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International Classification of Sleep Disorders

The International Classification of Sleep Disorders (ICSD) is the authoritative clinical manual for the diagnosis, classification, and coding of sleep disorders, developed and published by the American Academy of Sleep Medicine (AASM).^[1] It serves as the primary reference for clinicians, researchers, and epidemiologists worldwide to identify and categorize more than 80 distinct sleep disorders based on standardized criteria derived from clinical evidence and expert consensus.^[2] The ICSD originated from earlier diagnostic systems in the 1970s and 1980s but evolved into its modern form with the first edition in 1990, followed by revisions that incorporated advances in sleep medicine research.^[3] The current edition, the ICSD-3 Text Revision (ICSD-3-TR), was released in June 2023 as an update to the 2014 ICSD-3, incorporating new scientific literature, minor textual corrections, and refinements to diagnostic criteria for improved accuracy and relevance.^[1] This edition organizes sleep disorders into seven major categories: insomnia disorders, sleep-related breathing disorders, central disorders of hypersomnolence, circadian rhythm sleep-wake disorders, parasomnias, sleep-related movement disorders, and other sleep disorders, along with appendices covering isolated symptoms and normal variants.^[1] Key updates in the ICSD-3-TR include refinements to criteria for conditions like obstructive sleep apnea and restless legs syndrome based on recent literature, integration of International Classification of Diseases (ICD-10 and ICD-11) codes in appendices for billing and research compatibility, and emphasis on comorbidities such as sleep disorders in neurological and psychiatric conditions.^[4] By providing detailed diagnostic algorithms, polysomnography guidelines, and differential diagnosis tools, the ICSD facilitates evidence-based practice and advances global understanding of sleep health's role in overall well-being.^[1]

Introduction

Purpose and Scope

The International Classification of Sleep Disorders (ICSD) serves as the primary clinical text produced by the American Academy of Sleep Medicine (AASM) for diagnosing sleep disorders, providing standardized criteria to guide clinicians and researchers in identifying and classifying these conditions.^[1] First published in 1990 and most recently revised as the ICSD-3 Text Revision (ICSD-3-TR) in 2023, it addresses the need for a comprehensive nosology in sleep medicine, building on earlier efforts to organize sleep disturbances into diagnosable entities.^[2] The ICSD outlines detailed diagnostic criteria for over 60 sleep disorders, emphasizing the integration of clinical symptoms, historical data, and objective testing to ensure accurate identification.^[5] The scope of the ICSD encompasses a broad spectrum of sleep pathologies, including those influenced by intrinsic physiological factors (such as central nervous system abnormalities) and extrinsic environmental or behavioral elements (like substance use or poor sleep hygiene).^[5] It distinguishes between disorders primarily affecting adults and those in pediatric populations, with criteria tailored to developmental differences, and incorporates diagnostic tools like polysomnography, multiple sleep latency testing, and actigraphy to support clinical evaluation.^[1] This framework facilitates the differentiation of primary sleep disorders from those secondary to medical, neurological, or psychiatric conditions, promoting a holistic approach to assessment.^[2] Beyond diagnosis, the ICSD fulfills key epidemiological and coding functions by enabling consistent tracking of sleep disorder prevalence and facilitating billing and research through alignment with International Classification of Diseases (ICD-10 and ICD-11) codes, as detailed in its appendices.^[1] It emerged to unify the fragmented classifications in sleep medicine that existed prior to the 1979 Diagnostic Classification of Sleep and Arousal Disorders, providing a single authoritative system amid growing recognition of sleep's role in health.^[6] The manual has evolved through successive editions to reflect advancing scientific understanding.^[4]

Development and Governing Organizations

The International Classification of Sleep Disorders (ICSD) originated from collaborative efforts in the sleep medicine community, beginning with the Association of Sleep Disorders Centers (ASDC), which in 1979 published the Diagnostic Classification of Sleep and Arousal Disorders (DCSAD) as the first consensus-based system for categorizing sleep disorders.^[7] This precursor laid the groundwork for standardized terminology and diagnostic criteria, involving experts in sleep medicine, neurology, and psychiatry.^[6] The American Sleep Disorders Association (ASDA), now known as the American Academy of Sleep Medicine (AASM), assumed the primary role as publisher starting with the first ICSD edition in 1990, developed by a dedicated committee that incorporated input from international organizations including the European Sleep Research Society (ESRS), the Japanese Society of Sleep Research (JSSR), and the Latin American Sleep Society (LASS).^[8]^[7] Subsequent editions, such as ICSD-2 (2005) and ICSD-3 (2014), were overseen by the AASM Board of Directors, with contributions from the ASDC and a broad network of sleep specialists, neurologists, and pulmonologists.^[1] The AASM has maintained this leadership, ensuring the ICSD serves as the premier diagnostic manual for sleep disorders worldwide.^[1] Development of each edition involves interdisciplinary task forces and workgroups comprising expert clinicians and researchers who conduct systematic literature reviews to incorporate evidence from sleep studies and refine criteria based on advancing scientific knowledge.^[4] For instance, the ICSD-3 Text Revision (ICSD-3-TR) in 2023 was managed by a core task force of four members and seven specialized workgroups, each focusing on specific chapters to update classifications while preserving core structures.^[4] These processes emphasize consensus-building among international experts to promote global applicability.^[7] Publication is handled exclusively by the AASM, with editions available in print and digital formats through their online store and resource library, accessible to members for $153 and non-members for $210, supporting ongoing education and clinical use.^[1] While specific funding details are not publicly detailed, the AASM sustains these efforts through membership dues, publication sales, and organizational resources dedicated to advancing sleep medicine standards.^[1]

