tutto quello che dovreste sapere sul sonno

Prof. Dott. Francesco Peverini

• Chi siamo
  • Modalità e costi
  • Organizzazione
  • Dove siamo
  • Contattateci
  • Consulenti
• Il sonno
• la diagnosi
  • Test diagnostici
  • Pulsossimetria dinamica ed Actigrafia
  • Polisonnografia
  • Video-Polisonnografia
  • Sleep Endoscopy
• Le terapie
  • Narcolessia
  • Insonnia
  • Sindrome delle apnee notturne
• Linee guida
  • Il sonno
  • Sleep Disturbances
  • Bibliografia
  • Glossario
  • Libri
• 
• Didattica
  • Conferenze
  • Lezioni
• Sostenitori
• Links
• Collaborazioni

INTERNATIONAL CLASSIFICATION OF SLEEP DISORDERS

Classification Outline
1. Dyssomnias



A. Intrinsic Sleep Disorders

Either originate or develop within the body or arise from causes within the body. Psychologic and medical disorders producing a primary sleep disorder are listed here. Disorders arising within the body that are not primary sleep disorders are listed under Section 3, sleep disorders associated with mental, neurologic, or other medical disorders.

B. Extrinsic Sleep Disorders

Extrinsic sleep disorders either originate or develop from causes outside of the body. External factors are integral in producing these disorders. Removal of the external factor usually is associated with resolution of the sleep disturbance unless another sleep disorder develops during the course of the sleep disturbance (e.g., psychophysiologic insomnia may follow removal of an external factor responsible for the development of an adjustment sleep disorder).

C. Circadian Rhythm Sleep Disorders

Circadian rhythm sleep disorders are disorders that are related to the timing of sleep within the 24-hour day. Some of these disorders are influenced by the timing of the sleep period that is under the individual’s control (e.g., shift work or time-zone change), whereas others are disorders of neurologic mechanisms (e.g., irregular sleep-wake pattern and advanced sleep-phase syndrome). Some of these disorders can be present in both an intrinsic and extrinsic form; however, their common linkage through chronobiologic, pathophysiologic mechanisms dictates their recognition as a homogeneous group of disorders.

2. Parasomnias

The parasomnias (i.e., the disorders of arousal, partial arousal, and sleep-stage transition) are disorders that intrude into the sleep process and are not primarily disorders of sleep and wake states per se. These disorders are manifestations of central nervous system activation, usually transmitted through skeletal muscle or autonomic nervous system channels. They are divided into four groups: arousal disorders, sleep-wake transition disorders, parasomnias usually associated with rapid eye movement (REM) sleep, and other parasomnias

A. Arousal Disorders
B. Sleep-Wake Transition Disorders
C. Parasomnias Usually Associated with REM Sleep
D. Other Parasomnias


3. Sleep Disorders Associated with Mental, Neurologic, or Other Medical Disorders
A. Associated with Mental Disorders
B. Associated with Neurologic Disorders
C. Associated with Other Medical Disorders
4. Proposed Sleep Disorders

Sleepiness

Mild Sleepiness: This term describes sleep episodes that are present only during times of rest or when little attention is required. Situations in which mild sleepiness may become evident include but are not limited to watching television, reading while lying down in a quiet room, or being a passenger in a moving vehicle.
Mild sleepiness may not be present every day. The symptoms of mild sleepiness produce a minor impairment of social or occupational function.
This degree of sleepiness is usually associated with a multiple sleep latency test (MSLT) mean sleep latency of 10 to 15 minutes.

Moderate Sleepiness: This term describes sleep episodes that are present daily and that occur during very mild physical activities requiring, at most, a moderate degree of attention. Examples of situations in which moderate sleepiness occur include during concerts, movies, theater performances, group meetings and driving.
The symptoms of moderate sleepiness produce a moderate impairment of social or occupational function.
This degree of sleepiness is usually associated with an MSLT mean sleep latency of 5 to 10 minutes.

Severe Sleepiness: This term describes sleep episodes that are present daily and at times of physical activities that require mild to moderate attention. Situations in which severe sleepiness may occur include during eating, direct personal conversation, driving, walking, and physical activities. The symptoms of severe sleepiness produce a marked impairment of social or occupational function.
This degree of sleepiness is usually associated with an MSLT mean sleep latency of less than 5 minutes.

Insomnia

Mild Insomnia: This term describes an almost nightly complaint of an insufficient amount of sleep or not feeling rested after the habitual sleep episode. It is accompanied by little or no evidence of impairment of social or occupational functioning. Mild insomnia often is associated with feelings of restlessness, irritability, mild anxiety, daytime fatigue, and tiredness.

Moderate Insomnia: This term describes a nightly complaint of an insufficient amount of sleep or not feeling rested after the habitual sleep episode. It is accompanied by mild or moderate impairment of social or occupational functioning.
Moderate insomnia always is associated with feelings of restlessness, irritability, anxiety, daytime fatigue, and tiredness.

Severe Insomnia: This term describes a nightly complaint of an insufficient amount of sleep or not feeling rested after the habitual sleep episode. It is accompanied by severe impairment of social or occupational functioning. Severe insomnia is associated with feelings of restlessness, irritability, anxiety, daytime fatigue, and tiredness.

