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INTRODUCTION: University students tend to suffer from problems of sleep regularity, quantity and quality, which can affect their academic performance. These problems are related to changes typical of the phase of the life cycle in which they find themselves due to maturational, psychosocial development (associated with the processes of individuation and socialisation) and academic factors. The study of the relationship between sleep and academic performance in university students is an area of research of growing interest, which has started to be studied over the last two decades. AIM: To conduct a systematic review of the existing literature on the relationship between sleep and academic performance in university students. SUBJECTS AND METHODS: The articles included in the PubMed database were selected, following the PRISMA guidelines. Studies evaluating samples of subjects with an average age between 18 and 26 years, published in English or Spanish during the period 2000-2019 were included. Subsequently, the quality of the selected articles was evaluated according to the STROBE standard. RESULTS: Thirty studies were identified, which were grouped according to different aspects of sleep: drowsiness, duration, experience of total sleep deprivation, sleep quality, chronotype, regularity and sleep disorders. CONCLUSION: The results of these studies suggest that inadequate sleep has a negative effect on the academic performance of university students.

TITLE: Sueño y rendimiento académico en estudiantes universitarios: revisión sistemática.Introducción. Los estudiantes universitarios tienden a padecer problemas de regularidad, cantidad y calidad de sueño, que pueden afectar a su rendimiento académico. Estos problemas se relacionan con cambios propios de la fase del ciclo vital en la que se encuentran debido a diversos factores: madurativos, del desarrollo psicosocial (asociados con los procesos de individuación y socialización) y académicos. El estudio de la relación entre el sueño y el rendimiento académico en estudiantes universitarios es un área de investigación de interés creciente, que ha empezado a ser objeto de estudio en las últimas dos décadas. Objetivo. Revisión sistemática de la bibliografía existente sobre la relación del sueño y el rendimiento académico en los estudiantes universitarios. Sujetos y métodos. Se seleccionaron los artículos recogidos en la base de datos PubMed, siguiendo las directrices PRISMA. Se incluyeron los estudios que valoraban muestras de sujetos con una edad media entre 18 y 26 años, publicados en inglés o castellano, durante el período 2000-2019. Posteriormente, se evaluó la calidad de los artículos seleccionados siguiendo la normativa STROBE. Resultados. Se identificaron 30 estudios, que fueron agrupados según distintos aspectos del sueño: somnolencia, duración, experiencia de privación total de sueño, calidad de sueño, cronotipo, regularidad y trastornos del sueño. Conclusión. Los resultados de estos estudios sugieren que un sueño inadecuado afecta negativamente al rendimiento académico de los estudiantes universitarios.

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INTRODUCTION: Epidemiological studies suggest the importance of environmental factors in the etiology of narcolepsy-cataplexy in genetically predisposed subjects. AIM: To assess the role of environmental factors in the development of narcolepsy-cataplexy, using a case-control design with control subjects being matched for ethnicity and age. PATIENTS AND METHODS: All patients were recruited through two outpatient clinics at the community of Madrid, ant the diagnosis of narcolepsy fulfilled the criteria of the International Classification on Sleep Disorders-2005. A questionnaire, including 54 environmental psychological stressor life events and 42 infectious diseases items, was administered to 54 patients. We specifically assessed the stressful factors and infectious diseases that occurred in the year preceding the onset of the first symptom of narcolepsy (excessive daytime sleepiness and/or cataplexy). The same questionnaire was administered to 84 control subjects recruited from non-related family members of the same community. RESULTS: Fifty four patients (55.6% males) answered the questionnaire, The mean age at onset of the first symptom was 21.6 ± 9.3 years, and the mean age at diagnosis was 36.5 ± 12.4 years. The main finding in narcoleptic patients as compared to control subjects was major changes in the 'number of arguments with partner, family, or friends' (odds ratio: 5.2; 95% confidence interval: 1.8-14.5). This can be interpreted as having a protective function and it suggests that psychological mechanisms are present since the beginning of the disease. As for the infectious factors, chickenpox was the most frequently reported. No significant differences were found in terms of total numbers of stress-related and infectious factors between cases and controls. CONCLUSION: Prospective studies regarding the interaction between environmental and genetic factors are warranted.