Historical Development

Pre-ICSD Classifications

The Diagnostic Classification of Sleep and Arousal Disorders (DCSAD), published in 1979, represented the first systematic attempt to categorize sleep disorders in a structured manner. Developed collaboratively by the Association of Sleep Disorders Centers (ASDC) and the Association for the Psychophysiological Study of Sleep (APSS), it divided disorders into four broad categories: Disorders of Initiating and Maintaining Sleep (DIMS), which encompassed insomnias such as psychophysiological and drug-related types; Disorders of Excessive Somnolence (DOES), including hypersomnias like narcolepsy and sleep apnea; Disorders of the Sleep-Wake Schedule, covering issues like jet lag and delayed sleep phase syndrome; and Dysfunctions Associated with Sleep Stages or Partial Arousals (parasomnias), such as sleepwalking and night terrors.^[9] Despite its pioneering role, the DCSAD had notable limitations that highlighted the need for a more refined system as the field of sleep medicine expanded. It lacked specific diagnostic criteria for many conditions, relying instead on descriptive groupings, and included duplicate entries for the same disorder across categories, which complicated clinical application. Additionally, its scope was primarily national and focused on U.S.-based research, lacking international collaboration and sufficient granularity to address emerging physiological disorders like those involving respiratory impairments, where knowledge was still limited by available technology.^[10] Contemporary general classification systems, such as the DSM-III (published in 1980) and ICD-9, further underscored these gaps by inadequately addressing sleep-specific disorders. The DSM-III included only a limited set of sleep-related diagnoses under dyssomnias, primarily primary insomnia and secondary types tied to other mental disorders, without detailed criteria or coverage of hypersomnias and parasomnias. Similarly, ICD-9 categorized sleep issues broadly as organic or nonorganic, oversimplifying complex etiologies and failing to provide the specificity required for advancing sleep medicine.^[10] These shortcomings were amplified by key developments in the field, including the 1975 establishment of the ASDC (later evolving into the American Academy of Sleep Medicine in 1999), which emphasized the growing recognition of sleep disorders as a distinct medical domain requiring a dedicated, comprehensive classification.^[8] This momentum paved the way for the first International Classification of Sleep Disorders (ICSD-1) in 1990 as a direct response to the need for an internationally oriented, criterion-based system.^[1]

ICSD-1 (1990)

The International Classification of Sleep Disorders, first edition (ICSD-1), was published in 1990 by the American Sleep Disorders Association (now the American Academy of Sleep Medicine) through collaborative efforts involving major international sleep societies, including the European Sleep Research Society and others.^[6]^[11] This inaugural manual inventoried 84 sleep disorders, organizing them into four primary categories: Dyssomnias, Parasomnias, Sleep Disorders Associated with Medical/Psychiatric Disorders, and Proposed Sleep Disorders.^[12] The Dyssomnias category encompassed intrinsic disorders (such as narcolepsy, restless legs syndrome, and periodic limb movement disorder), extrinsic disorders (including inadequate sleep hygiene and environmental sleep disorder), and circadian rhythm disorders (like jet lag type and shift work type).^[6] Parasomnias were subdivided into arousal disorders (e.g., sleepwalking and sleep terrors), sleep-wake transition disorders (e.g., sleep starts and nocturnal leg cramps), parasomnias usually associated with REM sleep (e.g., nightmares and REM sleep behavior disorder), and other parasomnias.^[6] The remaining categories addressed sleep disturbances linked to underlying medical or psychiatric conditions (e.g., fatal familial insomnia and sleep-related gastroesophageal reflux) and provisional entries for less established conditions (e.g., menstrual-associated sleep disorder).^[6] ICSD-1 built upon the 1979 Diagnostic Classification of Sleep and Arousal Disorders (DCSAD) framework but introduced significant advancements as the first comprehensive, internationally endorsed nosologic system dedicated to sleep disorders.^[6] It emphasized structured clinical diagnostic criteria—incorporating history, physical examination, and polysomnographic findings—rather than relying solely on presenting symptoms, thereby enhancing diagnostic precision, epidemiological tracking, and cross-study comparability in sleep medicine research and practice.^[6]^[11] This approach facilitated better integration with broader medical coding systems like the International Classification of Diseases (ICD) and promoted standardized communication among clinicians worldwide.^[6] Despite these innovations, ICSD-1 had notable limitations, including significant overlap between categories; for instance, multifactorial conditions like insomnia comorbid with restless legs syndrome or anxiety often required multiple codes, complicating clinical application and potentially leading to inconsistent diagnoses.^[13] Additionally, the classification provided limited dedicated focus on pediatric sleep disorders, with many entries derived primarily from adult-oriented descriptions and insufficient differentiation for age-specific presentations, such as developmental variations in arousal disorders.^[13]

ICSD-Revised (1997)

The ICSD-Revised (1997), published by the American Sleep Disorders Association (ASDA, predecessor to the AASM), served as a direct update to the 1990 ICSD-1, primarily to resolve ambiguities in diagnostic descriptions and criteria that had emerged in clinical application.^[1] This revision built upon the foundational structure of ICSD-1 while enhancing precision for both clinical diagnosis and research.^[6] Retaining the original 84 sleep disorders organized into four major categories—dyssomnias, parasomnias, sleep disorders associated with medical, neurologic, or other conditions, and proposed sleep disorders—the 1997 edition focused on refining diagnostic criteria to improve reliability and inter-observer agreement.^[1] Key modifications targeted dyssomnias, including clearer delineations between primary insomnia (arising independently) and secondary insomnia (linked to other medical or psychiatric factors), which helped clinicians distinguish etiologies more effectively.^[6] The revision also incorporated appendices detailing standardized sleep staging rules and expanded guidance on interpreting polysomnographic findings, such as respiratory events and arousal patterns, to standardize assessment protocols.^[1] A notable advancement was the introduction of more explicit exclusion criteria, requiring clinicians to rule out psychiatric conditions like major depressive disorder before diagnosing primary sleep disorders, thereby reducing overlap and misclassification.^[6] These changes stemmed from feedback on ICSD-1's limitations, with studies confirming improved reliability for most criteria in the revised manual.^[14] Development remained under primary ASDA oversight, involving a task force of sleep experts, though with limited international collaboration compared to later editions.^[1]

