General Approach to Classification of Sleep Disorders

1. General Approach to Classification of Sleep Disorders Dr. Ahmet U. Demir

3. ICSD-II (2005) Aims • In 2002 the American Academy of Sleep Medicine, set up a • committee to revise once again the classification of sleep disorders. • • Under the direction of Dr Peter Hauri, the committee has proposed a • more pragmatic classification, based on current clinical concepts of • the grouping of sleep disorders. • • The goals of ICSD-2 are: • 1. To describe all currently recognized sleep and arousal disorders, • and to base the description on scientific and clinical evidence. • 2. To present the sleep and arousal disorders in an overall structure • that is rational and scientifically valid • 3. To render the sleep and arousal disorders as compatible with • ICD-9 and ICD-10 as possible. • • Based on the thought express above, ICSD-2 sorts the sleep • disorders into the following eight categories:

4. I. Insomnias • • II. Sleep Related Breathing Disorders • • III. Hypersomnias of Central Origin Not Due to a Circadian • Rhythm, Sleep Disorder, Sleep Related Breathing Disorder, or • Other Cause of Disturbed Nocturnal Sleep. • • IV. Circadian Rhythm Sleep Disorders • • V. Parasomnias • • VI. Sleep Related Movement Disorders • • VII. Isolated Symptoms, Apparently Normal Variants, and • Unresolved Issues. • • VIII. Other Sleep Diorders.

5. I. Insomnias • • II. Sleep Related Breathing Disorders • • III. Hypersomnias of Central Origin Not Due to a Circadian • Rhythm, Sleep Disorder, Sleep Related Breathing Disorder, or • Other Cause of Disturbed Nocturnal Sleep. • • IV. Circadian Rhythm Sleep Disorders • • V. Parasomnias • • VI. Sleep Related Movement Disorders • • VII. Isolated Symptoms, Apparently Normal Variants, and • Unresolved Issues. • • VIII. Other Sleep Diorders.

6. Insomnia • Insomnia is a symptom of perceived • reduction in the quantity or quality of sleep • and is not a single clinical entity. • • However, certain causes of chronic • insomnia are believed to be due to intrinsic • disturbances of brain function.

7. General Criteria for Insomnia : ICSD-2 ( 2005) • A. A complaint for difficulty initiating sleep, difficulty • maintaining sleep, or waking up too early or sleep that is • chronically nonrestorative or poor in quality. In children, the sleep • difficulty is often reported by the caretaker and may consist of • observed bedtime resistance or inability to sleep independently. • • B. The above sleep difficulty occurs despite adequate opportunity • and circumstances for sleep. • • C. At least one of the following forms of daytime impairment • related to the nighttime sleep difficulty is reported by the patient: • • i. Fatigue or malaise • • ii. Attention, concentration, or memory impairment • • iii. Social or vocational dysfunction or poor school performance • • iv. Mood disturbance or irritability • • v. Daytime sleepiness • • vi. Motivation, energy, or initiative reduction • • vii. Proneness for errors or accidents at work or while driving • • viii. Tension, headaches, or gastrointestinal symptoms.

8. Adjustment Insomnia (Acute Insomnia) • 1. Adjustment Insomnia (Acute Insomnia) • • 2. Psychophysiological Insomnia • • 3. Paradoxical Insomnia • • 4. Idiopathic Insomnia • • 5. Insomnia Due to Mental Disorder • • 6. Inadequate Sleep Hygiene • • 7. Behavioral Insomnia of Childhood • • 8. Insomnia Due to Drug or Substance • • 9. Insomnia Due to Medical Condition • • 10. Insomnia Not Due to Substance or Known Physiological • Condition, Unspecified (Nonorganic Insomnia, NOS) • • 11. Physiological (Organic) Insomnia, Unspecified

9. Adjustment insomnia Diagnostic Criteria: • A. The patients symptoms meet the criteria for insomnia. • B. The sleep disturbance is temporally associated with an identifiable stressor that is psychological, psychosocial, interpersonal, environmental, or physical nature. • C. The sleep disturbance is expected to resolve when the acute stressor resolves or when the individual adapts to the stressor. • D. The sleep disturbance lasts for less than three months. • E. The sleep disturbance is not better explained by another current sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

