Restless Legs Syndrome Sleep-related Rhythmic Movement Disorder However, this classification brought some confusion into the field, which led to the revision of the classification in The classification was much more discussed by experts of the field and led to the third edition of the ICSD. This revision ntergrates pediatric diagnosis into clinical adult diagnosis expect for Obstructive Sleep Apnea ane led to the third edition of the ICSD, which was released in ICSD-3 includes specific diagnoses within the seven major categories, as well as an appendix for classification of sleep disorders associated with medical and neurologic disorders. Primary vs. Narcolepsy have been dived into narcolepsy Type 1 and narcolepsy Type 2.
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The term secondary insomnia is still appropriate for use when there is clear causality with the underlying medical or psychiatric disorder, such as one might see in insomnia secondary to pain disorders. In the ICSD, there are 6 types of primary insomnia.
Adjustment insomnia [ 4 , 5 ] is the insomnia that is associated with a specific stressor. The stressor can be psychological, physiologic, environmental, or physical.
This disorder exists for a short period of time, usually days to weeks, and it usually resolves when the stressor is no longer present. There is an over-concern with the inability to sleep. Paradoxical insomnia [ 8 , 9 ] is a complaint of severe insomnia that occurs without evidence of objective sleep disturbance and without daytime impairment to the extent that would be suggested by the amount of sleep disturbance reported.
The patient often reports little or no sleep on most nights. Idiopathic insomnia [ 10 , 11 ] is a longstanding form of insomnia that appears to date from childhood and has an insidious onset. Typically, there are no factors associated with the onset of the insomnia, which is persistent and without periods of remission. Inadequate sleep hygiene [ 12 , 13 ] is a disorder associated with common daily activities that are inconsistent with good-quality sleep and full daytime alertness.
Such activities include irregular sleep onset and wake times, stimulating and alerting activities before bedtime, and substances e. These practices do not necessarily cause sleep disturbance in other people. For example, an irregular bedtime or wake time that produces insomnia in one person may not be important in another.
Behavioral insomnia of childhood [ 14 , 15 ] includes limit-setting sleep disorder and sleep-onset association disorder. Limit-setting sleep disorder is stalling or refusing to go to sleep that is eliminated once a caretaker enforces limits on sleep times and other sleep-related behaviors.
Sleep-onset association disorder occurs when there is reliance on inappropriate sleep associations, such as rocking, watching television, holding a bottle or other object, or requiring environmental conditions, such as a lit room or an alternative place to sleep.
There are several secondary insomnias. Insomnia due to a drug or substance [ 16 , 17 ] is applied when there is dependence on or excessive use of a substance, such as alcohol, a recreational drug, or caffeine that is associated with the occurrence of the insomnia. The insomnia may be associated with the ingestion or discontinuation of the substance. Excessive use or dependency is not a feature of this diagnosis.
Insomnia due to a medical condition [ 18 , 19 ] is applied when a medical or neurological disorder gives rise to the insomnia. The medical disorder and the insomnia type are given when a patient is diagnosed.
Insomnia not due to a substance or known physiological condition [ 20 , 21 ] is the diagnosis applied when an underlying mental disorder is associated with the occurrence of the insomnia, and when the insomnia constitutes a distinct complaint or focus of treatment.
Physiologic organic insomnia, unspecified, is applied when insomnia is due to a medical condition or substance use not specified elsewhere [ 22 , 23 ]. Inadequate sleep hygiene, and other insomnia due to a substance, requires some discussion of the differentiation between the 2 diagnoses. Caffeine ingestion in the form of coffee or soda can produce a disorder of inadequate sleep hygiene, if the intake amount is normal and within the limits of common use, but the timing of ingestion is inappropriate.
On the other hand, ingestion of caffeine in an amount that is considered excessive by normal standards can lead to a diagnosis of other insomnia due to a substance. Sleep-Related Breathing Disorders Disordered ventilation during sleep is the characteristic feature of the disorders in this article. Central apnea syndromes [ 24 , 25 ] include those in which respiratory effort is diminished or absent in an intermittent or cyclical fashion as a result of central nervous system dysfunction.
Other central sleep apnea forms are associated with underlying pathologic or environmental causes, such as Cheyne-Stokes breathing pattern [ 26 , 27 ] or high-altitude periodic breathing [ 28 , 29 ]. Primary central sleep apnea is a disorder of unknown cause characterized by recurrent episodes of cessation of breathing during sleep without associated ventilatory effort. A complaint of excessive daytime sleepiness, insomnia, or difficulty breathing during sleep is reported.
