대한수면호흡학회

ICD-3를 중심으로 정리한 불면증

(2020년 12월 17일 수면연구회 발표 내용을 정리한 것입니다)

양산부산대학교병원 문수진

Insomnia (불면증): A persistent difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, and results in some form of daytime impairment

• 1. Chronic insomnia disorder (ICD-9-CM 307.42 / KCD G470), 만성불면장애

  일주일에 3회 이상, 3개월 이상 잠들기 어렵거나, 중간에 자주 깨거나, 아침에 일찍 깨는 것을 말하며, 이러한 증상이 지속될 때

  • 1) Alternative names: chronic insomnia, primary insomnia, secondary insomnia, comorbid insomnia, disorder of initiating and maintaining sleep, behavioral insomnia of childhood, sleep-onset association disorder, limit-setting sleep disorder
  • 2) Diagnostic criteria, criteria A-F must be met
    • The patient reports, or the patient’s parent or caregiver observes, one or more of the following:
      - Difficulty initiating sleep
      - Difficulty maintaining sleep
      - Waking up earlier than desired
      - Resistance to going to bed on appropriate schedule
      - Difficulty sleeping without parent or caregiver intervention
    • The patient reports, or the patient’s parent or caregiver observes, one or more of the following related to the nighttime sleep difficulty:
      - Fatigue/malaise
      - Attention, concentration, or memory impairment
      - Impaired social, family, occupational, or academic performance
      - Mood disturbance/irritability
      - Daytime sleepiness
      - Behavioral problems (ex. Hyperactivity, impulsivity, aggression)
      - Reduced motivation/energy/initiative
      - Proneness for errors/accidents
      - Concerns about or dissatisfaction with sleep
      
    • The reported sleep/wake complaints cannot be explained purely by inadequate opportunity or circumstances for sleep
    • The sleep disturbance and associated daytime symptoms occur at least 3 times per week
    • The sleep disturbance and associated daytime symptoms have been present for at least 3 months
    • The sleep/wake difficulty is not better explained by another sleep disorder
  • 3) Essential features
    
    • - Sleep complaints: difficulties initiating sleep or difficulties maintaining sleep (waking up during the night with difficulty returning to sleep or having a final awakening occurring too early, well before the desired rising time)
      • Sleep onset latencies and periods of wakefulness after sleep onset which are considered clinically significant sleep disturbances, > 20 min in children and young adults & > 30 min in middle and older adults
      • Early morning awakening: Termination of sleep at least 30 minutes before the desired rising time and a concomitant reduced total sleep time compared to the usual premorbid sleep pattern
    • - Waking symptoms: fatigue; reduced motivation; reduced concentration, attention, and memory functioning; and irritability or reduced mood; reduced performance at work or school or impaired social functioning; errors or accidents at work
    • - Somatic symptoms: headaches or gastrointestinal dysfunction
  • 4) Associated features

    Feelings of reduced well-being and general malaise during the day, excessive focus on and worry about ongoing sleep difficulties