ICSD-2 (2005)

The second edition of the International Classification of Sleep Disorders (ICSD-2), published in 2005 by the American Academy of Sleep Medicine, reorganized 81 sleep disorders into eight major categories to reflect advances in sleep medicine research and improve diagnostic precision. These categories included Insomnias, Sleep-Related Breathing Disorders, Hypersomnias of Central Origin, Circadian Rhythm Sleep Disorders, Parasomnias, Sleep-Related Movement Disorders, Isolated Symptoms, Apparently Normal Variants, and Unresolved Issues, as well as Other Sleep Disorders and an Appendix for additional diagnostic tools and codes. This structure evolved from the four broad categories in the 1997 ICSD-Revised edition by consolidating and specifying subtypes previously grouped under dyssomnias, such as intrinsic and extrinsic forms, into more targeted classifications like central hypersomnias and expanded breathing disorder subtypes.^[6]^[15]^[13] Key innovations in ICSD-2 emphasized etiology and pathophysiology, particularly by focusing the hypersomnias category on central origins to distinguish them from secondary causes like circadian disruptions or breathing issues. Sleep-related breathing disorders were expanded to include detailed obstructive sleep apnea (OSA) subtypes, such as OSA due to medical conditions and pediatric OSA, alongside central sleep apnea variants like Cheyne-Stokes respiration. A separate pediatric-focused section was added in the 2006 pocket edition, listing age-specific diagnoses like behavioral insomnia of childhood and congenital central hypoventilation syndrome to address developmental differences not fully integrated in the main text. These changes aimed to enhance clinical utility for diverse patient populations.^[16]^[17] Structural shifts in ICSD-2 introduced a dedicated category for isolated symptoms and normal variants, such as sleep starts, long sleeper, and rhythmic movement disorder, to differentiate benign phenomena from pathological conditions and reduce misdiagnosis. This reorganization consolidated dyssomnias—previously a catch-all for initiation and maintenance issues—into specific types like adjustment insomnia and psychophysiologic insomnia, promoting a more hierarchical and evidence-driven framework. Updates were grounded in 1990s research, including genetic studies identifying HLA-DQB1*06:02 as a key risk factor for narcolepsy with cataplexy, which refined diagnostic criteria for hypersomnias of central origin.^[6]^[13]^[18]

ICSD-3 (2014) and ICSD-3-TR (2023)

Key Revisions from Prior Editions

The third edition of the International Classification of Sleep Disorders (ICSD-3), published in 2014 by the American Academy of Sleep Medicine (AASM), introduced significant structural refinements compared to the second edition (ICSD-2) from 2005, reducing the major categories from eight to seven by consolidating the previous "Other Sleep Disorders" into a catch-all category and integrating most pediatric diagnoses directly into the corresponding adult categories, with the notable exception of pediatric obstructive sleep apnea (OSA), which retained a separate entry due to its distinct clinical presentation and diagnostic criteria.^[2]^[1] This reorganization aimed to streamline classification while accommodating age-specific variations without fragmenting the nosology.^[19] ICSD-3 encompassed a total of 81 specific sleep disorders, reflecting an expansion from ICSD-2's approximately 70 entries through the addition of new diagnoses and refinements to existing ones, such as updated criteria for idiopathic hypersomnia that incorporated prolonged sleep duration of ≥11 hours (≥660 minutes) total 24-hour sleep time, typically 12-14 hours, confirmed by polysomnography or actigraphy, and the introduction of treatment-emergent central sleep apnea as a distinct entity to describe central apneas arising during positive airway pressure therapy for OSA that do not resolve after optimization.^[2]^[5] These changes addressed emerging clinical patterns not adequately captured in prior editions, enhancing diagnostic precision for complex cases.^[20] The revisions were grounded in evidence-based updates drawn from 2010s research, including the established role of orexin (hypocretin) deficiency in narcolepsy type 1—supported by cerebrospinal fluid assays showing levels below 110 pg/mL—and genetic markers like HLA-DQB1*06:02 positivity, which informed refined diagnostic criteria for hypersomnolence disorders; similarly, advances in circadian genetics, such as PER2 and CLOCK gene mutations, led to expanded criteria for circadian rhythm sleep-wake disorders.^[2]^[21] Outdated terminology from ICSD-2, such as the broad "dyssomnias" category encompassing intrinsic, extrinsic, and circadian issues, was eliminated in favor of more granular, clinically oriented groupings to align with contemporary pathophysiology.^[22] Appendices in ICSD-3 were substantially enhanced to support practical application, including a dedicated section on sleep-related medical and neurological disorders (e.g., associations with Parkinson's disease or epilepsy), mappings to ICD-10-CM codes for billing and interoperability (such as G47.33 for narcolepsy), and a glossary referencing the AASM Manual for the Scoring of Sleep and Associated Events for standardized staging of sleep architecture and events like arousals or leg movements.^[1]^[22] These additions facilitated cross-referencing with other diagnostic systems and improved clinical utility without altering the core classification framework.^[2]

