Chapter 8 Eating and Sleep Disorders

1
Chapter 8 Eating and Sleep Disorders
2
Eating Disorders An Overview

• Two Major Types of DSM-IV-TR Eating Disorders
• Anorexia nervosa and bulimia nervosa
• Severe disruptions in eating behavior
• Extreme fear and apprehension about gaining
  weight
• Strong sociocultural origins Westernized views

3
Eating Disorders An Overview (continued)

• Other Subtypes of DSM-IV-TR Eating Disorders
• Binge eating disorder Buffet diet!
• Obesity A Growing Epidemic not yet a disorder
  but the side effects are diagnosed. Can be on
  Axis III

4
Bulimia Nervosa Overview and Defining Features

• Binge Eating Hallmark of Bulimia
• Binge
• Eating excess amounts of food
• Eating is perceived as uncontrollable

5
Bulimia Nervosa Overview and Defining Features
(continued)

• Compensatory Behaviors
• Purging
• Self-induced vomiting, diuretics, laxatives
• Some exercise excessively, whereas others fast

6
Bulimia Nervosa Overview and Defining Features
(continued)

• DSM-IV-TR Subtypes of Bulimia
• Purging subtype Most common subtype
• Nonpurging subtype About one-third of bulimics

7
Bulimia Nervosa Associated Features

• Associated Medical Features
• Most are within 10 of target body weight
• Purging methods can result in severe medical
  problems
• Erosion of dental enamel, electrolyte imbalance
• Kidney failure, cardiac arrhythmia, seizures,
  intestinal problems, permanent colon damage

8
Bulimia Nervosa Associated Features (continued)

• Associated Psychological Features
• Most are over concerned with body shape
• Fear of gaining weight
• Most have comorbid psychological disorders

9
Anorexia Nervosa Overview and Defining Features

• Successful Weight Loss Hallmark of Anorexia
• Defined as 15 below expected weight
• Intense fear of obesity and losing control over
  eating
• Anorexics show a relentless pursuit of thinness
• Often begins with dieting

10
Anorexia Nervosa Overview and Defining Features
(continued)

• DSM-IV-TR Subtypes of Anorexia
• Restricting subtype Limit caloric intake via
  diet and fasting
• Binge-eating-purging subtype About 50 of
  anorexics

11
Anorexia Nervosa Overview and Defining Features
(continued)

• Associated Features
• Most show marked disturbance in body image
• Most are comorbid for other psychological
  disorders
• Methods of weight loss have life threatening
  consequences

12
Binge-Eating Disorder Overview and Defining
Features

• Binge-Eating Disorder Appendix of DSM-IV-TR
• Experimental diagnostic category
• Engage in food binges without compensatory
  behaviors

13
Binge-Eating Disorder Overview and Defining
Features (continued)

• Associated Features
• Many persons with binge-eating disorder are obese
• Concerns about shape and weight
• Often older than bulimics and anorexics
• More psychopathology vs. non-binging obese people

14
Bulimia and Anorexia Facts and Statistics

• Bulimia
• Majority are female
• Onset around 16 to 19 years of age
• Lifetime prevalence is about 1.1 for females,
  0.1 for males
• 6-8 of college women suffer from bulimia
• Tends to be chronic if left untreated

15
Bulimia and Anorexia Facts and Statistics
(continued)

• Anorexia
• Majority are female and white
• From middle-to-upper middle class families
• Usually develops around age 13 or early
  adolescence
• More chronic and resistant to treatment than
  bulimia
• Both Bulimia and Anorexia Are Found in
  Westernized Cultures

16
Causes of Bulimia and Anorexia Toward an
Integrative Model

• Media and Cultural Considerations
• Being thin Success, happiness....really?
• Cultural imperative for thinness
• Translates into dieting
• Gossip News and People magazine Playboy model
  appearance

17
Causes of Bulimia and Anorexia Toward an
Integrative Model (continued)

• Standards of ideal body size
• Change as much as fashion What is a size 00?
• Media standards of the ideal
• Are difficult to achieve
• Biological Considerations
• Can lead to neurobiological abnormalities

18
Causes of Bulimia and Anorexia Toward an
Integrative Model

• Psychological and Behavioral Considerations
• Low sense of personal control and self-confidence
• Perfectionistic attitudes
• Distorted body image
• Preoccupation with food
• Mood intolerance
• An Integrative Model

19
Fig. 8.4, p. 315
20
Medical and Psychological Treatment of Bulimia
Nervosa

• Medical and Drug Treatments
• Antidepressants
• Can help reduce binging and purging behavior
• Are not efficacious in the long-term

21
Medical and Psychological Treatment of Bulimia
Nervosa (continued)

• Psychosocial Treatments
• Cognitive-behavior therapy (CBT)
• Is the treatment of choice
• Basic components of CBT
• Interpersonal psychotherapy
• Results in long-term gains similar to CBT