TITLE: Factores ambientales en la etiologia de la narcolepsia-cataplejia. Estudio de casos y controles de una serie.Introduccion. Los estudios epidemiologicos subrayan la importancia de los factores ambientales en la etiologia de la narcolepsia con cataplejia en pacientes geneticamente predispuestos. Objetivo. Evaluar el papel de los factores ambientales en la etiologia de la narcolepsia-cataplejia utilizando un diseño de casos y controles comparados por edad y etnia. Pacientes y metodos. Todos los pacientes fueron diagnosticados en nuestras unidades de sueño, segun los criterios de la Clasificacion Internacional de los Trastornos del Sueño de 2005. Utilizamos un cuestionario consistente en 54 preguntas relacionadas con acontecimientos psicologicos estresantes y 42 enfermedades infecciosas en 54 pacientes. Evaluamos especificamente la presencia de factores estresantes y/o infecciosos en el año previo al comienzo del primer sintoma de narcolepsia-cataplejia (somnolencia excesiva diurna y/o cataplejia). El mismo cuestionario se administro a 84 controles, miembros de la misma comunidad, sin relacion de parentesco. Resultados. Respondieron el cuestionario 54 pacientes (55,6%, hombres) (edad media del primer sintoma: 21,6 ± 9,3 años; edad media del diagnostico: 36,5 ± 12,4 años) y 84 controles. El principal hallazgo fue un cambio importante en el 'numero de discusiones con la pareja, la familia o los amigos' (odds ratio: 5,2; intervalo de confianza al 95%: 1,8-14,5) en los narcolepticos, lo que sugiere que los mecanismos psicologicos estan presentes desde el comienzo de la enfermedad con una funcion protectora. La varicela fue el factor infeccioso mas frecuente. No se obtuvieron diferencias significativas en el numero de factores psicologicos estresantes e infecciosos entre los pacientes narcolepticos y los controles. Conclusion. Estudios prospectivos epidemiologicos en series de individuos susceptibles geneticamente estan justificados para aclarar la implicacion de los factores ambientales en la etiopatogenia de la narcolepsia-cataplejia.

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Introducción. Los estudios epidemiológicos subrayan la importancia de los factores ambientales en la etiología de la narcolepsia con cataplejía en pacientes genéticamente predispuestos. Objetivo. Evaluar el papel de los factores ambientales en la etiología de la narcolepsia-cataplejía utilizando un diseño de casos y controles comparados por edad y etnia. Pacientes y métodos. Todos los pacientes fueron diagnosticados en nuestras unidades de sueño, según los criterios de la Clasificación Internacional de los Trastornos del Sueño de 2005. Utilizamos un cuestionario consistente en 54 preguntas relacionadas con acontecimientos psicológicos estresantes y 42 enfermedades infecciosas en 54 pacientes. Evaluamos específicamente la presencia de factores estresantes y/o infecciosos en el año previo al comienzo del primer síntoma de narcolepsia-cataplejía (somnolencia excesiva diurna y/o cataplejía). El mismo cuestionario se administró a 84 controles, miembros de la misma comunidad, sin relación de parentesco. Resultados. Respondieron el cuestionario 54 pacientes (55,6%, hombres) (edad media del primer síntoma: 21,6 ± 9,3 años; edad media del diagnóstico: 36,5 ± 12,4 años) y 84 controles. El principal hallazgo fue un cambio importante en el ‘número de discusiones con la pareja, la familia o los amigos’ (odds ratio: 5,2; intervalo de confianza al 95%: 1,8-14,5) en los narcolépticos, lo que sugiere que los mecanismos psicológicos están presentes desde el comienzo de la enfermedad con una función protectora. La varicela fue el factor infeccioso más frecuente. No se obtuvieron diferencias significativas en el número de factores psicológicos estresantes e infecciosos entre los pacientes narcolépticos y los controles. Conclusión. Estudios prospectivos epidemiológicos en series de individuos susceptibles genéticamente están justificados para aclarar la implicación de los factores ambientales en la etiopatogenia de la narcolepsia-cataplejía (AU)