Overall Structure and Appendices

The International Classification of Sleep Disorders, third edition, text revision (ICSD-3-TR), published in 2023 by the American Academy of Sleep Medicine (AASM), maintains the foundational organizational framework established in the 2014 ICSD-3 without introducing a structural overhaul.^[23] Instead, it refines diagnostic criteria and textual content based on literature published after 2014, incorporating evidence-based updates such as adjusted thresholds for central disorders of hypersomnolence (e.g., revised mean sleep latency requirements in multiple sleep latency testing).^[23] These modifications ensure the classification remains aligned with evolving clinical and research insights while preserving the overall layout for consistency in diagnostic practice.^[2] At its core, the ICSD-3-TR organizes sleep disorders into seven major categories: Insomnia Disorders, Sleep-Related Breathing Disorders, Central Disorders of Hypersomnolence, Circadian Rhythm Sleep-Wake Disorders, Parasomnias, Sleep-Related Movement Disorders, and Other Sleep Disorders.^[1] Each category encompasses specific sub-disorders with detailed diagnostic criteria, epidemiology, pathophysiology, and management considerations, totaling 81 distinct disorders across the classification.^[1] Additionally, the structure includes sections on isolated symptoms and normal variants in areas such as sleep-related movements or breathing patterns, providing context for phenomena that do not meet full disorder criteria but may warrant clinical attention.^[1] This hierarchical arrangement facilitates systematic diagnosis by grouping related conditions while allowing for cross-references to comorbidities. The ICSD-3-TR features five dedicated appendices to support comprehensive clinical application. Appendix A addresses sleep manifestations in medical and neurological conditions, detailing how disorders like fatal familial insomnia or sleep-related epilepsy intersect with primary non-sleep pathologies.^[24] Appendix B provides guidance on circadian rhythm monitoring techniques, including actigraphy protocols and interpretation for disorders like delayed sleep-wake phase disorder. Appendix C differentiates sleep-related seizures from parasomnias, offering differential diagnostic tools based on electroencephalographic and video-polysomnographic features. Appendix D maps ICSD-3-TR codes to International Classification of Diseases (ICD-10 and ICD-11) systems, enabling seamless integration with global health coding standards. Finally, Appendix E serves as a glossary of key terms, defining concepts like hypersomnolence or REM sleep behavior disorder to promote standardized terminology across sleep medicine.^[1] The ICSD-3-TR is available in both print and digital formats through the AASM, enhancing accessibility for clinicians and researchers. The eBook version integrates with the AASM Resource Library app, allowing offline access on mobile devices for quick reference during patient evaluations or scoring of sleep studies.^[25] This multi-format distribution underscores the classification's role as a practical tool in diverse clinical settings.^[1]

Major Categories in ICSD-3-TR

Insomnia Disorders

Insomnia Disorders in the International Classification of Sleep Disorders, Third Edition, Text Revision (ICSD-3-TR), encompass conditions characterized by persistent difficulty initiating sleep, maintaining sleep, or experiencing nonrestorative sleep, despite adequate opportunity for sleep, accompanied by daytime impairment such as fatigue, impaired attention, or mood disturbances.^[26] This category emphasizes the subjective nature of sleep complaints, requiring that the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.^[23] Unlike hypersomnolence disorders, which involve excessive daytime sleepiness despite sufficient sleep, insomnia focuses on inadequate sleep quality leading to wakefulness issues.^[2] The ICSD-3-TR delineates three primary sub-disorders within this category. Chronic Insomnia Disorder is defined by predominant complaints of difficulty initiating sleep, maintaining sleep, or early-morning awakening with inability to return to sleep, occurring at least three times per week for at least three months, with associated daytime consequences.^[26] Short-Term Insomnia Disorder shares similar sleep complaints and daytime impairment but lasts less than three months and is often precipitated by acute stress or life events.^[26] Other Insomnia Disorder applies to cases that do not meet the duration criteria for chronic or short-term but still require clinical attention, such as insomnia due to medications or substances.^[26] Diagnostic criteria for these disorders include quantitative thresholds such as sleep onset latency exceeding 30 minutes, wake after sleep onset greater than 30 minutes on three or more nights per week, or early morning awakenings with terminal insomnia, alongside reports of sleep dissatisfaction and ruling out other primary causes through clinical history, sleep diaries, actigraphy, or polysomnography when necessary.^[26] The criteria also require that the sleep disturbance is not better explained by circadian rhythm misalignment or other sleep disorders, with isolated symptoms of poor sleep quality—without meeting full duration or impairment thresholds—considered separately as non-disorder complaints.^[23] Key updates in the ICSD-3-TR refined the exclusion criteria, particularly for circadian rhythm sleep-wake disorders, by specifying that the insomnia symptoms must not be solely attributable to another sleep disorder, thereby allowing for comorbid diagnoses while clarifying primary insomnia presentation.^[23] This revision supports a more nuanced differential diagnosis, emphasizing comorbidity over exclusionary subtypes from prior editions.^[23] Sleep-Related Breathing Disorders in the ICSD-3-TR represent a major category of sleep disorders characterized by abnormalities in breathing during sleep, including recurrent apneas, hypopneas, hypoventilation, or hypoxemia, which disrupt sleep continuity and may lead to daytime consequences such as excessive sleepiness or cognitive impairment.^[2] These disorders are diagnosed primarily through polysomnography (PSG), which quantifies respiratory events and gas exchange, ensuring objective evidence of sleep-related respiratory instability.^[23] The category emphasizes the distinction between obstructive events, driven by upper airway collapse, and central events, resulting from reduced neural drive to breathe.^[2] The primary subgroups include Obstructive Sleep Apnea (OSA), Central Sleep Apnea Syndromes, Sleep-Related Hypoventilation Disorders, and Sleep-Related Hypoxemia Disorder. OSA, the most common subgroup, involves partial or complete upper airway obstruction during sleep despite respiratory effort. In adults, diagnosis requires PSG demonstrating an apnea-hypopnea index (AHI) of ≥5 events per hour, accompanied by symptoms like snoring, witnessed apneas, or sleepiness; an AHI ≥15 alone suffices without symptoms.^[2] Central Sleep Apnea Syndromes encompass conditions such as Cheyne-Stokes breathing pattern, often seen in heart failure patients with a crescendo-decrescendo respiratory pattern and central AHI ≥5; idiopathic central sleep apnea, featuring recurrent central apneas without known cause; and treatment-emergent central sleep apnea, where central events emerge during positive airway pressure therapy but resolve over time.^[2] Sleep-Related Hypoventilation Disorders include opioid-induced hypoventilation, marked by elevated PaCO₂ during sleep due to opioid effects; obesity hypoventilation syndrome, combining obesity with nocturnal hypercapnia; and neuromuscular or chest wall-related hypoventilation, all requiring PSG evidence of PaCO₂ >55 mm Hg for ≥10 minutes or >50 mm Hg for ≥25% of sleep time.^[23] Sleep-Related Hypoxemia Disorder is diagnosed when oxygen saturation drops below 88% for ≥5 minutes during sleep without qualifying apneas, hypopneas, or hypoventilation, often linked to pulmonary conditions.^[2] Pediatric cases are integrated within these subgroups but feature distinct criteria to account for developmental differences, with OSA being the predominant presentation. For children, OSA diagnosis via PSG requires an obstructive AHI ≥1 event per hour or evidence of obstructive hypoventilation (e.g., ≥25% of sleep time with PaCO₂ >50 mm Hg), alongside symptoms such as habitual snoring, labored breathing, or behavioral issues like inattention.^[27] Primary snoring in children, without obstructive events, is noted as a milder entity within the OSA spectrum but does not meet full disorder criteria unless associated with complications.^[27] PSG remains essential for pediatric diagnosis to differentiate from central events or hypoventilation, which may manifest differently due to smaller airways and higher arousal thresholds.^[27] The ICSD-3-TR introduces refinements, including explicit recognition of high-altitude periodic breathing as a central sleep apnea syndrome, defined by recurrent central apneas or hypopneas with a central AHI ≥5 events per hour during exposure to altitudes above 2,500 meters, often resolving upon descent.^[23] These updates incorporate recent evidence on environmental and post-infectious factors influencing respiratory control during sleep.^[23] Overlap with underlying medical conditions, such as cardiac or pulmonary diseases, is briefly referenced in the appendices for comorbid coding.^[2]

