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[ Contemporary Reviews in ]

I n t e r n a t i o n a l C l a s s i fi cation of Sleep Disorders-Th ird Edition Highlights and Modifi cations

Michael J. Sateia , MD

The recently released third edition of the International Classifi cation of Sleep Disorders (ICSD) is a fully revised version of the American Academy of ’s manual of sleep disorders nosology, published in cooperation with international sleep societies. It is the key reference work for the diagnosis of sleep disorders. The ICSD-3 is built on the same basic outline as the ICSD-2, identifying seven major categories that include disorders, sleep-related disorders, central disorders of hypersomnolence, sleep-wake dis- orders, sleep-related movement disorders, , and other sleep disorders. Signifi cant modifi cations have been made to the nosology of insomnia, , and parasomnias. Major features and changes of the manual are reviewed in this article. The rationales for these changes are also discussed. CHEST 2014; 146 ( 5): 1387- 1394

ABBREVIATIONS : A A S M 5 American Academy of Sleep Medicine ; CRSWD 5 circadian rhythm sleep- wake disorder ; CSA 5 central sleep ; CSB 5 Cheyne-Stokes breathing ; ICD 5 International Classification of ; I C S D 5 International Classification of Sleep Disorders ; I H 5 idiopathic ; MSLT 5 multiple sleep latency test ; NREM 5 non-rapid eye movement ; OCST 5 out-of- center sleep testing; PAP 5 p o s i t i v e a i r w a y p r e s s u r e ; P L M 5 periodic limb movement; PLMD 5 p e r i o d i c limb ; PSG 5 polysomnogram ; RBD 5 behavior disorder ; REM 5 rapid eye movement ; RLS 5 restless legs ; SOREMP 5 sleep-onset rapid eye movement p e r i o d

Th e recent publication of the third edition recommendations were added. of the International Classifi cation of Sleep Several key considerations apply to all Disorders (ICSD) 1 represents another diagnoses within ICSD-3. Although the step forward in the evolution of sleep criteria for each diagnosis have been disorders nosology. ICSD-3 builds on the reviewed and revised carefully to be as basic foundation of ICSD-2, retaining the sensitive and specifi c to the disorder as same major diagnostic sections of that possible, the reality is that there is much manual ( Table 1 ). Th e preparation of the still unknown about the classifi cation of classifi cation system included extensive these disorders. Th is is particularly true with literature reviews for each diagnosis, as well respect to the degree of disturbance required as for major associated features. Th e text was to achieve clinical signifi cance and the most fully revised, and additional text headings eff ective metrics for determining this. As a (eg, Developmental Features) and coding result of these shortcomings,

Manuscript received April 21 , 2014 ; revision accepted June 16 , 2014 . © 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of AFFILIATIONS: From Geisel School of Medicine at Dartmouth, this article is prohibited without written permission from the American Lebanon, NH. College of Chest Physicians. See online for more details. CORRESPONDENCE TO: Michael J. Sateia, MD, Geisel School of Medi- DOI: 10.1378/chest.14-0970 cine at Dartmouth, One Medical Center Dr, Lebanon, NH 03756; e-mail: [email protected]

journal.publications.chestnet.org 1387 TABLE 1 ] ICSD -3 Major Diagnostic Sections dichotomized in several ways that relate to duration

Section and presumed pathophysiology. Th e distinction of acute and chronic insomnia has existed in most diagnostic Insomnia systems since the inception of sleep-wake disorders Sleep-related breathing disorders nosology. Th e ICD system has, at least through its Central disorders of hypersomnolence 10th edition, clung to the now-archaic distinction of Circadian rhythm sleep-wake disorders “organic” vs “nonorganic” insomnia (ie, psychogenic). Parasomnias ICSD-1, ICSD-2, and the Diagnostic and Statistical Sleep-related movement disorders Manual of Mental Disorders 4 (through the fourth edition) Other sleep disorders have used the familiar primary vs secondary (or