General Criteria for Insomnia

A.A complaint of 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 soften 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:
- Fatigue or malaise
- Attention, concentration or memory impairment
- Social or vocational dysfunction or poor school performance
- Mood disturbance or irritability
- Daytime sleepiness
- Motivation, energy, or initiative reduction
- Proneness for errors or accidents at work or while driving
- Tension, headaches, or gastrointestinal symptoms in response to sleep loss
- Concerns or worries about sleep

Adjustment Insomnia 307.41

A. The patient’s 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 in 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 month
E. The sleep disturbance is not better explained by another current sleep disorder, medical or neurological disorder, mental disorder, mediation use, or substance use disorder


Psychophysiological Insomnia 307.42

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 indicated by one more of the following:
- Excessive focus on and heightened anxiety about sleep
- 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
- Ability to sleep better away from home than at home
- Mental arousal in bed characterized either by intrusive thoughts or a perceived inability to volitionally cease sleep-preventing mental activity
- 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.

Paradoxical Insomnia 307.42

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:
- The patient reports a chronic pattern of little or no sleep most nights during which relatively normal amounts of sleep are obtained
- 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
- The patient shows 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:
- The patient reports constant or near constant awareness of environmental stimuli throughout most nights
- 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 sleep disturbance is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

Idiopathic Insomnia 307.42

A. The patient’s symptoms meet the criteria for insomnia.
B. The course of the disorder is chronic, as indicated bye ach of the following:
- Onset during infancy or childhood
- No identifiable precipitant or cause
- 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.


Insomnia Due to Mental Disorder 327.02

A. The patient’s symptoms meet the criteria for insomnia.
B. The insomnia is present for at least one month.
C. A mental disorder has been diagnosed according to standard criteria.
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 disorder, 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.


Inadequate Sleep Hygiene v69.4

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:
- Improper sleep scheduling consisting of frequent daytime napping, selecting highly variable bedtimes or rising times, or spending excessive amounts of time in bed
- Routine use of products containing alcohol, nicotine, or caffeine, especially in the period preceding bedtime
- Engagement in mentally stimulating, physically activating, or emotionally upsetting activities too close to bedtime
- Frequent use of the bed for activities other than sleep (e.g., television watching, reading, studying, snacking, thinking, planning)
- Failure to maintain a comfortable sleeping environment
D. The sleep disturbance is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.


Insomnia Due to Drug or Substance 292.85 (for Alcohol use 291.82)

A. The patient’s symptoms meet the criteria for insomnia.
B. The insomnia is present for at least one month.
C. One of the following applies:
- There is current ongoing dependence on or abuse of a drug or substance known to have sleep-disruptive properties either during periods of use or intoxication or during periods of withdrawal
- The patient has current ongoing use of or exposure to a medication, food, or toxin known to have sleep-disruptive properties in susceptible individuals
D. The insomnia is temporally associated with the substance exposure, use or abuse, or acute withdrawal.
E. The sleep disturbance is not better explained by another sleep disorder, medical or neurological disorder, or mental disorder.
Insomnia Due to Medical Condition 327.01
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 physiological 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.
E. The sleep disturbance is not better explained by another sleep disorder, mental disorder, medication use, or substance use disorder.


II. Sleep Related Breathing Disorders

Primary Central Sleep Apnea 327.21

A. The patient reports at least one of the following:
- Excessive daytime sleepiness
- Frequent arousals and awakenings during sleep or insomnia complaints
- Awakening short of breath
B. Polysomnography shows five or more central apneas per hour of sleep.
C. The disorder is not better explained by another current sleep disorder, medical or neurological disorder, medication use, or substance use disorder.

Cheyne Stokes Breathing Pattern 786.04

A. Polysomnography shows at least 10central apneas and hypopneas per hour of sleep in which the hypopnea has a crescendo-decrescendo pattern of tidal volume accompanied by frequent arousals from sleep and derangement of sleep structure.
Note: Although symptoms are not mandatory to make this diagnosis, patients often report excessive daytime sleepiness, frequent arousals and awakenings during sleep, insomnia complaints, or awakening short of breath.
B. The breathing disorder occurs in association with a serious medical illness, such as heart failure, stroke, or renal failure.
C. The disorder is not better explained by another current sleep disorder, medication use, or substance use disorder.


High-Altitude Periodic Breathing 327.22

A. Recent ascent to altitude of at least 4000 meters
B. Polysomnography demonstrates recurrent central apneas primarily during NREM sleep at a frequency greater than five per hour. The cycle length should be 12 to 34 seconds. Note: Because high-altitude periodic breathing is a normal adaptation to altitude, there are no specific criteria regarding the frequency of central apneas that should be considered normal or abnormal. Although no specific symptoms are required, recurrent awakening during the night and fatigue during the day may be present.


Central Sleep Apnea Due to Drug or Substance 327.29

A. The patient has been taking a long-acting opioid regularly for at least two months.
B. Polysomnography shows a central apnea index of five or more or periodic breathing (10 or more central apneas and hypopneas per hour of sleep in which the hyperpneas has a crescendo-decrescendo pattern of tidal volume, accompanied by frequent arousals from sleep and derangement of sleep structure).
C. The disorder is not better explained by another current sleep disorder or medical or neurological disorder.


Obstructive Sleep Apnea, Adult 327.23

A, B, and D or C and D satisfy the criteria:
A. At least one of the following applies:
- The patient complains of unintentional sleep episodes during wakefulness, daytime sleepiness, unrefreshing sleep, fatigue, or insomnia
- The patient wakes with breath holding, gasping, or choking
- The bed partner reports loud snoring, breathing interruptions, or both during the patient´ s sleep

B. Polysomnographic recording shows the following:
- Five or more scoreable respiratory events (i.e., apneas, hypopneas, or RERAs) per hour of sleep
- Evidence of respiratory effort during all or a portion of each respiratory event (In the case of a RARE, this is best seen with the use of esophageal manometry)

OR

C. Polysomnographic recording shows the following:
- Fifteen or more scoreable respiratory events (i.e., apneas, hypopneas, or RERAs) per hour of sleep
- Evidence of respiratory effort during all or a portion of each respiratory event (In the case of RERA, this is best seen with the use of esophageal manometry)

D. The disorder is not better explained by another current sleep disorder, medical or neurological disorder, medication use, or substance use disorder.