Introduction. Epidemiological studies suggest the importance of environmental factors in the etiology of narcolepsycataplexy in genetically predisposed subjects. Aim. To assess the role of environmental factors in the development of narcolepsy-cataplexy, using a case-control design with control subjects being matched for ethnicity and age. Patients and methods. All patients were recruited through two outpatient clinics at the community of Madrid, ant the diagnosis of narcolepsy fulfilled the criteria of the International Classification on Sleep Disorders-2005. A questionnaire, including 54 environmental psychological stressor life events and 42 infectious diseases items, was administered to 54 patients. We specifically assessed the stressful factors and infectious diseases that occurred in the year preceding the onset of the first symptom of narcolepsy (excessive daytime sleepiness and/or cataplexy). The same questionnaire was administered to 84 control subjects recruited from non-related family members of the same community. Results. Fifty four patients (55.6% males) answered the questionnaire, The mean age at onset of the first symptom was 21.6 ± 9.3 years, and the mean age at diagnosis was 36.5 ± 12.4 years. The main finding in narcoleptic patients as compared to control subjects was major changes in the ‘number of arguments with partner, family, or friends’ (odds ratio: 5.2; 95% confidence interval: 1.8-14.5). This can be interpreted as having a protective function and it suggests that psychological mechanisms are present since the beginning of the disease. As for the infectious factors, chickenpox was the most frequently reported. No significant differences were found in terms of total numbers of stress-related and infectious factors between cases and controls. Conclusion. Prospective studies regarding the interaction between environmental and genetic factors are warranted (AU)

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Objetivo. Se trata de explorar la prevalencia del insomnio y la calidad del sueño en una muestra de médicos de atención primaria desde una perspectiva de género. Sujetos y métodos. Se seleccionó una muestra representativa compuesta por 240 médicos de 70 centros de atención primaria de la Comunidad de Madrid. La tasa de respuesta fue del 71,6%. El cuestionarioincluía información sociodemográfica, síntomas de insomnio según los criterios del Manual diagnóstico y estadístico de los trastornos mentales (DSM-IV) y el índice de calidad del sueño de Pittsburgh (ICSP). Resultados. El 18,8% del total de a muestra cumplió los criterios diagnósticos de insomnio del DSM-IV, con una mayor frecuencia en las mujeres (23%) comparadascon los hombres (9,6%). El mismo patrón apareció en el despertar antes de lo deseado y en el malestar diurno. La relación entre género e insomnio se confirmó mediante análisis de regresión binaria, controlando las variables sociodemográficas. Además, los resultados indicaron que las mujeres obtuvieron puntuaciones significativamente mayores que las de los hombres en el índice ICSP y en sus componentes. Una puntuación global igual o mayor de 5 en el ICSP resulta un criterio válido desde el punto de vista clínico para discriminar entre buenos y malos durmientes. Mediante este criterio, puede considerarseque el 35,4% de los médicos encuestados era mal durmiente, y es significativamente mayor el porcentaje de mujeres que cumplía dicho criterio (el 40% frente al 25,3%). Conclusiones. Los datos indican una elevada prevalencia de las alteraciones del sueño en médicos de atención primaria, especialmente entre las mujeres

Aim. To assess insomnia and sleep quality in primary care physicians from a gender perspective. Subjects and methods. A representative sample of 240 physicians was drawn from 70 medical centers from the Madrid Autonomous region. The participation rate was 71.6%. The questionnaire included sociodemographic data, insomnia symptomatology using DSM-IVcriteria and the Pittsburgh Sleep Quality Index (PSQI). Results. 18.8% of the total sample met DSM-IV criteria for insomnia diagnosis, with higher frequency among women (23%) compared to men (9.6%). The same pattern appeared for early morning awakening and daytime impairment.Results of logistic regression analyses showed that, after controlling for sociodemographic variables, this relationship between gender and insomnia remained significant. Furthermore, the results indicate that women scored significantly higher than men on global sleep quality and on its components. A PSQI global score= or > 5 is an optimal cut-off score for distinguishing good sleepers from subjects with clinical sleep problems. Following this criteria, 35.4% of physicians had sleep problems, with a significant higher prevalence among women (40% vs. 25.3%).Conclusions. The data indicates that the prevalence of sleep disturbances is high among primary care physicians, especially among women

