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Classification of sleep disorders
Classification of sleep disorders
The pathophysiology and main symptoms of sleep disorders form the basis of the approach to these conditions in this section (Table 1.5).
The complaints of insomnia and excessive daytime sleepiness are covered later in this section. The circadian rhythm disorders are separately identified since they form a physiological entity. The links between the pathophysiology, clinical features and treatment of these sleep disorders are emphasized throughout these chapters.
This approach has many similarities to, but also some differences from, the widely used 1997 third revision of the International Classification of Sleep Disorders (ICSD) produced by the American Sleep Disorders Association (ASDA) in association with other national and international sleep societies.
Sleep disorders are frequent processes, both as a symptom associated with other diseases and as independent disorders. However, only in the last 4 decades has Sleep medicine gained its position among the medical specialties.
In fact, it was only in these years that significant advances were obtained in the study of the etiology and treatment of these disorders. Similarly, the different classifications have been evolving over the years.
First, they were based upon the clinical symptom; later on, more emphasis was given to the diseases. Finally, in 2005, the new classification was once again based on the symptoms. More than 90 disorders are listed in this latest classification, and an attempt is made to include the symptoms and the diseases of sleep, as well as those in which sleep disorders are fundamental.
It is essential to have a clear idea of this complete classification of sleep disorders in order to deal with these patients appropriately.
The International Classification of Sleep Disorders (ICSD) was produced primarily for diagnostic and epidemiologic purposes so that disorders could be indexed and morbidity and mortality information could be recorded and retrieved.
This classification is not intended to provide a differential diagnostic listing of sleep and arousal disorders. A differential diagnostic listing is presented on page 331 and is included to assist the clinician in diagnosing disease related to one of three major sleep symptoms: insomnia, excessive sleepiness, or an abnormal event during sleep.
The ICSD is consistent in style with International Classification of Diseases (ICD-9-CM) classifications for disorders affecting systems such as the cardiovascular or respiratory.
The ICSD consists of four categories. The first category comprises the dyssomnias (i.e.,the disorders of initiating and maintaining sleep and the disorders of excessive sleepiness).
Rapid eye movement (REM) sleep
Rapid eye movement sleep, or REM, is one of the five stages of sleep that most people experience nightly....
There are currently three systems used to classify sleep disorders:
ICSD-3 is published in association with the European Sleep Research Society, the Japanese Society of Sleep Research, and the Latin American Sleep Society. It distinguishes six subcategories of sleep disorders:
The Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition
(commonly known as the DSM-V), published by the American Psychiatric Association, Washington, DC, 2013.;This system lists 10 "sleep-wake disorders," conditions (or groups of conditions) that are manifested by disturbed sleep that cause both distressed and impaired functioning during the daytime:
- Insomnia disorder
- Hypersomnolence disorder
- Narcolepsy
- Breathing-related sleep disorders, including:
- Obstructive sleep apnea hypopnea
- Central sleep apnea
- Sleep-related hypoventilation
- Circadian rhythm sleep disorders, including:
- Advanced sleep phase syndrome
- Irregular sleep-wake type
- Non-24-hour sleep-wake type
- Non-REM (NREM) sleep arousal disorders
- Nightmare disorder
- REM sleep behavior disorder
- Restless legs syndrome
- Substance- or medication-induced sleep disorder.
The International Classification of Sleep Disorders, Third Edition (ICSD-3), published by the American Academy of Sleep Medicine, Chicago, 2014.
ICSD-3 is published in association with the European Sleep Research Society, the Japanese Society of Sleep Research, and the Latin American Sleep Society. It distinguishes six subcategories of sleep disorders:
- Insomnia
- Sleep Related Breathing Disorders
- Central Disorders of Hypersomnolence
- Circadian Rhythm Sleep-Wake Disorders
- Parasomnias
- Sleep-Related Movement Disorders
The International Classification of Diseases, 10th edition (ICD-10), published by the World Health Organization, Geneva, Switzerland, 1994.
The ICD-10 system sets aside two areas for sleep disorders: organic (ICD-10 code: G47) and nonorganic (ICD-10 code: F51), but it only includes a few actual sleep disorder diagnoses.
The United States still uses a precursor to the ICD-10, the ICD-9-CM (CM stands for "clinical modifications") - although the country will change over to the ICD-10 system in October 2015. ICD-9 recently incorporated most sleep disorder diagnoses listed in ICSD-2.
The second category, the parasomnias, comprises the disorders of arousal, partial arousal, or sleep stage transition, which do not cause a primary complaint of insomnia or excessive sleepiness. The third category, sleep disorders associated with mental, neurologic, or other medical disorders, comprises disorders with a prominent sleep complaint that is felt to be secondary to another condition. The fourth category, proposed sleep disorders, includes those disorders for which there is insufficient information available to confirm their acceptance as definitive sleep disorders.
