後對這些病例進行跟進。 / 第四部分研究: 對參與過第三部分研究並且被診斷為憂鬱症的病人,我們進行為期 4 年的前瞻性觀察研究。 研究內容包括結構式精神病學訪談以及全面的問卷調查(包括睡眠問卷, 醫院焦慮憂鬱量表,人格量表,SF-12 健康調查量表) 。 / 第五部分研究: 這是一項病例-對照研究。研究對象包括35 例受到頻繁惡夢困擾的憂鬱病患者、以及與他們年齡、性別匹配的35 例無惡夢困擾的憂鬱症病患者和35 例健康對照者。研究評估包括臨床診斷、憂鬱症狀嚴重程度測量、心理社會因素量表、多導睡眠圖和腕動計的客觀睡眠檢查、24 小時尿液兒茶酚胺和皮質醇濃度、以及唾液皮質醇濃度的測量。 / 結果:以一星期一次或者以上為標準, 頻繁惡夢患病率在一般人群的成人和兒童當中分別為5.1%和5.2%。在成人中, 女性、低家庭月收入、失眠症狀、睡眠呼吸障礙的症狀、 及睡眠相關的日間症狀與發惡夢的頻率有顯著的關聯 。患有頻繁惡夢的成人比起其他沒有惡夢困擾的成人患上精神疾病的風險要高出5.74 倍(95% CI 2.03-16.26),尤其是情緒病(odds ratio [OR] = 15.57,95% CI 3.77-64.37)。排除併發的精神障礙, 患有頻繁惡夢的成人在人格量表中神經質得分顯著高于其他沒有惡夢的成人 (p<0.05)。 在兒童中, 頻繁惡夢與低家庭月收入、 父母親發惡夢的頻率、 失眠症狀、類睡症症狀和日間症狀有明顯的關聯。同時, 在控制了相關的危險因素後, 頻繁惡夢與兒童的過度活躍 (OR = 1.68, 95% CI 1.16-2.44)、 頻繁情緒失控 (OR = 1.76, 95% CI1.27-2.44)、和成績不好 (OR = 1.62, 95% CI 1.11-2.36)有關。失眠和頻繁惡夢的共病性在成人和小孩當中都非常普遍。在臨床人口中, 患有頻繁惡夢的終生及1 年患病率分別為 22.5% 和21.7%。頻繁惡夢在憂鬱症和焦慮症患者中更為高發。在4 年的前瞻性跟進研究中, 憂鬱症患者基線和隨訪的惡夢患病率分別為32%和19%。大約有三分之一的憂鬱症患者持續地患有頻繁惡夢;而在憂鬱病患者中, 頻繁惡夢的新發病率為10%。基線時失眠和頻繁惡夢的共病是隨訪時病情未緩解的危險因數(OR = 3.25. 95% CI 1.56-6.77)。 持續地患有頻繁惡夢和新發病的頻繁惡夢的憂鬱病患者在隨訪時憂鬱和焦慮症狀上要更為嚴重,並且更可能在過往的4 年裡有自殺和住院的紀錄。同時, 在恢複期的憂鬱病患者當中, 患有頻繁惡夢與生活質量的各方面受損以及自殺意念 (OR= 8.40, 95% C.I. 1.79-39.33)有關。此外, 我們的病例-對照研究顯示頻繁惡夢與抑鬱型憂鬱、比較嚴重的憂鬱病症、以及高度的自殺傾向有關。同時, 患有頻繁惡夢的憂鬱病患者在多導睡眠圖檢查中的快速眼動期顯示更高的快速眼動頻率, 和在縱向的腕動計睡眠檢查中顯示更大的每晚之間的變異性 。 / 結論:頻繁惡夢在一般人群中並非罕見, 並和不同的因素有關， 其中包括遺傳易感性 、社會人口特點、社會心理因素、睡眠問題的共病性和精神病理學症狀。同時, 頻繁惡夢在臨床人口中, 特別是憂鬱病患者代表著一類常見的、持續的、和令人困擾的睡眠問題。我們研究提示應該加強對患有頻繁惡夢的憂鬱病患者的臨床關注,同時需要更多的研究以瞭解在憂鬱病患者中進行針對睡眠問題的臨床治療的有效性。隨著認知神經科學研究的進一步發展, 未來的研究應該探討與惡夢困擾和精神病理學有關的認知神經科學機理。 / Objectives: Frequent nightmares may represent a sleep disorder or/and in association with psychopathology. We aimed to examine the epidemiology of frequent nightmares in both general and clinical populations. / Methods: Part I & Part II: A community-based study with questionnaire assessment of 6359 children and 8558 adults in phase 1 was followed by clinical evaluation of psychopathology and personality of 252 adult subjects in phase 2. / Part III: A study with sleep questionnaire assessment in the psychiatric outpatients (n=1231). / Part IV: A 4-year, prospective study in a cohort of depressive patients depression (n= 371, response rate = 88.5%) with a standardized interview and psychometric inventories. / Part V: A case-control study was conducted with clinical, psychosocial, sleep andbiological measurements. / Major Results: Prevalence of frequent nightmares was 5.1% and 5.2% in the adults and children, respectively, of the local general population. Female, low family income, sleep-related symptoms, psychopathology, and neuroticism trait were associated with nightmares in the general adult population. In children, frequent nightmares were associated with socioeconomic status, parental predisposition, sleep-related symptoms and childhood psychopathology. The prevalence rates of recurrent nightmares in depressed subjects at baseline and 4-year follow-up were 32% and 19%, respectively. The comorbidity of nightmares and insomnia disturbances reported at baseline was a significant risk factor of non-remission at follow-up (OR = 3.25. 