sleep disorders. two major categories* dyssomnias parasomnias * this classification system is...

Sleep DisordersSleep Disorders

Two Major Categories*Two Major Categories*

DyssomniasDyssomnias

ParasomniasParasomnias

**This classification system is similar to that used This classification system is similar to that used by the American Sleep Disorders Association. by the American Sleep Disorders Association.


The sleep itself is pretty normal.The sleep itself is pretty normal.But the client sleeps too little, too But the client sleeps too little, too

much, or at the wrong time.much, or at the wrong time.So, the problem is with the So, the problem is with the

amount (quantity), or with its amount (quantity), or with its timing, and sometimes with the timing, and sometimes with the quality of sleep.quality of sleep.

ParasomniasParasomniasSomething abnormal occurs during Something abnormal occurs during

sleep itself, or during the times sleep itself, or during the times when the client is falling asleep or when the client is falling asleep or waking up (e.g., bad dreams.waking up (e.g., bad dreams.

The quality, quantity, and timing of The quality, quantity, and timing of the sleep are essentially normal. the sleep are essentially normal.

The Sleep Disorders chapter has The Sleep Disorders chapter has four major sections:four major sections:

I. Primary Sleep Disorders include all I. Primary Sleep Disorders include all sleep disorders, sleep disorders, exceptexcept::

II. Sleep Disorder Related to Another II. Sleep Disorder Related to Another Mental DisorderMental Disorder

III. Sleep Disorder Due to a General III. Sleep Disorder Due to a General

Medical Condition (GMC)Medical Condition (GMC)

IV. Substance-Induced Sleep DisorderIV. Substance-Induced Sleep Disorder

I. Primary Sleep DisordersI. Primary Sleep Disorders


A. A. Primary InsomniaPrimary Insomnia - too little sleep - too little sleep (criteria listed on p. 604)(criteria listed on p. 604) CharacteristicsCharacteristics

• Difficulty initiating or maintaining sleepDifficulty initiating or maintaining sleep• Persists for 1 month or longerPersists for 1 month or longer• This diagnosis is rarely independent of an Axis I or This diagnosis is rarely independent of an Axis I or

II disorder or a GMC or substance use. II disorder or a GMC or substance use.

I. Primary Sleep Disorders (cont.)I. Primary Sleep Disorders (cont.)

A. Primary Insomnia (too little sleep) A. Primary Insomnia (too little sleep)

Often due to: Often due to: • Major Depressive Episode, Manic Episode, or Major Depressive Episode, Manic Episode, or

anxiety disorderanxiety disorder• Commonly misused substances, as well as some Commonly misused substances, as well as some

prescription medicines. prescription medicines. • Breathing-related problems Breathing-related problems

The cause sometimes can not be identified. The cause sometimes can not be identified.


A.A. Primary Insomnia (too little sleep)Primary Insomnia (too little sleep)TreatmentTreatment Vigorous daytime exercise, not exercising before Vigorous daytime exercise, not exercising before

sleepsleep Sexual intercourse, if pleasurableSexual intercourse, if pleasurable Metronome or ticking clock- slow, 60 beats per Metronome or ticking clock- slow, 60 beats per

minute or slower, beat of human heartminute or slower, beat of human heart Relaxation exercises, practice regularly but Relaxation exercises, practice regularly but

condensed to 5 minutescondensed to 5 minutes Decrease stimulation and increase soothing Decrease stimulation and increase soothing

environments, such as ear plugs or calm readingenvironments, such as ear plugs or calm reading Practice good sleep habitsPractice good sleep habits Read “How to Become an Insomniac”Read “How to Become an Insomniac”

I. Primary Sleep DisordersI. Primary Sleep Disorders DyssomniasDyssomnias

B. B. Primary HypersomniaPrimary Hypersomnia (sleeping too much, as (sleeping too much, as well as being drowsy at times when client should well as being drowsy at times when client should be alert) (criteria listed on p. 609)be alert) (criteria listed on p. 609) CharacteristicsCharacteristics

• Excessive sleepinessExcessive sleepiness• Persists for 1 month or longerPersists for 1 month or longer• Rarely a diagnosis independent of an Axis I or II disorder or a Rarely a diagnosis independent of an Axis I or II disorder or a

GMC or substance use. GMC or substance use. Specify if: Recurrent.Specify if: Recurrent.


B. Primary Hypersomnia (too much sleep) B. Primary Hypersomnia (too much sleep) (cont.)(cont.) Often due to: Often due to:

• Major Depressive Episode, Dysthymic Disorder Major Depressive Episode, Dysthymic Disorder with atypical featureswith atypical features

• Use of substances is less likely to produce Use of substances is less likely to produce hyersomnia than insomnia, but it can happen (e.g., hyersomnia than insomnia, but it can happen (e.g., sleeping pills overdose) sleeping pills overdose)

The cause sometimes can not be identified.The cause sometimes can not be identified.