Textual content is included for all the ICSD disorders that are listed in Axis A.
THE AXIAL SYSTEM
The International Classification of Sleep Disorders (ICSD) uses a multiaxial system for stating and coding diagnoses both in clinical reports or for data base purposes. The axial system uses International Classification of Diseases (ICD-9-CM) coding wherever possible. Additional codes are included for procedures and physical signs of particular interest to sleep disorders clinicians and researchers.
Modifying information,such as severity, duration, and symptoms, also can be specified and coded by a special ICSD sleep code. Diagnoses and procedures are listed and coded on three main "axes."
The axial system is arranged as follows:
- Axis A ICSD Classification of Sleep Disorders
- Axis B ICD-9-CM Classification of Procedures
- Axis C ICD-9-CM Classification of Diseases (nonsleep diagnoses)
In the revised International Classification of Sleep Disorders Diagnostic and Coding Manual (ICSD-DCM), the American Sleep Disorders Association (ASDA; 1990) broadly classifies three categories of disordered sleep: 1) dyssomnias, 2) parasomnias, and 3) sleep disorders associated with medical and psychiatric conditions.
A partial list of ICSD-DCM and DSM-IV dyssomnias that are commonly observed in children and adolescents is presented in Tables 17-1 and 17-2, respectively.
The ICSD-DCM and DSM-IV parasomnias that most commonly affect children and adolescents are listed in Tables 17-3 and 17-4, respectively. Again, concordance between the two systems is good.
The ICSD-DCM sleep disorders that co-occur most commonly with medical and psychiatric disorders of children and their DSM-IV equivalents are listed in Tables 17-5 and 17-6, respectively.
Table 1.6 ASDA classification of sleep disorders 1997.
- Dyssomnias
- Parasomnias
- Sleep disorders associated with mental, neurologic, or other medical disorders
- Proposed sleep disorders
Dyssomnias
- Psychophysiologic insomnia 307.42-0
- Sleep state misperception 307.49-1
- Idiopathic insomnia 780.52-7
- Narcolepsy 347
- Recurrent hypersomnia 780.54-2
- Idiopathic hypersomnia 780.54-7
- Post-traumatic hypersomnia 780.54-8
- Obstructive sleep apnoea syndrome 780.53-0
- Central sleep apnoea syndrome 780.51-0
- Central alveolar hypoventilation syndrome 780.51-1
- Periodic limb movement disorder 780.52-4
- Restless legs syndrome 780.52-5
- Intrinsic sleep disorder NOS 780.52-9
- Inadequate sleep hygiene 307.41-1
- Environmental sleep disorder 780.52-6
- Altitude insomnia 289.0
- Adjustment sleep disorder 307.41-0
- Insufficient sleep syndrome 307.49-4
- Limit-setting sleep disorder 307.42-4
- Sleep-onset association disorder 307.42-5
- Food allergy insomnia 780.52-2
- Nocturnal eating (drinking) syndrome 780.52-8
- Hypnotic-dependent sleep disorder 780.52-0
- Stimulant-dependent sleep disorder 780.52-1
- Alcohol-dependent sleep disorder 780.52-3
- Toxin-induced sleep disorder 780.54-6
- Extrinsic sleep disorder NOS 780.52-9
Circadian-rhythm sleep disorders
- Time zone change (jet lag) syndrome 307.45-0
- Shift work sleep disorder 307.45-1
- Irregular sleep-wake pattern 307.45-3
- Delayed sleep-phase syndrome 780.55-0
- Advanced sleep-phase syndrome 780.55-1
- Non-24-hour sleep-wake disorder 780.55-2
- Circadian rhythm sleep disorder NOS 780.55-9
Parasomnias
- Confusional arousals 307.46-2
- Sleepwalking 307.46-0
- Sleep terrors 307.46-1
Sleep-wake transition disorders
- Rhythmic movement disorder 307.3
- Sleep starts 307.47-2
- Sleep talking 307.47-3
- Nocturnal leg cramps 729.82
Parasomnias usually associated with REM sleep
- Nightmares 307.47-0
- Sleep paralysis 780.56-2
- Impaired sleep-related penile erections 780.56-3
- Sleep-related painful erections 780.56-4
- REM sleep-related sinus arrest 780.56-8
- REM sleep behavior disorder 780.59-0
- Sleep bruxism 306.8
- Sleep enuresis 788.36-0
- Sleep-related abnormal swallowing syndrome 780.56-6
- Nocturnal paroxysmal dystonia 780.59-1
