1. Sleep Disorders

2. Two Major Categories*  Dyssomnias  Parasomnias * This classification system is similar to that used by the American Sleep Disorders Association. * This classification system is similar to that used by the American Sleep Disorders Association.

3. Dyssomnias  The sleep itself is pretty normal.  But the client sleeps too little, too much, or at the wrong time.  So, the problem is with the amount (quantity), or with its timing, and sometimes with the quality of sleep.

4. Parasomnias  Something abnormal occurs during sleep itself, or during the times when the client is falling asleep or waking up (e.g., bad dreams.  The quality, quantity, and timing of the sleep are essentially normal.

5. The Sleep Disorders chapter has four major sections: I. Primary Sleep Disorders include all sleep disorders, except: sleep disorders, except: II. Sleep Disorder Related to Another Mental Disorder III. Sleep Disorder Due to a General Medical Condition (GMC) IV. Substance-Induced Sleep Disorder

6. I. Primary Sleep Disorders  Dyssomnias A. Primary Insomnia - too little sleep (criteria listed on p. 604) Characteristics Characteristics 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 II disorder or a GMC or substance use.This diagnosis is rarely independent of an Axis I or II disorder or a GMC or substance use.

7. I. Primary Sleep Disorders (cont.) A. Primary Insomnia (too little sleep) Often due to: Often due to: Major Depressive Episode, Manic Episode, or anxiety disorderMajor Depressive Episode, Manic Episode, or anxiety disorder Commonly misused substances, as well as some prescription medicines.Commonly misused substances, as well as some prescription medicines. Breathing-related problemsBreathing-related problems The cause sometimes can not be identified. The cause sometimes can not be identified.

8. I. Primary Sleep Disorders (cont.) A.Primary Insomnia (too little sleep) Treatment Vigorous daytime exercise, not exercising before sleep Vigorous daytime exercise, not exercising before sleep Sexual intercourse, if pleasurable Sexual intercourse, if pleasurable Metronome or ticking clock- slow, 60 beats per minute or slower, beat of human heart Metronome or ticking clock- slow, 60 beats per minute or slower, beat of human heart Relaxation exercises, practice regularly but condensed to 5 minutes Relaxation exercises, practice regularly but condensed to 5 minutes Decrease stimulation and increase soothing environments, such as ear plugs or calm reading Decrease stimulation and increase soothing environments, such as ear plugs or calm reading Practice good sleep habits Practice good sleep habits Read “How to Become an Insomniac” Read “How to Become an Insomniac”

9. I. Primary Sleep Disorders  Dyssomnias B. Primary Hypersomnia (sleeping too much, as well as being drowsy at times when client should be alert) (criteria listed on p. 609) Characteristics Characteristics 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 GMC or substance use.Rarely a diagnosis independent of an Axis I or II disorder or a GMC or substance use. Specify if: Recurrent. Specify if: Recurrent.

10. I. Primary Sleep Disorders (cont.) B. Primary Hypersomnia (too much sleep) (cont.) Often due to: Often due to: Major Depressive Episode, Dysthymic Disorder with atypical featuresMajor Depressive Episode, Dysthymic Disorder with atypical features Use of substances is less likely to produce hyersomnia than insomnia, but it can happen (e.g., sleeping pills overdose)Use of substances is less likely to produce hyersomnia than insomnia, but it can happen (e.g., sleeping pills overdose) The cause sometimes can not be identified. The cause sometimes can not be identified. Treatment: Exercise when becoming sleepy

11. I. Primary Sleep Disorders  Dyssomnias C. Narcolepsy (Sleeping at the wrong time) (criteria listed on pg. 615) Characteristics Characteristics Sleep intrudes into wakefulness, causing clients to fall asleep almost instantlySleep intrudes into wakefulness, causing clients to fall asleep almost instantly Sleep is brief but refreshingSleep is brief but refreshing May also have sleep paralysis, sudden loss of strength, and hallucinations as fall asleep or awaken.May also have sleep paralysis, sudden loss of strength, and hallucinations as fall asleep or awaken. Treatment: Stimulants, sometimes antidepressants, with less success.