This diagnosis requires that 5 or more apneic episodes per hour of sleep be seen by polysomnography. The pattern is typically seen in medical disorders, such as heart failure, cerebrovascular disorders, and renal failure.
Central sleep apnea due to high-altitude periodic breathing [ 28 , 29 ] is characterized by sleep disturbance that is caused by cycling periods of apnea and hyperpnea without ventilatory effort.
Five or more central apneas per hour of sleep are required to make the diagnosis. Most people will have this ventilatory pattern at elevations greater than meters, and some at lower altitudes. A secondary form of central sleep apnea due to drug or substance substance abuse [ 30 , 31 ] is most commonly associated with users of long-term opioid use. The substance causes a respiratory depression by acting on the mu receptors of the ventral medulla. Primary sleep apnea of infancy [ 32 , 33 ] is a disorder of respiratory control most often seen in preterm infants apnea of prematurity , but it can occur in predisposed infants apnea of infancy.
This may be a developmental pattern, or it may be secondary to other medical disorders. The obstructive sleep apnea syndromes include those in which there is an obstruction in the airway resulting in increased breathing effort and inadequate ventilation. Upper airway resistance syndrome has been recognized as a manifestation of obstructive sleep apnea syndrome and therefore is not included as a separate diagnosis.
Adult and pediatric forms of obstructive sleep apnea syndrome are discussed separately because the disorders have different methods of diagnosis and treatment. Obstructive sleep apnea in adults [ 34 , 35 ] is characterized by repetitive episodes of cessation of breathing apneas or partial upper airway obstruction hypopneas. These events are often associated with reduced blood oxygen saturation. Snoring and sleep disruption are typical and common.
Excessive daytime sleepiness or insomnia can result. Five or more respiratory events apneas, hypopneas, or respiratory effort-related arousals per hour of sleep are required for diagnosis. Increased respiratory effort occurs during the respiratory event. Obstructive sleep apnea in pediatrics [ 36 , 37 ] is characterized by features similar to those seen in the adult, but cortical arousals may not occur, possibly because of a higher arousal threshold.
At least 1 obstructive event, of at least 2 respiratory cycles of duration per hour of sleep, is required for diagnosis. Sleep-related nonobstructive alveolar hypoventilation, idiopathic, refers to decreased alveolar hypoventilation resulting in sleep-related arterial oxygen desaturation in patients with normal mechanical properties of the lungs [ 38 , 39 ]. Congenital central alveolar hypoventilation syndrome [ 40 , 41 ] is a failure of automatic central control of breathing in infants who do not breathe spontaneously or whose breathing is shallow and erratic.
It is a failure of the central automatic control of breathing. The hypoventilation begins in infancy and it is worse in sleep than in wakefulness. Hypersomnia of Central Origin The hypersomnia disorders are those in which the primary complaint is daytime sleepiness and the cause of the primary symptom is not disturbed nocturnal sleep or misaligned circadian rhythms.
Daytime sleepiness is defined as the inability to stay alert and awake during the major waking episodes of the day, resulting in unintended lapses into sleep. The term hypersomnia has been used differently in the different diagnostic classifications.
In the ICSD, the term hypersomnia is diagnostic, with the preferred term for the complaint being daytime sleepiness or excessive daytime sleepiness. Other sleep disorders may be present with the hypersomnias, but they must be effectively treated first before a hypersomnia diagnosis can be made. The hypersomnias of central origin are not due to a circadian rhythm sleep disorder, sleep-related breathing disorder, or other cause of disturbed nocturnal sleep.
Narcolepsy with cataplexy [ 48 , 49 ] requires the documentation of a definite history of cataplexy or the documentation of a cerebrospinal fluid hypocretin level less than one third of control values.
The diagnosis of narcolepsy with cataplexy is based on the belief that most cases are due to loss of hypocretin possibly on an autoimmune basis. Whether narcolepsy without cataplexy is the same disorder as narcolepsy with cataplexy, or if it is a disorder based on an entirely different pathophysiology is not clear.
Most cases of narcolepsy without cataplexy have intact hypocretin levels. Narcolepsy due to a medical condition [ 52 , 53 ] is the diagnosis applied to a patient with sleepiness who has a significant neurological or medical disorder that accounts for the daytime sleepiness. Recurrent hypersomnia [ 54 , 55 ], also known as periodic hypersomnia is comprised of 2 subtypes: 1 Kleine-Levin Syndrome and 2 menstrual-related hypersomnia.
