ABPSYCH Finals

https://open.spotify.com/track/3MrRksHupTVEQ7YbA0FsZK?si=f39183f6df7041fa

Voyeuristic Disorder

A 29-year-old man, Alex, has a consistent urge to watch people undress without their knowledge. Over the past few years, he has secretly observed neighbors through his window when they leave their blinds open in the evening. Although he feels guilty and ashamed afterward, he continues to do so because he finds it difficult to control the impulse. This behavior has led to a deterioration in his romantic relationship because he feels the need to lie and hide his actions, and it has affected his performance at work as he is frequently preoccupied with these thoughts.

Exhibitionistic Disorder

Mark is a 35-year-old man who has an uncontrollable urge to expose himself to strangers in public spaces. Over the past year, he has occasionally sought out places like parks at dusk, where he exposes himself briefly to passersby. Although he doesn’t physically interact with the people, he finds the act of exposing himself highly stimulating and struggles to stop.

Frotteuristic Disorder

John is a 27-year-old man who experiences strong urges to rub against strangers in crowded places, such as on public transportation during rush hour. Over the past year, he has acted on these urges several times, positioning himself close to people in crowded subway cars and subtly brushing against them. He feels a brief sense of relief and arousal, but afterward experiences intense guilt and shame, fearing that his actions might be noticed or that he could get into legal trouble.

Sexual Masochism Disorder

Sarah, a 32-year-old woman, has recurrent fantasies and urges involving being physically hurt and humiliated during sexual activities. Over the past two years, she has frequently sought out partners who would engage in these behaviors with her, feeling that these experiences are necessary for her sexual satisfaction. However, unlike typical consensual BDSM practices, Sarah often pursues extreme situations that leave her physically injured, and she doesn’t always communicate her boundaries clearly, sometimes pushing herself past her comfort zone.

Sexual Sadism Disorder

Tom, a 40-year-old man, has recurring fantasies about inflicting pain and humiliation on others during sexual activity. Over the past year, he has acted on these urges with partners who were initially willing to explore sadomasochistic activities. However, he often pushes beyond the agreed-upon boundaries, causing physical harm without full consent. His need for increasingly extreme behavior has led to injuries in partners.

Pedophilic Disorder

Old dude has sexually arousing feelings for a little kid and the kid is about 13 years or younger.

Fetishistic Disorder

Michael, a 34-year-old man, has a strong sexual fixation on women’s high-heeled shoes. Over the past year, his desire to touch and collect high heels has intensified, to the point where he feels unable to achieve sexual satisfaction without them. Michael often finds himself distracted by these urges, spending excessive amounts of money on high-heeled shoes and hiding them from his family.

Transvestic Disorder

David, a 38-year-old married man, finds intense sexual arousal when dressing in women’s clothing, such as lingerie and dresses. Over the past year, this behavior has become a source of distress for him, as he feels ashamed and fears judgment from his spouse and friends. Although he has tried to stop, he feels compelled to continue, and his urges have intensified, leading to increased secrecy and anxiety.

Delayed Ejaculation

Ryan, a 30-year-old man, has been experiencing difficulties with ejaculation for the past year. During sexual intercourse with his partner, he often finds himself unable to ejaculate, even after prolonged stimulation. While he can achieve orgasm through masturbation, the inability to ejaculate during partnered sex causes him significant anxiety and frustration.

Erectile Disorder

Grayson, a 45-year-old man, has recently begun experiencing difficulties with erections. Although he has had a healthy sexual history, over the past several months, he finds that he often cannot maintain an erection during intercourse with his partner. Despite feeling aroused, he experiences anxiety and self-doubt during intimate moments, leading to further difficulties.

Female Orgasmic Disorder

Emily, a 29-year-old woman, has been experiencing difficulty reaching orgasm during sexual activity with her partner. Although she enjoys sexual experiences and feels physically aroused, she often finds that she cannot achieve orgasm, even after extensive stimulation. This has been a persistent issue for the past year.

Female Sexual Interest/Arousal Disorder

Marie, a 34-year-old woman, has noticed a significant decline in her sexual interest and arousal over the past year. Previously, she enjoyed a fulfilling sexual relationship with her partner, but now she often feels indifferent toward sexual activity and struggles to feel aroused, even when engaging in intimate moments.

Genito-Pelvic Pain/Penetration Disorder

Jessica, a 28-year-old woman, has been experiencing significant discomfort and pain during sexual intercourse for the past year. Although she desires intimacy with her partner, she often finds herself tensing up and feeling anxious at the thought of penetration. During attempts at intercourse, she experiences sharp pain, which has led to avoidance of sexual activity altogether.

