前幾天睡眠醫學會晨會在講 Sleep terror (睡驚)，就是剛進入深睡時突然驚恐醒來，但沒有完全醒，會吼叫或防衛性肢體動作，造成東西損壞（少數造成自己受傷，大部份都是室友比當事者還驚嚇），但事後本人不會記得。我今天整理資料，突然想到陰陽蹻脈病。Sleep terror幼兒比較常見，但成人也有。這讓我想到之前門診的一位大學生，有一陣子就是剛睡沒多久會聞到電線燒焦味，然後恐慌，心臟很用力跳動，快喘不過氣、滿身大汗的醒來。
A few days ago, the TSSM held a morning meeting to talk about “sleep terror,” a sleep disorder in which a person has a sudden arousal from deep sleep in a terrified state, while not fully awake. The person may scream or engage in violent/defensive bodily activity, causing damage to things (in some cases, people cause injuries to themselves, but in most cases, their roommates are more frightened than the person involved), but the person will not remember it afterwards. When I was sorting out some information today, the idea of the Yin/Yang Heel Vessels disease suddenly came to me.
Sleep terror is more common in young children, but it can also happen in adults. This reminds me of a college student who I saw in the outpatient clinic before. For some time, he would smell the smell of burning wires not long after falling asleep, and then he would panic, his heart racing, and he would wake up gasping for breath and covered in sweat.
睡驚是異睡症的一種，是一種影響動作和行為的睡眠障礙，發生在大腦從深睡或非快速動眼期(NREM)第三期不完全醒來的時候，通常是在夜間的最初一段時間，但可以發生在一天當中任何睡著的時候。睡驚發作時，人是處在非常害怕和恐慌的狀態，很難安撫，患者可能會坐起來或跳下床、哭泣、尖叫、大出汗並且感覺心跳加速。通常持續 1 至 30 分鐘，很少超過30分鐘，然後又會重新睡著，到了早上醒來，當事者並沒有這段過程的記憶。
Sleep terror is a type of parasomnia, which is a group of sleep disorders that affect sleep movements and behaviour. Sleep terror occurs from impaired arousal from deep sleep or NREM stage 3, usually in the first part of the night, but it may occur at any time during the 24-hour continuum when sleep occurs. During an attack of sleep terror, the person may sit up or jump out of bed, cry, scream, start sweating and feel the heart thumping fast. The person is panicky and difficult to console. Night terrors usually last between one and 30 minutes, and then fall back to sleep. In the morning, the person won’t remember what happened.
睡驚的病灶位於腦皮質下層(subcortex)，發作時，大腦的前額葉，也就是執行功能和記憶的腦區是睡著的，但後腦控制肢體動作的部分是醒著的，類似夢遊，不同的是夢遊和說夢話是發生在腦皮質層(cortical level)。雖然人們尚未完全掌握睡驚的具體原因，但目前認為與大腦的喚醒系統失調有關；視丘和側縫(頂葉和顳葉交界處)深處的腦島葉的損傷，也可能與睡驚有關。再者，島葉也是大腦中負責處理情緒的區域之一。
During sleep terrors, the front part of your brain that controls executive functioning and memory is asleep while the back part that controls motor movement is awake. This is similar to sleepwalking, but the difference is that sleep walking and sleep talking happens at the cortical level.
While the exact cause of sleep terrors is not fully understood, they are often linked to the brain's arousal system. Brain lesions in the thalamus and the insula can be associated with sleep terrors. And insula is a brain region involved in emotional processing.
前額葉和腦幹的病變也被認為會引發睡驚。正常情況下，杏仁核受到前額葉的抑制來調節，但在睡眠不足時，前額葉對杏仁核的抑制就會解除，增加杏仁核的活動。當杏仁核過度活躍，就連無關緊要的事情也會變得敏感，例如把別人的動作和言行看作是對自己的指責，這樣即使是在客觀上非常平和的環境，也會感覺自己承受著巨大的壓力。有點像是睡眠不足或是前額葉的供血不足會啟動原始的防衛機制。
Lesions in the prefrontal lobes and brainstem have also been implicated in triggering sleep terror in some cases. Normally, the amygdala is regulated by the inhibition from the prefrontal cortex, but when the person is afflicted by sleep deprivation, the inhibition of the prefrontal cortex on the amygdala is lifted, increasing the activity of the amygdala. When the amygdala is overactive, the individual will become sensitive to even the least significant things, such as regarding other people's actions and words as accusations against oneself, so that even in an objectively very peaceful environment, one will feel under tremendous pressure. It's a bit like the lack of sleep or an insufficient blood supply in the prefrontal lobe can trigger our primitive defence mechanism.
