Chapter 8

Eating and Sleep Disorders

 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
 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
 Bulimia Nervosa: Overview and Defining
Features

• Binge Eating – Hallmark of Bulimia

– Binge
• Eating excess amounts of food
– Eating is perceived as uncontrollable
 Bulimia Nervosa: Overview and Defining
Features (continued)

• Compensatory Behaviors
– Purging
• Self-induced vomiting, diuretics,
laxatives
– Some exercise excessively, whereas
others fast
 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
 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
 Bulimia Nervosa: Associated Features
(continued)

• Associated Psychological Features

– Most are over concerned with body shape
– Fear of gaining weight
– Most have comorbid psychological
disorders
 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
 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
 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
 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
 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
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
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
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
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
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
Fig. 8.4, p. 315
 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
 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
 Goals of Psychological Treatment of
Anorexia Nervosa

• General Goals and Strategies

– Weight restoration
• First and easiest goal to achieve
– Psycho-education
 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
 Medical and Psychological Treatment of
Binge Eating Disorder

• Medical Treatment
– Sibutramine (Meridia)
• Psychological Treatment
– CBT
• Similar to that used for bulimia
• Appears efficacious
Medical and Psychological Treatment of
Binge Eating Disorder (continued)

– Interpersonal psychotherapy
• Equally as effective as CBT
– Self-help techniques
• Also appear effective
p. 342
 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
 Obesity: Background and Overview
(continued)

– Increasing more rapidly

• For teens and young children
– Obesity
• Is growing rapidly in developing nations
 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
 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
 Obesity Treatment

• Treatment
– Moderate success with adults
– Greater success with children and
adolescents
• Treatment Progression -- From least-to-most
intrusive options
 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
p. 342
 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

C. Marked distress regarding binge eating is present.

D. 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.
 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)
 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)

 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 individual’s 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 individual’s 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.
 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
 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
 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)
 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
 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!)
 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
 The Dyssomnias: Overview and Defining
Features of Narcolepsy

• Narcolepsy -- Daytime sleepiness and

cataplexy
– Cataplexic attacks
• REM sleep, precipitated by strong
emotion
 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
 The Dyssomnias: Overview and Defining
Features of Narcolepsy (continued)

• Associated Features
– Cataplexy, sleep paralysis, and
hypnagogic hallucinations
– Daytime sleepiness does not remit without
treatment
 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
 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
 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
 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
 Circadian Rhythm Sleep Disorders

• Circadian Rhythm Disorders

– Disturbed sleep (i.e., either insomnia or
excessive sleepiness)
– Due to brain’s inability to synchronize day
and night
 Circadian Rhythm Sleep Disorders
(continued)
• Nature of Circadian Rhythms and Body’s
Biological Clock
– Circadian Rhythms – Do not follow a 24 hour
clock
– Suprachiasmatic nucleus
• Brain’s biological clock, stimulates
melatonin
• Types of Circadian Rhythm Disorders
– Jet lag type
– Shift work type
 Medical Treatments

• Insomnia
– Benzodiazepines and over-the-counter
sleep medications
– Prolonged use
• Can cause rebound insomnia,
dependence
– Best as short-term solution
 Medical Treatments (continued)

• Hypersomnia and Narcolepsy

– Stimulants (i.e., Ritalin)
– Cataplexy
• Usually treated with antidepressants
 Medical Treatments

• Breathing-Related Sleep Disorders

– May include medications, weight loss, or
mechanical devices (C-PAP units)
• Circadian Rhythm Sleep Disorders
 Medical Treatments (continued)

• Phase delays
– Moving bedtime later (best approach)
• Phase advances
– Moving bedtime earlier (more difficult)
• Use of very bright light
– Trick the brain’s biological clock
 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
 Psychological Treatments (continued)

• Combined Treatments
– Insomnia – Short-term medication plus
psychotherapy
– Other Dyssomnias
• Little evidence for the efficacy of
combined treatments
 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”!
 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
 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
 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
 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
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
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
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
 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
 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
 The Parasomnias: Overview of Sleep
Walking Disorder (continued)

• Related Conditions
– Nocturnal eating syndrome – Person eats
while asleep
 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
 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
p. 343
 Sleep Disorders

Kleine Levin Syndrome

A. The patient experiences recurrent episodes of excessive sleep
(>11 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).
 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.
 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.
 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.
 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.
 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 movement
4. 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)
 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 person’s 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)
 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.
 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 person’s 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)
 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 person’s 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)
 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
 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 (<1 month)
2.    Sub acute insomnia (1-3 months)
3.    Persistent insomnia (> 3 months)
Clinically Comorbid Conditions:
-Psychiatric disorder (specify)
-Medical disorder (specify)
-Another disorder (specify)
 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 (>9 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 > 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)
 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 (<1/3 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.
 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 person’s 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)
 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.