Male Hypoactive Sexual Desire Disorder

Toby, a 40-year-old man, has been experiencing a marked decrease in sexual desire for the past year. Despite being in a long-term relationship with his partner, he finds that he rarely thinks about sex and often declines opportunities for intimacy. While he enjoys spending time with his partner, he feels detached from sexual experiences and does not have the motivation to engage in sexual activity.

Premature (Early) Ejaculation

Stanley, a 29-year-old man, has been struggling with his ejaculation for the past year. During sexual encounters, he finds that he consistently ejaculates within a minute of penetration, often before he or his partner feels fully satisfied. Despite wanting to last longer and pleasuring his partner, Stanley feels unable to control his ejaculation, which has led to significant distress.

Gender Dysphoria

Ruth, a 25-year-old individual assigned female at birth, has felt a deep sense of discomfort with their gender identity for as long as they can remember. Throughout childhood and adolescence, Ruth often identified more with male peers and felt a strong desire to be recognized as male. As they grew older, this discomfort intensified, leading to feelings of anxiety and depression.

Pica

Samantha is a 6-year-old girl who has been exhibiting unusual eating behaviors for the past six months. Her parents have noticed that she often tries to eat non-food items, such as dirt from the garden, pieces of chalk, and even crayons. Despite being offered a variety of healthy food options, Samantha expresses little interest in traditional meals and instead seeks out these inedible items.

Rumination Disorder

Evelyn, a 10-year-old girl, has been displaying unusual eating behavior for several months. After meals, she often regurgitates food, which she then re-chews and swallows again. This behavior occurs several times a week and has become a routine part of her eating process. Evelyn does not appear distressed by this behavior and does not seem to have any medical issues that would explain the regurgitation.

Avoidant/Restrictive Food Intake Disorder

Robert is a 10-year-old boy who has exhibited extreme selectivity regarding food for several years. He has a very limited diet consisting mainly of a few foods, such as plain pasta and crackers. Robert refuses to eat fruits, vegetables, or proteins, claiming they "feel weird" or "taste bad."

Anorexia Nervosa

Kelly is a 17-year-old high school student who has recently become increasingly focused on her weight and body image. Over the past year, she has drastically reduced her food intake, often skipping meals and avoiding social situations involving food. Despite being at a healthy weight initially, Kelly has lost a significant amount of weight and now weighs 30% below her ideal body weight.

Kelly is constantly worried about gaining weight and spends hours exercising each day to burn calories. She often looks in the mirror and criticizes her appearance, feeling that she is still "too fat." Her friends and family have expressed concern, but Kelly dismisses their worries, insisting that she is healthy and has control over her diet.

Bulimia Nervosa

Meredith is a 24-year-old woman who has been struggling with her eating pattern for the past two years. She often finds herself in a cycle of binge eating, typically at night when she feels alone and anxious. During these episodes, she consumes large amounts of food, often high in sugar and fat, and feels a temporary sense of relief.

Afterward, Meredith feels intense guilt and shame about her eating behavior, leading her to engage in compensatory behaviors such as vomiting and excessive exercise. She avoids eating in front of others and becomes increasingly secretive about her eating habits. Although she maintains a weight within the normal range, she is constantly dissatisfied with her appearance and feels that she must lose weight.

Binge-Eating Disorder

Jason is a 32-year-old man who finds himself frequently consuming large amounts of food, especially when he is stressed or feeling down. Jason often binges on fast food, snacks, and sweets, eating rapidly and without mindfulness.

After binge episodes, he feels a mix of guilt and shame, which leads him to promise himself he will eat healthier or restrict his food intake the next day. However, when faced with stress or emotional triggers, he finds himself bingeing again, creating a cycle of overeating and regret. Despite being aware of his eating habits, he feels powerless to change them.

“high.”

… the drugs typically activate the system and produce feelings of pleasure, often referred to as a “____.”

Substance Use Disorders

Its essential feature is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems.

Its important characteristic is an underlying change in brain circuits that may persist beyond detoxification, particularly in individuals with severe disorders. The behavioral effects of these brain changes may be exhibited in the repeated relapses and intense drug cravings when the individuals are exposed to drug-related stimuli.

Overall, its diagnosis is based on a pathological pattern of behaviors related to use of the substance.

Craving

It is manifested by an intense desire or urge for the drug that may occur at any time but is more likely when in an environment where the drug is previously was obtained or used.

Tolerance

It is signaled by requiring a markedly increased dose of the substance to achieve the desired effect or a markedly reduced effect when the usual dose is consumed.

Withdrawal

It is a syndrome that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance.

• disturbances of perception,

• wakefulness,

• attention,

• thinking,

• judgement,

• psychomotor behavior and interpersonal behavior

The most common changes in Intoxication:

Caffeine

It is the most widely used behaviorally active drug in the world. It can be consumed from a number of different sources, including coffee, tea, _________ soda, “energy” drinks, over-the-counter analgesics and cold remedies, energy aids (e.g. drinks), weight-loss aids, and chocolate.