為什麼我會想到陰陽蹻脈呢？因為和醒睡轉換有關的經脈就是陰陽蹻脈了。而且陰陽蹻脈不只是功能上和眼睛的開合、肢體動作的共軛有關，其循行路線就聯絡了前額葉和腦幹。睡驚就像是原本該潛入陰分循行的衛氣突然反常的衝出到陽分，有一種陰陽的節律和接替失調的感覺，尤其是夜間衛氣的流動。也許我們可以簡單地看看最多人抱怨醒來的早上1~5點這段時間。
Why did sleep terror remind me of the Yin/Yang Heel vessel? Because the Yin/Yang Heel vessels regulate the sleep-wake transition. Moreover, the Yin/Yang Heel vessels are not only functionally related to the opening and closing of the eyes and the agonist and antagonist muscles that enable our limb movements, but also its route connects the prefrontal lobe and brain stem. Sleep terror is like the defence qi that should have entered the Yin suddenly and abnormally rushing out to the Yang. So it seems to me something is wrong with the flow of defence qi at night, a disharmony in the rhythm and succession of Yin and Yang. Perhaps we can simply look at the time between 1 to 5 a.m., when most people complain about unwanted arousals.
蹻ㄑㄧㄠ，通「蹺」，「舉足小高」的意思，蹻脈是奇經八脈中和腳跟有關的脈。陰陽蹻脈聯繫足跟、眼睛及腦部，控制眼睛的開合、醒睡和肢體活動，而衛氣也通過陰陽蹻脈散佈全身。衛氣的運行和醒睡的轉換息息相關，衛氣在一晝夜之間共繞全身五十周，約24小時會走完28星宿 (身體對應宇宙)。(房昴為緯，虛張為經。房至畢為陽，昴至心為陰。) 白天循行於陽分(手足陽經) 二十五周，入夜後就會潛入陰分，循行於五臟之間二十五周。
蹻 (Qiao), the same as “蹺”, is interpreted as “raising the foot slightly higher.” Heel vessels are the meridians among the eight extra meridians that connect the heel, eyes and the brain. The movement of defence qi is closely related to the transition between waking and sleeping. The defence qi circulates the body fifty times in one day and night, and passes through the 28 Mansions (our body mirrors the universe) in approximately 24 hours. (Fang [π Scorpii] - Mao [17 Tauri] are the latitude, Xu [β Aquarii] - Zhang [υ Hydrae] are the longitude. Fang to Bi [ε Tauri] are the Yang, Mao to Xin [α Scorpii] are the Yin.) During the day, it circulates in the Yang (the six yang meridians) twenty-five times, and at night, it circulates in the Yin (between five internal organs) twenty-five times.
入夜時，衛氣從陽分轉入陰分是從腳心走到內踝，沿足少陰腎經傳注到腎臟，由腎傳注到心臟，由心傳注到肺臟，由肺傳注到肝臟，由肝傳注到脾臟，由脾又傳注到腎，這樣就是繞了一周。整個晚上衛氣會在五臟之間繞行25周，到了天明時，於內眼角與陽蹻和太陽膀胱經會合，浮出陽分，人就會開始一天的活動。
The defence qi shifts from the Yang to the Yin after sunset as it enters the centre of the sole to the inner ankle. From here, the defence qi then runs along the kidney meridian and into the Kidney, from the Kidney to the Heart, from the Heart to the Lungs, from the Lungs to the Liver, from the Liver to the Spleen, and from the Spleen to the Kidney, thus completing a cycle. Throughout the night, the defence qi circulates the five internal organs 25 times. At dawn, it meets with the Yang Heel vessel and the bladder meridian at the inner corner of the eye, emerges to the Yang, and people open their eyes and start their activities.
是否有氣滯血瘀痰凝水飲等等阻滯與某臟，就會造成衛氣行於陰分堵塞，無法順利流動？又民間流傳的臟腑生理時鐘是指營氣，丑時(早上1~3點) 是營氣走到肝臟，肝陰不足(營氣沒跟上衛氣的需求？) 無法涵容衛氣於陰分而醒來fighting (肝陽的能量運作性質) ？
Is there any obstruction in a certain organ caused by qi stagnation, blood stasis, phlegm, water retention, etc., which would cause the defence qi to be blocked in the Yin and so cannot flow smoothly? The internal organs' biological clock, which is popular among Taiwan people, refers to the nutrient qi. During 1-3 a.m., the nutrient qi goes to the Liver; when there’s Liver Yin deficiency (such as the nutrient qi cannot keep up with the demand of the defence qi) therefore the defence qi cannot be contained in the Yin, so the Liver Yang goes off and fights (the energy operation nature of the Liver).
