In , the International Classification of Sleep Disorders (ICSD) was The ICSD-2 classification (Table 1) lists 81 major sleep disorder The proposed DSM-V edition of the classification of the sleep disorders .. not receive a second diagnosis of a circadian rhythm sleep disorder .. ESM 1(K, pdf). International Classification of Sleep Disorders (2nd edn),. International Classification classification replaces the previous edition (ICSD-2; Ameri- can Academy of .. In the nonh sleep–wake disorder (or free-running disorder), which was. Classification of Diseases; ICSD 5 International Classification of Sleep Disorders; IH 5 idiopathic As with ICSD-2, pediatric diagnoses are not distin- guished.
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Unless authorized in writing by the AASM, no portion of this book be reproduced ICSD - International classification of sleep disorders, revised: Diagnostic and Includes bibliographies and index. 1. Sleep Disorders– Classification. 2. Sleep .. syndrome) to reflect crucial developments since the first edition. Changes. From Wikipedia, the free encyclopedia. Jump to navigation Jump to search. International Classification of Sleep Disorder. Specialty · Sleep medicine. The International Classification of Sleep Disorders (ICSD) is "a primary diagnostic, A second edition, called ICSD-2, was published in The third edition, ICSD- 3, was. 2. Learn the classification of sleep disorders as outlined by the. AASM. 3. disorder free-running circadian International Classiffcation of Sleep Disorders ( ICSD), orders. A second edition of the ICSD was published in.
Secondly, daytime manifestations of a number of sleep disorders e. Considering the recent evidences and changes in the management of sleep disorders,, Indian Psychiatric Society has decided to update the existing guidelines.
However, few points must be kept in mind while you consider these guidelines for your practice: 1. These are consensus statements 2. Original research in this area from India is limited.
International Classification of Sleep Disorders
Most of the literature reviewed has been generated from the studies involving Caucasian and European population. They are culturally, phenotypically and genetically different from Indian population. All three factors-culture, phenotype and genotype influence the sleep patterns, pathophysiology of sleep disorders and their management- both pharmacological as well as non-pharmacological. With this background, we will discuss the guidelines regarding management of individual sleep disorders.
It should be associated with significant distress and persistent preoccupation with the deficiency of sleep. DSM-5 defines insomnia as a condition where a problem has been reported in initiating , maintaining the sleep or there is an early morning awakening.
This problem should occur despite adequate opportunities to fall asleep and must occur at least 3 nights a week. It should be associated with significant distress in the personal, social or occupational life. If it persists for at least 1 month but less than 3 months, it is considered as episodic; if it persists for at least 3 months, it is considered as persistent insomnia.
Our understanding regarding insomnia has changed over the years. Earlier we used to differentiate between primary and secondary insomnia, however, the recent research has challenged this belief.
Current literature suggests that insomnia cannot be considered merely as a symptom of psychiatric disorders. It is rather co-morbid with the psychiatric and other medical conditions, and if not treated early, through the process of kindling it becomes chronic which has multiple health and economic implications.
For this reason, in the third edition of International Classification of Sleep Disorder ICSD-3 , which appeared in , insomnia has been divided into two categories: short term insomnia disorder and chronic insomnia disorder. In addition, subtyping of the primary insomnia into adjustment, psychophysiological, paradoxical and idiopathic that prevailed till ICSD-2 has been omitted. This has happened for multiple reasons. First, all the insomnia sufferers have in common one issue i.
Hence, all the modalities that are used for the treatment of insomnia are directed towards reducing the hyperarousal. Assessment and evaluation Management of the insomnia case starts with the history taking and general physical examination. It is of paramount importance as a number of sleep disorders may mimic insomnia. Hence, having knowledge regarding these mimics will help the clinician to reach to an accurate diagnosis. Through a careful history and clinical examination, these conditions can be ruled out [Table 2].
Table 2: Sleep Disorders that may mimic insomnia Click here to view While taking the history of a patient with insomnia, special focus should be provided to the initiation of symptoms, its course and progression.
Table 3: Information regarding a typical night Click here to view He should be asked for the daytime symptoms of insomnia, as in their absence, insomnia can't be diagnosed.
Frequency of symptoms must be asked along with the duration and frequency of symptoms per week. It must be ensured that the patient has adequate opportunities to fall asleep. Excessive daytime sleepiness must be ruled out. Clues regarding the predisposing, precipitating and perpetuating factors of insomnia should be assessed in detail.
It is essential to ask for the sleep pattern while the patient was asymptomatic and compare it with the sleep schedule during symptomatic period.