4-6 hours

Approximate duration of caffeine intoxication.

Substance Use

It is the ingestion of psychoactive substances in moderate amounts that does not significantly interfere with social, educational, or occupational functioning.

Depressants

These substances can cause behavioral sedation and promote relaxation. Examples include alcohol (ethyl alcohol) and sedative or hypnotic drugs from the barbiturate family (such as Seconal) and the benzodiazepine family (like Valium and Xanax).

Stimulants

These substances make us more active and alert while enhancing our mood. This group includes amphetamines, cocaine, nicotine, and caffeine.

Opiates

These substances' major effects are to temporarily produce analgesia (reduce pain) and euphoria. Heroin, opium, codeine, and morphine are included in this group.

Hallucinogens

These substances alter sensory perception and can produce delusions, paranoia, and hallucinations. Cannabis and LSD are included in this category.

Voyeuristic Disorder

Diagnostic Criteria

A. Over at least 6 months, the individual experiences recurrent and intense sexual arousal from observing an unsuspecting person who is nude, disrobing, or engaging in sexual activity. This arousal can be manifested through fantasies, urges, or behaviors.

B. The individual has either acted on these urges with a nonconsenting person or experiences significant distress or impairment in important areas of life (social, work, etc.) due to these urges or fantasies.

C. The individual must be at least 18 years old.

Specifiers

• In a controlled environment: For individuals in environments where opportunities for voyeuristic behavior are restricted, such as institutions.

• In full remission: The individual has not acted on urges with a nonconsenting person and has no distress or impairment related to these urges for at least 5 years while not in a restricted setting.

Exhibitionistic Disorder

Diagnostic Criteria

A. Duration and Arousal: For at least 6 months, the individual experiences recurrent and intense sexual arousal from exposing their genitals to an unsuspecting person, as shown through fantasies, urges, or behaviors.

B. Impact of Urges: The individual has either acted on these urges with a nonconsenting person or the urges/fantasies cause significant distress or impairment in important life areas (social, work, etc.).

Specifiers

• Aroused by exposing genitals to prepubertal children

• Aroused by exposing genitals to physically mature individuals

• Aroused by exposing genitals to both prepubertal children and physically mature individuals

• In a controlled environment: Applicable to individuals in settings where exposure opportunities are restricted (e.g., institutional settings).

• In full remission: The individual has not acted on urges with a nonconsenting person and has had no distress or impairment related to these urges for at least 5 years while not in a controlled environment.

Frotteuristic Disorder

Diagnostic Criteria

A. Over at least 6 months, the individual experiences recurrent and intense sexual arousal from touching or rubbing against a nonconsenting person, as demonstrated by fantasies, urges, or behaviors.

B. The individual has either acted on these urges with a nonconsenting person or the urges/fantasies cause significant distress or impairment in major areas of life (social, work, etc.).

Specifiers

• In a controlled environment: Applicable to individuals in settings where opportunities to engage in frotteuristic behavior are restricted (e.g., institutional environments).

• In full remission: The individual has not acted on the urges with a nonconsenting person and has had no related distress or impairment for at least 5 years while in an unrestricted environment.

Sexual Masochism Disorder

Diagnostic Criteria

A. Over at least 6 months, the individual experiences recurrent and intense sexual arousal from being humiliated, beaten, bound, or otherwise made to suffer, as shown by fantasies, urges, or behaviors.

B. These fantasies, urges, or behaviors cause significant distress or impairment in major areas of life (social, work, etc.).

Specifiers

• With asphyxiophilia: The individual experiences sexual arousal specifically related to the restriction of breathing.

• In a controlled environment: For individuals in settings where opportunities for masochistic behaviors are restricted (e.g., institutions).

• In full remission: No distress or impairment has been present for at least 5 years in an unrestricted setting.

Pedophilic Disorder

Diagnostic Criteria

A. For at least 6 months, the individual experiences recurrent and intense sexually arousing fantasies, urges, or behaviors involving sexual activity with a prepubescent child or children (typically age 13 or younger).

B. The individual has acted on these urges, or the fantasies/urges cause significant distress or interpersonal issues.

C. The individual is at least 16 years old and at least 5 years older than the child or children described in Criterion A.

• Note: This does not include late adolescents in ongoing sexual relationships with a 12- or 13-year-old.

Specifiers

• Exclusive type: Attracted only to children.

• Nonexclusive type: Attracted to both children and adults.

• Sexually attracted to males

• Sexually attracted to females

• Sexually attracted to both

• Limited to incest: The attraction is specifically limited to incestuous relationships.