Central Disorders of Hypersomnolence

Central disorders of hypersomnolence encompass a group of sleep disorders characterized by excessive daytime sleepiness (EDS) or prolonged sleep duration that is not attributable to insufficient sleep, circadian rhythm disruptions, or other primary sleep disorders. These conditions arise from intrinsic dysfunctions in the central nervous system's regulation of wakefulness and sleep-wake transitions, leading to inappropriate intrusions of sleep into wakeful periods despite adequate nocturnal sleep. In the ICSD-3-TR, this category emphasizes objective measures of sleep propensity to differentiate central hypersomnolence from secondary causes, such as medical or psychiatric conditions.^[28] The primary sub-disorders include narcolepsy type 1, narcolepsy type 2, idiopathic hypersomnia, and Kleine-Levin syndrome. Narcolepsy type 1 is defined by the presence of cataplexy—sudden, bilateral loss of muscle tone triggered by emotions—along with EDS, and is often confirmed by low cerebrospinal fluid (CSF) hypocretin-1 levels (≤110 pg/mL), reflecting orexin neuron loss in the hypothalamus. Diagnostic criteria require daily irrepressible sleep episodes for at least three months, a mean sleep latency of ≤8 minutes on the Multiple Sleep Latency Test (MSLT), and at least two sleep-onset REM periods (SOREMPs).^[28]^[29] Narcolepsy type 2 shares the EDS and MSLT findings (mean latency ≤8 minutes with ≥2 SOREMPs) but lacks cataplexy and has normal CSF hypocretin-1 levels (>110 pg/mL or 1/3 of mean normal value).^[28] Idiopathic hypersomnia involves daily EDS for at least three months, with MSLT mean latency ≤8 minutes but fewer than two SOREMPs, and may include prolonged total sleep time (>660 minutes over 24 hours) or unrefreshing naps; it excludes cataplexy and requires normal hypocretin levels.^[28]^[30] Kleine-Levin syndrome features recurrent episodes of marked EDS and hypersomnia lasting from days to weeks (at least twice in a lifetime), accompanied by cognitive dysfunction, derealization, apathy, or hyperphagia, with full inter-episode remission and onset typically in adolescence.^[28]^[31] Diagnosis relies on a combination of clinical history, subjective scales, and objective polysomnography (PSG)-based tests. The MSLT, performed after an overnight PSG demonstrating adequate sleep (>6 hours), measures the time to sleep onset across four to five naps; a mean latency <8 minutes indicates pathological sleepiness, while SOREMPs (REM sleep within 15 minutes of onset) support narcolepsy subtypes.^[28] The Epworth Sleepiness Scale integrates subjective assessment by rating the likelihood of dozing in eight situations, with scores >10 suggesting significant EDS that correlates with MSLT findings in central hypersomnolence.^[28]^[29] These tools help confirm central etiology while ruling out confounders like sleep deprivation. An isolated symptom within this category is the long sleeper variant, classified under normal variants, where individuals habitually sleep more than 10 hours per night without EDS or impairment when sleep needs are met, distinguishing it from pathological hypersomnia.^[28] The ICSD-3-TR refines prior criteria by consolidating idiopathic hypersomnia into a single disorder, eliminating the distinction between cases with and without long sleep time to encompass heterogeneous presentations under unified objective sleep measures.^[28]^[30] This update enhances diagnostic flexibility while maintaining emphasis on MSLT and CSF testing for precision. These disorders are differentiated from hypersomnolence secondary to sleep-related breathing disorders through exclusion criteria ensuring no confounding respiratory events.^[28]

