The new international classification of

sleep disorders (ICSD-2)

Patrick J. Strollo, Jr., M.D., FCCP, D,ABSMUniversity of Pittsburgh Medical Center

Turkish Thoracic Society9th Annual Congress

Major Sleep Disorders

• Evolution of the Field of Sleep Medicine

• Classification of Sleep Disorders– Emphasis on common disorders

Association for the PsychophysiologicalStudy of Sleep (APSS) 1964 Stanford Narcolepsy Center

1968 Manual for Scoring Sleep1970 Stanford Sleep Center

Association of Sleep Disorders Centers (ASDC) 1975 5 CentersPSGs Reimbursed

1977 ASDC Center Accreditation1978 Journal SLEEP

Certification in Sleep MedicineClinical Sleep Society (CSS) 1984Association of Professional Sleep Societies (APSS) 1986American Sleep Disorders Association (ASDA) 1987Associated Professional Sleep Societies 1988

1989 ASDA Fellowship Training ProgramsAmerican Board of Sleep Medicine (ABSM), 1991 International Classification of Sleep

National Sleep Foundation (NSF) Disorders (ICSD-1)Sleep Medicine Education & Research Foundation 1998American Academy of Sleep Medicine (AASM) 1999American Sleep Medicine Foundation (ASMF) 2003 Behavioral Sleep Medicine

Certification2005 International Classification of Sleep

Disorders (ICSD-2)

Evolution of the field of Sleep Medicine

J Clin Sleep Med2005: 1:61-82

MilestonesSocieties

International Classification of Sleep Disorders Version 2 (ISCD-2)

1) Insomnias2) Sleep-Related Breathing Disorders3) Hypersomnias Not Due to a Sleep-

Related Breathing Disorder4) Circadian Rhythm Sleep Disorders5) Parasomnias6) Sleep-Related Movement Disorders7) Other Sleep Disorders

AASM, Chicago

ISCD-2: Insomnias

• Adjustment sleep disorders (acute insomnia)• Psychophysiological Insomnia• Paradoxical Insomnia (formerly Sleep State

Misperception)• Idiopathic Insomnia• Insomnia due to mental disorder• Behavioral Insomnia of Childhood • Insomnia due to a medical condition• Insomnia due to a a drug or substance (alcohol)• Insomnia not due to a substance or known physiological

condition (Nonorganic Insomnia, NOS)• Physiological (organic) insomnia, unspecified, unspecified;

(Organic Insomnia, NOS)

AASM, Chicago

Insomnia in the Population

Insomnia symptoms + daytime

consequences 9-15%

Insomnia symptoms-Overall prevalence 30-48%-Often or always: 16-21%-Moderate to extreme: 10-28%

Insomnia diagnosis

6%Direct economic costsof insomnia in the US are estimated ~ $14 billion Ohayon, Sleep Med Rev, 2002

ICSD-2: 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

• Obstructive Sleep Apnea Syndromes– Obstructive Sleep Apnea

• Sleep-Related Hypoventilation / Hypoxemic Syndromes– Sleep-Related Non-Obstructive Alveolar Hypoventilation, Idiopathic– Congenital Central Alveolar Hypoventilation Syndrome– Sleep-Related Hypoventilation / Hypoxemia due to Lower Airways Obstruction– Sleep-Related Hypoventilation / Hypoxemia due to Neuromuscular and Chest

Wall Disorders– Sleep-Related Hypoventilation / Hypoxemia due to Pulmonary Parenchymal or

Vascular Pathology• Other Sleep-Related Breathing Disorder

– Sleep Apnea / Sleep Related Breathing Disorder, unspecified

AASM, Chicago

ISCD-2: Hypersomnias not due to a breathing disorder

• Narcolepsy– Narcolepsy with Cataplexy– Narcolepsy without Cataplexy– Narcolepsy due to a medical condition with Cataplexy– Narcolepsy due to a medical condition without Cataplexy– Narcolepsy, unspecified