Fetishistic Disorder

Diagnostic Criteria

A. For at least 6 months, the individual experiences recurrent and intense sexual arousal from using nonliving objects or focusing on specific non-genital body parts, as shown through fantasies, urges, or behaviors.

B. Impact of Fantasies/Behaviors: These fantasies, urges, or behaviors cause significant distress or impairment in important areas of life (e.g., social, occupational).

C. Exclusions: The fetish is not limited to clothing articles used in cross-dressing (as in transvestic disorder) or devices specifically designed for genital stimulation (e.g., vibrators).

Specifiers

• Body part(s)

• Nonliving object(s)

• Other

• In a controlled environment: For individuals in settings where opportunities for fetishistic behaviors are restricted (e.g., institutions).

• In full remission: No distress or impairment has been present for at least 5 years in an unrestricted setting.

Transvestic Disorder

Diagnostic Criteria

A. Over at least 6 months, the individual experiences recurrent and intense sexual arousal from cross-dressing, demonstrated by fantasies, urges, or behaviors.

B. These fantasies, urges, or behaviors cause significant distress or impairment in important areas of life (e.g., social, occupational).

Specifiers

• With fetishism: Arousal is related to specific fabrics, materials, or garments.

• With autogynephilia: Arousal is associated with thoughts or images of oneself as female.

• In a controlled environment: Applicable to individuals in settings where cross-dressing opportunities are restricted (e.g., institutional settings).

• In full remission: No distress or impairment has been present for at least 5 years in an unrestricted setting.

Other Specified Paraphilic Disorder

Diagnostic Criteria

A. The individual shows symptoms typical of a paraphilic disorder that cause significant distress or impairment in major areas of life (social, work, etc.) but does not fully meet the criteria for any specific paraphilic disorder.

B. The clinician specifies the reason why the presentation does not meet the criteria for a specific disorder

Presentations may include intense sexual arousal associated with:

• Telephone scatologia (obscene phone calls)

• Necrophilia (corpses)

• Zoophilia (animals)

• Coprophilia (feces)

• Klismaphilia (enemas)

• Urophilia (urine)

These symptoms must persist for at least 6 months and cause significant distress or functional impairment.

Specifiers

• In a controlled environment: For individuals in settings where opportunities for the behavior are restricted.

• In full remission: No distress or impairment has been present for at least 5 years in an unrestricted setting.

Delayed Ejaculation

Diagnostic Criteria

A. Symptoms: On nearly all occasions (75%-100%) of partnered sexual activity, without the individual desiring delay, the individual experiences either:

• A significant delay in ejaculation, or

• Marked infrequency or absence of ejaculation.

B. Duration: The symptoms persist for at least 6 months.

Specifiers

• Lifelong: Present since the individual became sexually active.

• Acquired: Began after a period of normal sexual function.

• Generalized: Occurs in all contexts and is not limited by type of stimulation, situation, or partner.

• Situational: Limited to specific types of stimulation, situations, or partners.

• Severity:

  • Mild: Mild distress over symptoms.

  • Moderate: Moderate distress over symptoms.

  • Severe: Severe or extreme distress over symptoms.

Erectile Disorder

Diagnostic Criteria

A. Symptoms: On nearly all (75%-100%) occasions of sexual activity, the individual experiences at least one of the following:

1. Significant difficulty in obtaining an erection.

2. Difficulty maintaining an erection until the completion of sexual activity.

3. A noticeable decrease in erectile rigidity.

B. Duration: The symptoms have persisted for at least 6 months.

Specifiers

• Lifelong: Present since the individual first became sexually active.

• Acquired: Began after a period of normal sexual function.

• Generalized: Occurs in all situations, regardless of type of stimulation, situation, or partner.

• Situational: Limited to specific types of stimulation, situations, or partners.

• Severity:

  • Mild: Mild distress over symptoms.

  • Moderate: Moderate distress over symptoms.

  • Severe: Severe or extreme distress over symptoms.

Female Orgasmic Disorder

Diagnostic Criteria

A. On nearly all (75-100%) occasions of sexual activity, the individual (woman) experiences one or both of the following:

• Significant delay, infrequency, or absence of orgasm.

• Noticeably reduced intensity of orgasmic sensations.

B. Symptoms persist for at least 6 months.

C. Symptoms cause clinically significant distress to the individual.

Specifiers:

• Lifelong (present since becoming sexually active) or Acquired (began after a period of normal function).

• Generalized (occurs in all situations) or Situational (occurs only in certain contexts).

• Indicate if the individual has never experienced orgasm under any circumstance.