Circadian Rhythm Sleep-Wake Disorders

Circadian Rhythm Sleep-Wake Disorders in the ICSD-3-TR encompass conditions arising from persistent disruptions in the timing of the sleep-wake cycle due to misalignment between an individual's endogenous circadian rhythm and required sleep-wake schedules dictated by social, occupational, or environmental demands.^[32] These disorders are characterized by symptoms such as insomnia, excessive daytime sleepiness, or both, leading to significant distress or impairment in social, occupational, or other areas of functioning.^[32] Diagnosis requires evidence of a chronic or recurrent pattern of sleep-wake disruption that is temporally associated with a conflicting social or physical environment, with no better explanation by another sleep disorder, medical condition, or substance use.^[32] The ICSD-3-TR identifies six specific circadian rhythm sleep-wake disorders, each with distinct patterns of misalignment. Delayed Sleep-Wake Phase Disorder (DSWPD) involves a significant delay in the sleep episode, typically with preferred sleep onset two or more hours after midnight, making it difficult to fall asleep at conventional times and wake up for morning obligations, though sleep quality improves on a free-running schedule.^[32] Criteria include chronicity of at least three months, confirmed by sleep logs and actigraphy for at least seven days (preferably 14 or more), and dim light melatonin onset (DLMO) assessment showing a delayed circadian phase.^[32] Genetic factors, such as polymorphisms in hPer3 and CRY1 genes, contribute to familial cases, while environmental influences like evening light exposure exacerbate the delay.^[32] Advanced Sleep-Wake Phase Disorder (ASWPD) features an abnormally advanced sleep episode, with sleep onset typically before 7:00 PM and offset before 4:00 AM, resulting in early evening sleepiness and early morning awakenings that conflict with typical daily routines.^[32] Diagnostic requirements mirror those of DSWPD, including three months of chronic symptoms and phase assessment via DLMO to confirm an advanced circadian rhythm, with actigraphy preferred for objective measurement.^[32] This disorder is linked to genetic mutations in hPer2 and CK1ε, particularly in familial advanced sleep phase syndrome, and is more prevalent in older adults due to age-related circadian shifts.^[32] Irregular Sleep-Wake Rhythm Disorder (ISWRD) is marked by a lack of a clear circadian sleep-wake pattern, with no dominant sleep period and instead multiple irregular sleep bouts totaling a normal sleep duration but scattered across 24 hours.^[32] It requires at least three months of symptoms, documented by actigraphy showing three or more sleep bouts per day and sleep logs, often associated with neurodegenerative conditions like Alzheimer's disease or developmental disorders.^[32] Environmental factors, such as institutionalization, contribute to its onset in vulnerable populations.^[32] Non-24-Hour Sleep-Wake Rhythm Disorder (N24SWD) occurs when the endogenous circadian period exceeds 24 hours, leading to a progressive daily delay in sleep and wake times that cycles in and out of alignment with the external day.^[32] This disorder affects 50-80% of totally blind individuals due to lack of light entrainment but is rare in sighted people, requiring at least three months of symptoms confirmed by actigraphy over 14 or more days and DLMO indicating a non-entrained rhythm.^[32] Environmental absence of zeitgebers like light is the primary factor, though psychiatric comorbidities increase risk in sighted cases.^[32] Shift Work Disorder arises from recurrent sleep-wake disruptions caused by work schedules that overlap with typical sleep times, such as night or rotating shifts, resulting in insomnia or excessive sleepiness.^[32] It demands at least three months of symptoms tied to the work pattern, with evidence from sleep logs and actigraphy over 14 or more days capturing work and free days, plus DLMO if needed to verify misalignment.^[32] Genetic variants in PER3 influence susceptibility, alongside environmental factors like light exposure during shifts.^[32] Jet Lag Disorder is a temporary condition following rapid travel across two or more time zones, causing misalignment of the circadian rhythm with local time, leading to insomnia, sleepiness, or impaired alertness.^[32] Unlike other subtypes, it lacks a three-month chronicity requirement, with symptoms resolving within days (approximately one day per time zone crossed), assessed via sleep logs and optional actigraphy.^[32] Eastward travel often worsens symptoms due to phase advance difficulties, influenced by pre-travel sleep deprivation.^[32] Across all disorders, sleep logs are mandatory for diagnosis, with actigraphy and DLMO serving as key tools for objective phase assessment, and chronotype questionnaires aiding in evaluation.^[32] These conditions may overlap with insomnia symptoms, such as difficulty initiating sleep, but are distinguished by their circadian etiology.^[32]

