The International Classification of Sleep Disorders – Third Edition (ICSD-3) is the authoritative clinical text for the diagnosis of sleep disorders. This is an. International Classification of Sleep Disorders (2nd edn),. International Classification classification replaces the previous edition (ICSD-2; Ameri- can Academy of .. In the nonh sleep–wake disorder (or free-running disorder), which was. ICSD – International classification of sleep disorders, revised: Diagnostic and Includes bibliographies and index. 1. Sleep Disorders–Classification. 2. Sleep .. syndrome) to reflect crucial developments since the first edition. Changes .. The second section, the parasomnias, comprises disorders that intrude into or.

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The classification of sleep disorders is necessary to discriminate between disorders and to facilitate an understanding of symptoms, etiology, and pathophysiology that allows for appropriate treatment. The earliest classification systems, largely organized according to major symptoms insomnia, excessive sleepiness, and abnormal events that occur during sleepwere unable to be based on pathophysiology because the cause of most sleep disorders was unknown.

These 3 symptom-based categories are easily understood by physicians and ixsd-2 therefore useful for developing a differential diagnosis.

The International Classification of Sleep Disorders, version 2, published in and currently undergoing revision, combines a symptomatic presentation e. This organization of sleep disorders is necessary because of the varied nature and because the pathophysiology for many of the disorders is still unknown. The International Classification of Sleep Disorders, version 2 provides relevant diagnostic and epidemiological information on sleep disorders to more easily differentiate between the disorders.

The online version of this article doi: The first major classification of sleep disorders, the Diagnostic Classification of Sleep and Arousal Disorders, published in [ 1 ], organized the sleep disorders into symptomatic categories to form the basis of the current classification systems. The ICSD classification, developed primarily for diagnostic, epidemiologic, and at the time, research purposes, has been widely used by clinicians and has allowed improved international communication in sleep disorder research.

The current classification system is undergoing review and is being updated. In addition, there are 13 diagnostic items listed in the appendices that include sleep disorders associated with disorders classified elsewhere, and psychiatric disorders frequently encountered in the differential diagnosis of sleep disorders. The ICSD-2 lists the dieorders disorders major sleep disorders in 8 major categories:. Both a symptom and a diagnostic category, the insomnia diagnoses are best referred to by their subcategory terms.


These diagnoses are defined by various combinations of repeated difficulties with sleep initiation, duration, consolidation, or quality that occurs despite adequate time and opportunity for sleep, and they result in some form of daytime impairment. The definition of insomnia as being a complaint of sleep onset, sleep maintenance, waking too early, or unrestorative sleep is less precise than that required for research in insomnia.

Specific research criteria have been developed for insomnia disorder [ ]. The criteria includes not only a primary complaint of difficulty initiating sleep, maintaining sleep, waking too early, or unrestorative or poor quality sleep, but also that the sleep difficulty occurs despite adequate opportunity and circumstances for sleep, and that one or more complaints of daytime impairment are due to the sleep difficulty.

Specific research diagnostic criteria have been developed for the following: The insomnia disorders can be either primary or secondary. Primary insomnias can have both intrinsic and extrinsic factors involved in their etiology, but they are not regarded as being secondary to another disorder. Secondary forms occur when the insomnia is a symptom of a medical or psychiatric illness, another sleep disorder, or substance abuse. Comorbid insomnia does not indicate whether the associated medical disorder is causative or coincidental.

The term secondary insomnia is still appropriate for use when there is clear causality with the underlying medical or psychiatric disorder, such as one might see in insomnia secondary to pain disorders. In the ICSD, there are 6 types of primary insomnia. Adjustment insomnia [ 45 ] is the insomnia that is associated with a specific stressor. The stressor can be psychological, physiologic, environmental, or physical.

This disorder exists for a short period of time, usually days to weeks, and it usually resolves when the stressor is no longer present. There is an over-concern with the inability to sleep.

Paradoxical insomnia [ 89 ] is a complaint of severe insomnia that occurs without evidence of objective sleep disturbance and without daytime impairment to the extent that would be suggested by the amount of sleep disturbance reported.