Severity:

• Mild: Mild distress over symptoms of criterion A

• Moderate: Moderate distress

• Severe: Severe or extreme distress

Female Sexual Interest/Arousal Disorder

Diagnostic Criteria

A. Lack of, or significantly reduced, sexual interest/arousal in women, as shown by at least three of the following:

1. Absent or reduced interest in sexual activity.

2. Absent or reduced sexual or erotic thoughts or fantasies.

3. No or reduced initiation of sexual activity and typically unreceptive to a partner’s attempts to initiate.

4. Absent or reduced sexual excitement or pleasure during almost all (75-100%) sexual encounters (in specific contexts or generalized).

5. Absent or reduced sexual interest or arousal in response to any internal or external sexual or erotic cues (e.g., written, verbal, visual).

6. Absent or reduced genital or non-genital sensations during almost all (75-100%) sexual encounters (in specific contexts or generalized).

B. Symptoms persist for at least 6 months.

Specifiers:

• Lifelong: Present since becoming sexually active.

• Acquired: Began after a period of normal function.

• Generalized: Occurs in all situations.

• Situational: Occurs only in certain contexts.

Severity:

• Mild: Mild distress.

• Moderate: Moderate distress.

• Severe: Severe or extreme distress.

Genito-Pelvic Pain/Penetration Disorder

Diagnostic Criteria

A. Persistent or recurrent difficulties with one (or more) of the following:

1. Difficulty with vaginal penetration during intercourse.

2. Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts.

3. Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration.

4. Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.

B. Symptoms persist for at least 6 months.

D. Symptoms are not due to:

• Another mental health disorder.

• Severe relationship distress (e.g., partner violence) or other stressors.

• Effects of substances, medications, or a medical condition.

Specifiers:

• Lifelong: Present since becoming sexually active.

• Acquired: Began after a period of normal function.

Severity:

• Mild: Mild distress.

• Moderate: Moderate distress.

• Severe: Severe or extreme distress.

Male Hypoactive Sexual Desire Disorder

Diagnostic Criteria

A. Persistently or recurrently deficient (or absent) sexual or erotic thoughts or fantasies, and desire for sexual activity in males. This judgment of deficiency is made by the clinician, considering factors such as age, general health, and sociocultural context.

B. Symptoms persist for at least 6 months.

Specifiers:

• Lifelong: Present since becoming sexually active.

• Acquired: Began after a period of normal function.

• Generalized: Occurs in all situations.

• Situational: Occurs only in certain contexts.

Severity:

• Mild: Mild distress.

• Moderate: Moderate distress.

• Severe: Severe or extreme distress.

Premature (Early) Ejaculation

Diagnostic Criteria

A. Primary Symptoms: A persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it.

• Note: While this diagnosis can apply to nonvaginal activities, specific duration criteria have not been established for these contexts.

B. Duration Requirement: The symptom in Criterion A has been present for at least 6 months and occurs on nearly all (75-100%) occasions of sexual activity (in specific contexts or generalized).

C. Distress Requirement: The symptom causes clinically significant distress to the individual

Specifiers:

• Lifelong: Present since becoming sexually active.

• Acquired: Began after a period of normal function.

• Generalized: Occurs in all situations.

• Situational: Occurs only in certain contexts.

Severity:

• Mild: Ejaculation within approximately 30 seconds to 1 minute of vaginal penetration.

• Moderate: Ejaculation within approximately 15-30 seconds of vaginal penetration.

• Severe: Ejaculation occurs before, at the start of, or within approximately 15 seconds of vaginal penetration.

Gender Dysphoria in Children

Diagnostic Criteria

A. Primary Symptoms: A marked incongruence between one’s experienced/expressed gender and assigned gender, lasting at least 6 months, with at least six of the following (one of which must be Criterion A1):

1. Strong desire to be, or insistence that one is, the other gender (or an alternative gender different from assigned gender).

2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; in girls (assigned gender), a strong preference for wearing typical masculine clothing and resistance to typical feminine clothing.

3. Strong preference for cross-gender roles in make-believe or fantasy play.

4. Strong preference for toys, games, or activities stereotypically engaged in by the other gender.

5. Strong preference for playmates of the other gender.

6. In boys (assigned gender), strong rejection of masculine toys, games, activities, and avoidance of rough play; in girls (assigned gender), strong rejection of feminine toys, games, and activities.

7. Strong dislike of one’s sexual anatomy.

8. Strong desire for primary and/or secondary sex characteristics that match experienced gender.

B. Distress Requirement: The condition causes clinically significant distress or impairment in social, school, or other important areas of functioning.

Specifiers:

• With a disorder of sex development: For example, congenital adrenal hyperplasia or androgen insensitivity syndrome.

Gender Dysphoria in Adolescents and Adults

Diagnostic Criteria

A. Primary Symptoms: A marked incongruence between one’s experienced/expressed gender and assigned gender, lasting at least 6 months, with at least two of the following:

1. Marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, anticipated secondary sex characteristics).

2. Strong desire to be rid of primary and/or secondary sex characteristics due to incongruence with experienced gender (or in young adolescents, to prevent development of anticipated secondary sex characteristics).

