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
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)
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. Figure 8.4 An integrative causal model of eating disorders
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 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.

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
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 brain’s inability to synchronize day and night

52. 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

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 brain’s 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 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
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
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

72. p. 343

73. 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).

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 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)

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 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)

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 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)

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 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)

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 (<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)

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 (>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)
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 (<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.

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 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)

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.