ICSD 5 International Classifi cation of Sleep Disorders . comorbid) insomnia distinction. ICSD-1 and ICSD-2 further subtyped primary insomnia into psychophysio- logic, idiopathic, and paradoxical (sleep-state misper- must allow some room for judgment in the application ception) insomnia disorders. However, these approaches of these criteria. In general, unless otherwise specifi ed, to classifi cation, especially the primary vs secondary all criteria must be met to establish a diagnosis. How- (comorbid) distinction, have been challenged. ever, there are undoubtedly individuals with clinically signifi cant sleep disorders who do not meet all the The 2005 National Institutes of Health Consensus criteria for a given diagnosis. In such cases, provisional Panel on Manifestations and Management of Chronic 5 diagnoses with careful follow-up and retesting may be in Insomnia in Adults noted that considerable uncertainty order. Application of the criteria should be guided by the exists with respect to the “nature of (the) associations notes that follow many of the criteria sections. and the direction of causality” in cases of comorbid insomnia. Furthermore, the panel noted that an As with ICSD-2, pediatric diagnoses are not distin- emphasis on the “secondary” nature of many insomnia guished from adult diagnoses, with the exception of disorders may promote inadequate treatment (presum- pediatric OSA. ICSD-3 consistently refers to the AASM ably as a result of an assumption on the part of physi- [American Academy of Sleep Medicine] Manual for the cians that treatment of the “primary” condition is Scoring of Sleep and Associated Events 2 for defi nitions of suffi cient to resolve the insomnia condition). Beyond specifi c polysomnogram (PSG) fi ndings (eg, respiratory these considerations, other concerns have been regis- events or movement abnormalities). Th is will allow tered. It has been clear for some time that the vast up-to-date accuracy of defi nitions as scoring rules majority of chronic insomnia conditions (if not all) evolve prior to the next ICSD publication. share numerous characteristics, regardless of their Finally, the ICSD-3 provides specifi c coding information “primary” vs “comorbid” status. Specifi cally, chronic for each diagnosis. Th e International Classifi cation of insomnia disorders as a whole are typically associated Diseases (ICD) 3 coding system for the with maladaptive cognitions and behaviors that (clinical modifi cation version) is in transition from the represent major perpetuating factors. These factors ninth to the 10th edition at the time of this writing. must be addressed therapeutically to achieve a suc- Th erefore, both International Classifi cation of Diseases , cessful long-term outcome. Beyond the clearly impor- Ninth Revision , Clinical Modifi cation and International tant management of comorbid disorders such as major Classifi cation of Diseases , Tenth Revision , Clinical or chronic pain, treatment approaches to Modifi cation codes are included. Because ICD system chronic insomnia are essentially the same (ie, cognitive- changes inevitably lag behind changes to the ICSD, users behavioral and/or pharmacologic), regardless of the will note certain discrepancies between the systems in presence or type of comorbidity. Finally, the diagnostic the coding approach for various diagnoses. Th e ICD reliability and validity of insomnia diagnoses, especially codes listed in ICSD-3 represent the best approxima- primary insomnia, have been challenged on the basis of tions within the confi nes of the system. several studies. 6 , 7 In light of the concerns raised by these issues, the Insomnia ICSD-3 task force elected to consolidate all insomnia Th e classifi cation of insomnia disorders in ICSD-3 diagnoses (ie, “primary” and “comorbid”) under a represents a marked departure from that of prior single, chronic insomnia disorder. Th is decision is not systems. Historically, insomnia disorders have been intended to suggest that there may not be important