22
Goals of Psychological Treatment of Anorexia
Nervosa

• General Goals and Strategies
• Weight restoration
• First and easiest goal to achieve
• Psycho-education

23
Goals of Psychological Treatment of Anorexia
Nervosa (continued)

• Behavioral, and cognitive interventions
• Target food, weight, body image, thought and
  emotion
• Treatment often involves the family
• Long-term prognosis for anorexia is poorer than
  for bulimia

24
Medical and Psychological Treatment of Binge
Eating Disorder

• Medical Treatment
• Sibutramine (Meridia)
• Psychological Treatment
• CBT
• Similar to that used for bulimia
• Appears efficacious

25
Medical and Psychological Treatment of Binge
Eating Disorder (continued)

• Interpersonal psychotherapy
• Equally as effective as CBT
• Self-help techniques
• Also appear effective

26
p. 342
27
Obesity Background and Overview

• Not a formal DSM disorder
• Statistics
• In 2000, 20 of adults in the United States were
  obese
• Mortality rates
• Are close to those associated with smoking

28
Obesity Background and Overview (continued)

• Increasing more rapidly
• For teens and young children
• Obesity
• Is growing rapidly in developing nations

29
Obesity and Disordered Eating Patterns

• Obesity and Night Eating Syndrome
• Occurs in 7-15 of treatment seekers
• Occurs in 27 of individuals seeking bariatric
  surgery
• Patients are wide awake and do not binge eat

30
Obesity and Disordered Eating Patterns (continued)

• Causes
• Obesity is related to technological advancement
• Genetics account for about 30 of obesity cases
• Biological and psychosocial factors contribute as
  well

31
Obesity Treatment

• Treatment
• Moderate success with adults
• Greater success with children and adolescents
• Treatment Progression -- From least-to-most
  intrusive options

32
Obesity Treatment (continued)

• First step
• Self-directed weight loss programs
• Second step
• Commercial self-help programs
• Third step
• Behavior modification programs
• Last step
• Bariatric surgery

33
p. 342
34
Binge Eating Disorder-DSM-5

• A. Recurrent episodes of binge eating. An
  episode of binge eating is characterized by both
  of the following
• 1. eating, in a discrete period of time (for
  example, within any 2-hour period), an amount of
  food that is definitely larger than most people
  would eat in a similar period of time under
  similar circumstances
• 2. a sense of lack of control over eating during
  the episode (for example, a feeling that one
  cannot stop eating or control what or how much
  one is eating)
• B. The binge-eating episodes are associated
  with three (or more) of the following
• 1. eating much more rapidly than normal
• 2. eating until feeling uncomfortably full
• 3. eating large amounts of food when not feeling
  physically hungry
• 4. eating alone because of feeling embarrassed
  by how much one is eating
• 5. feeling disgusted with oneself, depressed, or
  very guilty afterwards
• Marked distress regarding binge eating is
  present.
• The binge eating occurs, on average, at least
  once a week for three months.
• E. The binge eating is not associated with
  the recurrent use of inappropriate compensatory
  behavior (for example, purging) and does not
  occur exclusively during the course Anorexia
  Nervosa, Bulimia Nervosa, or Avoidant/Restrictive
  Food Intake Disorder.

35
Anorexia Nervosa- DSM-5

• A. Restriction of energy intake relative to
  requirements leading to a significantly low body
  weight in the context of age, sex, developmental
  trajectory, and physical health. Significantly
  low weight is defined as a weight that is less
  than minimally normal, or, for children and
  adolescents, less than that minimally expected.
  (Rewording of DSM-IV criterion to focus on
  behavior, not refusal to maintain body weight)
• B. Intense fear of gaining weight or becoming
  fat, or persistent behavior that interferes
  with weight gain, even though at a
  significantly low weight. (Addition of
  behavioral clause, as many deny fear)
• C.  Disturbance in the way in which one's body
  weight or shape is experienced, undue influence
  of body weight or shape on self-evaluation, or
  persistent lack of recognition of the seriousness
  of the current low body weight.
• (Criterion D Amenorrhea deleted many
  exhibit some menstrual activity, does not apply
  to pre-menarchal females, post-menarchal females,
  those taking modern oral contraceptives, and
  males)
• Specify current type (Due to cross-over
  complication in current episode sub-typing in the
  DSM-IV, current types are now specified during
  the last three months)
• Restricting Type during the last three months,
  the person has not engaged in recurrent episodes
  of binge eating or purging behavior (i.e.,
  self-induced vomiting or the misuse of laxatives,
  diuretics, or enemas)
• Binge-Eating/Purging Type during the last three
  months, the person has engaged in  recurrent
  episodes of binge eating or purging behavior
  (i.e., self-induced vomiting or the misuse of
  laxatives, diuretics, or enemas)