• Other Hypersomnias– 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 a medical condition– Hypersomnia due to a drug or substance (Alcohol)– Hypersomnia not due to a substance or known physiologic condition– Physiological Hypersomnia, Unspecified

AASM, Chicago

Change in average amount of sleep per night over the past century

• 1910 = 9.0 hrs/night

• 1975 = 7.5 hrs/night

• Today = 6.9 hrs/night

Bull Psychon Soc1975 6:47-48Neurophysiol Clin1996 26:30-39

Prevalence of Narcolepsy/Cataplexy (USA)P

reva

len

ce

pe

r 1

00,0

00

0

50

100

150

200

250

300

ALS Narcolepsy(with

cataplexy)

Multiplesclerosis

Parkinson'sdisease

IDDM (type 1)

4-640

113

162

260

ALS = amyotrophic lateral sclerosis.

National Sleep Foundation.Mittler. An Introduction to Narcolepsy. National Sleep Foundation Slide Kit.

Narcolepsy: Epidemiology

• Prevalence ~1 in 2000 (US)– Comparable to multiple sclerosis,

greater than cystic fibrosis• Men and women affected equally• Age at onset

– Can present at any age– Majority 15-30 years of age– 6% prior to 10 years of age

J Clin Neurophysiol 2001;18:78.

Mean Hours of Sleep Reported

6.2

6.4

6.6

6.8

7

7.2

7.4

7.6

7.8

8

Hours

Week Days Weekends

National Sleep Foundation (NSF): 2002 “Sleep in America” Poll (N = 1,010 adults)

8 hrs recommended = adequate sleep

ISCD-2: Circadian Rhythm Sleep Disorders

• Circadian Rhythm Sleep Disorders– Delayed Phase type– Advanced Phase type– Irregular Sleep-Wake type– Nonentrained type (Free running)– Due to a medical condition– Jet Lag type– Shift Work type– Due to a Drug or Substance (Alcohol)– Other

AASM, Chicago

ISCD-2: Parasomnias

• Disorder of Arousal (From Non-REM Sleep)– Confusional arousals– Sleepwalking– Sleep terrors

• Parasomnias Usually Associated with REM Sleep– REM Sleep Behavior Disorder– Recurrent Isolated Sleep Paralysis– Nightmare Disorder

• Other Parasomnias– Sleep-Related Dissociative Disorder– Sleep-Related Enuresis– Sleep-Related Groaning– Exploding Head Syndrome– Sleep-Related Hallucinations– Sleep-Related Eating Disorder– Parasomnia, unspecified– Parasomnia due to drug or substance (Alcohol)– Parasomnia due to a medical condition

AASM, Chicago

ISCD-2: Sleep-related Movement Disorders

• Restless Legs Syndrome (included Sleep-Related Growing Pains)• Periodic Limb Movement Sleep Disorder• Sleep-Related Leg Cramps• Sleep-Related Bruxism• Sleep-Related Rhythmic Movement Disorder• Sleep-Related Movement Disorder, unspecified• Sleep-Related Movement Disorder due to a drug or substance• Sleep-Related Movement Disorder due to a medical condition

AASM, Chicago

Prevalence: Estimated 10% of population (US & Europe)Symptoms:• A compelling urge to move the limbs. • Motor restlessness; for example, floor pacing, tossing and turning, and rubbing the legs. • The symptoms may be worse or exclusively present at rest, with variable and temporary relief by activity. • Symptoms are worse in the evening and at night. Associated features commonly found in RLS include:• Sleep disturbances and daytime fatigue. • Normal neurological exam in primary RLS. • Involuntary, repetitive, periodic, jerking limb movements, either in sleep or while awake and at rest.

Restless Legs Syndrome

National Sleep Foundation

ISCD-2:Other Sleep Disorders

• Physiological Sleep Disorder, unspecified

• Environmental Sleep Disorder

• Fatal Familial Insomnia

AASM, Chicago

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