1388 Contemporary Reviews in Sleep Medicine [ 146#5 CHEST NOVEMBER 2014 ] pathophysiologic diff erences among chronic insomnia TABLE 3 ] Sleep-Related Breathing Disorders subtypes. Rather, it is the recognition that we are not Disorder yet able to reliably make such distinctions nor to translate them into more customized therapeutic OSA disorders approaches. Th e insomnia diagnoses for ICSD-3 are OSA, adult listed in Table 2. OSA, pediatric Central Chronic Insomnia Disorder with Cheyne-Stokes breathing Th e criteria for this diagnosis are largely congruent Central sleep apnea due to a medical disorder without with those of the general criteria for an insomnia Cheyne-Stokes breathing disorder found in ICSD-2. Th ey include (1) a report of Central sleep apnea due to high altitude periodic breathing sleep initiation or maintenance problems, (2) adequate Central sleep apnea due to a or substance opportunity and circumstances to sleep, and (3) daytime Primary central sleep apnea consequences. Th e ICSD-3 duration criterion for chronic Primary central sleep apnea of infancy insomnia disorder is 3 months, and a frequency criterion (at least three times per week) has been added. Primary central sleep apnea of prematurity Treatment-emergent central sleep apnea It is also important to note that behavioral insomnia of Sleep-related hypoventilation disorders childhood is included within the chronic insomnia hypoventilation syndrome disorder diagnosis. Th e unique aspects of presentation Congenital central alveolar hypoventilation syndrome in children (specifi cally, limit-setting and sleep-onset Late-onset central hypoventilation with hypothalamic association issues) are discussed within the text. dysfunction Not every with poor sleep merits an independent Idiopathic central alveolar hypoventilation insomnia diagnosis. Many individuals experience what Sleep-related hypoventilation due to a medication or substance would reasonably be considered poor sleep but have no Sleep-related hypoventilation due to a medical complaint and/or do not experience signifi cant daytime disorder consequences. Moreover, insomnia is an expected aspect Sleep-related disorder of many medical and psychiatric conditions. A diagnosis of chronic insomnia disorder should be used only when the insomnia is especially prominent or unexpectedly prolonged, and is the focus of clinical evaluation and signs/symptoms (eg, associated sleepiness, , treatment. insomnia, , subjective nocturnal respiratory disturbance, or observed apnea) or associated medical Sleep-Related Breathing Disorders or psychiatric disorder (ie, hypertension, coronary Sleep-related breathing disorders are divided into four artery , atrial fi brillation, congestive , sections: OSAs, central sleep apnea (CSA) syndromes, , , cognitive dysfunction, or mood sleep-related hypoventilation disorders, and sleep- disorder) coupled with fi ve or more predominantly related hypoxemia disorder. Th e full listing of diagnoses obstructive respiratory events (obstructive and mixed can be found in Table 3 . , , or respiratory eff ort-related arousals, as defi ned by the AASM scoring manual) per hour of OSA (Adult) sleep during PSG. Alternatively, a frequency of obstruc- tive respiratory events Ն 15/h satisfi es the criteria, even Th e core criteria for a diagnosis of OSA are largely in the absence of associated symptoms or disorders. Th e unchanged from ICSD-2. Th e diagnosis requires either most signifi cant change from ICSD-2 is that a respira- tory event index (based on hours of monitoring time) TABLE 2 ] Insomnia may be derived from out-of-center sleep testing (OCST). Disorder Th e same criterion frequencies of breathing disturbance

Chronic insomnia disorder apply when OCST is used, although OCST oft en under- Short-term insomnia disorder estimates frequency because recording time, rather than sleep time, becomes the denominator for calculation of Other insomnia disorder the index.