10. Psychophysiological Insomnia • Alternate Names : Learned insomnia, conditioned insomnia, functionally • autonomous insomnia, chronic insomnia, primary insomnia, chronic somatized • tension, internal arousal without psychopathology. • • Diagnostic Criteria : • • A.The patient’s symptoms meet the criteria for insomnia • • B. The insomnia is present for at least one month. • • C. The patient has evidence of conditioned sleep difficulty and/or heightened arousal in bed • as indicated by one or more of the following: • • i. Excessive focus on and heightened anxiety about sleep • • ii. Difficulty falling asleep in bed at the desired bedtime or during planned naps, • but no difficulty falling asleep during other monotonous activities when not intending to • sleep • • iii. Ability to sleep better away from home than at home • • iv. Mental arousal in bed characterized either by intrusive thoughts or a perceived • inability to volitionally cease sleep-preventing mental activity • • v. Heightened somatic tension in bed reflected by a perceived inability to relax • the body sufficiently to allow the onset of sleep • • D. The sleep disturbance is not better explained by another sleep disorder, medical or • neurological disorder, mental disorder, medication use, or substance use disorder.

11. Paradoxical Insomnia • Alternate Names: Sleep state misperception, subjective insomnia, pseudo-insomnia, • subjective complaint of sleep initiation and maintenance difficulty without objective • findings, insomnia without objective findings, sleep hypochondriasis, subjective • sleep complaint. • • Diagnostic Criteria : • • A. The patient’s symptoms meet the criteria for insomnia. • • B. The insomnia is present for at least one month. • • C. One or more of the following criteria apply: • • i. The patient reports a chronic pattern of little or no sleep most nights with rare nights during which • relatively normal amounts of sleep are obtained. • • ii. Sleep-log data during one or more weeks of monitoring show an average sleep time well below published • age-adjusted normative values, often with no sleep at all indicated for several nights per week; typically there is an • absence of daytime naps following such nights • • iii. The patients show a consistent marked mismatch between objective findings from polysomnography or • actigraphy and subjective sleep estimates derived either from self-report or a sleep diary • • D. At least one of the following is observed: • • i. The patients reports constant or near constant awareness of environmental stimuli throughout most nights • • ii. The patient reports a pattern of conscious thoughts or rumination throughout most nights while • maintaining a recumbent posture • • E. The daytime impairment reported is consistent with that reported by other insomnia subtypes, but it is much less • severe than expected given the extreme level of sleep deprivation reported; there is no report of intrusive daytime sleep • episodes, disorientation, or serious mishaps due to marked loss of alertness or vigilance, even following reportedly • sleepless nights. • • F. The reported sleep disturbance is not better explained by another sleep disorder, medical or neurological disorder, • mental disorder, medication use, or substance use disorder.

12. Idiopathic Insomnia • • Alternate Names :Childhood-onset insomnia, life-long insomnia, • insomnia first evident during infancy or childhood. • • Diagnostic Criteria : • • A. The patient’s symptoms meet the criteria for insomnia. • • B. The course of the disorder is chronic, as indicated by each of the • following: • • i. Onset during infancy or childhood • • ii. No identifiable precipitant or cause • • iii. Persistent course with no periods of sustained remission • • C. The sleep disturbance is not better explained by another sleep • disorder, medical or neurological disorder, mental disorder, • medication use, or substance use disorder.

13. Insomnia Due to Mental Disorder • • Alternate Names : Insomnia related to psychopathology, psychiatric insomnia; • insomnia due to depression, insomnia due to anxiety disorder. • • Diagnostic Criteria • • A. The patient’s symptoms meet the criteria for insomnia. • • B. The insomnia is present at least one month. • • C. A mental disorder has been diagnosed according to standard criteria (i.e., • formal criteria as provided in the Diagnostic and Statistical Manual of Mental • Disorders- see Appendix B). • • D. The insomnia is temporally associated with the mental disorder, however, in • some cases, insomnia may appear a few days or weeks before the emergence of • the underlying mental disorder. • • E. The insomnia is more prominent than that typically associated with the • mental disorders, as indicated by causing marked distress or constituting an • independent focus of treatment. • • F. The sleep disturbance is not better explained by another sleep disorder, • medical or neurological disorder, medication use, or substance use disorder.