3. Strong desire for the primary and/or secondary sex characteristics of the other gender.

4. Strong desire to be of the other gender (or an alternative gender different from assigned gender).

5. Strong desire to be treated as the other gender (or some alternative gender).

6. Strong conviction of having typical feelings and reactions of the other gender (or an alternative gender).

B. Distress Requirement: The condition causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specifiers:

• With a disorder of sex development: For example, congenital adrenal hyperplasia or androgen insensitivity syndrome.

• Posttransition: The individual lives full-time in the desired gender (with or without legal gender change) and has undergone, or is preparing to undergo, at least one medical procedure (e.g., hormone treatment, gender reassignment surgery).

Sexual Sadism Disorder

Diagnostic Criteria

A. Primary Symptoms: Over at least 6 months, the individual experiences recurrent and intense sexual arousal from the physical or psychological suffering of another person, as demonstrated by fantasies, urges, or behaviors.

B. Distress or Acting Requirement: The individual has either:

• Acted on these sexual urges with a nonconsenting person, or

• Experiences clinically significant distress or impairment in social, occupational, or other important areas of functioning due to these urges or fantasies.

Specifiers:

• In a controlled environment: The individual resides in an institutional or similar setting where opportunities for engaging in sadistic sexual behaviors are restricted.

• In full remission: The individual has not acted on the urges with a nonconsenting person, and has had no distress or impairment in functioning, for at least 5 years in an uncontrolled environment.

Enuresis

A 9-year-old child, Dwight, has been experiencing regular bedwetting episodes at night, about 3–4 times per week. Despite attempts at limiting fluids before bedtime and encouraging bathroom use, Dwight continues to have involuntary urination while asleep. This pattern has been present for over a year and has not been resolved on its own.

Encopresis

Jamie, a 7-year-old child, has been experiencing regular episodes of involuntary stool passage in his underwear, occurring about twice a week for the past year. Jamie avoids using the toilet for bowel movements at school, often holding it in until he returns home. This habit has led to constipation and painful bowel movements, which worsen the cycle of avoiding the toilet.

Enuresis

Diagnostic Criteria

A. Repeated voiding of urine into bed or clothes, whether involuntary or intentional.

B. Occurs at least twice a week for 3 consecutive months, or causes clinically significant distress or impairment in social, academic, or other areas of functioning.

C. Chronological age is at least 5 years (or equivalent developmental level).

Specifiers:

• Nocturnal only: Urination occurs only during nighttime sleep.

• Diurnal only: Urination occurs only during waking hours.

• Nocturnal and diurnal: A combination of nighttime and waking hours.

Encopresis

Diagnostic Criteria

A. Primary Symptoms: Repeated passage of feces into inappropriate places (e.g., clothing, floor), whether involuntary or intentional.

B. Occurs at least once a month for a minimum of 3 months.

C. Chronological age is at least 4 years (or equivalent developmental level).

D. The behavior is not due to the physiological effects of a substance (e.g., laxatives) or another medical condition, except when involving constipation.

Specifiers:

• With constipation and overflow incontinence: Evidence of constipation is present on physical examination or by history.

• Without constipation and overflow incontinence: No evidence of constipation is present on physical examination or by history.

Oppositional Defiant Disorder

Sam, an 8-year-old child, has been showing a persistent pattern of angry, irritable moods and defiant behaviors for over 6 months. His parents and teachers report frequent issues with defiance and hostility, particularly toward authority figures.

At home, Sam often argues with his parents over daily routines, such as bedtime, chores, and homework. He frequently refuses to follow the rules, talks back and loses his temper when asked to do things he doesn’t want to do.

At school, he challenges his teacher’s instructions, refuses to complete tasks, and sometimes deliberately annoys other students. If corrected, Sam often responds with anger, blames others for his own mistakes, and shows a general reluctance to take responsibility for his actions.

Intermittent Explosive Disorder

Jim, a 13-year-old middle school student, has been experiencing sudden, intense outbursts of anger over the past year. These episodes often occur multiple times a week and are severe compared to the situations that trigger them. After outbursts, he feels a sense of relief.

At school, Jim has had episodes where he yells or throws objects when he feels frustrated or is corrected by a teacher. For example, during a recent group activity, a minor disagreement with a classmate led him to scream, throw his chair, and push his desk across the room.

At home, Jim’s reactions are similar. When asked to stop playing video games to do homework, he has slammed the game controller down, shouted at his parents, and even punched the wall, startling his younger siblings.

Conduct Disorder

Andy has been involved in several physical fights at school over the past year, often initiated by him over minor disagreements. He recently got into trouble for bullying a younger student and was found trying to harm a stray dog in his neighborhood. On multiple occasions, Andy has shown little remorse, even laughing when confronted about the harm he caused.

