[Primary insomnia].

Primary insomnia is relatively common. According to The International Classification of Sleep Disorders, primary insomnia is a syndrome mainly composed of psychophysiological insomnia, paradoxical insomnia and idiopathic insomnia. Primary insomnia is difficulty initiating sleep (sleep onset insomnia), difficulty maintaining sleep (mid-sleep awakening, early morning awakening) or chronic non restorative sleep, which persist longer than three weeks despite having adequate opportunity for sleep and result in impaired daytime functioning. Primary insomnia is not explained by currently known psychiatric disorders, medical conditions, substance use disorders. Primary insomnia is a non-organic, unknown etiology, middle-aged female predominant sleep disturbance. Recent findings suggest the hyperarousal hypothesis of primary insomnia. In the near future, non restorative sleep might be excluded from the definition of primary insomnia.

Risk factors for obstructive sleep apnea syndrome screening in mood disorder patients.

AIMS: Previous studies have reported that the incidence of obstructive sleep apnea syndrome (OSAS) in patients with depression is higher than in the general population. We examined the risk factors to predict OSAS in mood disorder patients with depressive symptoms. METHOD: We conducted polysomnography for patients who satisfied the following criteria: (i) diagnosis of major depressive disorder or bipolar disorder according to the Mini-International Neuropsychiatric Interview (MINI); (ii) a score of > or =10 on the Hamilton Rating Scale for Depression (HAM-D); (iii) fulfillment of either (a) or (b) below: (a) at least one of the following: severe snoring, witnessed apnea during sleep, excessive daytime sleepiness; (b) at least one of the following plus an oxygen desaturation index of 4% > or =5 times/h by pulse oximeter: mild snoring, sleep disturbance, headache, high blood pressure. The patients with apnea hypopnea index > or =5 were diagnosed with OSAS. RESULTS: Of the 32 mood disorder patients who met the subject conditions, 59.4% had OSAS. The diagnosis rate with our criteria was significantly higher than the previously reported incidence of OSAS in patients with depression. There was no significant difference among diagnosis rates as to individual risk factors or the number of risk factors. A multiple regression test showed no significant association between apnea-hypopnea index and other clinical factors including depression severity. CONCLUSION: The present results showed that OSAS can be detected at a remarkably higher rate by considering appropriate OSAS risk factors in mood disorder patients, and suggested that there is a high rate of undetected and therefore untreated OSAS among mood disorder patients.

Nasal resistance for determinant factor of nasal surgery in CPAP failure patients with obstructive sleep apnea syndrome.

OBJECTIVES: Given that criteria for nasal surgery in individuals with obstructive sleep apnea syndrome (OSAS) have not been proposed, we investigated the effectiveness of nasal surgery for CPAP failure in patients with both severe OSAS and nasal obstruction. PATIENTS AND METHODS: Conventional nasal surgery was performed in 12 patients who were refractory to treatment by CPAP. The subject group consisted of 12 males (mean age, 54.2 +/- 9.2 years; range 39-66 years). The effect of nasal surgery was evaluated with data from preoperative and postoperative polysomunography. The nasal resistance value was first deduced to determine which OSAS patients with CPAP failure should undergo nasal surgery, compared to control values. RESULTS: Nasal surgery resulted in a significant decrease in nasal resistance, as measured by rhinomanometry, from 0.57 +/- 0.31 Pa/cm3 /sec to 0.16 +/- 0.03 Pa/cm3/sec and rendered all patients tolerant to CPAP. In addition, the lowest nocturnal oxygen saturation significantly increased from 68.3 +/- 12.1% to 75.3 +/- 7.1% after surgery. Subjectively, Epworth sleepiness scale (ESS) significantly decreased from 11.7 +/- 4.1 to 3.3 +/- 1.3 after surgery, but the number of apnea and hypopnea episodes per hour did not change significantly. In five patients, for whom it was possible to perform a CPAP titration before nasal surgery, the value decreased significantly from 16.8 +/- 1.1 to 12.0 +/- 1.9 cmH2O. The bilateral nasal resistance of the 410SAS patients with CPAP therapy (control group) was 0.24 +/- 0.11 Pa/cm3/sec. The cut off value for differentiation between CPAP failure patients and control group was determined as 0.38 Pa/cm3 /sec. CONCLUSION: Increased nasal resistance is a determinant of CPAP failure, and the surgical correction of severe nasal obstruction should thus be considered to facilitate treatment of OSAS patients with CPAP.

[Excessive daytime sleepiness and low CSF orexin-A/hypocretin-I levels in a patient with probable progressive supranuclear palsy].

We report a 74-year-old woman with excessive daytime sleepiness (EDS) who were diagnosed as probable progressive supranuclear palsy (PSP). Her EDS mimicked narcolepsy without cataplexy, because multiple sleep latency tests showed short latencies, human leukocyte antigen testing was positive for DR2/DQB1, and orexin A (hypocretin-I) concentration in her cerebrospinal fluid was undetectable. In PSP, neurofibrillary tangles appears in the hypothalamus, neuronal loss and gliosis are seen in a number of pontine and mesencephalic tegmental nuclei, substantia nigra, locus caeruleus. These neuropathological changes of PSP may cause decreased pre- or post-synaptic hypothalamic orexin neurotransmission because orexin neurons are located in the hypothalamus and project widely to the forebrain and the brain stem. In our patient, the treatment with methylphenidate HCl was effective on EDS.

Evaluating mental fatigue in patients with obstructive sleep apnea syndrome by the Maastricht Questionnaire.

Mental fatigue in patients with obstructive sleep apnea syndrome (OSAS) was investigated and compared with subjects without OSAS. The study series comprised 189 habitual snoring patients and 75 controls. To measure subjective mental fatigue and somnolence, subjects were asked to complete the Maastricht Questionnaire (MQ) and the Epworth Sleepiness Scale (ESS), respectively, and patients also underwent diagnostic polysomnography. According to the apnea and hypopnea index, patients were classified into the following groups: primary snorers, or having mild, moderate, or severe OSAS. The lowest MQ and highest ESS scores were found in those patients with severe OSAS. It is proposed that the lowest MQ score is due to mental fatigue impairing awareness in patients with severe OSAS, probably because of attention loss.

Rapid eye movement-localized apnea in a female patient with chronic insomnia.

A middle-aged female patient with chronic insomnia showed rapid eye movement (REM)- localized obstructive sleep apnea. She visited the Sleep Disorders Clinic and complained of insomnia with loud snoring. Once, in the past, her sleep complaints had disappeared after weight reduction but, 6 months later, she complained of excessive daytime sleepiness. Overnight polysomnography revealed REM-localized apnea. Careful follow up is strongly recommended for a female patient with chronic insomnia who shows REM-localized apnea.