36
Bulimia Nervosa-DSM-5

• A. Recurrent episodes of binge eating. An episode
  of binge eating is characterized by both of the
  following
• 1. Eating, in a discrete period of time (for
  example, within any 2-hour period), an amount of
  food that is definitely larger than most people
  would eat during a similar period of time and
  under similar circumstances.
• 2. A sense of lack of control over eating during
  the episode (for example, a feeling that one
  cannot stop eating or control what or how much
  one is eating).
• B. Recurrent inappropriate compensatory behavior
  in order to prevent weight gain, such as
  self-induced vomiting misuse of laxatives,
  diuretics, or other medications, fasting or
  excessive exercise.
• C. The binge eating and inappropriate
  compensatory behaviors both occur, on average, at
  least once a week for 3 months. (change from
  twice/week for past two months)
• D. Self-evaluation is unduly influenced by body
  shape and weight.
• E. The disturbance does not occur exclusively
  during episodes of anorexia nervosa.
• (Removal of purging/non-purging subtype)

37
Feeding or Eating Conditions Not Elsewhere
Classified DSM-5

• Originally termed Eating Disorder NOS
• Atypical Anorexia Nervosa - All criteria for AN
  are met, except that, despite significant weight
  loss, the individuals weight is within or above
  the normal range.
• Subthreshold Bulimia Nervosa (low frequency or
  limited duration) - All criteria for BN are met,
  except that the binge eating and inappropriate
  compensatory behaviors occur, on average, less
  than once a week and/or for less than for 3
  months.
• Subthreshold Binge Eating Disorder (low frequency
  or limited duration) -All criteria for BED are
  met, except that the binge eating occurs, on
  average, less than once a week and/or for less
  than for 3 months.
• Purging Disorder - Recurrent purging behavior to
  influence weight or shape (self-induced vomiting,
  misuse of laxatives, diuretics, or other
  medications), in the absence of binge eating.
  Self-evaluation unduly influenced by body shape
  or weight or there is an intense fear of gaining
  weight or becoming fat.
• Night Eating Syndrome - Recurrent episodes of
  night eating, as manifested by eating after
  awakening from sleep or excessive food
  consumption after the evening meal. There is
  awareness and recall of the eating. The night
  eating is not better accounted for by external
  influences such as changes in the individuals
  sleep/wake cycle or by local social norms. The
  night eating is associated with significant
  distress and/or impairment in functioning. The
  disordered pattern of eating is not better
  accounted for by Binge Eating Disorder, another
  psychiatric disorder, substance abuse or
  dependence, a general medical disorder, or an
  effect of medication.
• Other Feeding or Eating Condition Not Elsewhere
  Classified - Residual category for clinically
  significant problems meeting the definition of a
  Feeding or Eating Disorder but not satisfying the
  criteria for any other Disorder or Condition.

38
Sleep Disorders An Overview

• Two Major Types of DSM-IV-TR Sleep Disorders
• Dyssomnias
• Difficulties in amount, quality, or timing of
  sleep
• Parasomnias
• Abnormal behavioral and physiological events
  during sleep

39
Sleep Disorders An Overview (continued)

• Assessment of Disordered Sleep Polysomnographic
  (PSG) Evaluation
• Electroencephalograph (EEG) Brain wave activity
• Electrooculograph (EOG) Eye movements
• Electromyography (EMG) Muscle movements
• Detailed history, assessment of sleep hygiene and
  sleep efficiency

40
The Dyssomnias Overview and Defining Features
of Insomnia

• Insomnia and Primary Insomnia
• One of the most common sleep disorders
• Problems initiating, maintaining, and/or
  non-restorative sleep
• Primary insomnia Unrelated to any other
  condition (rare!)
• Mental health disorders can underlie sleep
  problems (e. g. depression, anxiety)

41
The Dyssomnias Overview and Defining Features
of Insomnia (continued)

• Facts and Statistics
• Often associated with medical and/or
  psychological conditions
• Affects females twice as often as males
• Associated Features
• Unrealistic expectations about sleep
• Believe lack of sleep will be more disruptive
  than it usually is

42
The Dyssomnias Overview and Defining Features
of Hypersomnia

• Hypersomnia and Primary Hypersomnia
• Sleeping too much or excessive sleep
• Experience excessive sleepiness as a problem
• Primary hypersomnia Unrelated to any other
  condition (rare!)