journal.publications.chestnet.org 1389 Although not substantially diff erent from ICSD-2 (PAP) without backup rate. regarding what qualifies as a “respiratory event,” For cases in which the CSA is attributable to other ICSD-3 emphasizes that obstructive respiratory distur- causes, dual diagnoses of OSA and CSA with CSB or bance includes not only obstructive apnea and CSA due to substance should be made. but also respiratory eff ort-related arousal. Th e term Caution is advised in establishing a diagnosis of upper airway resistance syndrome is discouraged treatment-emergent CSA. It is well recognized that there because this represents a variant of OSA and does not are substantial numbers of with central apneic require distinct nomenclature. As has been the case for events during PAP titrations that resolve over time once some time, Medicare standards of qualifi cation for PAP is well established. treatment diff er from the ICSD criteria when arousal- based scoring of hypopneas is used. As noted previously, Sleep-Related Hypoventilation Disorders the ICSD refers to the current version of the AASM Manual for the Scoring of Sleep and Associated Events for Hypoventilation, as defi ned by the most recent version defi nitions of respiratory events and all other specifi c of the AASM scoring manual, is the hallmark of these physiologic events during sleep. conditions. ICSD-2 lumped sleep-related hypoventila- tion and hypoxemia into a single category, allowing OSA ( Pediatric ) physicians to infer the diagnosis on the basis of sus- tained declines in arterial oxygen saturation during PSG. Th e criteria for pediatric OSA have been simplifi ed in Th is practice, however, is not altogether accurate or the ICSD-3. are consolidated reliable, because hypoventilation, strictly speaking, is into a single criterion. One of these fi ndings (snoring, defi ned by the elevation of arterial CO and there are labored/obstructed breathing, or daytime consequences 2 potential causes of sustained hypoxemia other than [sleepiness, hyperactivity, and so forth]) must be hypoventilation. Th erefore, the criteria for sleep-related present. Th e PSG criterion for diagnosis requires either hypoventilation now explicitly require demonstration of (1) one or more obstructive events (obstructive or mixed elevated P co levels, either by direct determination with apnea or obstructive hypopnea) per hour of sleep 2 arterial blood gases or, more commonly, by proxy or (2) obstructive hypoventilation, manifested by measures such as end-tidal or transcutaneous CO . Pa co . 50 mm Hg for . 25% of sleep time, coupled 2 2 When sustained drops in arterial oxygen saturation with snoring, paradoxical thoracoabdominal movement, ( Յ 88% for . 5 min) are seen in the absence of CO or fl attening of the nasal airway pressure waveform. 2 measurement, the now separate diagnosis of sleep-related hypoxemia disorder should be used. CSA Syndromes Th e major change in this section of ICSD-3 is the Obesity hypoventilation syndrome has been added as a addition of treatment-emergent CSA. Th is diagnosis distinct hypoventilation diagnosis in the ICSD-3 corresponds to what has been termed “complex sleep primarily because it is so frequently encountered in apnea.” However, the defi nition of complex sleep apnea clinical practice. Th e condition is commonly comorbid in published studies has varied. Although all defi nitions with other sleep-related breathing disorders and requires have included a requirement of persistent or residual careful consideration in the formulation of a comprehen- CSA following eff ective treatment of OSA, there has sive therapeutic approach to breathing disturbances. been substantial discrepancy regarding the nature of the However, in contrast to other sleep-related hypoventilation CSA. Some studies include patients with CSA with disorders, an obesity hypoventilation diagnosis requires . Cheyne-Stokes breathing (CSB) and substance-induced demonstration of elevated daytime Paco 2 ( 45 mm Hg), . CSA, whereas others specifi cally exclude such patients. 8 in addition to BMI 30. Patients with other forms of As a result, the term “complex sleep apnea” lacks sleep-related hypoventilation may or may not exhibit specifi city. For this reason, new terminology, “treatment- daytime hypoventilation. emergent central sleep apnea,” is used in ICSD-3. Th e criteria for this disorder require demonstration of Central Disorders of Hypersomnolence predominately OSA (fi ve or more obstructive respira- Th ese disorders are characterized by excessive daytime tory events per hour of sleep) followed by signifi cant sleepiness (hypersomnolence) that is not attributable resolution of the obstructive apnea and emergence or to another , specifi cally those that result persistence of CSA (not caused by another identifi able in disturbed sleep (eg, sleep-related breathing disorders) comorbidity such as CSB or substance) during PSG with or abnormalities of circadian rhythm. Th e central

