DSM 5 Sleep Disorders Overhaul

The DSM-5 Sleep Disorders workgroup has been especially busy. They are calling for a nearly complete overhaul of the sleep disorders category in the Diagnostic and Statistical Manual of Mental Disorders (“DSM”).

According to a presentation at the annual meeting of the American Psychiatric Association in May, Charles Reynolds, MD, suggested that the reworking of this category will make sleep problems easier for professionals to diagnose and discriminate between different sleep disorders.

He stated that the current DSM-IV puts too much emphasis on presumed causes of symptoms, something that the rest of the DSM-IV does not do. Bringing the sleep disorder section more in line with the other sections in the DSM should make it less confusing.

Primary and commonly diagnosed sleep disorders are being organized in the DSM-5 into three major categories: insomnia, hypersomnia and arousal disorder. The new DSM will allow professionals to choose amongst sub-types in each category, as can be done with many other major disorders in the manual.

Here’s a summary of some of the proposed additions and changes in the sleep disorders category for the DSM-5, slated for publication in May 2013.

These sleep disorders criteria are summarized from the proposed changes found on the DSM 5 website.

Kleine Levin Syndrome

This syndrome is characterized by a person who experiences recurrent episodes of excessive sleep (more than 11 hours/day). These episodes occur at least once a year, and are between 2 days and 4 weeks in duration.

During one of these episodes, when awake, cognition is abnormal with feeling of unreality or confusion. Behavioral abnormalities such as megaphagia or hypersexuality may occur in some episodes.

The patient has normal alertness, cognitive functioning, and behavior between the episodes.

Obstructive Sleep Apnea Hypopnea Syndrome

(Previously known as Breathing Related Sleep Disorder)

• Symptoms of snoring, snorting/gasping or breathing pauses during sleep

  AND/OR

• Symptoms of daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities to sleep and unexplained by another medical or psychiatric morbidityAND
• Evidence by polysomnography (a type of measurement of sleep breathing used in a sleep lab) of 5 or more obstructive apneas or hypopneas per hour of sleep or evidence by polysomnography of 15 more obstructive apneas and/or hypopneas per hour of sleep.

Primary Central Sleep Apnea

(Previously known as Breathing Related Sleep Disorder)

At least one of the following is present:

1. Excessive daytime sleepiness
2. Frequent arousals and awakenings during sleep or insomnia complaints
3. Awakening short of breath

Polysomnography (a type of measurement of sleep breathing used in a sleep lab) shows five or more central apneas per hour of sleep.

Primary Alveolar Hypoventilation

(previously Breathing Related Sleep Disorder)

Polysomnographic (a type of measurement of sleep breathing used in a sleep lab) 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.

Rapid Eye Movement Behavior Disorder

This disorder is characterized by 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 bed partner.

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.

Upon awakening, the individual is completely awake, alert, and not confused or disoriented.

The observed vocalizations or motor behavior often correlate with simultaneously occurring dream mentation leading to the report of “acting out of dreams”.

The behaviors cause clinically significant distress or impairment in social or other important areas of functioning — particularly pertaining to distress to bed partner or injury to self or bed partner.

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.

Restless Legs Syndrome

The exact criteria used to diagnose Restless Legs Syndrome has not been decided. But one set of criteria proposed include a patient meeting all of the following:

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).

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

Circadian Rhythm Sleep Disorder

This disorder is characterized by 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.

Disorder of Arousal

(Includes previous diagnoses of Sleepwalking Disorder and Sleep Terror Disorder)

Recurrent episodes of incomplete awakening from sleep usually occurring during the first third of the major sleep episode.

Subtypes:

• 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.
• 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.
• 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.

Relative unresponsiveness to efforts of others to comfort the person during the episode.

No detailed dream is recalled and there is amnesia for the episode.

Circadian Rhythm Sleep Disorder

This disorder is characterized by 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.

Subtypes:

• 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
• Irregular Sleep — Wake Type: a temporally disorganized sleep and wake pattern, so that sleep and wake periods are variable throughout the 24 hour period.

As with all mental disorders, sleep disorders must cause a significant impact or distress in the person’s normal, everyday functioning in their life — work, at home, and at play. All of the sleep disorders listed above are proposed to generally not be diagnosed if directly caused by a known medical condition, disease, or impairment in the person’s health.