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The The International International Classification Classification of Sleep Disorders of Sleep Disorders Second Edition Second Edition Diagnostic & Coding Manual Diagnostic & Coding Manual American Academy of Sleep Medicine American Academy of Sleep Medicine

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Page 1: Icsdsleepdisorders Pgs[1]

The The International International

ClassificationClassification of Sleep Disordersof Sleep Disorders

Second EditionSecond Edition

Diagnostic & Coding ManualDiagnostic & Coding Manual

American Academy of Sleep MedicineAmerican Academy of Sleep Medicine

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IntroductionIntroduction

Sleep disorders are classified in the Sleep disorders are classified in the newly revised International newly revised International Classification of Sleep Disorders, Classification of Sleep Disorders, Second Edition (ICSD-2)Second Edition (ICSD-2) Revision involved >100 members of sleep Revision involved >100 members of sleep

community in USA and other countriescommunity in USA and other countries Divided into eight categoriesDivided into eight categories Each category was assigned a task force Each category was assigned a task force

consisting of leading sleep professionalsconsisting of leading sleep professionals

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AGENDAAGENDA Categories of sleep disordersCategories of sleep disorders

Symptoms and underlying pathologySymptoms and underlying pathology

PSG FindingsPSG Findings

TreatmentTreatment

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OVERVIEWOVERVIEW

InsomniasInsomnias Sleep Related Sleep Related

Breathing DisordersBreathing Disorders Hypersomnia of Hypersomnia of

Central OriginCentral Origin Not due to other Not due to other

causescauses Circadian Rhythm Circadian Rhythm

Sleep DisordersSleep Disorders

ParasomniasParasomnias Sleep Related Sleep Related

Movements Movements DisordersDisorders

Isolated symptoms, Isolated symptoms, Apparently Normal Apparently Normal Variants and Variants and Unresolved IssuesUnresolved Issues

Other Sleep Other Sleep DisordersDisorders

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INSOMNIASINSOMNIAS Repeated difficulty with sleep initiation, Repeated difficulty with sleep initiation,

duration, consolidation or quality.duration, consolidation or quality. With adequate sleep opportunity, persistent sleep With adequate sleep opportunity, persistent sleep

difficulty and associated daytime dysfunctiondifficulty and associated daytime dysfunction Symptoms depend on age and severitySymptoms depend on age and severity

Mild: fatigue, decreased mood or irritability, Mild: fatigue, decreased mood or irritability, general malaise and cognitive impairment general malaise and cognitive impairment

Chronic Adult: impaired social or vocational Chronic Adult: impaired social or vocational functioning, reduced quality of lifefunctioning, reduced quality of life

May include physical symptoms of GI upset or May include physical symptoms of GI upset or headacheheadache

Increased traffic and work place accidentsIncreased traffic and work place accidents Psychiatric disordersPsychiatric disorders Concerns or worries about sleepConcerns or worries about sleep

Children: Poor school performance Children: Poor school performance

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11 categories of11 categories ofINSOMNIA INSOMNIA

Adjustment InsomniaAdjustment Insomnia Psychophysiological Psychophysiological

InsomniaInsomnia Paradoxical InsomniaParadoxical Insomnia Idiopathic InsomniaIdiopathic Insomnia Inadequate Sleep Inadequate Sleep

HygieneHygiene Behavioral Insomnia Behavioral Insomnia

of Childhoodof Childhood

Insomnia due to Drug Insomnia due to Drug or Substance abuseor Substance abuse

Insomnia Due to Insomnia Due to Medical ConditionMedical Condition

Insomnia Due to Insomnia Due to SubstanceSubstance

Known physiological Known physiological condition or condition or Unspecified (Non-Unspecified (Non-organic Insomnia)organic Insomnia)

Physiological (Organic) Physiological (Organic) Insomnia, UnspecifiedInsomnia, Unspecified

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Adjustment Insomnia Adjustment Insomnia (Acute Insomnia) (Acute Insomnia)