95% C.I. 1.56-6.77). Subjects with persistence or incidence of frequent nightmares had more severe depression. Meanwhile, among those remitted depressed subjects, residual nightmares were associated with various aspects of impaired quality of life and suicidal ideation (OR= 8.40, 95% C.I. 1.79-39.33). / ConclusionsFrequent nightmares were associated with a constellation of personal, sleep and psychopathological factors in general population, and represent a common complaint with detrimental effects in the psychiatric populations. There is a need of enhanced clinical attention in patients with frequent nightmare complaints. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Li, Xin. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2012. / Includes bibliographical references (leaves 173-199). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract also in Chinese; some appendixes also in Chinese. / ABSTRACT --- p.I / ACKNOWLEDGE --- p.V / THESIS/ASSESSMENT COMMITTEE --- p.VII / TABLE OF CONTENTS --- p.VIII / TABLE LIST --- p.XV / FIGURE LIST --- p.XVII / Chapter CHAPTER 1 --- GENERAL INTRODUCTION / Chapter 1.1 --- Dream Research: A Historical Perspective --- p.1 / Chapter 1.2 --- Nightmares: Definitions and Differentials --- p.2 / Chapter 1.2.1 --- Clinical and Research Definitions of Nightmares --- p.2 / Chapter 1.2.2 --- Differentials of Nightmares --- p.4 / Chapter 1.3 --- Epidemiological Studies of Nightmares in Adults --- p.6 / Chapter 1.4 --- Epidemiological Studies of Nightmares in Children --- p.6 / Chapter 1.5 --- Associated Factors of Frequent Nightmares in General Populations --- p.7 / Chapter 1.5.1 --- Psychological Correlates of Frequent Nightmares - Anxiety and Personality Dimensions --- p.8 / Chapter 1.5.2 --- Stress as a Precipitating Factor of Frequent Nightmares --- p.8 / Chapter 1.6 --- Nightmare Disturbances and Major Psychopathology --- p.9 / Chapter 1.6.1 --- Posttraumatic Nightmares and PTSD Prevalence, Phenomenology and Associations --- p.10 / Chapter 1.6.2 --- Nightmare Disturbances and Other Psychiatric Disorders --- p.12 / Chapter 1.7 --- Prognostic Implications of Nightmare Disturbances in Predicting Suicidality Clinical and Community-Based Evidence --- p.13 / Chapter 1.8 --- Summary and Research Directions --- p.15 / Chapter CHAPTER 2 --- Part I Study - Epidemiology of Frequent Nightmares in Hong Kong Chinese Adults: A Community-based 2-Phase Study / Chapter 2.1 --- INTRODUCTION --- p.26 / Chapter 2.1.1 --- Objectives and Hypotheses of the Study --- p.26 / Chapter 2.2 --- METHODS / Chapter 2.2.1 --- Overview of the Project --- p.27 / Chapter 2.2.2 --- Subjects and Measurements / Chapter 2.2.2.1 --- Study Subjects in Phase 1 --- p.28 / Chapter 2.2.2.2 --- Study Instruments in Phase 1 --- p.29 / Chapter 2.2.2.3 --- Study Subjects in Phase 2 --- p.30 / Chapter 2.2.2.4 --- Study Instruments in Phase 2 --- p.32 / Chapter 2.2.3 --- Statistical Analysis --- p.33 / Chapter 2.3 --- RESULTS / Chapter 2.3.1 --- Phase 1 Results: Socio-demographic Characteristics and Other Sleep Problems in Relation to Frequent Nightmares --- p.34 / Chapter 2.3.2. --- Phase 2 Results: Psychopathology and Psychosocial Characteristics in Relation to Frequent Nightmares --- p.38 / Chapter 2.4 --- DISCUSSIONS / Chapter 2.4.1 --- Frequent nightmares in Hong Kong Chinese Adults - Prevalence and Gender Difference --- p.40 / Chapter 2.4.2 --- Sleep Correlates of Frequent Nightmares --- p.40 / Chapter 2.4.3 --- Sociodemographic Features and Psychopathology in Relation to Frequent Nightmares --- p.41 / Chapter 2.4.4 --- Personality Dimensions Independently Associated with