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AIM: To assess insomnia and sleep quality in primary care physicians from a gender perspective. SUBJECTS AND METHODS: A representative sample of 240 physicians was drawn from 70 medical centers from the Madrid Autonomous region. The participation rate was 71.6%. The questionnaire included sociodemographic data, insomnia symptomatology using DSM-IV criteria and the Pittsburgh Sleep Quality Index (PSQI). RESULTS: 18.8% of the total sample met DSM-IV criteria for insomnia diagnosis, with higher frequency among women (23%) compared to men (9.6%). The same pattern appeared for early morning awakening and daytime impairment. Results of logistic regression analyses showed that, after controlling for sociodemographic variables, this relationship between gender and insomnia remained significant. Furthermore, the results indicate that women scored significantly higher than men on global sleep quality and on its components. A PSQI global score = or > 5 is an optimal cut-off score for distinguishing good sleepers from subjects with clinical sleep problems. Following this criteria, 35.4% of physicians had sleep problems, with a significant higher prevalence among women (40% vs. 25.3%). CONCLUSIONS: The data indicates that the prevalence of sleep disturbances is high among primary care physicians, especially among women.

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OBJECTIVE: Many epidemiologic studies have reported that obesity is associated with short sleep duration. How the degree of obesity or other clinical characteristics of the obese individuals, such as sleep disturbances or emotional stress, define this relation is not known. DESIGN: We studied a random sample of 1300 middle-aged men and women from the Penn State Cohort in the sleep laboratory for one night. Sleep disturbances were recorded as insomnia, excessive daytime sleepiness (EDS) or sleep difficulty. Chronic emotional stress was determined by the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). RESULTS: Obese individuals (body mass index, BMI>30) reported shorter duration of sleep, had a higher incidence of subjective sleep disturbances (47.4 vs 25.5%; P<0.01) and scored higher for chronic emotional stress than nonobese subjects. However, there was no difference in self-reported sleep duration between obese and nonobese individuals without subjective sleep disturbances, while both obese men and women with sleep complaints scored higher in the MMPI-2 compared to obese individuals without sleep complaints. The shortest sleep duration was reported by the obese insomniac patients (5.9 h), followed by obese with EDS (6.3 h) or sleep difficulty (6.6 h). The effect of chronic emotional stress was stronger than that of the BMI on the reported sleep duration, with a synergistic joint effect. The presence of a sleep disturbance was associated with a reduction of reported sleep by 18 min for men and 42 min in women, whereas a 10 kg m(-2) increase of BMI was associated with a 16 and 6 min decrease of sleep in men and women, respectively. Interestingly, there was no association between objective sleep duration and BMI. CONCLUSION: Self-reported short sleep duration in obese individuals may be a surrogate marker of emotional stress and subjective sleep disturbances, whose detection and management should be the focus of our preventive and therapeutic strategies for obesity.

