Environmental and behavioral sleep disorders

Stephanie Bissonnette DO (Dr. Bissonnette, Movement Disorders Fellow at Boston University School of Medicine has no relevant financial relationships to disclose.)
Michael J Howell MD, editor. (Dr. Howell of the University of Minnesota received grant support from Apnex and GE and honorariums from Inspire as a panel member.)
Originally released January 18, 1994; last updated January 9, 2018; expires January 9, 2021

This article includes discussion of environmental and behavioral sleep disorders, behaviorally induced insufficient sleep syndrome, chronic insomnia related to external factors, other sleep disorder due to sleep disruptive environmental circumstances, short-term insomnia disorder (adjustment sleep disorder), and substance-induced sleep disorder. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Environmental and behavioral sleep disorders encompass all disorders that cause sleep disruption or excessive daytime sleepiness. They are the result of exogenous factors, ie, the causes originate from outside the body. Removal of these external factors leads to resolution of the sleep disorder. In this article, the author reviews environmental and behavioral sleep disorders. This clinical article update reflects the organization system found in the International Classification of Sleep Disorders, 3rd edition (ICSD-3).

Key points

 

• Behavioral and environmental sleep disorders may appear at any age.

 

• Multiple environmental sleep disorders may occur simultaneously in the same patient, which may pose challenges to treatment.

 

• Removal of the inciting environmental factor can ultimately lead to resolution of the subsequent sleep disorder.

Historical note and terminology

The first International Classification of Sleep Disorders (ICSD) listed 13 extrinsic sleep disorders (American Sleep Disorders Association 1997). Extrinsic sleep disorders are those that cause sleep disruption or excessive daytime sleepiness as a result of causes that arise outside the body. This contrasts with intrinsic sleep disorders, which lead to sleep disruption or excessive daytime sleepiness due to factors that are based within various body systems. The International Classification of Sleep Disorders, 2nd edition (ICSD-2), does not use the term “extrinsic sleep disorders.” Instead, diagnoses previously listed in this category fell into various categories: insomnia; hypersomnias of central origin not due to a circadian rhythm sleep disorder, sleep-related breathing disorder, or other cause of disturbed nocturnal sleep; circadian sleep disorders; and other sleep disorders (American Academy of Sleep Medicine 2005). For some of the original extrinsic sleep disorders, this designation was continued in the International Classification of Sleep Disorders, 3rd edition (ICSD-3). However, the ICSD-3 eliminated the specific diagnostic criteria for many of the extrinsic sleep disorders (American Academy of Sleep Medicine 2014).

Inadequate sleep hygiene, behavioral insomnia of childhood (both limit-setting and sleep-onset type), and insomnia due to drug or substance use are now part of a single diagnosis of chronic insomnia. The American Academy of Sleep Medicine eliminated these diagnostic subtypes due to the large amount of overlap between them, the difficulty in clinically identifying a single factor as the cause of many patients' insomnia, and common treatment modalities for these subtypes (American Academy of Sleep Medicine 2014). In the case of behavioral insomnia of childhood, it was found that the factors related to this subtype can often be seen in many age groups and that it's defining features are ultimately the same as those for global insomnia. Although there are no longer specific diagnostic criteria for the above-mentioned extrinsic sleep disorders, these subtypes may still be of use in clinical practice when assessing and treating a patient with sleep disorders (Owens 2017). Additionally, adjustment insomnia is now named short-term insomnia disorder. Environmental sleep disorder is a component of “other sleep disorder” in the ICSD-3 as it is rarely diagnosed in clinical practice and there is controversy regarding it as a true clinical diagnosis (American Academy of Sleep Medicine 2014). The clinical manifestations, etiology, pathophysiology, diagnostic evaluation, and management of each diagnosis will be discussed in this clinical article as they are found in the ICSD-3.

Table 1. Extrinsic Sleep Disorders

Sleep Disorder from ICSD-1 Criteria

ICSD-3 Category

Inadequate sleep hygiene

V

Environmental sleep disorder

XI

Adjustment insomnia

V

Behaviorally induced insufficient sleep syndrome

IV

Behavioral insomnia of childhood, limit-setting type

V

Behavioral insomnia of childhood, sleep-onset type

V

Insomnia due to drug or substance

V

Hypersomnia due to drug or substance

IV

Other circadian rhythm sleep disorder due to drug or substance

VIII

Table 2. Categories According to ICSD-3

I.

Obstructive sleep apnea

II.

Central sleep apnea

III.

Sleep-related hypoventilation disorder

IV.

Central disorder of hypersomnolence

V.

Insomnia

VI.

NREM parasomnia

VII.

REM and other parasomnias

VIII.

Circadian rhythm disorder

IX.

Restless legs syndrome and periodic limb movement disorder

X.

Other movement disorders

XI.

Other sleep disorder and normal variant

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