43
The Dyssomnias Overview and Defining Features
of Hypersomnia (continued)

• Facts and Statistics
• About 39 have a family history of hypersomnia
• Often associated with medical and/or
  psychological conditions
• Associated Features
• Complain of sleepiness throughout the day
• Able to sleep through the night

44
The Dyssomnias Overview and Defining Features
of Narcolepsy

• Narcolepsy -- Daytime sleepiness and cataplexy
• Cataplexic attacks
• REM sleep, precipitated by strong emotion

45
The Dyssomnias Overview and Defining Features
of Narcolepsy (continued)

• Facts and Statistics Rare Condition
• Affects about .03 to .16 of the population
• Equally distributed between males and females
• Onset during adolescence
• Typically improves over time

46
The Dyssomnias Overview and Defining Features
of Narcolepsy (continued)

• Associated Features
• Cataplexy, sleep paralysis, and hypnagogic
  hallucinations
• Daytime sleepiness does not remit without
  treatment

47
The Dyssomnias Overview of Breathing-Related
Sleep Disorders

• Breathing-Related Sleep Disorders
• Sleepiness during the day and/or disrupted sleep
  at night
• Sleep apnea
• Restricted air flow and/or brief cessations of
  breathing

48
The Dyssomnias Overview of Breathing-Related
Sleep Disorders (continued)

• Subtypes of Sleep Apnea
• Obstructive sleep apnea (OSA)
• Airflow stops, but respiratory system works
• Central sleep apnea (CSA)
• Respiratory systems stops for brief periods
• Mixed sleep apnea
• Combination of OSA and CSA

49
The Dyssomnias Facts and Features Associated
With Breathing-Related Sleep Disorders

• Facts and Statistics
• Occurs in 1-2 of population
• More common in males
• Associated with obesity and increasing age

50
The Dyssomnias Facts and Features Associated
With Breathing-Related Sleep Disorders (continued)

• Associated Features
• Persons are usually minimally aware of apnea
  problem
• Often snore, sweat during sleep, wake frequently
• May have morning headaches
• May experience episodes of falling asleep during
  the day

51
Circadian Rhythm Sleep Disorders

• Circadian Rhythm Disorders
• Disturbed sleep (i.e., either insomnia or
  excessive sleepiness)
• Due to brains inability to synchronize day and
  night

52
Circadian Rhythm Sleep Disorders (continued)

• Nature of Circadian Rhythms and Bodys Biological
  Clock
• Circadian Rhythms Do not follow a 24 hour clock
• Suprachiasmatic nucleus
• Brains biological clock, stimulates melatonin
• Types of Circadian Rhythm Disorders
• Jet lag type
• Shift work type

53
Medical Treatments

• Insomnia
• Benzodiazepines and over-the-counter sleep
  medications
• Prolonged use
• Can cause rebound insomnia, dependence
• Best as short-term solution

54
Medical Treatments (continued)

• Hypersomnia and Narcolepsy
• Stimulants (i.e., Ritalin)
• Cataplexy
• Usually treated with antidepressants

55
Medical Treatments

• Breathing-Related Sleep Disorders
• May include medications, weight loss, or
  mechanical devices (C-PAP units)
• Circadian Rhythm Sleep Disorders

56
Medical Treatments (continued)

• Phase delays
• Moving bedtime later (best approach)
• Phase advances
• Moving bedtime earlier (more difficult)
• Use of very bright light
• Trick the brains biological clock

57
Psychological Treatments

• Relaxation and Stress Reduction
• Reduces stress and assists with sleep
• Modify unrealistic expectations about sleep
• Stimulus Control Procedures
• Improved sleep hygiene Bedroom is a place for
  sleep
• For children Setting a regular bedtime routine

58
Psychological Treatments (continued)

• Combined Treatments
• Insomnia Short-term medication plus
  psychotherapy
• Other Dyssomnias
• Little evidence for the efficacy of combined
  treatments

59
Sleep Hygiene

• Have a bed time routine same time, and strive
  for the same number of hours each night in and
  out at the same time.
• Determine your standard number of hours for
  sleep it changes with age
• Be careful of stimulants 2 hours before bed time
• No alcohol, heavy food, smoking before 4-6 hours
  before bed
• Your bed is for two purposes one is sleep the
  other.! Do not eat, watch TV, do papers, or
  online work in bed
• Do not exercise two hours before bed time
• Keep room cool dark
• Set up white noise - if outside noises bother
  you
• Identify stressors and try to cope with them
• Get up if you do not sleep in 20-30 minutes
• Get out in the sunshine 20 minutes per day
• Relaxing activities 30 minutes before bed
  relaxation, meditation, Dr. Seuss music (soft)
• Snore? Sleepy all day? Taking frequent naps? New
  meds? Check it out!
• Bedrooms are No Tech Zones!

60
The Parasomnias Nature and General Overview

• Nature of Parasomnias
• The problem is not with sleep itself
• Problem is abnormal events during sleep, or
  shortly after waking

61
The Parasomnias Nature and General Overview
(continued)

• Two Classes of Parasomnias
• Those that occur during REM (i.e., dream) sleep
• Those that occur during non-REM (i.e., non-dream)
  sleep

62
The Parasomnias Overview of Nightmare Disorder

• Nightmare Disorder
• Occurs during REM sleep
• Involves distressful and disturbing dreams
• Such dreams interfere with daily life functioning
  and interrupt sleep

63
The Parasomnias Overview of Nightmare Disorder
(continued)

• Facts and Associated Features
• Dreams often awaken the sleeper
• Problem is more common in children than adults
• Treatment
• May involve antidepressants and/or relaxation
  training