Frequent Nightmares --- p.42 / Chapter 2.4.5 --- Strengths and Limitations of the Study --- p.43 / Chapter CHAPTER 3 --- Part II Study - Epidemiology and Familial Aggregation of Frequent Nightmares in Hong Kong Chinese Children / Chapter 3.1 --- INTRODUCTION --- p.44 / Chapter 3.1.1 --- Objectives and Hypotheses of the Study --- p.45 / Chapter 3.2 --- METHODS / Chapter 3.2.1 --- Overview of the Project --- p.45 / Chapter 3.2.2 --- Subjects and Measurements / Chapter 3.2.2.1 --- Study Subjects --- p.46 / Chapter 3.2.2.2 --- Study Instruments --- p.47 / Chapter 3.2.3 --- Statistical Analysis --- p.48 / Chapter 3.3 --- RESULTS / Chapter 3.3.1 --- Prevalence and Associated Factors of Frequent Nightmares in Hong Kong Chinese Children --- p.49 / Chapter 3.3.2 --- Association of Frequent Nightmares with Parent-Reported Mood, Behaviors, and Academic Performance --- p.54 / Chapter 3.4 --- DISCUSSIONS / Chapter 3.4.1 --- Prevalence and Sleep Correlates of Frequent Nightmares in Children --- p.56 / Chapter 3.4.2 --- Stronger Paternal Effect in the Familial Aggregation of Frequent Nightmares --- p.56 / Chapter 3.4.3 --- Frequent Nightmares in Children Associations with Adverse Neurobehavioral Outcomes and Academic Performance --- p.57 / Chapter 3.4.4 --- Strengths and Limitations of the Study --- p.58 / Chapter 3.4.5 --- Summary --- p.59 / Chapter CHPATER 4 --- Part III Study - A Clinical Epidemiologic Study of Frequent Nightmares among Psychiatric Patients / Chapter 4.1 --- INTRODUCTION --- p.60 / Chapter 4.1.1 --- Objectives and Hypotheses of the Study --- p.61 / Chapter 4.2 --- METHODS / Chapter 4.2.1 --- Procedure and Study Subjects --- p.61 / Chapter 4.2.2. --- Study Instrument --- p.62 / Chapter 4.2.3 --- Statistical Analysis --- p.63 / Chapter 4.3 --- RESULTS --- p.64 / Chapter 4.4 --- DISCUSSIONS --- p.70 / Chapter 4.4.1 --- Comorbidity of Nocturnal Sleep Disturbances in Psychiatric Patients --- p.70 / Chapter 4.4.2 --- Nocturnal Sleep Disturbances in Association with Suicidal Risk --- p.71 / Chapter 4.4.3 --- Nightmare Disturbances and Psychopharmacologic Treatments --- p.72 / Chapter 4.4.4. --- Limitations of the study --- p.73 / Chapter 4.4.5 --- Summary --- p.73 / Chapter CHAPTER 5 --- Part IV Study - A Prospective Study of Nightmare Disturbances in a Cohort of Psychiatric Outpatients with Major Depressive Disorder (MDD) / Chapter 5.1 --- INTRODUCTION --- p.74 / Chapter 5.1.1 --- Major Depressive Disorder --- p.74 / Chapter 5.1.2 --- Disturbed Dreaming and Nightmares in Depression - Phenomenology and Correlates --- p.75 / Chapter 5.1.2.1 --- Phenomenological Characteristics of Disturbed Dreaming in Depression --- p.75 / Chapter 5.1.2.2 --- Disturbed dreaming in Relation to the Treatments and Clinical Outcome of Depression --- p.76 / Chapter 5.1.2.3 --- Recent Findings on Frequent Nightmares in Depression --- p.77 / Chapter 5.1.3 --- Insomnia and Depression - Associations with Frequent Nightmares --- p.78 / Chapter 5.1.4 --- Nightmare Disturbances in the Context of Residual Symptomatology of Depression --- p.79 / Chapter 5.1.5 --- Objectives and Hypotheses of the Study --- p.80 / Chapter 5.2 --- METHODS / Chapter 5.2.1 --- Overview of the Study - Procedure and Study Subjects --- p.88 / Chapter 5.2.2 --- Measurements / Chapter 5.2.2.1 --- Sleep Questionnaire (Baseline and Follow-up) --- p.89 / Chapter 5.2.2.2 --- Psychometric Instruments (Follow-up) --- p.89 / Chapter 5.2.2.3 --- Psychiatric Diagnosis, Suicidal ideation and Related Clinical History --- p.90 / Chapter 5.2.3 --- Statistical Analysis --- p.91 / Chapter 5.2.3.1 --- Analysis on the Frequent Nightmares as a Predictor of Remission Outcome in Depression --- p.92 / Chapter 5.2.3.2 --- Analysis on the Progress of Frequent Nightmares in the Depressed Patients --- p.93 / Chapter 5.2.3.3 --- Analysis on the Frequent Nightmares as a Residual Symptom in the Remitted Depressed Patients --- p.93 / Chapter 5.3 --- RESULTS / Chapter 5.3.1 --- Study Recruitment and Overall Sample Characteristics --- p.93 / Chapter 5.3.2 --- Factors Associated With the Remission Outcome in Depression --- p.97 / Chapter 5.3.2.1 --- Socio-Demographic & Clinical Characteristics --- p.97 / Chapter 5.3.2.2 --- Baseline Nightmare and Insomnia Disturbances --- p.98 / Chapter 5.3.3 --- Longitudinal Course of Frequent Nightmares in Depression --- p.101 / Chapter 5.3.4 --- Factors Associated with the Progress of Frequent Nightmares in the Depressed Patients --- p.102 / Chapter 5.3.4.1 --- Factors Associated with Persistence of Frequent Nightmares --- p.102 / Chapter 5.3.4.2 --- Factors Associated with Incidence of Frequent Nightmares --- p.103 / Chapter 5.3.4.3 --- Residual Nightmare Disturbances in Remitted Depressed Patients --- p.108 / Chapter 5.4 --- DISCUSSIONS / Chapter 5.4.1 --- Prevalence of Frequent Nightmares and Its Association with the Remission Outcome in Depression --- p.114 / Chapter 5.4.2 --- Persistence and Incidence of Frequent Nightmares in Depression --- p.115 / Chapter 5.4.3 --- Frequent nightmares as a Residual Symptom in Depression --- p.116 / Chapter 5.4.3.1 --- Prevalence & Correlates of Residual Nightmares in Remitted Depressed Patients --- p.116 / Chapter 5.4.3.2 --- Impaired Functional Outcomes and Suicidal Ideation Associated with Residual Nightmare Disturbances --- p.118 / Chapter 5.4.4. --- Study Strengths and Limitations --- p.119 / Chapter CHAPTER 6 --- Part V study - An In-depth Clinical, Polysomnographic and Neurobiological Investigation of Depressive Patients with Recurrent Nightmares: A Case-Control Study / Chapter 6.1 --- INTRODUCTION --- p.120 / Chapter 6.1.1 --- Objective Sleep Abnormalities in Depression --- p.120 / Chapter 6.1.2 --- Objective Studies of Nightmares --- p.121 / Chapter 6.1.3 --- Hormonal Responses in Relation to Recurrent Nightmare Disturbances. --- p.122 / Chapter 6.1.4 --- Objectives and Hypotheses of the Study --- p.124 / Chapter 6.2 --- METHODS / Chapter 6.2.1 --- Procedure and Study Subjects --- p.124 / Chapter 6.2.2 --- Measurements / Chapter 6.2.2.1 --- In-Home Assessments --- p.127 / Chapter 6.2.2.2 --- Laboratory Assessments --- p.128 / Chapter 6.2.2.3 --- Diagnostic Assessment and Psychometric Inventories --- p.130 / Chapter 6.2.3 --- Statistical Analysis --- p.133 / Chapter 6.3 --- RESULTS / Chapter 6.3.1. --- Study Recruitment --- p.135 / Chapter 6.3.2 --- Nightmare-Related History and Characteristics of Depressed Subjects with Frequent Nightmares --- p.137 / Chapter 6.3.3 --- Clinical Characteristics of Depressed Subjects With and Without Frequent Nightmares --- p.138 / Chapter 6.3.4 --- Comparison on the Demographic Features and Self-reported Sleep Measures --- p.139 / Chapter 