Andy has even stolen items from his classmates' lockers, including electronic devices, and has been caught lying about it. At home, his parents reported missing money, which they later found out he had taken to buy items from the local store without permission.

Pyromania

Cassie has set several small fires over the past year. These incidents range from igniting trash cans and burning leaves in a local park to lighting candles and matches in isolated areas, such as abandoned buildings. Each time she lights a fire, Cassie does so intentionally and with a sense of compulsion, rather than as a form of vandalism or for any material gain.

Kleptomania

Over the past year, Lisa has engaged in repeated thefts of small items from stores, such as cosmetics, jewelry, and office supplies. She usually steals items that are not particularly valuable, often taking things that she does not need and could easily afford to buy. Before stealing, Lisa experiences a strong sense of tension and anxiety. This feeling builds up over time, and she describes an overwhelming urge to take something, often feeling that she "must" do it despite knowing it is wrong.

Kleptomania

Diagnostic Criteria

A. Recurrent failure to resist the urge to steal items that are not needed for personal use or their monetary value.

B. An increasing sense of tension occurs immediately before committing the theft.

C. Pleasure, gratification, or relief is experienced at the time of the theft.

D. The stealing is not motivated by anger, vengeance, or in response to delusions or hallucinations.

Pyromania

Diagnostic Criteria

A. Deliberate and purposeful fire setting on more than one occasion.

B. There is a sense of tension or affective arousal before the setting of the fire.

C. A strong fascination, interest, curiosity, or attraction to fire and its related contexts (e.g., paraphernalia, uses, and consequences).

D. Experience of pleasure, gratification, or relief when setting fires or witnessing their aftermath.

E. The fire setting is not for monetary gain, sociopolitical expression, concealing criminal activity, expressing anger or vengeance, improving living circumstances, or due to delusions, hallucinations, or impaired judgment.

Conduct Disorder

Diagnostic Criteria

A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms/rules are violated. At least three of the following 15 criteria must be present in the past 12 months, with at least one in the past 6 months:

1. Aggression to People and Animals:

   • Often bullies, threatens, or intimidates others.

   • Initiates physical fights.

   • Uses weapons that can cause serious harm.

   • Physically cruel to people or animals.

   • Steals while confronting a victim.

   • Forces someone into sexual activity.

2. Destruction of Property:

   • Engages in fire setting to cause serious damage.

   • Deliberately destroys others' property.

3. Deceitfulness or Theft:

   • Breaks into someone else’s property.

   • Lies to obtain goods/favors or avoid obligations.

   • Steals items of nontrivial value without confrontation.

4. Serious Violations of Rules:

   • Stays out at night despite parental prohibitions.

   • Runs away from home overnight.

   • Is often truant from school.

B. Impairment:
The behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. Age Consideration:
If age 18 or older, criteria for antisocial personality disorder are not met.

Specifiers

• Onset Type:

  • Childhood-onset: Symptoms before age 10.

  • Adolescent-onset: No symptoms before age 10.

  • Unspecified onset: Not enough information to determine onset.

• With Limited Prosocial Emotions: Requires at least two of the following:

  • Lack of remorse or guilt: Does not feel bad for wrongdoings.

  • Callous—lack of empathy: Unconcerned about others' feelings.

  • Unconcerned about performance: Does not care about poor performance.

  • Shallow or deficient affect: Emotion is insincere or superficial.

Severity:

• Mild: Few conduct problems causing minor harm.

• Moderate: Intermediate number of conduct problems.

• Severe: Many conduct problems cause considerable harm.

Intermittent Explosive Disorder

Diagnostic Criteria

A. Recurrent Behavioral Outbursts:
Characterized by a failure to control aggressive impulses, as evidenced by one of the following:

1. Verbal Aggression:

   • Occurs twice weekly on average for 3 months.

   • Examples include temper tantrums, verbal arguments, or fights.

   • Physical aggression does not cause property damage or physical injury to animals or individuals.

2. Physical Aggression:

   • At least three behavioral outbursts involving damage to property or physical assault causing injury to others or animals within a 12-month period.

B. The aggressiveness expressed during the outbursts is grossly disproportionate to any provocation or psychosocial stressors.

C. The outbursts are not premeditated (impulsive and/or anger-based) and are not aimed at achieving a tangible objective (e.g., money, or power).

D. The recurrent aggressive outbursts cause marked distress for the individual or impair occupational or interpersonal functioning, or result in financial or legal consequences.

E. Age Requirement:
Chronological age must be at least 6 years (or equivalent developmental level).

Note:

This diagnosis can coexist with attention-deficit/hyperactivity disorder (ADHD), conduct disorder, oppositional defiant disorder, or autism spectrum disorder if the aggressive outbursts are excessive and warrant separate clinical attention.