64
The Parasomnias Overview of Sleep Terror
Disorder

• Sleep Terror Disorder
• Recurrent episodes of panic-like symptoms during
  non-REM sleep
• Often noted by a piercing scream

65
The Parasomnias Overview of Sleep Terror
Disorder (continued)

• Facts and Associated Features
• More common in children than adults
• Child cannot be easily awakened during the
  episode
• Child has little memory of it the next day

66
The Parasomnias Overview of Sleep Terror
Disorder (continued)

• Treatment -- A Wait-and-See Posture
• Scheduled awakenings prior to the sleep terror
• Severe Cases
• Antidepressants (i.e., imipramine) or
  benzodiazepines

67
The Parasomnias Overview of Sleep Walking
Disorder

• Sleep Walking Disorder Somnambulism
• Occurs during non-REM sleep
• Usually during first few hours of deep sleep
• Person must leave the bed

68
The Parasomnias Overview of Sleep Walking
Disorder (continued)

• Facts and Associated Features
• Problem is more common in children than adults
• Problem usually resolves on its own without
  treatment
• Seems to run in families

69
The Parasomnias Overview of Sleep Walking
Disorder (continued)

• Related Conditions
• Nocturnal eating syndrome Person eats while
  asleep

70
Summary of Eating and Sleep Disorders

• All Eating Disorders Share
• Gross deviations in eating behavior
• Fear or concern about weight, body size,
  appearance
• Heavily influenced by social, cultural, and
  psychological factors

71
Summary of Eating and Sleep Disorders (continued)

• All Sleep Disorders Share
• Interference with normal process of sleep
• Interference results in problems during waking
• Heaving influenced by psychological and
  behavioral factors
• Incidence of Eating and Sleep Disorders Is
  Increasing
• More Effective Treatments for Eating and Sleep
  Disorders Are Needed

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73
Sleep Disorders

• Kleine Levin Syndrome
• A. The patient experiences recurrent episodes of
  excessive sleep (gt11 hours/day).
• B. Episodes occur at least once a year, and are
  generally 2 days to 4 weeks in duration.
• C. During episodes, when awake, cognition is
  abnormal with feeling of unreality or confusion. 
  Behavioral abnormalities such as megaphagia or
  hypersexuality may occur in some episodes.
• D. The patient has normal alertness, cognitive
  functioning, and behavior between the episodes.
• E. The condition is not better accounted for by
  another mental disorder (e.g, mood disturbance),
  and is not due to the direct physiological
  effects of a substance (e.g., a drug of abuse, a
  medication) or another general medical condition
  (e.g. a metabolic disorder).

74
Sleep Disorders

• Obstructive Sleep Apnea Hypopnea Syndrome
  (previously Breathing Related Sleep Disorder)
• A. Symptoms of snoring, snorting/gasping or
  breathing pauses during sleep AND/OR
• B. Symptoms of daytime sleepiness, fatigue, or
  unrefreshing sleep despite sufficient
  opportunities to sleep and unexplained by another
  medical or psychiatric morbidity AND
• C. Evidence by polysomnography of 5 or more
  obstructive apneas or hypopneas per hour of
  sleep  OR
• D. Evidence by polysomnography of 15 more
  obstructive apneas and/or hypopneas per hour of
  sleep.
• Coding note Also code sleep-related breathing
  disorder on Axis III.

75
Sleep Disorders

• Primary Central Sleep Apnea (previously Breathing
  Related Sleep Disorder)
• A. The patient reports at least one of the
  following
• 1. excessive daytime sleepiness
• 2. frequent arousals and awakenings during sleep
  or insomnia complaints
• 3. awakening short of breath
• B. Polysomnography shows five or more central
  apneas per hour of sleep
• C. The disorder is not better explained by
  another current sleep disorder, medical or
  neurological disorder, medication use, or
  substance use disorder.

76
Sleep Disorders

• Primary Alveolar Hypoventilation (previously
  Breathing Related Sleep Disorder)
• A. Polysomnographic monitoring demonstrates
  episodes of shallow breathing longer than 10
  seconds in duration associated with arterial
  oxygen desaturation and frequent arousals from
  sleep associated with the breathing disturbances
  or brady-tachycardia.  Note although symptoms
  are not mandatory to make this diagnosis,
  patients often report excessive daytime
  sleepiness, frequent arousals and awakenings
  during sleep, or insomnia complaints.
• B. No primary lung diseases, skeletal
  malformations, or peripheral neuromuscular
  disorders at affect ventilation are present.
• C. The disorder is not better explained by
  another current sleep disorder, medical or
  neurological disorder, mental disorder,
  medication use, or substance use disorder.