6.3.5 --- Comparison on the Psychometric Measurements --- p.141 / Chapter 6.3.6 --- Comparison on the Actigraphic Measurements --- p.145 / Chapter 6.3.7 --- Comparison on the Polysomnographic Data --- p.148 / Chapter 6.3.8 --- Comparison on the Mood States and Self-reported Sleep Measures in Association with the Presence of Nightmares --- p.150 / Chapter 6.3.9 --- Comparison on the Endocrine Data --- p.152 / Chapter 6.4 --- DISCUSSIONS / Chapter 6.4.1 --- Nightmare-Related History in Depression --- p.154 / Chapter 6.4.2 --- Treatment Seeking in Depressed Patients for Nightmare Disturbances --- p.155 / Chapter 6.4.3 --- Frequent Nightmares in Depression - Clinical Correlates and Psychosocial Characteristics --- p.156 / Chapter 6.4.4 --- Subjective and Objective Sleep Features in Relation to Frequent Nightmares in Depression --- p.157 / Chapter 6.4.5 --- Neuroendocrine Measurements in Relation to Frequent Nightmares in Depression --- p.160 / Chapter 6.4.6 --- Study Strengths and Limitations --- p.161 / Chapter CHAPTER 7 --- GENERAL DISCUSSIONS / Chapter 7.1 --- Recapitulation and Elaboration of Our Major Findings / Chapter 7.1.1 --- Epidemiology of Frequent nightmares --- p.162 / Chapter 7.1.2 --- Etiology of Frequent Nightmares --- p.163 / Chapter 7.1.2.1 --- Predisposing Factors of Frequent nightmares --- p.163 / Chapter 7.1.2.2 --- Precipitating Factors of Frequent Nightmares --- p.165 / Chapter 7.1.2.3 --- Perpetuating Factors - The Interplay of Nightmares, Insomnia and Psychopathology --- p.165 / Chapter 7.1.4 --- Nightmares in the Context of Psychopathology Implications for Clinical Management --- p.168 / Chapter 7.2 --- Future Research Directions --- p.169 / Chapter 7.2.1 --- Genetic Studies and Interventional Studies on Nightmares --- p.169 / Chapter 7.2.2 --- Linking Nightmares and Mood Disturbances to Memory Consolidation: A Hypothesis from A Neurocognitive Perspective --- p.171 / Chapter 7.2.2.1 --- Sleep and Memory Consolidation --- p.171 / Chapter 7.2.2.2 --- Dreaming as Off-line Processing of Memory in the Psychopathological Context --- p.171 / Chapter 7.3 --- Summary --- p.172 / REFERENCES --- p.173 / APPENDICES / Chapter A --- Study Instruments of Part I & Part II Studies --- p.200 / Chapter B --- Study Instruments of Part III Study --- p.217 / Chapter C --- Study Instruments of Part IV Study --- p.220 / Chapter D --- Study Instruments of Part V Study --- p.231 / Chapter E --- Documentation of Permission to Republish the Copyrighted Materials in the Dissertation / Chapter F --- Li SX, Zhang B, Li AM, Wing YK. Prevalence and correlates of frequent nightmares: a community-based 2-phase study. Sleep. 2010;33:774-80. / Chapter G --- Li SX, Yu MW, Lam SP, Zhang J, Li AM, Lai KY, Wing YK. Frequent nightmares inchildren: familial aggregation and associations with parentreported behavioral and mood problems. Sleep. 2011;34:487-93. / Chapter H --- Li SX, Lam SP, Yu MWM, Zhang J, Wing YK. Nocturnal sleep disturbances as a predictor of suicide attempts among psychiatric outpatients: a clinical, epidemiologic, prospective study. J Clin Psychiatry 2010;71:1440-6. / Chapter I --- Li SX, Lam SP, Chan JWY, Yu MWM, Wing YK. Residual Sleep Disturbances in Patients Remitted From Major Depressive Disorder: A 4- Year Naturalistic Follow-up Study [In press] / Chapter J --- Curriculum Vitae