1390 Contemporary Reviews in Sleep Medicine [ 146#5 CHEST NOVEMBER 2014 ] disorders of hypersomnolence are oft en caused by Narcolepsy intrinsic CNS abnormalities in control of sleep-wake, Narcolepsy has historically been subdivided into although other medical conditions or substances may narcolepsy with and without . Th is symptom- account for the hypersomnolence. Behaviorally induced based approach was sensible prior to the identifi cation insuffi cient sleep is also included in this group of of a defi nitive cause for what has been termed “narcolepsy disorders. Specifi c diagnoses are listed in Table 4 and with cataplexy.” However, establishment of hypocretin are discussed later. defi ciency as the cause of this disorder 14 has rendered All these disorders have in common a subjective the “with cataplexy” terminology problematic. A small, complaint of excessive sleepiness. ICSD-3 defi nes this but not insignifi cant, population of patients with clear as “daily episodes of an irrepressible need to sleep or hypocretin defi ciency do not manifest cataplexy at the daytime lapses into sleep.” For those disorders, such as time of diagnosis, 15 although some will eventually do so. narcolepsy and (IH), which Th erefore, a new approach to the subdivision of narco- require demonstration of objective sleepiness by the lepsy is required. For this reason, the terminology of multiple sleep latency test (MSLT), a mean sleep ICSD-3 has been changed to “narcolepsy type 1” and latency of , 8 min on the MSLT is required. Th is “narcolepsy type 2.” Although hypocretin defi ciency is criterion is unchanged from the ICSD-2 and represents the hallmark of narcolepsy type 1, the relative unavail- the best compromise between sensitivity and speci- ability of hypocretin assays to date results, to a great fi city. 9 , 10 However, physicians must recognize that there extent, in continued dependence on the identifi cation of is substantial overlap between pathologically sleepy cataplexy to establish a narcolepsy type 1 diagnosis. individuals and “normal” (oft en sleep-deprived) In addition to a subjective complaint of sleepiness, persons. Th erefore, in establishing a diagnosis of a narcolepsy type 1 may be diagnosed by the demonstra- central disorder of hypersomnolence, physicians must tion of either cerebrospinal fl uid hypocretin-1 defi - be keenly aware that , especially in ciency (, 110 pg/mL or less than one-third of the those with longer sleep requirements, may account for normative values with the same standardized assay) or 11 abnormal MSLT results. Th e use of sleep logs and a mean latency of , 8 min on MSLT, with evidence of for at least 1 week prior to MSLT is strongly sleep-onset rapid eye movement periods (SOREMPs) encouraged to rule out insuffi cient sleep, sleep-wake and clear cataplexy (defi ned as “more than one episode schedule disturbances, or both as potential explanations of generally brief [ , 2 min], usually bilaterally symmet- for abnormal MSLT findings. Limited data suggest rical, sudden loss of muscle tone with retained con- that one-off subjective reports and sleep logs alone may sciousness”). Recent evidence suggests that a SOREMP significantly overestimate total sleep time in the days (, 15 min) on the preceding overnight PSG is highly 12 prior to MSLT. Conversely, some patients with legiti- specifi c for a diagnosis of narcolepsy (although it lacks mate central hypersomnolence conditions may not sensitivity) and shows signifi cant positive predictive consistently demonstrate mean MSLT latencies value. 16 Th erefore, the MSLT criteria of ICSD-3 for both , 13 of 8 min. Clinical judgment is required in such types of narcolepsy include a requirement of either two cases. Repeat MSLT at a later date may confi rm objective SOREMPs on MLST, or a SOREMP on the PSG coupled sleepiness. with at least one SOREMP on the MSLT. Narcolepsy type 2 maintains the same MSLT require- TABLE 4 ] Central Disorders of Hypersomnolence ments of a mean latency , 8 min and two SOREMPs