77
Sleep Disorders

• Rapid Eye Movement Behavior Disorder
• A. Repeated episodes of arousal during sleep
  associated with vocalization and/or complex motor
  behaviors which may be sufficient to result in
  injury to the individual or bedpartner.
• B. These behaviors arise during REM sleep and
  therefore usually occur greater that 90 minutes
  after sleep onset, are more frequent during the
  later portions of the sleep period, and rarely
  occur during daytime naps.
• C. Upon awakening, the individual is completely
  awake, alert, and not confused or disoriented.
• D. The observed vocalizations or motor behavior
  often correlate with simultaneously occurring
  dream mentation leading to the report of acting
  out of dreams.
• E. The behaviors cause clinically significant
  distress or impairment in social or other
  important areas of functioning particularly
  pertaining to distress to bedpartner or injury to
  self or bedpartner.
• F. At least one of the following is present 1)
  Sleep related injurious, potentially injurious,
  or disruptive behaviors arising from sleep and 2)
  Abnormal REM sleep behaviors documented by
  polysomnographic recording
• G. REM sleep without atonia on polysomnographic
  recording
• H. The disturbance is not due to the direct
  physiological effects of a substance (e.g., a
  drug of abuse, a medication) or a general medical
  condition.

78
Sleep Disorders

• Restless Legs Syndrome
• A. Each of the following criteria must be met.
• The patient reports
• 1. An urge to move the legs usually accompanied
  or caused by uncomfortable and unpleasant
  sensations in the legs (or for pediatric RLS the
  description of these symptoms should be in the
  child's own words).2. The urge or unpleasant
  sensations begin or worsen during periods of rest
  or inactivity. 3. Symptoms are partially or
  totally relieved by movement4. Symptoms are
  worse in the evening or at night than during the
  day or are present only at night or in the
  evening. (The worsening occurs independently of
  any differences in activity, which is important
  for pediatric RLS as children are sitting much of
  the day at school).
• B. These symptoms are accompanied by significant
  distress or impairment in social, occupational,
  academic, behavioral or other important areas of
  functioning indicated by the presence of at least
  one of the following
• 1. Fatigue or low energy, 2. Daytime sleepiness,
  3. Cognitive impairments (e.g., attention,
  concentration, memory, learning), 4. Mood
  disturbance (e.g., irritability, dysphoria,
  anxiety), 5. Behavioral problems (e.g.,
  hyperactivity, impulsivity, aggression), 6.
  Impaired academic or occupational function, 7.
  Impaired interpersonal/social functioning
• C. Frequency Remains under discussion pending
  consideration of secondary data analysis
• D. Duration Remains under discussion pending
  considerations of secondary data analysis.
• E. The occurence of the above symptoms are not
  solely accounted for as symptoms primary to
  another medical or behavioral condition (e.g.,
  positional discomfort, leg cramps, habitual foot
  tapping, arthritis, neuropathic pain and
  peripheral ischemia).
• F. The sleep difficulty occurs despite adequate
  age-appropriate circumstances and opportunity for
  sleep.
• Clinically Comorbid Conditions
• 1.     Mental/Psychiatric Disorder (to be
  specified)
• 2.     Medical Disorder (to be specified)
• 3.     Another Disorder (to be specified)

79
Sleep Disorders

• Circadian Rhythm Sleep Disorder - Advanced Sleep
  Phase Type
• A. Persistent or recurrent pattern of sleep
  disruption leading to excessive sleepiness,
  insomnia, or both that is primarily due to an
  alteration of the circadian system or to a
  misalignment between the endogenous circadian
  rhythm and the sleep-wake schedule required by a
  persons physical environment or
  social/professional schedule.
• B. The sleep disturbance causes clinically
  significant distress or impairment in social,
  occupational, or other important areas of
  functioning.
• Specify type
• Advanced Sleep Phase Type a persistent or
  recurrent pattern of advanced sleep onset and
  awakening times, with an inability to remain
  awake and asleep until the desired or
  conventionally acceptable later sleep and wake
  times
• Clinically Comorbid Conditions
• 1.     Mental/Psychiatric Disorder (specify)
• 2.     Medical Disorder (specify)

80
Sleep Disorders

• Disorder of Arousal - Includes previous diagnoses
  of Sleepwalking Disorder and Sleep Terror
  Disorder.
•  
• A. Recurrent episodes of incomplete awakening
  from sleep usually occurring during the first
  third of the major sleep episode.
• B. Subtypes
• 1. Confusional Arousals - Recurrent episodes of
  incomplete awakening from sleep without terror or
  ambulation, usually occurring during the first
  third of the major sleep episode. There is a
  relative lack of autonomic arousal such as
  mydriasis, tachycardia, rapid breathing, and
  sweating during an episode.
• 2. Sleepwalking - Repeated episodes of rising
  from bed during sleep and walking about, usually
  occurring during the first third of the major
  sleep episode. While sleepwalking, the person has
  a blank, staring face, is relatively unresponsive
  to the efforts of others to communicate with him
  or her, and can be awakened only with great
  difficulty.
• 3. Sleep terrors - Recurrent episodes of abrupt
  awakening from sleep, usually occurring during
  the first third of the major sleep episode and
  beginning with a panicky scream. There is intense
  fear and signs of autonomic arousal, such as
  mydriasis, tachycardia, rapid breathing, and
  sweating, during each episode.
• C. Relative unresponsiveness to efforts of others
  to comfort the person during the episode.
• D. No detailed dream is recalled and there is
  amnesia for the episode.
• E. The episodes cause clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.
• The disturbance is not due to the direct
  physiological effects of a substance (e.g., a
  drug of abuse, a medication) or a general medical
  condition.