Essential feature is association with a stressor Essential feature is association with a stressor that can be identifiedthat can be identified Disappears when stressor is resolvedDisappears when stressor is resolved

Short duration (few days to few weeks)Short duration (few days to few weeks) lasts no more than few monthslasts no more than few months

Occurs at any ageOccurs at any age More often in woman than menMore often in woman than men

PSG Findings: (based on experimental models PSG Findings: (based on experimental models only) prolonged sleep latency, increased only) prolonged sleep latency, increased arousals and awakenings and decreased sleep arousals and awakenings and decreased sleep efficiency. Reduced REM and SWS with efficiency. Reduced REM and SWS with increased stage 1 and 2. increased stage 1 and 2.

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Psychophysiologic InsomniaPsychophysiologic Insomnia(Conditioned Insomnia)(Conditioned Insomnia)

Symptoms present for > 1 monthSymptoms present for > 1 month Conditioned arousalsConditioned arousals

““racing mind” commonracing mind” common May report sleeping better away from their own May report sleeping better away from their own

bedrooms and away from their usual routinebedrooms and away from their usual routine

PSG FindingsPSG Findings Increased sleep latency and increased WASOIncreased sleep latency and increased WASO

Exceeds 30 minutesExceeds 30 minutes Increased stage 1 and decrease in slow-wave Increased stage 1 and decrease in slow-wave

sleepsleep May show reverse first-night effectMay show reverse first-night effect

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Paradoxical Insomnia Paradoxical Insomnia (Sleep State (Sleep State Misperception)Misperception) Complaints of severe insomnia without objective Complaints of severe insomnia without objective

evidence to support it.evidence to support it. Report daytime symptomsReport daytime symptoms

Severity of nocturnal complaints not matched with Severity of nocturnal complaints not matched with evidence for pathologic sleepinessevidence for pathologic sleepiness

MSLT latencies of <5 minutes are not evidentMSLT latencies of <5 minutes are not evident

PSG Findings: Normal latencies and sleep times. PSG Findings: Normal latencies and sleep times. Estimated sleep times are at least 50% less than Estimated sleep times are at least 50% less than

actual actual Estimated onset latencies and wake after onset at Estimated onset latencies and wake after onset at

least 1.5 times actual amount least 1.5 times actual amount Some evidence of increased EEG frequency in sleep Some evidence of increased EEG frequency in sleep

reported in recent researchreported in recent research

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Idiopathic InsomniaIdiopathic Insomnia(Childhood-Onset (Childhood-Onset

Insomnia)Insomnia) Lifelong sleep difficultyLifelong sleep difficulty

Onset in early childhoodOnset in early childhood Absence of factors associated with onsetAbsence of factors associated with onset

PSG FindingsPSG Findings Prolonged sleep latency and increased WASOProlonged sleep latency and increased WASO Reduced total sleep time and sleep efficiencyReduced total sleep time and sleep efficiency Increased stages 1 and 2, decrease in 3 and 4Increased stages 1 and 2, decrease in 3 and 4 Increased EEG frequency reported during Increased EEG frequency reported during

sleepsleep Not specific to idiopathic insomniaNot specific to idiopathic insomnia

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Insomnia Due To Mental Insomnia Due To Mental DisorderDisorder

Insomnia caused by underlying mental disorderInsomnia caused by underlying mental disorder Diagnosed only when severe enough to warrant Diagnosed only when severe enough to warrant

independent treatmentindependent treatment Associated featuresAssociated features

Difficulty falling asleep in anxiety disordersDifficulty falling asleep in anxiety disorders Frequent nighttime and early morning awakenings in Frequent nighttime and early morning awakenings in

depressiondepression PSG findings same as with other types of insomniaPSG findings same as with other types of insomnia

Decreased sleep efficiency and increase in sleep latencyDecreased sleep efficiency and increase in sleep latency Early REM latency and increased REM density in Early REM latency and increased REM density in

depressiondepression

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Inadequate Sleep HygieneInadequate Sleep Hygiene (sleep incompatible (sleep incompatible

behaviors)behaviors) Associated with daily routines that are Associated with daily routines that are

incompatible with sleep (5-10% of insomnias)incompatible with sleep (5-10% of insomnias) Behaviors are under the individuals controlBehaviors are under the individuals control Contribute to mood and motivational disturbance, Contribute to mood and motivational disturbance,

reduced attention, vigilance and concentration reduced attention, vigilance and concentration and daytime fatigue or sleepiness.and daytime fatigue or sleepiness.