Disorder (or one SOREMP on PSG and one or more on MSLT). Cataplexy must be absent and cerebrospinal fl uid Narcolepsy type 1 hypocretin-1 levels, if measured, must not meet the Narcolepsy type 2 narcolepsy type 1 criterion. Idiopathic hypersomnia Kleine-Levin syndrome Idiopathic Hypersomnia Hypersomnia due to a medical disorder Hypersomnia due to a medication or substance Th e diagnosis of IH has long been problematic. Clearly, Hypersomnia associated with a psychiatric disorder there is a group of individuals with signifi cant daytime sleepiness that cannot be explained by another condition Insuffi cient sleep syndrome despite comprehensive evaluation. It is not clear to what

journal.publications.chestnet.org 1391 extent patients with IH represent a cohesive group onset in establishing a circadian rhythm whose sleepiness is caused by a single, defi nable CNS sleep-wake disorder (CRSWD) diagnosis, 17 although , as opposed to a diverse population with these are not required to meet the criteria for any varied causes of their hypersomnolence. As noted diagnosis. Th e use of questionnaires such as the previously, sleep deprivation can easily be overlooked as Morningness-Eveningness Questionnaire 18 to identify a potential cause for sleepiness, especially in those with is also encouraged. As in ICSD-2, a general longer sleep requirements, when adequate pre-MSLT set of criteria applies to all CRSWDs. These include monitoring is not conducted. A trial of sleep extension (1) a chronic or recurrent pattern of sleep-wake rhythm may be the only reliable methodology for identifying disruption primarily caused by an alteration in the this causation, although this can be surprisingly diffi cult endogenous circadian timing system or misalignment to accomplish in the routine clinical setting. Th e core between the endogenous circadian rhythm and the criteria for IH remain largely unchanged; that is, a sleep-wake schedule desired or required, (2) a sleep- report of subjective sleepiness, MSLT showing a mean wake disturbance (ie, insomnia or excessive sleepiness, latency of , 8 min with fewer that two SOREMPs and (3) associated distress or impairment. For all (including any SOREMP on the PSG from the preceding CRSWDs, with the exception of disorder, a duration night), absence of cataplexy and hypocretin defi ciency criterion of at least 3 months has been added. (if measured), and no other identifi able cause. Some patients may present with long sleep times as a primary Parasomnias manifestation of their IH. Th erefore, in patients who Th e parasomnias are divided onto three clusters: do not meet the objective MSLT criterion for sleepi- non-rapid eye movement (NREM) related, rapid eye ness, 24-h PSG or 1-week actigraphy/sleep logs with movement (REM) related, and other (Table 6). unrestricted sleep may be pursued. Demonstration Ն of 660 min average daily sleep time in adults satisfi es Disorders of Arousal From NREM the criterion for objective sleepiness in lieu of the MSLT Th e NREM group includes confusional arousal, sleep- fi ndings. 13 walking, and sleep terrors. Sleep-related disorder Th e ICSD-2 subdivided IH into conditions with and has now been included with the NREM group as well, without a long sleep time. However, further analysis of because it has many features in common with these the data related to this dichotomy was deemed insuffi - disorders. ICSD-2 addressed the arousal disorders as cient to support the continuation of this division. separate diagnoses. In light of the great similarity in

Circadian Rhythm Sleep-Wake Disorders TABLE 6 ] Parasomnias

Th e nomenclature for these disorders has been changed Disorder to “sleep-wake” to underscore that the physiologic alterations associated with these conditions are evident NREM-related parasomnias throughout the 24-h cycle. Th e diagnoses included in this section are the same as those in ICSD-2 ( Table 5 ). Th e criteria for these diagnoses are also much the same. Sleep terrors Physicians are more strongly encouraged to consider the Sleep-related use of actigraphy and biomarkers such as dim-light REM-related parasomnias REM sleep behavior disorder TABLE 5 ] Circadian Rhythm Sleep-Wake Disorders Recurrent isolated sleep disorder Disorder Other parasomnias Delayed sleep-wake phase disorder Advanced sleep-wake phase disorder Sleep-related Irregular sleep-wake rhythm disorder Sleep Non-24-h sleep-wake rhythm disorder due to a medical disorder disorder Parasomnia due to a medication or substance Jet lag disorder Parasomnia, unspecifi ed Circadian sleep-wake disorder not otherwise specifi ed NREM 5 non-rapid eye movement; REM 5 rapid eye movement.