Sleep Related Nonobstructive Alveolar Hypoventilation, Idiopathic 327.24

A. Polysomnographic monitoring demonstrates episodes of shallow breathing longer than 10 seconds in duration associated with arterial oxygen desaturation and frequent arousals from sleep associated with the breathing disturbances or brady-tachycardia.
Note: Although symptoms are not mandatory to make this diagnosis, patients often report excessive daytime sleepiness, frequent arousals and awakenings during sleep, or insomnia complaints.

B. No primary lung diseases, skeletal malformations, or peripheral neuromuscular disorders that affect ventilation are present.

C. The disorder is not better explained by another current sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

Sleep Related Hypoventilation/Hypoxemia Due to Pulmonary Parenchymal or Vascular Pathology 327.26

A. Lung parenchymal disease or pulmonary vascular disease is present and believed to be the primary cause of hypoxemia.

B. Polysomnography or sleeping arterial blood gas determination shows at least one of the following:
- An SpO2 during sleep of less than 90% for more than five minutes with a nadir of at least 85%
- More than 30% of total sleep time at an SpO2 of less than 90%
- Sleeping arterial blood gas with PaCO2 that is abnormally high or disproportionately increased relative to levels during wakefulness

C. The disorder is not better explained by another current sleep disorder, medical or neurological disorder, medication use, or substance use disorder.

Sleep Related Hypoventilation/Hypoxemia Due to Lower Airways Obstruction 327.26

A. Lower airways obstructive disease is present (as evidence by a forced expiratory volume exhaled in one-second/forced vital capacity ration less than 70% of predicted values on pulmonary function testing) and is believed to be the primary cause of hypoxemia.

B. Polysomnography or sleeping arterial blood gas determination shows at least one of the followings:
- An SpO2 during sleep of less than 90% for more than five minutes with a nadir of at least 85%
- More than 30% of total sleep time with an SpO2 of less than 90%
- Sleeping arterial blood gas with PaCO2 that is abnormally high or disproportionately increased relative to levels during wakefulness

C. The disorder is not better explained by another current sleep disorder, medical or neurological disorder, medication use, or substance use disorder.

Sleep Related Hypoventilation/Hypoxemia Due to Neuromuscular and Chest Wall Disorders 327.26

A. A neuromuscular or chest wall disorder is present and believed to be the primary cause of hypoxemia.

B. Polysomnography or sleeping arterial blood gas determination shows at least one of the following:
- An SpO2 during sleep of less than 90% for more than five minutes with a nadir of at least 85%
- More than 30% of total sleep time at an SpO2 of less than 90%
- Sleeping arterial blood gas with PaCO2 that is abnormally high or disproportionately increased relative to levels during wakefulness

C. The disorder is not better explained by another current sleep disorder, medical or neurological disorder, medication use, or substance use disorder.


Narcolepsy With Cataplexy 347.01

A. The patient has a complaint of excessive daytime sleepiness occurring almost daily for at least three month.

B. A definite history of cataplexy, defined as sudden and transient episodes of loss of muscle tone triggered by emotions, is present. Note: To be labeled as cataplexy, these episodes must be triggered by strong emotions – most reliably laughing or joking – and must be generally bilateral and brief (less than two minutes). Consciousness is preserved, at least at the beginning of the episode. Observed cataplexy with transient reversible loss of deep tendon reflexes is a very strong, but rare, diagnostic finding.

C. The diagnosis of narcolepsy with cataplexy should, whenever possible, be confirmed by nocturnal polysomnography followed by an MSLT; the mean sleep latency on MSLT is less than or equal to eight minutes and two or more SOREMPs are observed following sufficient nocturnal sleep (minimum six hours) during the night prior to the test. Alternatively, hypocertin-1 levels in the CSF are less than or equal to 110 pg/mL or one-third of mean normal control values. Note: The presence of two or more SOREMPs during MSLT is a very specific finding, whereas a mean sleep latency of less than eight minutes can be found in up to 30% of the normal population. Low CSF hypocertin-1 levels (less than or equal to 110 pg/mL or one-third of mean normal control values) are found in more than 90% of patients with narcolepsy with cataplexy and almost never in controls or in other patients with other pathologies.

D. The hypersomnia is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

PEDIATRICS: The daytime sleepiness of narcolepsy may present as sleeping at school or the reappearance of regular daytime naps. Narcolepsy in children can also manifest as behavioral problems, decreased performance, inattentiveness, lack of energy, or insomnia. Affected children may be misdiagnosed with attention-deficit/hyperactivity disorder, schizophrenia, or depression. Episodes of cataplexy may be misdiagnosed as seizures. The presence of sleep paralysis or hypnagogic hallucinations may be difficult to confirm, depending on the child’s verbal ability. Narcolepsy with cataplexy is extreme rare prior to the age of four years.

Narcolepsy Without Cataplexy 347.00

A. The patient has a complaint of excessive daytime sleepiness occurring almost daily for at least three month.

B. Typical cataplexy is not present, although doubtful or atypical cataplexy-like episodes may be reported.

C. The diagnosis of narcolepsy without cataplexy must be confirmed by nocturnal polysomnography followed by MSLT. In narcolepsy without cataplexy, the mean sleep and two more SOREMPs are observed following sufficient nocturnal sleep (minimum six hours) during night prior to the test. Note: The presence of two or more SOREMs during the MALT is a specific finding, whereas a mean sleep latency of less than eight minutes can be found in up to 30% of the normal population.