The patient often reports little or no sleep on most nights. Idiopathic insomnia [ 1011 ] is a longstanding form of insomnia that appears to date from childhood and has an insidious onset.

International Classification of Sleep Disorders

Typically, there are no factors associated with the onset of the insomnia, which is persistent and without periods of remission. Inadequate sleep icse-2 [ 1213 ] is a disorder associated with common daily activities that are inconsistent with good-quality sleep and full daytime alertness.

Such activities include irregular sleep onset and wake times, stimulating and alerting activities before bedtime, and substances e. These practices do not necessarily cause sleep disturbance in other people. For example, classirication irregular bedtime or wake time that produces insomnia in one person may not be important in another. Behavioral insomnia of childhood [ 1415 ] includes limit-setting sleep disorder and sleep-onset association disorder.

Classification of Sleep Disorders

Limit-setting sleep disorder is stalling or refusing to go to sleep that is eliminated once a caretaker enforces limits on sleep times and other sleep-related behaviors. Sleep-onset association disorder occurs when there is reliance on inappropriate sleep associations, such as rocking, watching television, holding a bottle or other object, or requiring environmental conditions, such as a lit room or an alternative place to sleep.

There are several secondary insomnias. Insomnia due to a drug or substance [ 1617 ] is applied when there is dependence on or excessive use of a substance, such as alcohol, a recreational drug, or caffeine that is associated with the occurrence of the insomnia. The insomnia may be associated with the ingestion or discontinuation of the substance.

Excessive use or dependency is not a feature of this diagnosis. Insomnia due to a medical condition [ 1819 ] is applied when a medical or neurological disorder gives rise to the insomnia. The medical disorder and the insomnia type are given when a patient is diagnosed. Insomnia not due to a substance or known physiological condition [ 2021 ] is the diagnosis applied when an underlying mental disorder is associated with the occurrence of the insomnia, and when the insomnia constitutes a distinct complaint or focus of treatment.

Physiologic organic insomnia, unspecified, is applied when insomnia is due to a medical condition or substance use not specified elsewhere [ 2223 ].

Inadequate sleep hygiene, and other insomnia due to a substance, requires some discussion of the differentiation between the 2 diagnoses. Caffeine ingestion in the form of coffee or soda can produce a disorder of inadequate sleep hygiene, if the intake amount is normal and within the limits of common use, but the timing of ingestion is inappropriate.

On the other hand, ingestion of caffeine in an amount that is considered excessive by normal standards can lead to a diagnosis of other insomnia due to a substance. Disordered ventilation during sleep is the characteristic feature of the disorders in this article. Central apnea syndromes [ 2425 ] include those in which respiratory effort is diminished or absent in an intermittent or cyclical fashion as a result of central nervous system dysfunction.

Other central sleep apnea forms are associated with underlying pathologic or environmental causes, such as Cheyne-Stokes breathing pattern [ 2627 ] or high-altitude periodic breathing [ 2829 ]. Primary central sleep apnea is a disorder of unknown cause characterized by recurrent episodes of cessation of breathing during sleep without associated ventilatory effort. A complaint of excessive daytime sleepiness, insomnia, or difficulty breathing during sleep is reported.

This diagnosis requires that 5 or more apneic episodes per hour of sleep be seen by polysomnography. The pattern is typically seen in medical disorders, such as heart failure, cerebrovascular disorders, and renal failure.

Central sleep apnea due to high-altitude periodic breathing [ 2829 ] is characterized by sleep disturbance that is caused by cycling periods of apnea and hyperpnea without ventilatory effort.

Five or more central apneas per hour of sleep are required to make the diagnosis. Most people will have this ventilatory pattern at elevations greater than meters, and some at lower altitudes. A secondary form of central sleep apnea due to drug or substance substance abuse [ 3031 ] is most commonly associated with users of long-term opioid use. The substance causes a respiratory depression by acting on the mu receptors of the ventral medulla.

Primary sleep apnea of infancy [ 3233 ] is a disorder of respiratory control most often seen in preterm infants apnea of prematuritybut it can occur in predisposed infants apnea of infancy. This may be a developmental pattern, or it may be secondary to other medical disorders.