Treatment: Exercise when becoming sleepy Treatment: Exercise when becoming sleepy


C. NarcolepsyC. Narcolepsy (Sleeping at the wrong time) (Sleeping at the wrong time)

(criteria listed on pg. 615)(criteria listed on pg. 615) CharacteristicsCharacteristics

• Sleep intrudes into wakefulness, causing clients to fall Sleep intrudes into wakefulness, causing clients to fall asleep almost instantlyasleep almost instantly

• Sleep is brief but refreshingSleep is brief but refreshing• May also have sleep paralysis, sudden loss of strength, and May also have sleep paralysis, sudden loss of strength, and

hallucinations as fall asleep or awaken.hallucinations as fall asleep or awaken.

Treatment: Stimulants, sometimes antidepressants, with Treatment: Stimulants, sometimes antidepressants, with less success. less success.


D. Breathing-Related Sleep DisorderD. Breathing-Related Sleep Disorder

(criteria listed on p. 622)(criteria listed on p. 622)

Characteristics Characteristics Sleep disruption (excessive sleepiness or Sleep disruption (excessive sleepiness or

insomnia)insomnia)• Due to sleep-related breathing condition (e.g., Due to sleep-related breathing condition (e.g.,

Obstructive Sleep Apnea Syndrome) Obstructive Sleep Apnea Syndrome)


D.D. Breathing-Related Sleep DisorderBreathing-Related Sleep Disorder

Treatment Treatment (Criteria on p. 622) (Criteria on p. 622) In mild cases: weight loss, sleeping on one’s side, In mild cases: weight loss, sleeping on one’s side,

and avoiding hypnotics and alcoholand avoiding hypnotics and alcohol

(To sleep on side, a tennis ball can be sewn into (To sleep on side, a tennis ball can be sewn into back of client’s sleep wear)back of client’s sleep wear)

In more serious cases: a machine that provides In more serious cases: a machine that provides continuous positive airway pressurecontinuous positive airway pressure

Surgery: Few benefitsSurgery: Few benefits


E.E. Circadian Rhythm Sleep DisorderCircadian Rhythm Sleep Disorder

(criteria on p. 629)(criteria on p. 629)

CharacteristicsCharacteristics• Persistent or recurrent pattern of sleep disruption Persistent or recurrent pattern of sleep disruption

leading to excessive sleepiness or insomnia, due leading to excessive sleepiness or insomnia, due to mismatch between sleep-wake schedule to mismatch between sleep-wake schedule required by a person’s environment and his/her required by a person’s environment and his/her circadian sleep-wake pattern (e.g., shift work, jet circadian sleep-wake pattern (e.g., shift work, jet lag). lag).


E.E. Circadian Rhythm Sleep DisorderCircadian Rhythm Sleep DisorderTreatment: Difficult to treat, because it has to Treatment: Difficult to treat, because it has to involve the entire familyinvolve the entire family

Darken bedroom and use soundproofingDarken bedroom and use soundproofing Limit caffeine and hard to digest food.Limit caffeine and hard to digest food. Ensure all family members learns shiftEnsure all family members learns shift To help jet lag, exposure to sun helpsTo help jet lag, exposure to sun helps

Specify type: Delayed Sleep Phase Type, Jet Lag Specify type: Delayed Sleep Phase Type, Jet Lag Type, Shift Work Type, and Unspecified TypeType, Shift Work Type, and Unspecified Type

I. Primary Sleep DisordersI. Primary Sleep DisordersDyssomniasDyssomnias

F.F. Dyssomnia NOS Dyssomnia NOS (listed on p. 629)(listed on p. 629)

This category is for insomnias, This category is for insomnias,

hypersomnias, or circadian rhythm hypersomnias, or circadian rhythm disturbances that do not meet criteria for disturbances that do not meet criteria for any specific Dyssomnia.any specific Dyssomnia.

I. Primary Sleep DisordersI. Primary Sleep Disorders ParasomniasParasomnias

A.A. Nightmare Disorder (Nightmare Disorder (Criteria listed on p. Criteria listed on p. 634)634)

Characteristics:Characteristics:(1) Repeated awakenings from bad dreams(1) Repeated awakenings from bad dreams

(2) When awakened client (2) When awakened client becomes becomes oriented and alertoriented and alert


A.A. Information about Information about Nightmare Disorder Nightmare Disorder Usually occurs in early morning when REM sleep Usually occurs in early morning when REM sleep

dominates.dominates. The same nightmare may recur repeatedly or The same nightmare may recur repeatedly or

different ones may pop up three times a week.different ones may pop up three times a week. Stress may induce 60% of nightmares.Stress may induce 60% of nightmares. Half of the cases of nightmare disorder appear Half of the cases of nightmare disorder appear

before age 10; 2/3 before age 20.before age 10; 2/3 before age 20. Dreams are clearly rememberedDreams are clearly remembered Drugs can trigger nightmares. Drugs can trigger nightmares. Suddenly withdrawing REM-suppressant Suddenly withdrawing REM-suppressant

medications and drugs can cause REM rebound.medications and drugs can cause REM rebound.