D.The hypersomnia is not better explained by another sleep disorder, medical or neurological disorder, mental disorder use, or substance use disorder.

PEDIATRICS: The daytime sleepiness of narcolepsy may present as sleeping at school or the reappearance of regular daytime naps. Narcolepsy in children can also manifest as behavioral problems, decreased performance, inattentiveness, lack of energy or insomnia. Affected children may be misdiagnosed with attention-deficit/hyperactivity disorder, schizophrenia, or depression. The presence of sleep paralysis or hypnagogic hallucinations may be difficult to confirm, depending on the child’s verbal ability. Narcolepsy without cataplexy is extremely rare prior to the age of four years. In all pediatric cases, one should consider the possibility that the patient will, with time, develop full narcolepsy with cataplexy. In peri-pubertal children and adolescents, the most common causes of short sleep latencies, often with multiple SOREMPs on the MSLT, are chronic sleep deprivation and delayed sleep phase syndrome.

Narcolepsy Due to Medical Condition (with cataplexy – 347.10) (without cataplexy – 347.11)

A. The patient has a complaint of excessive daytime sleepiness occurring almost daily for at least three months.

B. One of the following must be observed:
- A definite history of cataplexy, defined as sudden and transient episodes of loss of muscle tone (muscle weakness) triggered by emotions, is present Note: To be cataplexy, these episodes must be triggered by strong emotions, most reliably laughing or joking, and must be generally bilateral and brief (less than two minutes). Consciousness is preserved at least at the beginning of the episode. In narcolepsy (with cataplexy) due to a medical condition, the diagnosis should whenever possible, be confirmed by nocturnal polysomnography followed by an MSLT (see MSLT criteria below).
- If cataplexy is not present or is very atypical, polysomnographic monitoring performed over the patient’s habitual sleep period followed by an MSLT must demonstrate a mean sleep latency on the MSLT of less than eight minutes with two or more SOREMPs, despite sufficient nocturnal sleep prior to the test (minimum six hours) Note: The presence of two or more SOREMPs during the MSLT is a very specific finding, whereas a mean sleep latency of less than eight minutes can be found in up to 30% of the general population. - Hypocretin-1 levels in the CSF are less than 110 pg/mL (or 30% of normal control values), provided the patient is not comatose
Note: In patients with severe medical or neurological illness, nocturnal polysomnography or the MSLT may be impossible to conduct or to interpret. Similarly, the value of measuring hypocretin-1 levels in the CSF in critically ill patients is uncertain. Abnormal polysomnography and low CSF hypocretin-1 levels should be interpreted within the clinical context.

C. A significant underlying medical or neurological disorder accounts for the daytime sleepiness

D. The hypersomnia is not better explained by another sleep disorder, mental disorder, medication use, or substance use disorder.

Recurrent Hypersomnia (Including Kleine-Levin Syndrome and Menstrual-Related Hypersomnia) 327.13

A. The patient experiences recurrent episodes of excessive sleepiness of two days to four weeks duration.
B. Episodes recur at least once a year.
C. The patient has normal alertness, cognitive functioning and behavior between attacks.
D. The hypersomnia is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

PEDIATRICS: The onset of the condition has been reported in children as young as six years of age. Most cases affect adolescents.

Idiopathic Hypersomnia With Long Sleep Time 327.11

A. The patient has a complaint of excessive daytime sleepiness occurring almost daily for at least three months.
B. The patient has prolonged nocturnal sleep time (more than 10 hours) documented by the interview, actigraphy, or sleep logs. Waking up in the morning or at the end of naps is almost always laborious.
C. Nocturnal polysomnogram has excluded other causes of daytime sleepiness.
D. The polysomnogram demonstrates a short sleep latency and a major sleep period that is prolonged to more than 10 hours in duration.
E. If an MSLT is performed following overnight polysomnography, a mean sleep latency of less than eight minutes is found and fewer two SOREMPs are recorded. Mean sleep latency in idiopathic hypersomnia with long sleep time has been shown to be 6.2 ± 3.0 minutes. Note: A mean sleep latency on the MSLT of less than eight minutes can be found in op to 30% of the general population. Both the mean sleep latency on the MSLT and the clinician’s symptoms, most notably a clinically significant complaint of sleepiness, should be taken into account in reaching the diagnosis of idiopathic hypersomnia with long sleep time.
F. The hypersomnia is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder. Note: Of particular importance, head trauma should not be considered to be the cause of the sleepiness.
PEDIATRICS: Idiopathic hypersomnia is rarely seen before adolescence.

Idiopathic Hypersomnia Without Long Sleep Time 327.12

A. The patient has a complaint of excessive daytime sleepiness occurring almost daily for at least three months.
B. The patient has normal nocturnal sleep (greater than six hours but less than 10 hours) documented by interviews, actigraphy, or less sleep logs.
C. Nocturnal polysomnography has excluded other causes of daytime sleepiness.
D. Polysomnography demonstrates a major sleep period that is normal in duration (greater than six hours but less than 10 hours).
E. An MSLT following overnight polysomnography demonstrates a mean sleep latency of less than eight minutes and fewer than two SOREMPs. Mean sleep latency in idiopathic hypersomnia has been shown to be 6.2 ± 3.0 minutes. Note: A mean sleep latency of less than eight minutes can be found in up to 30% of the general population. Both the mean sleep latency on the MSLT and the clinical’s interpretation of the patient’s symptoms, most notably a clinically significant complaint of idiopathic hypersomnia without long sleep time.
F. The hypersomnia is not better explained by another sleep disorder, medication use, or substance use disorder.