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CONTEXT: Excessive daytime sleepiness (EDS) is commonly considered a cardinal sign of sleep apnea; however, the mechanism underlying the association is unclear. OBJECTIVE: The purpose of this study was to assess the association between the complaint of EDS and sleep apnea, considering a wide range of possible risk factors in a population sample. DESIGN AND SETTING: We examined this question in the Penn State cohort (a random sample of 16,583 men and women from central Pennsylvania, ranging in age from 20 to 100 yr). A random subset of this cohort (n = 1,741) was further evaluated for one night in the sleep laboratory. MAIN OUTCOME MEASURE: The main measure was a complaint of EDS. RESULTS: The final logistic regression model indicated depression was the most significant risk factor for EDS followed by body mass index, age, typical sleep duration, diabetes, smoking, and finally sleep apnea. The strength of the association with EDS decreased with increasing age, whereas the association of depression with EDS was stronger in the young. EDS is more prevalent in the young (<30 yr), suggesting the presence of unmet sleep needs and depression, and in the very old (>75 yr), suggesting increasing medical illness and health problems. EDS was associated with a reduced report of typical sleep duration without any association with objective polysomnographic measures. CONCLUSIONS: It appears that the presence of EDS is more strongly associated with depression and metabolic factors than with sleep-disordered breathing or sleep disruption per se. Our findings suggest that patients with a complaint of EDS should be thoroughly assessed for depression and obesity/diabetes independent of whether sleep-disordered breathing is present.

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OBJECTIVE: Establish the association between insomnia and various physical and mental health symptoms as well as objective measures of sleep disturbance while controlling for age, gender and BMI in a large random sample of the general public. METHODS: A subsample (N=1741) was selected for a single-night sleep laboratory evaluation from a larger random sample (N=16,583) of the general public (20-100 years old). RESULTS: The prevalence of insomnia was 7.5% and difficulty sleeping an additional 22.4%. The complaints were more frequent in women and in non-Caucasian minorities. A multivariate logistic regression analysis indicated that depression was the single strongest factor followed by female gender associated with either insomnia or difficulty sleeping. Minority status and a history of colitis, hypertension and anemia were also associated, but to a lesser degree. The final model did not include age, BMI as well as any of the sleep laboratory findings. CONCLUSION: These findings support the conclusion that mental health variables have the primary independent association with a complaint of insomnia. Other factors including minorities and hypertension are also independently associated, though to a lesser degree. Other primary sleep disorders, e.g., sleep apnea, do not seem to play a major role in insomnia. These findings underscore the fact that insomnia is a symptom associated with a wide variety of mental and physical health problems requiring a proper psychiatric and medical management.

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Chronic insomnia, by far the most commonly encountered sleep disorder in medical practice, is characterized by difficulty falling or staying asleep at night and increased fatigue during the day. Interleukin-6 (IL-6) and tumor necrosis factor (TNF) are fatigue-inducing cytokines, and the daytime secretion of IL-6 is negatively influenced by the quantity and quality of the previous night's sleep. We hypothesize that the poor quality of insomniacs' sleep is associated with a hypersecretion of these 2 cytokines during the daytime, which, in turn, correlates with the fatigue experienced by these patients. Eleven young insomniacs (6 men and 5 women) and 11 (8 men and 3 women) age- and body mass index (BMI)-matched healthy controls participated in the study. Subjects were recorded in the sleep laboratory for 4 consecutive nights and serial 24-hour plasma measures of IL-6 and TNF were obtained during the 4th day. Insomniacs compared to controls slept poorly (sleep latency and wake were increased, whereas percentage sleep time was decreased during baseline nights, all P <.05). The mean 24-hour IL-6 and TNF secretions were not different between insomniacs and controls. However, the difference in the change (increase) of IL-6 plasma levels from midafternoon (2 PM) to evening (9 PM) between insomniacs and controls was significant (P <.01). Furthermore, cosinor analysis showed a significant shift of the major peak of IL-6 secretion from nighttime (4 AM) to evening (7 PM) in insomniacs compared to controls (P <.05). Also, while TNF secretion in controls showed a distinct circadian rhythm with a peak close and prior to the offset of sleep (P <.05), such a rhythm was not present in insomniacs. Finally, daytime secretion of TNF in insomniacs was characterized by a regular rhythm of 4 hours (P <.05); such a distinct periodicity was not present in controls. We conclude that chronic insomnia is associated with a shift of IL-6 and TNF secretion from nighttime to daytime, which may explain the daytime fatigue and performance decrements associated with this disorder. The daytime shift of IL-6 and TNF secretion, combined with a 24-hour hypersecretion of cortisol, an arousal hormone, may explain the insomniacs' daytime fatigue and difficulty falling asleep.