B.B. Sleep Terror Disorder Sleep Terror Disorder (criteria listed on (criteria listed on pg. 639)pg. 639)

Characteristics:Characteristics:(1)(1) Abrupt awakening from sleep, usually Abrupt awakening from sleep, usually

beginning with a panicky scream or cry.beginning with a panicky scream or cry.(2)(2) Intense fear and signs of autonomic Intense fear and signs of autonomic

arousalarousal(3)(3) Unresponsive to efforts from other to calmUnresponsive to efforts from other to calm

clientclient(4)(4) No detailed dream recalledNo detailed dream recalled(5)(5) Amnesia for episodeAmnesia for episode


B.B. Sleep Terror DisorderSleep Terror Disorder

Usually only children have sleep terror disorder.Usually only children have sleep terror disorder.

The client is not having a nightmare. The client is not having a nightmare.

The eyes are open, screams erupt. The eyes are open, screams erupt.

Usually happens in early evening. Usually happens in early evening.

In contrast to nightmares, sleep terrors do not respond to In contrast to nightmares, sleep terrors do not respond to psychotherapy. psychotherapy.

Probably due to brain wave upset, fever, or medicationsProbably due to brain wave upset, fever, or medications

However, some medications may help.However, some medications may help.


C.C. Sleepwalking Disorder Sleepwalking Disorder (criteria listed (criteria listed on pg. 644)on pg. 644)

Characteristics:Characteristics:

(1) (1) Rising from bed during sleep and walking about.Rising from bed during sleep and walking about.

(2)(2) Usually occurs early in the night.Usually occurs early in the night.

(3)(3) On awakening, the person has amnesia for episodeOn awakening, the person has amnesia for episode


C.C. Sleepwalking DisorderSleepwalking Disorder

Most sleepwalking children are psychologically normal. Most sleepwalking children are psychologically normal.

Runs in families. Runs in families.

Begins between ages 6 and 12 and may be stress-related. Begins between ages 6 and 12 and may be stress-related.

Customarily sleepwalkers exhibit other delta-sleep Customarily sleepwalkers exhibit other delta-sleep interruptions. interruptions.

At some time 1-6% of children sleepwalk; of these, 15% do At some time 1-6% of children sleepwalk; of these, 15% do so occasionally.so occasionally.

Adult sleepwalking is far less common, usually worse and Adult sleepwalking is far less common, usually worse and more chronic.more chronic.


C.C. Sleepwalking DisorderSleepwalking Disorder

Treatment:Treatment:

Relaxation techniquesRelaxation techniques

Biofeedback trainingBiofeedback training

Hypnosis. Hypnosis.

May need to sleep on the ground floor, have outside May need to sleep on the ground floor, have outside doors securely locked, and have car keys unavailable. doors securely locked, and have car keys unavailable.


D. Parasomnia NOS D. Parasomnia NOS (listed on p. 644) (listed on p. 644)

Characteristics:Characteristics:Abnormal behavioral or physiological Abnormal behavioral or physiological events during sleep or sleep-wake events during sleep or sleep-wake transitions, but that do not meet criteria transitions, but that do not meet criteria for a more specific Parasomniafor a more specific Parasomnia


D. Parasomnia NOS D. Parasomnia NOS (listed on p. 644) (listed on p. 644) ExamplesExamples

Sleep-Talking: Often more annoying to partner than to Sleep-Talking: Often more annoying to partner than to sleeper. Has no memory in morning. Can be during REM or sleeper. Has no memory in morning. Can be during REM or delta sleep. In REM sleep, pronunciation is clear and delta sleep. In REM sleep, pronunciation is clear and understandable; in deep sleep (delta) apt to be mumbled and understandable; in deep sleep (delta) apt to be mumbled and unintelligibleunintelligible

Sleep paralysis: inability to perform voluntary movement Sleep paralysis: inability to perform voluntary movement during the transition between waking and sleep. Usually during the transition between waking and sleep. Usually associated with extreme anxiety, and sometimes fear of associated with extreme anxiety, and sometimes fear of impending death. impending death.

REM sleep behavior disorder: characterized by agitated and REM sleep behavior disorder: characterized by agitated and violent behavior.violent behavior.