陽蹻脈病，則會失眠，目痛從內眥始，肢體內側肌肉弛緩而外側拘急，足外翻，腰背強直，癲癇，骨節疼痛，遍身腫，滿頭出汗。陰蹻脈病，也會失眠，眼瞼下垂或目開闔失調，肢體外側肌肉弛緩而內側拘急，足內翻，肢體痿痹，喉痛。
Manifestation of Yang Heel vessel disease include insomnia, pain of the eye starting from inner corner, weakness of the medial muscles of the limbs and stiffness of the lateral muscles, eversion of the feet, back stiffness, pain in the joints, swelling all over the body, and head sweating. Yin Heel vessel disease can also cause insomnia, drooping eyelids or apraxia of eyelid opening, weakness of the lateral muscles of the limbs and stiffness of the medial muscles, inversion of the foot, limb weakness, and sore throat.
所以我在想，陰陽蹻脈對應到睡眠生理的解剖部位可能是這樣的：
陽蹻脈（有拉到後腦勺，風池）：腦幹、覺醒系統
陰蹻脈（走到靠近眉心）：前額葉、內在光敏視網膜神經節細胞、松果體
So I think the anatomical location covered by Yin/Yang Heel vessels corresponding to sleep physiology may be as follows:
Yang Heel Vessel: brain stem, ascending reticular activating system (ARAS)
Yin Heel Vessel: prefrontal lobes, intrinsically photosensitive retinal ganglion cells (ipRGCs), the pineal gland
⭑𓍯𓂃 ֶָ
˖ ࣪⊹ 睡驚在成年人雖然不如兒童常見，但成年人可能比兒童更容易受傷。而且成年人的睡驚通常表示有潛在的精神健康問題，例如創傷後壓力症候群或焦慮症。過度疲勞、睡眠不足、飲酒、胃酸逆流，和部分種類的助眠藥，也都是誘發睡驚的可能因素。一般來說，如果睡驚只是偶爾發生（一年發生個幾次）並不需要特別做什麼處理，但如果發生得很頻繁（例如每個禮拜都會發生幾次），那就需要尋求專業的醫療協助了。
𓈒𓂂 𓈒
診斷主要透過病史詢問以及鑑別診斷排除其他原因造成類似睡驚的症狀，例如腦電圖檢查和睡眠多項式檢查來排除睡眠呼吸中止症。錄影紀錄下睡驚發作的狀況也可作為判斷依據。
𓈒𓂂 𓈒
睡驚並沒有特效藥或特定的處置方法，治療對每個人來說可能都不太一樣，不過通常是先確認睡眠環境的安全，讓患者可以在睡驚發作時安全渡過那段過程。當然，找出並處理誘發因素也相當有用，例如要睡飽、移除睡眠環境中的噪音、改善睡眠呼吸中止症、紓解壓力（例如找人談談或尋求專業諮商的協助），以及避免睡前飲酒或攝取咖啡因。此外，並不建議藥物治療作為主要的治療方式，但若是合併有焦慮症，那麼改善焦慮症的藥物也會對減少睡驚發作有幫助。
𓈒𓍼
太陽運行一個星宿，衛氣就在人體內運行一又十分之八周，走一個星宿約51.4分鐘，同時間衛氣就走了一周多一點點，在夜間的話，就是每40~50分鐘就繞了一遍五臟。(希望沒算錯 :(´◦ω◦ ˋ ):
這順帶也解釋了人每天入睡的時間會前後浮動，這和衛氣在晝夜繞行各25周的時間不會是剛好整數有關，而且白天和夜晚的長短會隨著季節的改變而改變，白天的陽和夜晚的陰並不是平分的。
話說有外國學者出了一本書，將奇經八脈與與心理情緒做了一番連結與闡釋。我無法做什麼評論，只是有些地方蠻有趣的（括號中是我的註解）：
陰陽維是「溝通與涵容／區隔我與他人、對抗外來物」有關
（中醫理論中的作用是：連繫陰經和陽經）
陰陽蹻和「往內在挖掘／往外探索」有關
（中醫理論中的作用是：眼睛開闔、肢體內外側的繃緊與鬆弛，陰靜與陽動的交替與遞傳）
Anyways，我現在很好奇陰陽蹻脈、陰陽維脈相當於胚胎發育學上的什麼？
˖ ࣪⊹
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