Sleep Disorders

Front 1

Primary Insomnia

Back 1

A. The predominant complaint is difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least 1 month.
B. The sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The sleep disturbance does not occur exclusively during the course of Narcolepsy, Breathing-Related Sleep Disorder, Circadian Rhythm Sleep Disorder, or a Parasomnia.
D. The disturbance does not occur exclusively during the course of another mental disorder (e.g., Major Depressive Disorder, Generalized Anxiety Disorder, a delirium).
E. 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.

Front 2

Primary Hypersomnia

Back 2

A. The predominant complaint is excessive sleepiness for at least 1 month (or less if recurrent) as evidenced by either prolonged sleep episodes or daytime sleep episodes that occur almost daily.
B. The excessive sleepiness causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The excessive sleepiness is not better accounted for by insomnia and does not occur exclusively during the course of another Sleep Disorder (e.g., Narcolepsy, Breathing-Related Sleep 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 disorder.
E. 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.

Specify if:

Recurrent: if there are periods of excessive sleepiness that last at least 3 days occurring several times a year for at least 2 years

Front 3

Narcolepsy

Back 3

A. Irresistible attacks of refreshing sleep that occur daily over at least 3 months.
B. The presence of one or both of the following:
(1) cataplexy (i.e., brief episodes of sudden bilateral loss of muscle tone, most often in association with intense emotion)
(2) recurrent intrusions of elements of rapid eye movement (REM) sleep into the transition between sleep and wakefulness, as manifested by either hypnopompic or hypnagogic hallucinations or sleep paralysis at the beginning or end of sleep episodes

C. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another general medical condition.

Front 4

Breathing-Related Sleep Disorder

Back 4

A. Sleep disruption, leading to excessive sleepiness or insomnia, that is judged to be due to a sleep-related breathing condition (e.g., obstructive or central sleep apnea syndrome or central alveolar hypoventilation syndrome).
B. The disturbance is not better accounted for by another mental disorder 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 (other than a breathing-related disorder).

Coding note: Also code sleep-related breathing disorder on Axis III.

Front 5

Circadian Rhythm Sleep Disorder

Back 5

A. A persistent or recurrent pattern of sleep disruption leading to excessive sleepiness or insomnia that is due to a mismatch between the sleep-wake schedule required by a person's environment and his or her circadian sleep-wake pattern.
B. The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The disturbance does not occur exclusively during the course of another Sleep Disorder or other mental disorder.
D. 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.

Specify type:

.31 Delayed Sleep Phase Type: a persistent pattern of late sleep onset and late awakening times, with an inability to fall asleep and awaken at a desired earlier time

.35 Jet Lag Type: sleepiness and alertness that occur at an inappropriate time of day relative to local time, occurring after repeated travel across more than one time zone

.36 Shift Work Type: insomnia during the major sleep period or excessive sleepiness during the major awake period associated with night shift work or frequently changing shift work

.30 Unspecified Type

Front 6

Dyssomnia Not Otherwise Specified (Examples 1 & 2)

Back 6

The Dyssomnia Not Otherwise Specified category is for insomnias, hypersomnias, or circadian rhythm disturbances that do not meet criteria for any specific Dyssomnia. Examples include

1. Complaints of clinically significant insomnia or hypersomnia that are attributable to environmental factors (e.g., noise, light, frequent interruptions).
2. Excessive sleepiness that is attributable to ongoing sleep deprivation.