Preoccupation with sleep disturbance commonPreoccupation with sleep disturbance common Recording in sleep lab may correct some Recording in sleep lab may correct some

inadequate hygiene practices and mask inadequate hygiene practices and mask severity of the problem.severity of the problem.

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Behavioral Insomnia of Behavioral Insomnia of ChildhoodChildhood

(limit-setting sleep (limit-setting sleep disorder)disorder) Difficulty falling asleep and/or staying Difficulty falling asleep and/or staying

asleep related to an identified behavioral asleep related to an identified behavioral etiology. etiology. Seen in 10-30% of childrenSeen in 10-30% of children

Inappropriate sleep associationsInappropriate sleep associations Dependency on specific stimulation, objects Dependency on specific stimulation, objects

or settings for initiating or returning to or settings for initiating or returning to sleep.sleep.

Inadequate limit-setting (by care giver)Inadequate limit-setting (by care giver) Bedtime stalling or refusalBedtime stalling or refusal

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Sleep Related Breathing Sleep Related Breathing DisordersDisorders

Central Sleep Central Sleep ApneaApnea

Obstructive Sleep Obstructive Sleep ApneaApnea

Sleep Related Sleep Related Hypoventilation/HypoHypoventilation/Hypoxemic Syndromesxemic Syndromes

Sleep Related Sleep Related Hypoventilation/Hypoxemia Hypoventilation/Hypoxemia Due to Medical ConditionDue to Medical Condition Due to pulmonary parenchymal Due to pulmonary parenchymal

or vascular pathologyor vascular pathology Due to lower airways Due to lower airways

obstructionobstruction Due to neuromuscular & chest Due to neuromuscular & chest

wall disorderswall disorders Other Sleep Related Other Sleep Related

Breathing DisordersBreathing Disorders Sleep apnea/Sleep related Sleep apnea/Sleep related

breathing disorder, unspecifiedbreathing disorder, unspecified

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Central Sleep ApneaCentral Sleep Apnea

Primary Central Primary Central ApneaApnea

Central Apnea Due Central Apnea Due to Cheyne Stokes to Cheyne Stokes BreathingBreathing

Central Apnea Due Central Apnea Due to High Altitude to High Altitude Periodic BreathingPeriodic Breathing

Central Apnea Due Central Apnea Due to Medical Condition to Medical Condition Not Cheyne StokesNot Cheyne Stokes

Central Apnea Due Central Apnea Due to Drug or to Drug or SubstanceSubstance

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Primary Central Sleep Primary Central Sleep ApneaApnea

Recurrent cessation of breathing in sleep with Recurrent cessation of breathing in sleep with no ventilatory effort (no ventilatory effort (at least 5 per hrat least 5 per hr.).)

C/O of frequent awakenings, excessive C/O of frequent awakenings, excessive daytime sleepiness, insomnia or awakening daytime sleepiness, insomnia or awakening short of breathshort of breath

Caused by instability of the respiratory Caused by instability of the respiratory control system in the transition from control system in the transition from wakefulness to sleepwakefulness to sleep

Tend to occur in patients with high ventilatory Tend to occur in patients with high ventilatory responsiveness to COresponsiveness to CO22

lower PaCOlower PaCO22 levels exist (close to apnea threshold) levels exist (close to apnea threshold)

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Cheyne Stokes Breathing Cheyne Stokes Breathing PatternPattern

Recurrent central apneas and hypopneas, Recurrent central apneas and hypopneas, alternating with periods of prolonged alternating with periods of prolonged crescendo-decrescendo pattern of tidal crescendo-decrescendo pattern of tidal volumevolume Usually in NREM, better in REMUsually in NREM, better in REM