- Sudden unexplained nocturnal death syndrome 780.59-3
- Primary snoring 786.09-1
- Infant sleep apnea 770.80
- Congenital central hypoventilation syndrome 770.81
- Sudden infant death syndrome 798.0
- Benign neonatal sleep myoclonus 780.59-5
- Other parasomnia NOS 780.59-9
Sleep disorders associated with mental, neurologic, or other medical disorders
Associated with mental disorders 290-319
- Psychoses 290-299
- Mood disorders 296-301, 311
- Anxiety disorders 300, 308, 309
- Panic disorders 300
- Alcoholism 303, 305
Associated with neurologic disorders 320-389
- Cerebral degenerative disorders 330-337
- Dementia 331
- Parkinsonism 332
- Fatal familial insomnia 337.9
- Sleep-related epilepsy 345
- Electrical status epilepticus of sleep 345.8
- Sleep-related headaches 346
Associated with other medical disorders
- Sleeping sickness 086
- Nocturnal cardiac ischemia 411-414
- Chronic obstructive pulmonary disease 490-496
- Sleep-related asthma 493
- Sleep-related gastroesophageal reflux 530.81
- Peptic ulcer disease 531-534
- Fibromyalgia 729.1
Proposed sleep disorders
- Short sleeper 307.49-0
- Long sleeper 307.49-2
- Subwakefulness syndrome 307.47-1
- Fragmentary myoclonus 780.59-7
- Sleep hyperhidrosis 780.8
- Menstrual-associated sleep disorder 780.54-3
- Pregnancy-associated sleep disorder 780.59-6
- Terrifying hypnagogic hallucinations 307.47-4
- Sleep-related neurogenic tachypnea 780.53-2
- Sleep-related laryngospasm 780.59-4
- Sleep choking syndrome 307.42-1
Table 1.7 American Academy of Sleep Medicine Classification of sleep disorders 2005
- Insomnia
- Sleep Related Breathing Disorders
- Hypersomnias of Central Origin Not Due to a Circadian Rhythm Sleep Disorder, Sleep Related Breathing Disorder, or Other Cause of Disturbed Nocturnal Sleep
- Circadian Rhythm Sleep Disorders
- Parasomnias
- Sleep Related Movement Disorders
- Isolated Symptoms, Apparently Normal Variants and Unresolved Issues
- Other Sleep Disorders
Insomnia
- Adjustment Insomnia (Acute Insomnia)
- Psychophysiological Insomnia
- Paradoxical Insomnia
- Idiopathic Insomnia
- Insomnia Due to Mental Disorder
- Inadequate Sleep Hygiene
- Behavioral Insomnia of Childhood
- Insomnia Due to Drug or Substance
- Insomnia Due to Medical Condition
- Insomnia Not Due to Substance or Known Physiological Condition
- Unspecified (Nonorganic Insomnia, NOS)
- Physiological (Organic) Insomnia, Unspecified
Sleep Related Breathing Disorders
- Central Sleep Apnea Syndromes
- Primary Central Sleep Apnea
- Central Sleep Apnea Due to Cheyne Stokes Breathing Pattern
- Central Sleep Apnea Due to High-Altitude Periodic Breathing
- Central Sleep Apnea Due to Medical Condition Not Cheyne Stokes
- Central Sleep Apnea Due to Drug or Substance
- Primary Sleep Apnea of Infancy (Formerly Primary Sleep Apnea of Newborn)
- Obstructive Sleep Apnea Syndromes
- Obstructive Sleep Apnea, Adult
- Obstructive Sleep Apnoea, Pediatric
- Sleep Related Hypoventilation/Hypoxemic Syndromes
- Sleep Related Nonobstructive Alveolar Hypoventilation, Idiopathic
- Congenital Central Alveolar Hypoventilation Syndrome
- Sleep Related Hypoventilation/Hypoxemia Due to Medical Condition
- Sleep Related Hypoventilation/Hypoxemia Due to Pulmonary Parenchymal or Vascular Pathology
- Sleep Related Hypoventilation/Hypoxemia Due to Lower Airways Obstruction
- Sleep Related Hypoventilation/Hypoxemia Due to Neuromuscular and Chest Wall Disorders
- Other Sleep Related Breathing Disorder
- Sleep Apnea/Sleep Related Breathing Disorder, Unspecified
Hypersomnias of Central Origin Not Due to a Circadian Rhythm Sleep Disorder, Sleep Related Breathing Disorder, or Other Cause of Disturbed Nocturnal Sleep
- Narcolepsy With Cataplexy
- Narcolepsy Without Cataplexy
- Narcolepsy Due to Medical Condition
- Narcolepsy, Unspecified
- Recurrent Hypersomnia
- Kleine-Levin Syndrome
- Menstrual-Related Hypersomnia
- Idiopathic Hypersomnia With Long Sleep Time
- Idiopathic Hypersomnia Without Long Sleep Time
- Behaviorally Induced Insufficient Sleep Syndrome