Behaviorally Induced Insufficient Sleep Syndrome 307.44

A. The patient has a complaint of excessive sleepiness or, in prepubertal children, a complaint of behavioral abnormalities suggesting sleepiness. The abnormal sleep pattern is present almost daily for at least three month.

B. The patient’s habitual sleep episode, established using history, a sleep log, or actigraphy, is usually shorter than expected from age-adjusted normative data. Note: In the case of individuals with long sleep time, habitual sleep periods may be normal, based on age-adjusted normative data. However, these sleep periods may be insufficient for this population.

C. When the habitual sleep schedule is not maintained (weekends or vacation time), patients will sleep considerably longer than usual.

D. When polysomnography is performed, sleep latency is less than 10 minutes and sleep efficiency greater than 90%. During the MSLT, a short mean sleep latency of less than eight minutes (with or without multiple SOREMPs) may be observed.

E. The hypersomnia is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medical use, or substance use disorder.

Hypersomnia Due to Medical Condition 327.14

A. The patient has a complaint of excessive sleepiness present almost daily for at least three months.

B. A significant underlying medical or neurological disorder accounts for the daytime sleepiness.

C. In an MSLT is performed, the mean sleep latency is less than eight minutes with no more than one SOREMP following polysomnographic monitoring performed over the patient’s habitual sleep period, with a minimum total sleep time of six hours.

D. The hypersomnia is not better explained by another sleep disorder, mental disorder, medication use, or substance use disorder. Note: In patient’s with severe medical or neurological illness, conducting and interpreting the results of nocturnal polysomnographiy or the MSLT may be impossible. Abnormal polysomnographic results should be interpreted within the clinical context. Additionally, mean sleep latency on MSLT of less than eight minutes can be found in up to 30% of the general population. A clinically significant complaint of excessive daytime sleepiness is far more important than is short sleep latency on MSLT in the diagnosis of hypersomnia due to medical condition.

PEDIATRICS: Special attention should be given to genetic disorders in the pediatric population.

Hypersomnia Due to Drug or Substance (Abuse) 292.85 (for Alcohol use 291.82)

A. The patient has a complaint of sleepiness or excessive sleep.
B. The complaint is believed to be secondary to current use, recent discontinuation, or prior prolonged use of drugs.
C. The hypersomnia is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, or medication use.

Hypersomnia Due to Drug or Substance (Medications) 292.85

A. The patient has a complaint of sleepiness or excessive sleep.
B. The complaint is associated with current use, recent discontinuation, or prior prolonged use of a prescribed medication.
C. The hypersomnia is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, or substance use disorder.
Hypersomnia Not Due to Substance or Known Physiological Condition (Nonorganic Hypersomnia, NOS) 327.15
A. The patient has a complaint of excessive daytime sleepiness or excessive sleep.
B. The complaint is temporally associated with a psychiatric diagnosis.
C. Polysomnographic monitoring demonstrates both of the following:
- Reduced sleep efficiency and increased frequency and duration of awakenings
- Variable, often normal, mean sleep latencies on the MSLT
D. The hypersomnia is not better explained by another sleep disorder, medical or neurological disorder, medication use, or substance use disorder.


IV. CIRCADIAN RHYTHM SLEEP DISORDERS

General Criteria for Circadian Rhythm Sleep Disorder

A. There is a persistent or recurrent pattern of sleep disturbance due to primarily to one of the following:
- Alternations of the circadian timekeeping system
- Misalignment between the endogenous circadian rhythm and exogenous factors that affect the timing or duration of sleep

B. The circadian related sleep disruption leads to insomnia, excessive daytime sleepiness, or both.
C. The sleep disturbance is associated with impairment of social, occupational, or other areas of functioning.

Circadian Rhythm Sleep Disorder, Delayed sleep Phase Type (Delayed Sleep Phase Disorder) 327.31

A. There is a delay in the phase of the major sleep period in relation to the desired sleep time and wake-up time, as evidenced by a chronic or recurrent complaint of inability to fall asleep at a desired conventional clock time together with the inability to awaken at a desired and socially acceptable time.

B. When allowed to choose their preferred schedule, patients will exhibit normal sleep quality and duration for age and maintain a delayed, but stable, phase of entrainment to the 24-hour sleep-wake pattern.

C. Sleep log or actigraphy monitoring (including sleep diary) for at least seven days demonstrates a stable delay in the timing of the habitual sleep period. Note: In addition, a delay in the timing of other circadian rhythms, such as the nadir of the core body temperature rhythm or DLMO, is useful for information of the delayed phase.

D. The disturbance is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

Circadian Rhythm Sleep Disorder, Advanced Sleep Phase Type (Advanced Sleep Phase Disorder) 327.32

A. There is an advance in the phase of the major sleep period in relation to the desired sleep time and wake-up time, as evidenced by a chronic or recurrent complaint of inability to stay awake until the desired and socially acceptable time for awakening.

B. When patients are allowed to choose their preferred schedule, sleep quality and duration are normal for age with an advanced, but stable, phase of entrainment to the 24-hour sleep-wake pattern.

C. Sleep logs or actigraphy monitoring (including sleep diaries) for at least seven days demonstrate a stable advance in the timing of the habitual sleep period. Note: In addition, an advance in the timing of other circadian rhythms such as the nadir of the core body temperature rhythm or DLMO, is useful for confirmation of the advanced circadian phase.