Seen in males, >60 yrs.Seen in males, >60 yrs. Atrial fib and hypocapnea frequently seenAtrial fib and hypocapnea frequently seen

Awake PaCOAwake PaCO22 of 38 mm/Hg or less of 38 mm/Hg or less Moderate oxygen desaturations Moderate oxygen desaturations

drops in SpOdrops in SpO22 to 80-85% to 80-85%

Seen in CHF, CVA or renal failureSeen in CHF, CVA or renal failure

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Cheyne Stokes BreathingCheyne Stokes Breathing

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Obstructive Sleep Apnea, Obstructive Sleep Apnea, AdultAdult

Repetitive episodes of complete (apnea) or Repetitive episodes of complete (apnea) or partial (hypopnea) airway obstruction in sleeppartial (hypopnea) airway obstruction in sleep Events 10-30 sec. long but can be a minute or moreEvents 10-30 sec. long but can be a minute or more

Events occur in NREM (stages 1 &2) or REMEvents occur in NREM (stages 1 &2) or REM Associated with desats from 1% to >40%Associated with desats from 1% to >40% Longer in duration and more severe desats in REMLonger in duration and more severe desats in REM

Snoring and excessive daytime sleepinessSnoring and excessive daytime sleepiness Worse with alcohol consumption & increase in Worse with alcohol consumption & increase in

weightweight At risk for systemic hypertension and type II At risk for systemic hypertension and type II

diabetesdiabetes

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Obstructive Apnea, Obstructive Apnea, PediatricPediatric

May have cyclic episodes of obstructive May have cyclic episodes of obstructive apneas or UARS similar to that of adultsapneas or UARS similar to that of adults

Many (esp. younger) have prolonged Many (esp. younger) have prolonged hypoventilation associated with hypoventilation associated with hypercarbia and or oxygen desaturationshypercarbia and or oxygen desaturations

Sleep architecture is usually normal may Sleep architecture is usually normal may be due to higher arousal thresholdbe due to higher arousal threshold

Large tonsils and adenoids; craniofacial Large tonsils and adenoids; craniofacial abnormalities (micrognathia, nasal abnormalities (micrognathia, nasal atresia, etc.); midface hypoplasia and atresia, etc.); midface hypoplasia and associated hypotonia; Down syndrome; associated hypotonia; Down syndrome; neuromuscular diseases; cerebral palsy; neuromuscular diseases; cerebral palsy; infants with gastroesophogeal reflux infants with gastroesophogeal reflux leading to edema of upper airway leading to edema of upper airway

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Hypersomnias of Central Origin

Not Due to Circadian Rhythm Disorder, SRBD

or other cause of disturbed nocturnal sleep NarcolepsyNarcolepsy

Recurrent Recurrent HypersomniaHypersomnia

Idiopathic Idiopathic HypersomniaHypersomnia

Behaviorally induced Behaviorally induced insufficient sleep insufficient sleep syndromesyndrome

Hypersomnia due to a Hypersomnia due to a medical conditionmedical condition

Hypersomnia due to Hypersomnia due to drug or substancedrug or substance

Hypersomnia not due Hypersomnia not due to substance (non-to substance (non-organic)organic)

Physiological Physiological (organic) (organic) HypersomnolenceHypersomnolence

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Narcolepsy with Narcolepsy with CataplexyCataplexy

Excessive daytime sleepinessExcessive daytime sleepiness with repeated episodes of with repeated episodes of naps or lapses into sleep across the daytimenaps or lapses into sleep across the daytime Short sleep latencies and positive MSLTShort sleep latencies and positive MSLT