Parasomnias

Parasomnias in the ICSD-3-TR are defined as undesirable physical events or experiences that occur during entry into sleep, within sleep, or during arousals from sleep, arising from incomplete arousals or dissociations across wakefulness, non-rapid eye movement (NREM) sleep, and rapid eye movement (REM) sleep states. These phenomena can lead to physical injury, potential harm to self or others, significant sleep disruption, or psychosocial distress, distinguishing them from normal sleep processes. The classification emphasizes clinical history, with polysomnographic confirmation where needed to exclude alternative explanations.^[1] The parasomnias category is organized into three primary subgroups. NREM-related parasomnias primarily involve disorders of arousal, including confusional arousals (characterized by mental confusion and disorientation upon partial awakening, with prevalence up to 4% in adults), sleepwalking (complex ambulatory behaviors during NREM sleep, affecting 1-7% lifetime in children and 2-4% in adults), and sleep terrors (intense fear with autonomic activation and screaming, peaking in childhood at 1-6.5%). Sleep-related eating disorder falls here as well, featuring recurrent nocturnal ingestions often triggered by arousals, sometimes linked to medications or stress. REM-related parasomnias include REM sleep behavior disorder (RBD), marked by dream-enacting behaviors due to REM sleep without atonia (prevalence 0.5-1% in the general population, higher in older males and neurodegenerative contexts), and nightmare disorder (recurrent distressing dreams causing awakenings with full recall, occurring weekly in 2-6% of adults). Other parasomnias encompass rarer entities such as exploding head syndrome (perception of explosive sounds or sensations at sleep onset, benign but startling) and sleep-related hallucinations (vivid hypnagogic or hypnopompic perceptual experiences, often visual or auditory).^[33]^[2] Diagnostic criteria across parasomnias require recurrent episodes that are unexplained by other sleep, medical, or psychiatric disorders and occur despite adequate sleep opportunity. Video-polysomnography (video-PSG) is recommended for confirmation, particularly in RBD to document REM without atonia or in cases of injury risk, and to differentiate from mimics; for instance, events must show persistence and inappropriateness to the sleep context. Isolated symptoms, not classified as disorders, include sleep talking (somniloquy, with lifetime prevalence up to 66%, typically benign) and benign neonatal sleep myoclonus (non-epileptic myoclonic jerks in infants under 6 months, resolving spontaneously).^[33]^[1] The ICSD-3-TR introduces refinements, including an appendix clarifying overlaps with seizures, such as distinguishing NREM disorders of arousal from sleep-related hypermotor epilepsy through video-PSG features like event stereotypy, abrupt onset/offset, and EEG ictal patterns (e.g., epilepsy events often arise from N2 sleep, unlike arousals from deep N3). This addresses diagnostic challenges in parasomnia overlap disorders, prioritizing neurophysiological evidence for accurate classification. Parasomnias differ from sleep-related movement disorders in emphasizing complex, arousal-linked behaviors over repetitive, non-behavioral limb or oral movements.^[24]^[1] Sleep-Related Movement Disorders in the ICSD-3-TR refer to a category of sleep disorders involving repetitive, involuntary movements that occur primarily during sleep and can lead to sleep disruption or daytime impairment. These disorders are distinguished from parasomnias by the absence of complex behaviors, focusing instead on stereotyped motor phenomena such as jerks, cramps, or rhythmic activities. The category emphasizes conditions where movements are the primary feature, often requiring polysomnography (PSG) for objective confirmation of their frequency and impact.^[23] Key sub-disorders include Restless Legs Syndrome (RLS), characterized by an irresistible urge to move the legs accompanied by uncomfortable sensations such as crawling or aching, which worsens during periods of rest or in the evening and is temporarily relieved by movement. Periodic Limb Movement Disorder (PLMD) involves periodic limb movements during sleep, defined by a periodic limb movement index exceeding 15 movements per hour in adults, leading to fragmented sleep or excessive daytime sleepiness; diagnosis typically requires PSG to quantify the movements. Sleep-Related Bruxism manifests as repetitive jaw-muscle activity, including teeth grinding or clenching, often resulting in dental damage, jaw pain, or complaints from bed partners, with PSG used optionally to assess electromyographic bursts. Benign Sleep Myoclonus of Infancy features brief myoclonic jerks of the limbs in otherwise healthy infants during quiet sleep, which resolve spontaneously by early childhood without long-term consequences or need for PSG.^[23]^[34]^[23] Diagnostic approaches for these disorders often incorporate PSG to measure the limb movement index, particularly for PLMD, where movements must meet specific criteria for duration (0.5-10 seconds) and periodicity (every 5-90 seconds). For RLS, evaluation includes assessing serum ferritin levels, as iron deficiency (ferritin below 75 μg/L) is a common underlying factor prompting iron supplementation as part of management. These tools help differentiate pathological movements from normal variants.^[23]^[34] Isolated symptoms within this category include physiologic myoclonus, which consists of normal, non-pathologic brief muscle twitches occurring at sleep onset or during sleep transitions in healthy individuals, without associated distress or need for intervention.^[23] Updates in the ICSD-3-TR include the addition of Propriospinal Myoclonus at Sleep Onset as a new disorder, involving axial myoclonic jerks propagating along the spinal cord at the transition to sleep, often triggered by sensory stimuli and distinguishable from other myoclonus by its propriospinal pattern on PSG.^[23]

Other Sleep Disorders

The "Other Sleep Disorders" category in the ICSD-3-TR encompasses sleep disturbances that do not align with the primary diagnostic groupings, providing a repository for atypical or residual conditions requiring further specification or investigation. This category includes fatal familial insomnia, a rare prion disease marked by severe, progressive insomnia and autonomic dysfunction leading to rapid deterioration and death; sleep-related dissociative disorders, which involve episodes of dissociation emerging from sleep transitions and often linked to underlying trauma or psychiatric conditions; insufficient sleep syndrome, characterized by chronic voluntary restriction of sleep duration resulting in daytime impairment; and unspecified sleep-wake complaints, applied when symptoms are present but insufficient for a more precise diagnosis.^[1] Diagnoses within this category rely on an exclusionary approach, confirming that the sleep-wake disturbance is not better explained by another sleep disorder, medical or neurological condition, mental disorder, medication, or substance use. Emphasis is placed on identifiable environmental or behavioral contributors, such as lifestyle choices or external pressures that perpetuate the issue, with polysomnography or actigraphy used sparingly to support rather than define the diagnosis.^[2]^[35] This grouping functions as a provisional framework for emerging or ill-defined conditions, such as environmentally induced hypersomnias potentially arising from toxin exposure or novel stressors, allowing clinicians to document cases pending additional research or reclassification. The ICSD-3-TR introduces updated notes highlighting the role of modern behavioral factors, including excessive digital media engagement before bedtime, in exacerbating insufficient sleep syndrome through delayed sleep onset and fragmented rest.^[23] For overlaps with medical etiologies, such as neurodegenerative aspects of fatal familial insomnia, the appendices offer supplementary guidance on differential diagnosis.^[24]

