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  • Updated 12.04.2021
  • Released 01.18.1994
  • Expires For CME 12.04.2024

Environmental and behavioral sleep disorders

Introduction

Overview

Environmental and behavioral sleep disorders encompass all disorders that cause sleep disruption or excessive daytime sleepiness, resulting from 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 authors review 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.

• Behavioral and environmental sleep disorders can also be related to drug or substance abuse.

• 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 (06). 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 (03). For some of the original extrinsic sleep disorders, this designation was continued in the International Classification of Sleep Disorders, 3rd edition (ICSD-3), see table 1. However, the ICSD-3 eliminated the specific diagnostic criteria for many of the extrinsic sleep disorders (04).

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 (04). In the case of behavioral insomnia of childhood, the factors related to this subtype can often be seen in many age groups and its 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 (47). 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 (04). 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

Insomnia

Environmental sleep disorder

Other sleep disorder and normal variant

Adjustment insomnia

Insomnia

Behaviorally induced insufficient sleep syndrome

Central disorder of hypersomnolence

Behavioral insomnia of childhood, limit-setting type

Insomnia

Behavioral insomnia of childhood, sleep-onset type

Insomnia

Insomnia due to drug or substance

Insomnia

Hypersomnia due to drug or substance

Central disorder of hypersomnolence

Other circadian rhythm sleep disorder due to drug or substance

Circadian rhythm sleep-wake disorder

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