14. Inadequate Sleep Hygiene • • Alternate Names : Poor sleep hygiene, sleep hygiene abuse, bad sleep habits, • irregular sleep habits, excessive napping, sleep incompatible behaviors . • • Diagnostic Criteria : • • A. The patient’s symptoms meet the criteria for insomnia. • • B. The insomnia is present for at least one month • • C. Inadequate sleep hygiene practices are evident as indicated by the presence of at least • one of the following: • • i. Improper sleep scheduling consisting of frequent daytime napping, selecting • highly variable bedtimes or rising times, or spending excessive amounts of time in bed • • ii. Routine use of products containing alcohol, nicotine, or caffeine especially in • the period preceding bedtime • • iii. Engagement in mentally stimulating physically activating, or emotionally • upsetting activities to close to bedtime • • iv. Frequent use of the bed for activities other than sleep (e.g., television watching, • reading studying, snacking, thinking, planning) • • v. Failure to maintain a comfortable sleeping environment • • The sleep disturbance is not better explained by another sleep disorder, medical or • neurological disorder, mental disorder, medication use, or substance use disorder.

15. Behavioral Insomnia of Childhood • • Alternate Names: Childhood insomnia, limit-setting sleep disorder, sleep-onset • association disorder. • • Diagnostic Criteria : • • A. A child’s symptoms meet the criteria for insomnia based upon reports of parents or other adult • caregivers. • • B. The child shows a pattern consistent with either the sleep-onset association or limit-setting type • of insomnia described below. • • i. Sleep-onset association type includes each of the following: • • 1. Falling asleep in an extended process that requires special conditions. • • 2. Sleep-onset associations are highly problematic or demanding. • • 3. In the absence of the associated conditions, sleep onset is significantly delayed or sleep is • otherwise disrupted. • • 4. Nighttime awakenings require caregiver intervention for the child to return to sleep. • • ii. Limit-setting type includes each of the following: • • 1. The individual has difficulty initiating or maintaining sleep. • • 2. The individual stalls or refuses to go to bed at an appropriate time or refuses to return t o bed • following a nighttime awakening. • • 3. The caregiver demonstrates insufficient or inappropriate limit setting to establish appropriate • sleeping behavior in the child. • • The sleep disturbance is not better explained by another sleep disorder, medical or neurological • disorder, mental disorder, or medication use.

16. Insomnia Due to Medical Condition • Alternate Names : Sleep disorder due to a general medical condition, medically based • insomnia, organic insomnia, insomnia due to a known organic condition. • Diagnostic Criteria : • A. The patient’s symptoms meet the criteria for insomnia. • B. The insomnia is present for at least one month. • C. The patient has a coexisting medical or physiologic condition known to disrupt sleep. • D. Insomnia is clearly associated with the medical or physiologic condition. The insomnia • began near the time of onset or with significant progression of the medical or • physiologic condition and waxes and wanes with fluctuations in the severity of this • condition. • The sleep disturbance is not better explained by another sleep disorder, mental disorder, • medication use, or substance use disorder.

17. Physiologic (Organic) Insomnia,Unspecified • • This diagnosis is used for forms of insomnia that cannot be classified • elsewhere but are suspected to be related to an underlying medical disorder, • physiological state, or substance used or exposure. In some cases, this • diagnosis may be assigned on a temporary basis when an insomnia diagnosis • seems appropriate but further evaluation is required to determine the specific • medical condition or toxin exposure responsible for the reported sleep • difficulty. This diagnosis can also be assigned when substance abuse or • dependence-related insomnia is suspected but is yet to be confirmed. In other • cases, this diagnosis may be assigned when an endogenous physiologic • disorder or condition appears to contribute to the insomnia but the patient’s • symptoms fail to meet the criteria for one of the other insomnia diagnoses.

19. I. Insomnias • • II. Sleep Related Breathing Disorders • • III. Hypersomnias of Central Origin Not Due to a Circadian • Rhythm, Sleep Disorder, Sleep Related Breathing Disorder, or • Other Cause of Disturbed Nocturnal Sleep. • • IV. Circadian Rhythm Sleep Disorders • • V. Parasomnias • • VI. Sleep Related Movement Disorders • • VII. Isolated Symptoms, Apparently Normal Variants, and • Unresolved Issues. • • VIII. Other Sleep Diorders.

20. Hypersomnias not related torespiratory issues • • Certain disorders of excessive daytime • somnolence are believed to be caused by intrinsic • brain dysfunction. • • Narcolepsy, recognized for over a century, consist • of excessive daytime sleepiness usually associated • with weakness of muscles with emotion (known as • cataplexy) and the premature occurrence of rapid • eye movement (REM) sleep. In most instances this • appears to be due to dysfunction of the hypocretin • (orexin) neurotransmitter system.