- Hypersomnia Due to Medical Condition
- Hypersomnia Due to Drug or Substance
- Hypersomnia Not Due to Substance or Known Physiological Condition (Nonorganic Hypersomnia, NOS)
- Physiological (Organic) Hypersomnia, Unspecified (Organic Hypersomina, NOS)
Circadian Rhythm Sleep Disorders
- Circadian Rhythm Sleep Disorder, Delayed Sleep Phase Type (Delayed Sleep Phase Disorder)
- Circadian Rhythm Sleep Disorder, Advanced Sleep Phase Type (Advanced Sleep Phase Disorder)
- Circadian Rhythm Sleep Disorder, Irregular Sleep-Wake Type (Irregular Sleep-Wake Rhythm)
- Circadian Rhythm Sleep Disorder, Free-Running Type (Nonentrained Type)
- Circadian Rhythm Sleep Disorder, Jet Lag Type (Jet Lag Disorder)
- Circadian Rhythm Sleep Disorder, Shift Work Type (Shift Work Disorder)
- Circadian Rhythm Sleep Disorder Due to Medical Condition
- Other Circadian Rhythm Sleep Disorder (Circadian Rhythm Disorder, NOS)
- Other Circadian Rhythm Sleep Disorder Due to Drug or Substance
Parasomnias
- Disorders of Arousal (From NREM Sleep)
- Confusional Arousals
- Sleepwalking
- Sleep Terrors
- Parasomnias Usually Associated With REM Sleep
- REM Sleep behavior Disorder (Including Overlap Disorder and Status Dissociatus)
- Recurrent Isolated Sleep Paralysis
- Nightmare Disorder
- Other Parasomnias
- Sleep Related Dissociative Disorders
- Sleep Enuresis
- Sleep Related Groaning (Catathrenia)
- Exploding Head Syndrome
- Sleep Related Hallucinations
- Sleep Related Eating Disorders
- Parasomnia, Unspecified
- Parasomnia Due to Drug or Substance
- Parasomnia Due to Medical Condition
Sleep Related Movement Disorders
- Restless Legs Syndrome
- Periodic Limb Movement Disorder
- Sleep Related Leg Cramps
- Sleep Related Bruxism
- Sleep Related Rhythmic Movement Disorder
- Sleep Related Movement Disorder, Unspecified
- Sleep Related Movement Disorder Due to Drug or Substance
- Sleep Related Movement Disorder Due to Medical Condition
Isolated Symptoms, Apparently Normal Variants and Unresolved Issues
- Long Sleeper
- Short Sleeper
- Snoring
- Sleep Talking
- Sleep Starts (Hypnic Jerks)
- Benign Sleep Myoclonus of Infancy
- Hypnagogic Foot Tremor and Alternating Leg Muscle Activation During Sleep
- Propriospinal Myoclonus at Sleep Onset
- Excessive Fragmentary Myoclonus
Other Sleep Disorders
- Other Physiological (Organic) Sleep Disorder
- Other Sleep Disorder Not Due to Substance or Known
- Physiological Condition
- Environmental Sleep Disorder
Disorders Association (ASDA) in association with other national and international sleep societies [25] (Table 1.6). This groups insomnia and excessive daytime sleepiness as dyssomnias and distinguishes them from disorders occurring during sleep (parasomnias).
It also has two other categories which are less satisfactory. First, a group of medical and psychiatric disorders which includes epilepsy and mood disorders, all of which interact with the sleep mechanisms in a similar fashion to the disorders in the dyssomnia and parasomnia categories. The second group of 'proposed sleep disorders' is heterogeneous and emphasizes the descriptive aspects and includes partly developed concepts such as the 'sleep choking syndrome'.
The 2005 version recognises eight categories of sleep disorder [26] (Table 1.7) with insomnia and hypersomnias separated, but motor disorders during sleep included in the parasomnia, sleep related movement disorders and isolated symptoms sections. The term 'parasomnia' has not been used in this book because of the wide range and heterogeneous nature of sleep conditions that it has come to represent, but the important influence of drugs is recognised by a separate chapter devoted to their effects. The AASM 2005 classification includes drug related sleep disorders in several different categories, but excludes disorders such as sleep related epilepsy and several medical and psychiatric disorders causing sleep related symptoms.
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