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Although insomnia is, by far, the most commonly encountered sleep disorder in medical practice, our knowledge in regard to its neurobiology and medical significance is limited. Activation of the hypothalamic-pituitary-adrenal axis leads to arousal and sleeplessness in animals and humans; however, there is a paucity of data regarding the activity of the hypothalamic-pituitary-adrenal axis in insomniacs. We hypothesized that chronic insomnia is associated with increased plasma levels of ACTH and cortisol. Eleven young insomniacs (6 men and 5 women) and 13 healthy controls (9 men and 4 women) without sleep disturbances, matched for age and body mass index, were monitored in the sleep laboratory for 4 consecutive nights, whereas serial 24-h plasma measures of ACTH and cortisol were obtained during the fourth day. Insomniacs, compared with controls, slept poorly (significantly higher sleep latency and wake during baseline nights). The 24-h ACTH and cortisol secretions were significantly higher in insomniacs, compared with normal controls (4.2 +/- 0.3 vs. 3.3 +/- 0.3 pM, P = 0.04; and 218.0 +/- 11.0 vs. 190.4 +/- 8.3 nM, P = 0.07). Within the 24-h period, the greatest elevations were observed in the evening and first half of the night. Also, insomniacs with a high degree of objective sleep disturbance (% sleep time < 70), compared with those with a low degree of sleep disturbance, secreted a higher amount of cortisol. Pulsatile analysis revealed a significantly higher number of peaks per 24 h in insomniacs than in controls (P < 0.05), whereas cosinor analysis showed no differences in the temporal pattern of ACTH or cortisol secretion between insomniacs and controls. We conclude that insomnia is associated with an overall increase of ACTH and cortisol secretion, which, however, retains a normal circadian pattern. These findings are consistent with a disorder of central nervous system hyperarousal rather than one of sleep loss, which is usually associated with no change or decrease in cortisol secretion or a circadian disturbance. Chronic activation of the hypothalamic-pituitary-adrenal axis in insomnia suggests that insomniacs are at risk not only for mental disorders, i.e. chronic anxiety and depression, but also for significant medical morbidity associated with such activation. The therapeutic goal in insomnia should be to decrease the overall level of physiologic and emotional arousal, and not just to improve the nighttime sleep.

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The prevalence of insomnia associated with emotional stress increases markedly in middle-age. Both the top and end hormones of the hypothalamic-pituitary-adrenal axis, i.e. CRH and glucocorticoids, stimulate arousal/wakefulness and inhibit slow wave (deep) sleep in experimental animals and man. The objective of this study was to test the hypothesis that middle-age is characterized by increased sensitivity to the sleep-disturbing effects of the hypothalamic-pituitary-adrenal axis. We studied 12 healthy middle-aged (45.1 +/- 4.9) and 12 healthy young (22.7 +/- 2.8) men by monitoring their sleep by polysomnography for 4 consecutive nights, including in tandem 1 adaptation and 2 baseline nights and a night during which we administered equipotent doses of ovine CRH (1 microg/kg, iv bolus) 10 min after sleep onset. Analyses included comparisons within and between groups using multiple ANOVA and regression analysis. Although both middle-aged and young men responded to CRH with similar elevations of ACTH and cortisol, the former had significantly more wakefulness and suppression of slow wave sleep compared with baseline sleep; in contrast, the latter showed no change. Also, comparison of the change in sleep patterns from baseline to the CRH night in the young men to the respective change observed in middle-aged men showed that middle-age was associated with significantly higher wakefulness and significantly greater decrease in slow wave sleep than in young age. We conclude that middle-aged men show increased vulnerability of sleep to stress hormones, possibly resulting in impairments in the quality of sleep during periods of stress. We suggest that changes in sleep physiology associated with middle-age play a significant role in the marked increase of prevalence of insomnia in middle-age.