D. The disturbance is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

Circadian Rhythm Sleep Disorder, Irregular Sleep-Wake Type (Irregular Sleep-Wake Rhythm) 327.33

A. There is a chronic complaint of insomnia, excessive sleepiness, or both.
B. Sleep logs or actigraphy monitoring (including sleep diaries) for at least seven days demonstrate multiple irregular sleep bouts (at least three) during a 24-hour period.
C. Total sleep time per 24-hour period is essentially normal for age.
D. The disturbance is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

Circadian Rhythm Sleep Disorder, Free-Running Type (Nonentrained Type) 327.34

A. There is a complaint of insomnia or excessive sleepiness related to abnormal synchronization between the 24-hour light-dark cycle and the endogenous circadian rhythm of sleep and wake propensity.
B. Sleep log or actigraphy monitoring (with sleep diaries) for at least seven days demonstrates a pattern of sleep and wake times that typically delays each with a period longer than 24 hours. Note: Monitoring sleep logs or actigraphy for more than seven days is preferred in order to clearly establish the daily drift.
C. The disturbance is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

Circadian Rhythm Sleep Disorder, Jet Lag Type (Jet Lag Disorder) 327.35

A. There is a complaint of insomnia or excessive daytime sleepiness associated with transmeridian jet travel across at least two time zones.
B. There is associated impairment of daytime function, general malaise, or somatic symptoms such as gastrointestinal disturbance within one to two days after travel.
C. The disturbance is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

Circadian Rhythm Sleep Disorder, Shift Work Type (Shift Work Disorder) 327.36

A. There is a complaint of insomnia or excessive sleepiness that is temporally associated with a recurring work schedule that overlaps the usual time for sleep.
B. The symptoms are associated with the shift-work schedule over the course of at least one month.
C. Sleep log or actigraphy monitoring (with sleep diaries) for at least seven days demonstrates disturbed circadian and sleep-time misalignment.
D. The sleep disturbance is not better explained by another current sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

Circadian Rhythm Sleep Disorder Due to Medical Condition 327.37

A. There is a complaint of insomnia or excessive sleepiness related to alterations of the circadian timekeeping system or a misalignment between the endogenous circadian rhythm and endogenous factors that effect the timing or duration of sleep.
B. An underlying medical or neurological disorder predominantly accounts for the circadian rhythm sleep disorder.
C. Sleep log or actigraphy monitoring (with sleep diaries) for at least seven days demonstrates disturbed or low amplitude circadian rhythmicity.
D. The sleep disturbance is not better explained by another current sleep disorder, mental disorder, medication use, or substance use disorder.


V. PARASOMNIAS

Confusional Arousals 327.41

A. Recurrent mental confusion or confusional behavior occurs during an arousal or awakening from nocturnal sleep or a daytime nap.
B. The disturbance is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

Sleepwalking 307.46

A. Ambulation occurs during sleep.

B. Persistence of sleep, an altered state of consciousness, or impaired judgment during ambulation is demonstrated by at least one of the following:
- Difficulty in arousing the person
- Mental confusion when awakened from an episode
- Amnesia (complete or partial) for the episode
- Routine behaviors that occur at inappropriate times
- Inappropriate or nonsensical behaviors
- Dangerous or potentially dangerous behaviors

C. The disturbance is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

Sleep Terrors 307.46

A. A sudden episode of terror occurs during sleep, usually initiating by a cry or loud scream that is accompanied by autonomic nervous system and behavioral manifestations of intense fear.

B. At least one of the following associated features is present:
- Difficulty in arousing the person
- Mental confusion when awakened form an episode
- Amnesia (complete or partial) for the episode
- Dangerous or potentially dangerous behaviors

C. The disturbance is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

Rapid Eye Movement Sleep Behavior Disorder (Including Parasomnia Overlap Disorder and Status Dissociatus) 327.42

A. Presence of REM sleep without atonia: the EMG finding of excessive amounts of sustained or intermittent elevation of submental EMG tone or excessive phasic submental or (upper or lower) limb EMG twitching.
B. At least one of the following is present:
- Sleep related injurious, potentially injurious, or disruptive behaviors by history
- Abnormal REM sleep behaviors documented during polysomnographic monitoring
- Awakening short of breath
C. Absence of EEG epileptiform activity during REM sleep unless RBD can be clearly distinguished from any concurrent REM sleep-related seizure disorder.
D. The sleep disturbance is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.


Recurrent Isolated Sleep Paralysis 327.43

A. The patient complains of an inability to move the trunk and all limbs at sleep onset or on waking from sleep.

B. Each episode lasts seconds to a few minutes.
C. The sleep disturbance is not better explained by another sleep disorder (particularly narcolepsy), a medical or neurological disorder, mental disorder, medication use, or substance use disorder.

Nightmare Disorder 307.47

A. Recurrent episodes of awakenings from sleep with recall of intensely disturbing dream mentation, usually involving fear or anxiety, but also anger, sadness, disgust, and other dysphoric emotions.

B. Full alertness on awakening, with little confusion or disorientation; recall of sleep mentation is immediate and clear.

C. At least one of the following associated features is present:
- Delayed return to sleep after the episodes
- Occurrence of episodes in the latter half of the habitual sleep period


Sleep Related Dissociative Disorders 300.15

A. A dissociative disorder, fulfilling Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnostic criteria is present and emerges in close association with the main sleep period.