Applications and Impact

Diagnostic and Coding Integration

The ICSD-3-TR facilitates practical clinical application by providing detailed mappings of its diagnostic categories to established global coding systems, including ICD-10-CM and ICD-11, as outlined in its appendices.^[1] These mappings enable dual-coding practices, where the ICSD-3-TR serves as the primary diagnostic framework for sleep specialists, while ICD codes are used for standardized billing, epidemiological reporting, and interoperability with healthcare systems.^[36] For instance, parasomnias in the ICSD-3-TR correspond to ICD-10-CM code G47.5, encompassing unspecified parasomnias and subtypes like confusional arousals (G47.51).^[37] In ICD-11, sleep-wake disorders fall under Chapter 07, with specific blocks such as 7A00-7A0Z for insomnia disorders, allowing for precise alignment across the broader category of sleep-related conditions (7A00-7A9Z).^[38] The diagnostic process follows a structured, stepwise application of ICSD-3-TR criteria, beginning with clinical history and symptom assessment, followed by objective testing where indicated, such as polysomnography (PSG) to evaluate sleep architecture and respiratory events or actigraphy to monitor sleep-wake patterns over extended periods.^[23] A key feature is the hierarchical organization of categories, which mandates ruling out more prevalent or treatable conditions before confirming others; for example, sleep-related breathing disorders must be excluded or adequately treated prior to diagnosing central disorders of hypersomnolence, as untreated obstructive sleep apnea can mimic hypersomnolence symptoms.^[31] For comorbidities, the ICSD-3-TR offers explicit guidance on coding multiple disorders independently when diagnostic criteria are independently met, avoiding subsumption under a single category; a representative case is comorbid chronic insomnia disorder (ICSD code 307.42; ICD-10-CM G47.00) and obstructive sleep apnea (ICSD code 327.23; ICD-10-CM G47.33), which are documented and coded as distinct entities to reflect their separate pathophysiology and treatment needs.^[26] Internationally, the ICSD-3-TR aligns with World Health Organization (WHO) frameworks through its ICD mappings, promoting uniform diagnostic practices across countries, and supports integration into electronic health records (EHRs) by enabling automated coding and data exchange compliant with standards like ICD-11, which took effect globally in 2022.^[39]

Clinical and Research Utility

The International Classification of Sleep Disorders, Third Edition, Text Revision (ICSD-3-TR) enhances clinical practice by providing standardized diagnostic criteria that improve inter-rater reliability, thereby reducing misdiagnosis rates in sleep medicine. For instance, studies evaluating ICSD-3 criteria for disorders of arousal, such as confusional arousals, sleepwalking, and sleep terrors, have reported "almost perfect" agreement among raters, with Cohen's kappa values ranging from 0.87 to 0.89 based on structured interviews with adults.^[40] Overall, a systematic review of ICSD-3 reliability across sleep-wake disorders found substantial inter-rater agreement (mean kappa = 0.66), supporting more consistent diagnoses compared to prior classifications.^[41] These criteria guide targeted treatments, such as continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea, by clearly delineating symptom thresholds and exclusion rules that align with evidence-based interventions.^[1] In research, the ICSD-3-TR facilitates epidemiological tracking and clinical trials by enabling uniform application of diagnostic standards across studies. Prevalence investigations, such as those using ICSD-3 criteria for chronic insomnia disorder, have yielded consistent estimates, including 20% in Norwegian adult cohorts and 14% in Spanish populations, allowing for cross-study comparisons and identification of risk factors like age and comorbidities.^[42]^[43] Similarly, the classification supports trials evaluating orexin receptor antagonists for central disorders of hypersomnolence, such as narcolepsy type 1, where ICSD-3 criteria ensure precise patient selection based on hypocretin deficiency markers.^[23] This standardization has addressed gaps, including underdiagnosis in pediatric populations, by refining criteria for conditions like insufficient sleep syndrome.^[44] The adoption of ICSD-3-TR has amplified its impact, with the core publication garnering over 1,500 citations in peer-reviewed literature since 2014, reflecting widespread use in advancing sleep disorder research and guidelines.^[2] Post-ICSD-3 implementation, sleep medicine publications incorporating its criteria have surged, contributing to more than 5,000 references in databases like PubMed by 2023, underscoring its role in shaping global clinical protocols.^[1] Despite these advances, the ICSD-3-TR faces limitations as an evolving framework in a dynamic field, necessitating periodic updates to incorporate emerging data on sleep pathophysiology. Critiques highlight variability in criterion application, such as the requirement for confirmed sleep opportunity in insufficient sleep syndrome, which may not hold in many real-world cases.^[44] Additionally, cultural variations in symptom reporting can influence prevalence estimates, with cross-cultural studies showing differences in insomnia expression between Western and non-Western populations, potentially leading to underrecognition in diverse groups.^[45] The ICSD-3-TR briefly references alignment with ICD-11 for coding but emphasizes its primary focus on sleep-specific diagnostics.^[4]

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