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The prevalence of sleep-disordered breathing has not been well studied in women, especially in terms of the effects of age, body mass index (BMI), and menopause. We evaluated this question using a two-phase random sample from the general population. In Phase I, 12,219 women and 4,364 men ranging in age from 20 to 100 yr were interviewed; and in Phase II, 1,000 women and 741 men of the Phase I subjects were selected for one night of sleep laboratory evaluation. The results of our study indicated that, for clinically defined sleep apnea (apnea/hypopnea index > or = 10 and daytime symptoms), men had a prevalence of 3.9% and women 1.2%, resulting in an overall ratio of sleep apnea for men to women of 3.3:1 (p = 0.0006). The prevalence of sleep apnea was quite low in premenopausal women (0.6%) as well as postmenopausal women with hormone replacement therapy (HRT) (0.5%). Further, in these women the presence of sleep apnea appeared to be associated exclusively with obesity (BMI > or = 32.3 kg/m2). Postmenopausal women without HRT had a prevalence of sleep apnea that was significantly higher than the prevalence in premenopausal women with HRT (2.7 versus 0.6%, p = 0.02) and was more similar to the prevalence in men (3.9%), although it remained significantly less when controlling for age and BMI (p = 0.001). These data combined indicate that menopause is a significant risk factor for sleep apnea in women and that hormone replacement appears to be associated with reduced risk.

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We describe the polysomnographic data of a 79-year-old woman with an 11-year history of nocturnal headaches that were clinically consistent with hypnic headache. A polysomnographic study showed arousal at stage 3 slow wave sleep because of a headache episode. Although this finding could be nonspecific, it suggests the possible relationship between stage 3 slow wave sleep and hypnic headache.

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BACKGROUND: To our knowledge, the association between sleep-disordered breathing (SDB) and hypertension has not been evaluated in subjects from the general population with a wide age range while adjusting for the possible confounding factors of age, body mass index, sex, menopause and use of hormone replacement therapy, race, alcohol use, and smoking. METHODS: In the first phase of this study, we interviewed 4364 men and 12,219 women, aged 20 to 100 years. In the second phase of this study, 741 men and 1000 women, previously interviewed, were selected based on the presence of risk factors for SDB (snoring, daytime sleepiness, obesity, hypertension, and, for women, menopause). Each subject selected for the second phase of the study provided a comprehensive history, underwent a physical examination, and was evaluated for 1 night in the sleep laboratory. In terms of severity of SDB, 4 groups were identified: moderate or severe (obstructive apnea/hypopnea index > or =15.0), mild (snoring and an obstructive apnea/hypopnea index of 0.1-14.9), snoring, and no SDB, the control group. RESULTS: Sleep-disordered breathing was independently associated with hypertension when potential confounders were controlled for in the logistic regression analysis. The strength of this association decreased with age and was proportional to the severity of SDB. In the best-fitted model, neither sex nor menopause changed the relationship between hypertension and SDB. CONCLUSIONS: In the results of this study, SDB, even snoring, was independently associated with hypertension in both men and women. This relationship was strongest in young subjects, especially those of normal weight, a finding that is consistent with previous findings that SDB is more severe in young individuals.

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OBJECTIVE: The differential diagnosis of primary (idiopathic) vs. psychiatric hypersomnia is challenging because of the lack of specific clinical or laboratory criteria differentiating these two disorders and the frequent comorbidity of mental disorders in patients with primary hypersomnia. The aim of this study was to assess whether polysomnography aids in the differential diagnosis of these two disorders. METHODS: After excluding patients taking medication and those with an additional diagnosis of sleep-disordered breathing, we compared the nocturnal and daytime sleep of 82 consecutive patients with a diagnosis of either primary hypersomnia (N = 59) or psychiatric hypersomnia (N = 23) and normal control subjects (N = 50). RESULTS: During nocturnal sleep, patients with psychiatric hypersomnia showed significantly higher sleep latency, wake time after sleep onset, and total wake time and a significantly lower percentage of sleep time than patients with primary hypersomnia and control subjects (p < .05). In addition, the daytime sleep of patients with psychiatric hypersomnia was significantly higher in terms of sleep latency, total wake time, and percentage of light (stage 1) sleep and lower in terms of percentage of sleep time and stage 2 sleep than in patients with primary hypersomnia and control subjects (p < .05). The daytime sleep of patients with primary hypersomnia as compared with that of control subjects was characterized by lower sleep latency and total wake time and a higher percentage of sleep time (p < .05). Finally, a sleep latency of less than 10 minutes or a sleep time percentage greater than 70% in either of the two daytime naps was associated with a sensitivity of 78.0% and a specificity of 95.7%. CONCLUSIONS: Our findings indicate that psychiatric hypersomnia is a disorder of hyperarousal, whereas primary hypersomnia is a disorder of hypoarousal. Polysomnographic measures may provide useful information in the differential diagnosis and treatment of these two disorders.