81
Sleep Disorders

• Circadiam Rhythm Sleep Disorder - Free-Running
  Type
• A. Persistent or recurrent pattern of sleep
  disruption leading to excessive sleepiness,
  insomnia, or both that is primarily due to an
  alteration of the circadian system or to a
  misalignment between the endogenous circadian
  rhythm and the sleep-wake schedule required by a
  persons physical environment or
  social/professional schedule.
• B. The sleep disturbance causes clinically
  significant distress or impairment in social,
  occupational, or other important areas of
  functioning.
• Specify type
• Free-Running Type a persistent or recurrent
  pattern of sleep and wake cycles that are not
  entrained to the 24 hour environment, with a
  daily drift (usually to later and later times) of
  sleep onset wake times
• Clinically Comorbid Conditions
• 1.     Mental/Psychiatric Disorder (specify)
• 2.     Medical Disorder (specify)

82
Sleep Disorders

• Circadiam Rhythm Sleep Disorder - Irregular
  Sleep-Wake Type
• A. Persistent or recurrent pattern of sleep
  disruption leading to excessive sleepiness,
  insomnia, or both that is primarily due to an
  alteration of the circadian system or to a
  misalignment between the endogenous circadian
  rhythm and the sleep-wake schedule required by a
  persons physical environment or
  social/professional schedule.
• B. The sleep disturbance causes clinically
  significant distress or impairment in social,
  occupational, or other important areas of
  functioning.
• Specify type
• Irregular Sleep Wake Type a temporally
  disorganized sleep and wake pattern, so that
  sleep and wake periods are variable throughout
  the 24 hour period.
• Conditions
• 1.     Mental/Psychiatric Disorder (specify)
• 2.     Medical Disorder (specify)

83
Sleep Disorders

• Removal of Circadian Rhythm Sleep Disorder -
  Unspecified Type, Sleep Disorder Due to a General
  Medical Condition, Parasomnia Type, Sleep
  Disorder Due to a General Medical Condition,
  Mixed Type

84
Sleep Disorders

• Insomnia Disorder 
• A. The predominant complaint is dissatisfaction
  with sleep quantity or quality made by the
  patient (or by a caregiver or family in the case
  of children or elderly).
• B. Report of one or more of the following
  symptoms
• -Difficulty initiating sleep in children this
  may be manifested as difficulty initiating sleep
  without caregiver intervention, Difficulty
  maintaining sleep characterized by frequent
  awakenings or problems returning to sleep after
  awakenings (in children this may be manifested as
  difficulty returning to sleep without caregiver
  intervention), Early morning awakening with
  inability to return to sleep, Non restorative
  sleep, Prolonged resistance to going to bed
  and/or bedtime struggles (children)
• C. The sleep complaint is accompanied by
  significant distress or impairment in daytime
  functioning as indicated by the report of at
  least one of the following 
• -Fatigue or low energy, Daytime sleepiness ,
  Cognitive impairments (e.g., attention,
  concentration, memory), Mood disturbance (e.g.,
  irritability, dysphoria), Behavioral problems
  (e.g., hyperactivity, impulsivity, aggression),
  Impaired occupational or academic function,
  Impaired interpersonal/social function, Negative
  impact on caregiver or family functioning (e.g.,
  fatigue, sleepiness
• D.   The sleep difficulty occurs at least three
  nights per week.
• E.   The sleep difficulty is present for at least
  three months.
• F.   The sleep difficulty occurs despite adequate
  age-appropriate circumstances and opportunity for
  sleep. Duration 
• 1.    Acute insomnia (lt1 month)
• 2.    Sub acute insomnia (1-3 months)
• 3.    Persistent insomnia (gt 3 months)
• Clinically Comorbid Conditions
• -Psychiatric disorder (specify)
• -Medical disorder (specify)
• -Another disorder (specify)