Sleep related behavior and rituals must be asked before and after the symptoms onset as they may provide a good idea about the possible interventions. Many of the patients with insomnia start worrying while they are not able to fall asleep in the bed. Dysfunctional thoughts before the bedtime or while in bed lead to hyperarousal and they may be assessed using Dysfunctional Beliefs and Attitudes about Sleep, which is available in English as well as Hindi Language.
Many of the medical conditions may induce symptoms that may mimic insomnia. Hence, the disorders provided in [Table 4] must be ruled out. Table 4: Other medical disorders that may induce sleep disturbance Click here to view Algorithm for the diagnosis of insomnia is depicted in Fig 1.
Effect of the insomnia on the daytime functioning must be assessed. Special care should be taken to differentiate between fatigue and sleepiness. Mood during the day must be assessed.
Depression and other psychiatric disorders that may mimic daytime symptoms of insomnia may be differentiated by asking "how do you feel during the day which is followed by a good night sleep? If the patient reports a remarkable improvement, diagnosis of psychiatric disorder shall be deferred till the insomnia resolves. If the patient is undergoing any treatment for other medical disorders pharmacological as well as non-pharmacological , its' effect on the sleep should be examined.
Severity of insomnia may be assessed using a brief questionnaire- Insomnia severity index, available in English as well as Hindi.
This should be followed by a thorough general physical examination and if any system appears dysfunctional, that should be examined in detail. Sleep diary provides a good opportunity to assess the sleep-pattern and helps in differentiating insomnia from circadian rhythm sleep disorders. At times, objective data is necessary to reach to a diagnosis and in those cases actigraphy may be performed.
In cases of chronic insomnia that is not responding to treatment, video-synchronized channel polysomnography is desirable. Figure 2: Sleep diary depicting long sleep onset latency with normal total sleep time when the patient is following natural pattern of sleep.
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However, the patient gets the sleep late in the night and wakes up late in the morning. This data suggests delayed sleep wake phase disorder Click here to view Formulating a treatment plan Treatment of insomnia is individualized and tailor-made.
For the short term insomnia, pharmacotherapy is indicated, while for the chronic insomnia, cognitive behavior therapy for insomnia CBT-I is preferred.
Various hypnotic agents are described below.
Importance of behavioral intervention should not be underestimated and it is better that they should be started even in cases with short term insomnia. For example, a person might be having genetic predisposition to insomnia and a recent stress might have precipitated the insomnia, which could be perpetuated by the dysfunctional beliefs about sleep or maladalptive strategies to control it. Common maladaptive strategies that we see include, but not limited to- spending excessive time in bed, start smoking or start drinking caffeine while awake, spending time on screen while awake or spending majority of the time during the day in bed.
Wherever indicated, opinion from a relevant specialist may be sought. If there is evidence of sleep disorders that mimic insomnia, management should be directed to those disorders, rather than the insomnia. In some cases, insomnia is co-morbid with these sleep disorders, and in these cases, both should be treated.
Goals of the therapy 1. Improve the sleep onset latency, total sleep time and reduce awakenings, thus improving sleep efficiency 2. Improving quality of sleep 3. Ameliorate or significantly reduce the daytime symptoms of insomnia 4. Sustain the effect of treatment and reduce the chances of the relapse Choice of treatment settings Treatment of insomnia is usually offered on an outpatient basis.
Hospitalization may rather worsen the condition by enhancing hyperarousal. However, in some patients it may improve sleep by removing environmental factors and may provide a clue to the underlying pathophysiology.
Pharmacological treatment Pharmacological treatment for the insomnia is limited to short-term insomnia and they are not routinely recommended for the management of chronic insomnia. A wide variety of drugs is available that may induce sleep e. Table 5: How to choose a drug from the available molecules? Click here to view Benzodiazepinesand benzodiazepine receptor agonists BzRA are usually divided into short, intermediate and long acting and one of them may be chosen based upon the case.
In general, short acting are preferred when the patient is having difficulty in sleep initiation, intermediate acting when the patient has difficulty in maintaining the sleep and long acting when the patients complain of early morning awakening.
However, intermediate and long acting agents may have residual daytime effects and may produce the somnolence during the day [Table 6]. Table 6: Benzodiazepines and Benzodiazepine Receptor Agonists Click here to view Melatonin and its agonists include the melatonin itself and the molecules that act on MT1 and MT2 receptors.
Hypersomnia and depressive symptoms: methodological and clinical aspects
Melationin is available as 3 mg tablet formulation. This may be used to induce sleep, however, data do not support its efficacy as a hypnotic agent. It is rather used as a chronobiotic.
Remelteon is a short-acting-drug with half-life of around hours. It shows an improvement in the time to fall asleep with minimal adverse effects. Agomelatine is another molecule that in addition to having an agonist action on melatonin receptors, also has antagonist action on 5-HT 2C receptors. It has been found effective in improving both sleep and mood in clinical trials, and because of it's short half life h is free from daytime somnolence.
