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Sleep medicine is a medical specialty or subspecialty devoted to the diagnosis and therapy of sleep disturbances and disorders. From the middle of the 20th century, research has provided increasing knowledge and answered many questions about sleep-wake functioning. The rapidly evolving field has become a recognized medical subspecialty in some countries. Dental sleep medicine also qualifies for board certification in some countries. Properly organized, minimum 12-month, postgraduate training programs are still being defined in the United States. In some countries, the sleep researchers and the physicians who treat patients may be the same people.
The first sleep clinics in the United States were established in the 1970s by interested physicians and technicians; the study, diagnosis and treatment of obstructive sleep apnea were their first tasks. As late as 1999, virtually any American physician, with no specific training in sleep medicine, could open a sleep laboratory.
Disorders and disturbances of sleep are widespread and can have significant consequences for affected individuals as well as economic and other consequences for society. The US National Transportation Safety Board has, according to Dr. Charles Czeisler, member of the Institute of Medicine and Director of the Harvard University Medical School Division of Sleep Medicine at Brigham and Women’s Hospital, discovered that the leading cause (31%) of fatal-to-the-driver heavy truck crashes is fatigue related, (though rarely associated directly with sleep disorders, such as sleep apnea), with drugs and alcohol as the number two cause (29%). Sleep deprivation has also been a significant factor in dramatic accidents, such as the Exxon Valdez oil spill, the nuclear incidents at Chernobyl and Three Mile Island and the explosion of the space shuttle Challenger.
Competence in sleep medicine requires an understanding of a plethora of very diverse disorders, many of which present with similar symptoms such as excessive daytime sleepiness, which, in the absence of volitional sleep deprivation, “is almost inevitably caused by an identifiable and treatable sleep disorder,” such as sleep apnea, narcolepsy, idiopathic hypersomnia, Kleine-Levin syndrome, menstrual-related hypersomnia, idiopathic recurrent stupor, or circadian rhythm disturbances. Another common complaint is insomnia, a set of symptoms that can have many causes, physical and mental. Management in the varying situations differs greatly and cannot be undertaken without a correct diagnosis.
ICSD, The International Classification of Sleep Disorders, was restructured in 1990, in relation to its predecessor, to include only one code for each diagnostic entry and to classify disorders by pathophysiologic mechanism, as far as possible, rather than by primary complaint. Training in sleep medicine is multidisciplinary, and the present structure was chosen to encourage a multidisciplinary approach to diagnosis. Sleep disorders often do not fit neatly into traditional classification; differential diagnoses cross medical systems. Minor revisions and updates to the ICSD were made in 1997 and in following years. The present classification system in fact follows the groupings suggested by Nathaniel Kleitman, the “father of sleep research,” in his seminal 1939 book Sleep and Wakefulness.
The revised ICSD, ICSD-R, placed the primary sleep disorders in the subgroups (1) dyssomnias, which include those that produce complaints of insomnia or excessive sleepiness, and (2) the parasomnias, which do not produce those primary complaints but intrude into or occur during sleep. A further subdivision of the dyssomnias preserves the integrity of circadian rhythm sleep disorders, as was mandated by about 200 doctors and researchers from all over the world who participated in the process between 1985–1990. The last two subgroups were (3) the medical or psychiatric sleep disorder section and (4) the proposed new disorders section. The authors found the heading “medical or psychiatric” less than ideal but better than the alternative “organic or non-organic,” which seemed more likely to change in the future. Detailed reporting schemes aimed to provide data for further research. A second edition, called ICSD-2, was published in 2005.
MeSH, Medical Subject Headings, a service of the US National Library of Medicine and the National Institutes of Health, uses similar broad categories: (1) dyssomnias, including narcolepsy, apnea, and the circadian rhythm sleep disorders, (2) parasomnias, which include, among others, bruxism (tooth-grinding), sleepwalking and bedwetting, and (3) sleep disorders caused by medical or psychiatric conditions. The system used produces “trees,” approaching each diagnosis from up to several angles such that each disorder may be known by several codes.
DSM-IV-TR, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, using the same diagnostic codes as the International Statistical Classification of Diseases and Related Health Problems (ICD), divides sleep disorders into three groups: (1) primary sleep disorders, both the dyssomnias and the parasomnias, presumed to result from an endogenous disturbance in sleep-wake generating or timing mechanisms, (2) those secondary to mental disorders and (3) those related to a general medical condition or substance abuse.
Recent thinking opens for a common cause for mood and sleep disorders occurring in the same patient; a 2010 review states that, in humans, “single nucleotide polymorphisms in Clock and other clock genes have been associated with depression” and that the “evidence that mood disorders are associated with disrupted or at least inappropriately timed circadian rhythms suggests that treatment strategies or drugs aimed at restoring ‘normal’ circadian rhythmicity may be clinically useful.”
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