1392 Contemporary Reviews in Sleep Medicine [ 146#5 CHEST NOVEMBER 2014 ] pathophysiology, demographics, and course, sleepwalk- Sleep-Related Movement Disorders ing, terrors, and confusional arousal are now addressed Th ese conditions ( Table 7 ) are characterized by simple, within a single section. Th e general criteria for disorders oft en stereotyped movements occurring during sleep. of arousal include (1) recurrent episodes of incomplete In the case of (RLS), a waking awakening, (2) absent or inappropriate responsiveness, dysesthesia is the predominant symptom, although (3) limited or no cognition or report, and repetitive limb movement during sleep is oft en observed (4) partial or complete for the episode. Th e in association with RLS. three subtypes maintain distinct diagnostic codes, and additional criteria are elaborated for each of the three Restless Legs Syndrome manifestations of partial arousal. A common text Th e criteria for RLS refl ect the International Restless section addresses all three disorders, with distin- Legs Syndrome Study Group 21 criteria with one impor- guishing factors contained within this text. Th ese tant distinction, as discussed later. Both criteria sets are disorders frequently overlap and it is not unusual for based on an urge to move the legs, sometimes accompa- patients to meet the criteria for more than one of these nied by an uncomfortable sensation that (1) occurs conditions. primarily with rest/inactivity; (2) is partially or totally REM-related parasomnias include REM sleep behavior relieved by movement, for as long as the movement disorder (RBD), , and recurrent occurs; and (3) occurs primarily in the evening or night. isolated . Th ese disorders occur as a Given the somewhat indescribable nature of the consequence of state disassociation between REM sleep symptoms, both criteria sets emphasize the importance and wake (in the case of RBD and recurrent sleep of ruling out other disorders, the symptoms of which paralysis) or disturbed cognitive-emotional regulation may mimic those of RLS (eg, , leg cramps, and arising from REM (in the case of ). In myalgias). Th e ICSD-3 criteria diff er from those of the contrast to the arousal disorders, which, for the most International Restless Legs Syndrome Study Group in part, occur in otherwise healthy individuals, in many that distress, associated sleep disturbance, or impair- cases RBD and nightmares arise from serious neuro- ment is required to establish the ICSD diagnosis. Th is pathology (RBD) or (nightmare diff erence is predicated on the concept that, although disorder). researchers may wish to include the entire population of individuals who manifest any degree of the physical REM Sleep Behavior Disorder symptoms for study purposes, a true clinical disorder Th e criteria for RBD have been somewhat simplifi ed. should include some form of adverse consequence(s). Th ey require (1) repeated episodes of behavior or Many individuals, when queried, will acknowledge the vocalization that are either documented by PSG to arise presence of infrequent and/or milder forms of RLS but from RÉM or are presumed to arise from REM based have no associated complaint. Th ese individuals should on reports of dream enactment, and (2) evidence of not receive an ICSD-3 diagnosis of RLS. REM sleep without atonia on PSG (as defi ned in the scoring manual). When REM sleep without atonia is TABLE 7 ] Sleep-Related Movement Disorders not observed, the diagnosis may be given on a provi- Disorder sional basis when other clinical fi ndings are strongly suggestive. Restless legs syndrome Periodic limb movement disorder Dream enactment behavior may also be observed in Sleep-related leg cramps association with other sleep disorders such as narcolepsy, 19 Sleep-related as well as with certain , 20 most notably the selective or serotonin- Sleep-related rhythmic movement disorder reuptake inhibitors. Th e relationship between medication- Benign sleep of infancy induced RBD and other forms is unclear, and the risk Propriospinal myoclonus at of development of in that population Sleep-related movement disorder due to a medical disorder is undetermined. When RBD is believed to occur as a Sleep-related movement disorder due to a medication result of medication use, a diagnosis of RBD should still or substance be used (as opposed to parasomnia due to medication or Sleep-related movement disorder, unspecifi ed substance), provided all criteria are met.

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1394 Contemporary Reviews in Sleep Medicine [ 146#5 CHEST NOVEMBER 2014 ]