CataplexyCataplexy: loss of muscle tone provoked by strong emotions: loss of muscle tone provoked by strong emotions Ranges in mild sensation of weakness to complete postural collapseRanges in mild sensation of weakness to complete postural collapse Sleep paralysis, hypnogogic hallucinations, and nocturnal sleep Sleep paralysis, hypnogogic hallucinations, and nocturnal sleep

disruption are commondisruption are common

Genetic linkGenetic link: associated with human leukocyte antigen (HLA) : associated with human leukocyte antigen (HLA) subtypes subtypes DR2/DRB1*1502 and DQB1*0602DR2/DRB1*1502 and DQB1*0602 Always found together in Caucasians and Asians (not African Always found together in Caucasians and Asians (not African

Americans)Americans) Associated with loss of hypothalamic neurons containing Associated with loss of hypothalamic neurons containing

neuropeptide hypocretinneuropeptide hypocretin Assessed by measuring CSF levels of hypocretin-1Assessed by measuring CSF levels of hypocretin-1

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Narcolepsy without Narcolepsy without CataplexyCataplexy

HLA typing is never used for diagnosingHLA typing is never used for diagnosing Measuring CSF hypocretin-1 levels Measuring CSF hypocretin-1 levels

rarely helpfulrarely helpful May be helpful in SRBDs, PLMD and RBDMay be helpful in SRBDs, PLMD and RBD

PSG shows short sleep latency (PSG shows short sleep latency (1010 min) min) and sleep onset and sleep onset REMREM period ( period (SOREMP)SOREMP)

MSLT shows mean sleep latencies of less than MSLT shows mean sleep latencies of less than 5 min. and SOREMP in 2 or more naps5 min. and SOREMP in 2 or more naps Same findings in narcolepsy with cataplexySame findings in narcolepsy with cataplexy

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Recurrent Hypersomnia Recurrent Hypersomnia Kleine-Levin Syndrome Kleine-Levin Syndrome

Recurrent bouts of sleepiness occurring Recurrent bouts of sleepiness occurring weeks or months apartweeks or months apart May have flu like symptoms prior to 1May have flu like symptoms prior to 1stst episode episode

Occurs in adolescents, mostly male (4:1)Occurs in adolescents, mostly male (4:1) During sleepy phase may sleep 18-20 hrsDuring sleepy phase may sleep 18-20 hrs

Behavioral abnormalities may be present with Behavioral abnormalities may be present with binge eating, hypersexuality, irritability and binge eating, hypersexuality, irritability and aggressivenessaggressiveness

PSG shows low voltage slow EEG or diffuse PSG shows low voltage slow EEG or diffuse alphaalpha

MSLT shows reduced sleep latencies and MSLT shows reduced sleep latencies and REM onset in one or more napsREM onset in one or more naps

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ParasomniasParasomnias

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ParasomniasParasomnias Disorders of Arousal Disorders of Arousal

(NREM Sleep)(NREM Sleep) Confusional ArousalsConfusional Arousals Sleep WalkingSleep Walking Sleep Terrors Sleep Terrors

Parasomnias Parasomnias Usually Associated Usually Associated with REMwith REM REM Behavior DisorderREM Behavior Disorder Recurrent isolated Recurrent isolated

sleep paralysissleep paralysis Nightmare Disorder Nightmare Disorder

Other ParasomniasOther Parasomnias Sleep Related DissociativeSleep Related Dissociative Sleep EnuresisSleep Enuresis Sleep Related GroaningSleep Related Groaning Exploding Head Exploding Head

SyndromeSyndrome Sleep Related Sleep Related

HallucinationsHallucinations Sleep Related Eating Sleep Related Eating

DisorderDisorder Parasomnia, UnspecifiedParasomnia, Unspecified Due to Drug or SubstanceDue to Drug or Substance Due to Medical ConditionDue to Medical Condition

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Confusional ArousalsConfusional Arousals

Episodes of mental confusion following Episodes of mental confusion following arousal from sleeparousal from sleep Typically from slow wave sleep in 1Typically from slow wave sleep in 1stst third of third of

nightnight Sleep talking and occasional shouting is Sleep talking and occasional shouting is

commoncommon Last 5-15 mins (can last as long as 30-40 min) Last 5-15 mins (can last as long as 30-40 min)

Prevalent in children and adults <35 yr.Prevalent in children and adults <35 yr. 17% of children 3-13 yrs. 17% of children 3-13 yrs.