Orexin-receptors antagonists have recently been discovered for the management of insomnia.
Controlled trial data is available for one of the molecule i. It has been found to improve total sleep time with variable findings on the nocturnal arousals and time spent awake after sleep onset.
Common adverse effects include nausea abnormal dreams. Sedating antidepressants e. In addition, they may also be preferred when adverse effects of the benzodiazepines and BzRAs are not tolerable. However, there are insufficient evidences for their efficacy in insomnia.
Antihistaminicdrugs are available as over-the-counter drugs, and they are commonly used for self medication. However, data regarding their efficacy in insomnia is limited. However, a tricyclic drug Doxeipin has been approved for the treatment of insomnia in low doses 10 mg. At this dose, it primarily acts on the H 1 receptors and work as an antihistaminic. Antipsychotics are used off-label for the treatment of insomnia, particularly chlorpromazine, clozapine, olanzapine and qutiapine.
The international classification of sleep disorders : diagnostic & coding manual.
However, we do not have data regarding their efficacy as hypnotic agents. In addition, while prescribing them, it is essential to consider potential adverse effects e. Long term pharmacotherapy Although the pharmacotherapy is not routinely recommended for the long term treatment in view of availablibility of non-pharmacological therapies, still, data is available for treatement with Z drugs for as long as 6 months without any major adverse effects. Considering the limited availability of trained CBT-I therapist, consensus was reached that in certain circunstances where CBT-I is not possible for any reason, pharmacothepray may be institutedfor long term.
It is a multicomponent therapy that includes education regarding sleep physiology, sleep hygiene, addressing dysfunctional beliefs, stimulus control therapy, sleep restriction and relaxation training.
Each of these components may be used as a primary focus in a given patient which makes this therapy highly individualized. In general, goal of the therapy is to reduce the hyperarousal, hence, educating the patient, cognitive restructuring to address dysfunctional belief and relaxation are necessary in almost all patients.
CBT-I has been found effective for long term management of insomnia in the randomized controlled trials comparing it with hypnotic agents. It has been repeatedly shown that though, it takes some time to show its effects, once they appear, they are longer lasting as compared to pharmacotherapy and also reduce the chances of relapse.
Thus, Discussion There were two significant differences between actigraphy and PSG regarding total sleep time and, in particular, terminal wakefulness. On the whole, our results indicated that actigraphy and PSG similarly detected the presence of insomnia, that is, in our sample, in the majority of cases, both tools discriminated similarly between subjects who met the criteria for insomnia. Moreover, if we considered insomnia type, the contingency coefficient was quite good, with a large size effect, suggesting that actigraphy and PSG were able to lead to a similar output.
Indeed, actigraphy makes it possible to obtain a measure of sleep patterns spanning 7 or more days, in an ecological setting and at a lower cost than that incurred when using PSG. From this point of view, actigraphy is an inexpensive approach to gathering objective data on the rest-activity cycle and may be an interesting solution in the management of insomnia where the objective is to provide an early diagnosis.
Actigraphy could also be useful within an early screening context. To date, the generalization of results is greatly-restricted because of the availability of diverse devices which use different technology for detecting movement and of different types of software analysis. Our results should be considered with caution, given the methodological limitations concerning the sample dimension.
However, the selected sample is homogenous, including only patients with primary insomnia; each of them had one valid night of PSG and seven valid nights of actigraphy. Moreover, the w index supports our results. Further studies should clarify the contribution of sleep-logs, actigraphy and PSG to the diagnosis of sleep disorders, in order to provide recommendations on insomnia assessment within different settings, from primary care to sleep disorder centres.For example, a diagnosis of jet lag type could be stated along with a diagnosis of narcolepsy, if appropriate.
Direct extrapolation of study results from different sleep laboratories has therefore not yet been possible. Hyperosmnia Alertness is an integral necessity for learning, performance and safety. Though the computerized CBT-I has been found superior to the placebo and pharmacotherapy, still it's efficacy has been found low when compared to the face to face CBT-I. Nevertheless, potential unwanted side effects must be carefully monitored. Case Presentation Patient 1 A year-old female presented with a chief complaint of sleep-onset insomnia, difficulty awakening in the morning, and intermittent excessive daytime sleepiness.
In the latter condition, the predominant complaint is excessive sleepiness for at least one month or less if recurrent , evidenced by either prolonged sleep episodes or daytime sleep episodes occurring almost daily. Electroencephalogr Clin Neurophysiol. Sleep logs can also be used for self-monitoring and in connection with behavioral and other treatment.
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