B. One of the following is present:
- Polysomnography demonstrates a dissociative episode or episodes that emerge during sustained EEG wakefulness, either in the transition from wakefulness to sleep or after an awakening from NREM or REM sleep
- In the absence of a polysomnographically-recorded episode of dissociation, the history provided by observers is compelling for a sleep related dissociative disorder, particularly if the sleep related behaviors are similar to observed daytime dissociative behaviors

C. The sleep disturbance is not better explained by another sleep disorder, medical or neurological disorder, medication use, or substance use disorder.

Sleep Related Groaning (Catathrenia) 327.49

A or B satisfies the criteria:
A. A history of regularly occurring groaning (or related monotonous vocalization) occurring during sleep.
B. Polysomnography with respiratory-sound monitoring reveals a characteristic respiratory dysrhythmia predominantly or exclusively during REM sleep.


Exploding Head Syndrome 327.49

A. The patient complains of a loud noise or sense of explosion in the head either at the wake-sleep transition or upon waking during the night.
B. The experience is not associated with significant pain complaints.
C. The patient rouses immediately after the event, usually with a sense of fright.
Note: In a minority of cases, a flesh of light or myoclonic jerk may accompany the event.

Sleep Related Hallucinations 368.16

A. The patient experiences hallucinations just prior to sleep onset or on awakening during the night or in the morning.
B. The hallucinations are predominantly visual.
Note: Hypnagogic or hypnopompic hallucinations may be difficult to differentiate from sleep-termination dreaming. Complex nocturnal visual hallucinations may clearly occur in wakefulness following sudden during the night.
C. The disturbance is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

Sleep Related Eating Disorder 327.49

A. Recurrent episodes of involuntary eating and drinking occur during the main sleep period.
B. One or more of the following must be present with the recurrent episodes of involuntary eating and drinking:
- Consumption of peculiar forms or combinations of food or inedible or toxic substances
- Insomnia related to sleep disruption from repeated episodes of eating, with a complaint of nonrestorative sleep, daytime fatigue, or somnolence
- Sleep-related injury
- Dangerous behaviors performed while in pursuit of food or while cooking food
- Morning anorexia
- Adverse health consequences from recurrent binge eating of high-caloric foods
C. The disturbance is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

VI. SLEEP RELATED MOVEMENT DISORDERS

Restless Legs Syndrome 333.99

Diagnosis in Adult Patients (Age Older Than 12 Years)
A. The patient reports an urge to move the legs, usually accompanied or caused by uncomfortable and unpleasant sensations of the legs.
B. The urge to move or the unpleasant sensations begin or worsen during periods of rest or inactivity such as lying or sitting.
C. The to move or the unpleasant sensations are partially or totally relieved by movement, such as walking or stretching, at least as long as the activity continues.
D. The urge to move or the unpleasant sensations are worse, or only occur, in the evening or night.
E. The disorder is not better explained by another current sleep disorder, medical or neurological disorder, medication use, or substance use disorder.

Periodic Limb Movement Disorder 327.51

A. Plysomnography demonstrates repetitive, highly stereotyped, limb movements that are:
- 0.5 to 5 seconds in duration
- Of amplitude greater than or equal to 25% of toe dorsiflexion during calibration
- In a sequence of four or more movements
- Separated by an interval of more than five seconds (from limb-movement onset to limb-movement onset) and less than 90 seconds (typically there is an interval of 20 to 40 seconds)

B. The PLMS Index exceeds five per hour in children and 15 per hour in most adult cases Note: The PLMS Index must be interpreted in the context of a patient’s sleep related complaint. In adults, normative values higher than the previously accepted value of five per hour have been found in studies that did not exclude RERAs (using sensitive respiratory monitoring) and other causes for PLMS. New data suggest a partial overlap of PLMS Index values between symptomatic and asymptomatic individuals, emphasizing the importance of clinical context over an absolute cutoff value.

C. There is clinical sleep disturbance or a complaint of daytime fatigue. Note: If PLMS are present without clinical sleep disturbance, the PLMS can be noted as a polysomnographic finding, but criteria are not met for a diagnosis of PLMD. D. The PLMs are not better explained by another current sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder (e.g., PLMs at the termination of cyclically occurring apneas should not be counted as true PLMS or PLMD).

Sleep Related Leg Cramps 327.52

A. A painful sensation in the leg or foot is associated with sudden muscle hardness or tightness indicating a strong muscle contraction.
B. The painful muscle contractions in the legs or feet occur during the sleep period, although they may arise from either wakefulness or sleep.
C. The pain is relieved by forceful stretching of the affected muscles, releasing the contraction.
D. The disorder is not better explained by another current sleep disorder, medical or neurological disorder, medication use, or substance use disorder.

Sleep Related Bruxism 327.53

A. The patient reports or is aware or tooth-grinding sounds or tooth clenching during sleep.
B. One or more of the following is present:
- Abnormal wear of the teeth
- Jaw muscle discomfort, fatigue, or pain and jaw lock upon awakening
- Masseter muscle hypertrophy upon voluntary forceful clenching
C. The disorder is not better explained by another current sleep disorder, medical or neurological disorder, medication use, or substance use disorder.

