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Chapter 8 Eating and Sleep Disorders

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Title: Durand and Barlow Chapter 8: Eating and Sleep Disorders Author: Brynn Cobb Last modified by: Pfohl, William Created Date: 11/4/2002 8:41:49 PM – PowerPoint PPT presentation

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Title: Chapter 8 Eating and Sleep Disorders


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
  • Bulimia
  • 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)
  • Anorexia
  • 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
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 individuals 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 individuals
    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
  • 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 brains inability to synchronize day and
    night

52
Circadian Rhythm Sleep Disorders (continued)
  • Nature of Circadian Rhythms and Bodys Biological
    Clock
  • Circadian Rhythms Do not follow a 24 hour clock
  • Suprachiasmatic nucleus
  • Brains 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 brains 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 20-30 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
  • 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
  • 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 (gt11 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 movement4. 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
    persons 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
    persons 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
    persons 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 (lt1 month)
  • 2.    Sub acute insomnia (1-3 months)
  • 3.    Persistent insomnia (gt 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 (gt9 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 gt 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 (lt1/3
    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
    persons 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.
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