  • 5) Clinical and Pathophysiological Subtypes in Primary insomnia
    • Psychophysiological insomnia: heightened arousal and learned sleep-preventing associations that result in a complaint of insomnia
    • Idiopathic insomnia: a longstanding complaint of sleep difficulties with insidious onset occurring during infancy or early childhood
    • Paradoxical insomnia: sleep state misperception, a complaint of severe sleep disturbance without corroborative objective evidence of the degree of sleep disturbance claimed
    • Inadequate sleep hygiene: result from or be sustained by daily living activities that are inconsistent with the maintenance of good-quality sleep and normal daytime alertness
    • Behavioral insomnia of childhood: result from improper sleep training or limit setting by parents or caretakers
      • - Sleep-onset association type: the child’s dependency on specific stimulation, objects, or settings for initiating sleep or returning to sleep following an awakening
      • - Limit-setting type: bedtime stalling or bedtime refusal that is the result of inadequate limit setting by a caregiver
      • - A mixed type
  • 6) Clinical and Pathophysiological Subtypes in Secondary insomnia
    • Insomnia due to (another) mental disorder: a common complaint among patients with mood disorders and anxiety disorders and various personality disorders
    • Insomnia due to (a) medical condition: result from some form of ongoing pain or discomfort, mobility limitation, or breathing disturbance
    • Insomnia due to drug or substance: caused by or secondary to use of or withdrawal from a drug or substance
  • 7) Pathology and Pathophysiology
    • Increased physiological arousal → heightened activity of the sympathetic nervous system and hypothalamic-pituitary-adrenal axis across sleep and wakefulness
      - Increased heart rate
      - altered heart rate variability
      - increased whole-body metabolic rate
      - elevated cortisol, adrenocorticotropic hormone, and CRF (corticotropin releasing factor) levels (particularly near sleep onset)
      - increased body temperature and increased high-frequency EEG activity during NREM sleep
    • No discrete structural brain pathology can be identified
  • 8) Objective findings
    • PSG: not indicated as routine evaluation
      - In the absence of other sleep disorders
      - Increased sleep latency
      - Increased wake time after sleep onset with reduced sleep efficiency
      - Reduced sleep duration of less than 6 hours / night
      - Some show altered sleep architecture with an increase in stage N1 sleep and a decrease in slow wave sleep
      - Some may show a reverse first-night effect in the sleep laboratory
    • MSLT (Multiple Sleep Latency Test): normal daytime alertness
  • 9) Differential diagnosis
    • Delayed sleep-wake phase disorder (뒤쳐진 수면위상형): Sleep initiation is consistently later than desired because the individual's endogenous circadian rhythm is delayed relative to the desired sleep schedule. Common in younger adults and children
    • Advanced sleep-wake phase disorder (앞당겨진 수면위상형): Sleep initiation is consistently earlier than desired because the individual’s endogenous circadian rhythm is advanced relative to the desired sleep schedule. Common in older adults
    • Sleep-disruptive environmental circumstances: Noise or light, smartphone usage

• 2. Short-Term insomnia disorder (ICD-9-CM 307.41 / KCD G470), 단기불면장애

  3개월 미만으로 잠들기 어렵거나, 중간에 자주 깨거나, 아침에 일찍 깨는 것을 말하며, 이러한 증상이 지속될 때

  • Alternative names: acute insomnia, adjustment insomnia
  • Diagnostic criteria, criteria A-E must be met
    • The patient reports, or the patient’s parent or caregiver observes, one or more of the following:
      - Difficulty initiating sleep
      - Difficulty maintaining sleep
      - Waking up earlier than desired
      - Resistance to going to bed on appropriate schedule
      - Difficulty sleeping without parent or caregiver intervention
      
    • The patient reports, or the patient’s parent or caregiver observes, one or more of the following related to the nighttime sleep difficulty:
      - Fatigue/malaise
      - Attention, concentration, or memory impairment
      - Impaired social, family, occupational, or academic performance
      - Mood disturbance/irritability
      - Daytime sleepiness
      - Behavioral problems (ex. Hyperactivity, impulsivity, aggression)
      - Reduced motivation/energy/initiative
      - Proneness for errors/accidents
      - Concerns about or dissatisfaction with sleep
      
    • The reported sleep/wake complaints cannot be explained purely by inadequate opportunity or circumstances for sleep
    • The sleep disturbance and associated daytime symptoms have been present forless than 3 months
    • The sleep/wake difficulty is not better explained by another sleep disorder
  • Essential features
    Sleep complaints: difficulties initiating sleep or difficulties maintaining sleep (waking up during the night with difficulty returning to sleep or having a final awakening occurring too early, well before the desired rising time)
  • Associated features
    Fatigue, impaired attention and concentration, poor memory, irritability, and distress about poor sleep When arises in reaction to a stressful life event, anxiety, worry, ruminative thoughts, sadness, or depression
  • Differential diagnosis
    i) Circadian rhythm sleep-wake disorders (시차 혹은 교대 근무):
    Resulting from rotating shift work or jet lag. The sleep disturbance arises from a sleep-wake schedule alteration that results in a mismatch between the endogenous circadian rhythm and the sleep-wake schedule chosen

• 3. Isolated symptoms and normal variants, 단독 증상 및 정상 변이형

  • - Excessive time in bed (잠자리에서 과도한 시간을 보내는 사람):
    Some individuals may present with isolated insomnia symptoms such as prolonged sleep latencies or long periods of wakefulness during the night, yet not complain of insomnia nor show daytime impairments
    In children, this pattern may emerge when parents or caregivers have unrealistic expectations for the child’s sleep needs and routinely allot too much time for the child to be in bed each night
    In adults, this pattern is perhaps most common in noncomplaining groups who routinely allot significantly more time in bed than needed for sleep
  • - Short sleeper (짧은 수면을 타고 난 사람):
    Some individuals routinely obtain less than 6 hours of sleep per night on average yet have no sleep/wake complaints