Parasomnia is present but unable to determine whether it is Parasomnia is present but unable to determine whether it is primary, due to GMC, or substance induced. primary, due to GMC, or substance induced.

The Sleep Disorders chapter has The Sleep Disorders chapter has four major sections:four major sections:

I. Primary Sleep Disorders include all I. Primary Sleep Disorders include all sleep disorders, sleep disorders, exceptexcept::

II. Sleep Disorder Related to Another II. Sleep Disorder Related to Another Mental DisorderMental Disorder

III. Sleep Disorder Due to a General III. Sleep Disorder Due to a General

Medical Condition (GMC)Medical Condition (GMC)

IV. Substance-Induced Sleep DisorderIV. Substance-Induced Sleep Disorder

II.II. Sleep Disorder Related toSleep Disorder Related toAnother Mental DisorderAnother Mental Disorder

Two DiagnosesTwo Diagnoses

1.1. Insomnia Related to Another MentalInsomnia Related to Another Mental Disorder (criteria listed on p. 650) Disorder (criteria listed on p. 650)

2. Hypersomnia Related to Another2. Hypersomnia Related to Another Mental Disorder (criteria listed on p. Mental Disorder (criteria listed on p.

650)650)


1.1. Insomnia Related to Another MentalInsomnia Related to Another Mental Disorder Disorder

CharacteristicsCharacteristics• Difficulty in initiating or maintaining sleepDifficulty in initiating or maintaining sleep• Persists for at least 1 month Persists for at least 1 month

2. Hypersomnia Related to Another2. Hypersomnia Related to Another Mental DisorderMental Disorder

Characteristics:Characteristics:• Excessive sleepinessExcessive sleepiness• Persists for at least 1 monthPersists for at least 1 month


Two DiagnosesTwo Diagnoses

1.1. Insomnia Related to… another mentalInsomnia Related to… another mental disorder – indicate the Axis I or II disorderdisorder – indicate the Axis I or II disorder

(criteria listed on p. 650) (criteria listed on p. 650)

2. Hypersomnia Related to…another2. Hypersomnia Related to…another mental disorder – indicate the Axis I or IImental disorder – indicate the Axis I or II

disorder (criteria listed on p. disorder (criteria listed on p. 650)650)

III. 327.xx Sleep Disorder Due to … a III. 327.xx Sleep Disorder Due to … a General Medical Condition General Medical Condition

(list the GMC) (criteria on p. 654)(list the GMC) (criteria on p. 654)Also GMC on Axis IIIAlso GMC on Axis III

Prominent disturbance in sleep that is sufficiently Prominent disturbance in sleep that is sufficiently severe to warrant independent clinical attention.severe to warrant independent clinical attention. Evidence has to be present that the sleep Evidence has to be present that the sleep

disturbance is a direct physiological disturbance is a direct physiological consequence of a general medical condition.consequence of a general medical condition.

Specify Type:Specify Type:(1) .52(1) .52 Insomnia TypeInsomnia Type(2) .54(2) .54 Hypersomnia TypeHypersomnia Type(3) .59(3) .59 Parasomnia TypeParasomnia Type(4) .59(4) .59 Mixed TypeMixed Type

IV. Substance-Induced Sleep IV. Substance-Induced Sleep Disorder (Indicate Substance) Disorder (Indicate Substance)

(criteria is on p. 660)(criteria is on p. 660)CharacteristicsCharacteristics

Evidence must be present that the sleep disturbance Evidence must be present that the sleep disturbance is a direct physiological consequence of substance is a direct physiological consequence of substance use.use.

Substance use that produces a sleep disorder severe Substance use that produces a sleep disorder severe enough to warrant independent clinical attentionenough to warrant independent clinical attention

Code:Code:291.8 Alcohol; 292.89 Amphetamine; 292.89 291.8 Alcohol; 292.89 Amphetamine; 292.89 Caffeine; 292.89 Cocaine; 292.89 Opioid; Caffeine; 292.89 Cocaine; 292.89 Opioid; 292.89 Sedative, Hypnotic, or Anxiolytic; 292.89 292.89 Sedative, Hypnotic, or Anxiolytic; 292.89 Other (or unknown) SubstanceOther (or unknown) Substance

IV. Substance-Induced Sleep IV. Substance-Induced Sleep Disorder (Indicate Substance) Disorder (Indicate Substance)

(criteria is on p. 660)(criteria is on p. 660)

Types:Types:Insomnia TypeInsomnia TypeHypersomnia TypeHypersomnia TypeParasomnia TypeParasomnia TypeMixed TypeMixed Type

Specify if:Specify if:With Onset During Intoxication With Onset During Intoxication With Onset During WithdrawalWith Onset During Withdrawal

sleep disorders. two major categories* dyssomnias parasomnias * this classification system is...

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