Front 7

Dyssomnia Not Otherwise Specified (Example 3: Restless Legs)

Back 7

3. "Restless legs syndrome": This syndrome is characterized by a desire to move the legs or arms, associated with uncomfortable sensations typically described as creeping, crawling, tingling, burning, or itching. Frequent movements of the limbs occur in an effort to relieve the uncomfortable sensations. Symptoms are worse when the individual is at rest and in the evening or night, and they are relieved temporarily by movement. The uncomfortable sensations and limb movements can delay sleep onset, awaken the individual from sleep, and lead to daytime sleepiness or fatigue. Sleep studies demonstrate involuntary periodic limb movements during sleep in a majority of individuals with restless legs syndrome. A minority of individuals have evidence of anemia or reduced serum iron stores. Peripheral nerve electrophysiological studies and gross brain morphology are usually normal. Restless legs syndrome can occur in an idiopathic form, or it can be associated with general medical or neurological conditions, including normal pregnancy, renal failure, rheumatoid arthritis, peripheral vascular disease, or peripheral nerve dysfunction. Phenomenologically, the two forms are indistinguishable. The onset of restless legs syndrome is typically in the second or third decade, although up to 20% of individuals with this syndrome may have symptoms before age 10. The prevalence of restless legs syndrome is between 2% and 10% in the general population and as high as 30% in general medical populations. Prevalence increases with age and is equal in males and females. Course is marked by stability or worsening of symptoms with age. There is a positive family history in 50%-90% of individuals. The major differential diagnoses include medication-induced akathisia, peripheral neuropathy, and nocturnal leg cramps. Worsening at night and periodic limb movements are more common in restless legs syndrome than in medication-induced akathisia or peripheral neuropathy. Unlike restless legs syndrome, nocturnal leg cramps do not present with thedesire to move the limbs nor are there frequent limb movements.

Front 8

Dyssomnia Not Otherwise Specified (Example 4: Periodic Limb Movements)

Back 8

4. Periodic limb movements: Periodic limb movements are repeated low-amplitude brief limb jerks, particularly in the lower extremities. These movements begin near sleep onset and decrease during stage 3 or 4 non-rapid eye movement (NREM) and rapid eye movement (REM) sleep. Movements usually occur rhythmically every 20-60 seconds and are associated with repeated, brief arousals. Individuals are often unaware of the actual movements, but may complain of insomnia, frequent awakenings, or daytime sleepiness if the number of movements is very large. Individuals may have considerable variability in the number of periodic limb movements from night to night. Periodic limb movements occur in the majority of individuals with restless legs syndrome, but they may also occur without the other symptoms of restless legs syndrome. Individuals with normal pregnancy or with conditions such as renal failure, congestive heart failure, and Posttraumatic Stress Disorder may also develop periodic limb movements. Although typical age at onset and prevalence in the general population are unknown, periodic limb movements increase with age and may occur in more than one-third of individuals over age 65. Men are more commonly affected than women.

Front 9

Dyssomnia Not Otherwise Specified (Example 5)

Back 9

5. Situations in which the clinician has concluded that a Dyssomnia is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced.

Front 10

Nightmare Disorder

Back 10

A. Repeated awakenings from the major sleep period or naps with detailed recall of extended and extremely frightening dreams, usually involving threats to survival, security, or self-esteem. The awakenings generally occur during the second half of the sleep period.
B. On awakening from the frightening 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.

Front 11

Sleep Terror Disorder

Back 11

A. Recurrent episodes of abrupt awakening from sleep, usually occurring during the first third of the major sleep episode and beginning with a panicky scream.
B. Intense fear and signs of autonomic arousal, such as 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.
F. 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.

Front 12

Sleepwalking Disorder

Back 12

A. Repeated episodes of rising from bed during sleep and walking about, usually occurring during the first third of the major sleep episode.
B. 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.
C. On awakening (either from the sleepwalking episode or the next morning), the person has amnesia for the episode.
D. Within several minutes after awakening from the sleepwalking episode, there is no impairment of mental activity or behavior (although there may initially be a short period of confusion or disorientation).
E. The sleepwalking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
F. 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.