Kleine-Levin Syndrome is associated with episodes of sleepiness together with binge eating, hypersexuality, or mood changes. Menstrual-related hypersomnia is having recurrent episodes of hypersomnia that occurs in association with the menstrual cycle.
Idiopathic hypersomnia, whether with sleep time or without it, is still poorly understood because there is no clear pathophysiological mechanism [ ]. The genetic basis of the disorders needs to be determined. Whether idiopathic hypersomnia without long sleep time is a variant of narcolepsy without cataplexy is not yet determined.
Behavioral-induced insufficient sleep syndrome [ 60 , 61 ] occurs in patients who have a habitual short sleep time episode and who sleep considerably longer when the habitual sleep episode is not maintained. Hypersomnia due to a medical condition [ 62 , 63 ] is hypersomnia that is caused by a medical or neurological disorder. Cataplexy or other diagnostic features of narcolepsy are not present. Hypersomnia due to a drug or substance [ 64 — 67 ] is diagnosed when the complaint is believed to be secondary to current or past use of drugs.
Hypersomnia not due to a substance or known physiological condition [ 68 , 69 ], is excessive sleepiness that is temporally associated with a psychiatric diagnosis. Circadian Rhythm Sleep Disorders The circadian rhythm sleep disorders have a specific diagnostic category because they share a common underlying chronophysiologic basis.
Maladaptive behaviors influence the presentation and severity of the circadian rhythm sleep disorders. The underlying problem in the majority of the circadian rhythm sleep disorders is that the patient cannot sleep when sleep is desired, needed, or expected. The wake episodes can occur at undesired times as a result of sleep episodes that occur at inappropriate times, and therefore, the patient may complain of insomnia or excessive sleepiness.
For several of the circadian rhythm sleep disorders, once sleep is initiated, the major sleep episode is normal in duration with normal REM and NREM cycling. The delayed sleep phase type [ 70 , 71 ], which is more commonly seen in adolescents, is characterized by a delay in the phase of the major sleep period in relation to the desired sleep time and wake time.
The advanced sleep phase type [ 72 , 73 ], which is more commonly seen in older adults, is characterized by an advance in the phase of the major sleep period in relation to the desired sleep time and wake time.
An alteration in the homeostatic regulation of sleep may be responsible. The irregular sleep—wake type [ 74 , 75 ], a disorder that involves a lack of a clearly defined circadian rhythm of sleep and wakefulness, is most often seen in institutionalized older adults and is associated with a lack of synchronizing agents, such as light, activity, and social activities.
The free running type [ 76 , 77 ], or non-trained type formerly known as the nonh sleep—wake syndrome , occurs because there is a lack of entrainment to the h period, and the sleep pattern often follows that of the underlying free-running pacemaker with a sequential shift in the daily sleep pattern. The jet lag type [ 78 , 79 ], or jet lag disorder, is related to a temporal mismatch between the timing of the sleep—wake cycle generated by the endogenous circadian clock produced by a rapid change in time zones.
The severity of the disorder is influenced by the number of time zones crossed and the direction of travel, with eastward travel usually being more disruptive.
Shift work type [ 80 , 81 ] is characterized by complaints of insomnia or excessive sleepiness that occurs in relation to work hours being scheduled during the usual sleep period. Circadian rhythm sleep disorders due to a medical condition [ 82 , 83 ] is related to an underlying primary medical or neurological disorder. A disrupted sleep—wake pattern leads to complaints of insomnia or excessive daytime sleepiness.
Another circadian rhythm sleep disorder not due to a known physiological condition is an irregular or unconventional sleep—wake pattern that can be the result of social, behavioral, or environmental factors [ 84 , 85 ]. Noise, lighting, or other factors can predispose an individual to developing this disorder. The appropriate timing of sleep within the h day can be disturbed in many other sleep disorders, particularly those associated with the complaint of insomnia. Patients with narcolepsy may have a pattern of sleepiness that is identical to that described as being caused by an irregular sleep—wake type.
However, because the primary sleep diagnosis is narcolepsy, the patient should not receive a second diagnosis of a circadian rhythm sleep disorder unless the disorder is unrelated to the narcolepsy.
Classification of Sleep Disorders
International Classification of Sleep Disorders