12. I. Primary Sleep Disorders  Dyssomnias D. Breathing-Related Sleep Disorder (criteria listed on p. 622) Characteristics Sleep disruption (excessive sleepiness or insomnia) Sleep disruption (excessive sleepiness or insomnia) Due to sleep-related breathing condition (e.g., Obstructive Sleep Apnea Syndrome)Due to sleep-related breathing condition (e.g., Obstructive Sleep Apnea Syndrome)

13. I. Primary Sleep Disorders  Dyssomnias D.Breathing-Related Sleep Disorder Treatment (Criteria on p. 622)  In mild cases: weight loss, sleeping on one’s side, and avoiding hypnotics and alcohol (To sleep on side, a tennis ball can be sewn into back of client’s sleep wear)  In more serious cases: a machine that provides continuous positive airway pressure  Surgery: Few benefits

14. I. Primary Sleep Disorders  Dyssomnias E.Circadian Rhythm Sleep Disorder (criteria on p. 629) Characteristics Persistent or recurrent pattern of sleep disruption leading to excessive sleepiness or insomnia, due to mismatch between sleep-wake schedule required by a person’s environment and his/her circadian sleep-wake pattern (e.g., shift work, jet lag).Persistent or recurrent pattern of sleep disruption leading to excessive sleepiness or insomnia, due to mismatch between sleep-wake schedule required by a person’s environment and his/her circadian sleep-wake pattern (e.g., shift work, jet lag).

15. I. Primary Sleep Disorders  Dyssomnias E.Circadian Rhythm Sleep Disorder Treatment: Difficult to treat, because it has to involve the entire family Darken bedroom and use soundproofing Darken bedroom and use soundproofing Limit caffeine and hard to digest food. Limit caffeine and hard to digest food. Ensure all family members learns shift Ensure all family members learns shift To help jet lag, exposure to sun helps To help jet lag, exposure to sun helps Specify type: Delayed Sleep Phase Type, Jet Lag Type, Shift Work Type, and Unspecified Type

16. I. Primary Sleep Disorders Dyssomnias F.Dyssomnia NOS (listed on p. 629) This category is for insomnias, hypersomnias, or circadian rhythm disturbances that do not meet criteria for any specific Dyssomnia.

17. I. Primary Sleep Disorders  Parasomnias A.Nightmare Disorder (Criteria listed on p. 634) Characteristics: Characteristics: (1) Repeated awakenings from bad dreams (2) When awakened client becomes oriented and alert (2) When awakened client becomes oriented and alert

18. I. Primary Sleep Disorders  Parasomnias A.Information about Nightmare Disorder Usually occurs in early morning when REM sleep dominates. Usually occurs in early morning when REM sleep dominates. The same nightmare may recur repeatedly or different ones may pop up three times a week. The same nightmare may recur repeatedly or 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 before age 10; 2/3 before age 20. Half of the cases of nightmare disorder appear before age 10; 2/3 before age 20. Dreams are clearly remembered Dreams are clearly remembered Drugs can trigger nightmares. Drugs can trigger nightmares. Suddenly withdrawing REM-suppressant medications and drugs can cause REM rebound. Suddenly withdrawing REM-suppressant medications and drugs can cause REM rebound.

19. I. Primary Sleep Disorders  Parasomnias B.Sleep Terror Disorder (criteria listed on pg. 639) Characteristics: (1)Abrupt awakening from sleep, usually beginning with a panicky scream or cry. (2)Intense fear and signs of autonomic arousal (3)Unresponsive to efforts from other to calm client client (4)No detailed dream recalled (5)Amnesia for episode

20. I. Primary Sleep Disorders  Parasomnias B.Sleep Terror Disorder Usually only children have sleep terror disorder. The client is not having a nightmare. The eyes are open, screams erupt. Usually happens in early evening. In contrast to nightmares, sleep terrors do not respond to psychotherapy. Probably due to brain wave upset, fever, or medications However, some medications may help.

21. I. Primary Sleep Disorders  Parasomnias C.Sleepwalking Disorder (criteria listed on pg. 644) Characteristics: (1) Rising from bed during sleep and walking about. (2)Usually occurs early in the night. (3)On awakening, the person has amnesia for episode

22. I. Primary Sleep Disorders  Parasomnias C.Sleepwalking Disorder Most sleepwalking children are psychologically normal. Runs in families. Begins between ages 6 and 12 and may be stress-related. Customarily sleepwalkers exhibit other delta-sleep interruptions. At some time 1-6% of children sleepwalk; of these, 15% do so occasionally. Adult sleepwalking is far less common, usually worse and more chronic.