VIII. OTHER SLEEP DISORDERS

Environmental Sleep Disorders 307.48

A. The patient complains of insomnia, daytime fatigue, or a parasomnia. In cases in which daytime fatigue is present, the daytime fatigue may occur as a result of the accompanying insomnia or as a result of poor quality of nocturnal sleep.
B. The complaint is temporally associated with the introduction of a physically measurable stimulus or environmental circumstance that disturbs sleep.
C. It is the physical properties, rather than the psychological meaning of the environmental factor, that accounts for the sleep complaint.
D. The sleep disturbance is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

PEDIATRIC SECTION

Behavioral Insomnia of Childhood (Sleep-Onset Type) v69.5

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 sleep-onset association with the following symptoms:
- Falling asleep is an extended process that requires special conditions
- Sleep-onset associations are highly problematic or demanding
- In the absence of the associated conditions, sleep onset is significantly delayed or sleep is otherwise disrupted
- Awakenings require caregiver intervention for the child to return to sleep

C. The sleep disturbance is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

Behavioral Insomnia of Childhood (Limit-Setting Type) v69.5

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 limit-setting type with the following symptoms:
- The individual has difficulty initiating or maintaining sleep
- The individual stalls or refuses to go to bed at an appropriate time or refuses to return to bed following a nighttime awakening
- The caregiver demonstrates insufficient or inappropriate limit setting to establish appropriate sleeping behavior in the child

C. The sleep disturbance is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

Primary Sleep Apnea of Infancy (formerly Primary Sleep Apnea of Newborn) 770.81

A. Apnea of Prematurity. Prolonged central respiratory pauses of 20 seconds or more in duration (or shorter-duration events that include obstructive or mixed respiratory patterns and are associated with a significant physiologic compromise, including decrease in heart rate, hypoxemia, clinical symptoms, or need for nursing intervention), are recorded in an infant younger than 37 weeks conceptional age.

B. Apnea of Infancy. Prolonged central respiratory pauses of 20 seconds or more in duration (or shorter-duration events that include obstructive or mixed respiratory patterns and are associated with bradycardia, cyanosis, pallor, or marked hypotonia), are recorded in an infant with a conceptional age of 37 weeks or older.

C. For either diagnosis, the disorder is not better explained by another current sleep disorder, medical or neurological disorder, or medication.

Obstructive Sleep Apnea, Pediatric 327.23

A. The caregiver reports snoring, labored or obstructed breathing, or both snoring and labored or obstructed breathing during the child’s sleep.

B. The caregiver of the child reports observing at least one of the following:
- Paradoxical inward rib-cage motion during inspiration
- Movement arousals
- Diaphoresis
- Neck hyperextension during sleep
- Excessive daytime sleepiness, hyperactivity, or aggressive behavior
- A slow rate of growth
- Morning headaches
- Secondary enuresis

C. Polysomnographic recording demonstrates one or more scoreable respiratory event per hour (i.e., apnea or hypopnea of at least two respiratory cycles in duration) Note: Very few normative data are available for hypopneas, and the data that are available have been obtained using a variety of methodologies. These criteria may be modified in the future once more comprehensive data become available.

D. Polysomnographic recording demonstrates either i or ii:
At least one of the following is observed:
- Frequent arousals from sleep associated with increased respiratory effort and/ or
- Arterial oxygen desaturation in association with the apneic episodes and/ or
- Hypercapnia during sleep and/ or
- Markedly negative esophageal pressure swings
Periods of hypercapnia, desaturation, or hypercapnia and desaturation during sleep associated with snoring, paradoxical inward ribcage motion during inspiration, and at least one of the following: - Frequent arousals from sleep and/ or
- Markedly negative esophageal pressure swings

E. The disorder is not better explained by another current sleep disorder, medical or neurological disorder, medication use, or substance use disorder.

Congenital Central Alveolar Hypoventilation Syndrome 327.25

A. The patient exhibits shallow breathing, or cyanosis and apnea, of perinatal onset during sleep.
Note: In severely affected infants, consequences of hypoxia, including pulmonary hypertension and cor, pulmonale, may also be present.
B. Hypoventilation is worse during sleep than during wakefulness.
C. The rebreathing ventilatory response to hypoxia and hypercapnia is absent or diminished.
D. Polysomnographic monitoring during sleep demonstrates severe hypercapnia and hypoxia, predominantly without apnea.
E. The disorder is not better explained by another current sleep disorder, medical or neurological disorder, medication use, or substance use disorder.

Sleep Enuresis 788.36

Primary

A. The patient is older than five years.
B. The patient exhibits recurrent involuntary voiding during sleep, occurring at least twice a week.
C. The patient has never been consistently dry during sleep.

Secondary

A. The patient is older than five years of age.
B. The patient exhibits recurrent involuntary voiding during sleep, occurring at least twice a week.
C. The patient has previously been consistently dry during sleep for at least six month.


Restless Leg Syndrome 333.99

Diagnosis in Pediatric Patients (Age 12 to 12 Years)
A. The child meets all four essential adult criteria for RLS listed previously and relates a description, in his or her own words, that is consistent with leg discomfort.
B. The child meets all four essential adult criteria for RLS listed previously but does not relate a description in his or her own words that is consistent with leg discomfort.
C. The child has at least two of the following three findings:
- A sleep disturbance for age
- A biological or sibling with definite RLS
- A polysomnographically documented periodic limb movement index of five or more movements per hour of sleep

Note: Criteria for probable and possible childhood RLS have been developed for research purposes and are included in a National Institutes of Health diagnostic workshop report. Sleep Related Rhythmic Movement Disorder 327.59

A. The patient exhibits repetitive, stereotyped, and rhythmic motor behaviors.
B. The movements involve large muscle groups.
C. The movements are predominantly sleep related, occurring near nap or bedtime, or when the individual appears drowsy or asleep.
D. The behaviors result in a significant complaint as manifest by at least one of the following:
- Interference with normal sleep
- Significant impairment in daytime function
- Self-inflicted bodily injury that requires medical treatment (or would result in injury if preventable measures were not used)
E. The rhythmic movements are not better explained by another current sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

Privacy, Legal disclaimer | Norme legali
Designed by: Borderzero studio creativo
Copyright ©2000-2008 Polisonnografia tutti i diritti riservati