Front 13

Parasomnia NOS

Back 13

The Parasomnia Not Otherwise Specified category is for disturbances that are characterized by abnormal behavioral or physiological events during sleep or sleep-wake transitions, but that do not meet criteria for a more specific Parasomnia. Examples include

1. REM sleep behavior disorder: motor activity, often of a violent nature, that arises during rapid eye movement (REM) sleep. Unlike sleepwalking, these episodes tend to occur later in the night and are associated with vivid dream recall.
2. Sleep paralysis: an inability to perform voluntary movement during the transition between wakefulness and sleep. The episodes may occur at sleep onset (hypnagogic) or with awakening (hypnopompic). The episodes are usually associated with extreme anxiety and, in some cases, fear of impending death. Sleep paralysis occurs commonly as an ancillary symptom of Narcolepsy and, in such cases, should not be coded separately.
3. Situations in which the clinician has concluded that a Parasomnia is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced.

Front 14

Insomnia Related to . . . [Indicate the Axis I or Axis II disorder]

Back 14

A. The predominant complaint is difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least 1 month that is associated with daytime fatigue or impaired daytime functioning.
B. The sleep disturbance (or daytime sequelae) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The insomnia is judged to be related to another Axis I or Axis II disorder (e.g., Major Depressive Disorder, Generalized Anxiety Disorder, Adjustment Disorder With Anxiety) but is sufficiently severe to warrant independent clinical attention.
D. The disturbance is not better accounted for by another Sleep Disorder (e.g., Narcolepsy, Breathing-Related Sleep Disorder, a Parasomnia).
E. 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.

Front 15

Hypersomnia Related to . . . [Indicate the Axis I or Axis II disorder]

Back 15

A. The predominant complaint is excessive sleepiness for at least 1 month as evidenced by either prolonged sleep episodes or daytime sleep episodes that occur almost daily.
B. The excessive sleepiness causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The hypersomnia is judged to be related to another Axis I or Axis II disorder (e.g., Major Depressive Disorder, Dysthymic Disorder) but is sufficiently severe to warrant independent clinical attention.
D. The disturbance is not better accounted for by another Sleep Disorder (e.g., Narcolepsy, Breathing-Related Sleep Disorder, a Parasomnia) or by an inadequate amount of sleep.
E. 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.

Front 16

Sleep Disorder Due to . . . [Indicate the General Medical Condition]

Back 16

A. A prominent disturbance in sleep that is sufficiently severe to warrant independent clinical attention.
B. There is evidence from the history, physical examination, or laboratory findings that the sleep disturbance is the direct physiological consequence of a general medical condition.
C. The disturbance is not better accounted for by another mental disorder (e.g., an Adjustment Disorder in which the stressor is a serious medical illness).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance does not meet the criteria for Breathing-Related Sleep Disorder or Narcolepsy.
F. The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify type:

.01 Insomnia Type: if the predominant sleep disturbance is insomnia

.14 Hypersomnia Type: if the predominant sleep disturbance is hypersomnia

.44 Parasomnia Type: if the predominant sleep disturbance is a Parasomnia

.8 Mixed Type: if more than one sleep disturbance is present and none predominates

Front 17

Substance-Induced Sleep Disorder (Specify Substance)

Back 17

A. A prominent disturbance in sleep that is sufficiently severe to warrant independent clinical attention.
B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2):
(1) the symptoms in Criterion A developed during, or within a month of, Substance Intoxication or Withdrawal
(2) medication use is etiologically related to the sleep disturbance

C. The disturbance is not better accounted for by a Sleep Disorder that is not substance induced. Evidence that the symptoms are better accounted for by a Sleep Disorder that is not substance induced might include the following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non-substance-induced Sleep Disorder (e.g., a history of recurrent non-substance-related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the sleep symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention.

Specify type:

Insomnia Type: if the predominant sleep disturbance is insomnia

Hypersomnia Type: if the predominant sleep disturbance is hypersomnia

Parasomnia Type: if the predominant sleep disturbance is a Parasomnia

Mixed Type: if more than one sleep disturbance is present and none predominates

Specify if (see Table 1 on page 193 for applicability by substance):

With Onset During Intoxication: if the criteria are met for Intoxication with the substance and the symptoms develop during the intoxication syndrome

With Onset During Withdrawal: if criteria are met for Withdrawal from the substance and the symptoms develop during, or shortly after, a withdrawal syndrome