85
Sleep Disorders

• Primary Hypersomnia/Narcolepsy without cataplexy
• A. The predominant complaint is unexplained
  hypersomnia (excessive sleep) or/and
  hypersomnolence (sleepiness in spite of
  sufficient nocturnal sleep), for at least 3
  months, occurring 3 or more times per week.
• 1. Hypersomnia (excessive sleep) is defined by a
  prolonged nocturnal sleep episode or daily sleep
  amounts (gt9 hours/day).
• 2. Hypersomnolence is defined by excessive
  daytime sleepiness with recurrent daytime naps or
  lapses into sleep that occurs daily or almost
  daily over at least the last 3 months (when the
  patient is untreated) and daily sleep amounts gt 6
  hours.  To document hypersomnolence, the Multiple
  Sleep Latency Test must show a mean sleep latency
  below 8 minutes, with or without Sleep Onset REM
  Periods (SOREMPs).  If the patient has more than
  2 SOREMPs, the condition may be called
  narcolepsy without cataplexy. 
• B. The sleep periods are non-restorative
  (unrefreshing) or so prolonged in length that
  this causes clinically significant distress or
  impairment in social, occupational, or other
  important areas of functioning.
• C. The hypersomnia is not better accounted for by
  insomnia and does not occur exclusively during
  the course of another Sleep Disorder (e.g.,
  Narcolepsy with Cataplexy, Sleep-Related
  Breathing Disorder, Circadian Rhythm Sleep
  Disorder, or a Parasomnia) and cannot be
  accounted for by an inadequate amount of sleep.  
  
• D. The disturbance does not occur exclusively
  during the course of another mental or medical
  disorder but may occur simultaneously with these
  disorders.
• E. The disturbance is not due to the direct
  physiological effects of a substance (e.g., a
  drug of abuse, a medication).
• Clinically Comorbid Conditions
• Mental/Psychiatric Disorder (specify)
• Medical Disorder (specify)

86
Sleep Disorders

• Narcolepsy/Hypocretin Deficiency
• A. Recurrent daytime naps or lapses into sleep
  that occurs daily or almost daily over at least
  the last 3 months (when the patient is
  untreated).
• B. The presence of one or both of the following
• 1. Cataplexy defined as brief (a few seconds to
  2 minutes) episodes of sudden bilateral loss of
  muscle tone with maintained consciousness, most
  often in association with laughter or joking. 
  These episodes must occur at least a few times
  per month providing the patient is untreated for
  this symptom.
• 2. Hypocretin deficiency, as measured using CSF
  hypocretin-1 immunoreactivity measurements (lt1/3
  of normal reference values). 
• C. Do not occur exclusively during the course of
  another mental or medical disorder but may occur
  simultaneously with these disorders.

87
Sleep Disorders

• Circadian Rhythm Sleep Disorder
• A. A persistent or recurrent pattern of sleep
  disruption leading to excessive sleepiness,
  insomnia, or both that is primarily due to an
  alteration of the circadian system or to a
  misalignment between the endogenous circadian
  rhythm and the sleep-wake schedule required by a
  persons physical environment or
  social/professional schedule.
• B. The sleep disturbance causes clinically
  significant distress or impairment in social,
  occupational, or other important areas of
  functioning.
• Specify type
• Delayed Sleep Phase Type a persistent or
  recurrent pattern of delayed sleep onset and
  awakening times, with an inability to fall asleep
  and awaken at a desired or conventionally
  acceptable earlier time
• Advanced Sleep Phase Type a persistent or
  recurrent pattern of advanced sleep onset and
  awakening times, with an inability to remain
  awake and asleep until the desired or
  conventionally acceptable later sleep and wake
  times
• Irregular Sleep Wake Type a temporally
  disorganized sleep and wake pattern, so that
  sleep and wake periods are variable throughout
  the 24 hour period.
• Free-Running Type a persistent or recurrent
  pattern of sleep and wake cycles that are not
  entrained to the 24 hour environment, with a
  daily drift (usually to later and later times) of
  sleep onset wake times
• Jet Lag Type sleepiness and alertness that
  occur at an inappropriate time of day relative to
  local time, occurring after travel across time
  zone
• Shift Work Type insomnia during the major sleep
  period and/or excessive sleepiness (including
  inadvertent sleep) during the major awake period
  associated with shift work schedule o(i.e.,
  requiring unconventional work hours) of at least
  one month
• Clinically Comorbid Conditions
• 1.     Mental/Psychiatric Disorder (specify)
• 2.     Medical Disorder (specify)

88
Sleep Disorders

• Nightmare Disorder
• A. Repeated awakenings from the major sleep
  period or naps with detailed recall of extended
  and extremely dysphoric dreams, usually involving
  active efforts to avoid threats to survival,
  security, or physical integrity. The awakenings
  generally occur during the second half of the
  sleep period.
• B. On awakening from the dysphoric dreams, the
  person rapidly becomes oriented and alert (in
  contrast to the confusion and disorientation seen
  in Sleep Terror Disorder and some forms of
  epilepsy).
• C. The dream experience, or the sleep disturbance
  resulting from the awakening, causes clinically
  significant distress or impairment in social,
  occupational, or other important areas of
  functioning.
• D. The nightmares do not occur exclusively during
  the course of another mental disorder (e.g., a
  delirium, Posttraumatic Stress Disorder) and are
  not due to the direct physiological effects of a
  substance (e.g., a drug of abuse, a medication)
  or a general medical condition.