Sleep Disorders

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Sleep Disorders

• RCS 6931
• June 21, 2007
• Steven R. Pruett, Ph.D.

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Categories of Sleep Disorders

• Dyssomnias
• Problem with quantity, quality or timing of
  sleep.
• Parasomnias
• Relatively normal quality, quantity and timing of
  sleep, but something odd happens during sleep
  itself or during the times when the patient is
  falling asleep or waking up.

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Dyssomnias

• Insomnia
• Not enough sleep is usually the presenting
  complaint (for at least a month).
• Usually as a result of an Axis I or II or general
  medical condition (rarely shows up by itself).
• MUST evaluate the cause of the Insomnia for
  proper treatment decisions.
• If no other Axis I, II or III disorders are made
  then its Primary Insomnia 307.42
• Diagnostic Criteria
• Morrison p. 400 DSM-IV-TR p. 604

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Dyssomnias

• Primary Hypersomnia 307.44
• Presenting complaint is that they sleep too much.
  
• Usually fall asleep quickly and sleep late the
  next day.
• Frequently complain of being chronically tired
  and sleepy during the day (may take naps)
• Sleep 9 hours/day
• Diagnostic Criteria
• Morrison p. 402-403 DSM-IV-TR p. 609

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Dyssomnias

• Narcolepsy 347
• Four major symptoms (do not have to have all of
  them)
• Sleep attacks
• Irresistible urge to fall asleep.
• Cataplexy
• Sudden bilateral loss of muscle tone
• Hallucinations (usually visual)
• Hypnagogic or hypnopompic
• Sleep paralysis
• Sensation of being awake, but unable to move,
  speak or even breathe adequately
• Associated with anxiety and fear of dying (lasts
  lt 10 mins)

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Narcolepsy

• REM sleep intrusions
• Uncommon, chronic, largely hereditary disorder
  that is difficult to manage requires lifelong
  treatment.
• No gender differences. Onset is usually in
  puberty always before age 30.
• Slow steady progression of symptoms
• Can lead to depression, impotence, work problems,
  accidents
• Not related to a general medical condition or
  substances/medications
• Treatment Stimulants (e.g. Ritalin)
• Diagnostic Criteria
• Morrison p. 406 DSM-IV-TR p. 615

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Breathing-Related Sleep Disorder 780.57

• Low oxygen levels in blood
• Causes insomnia or hypersomnia
• Symptoms
• Alveolar hypoventilation syndrome
• Sleep apnea (relatively common)
• Obstructive
• Central
• Use Axis III to specify which medical condition

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Circadian Rhythm Sleep Disorder 327.3x

• Circadian comes from about one day (circa
  approximately dia day)
• Presenting problem sleep-wake cycle is off
• NOTE this cycle is not constant through the
  lifespan
• Three major types of Circadian Rhythm Sleep
  Disorder (1st two are transient
  self-correcting)
• Jet Lag Type 327.31
• Shift Work Type 327.35
• Delayed Sleep Phase Type 327.36
• Unspecified Type 326.30
• Diagnostic Criteria
• Morrison p. 412 DSM-IV-TR p. 629.

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Dyssomnia NOS 307.47

• Complaints of clinically significant insomnia or
  hypersomnia related to the environment (e.g.
  airlines, trains, lights)
• Restless legs syndrome
• Sleep deprivation sleepiness.

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Parasomnias

• These are problems that encroach on sleep but
  dont cause insomnia or hypersomnia.
• Example
• Nightmares vs. Sleep apnea
• Scary vs. causing sleepiness during the next day

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Nightmare Disorder 307.47

• Nightmares occur during REM sleep
• Those that occur during childhood have no
  pathological significance.
• Nightmares are very common when does it become
  a disorder?
• Vivid nightmares sometime precede a psychosis.
• However most Nightmares are normal a reaction to
  stress
• Diagnostic criteria
• Morrison p. 416 DSM-IV-TR p. 634

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Sleep Terror Disorder 307.46

• Usually affect children (not pathological)
• Occur during non-REM sleep (most common early
  during the night).
• Attack lasts 5-15 minutes and ends with the
  individual going back to sleep.
• In adults the disorder is rare and usually
  coincides with another Axis I disorder (anxiety?)
  or a personality disorder.
• Diagnostic Criteria
• Morrison p. 419 DSM-IV-TR 639

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Sleepwalking Disorder 307.46

• AKA somnambuism
• Usually occurs during first third of the night
  (non-REM sleep)
• Some purposeful behavior is not uncommon
  (dressing, eating, using bathroom) but facial
  expression is blank and speech is either
  non-existent or garbled.
• Usually have amnesia regarding incident
• Incident can last from a few seconds to 30
  minutes.
• Hard to reawaken (not dangerous)
• 1-5 of children, lt1 of adults
• Diagnostic Criteria
• Morrison p. 422 DSM-IV-TR p. 644

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Parasomnia NOS 307.47

• REM sleep behavior disorder
• Sleep paralysis
• Code these sleep issues in Axis III
• Bruxism
• Tooth grinding
• Sleep-related cluster headaches

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Sleep disorders related to another Mental Disorder

• Insomnia related to a mental disorder 327.02
• Depression
• Anxiety disorders
• Adjustment disorders
• Somatization disorders
• Cognitive Disorders
• Manic/Hypomanic Episodes
• Schizophrenia
• OCPD
• Diagnostic Criteria
• Morrison p. 426 DSM-IV p. 650

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Hypersomnia Related to Another Mental Disorder
327.15

• Not as common as Insomnia Related to Another
  Mental Disorder
• Usually due to daytime drowsiness vs. excessive
  sleeping at night
• Diagnostic Criteria
• Morrison p. 429 DSM-IV-TR p. 650

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Other Sleep Disorders

• Sleep Disorder Due to a General Medical Condition
  327.xx (used to be 780.xx)
• Diagnostic Criteria
• Morrison p. 432 DSM-IV-TR p. 654
• Substance-Induced Sleep Disorder
• Alcohol 291.82
• Others 292.85
• Diagnostic Criteria and specifiers
• Morrison p. 435-436 DSM-IV-TR p. 660-661

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Code Changes for Sleep Disorders

• A link to get a pdf of the corrected pages (all
  49 of them) and new codes for DSM-IV-TR is
  http//www.dsmivtr.org/SleepDisorderCodeChangesDSM
  -IV-TR_1005.pdf