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Confusional ArousalConfusional Arousal

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Disorders of arousalDisorders of arousal Impaired arousal from Impaired arousal from

sleep, usually occur in sleep, usually occur in SWS. SWS.   awake enough to act awake enough to act

out complex behaviors out complex behaviors but still asleep (not but still asleep (not aware or able to aware or able to remember these remember these actions). actions).

Mental confusion & Mental confusion & disorientation. disorientation.

Relative non-reactivity Relative non-reactivity to external stimuli. to external stimuli.

Retrograde Retrograde amnesia for many amnesia for many intercurrent events intercurrent events

Fragmentary or no Fragmentary or no recall of dream recall of dream mentationmentation

Poor response to Poor response to efforts to provoke efforts to provoke behavioral behavioral wakefulnesswakefulness

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Sleepwalking Sleepwalking (Somnambulism)(Somnambulism)

Series of complex behaviors that are Series of complex behaviors that are initiated during slow wave sleep & initiated during slow wave sleep & result in walking during sleep.result in walking during sleep. Occur in first half of the night Occur in first half of the night

Usual duration of an episode is 1-5 Usual duration of an episode is 1-5 minutes. minutes.

Difficult to awaken Difficult to awaken once aroused, shows mental confusion once aroused, shows mental confusion

with amnesia for the event. with amnesia for the event.

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Copyright ©2003 American Academy of Pediatrics

Guilleminault, C. et al. Pediatrics 2003;111:e17-e25

PSG of Onset of Sleepwalking in a 8-year-old child

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Features of sleepwalkingFeatures of sleepwalking

Most common in children aged 4-6 Most common in children aged 4-6 years years Frequently disappears during Frequently disappears during

adolescence. adolescence. Adult cases are not infrequent. Adult cases are not infrequent.

Strong family history is commonStrong family history is common often family or personal history of other often family or personal history of other

arousal disorders from SWSarousal disorders from SWS specifically sleep terrors & confusional specifically sleep terrors & confusional

arousalsarousals

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PSG FindingsPSG Findings

Sleep lightens from SWS to stage 1 or 2 Sleep lightens from SWS to stage 1 or 2 patterns  patterns 

On nights without episodes, PSG often On nights without episodes, PSG often shows 3 or more direct slow-wave-shows 3 or more direct slow-wave-wakefulness transitions, an infrequent wakefulness transitions, an infrequent findings in normal subjects. findings in normal subjects.

More frequent & higher amplitude delta More frequent & higher amplitude delta bursts during incomplete arousals from bursts during incomplete arousals from non-REM sleep non-REM sleep

Higher frequency of brief micro-arousals. Higher frequency of brief micro-arousals.

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Differential DiagnosisDifferential Diagnosis

Psychomotor epilepsy. Psychomotor epilepsy.

REM sleep behavior disorders. REM sleep behavior disorders.

Nocturnal eating syndrome. Nocturnal eating syndrome.

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Sleep Terrors Sleep Terrors

Characterized by: Characterized by: sudden arousal from slow wave sleep sudden arousal from slow wave sleep a piercing scream or crya piercing scream or cry accompanied by autonomic ( part of the accompanied by autonomic ( part of the

nervous system that regulates motor nervous system that regulates motor functions of the heart, lungs, etc.) and functions of the heart, lungs, etc.) and behavioral manifestations of intense behavioral manifestations of intense fear. fear.

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Sleep Terrors: Sleep Terrors: Associated symptomsAssociated symptoms

PSG demonstrates PSG demonstrates the onset of the onset of episodes during episodes during SWS (stage 3 or 4 SWS (stage 3 or 4 sleep) sleep)

Tachycardia Tachycardia usually occurs in usually occurs in association with association with the episodes. the episodes.

Other medical Other medical disorders aredisorders are notnot the the cause of the episode, cause of the episode, (i.e., epilepsy) (i.e., epilepsy)

Other sleep Other sleep disorders can be disorders can be presentpresent nightmares, sleep nightmares, sleep

panic attacks, sleep panic attacks, sleep apnea. apnea.