23. I. Primary Sleep Disorders  Parasomnias C.Sleepwalking Disorder Treatment: Relaxation techniques Biofeedback training Hypnosis. May need to sleep on the ground floor, have outside doors securely locked, and have car keys unavailable.

24. I. Primary Sleep Disorders  Parasomnias D. Parasomnia NOS (listed on p. 644) Characteristics: Abnormal behavioral or physiological events during sleep or sleep-wake transitions, but that do not meet criteria for a more specific Parasomnia

25. I. Primary Sleep Disorders  Parasomnias D. Parasomnia NOS (listed on p. 644) Examples Sleep-Talking: Often more annoying to partner than to sleeper. Has no memory in morning. Can be during REM or delta sleep. In REM sleep, pronunciation is clear and understandable; in deep sleep (delta) apt to be mumbled and unintelligible Sleep paralysis: inability to perform voluntary movement during the transition between waking and sleep. Usually associated with extreme anxiety, and sometimes fear of impending death. REM sleep behavior disorder: characterized by agitated and violent behavior. Parasomnia is present but unable to determine whether it is primary, due to GMC, or substance induced.

26. The Sleep Disorders chapter has four major sections: I. Primary Sleep Disorders include all sleep disorders, except: sleep disorders, except: II. Sleep Disorder Related to Another Mental Disorder III. Sleep Disorder Due to a General Medical Condition (GMC) IV. Substance-Induced Sleep Disorder

27. II.Sleep Disorder Related to Another Mental Disorder  Two Diagnoses 1.Insomnia Related to Another Mental Disorder (criteria listed on p. 650) Disorder (criteria listed on p. 650) 2. Hypersomnia Related to Another Mental Disorder (criteria listed on p. 650) Mental Disorder (criteria listed on p. 650)

28. II.Sleep Disorder Related to Another Mental Disorder 1.Insomnia Related to Another Mental Disorder Disorder Characteristics Characteristics Difficulty in initiating or maintaining sleepDifficulty in initiating or maintaining sleep Persists for at least 1 monthPersists for at least 1 month 2. Hypersomnia Related to Another Mental Disorder Mental Disorder Characteristics: Characteristics: Excessive sleepinessExcessive sleepiness Persists for at least 1 monthPersists for at least 1 month

29. II.Sleep Disorder Related to Another Mental Disorder  Two Diagnoses 1.Insomnia Related to… another mental disorder – indicate the Axis I or II disorder disorder – indicate the Axis I or II disorder (criteria listed on p. 650) 2. Hypersomnia Related to…another mental disorder – indicate the Axis I or II mental disorder – indicate the Axis I or II disorder (criteria listed on p. 650)

30. III. 327.xx Sleep Disorder Due to … a General Medical Condition (list the GMC) (criteria on p. 654) Also GMC on Axis III Prominent disturbance in sleep that is sufficiently severe to warrant independent clinical attention.  Evidence has to be present that the sleep disturbance is a direct physiological consequence of a general medical condition.  Specify Type: (1).52Insomnia Type (2).54Hypersomnia Type (3).59Parasomnia Type (4).59Mixed Type

31. IV. Substance-Induced Sleep Disorder (Indicate Substance) (criteria is on p. 660) Characteristics Evidence must be present that the sleep disturbance is a direct physiological consequence of substance use. Evidence must be present that the sleep disturbance is a direct physiological consequence of substance use. Substance use that produces a sleep disorder severe enough to warrant independent clinical attention Substance use that produces a sleep disorder severe enough to warrant independent clinical attentionCode: 291.8 Alcohol; 292.89 Amphetamine; 292.89 Caffeine; 292.89 Cocaine; 292.89 Opioid; 292.89 Sedative, Hypnotic, or Anxiolytic; 292.89 Other (or unknown) Substance

32. IV. Substance-Induced Sleep Disorder (Indicate Substance) (criteria is on p. 660) Types: Insomnia Type Hypersomnia Type Parasomnia Type Mixed Type Specify if: With Onset During Intoxication With Onset During Withdrawal