The obstructive sleep apnea syndromes include those in which there is an obstruction in the airway resulting in increased breathing effort and inadequate ventilation. Upper airway resistance syndrome has been recognized as a manifestation of obstructive sleep apnea syndrome and therefore is not included as a separate diagnosis.

Adult and pediatric forms of obstructive sleep apnea syndrome are discussed separately because the disorders have different methods of diagnosis and treatment. Obstructive sleep apnea in adults [ 3435 ] is characterized by repetitive episodes of cessation of breathing apneas or partial upper airway obstruction hypopneas.

These events are often associated with reduced blood oxygen saturation. Snoring and sleep disruption are typical and common. Excessive daytime sleepiness or insomnia can result. Five or more respiratory events apneas, hypopneas, or respiratory effort-related arousals per hour of sleep are required for diagnosis. Increased respiratory effort occurs during the respiratory event. Obstructive sleep apnea in pediatrics [ 3637 ] is characterized by features similar to those seen in the adult, but cortical arousals may not occur, possibly because of a higher arousal threshold.

At least 1 obstructive event, of at least 2 respiratory cycles of duration per hour of sleep, is required for diagnosis. Sleep-related nonobstructive alveolar hypoventilation, idiopathic, refers to decreased alveolar hypoventilation resulting in sleep-related arterial oxygen desaturation in patients with normal mechanical properties of the lungs [ 3839 ]. Congenital central alveolar hypoventilation syndrome [ 4041 ] is a failure of automatic central control of breathing in infants who do not breathe spontaneously or whose breathing is shallow and erratic.

It is a failure of the central automatic control of breathing. The hypoventilation begins in infancy and it is worse in sleep than in wakefulness. The hypersomnia disorders are those in which the primary complaint is daytime sleepiness and the cause of the primary symptom is not disturbed nocturnal sleep or misaligned circadian rhythms.

Daytime sleepiness is defined as the inability to stay alert and awake during the major waking episodes of the day, resulting in unintended lapses into sleep. The term hypersomnia has been used differently in the different diagnostic classifications. In the ICSD, the term hypersomnia is diagnostic, with the preferred term for the complaint being daytime sleepiness or excessive daytime sleepiness.

Other sleep disorders may be present with the hypersomnias, but they must be effectively treated first before a hypersomnia diagnosis can be made. The hypersomnias of central origin are not due to a circadian rhythm sleep disorder, sleep-related breathing disorder, or other cause of disturbed nocturnal sleep.

Narcolepsy with cataplexy [ 4849 ] requires the documentation of a definite history of cataplexy or the documentation of a cerebrospinal fluid hypocretin level less than one third of control values. The diagnosis of narcolepsy with cataplexy is based on the belief that most cases are due to loss of hypocretin possibly on an autoimmune basis. Whether narcolepsy without cataplexy is the same disorder as narcolepsy with cataplexy, or if it is a disorder based on an entirely different pathophysiology is not clear.

Most cases of narcolepsy without cataplexy have intact hypocretin levels. Narcolepsy due to a medical condition [ 5253 ] is the diagnosis applied to a patient with sleepiness who has a significant neurological or medical disorder that accounts for the daytime sleepiness.

Recurrent hypersomnia [ 5455 ], also known as periodic hypersomnia is comprised of 2 subtypes: Kleine-Levin Syndrome is associated with episodes of sleepiness together with binge eating, hypersexuality, or mood changes.

Menstrual-related hypersomnia is having recurrent episodes inrernational hypersomnia that occurs in association with the menstrual cycle. Idiopathic hypersomnia, whether with sleep time or without it, is still poorly understood because there is no clear pathophysiological mechanism [ ].

The genetic basis of the disorders needs to be determined. Whether idiopathic hypersomnia without long sleep time is a variant of narcolepsy without cataplexy is not yet determined. Behavioral-induced insufficient sleep syndrome [ 6061 ] occurs in patients who have a habitual short sleep time episode and who sleep internationak longer when the habitual sleep episode is not maintained.

Hypersomnia due to a medical condition [ 6263 ] is hypersomnia that is caused by a medical or neurological disorder. Cataplexy or other diagnostic features of narcolepsy are sdcond present.

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