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How serious are Sleep How serious are Sleep Terrors?Terrors?

Some adults have Some adults have episodes of night episodes of night terror that may occur terror that may occur less than once per less than once per month, and do not month, and do not result in harm to the result in harm to the individual or others. individual or others.

Some adults Some adults experience episodes experience episodes less than once per less than once per week, and it does not week, and it does not result in harm to the result in harm to the individual or others. individual or others.

In its severest form, In its severest form, the episodes occur the episodes occur almost nightly, or are almost nightly, or are associated with associated with physical injury to the physical injury to the individual or others. individual or others.

Night terrors in adults Night terrors in adults is not normal. is not normal. Children generally have Children generally have

them, but tend to grow them, but tend to grow out of it. out of it.

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Copyright ©2003 American Academy of Pediatrics

Guilleminault, C. et al. Pediatrics 2003;111:e17-e25

Onset of Sleep Terror in a 3-year-old boy

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REM Behavior DisorderREM Behavior Disorder

Predominantly male after 50 yr. of agePredominantly male after 50 yr. of age Often with underlying neurological disorder Often with underlying neurological disorder

such as Parkinsonism, narcolepsy and strokesuch as Parkinsonism, narcolepsy and stroke Medication use common (venlafaxine, SSRI, Medication use common (venlafaxine, SSRI,

mirtazapine)mirtazapine) Intermittent loss of REM EMG atoniaIntermittent loss of REM EMG atonia Exaggerated motor activity with dreamsExaggerated motor activity with dreams PSG shows increased chin EMG in REM PSG shows increased chin EMG in REM

with prolonged limb movementswith prolonged limb movements Increase in REM density and SWS timeIncrease in REM density and SWS time

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SLEEP RELATED SLEEP RELATED MOVEMENT DISORDERSMOVEMENT DISORDERS

Restless Leg Restless Leg SyndromeSyndrome

Periodic Limb Periodic Limb Movement DisorderMovement Disorder

Sleep Related Leg Sleep Related Leg CrampsCramps

Sleep Related Sleep Related BruxismBruxism

Sleep Related Sleep Related Rhythmic Movement Rhythmic Movement DisorderDisorder

SRMD, UnspecifiedSRMD, Unspecified

Due to Drug or Due to Drug or SubstanceSubstance

Due to Medical Due to Medical ConditionCondition

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Restless Leg SyndromeRestless Leg Syndrome

Disagreeable leg sensations prior to sleep Disagreeable leg sensations prior to sleep onsetonset Creeping, crawling, tingling, aching or Creeping, crawling, tingling, aching or

itchingitching Feelings abate with leg movementFeelings abate with leg movement Complaints of inability to fall asleepComplaints of inability to fall asleep

Iron, dopamine and genetics are factors Iron, dopamine and genetics are factors in pathologyin pathology Serum ferritin levels <50Serum ferritin levels <50

PSG: Prolonged sleep latency.PSG: Prolonged sleep latency.

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Periodic Limb Movement Periodic Limb Movement DisorderDisorder

Onset at any age but increases with age (Onset at any age but increases with age (34% >6034% >60 yryr))

Iron deficiency may play roleIron deficiency may play role Also seen with RLS, RBD and narcolepsy Also seen with RLS, RBD and narcolepsy

Symptoms include leg cramps & insomniaSymptoms include leg cramps & insomnia

May be precipitated or aggravated by medicationsMay be precipitated or aggravated by medications tricyclic antidepressants, SSRIs, lithium and dopamine-tricyclic antidepressants, SSRIs, lithium and dopamine-

receptor antagonistsreceptor antagonists

PSG: periodic EMG bursts lasting 0.5-5 secsPSG: periodic EMG bursts lasting 0.5-5 secs 20-30 secs apart (4 movements in 90 sec)20-30 secs apart (4 movements in 90 sec) Sleep fragmentation and prolonged latenciesSleep fragmentation and prolonged latencies

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