21. Hypersomnias not related torespiratory issues • • Idiophatic hypersomnia is a similar but less well • defined disorder, with hypersomnolence but no • cataplexy and no disturbance in the timing of • REM sleep. • • Recurrent hypersomnia is a very rare disorder • with periods of sleep lasting days to weeks, often • associated with behavioral disturbances ( KLS).

22. Hypersomnias not related torespiratory issues • • Insufficient sleep syndrome is a major societal • problem in which voluntary sleep deprivation can • result in impairment of alertness and cognitive • abilities. • • Medications and illicit drug use can cause • excessive daytime sleepiness. • • Hypersomnia may also be due to medical • conditions, such as Parkinson’s disease and • dementias.

23. Narcolepsy • Canine narcolepsy was first reported in the early • 1970s • • The term narcolepsy was first coined by Glinean • in 1880 to designate a pathologic condition • characterized by irresistible episodes of sleep of • short duration recurring at close intervals. ( Gelinean, • 1880 Gaz Hop Paris).

25. Prevalence: (0.02% to 0.18%in US) (narcolepsy with cataplexy) • In Finland:0.026%. ( Hublin et al.,1996) • Great Britain, France , Czech Republic and US: 0.013% to 0.067 % . ( Dauvilliers et al., 2003 ; Mignot, 1998) African Americans: 0.02%. ( Solomon, 1945) • Japan:0.16% and 0.18%(did not use PSG to confirm the diagnosis). ( Honda et al., 1979) • Israel: as low as 0.002%. ( Lavie and Peled, 1987) • Southern Chinese (Hong Kong): 0.034%. ( Yun-Kwok Wing et al., 2002) The prevalence of narcolepsy without cataplexy: • Unknown cases of narcolepsy without cataplexy represent 10% to 50% of the narcoleptic population. (45.5% in Chang Gung hospital). ( Rosen et al., 2003) • Adult population: 1% to 3% may have unexplained sleepiness and SoREM during MSLT. • Higher Prevalence in adolescents or young adults : Because of voluntary chronic sleep deprivation.

26. PSG Criteria and Findings • • Short sleep latency • • Sleep-onset REM period occurs in about • 50% of narcoleptics • • Increased frequency of arousals • • Increased amounts of Stage 1 sleep • • If cataplexy is absent, narcolepsy is difficult • to diagnose in the presence of sleep • fragmentation from other sleep disorders

27. MSLT Criteria for Narcolepsy • • Mean sleep latency of less than 8 minutes • • 2 or more sleep-onset REM periods • (SOREMPs) • • No other sleep disorder that accounts for the • findings • • MSLT should be performed following • sufficiend nocturnal sleep (minimum 6 • hours).

28. Clinical Features: Cataplexy • • Most often occurs with in a year of onset • • Recurrent, brief episodes of muscle weakness • triggered by laughter or at least two of the • following: anger, surprise, elation, amusement • • One or more of the following symptoms: knees • buckling, weakness in legs, jaw, head and neck, • complete fall with no injury • • At least 5 episodes over lifetime

29. Clinical Features: Cataplexy • • Most episodes are bilateral • • Consciousness is maintained, at least at the • beginning of the episodes • • Most episodes last less than 2 minutes( a few • seconds to several minutes). • • Twitches and jerks may occur, particularly in face • (as p’t is trying to fight the episode). • • Cataplexy may vary in pattern, frequency and • severity.

30. Associated Features:• Hypnagogic hallucinations: • 􀂾Are vival perceptual experience typically • occurring at sleep onset • 􀂾Include visual, tactile, kinetic, and auditory • phenomena. • 􀂾Recurrent hypnagogic hallucinations are • experience by 40% to 80% of patients with • narcolepsy with cataplexy.

31. Sleep paralysis • 􀂾A transient, generalized inability to move or • to speak during the transition between sleep • and wakefulness. • 􀂾Sleep paralysis is experienced by 40% to • 80% of narcoleptic patients.

32. Nocturnal sleep disruption: • 􀂾Occurs in approximately 50% of • narcoleptics. • 􀂾Most typically sleep-maintenance rather • than sleep-onset insomnia.

33. Memory lapses: • 􀂾Especially during automatic behavior • without awareness of sleepiness. • 􀂾It may show inappropriate activity and poor • adjustment to abrupt environmental • demands.

34. Many of the symptoms of • narcolepsy can occur in any person • who is severe sleep deprived, only • cataplexy is unique to narcolepsy.

