DSM IV

Primary Sleep Disorders are those in which none of the etiologies listedbelow (i.e., another mental disorder, a general medical condition, or a substance) isresponsible. Five distinct sleep stages can be measured by polysomnography: rapid eyemovement (REM) sleep and four stages of non-rapid eye movement (NREM) sleep(stages 1, 2, 3, and 4). Stage 1 NREM sleep is a transition from wakefulness tosleep and occupies about 5% of time spent asleep in healthy adults. Stage 2 NREMsleep, which is characterized by specific EEG waveforms (sleep spindles and Kcomplexes), occupies about 50% of time spent asleep. Stages 3 and 4 NREMsleep (also known collectively as slow-wave sleep) are the deepest levels of sleepand occupy about 10%-20% of sleep time. REM sleep, during which the majority oftypical storylike dreams occur, occupies about 20%25% of total sleep_

Polysomnography is the monitoring of multiple electrophysiological parametersduring sleep and generally includes measurement of EEG activity,electrooculographic activity, and electromyographic activity. Additionalpolysomnographic measures may include oral or nasal airflow, respiratory effort,chest and abdominal wall movement, oxyhemoglobin saturation, or exhaled carbondioxide concentration; these measures are used to monitor respiration during sleepand to detect the presence and severity of sleep apnea. Sleep continuity refers to the overall balance of sleep andwakefulness during a night of sleep. "Better" sleep continuity indicates consolidatedsleep with little wakefulness; "worse" sleep continuity indicates disrupted sleep withmore wakefulness. Sleep architecture refers to the amount and distribution of specific sleepstages. Sleep architecture measures include absolute amounts of REM sleep andeach NREM sleep stage (in minutes), relative amount of REM sleep and NREMsleep stages (expressed as a percentage of total sleep time), and latency betweensleep onset and the first REM period (REM latency).

Primary Sleep Disorders

Dyssomnias
Dyssomnias are primary disorders of initiating or maintaining sleep or of excessivesleepiness and are characterized by a disturbance in the amount, quality, or timing of sleep. This section includes Primary Insomnia, Primary Hypersomnia, Narcolepsy,Breathing-Related Sleep Disorder, Circadian Rhythm Sleep Disorder, andDyssomnia Not Otherwise Specified Primary Insomnia difficulty initiating or maintaining sleep or of non restorative sleep that lasts for at least 1 month and causes clinically significant distress or impairment in social, occupational, or other important areas of functioning the disturbance in sleep does not occur exclusively during the course of another sleep disorder or mental disorder and is not due to the direct physiological effects of a substance or a general medical condition

Individuals with Primary Insomnia may have a history of mental disorders, particularly Mood Disorders and Anxiety Disorders. Differential Diagnosis: Short sleepers are distinguished from those with Primary Insomnia by their lack of difficulty falling asleep and by the absence of characteristic symptoms of Primary Insomnia (e.g., intermittent wakefulness, fatigue, concentration problems ,or irritability). Circadian Rhythm Sleep Disorder are distinguished from Primary Insomnia by the history of recent trans meridian travel or shift work. Individuals with the Delayed Sleep Phase Type of Circadian Rhythm Sleep Disorder report sleep-onset insomnia only when they try to sleep at socially normal times, but they do not report difficulty falling asleep or staying asleep when they sleep at their preferred times. Narcolepsy may cause insomnia complaints, particularly in older adults, Narcolepsy rarely involves a major complaint of insomnia and is distinguished from Primary Insomnia by symptoms of prominent daytime sleepiness, cataplexy, sleep paralysis, and sleep-related hallucinations Breathing-Related Sleep Disorder, particularly central sleep apnea, mayinvolve a complaint of chronic insomnia and daytime impairment. A careful historymay reveal periodic pauses in breathing during sleep or crescendo-decrescendobreathing (CheyneStokes respiration). A history of central nervous system injury ordisease may further

suggest a Breathing-Related Sleep Disorder. Polysomnographycan confirm the presence of apneic events. Most individuals with Breathing-RelatedSleep Disorder have obstructive apnea that can be distinguished from PrimaryInsomnia by a history of loud snoring, breathing pauses during sleep, and excessivedaytime sleepiness. Parasomnias are characterized by a complaint of unusual behavior or events during sleep that sometimes may lead to intermittent awakenings. However, it is these behavioral events that dominate the clinical picture in a Parasomnia rather than the insomnia. mental disorders that includeinsomnia as an essential or associated feature _ General Medical Condition Substance-Induced Sleep Disorder

Relationship to International Classification of Sleep Disorders_