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Este artículo revisa las características clínicas y el curso clínico del síndrome de apnea del sueño. En las dos primeras secciones se describen los principales síntomas y signos. En la última sección se incluye la historia natural del síndrome, tanto desde el punto de vista del orden de los síntomas y signos según su edad de comienzo, como de los diferentes estadios que van desde el ronquido simple a las formas más graves del síndrome (AU)

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Se revisa la asociación del síndrome de apnea del sueño con diferentes trastornos psiquiátricos. Se subrayan las implicaciones diagnósticas y terapéuticas de tal asociación. Se recuerda la conveniencia de que el médico general y el especialista tengan en cuenta la posibilidad de la presencia de ronquido o apnea del sueño al prescribir fármacos depresores del SNC (AU)

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INTRODUCTION: Sleep disorders are among the clinical entities with a great health and socioeconomic impact. So far, in Spain there are isolated epidemiologic data, lacking from studies that cover the full spectrum of sleep disorders in the general adult population. METHODS: A sample of 1,500 adult subjects from Madrid were interviewed during the first semester of 1990, using a clinical questionnaire including sociodemographic data, habits, sleep disorders, and information regarding somatic and psychiatric pathology. A detailed analysis of the influence of sex, age and occupational status on the prevalence of the different disorders is presented. RESULTS: 1,131 persons (75.4%) completed the interview. 22.8% (95% confidence interval, CI: 20.4-25.4) referred at least one sleep difficulty, 11.3% (9.5-13.3) of the sample complained of insomnia, this being more common in women, older individuals and unemployed. Daytime sleepiness was reported by 11.6% (9.8-13.7) of the sample, and 3.2% (2.2-4.4) referred hypersomnia, with sleep attacks and sleep paralysis being rarely found. Regarding parasomnias, 12.3% (10.4-14.4) had nightmares, with the prevalence of sonambulism, night terrors and enuresis being near 1%. Daily snoring was present in 11.9% (10.1-14.0) of the sample, whereas 1.1% (0.6-2.0) reported respiratory pauses during the night. CONCLUSIONS: A high prevalence of sleep disorders is estimated in the adult population of the city of Madrid, Spain. Our data are in general similar to those found in other countries, and differences found are discussed.

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UNLABELLED: AIM, SAMPLE AND MEASURES: Co-morbidity has been shown to influence the clinical course of mental disorders. This paper describes DSM-III-R 1-month co-morbidity across axes I, II and III in a sample of 153 benzodiazepine dependents. All patients were evaluated through several in-depth clinical interviews across all five DSM-III-R axes. RESULTS: Extensive co-morbidity existed across three DSM-III-R axes. All patients had at least one diagnosis in axis I; 81 (52.9%) in axis II and 50 (32.7%) in axis III. The most prevalent diagnoses were: insomnia, anxiety disorders and affective disorders in axis I; obsessive-compulsive, histrionic and dependent personality disorders in axis II and rheumatological, neurological and cardiovascular disorders in axis III. CONCLUSIONS: There were no cases of benzodiazepine dependence appearing alone. There were associations within and between axes, suggesting potential predisposing factors and a sequential model for benzodiazepine dependence is proposed. The findings reinforce the need for exhaustive diagnostic evaluation of patients prior to prescribing benzodiazepine.

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