35. Functions potentially interested byHypocretin containing neurons: • 􀂾FEEDING • 􀂾BLOOD PRESSURE REGULATION • 􀂾NEURO-ENDOCRINE REGULATION • 􀂾THERMOREGULATION • 􀂾SLEEP-WAKING CYCLE (effect on • arousal) • Peyron et al., 1998

37. I. Insomnias • • II. Sleep Related Breathing Disorders • • III. Hypersomnias of Central Origin Not Due to a Circadian • Rhythm, Sleep Disorder, Sleep Related Breathing Disorder, or • Other Cause of Disturbed Nocturnal Sleep. • • IV. Circadian Rhythm Sleep Disorders • • V. Parasomnias • • VI. Sleep Related Movement Disorders • • VII. Isolated Symptoms, Apparently Normal Variants, and • Unresolved Issues. • • VIII. Other Sleep Diorders.

42. I. Insomnias • • II. Sleep Related Breathing Disorders • • III. Hypersomnias of Central Origin Not Due to a Circadian • Rhythm, Sleep Disorder, Sleep Related Breathing Disorder, or • Other Cause of Disturbed Nocturnal Sleep. • • IV. Circadian Rhythm Sleep Disorders • • V. Parasomnias • • VI. Sleep Related Movement Disorders • • VII. Isolated Symptoms, Apparently Normal Variants, and • Unresolved Issues. • • VIII. Other Sleep Diorders.

43. Parasomnias • • Parasomnias are undesirable physical phenomena • that occur predominantly during sleep. • • Arousal disorders, comprising sleep-walking, • sleep terrors and confusional arousals, are a • spectrum of conditions in which a sudden arousal • from slow-wave sleep is associated with abnormal • behavior due to the patient’s inability to make a • rapid transition to complete wakefulness. They are • common in childhood but can persist or even • develop in adulthood, and may be associated with • potentially injurious behavior.

44. Parasomnias • • Parasomnias usually associated with REM sleep include • nightmares, which are frightening dreams during REM sleep • resulting in wakening. • • Sleep paralysis,occurign at sleep onset or on wakening, is an • inability to move from seconds to minutes. It is believed to be • due to the muscle atonia of REM sleep developing • inappropriately, and may occur both as a normal phenomenon • and in patients with narcolepsy. • • REM sleep behavior disorder occurs when the normal • muscle atonia of REM sleep is lost, allowing the enactment of • dreams. Patients flail their arms, kick and vocalize, frequently • resulting in injuries to themselves or their bed partners. The • conditions occurs predominantly in older men, and is often • associated with neurodegenerative diseases, especially • Parkinsonian syndromes.

45. Parasomnias • Other parasomnias (not state-related) include sleep • enuresis, the continued occurrence of bedwetting in • children beyond the age when it normally ceases. • • Parasomnias related to a known psychiatric disorder • include nocturnal panic attacks and nightmares in posttraumatic • stress disorder. • • Parasomnias related to medical conditions include • confusional behavior at night in patients with dementia.

47. I. Insomnias • • II. Sleep Related Breathing Disorders • • III. Hypersomnias of Central Origin Not Due to a Circadian • Rhythm, Sleep Disorder, Sleep Related Breathing Disorder, or • Other Cause of Disturbed Nocturnal Sleep. • • IV. Circadian Rhythm Sleep Disorders • • V. Parasomnias • • VI. Sleep Related Movement Disorders • • VII. Isolated Symptoms, Apparently Normal Variants, and • Unresolved Issues. • • VIII. Other Sleep Diorders.

48. Sleep-related movementdisorders • • Restless legs syndrome, is characterized by an overwhelming • urge to move the legs while sitting or lying and relief by • movement. It is a very common cause of insomnia, It is often • familial and appears to be due to central dopaminergic • dysfunction. • • Periodic limb movements disorder is usually associated with • rhythmic kicking of the legs during sleep. But PLM may also • accompany other sleep disorders and may occasionally alone • be a cause of insomnia or hypersomnina.

49. Sleep-related movementdisorders • Rhythmic movement disorder can occur during any stage of sleep, but is commonest during drowsiness. It consist of large rhythmic movements, usually of the axial musculature, and includes the conditions previously known as body rocking and head banging. • Bruxism (tooth grinding) may occur during any stage of sleep and can result in jaw pain and damage to teeth.

50. Sleep, Paris Louvre