Oppositional Defiant Disorder

Diagnostic Criteria

A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months, as evidenced by at least four symptoms from the following categories:

Angry/Irritable Mood:

1. Loses temper frequently.

2. Touchy or easily annoyed by others.

3. Angry and resentful often.

Argumentative/Defiant Behavior:

4. Argues with authority figures or adults.

5. Actively defies or refuses to comply with requests or rules from authority figures.

6. Deliberately annoys others.

7. Blames others for mistakes or misbehavior.

Vindictiveness:

8. Spiteful or vindictive at least twice in the past 6 months.

   Note: The persistence and frequency of these behaviors distinguish symptomatic behavior from normal behavior. For children under 5, symptoms should occur most days for at least 6 months. For those 5 and older, symptoms should occur at least once per week for at least 6 months. Additional factors include developmental level, gender, and culture.

B. Distress and Impact:
The disturbance causes distress to the individual or others in their immediate social context (e.g., family, peers) or negatively affects social, educational, occupational, or other important areas of functioning.

C. Exclusion of Other Disorders:
Behaviors do not occur exclusively during psychotic, substance use, depressive, or bipolar disorders, and the criteria for disruptive mood dysregulation disorder are not met.

Specify Current Severity:

• Mild: Symptoms are confined to one setting (e.g., home, school, work, peers).

• Moderate: Symptoms present in at least two settings.

• Severe: Symptoms present in three or more settings.

Dyssomnias

It involves difficulties in getting enough sleep, problems with sleeping when you want to, quality of sleep.

Parasomnias

It involves abnormal behavioral or physiological events that occur during sleep, such as nightmares and sleepwalking.

Insomnia Disorder

Maria often has trouble falling asleep despite feeling tired at bedtime. She lies awake for hours, unable to quiet her mind. On the rare nights when she does fall asleep easily, she wakes up multiple times throughout the night and finds it difficult to fall back asleep. Maria’s sleep issues have persisted for months, causing fatigue and irritability during the day, and her work performance has suffered due to constant tiredness.

Hypersomnolence Disorder

Evan sleeps for 9-10 hours each night but still feels excessively tired throughout the day. Despite getting what would be considered enough sleep, he often finds himself falling asleep at inappropriate times, such as during meetings or while watching television. Evan also experiences a feeling of fogginess and confusion upon waking, which sometimes lasts for hours, impacting his daily activities and social life.

Narcolepsy

Phil frequently experiences overwhelming sleep attacks during the day, where he suddenly feels an uncontrollable urge to sleep, even in situations like eating or conversing with friends. During these episodes, Phil sometimes experiences cataplexy, where his muscles suddenly go limp, causing him to slump or even collapse momentarily. These sudden sleep episodes disrupt his work and social life, and he lives in constant worry about when the next one will happen.

Breathing-related Sleep Disorder

Some people experience constricted and labored breathing during sleep, known as hypoventilation. In more severe cases, there may be short periods lasting 10 to 30 seconds when breathing stops altogether, a condition referred to as sleep apnea. These are called...

• Obstructive sleep apnea hypopnea syndrome

• Central sleep apnea

• Sleep-related hypoventilation

Three types of apnea:

Obstructive sleep apnea hypopnea syndrome

Occurs when airflow stops despite continued activity by the respiratory system. It is common in males and probably caused by obesity, night snoring, or medication, like MDMA (ecstasy).

Central sleep apnea

It involves the complete cessation of respiratory activity for brief periods and is often associated with certain central nervous system disorders, such as cerebral vascular disease, head trauma, and degenerative disorders. Individuals with this type of apnea wake more often at night but they tend to report no daytime sleepiness.

Sleep-related hypoventilation

It is a decrease in airflow without a complete pause in breathing. This tends to cause an increase in carbon dioxide (C02) levels, because insufficient air is exchanged with the environment.

Circadian Rhythm Sleep-Wake Disorders

Haley works the night shift but struggles to adjust her body’s body clock to match her work schedule. Even though she tries to sleep during the day, her body remains alert, leading to only a few hours of sleep. On her days off, Haley tries to revert to a regular sleep schedule, further disrupting her internal clock. As a result, she often feels fatigued, irritable, and has difficulty concentrating, with her overall health suffering due to lack of consistent, restful sleep.

Non-Rapid Eye Movement Sleep Arousal Disorders

During the night, Max’s partner often finds him wandering around the house in a dazed state, performing actions like opening cabinets or sitting on the edge of the bed. When she tries to guide him back to bed, he appears disoriented and unresponsive. In the morning, Max has no memory of these incidents. This sleepwalking behavior has occurred multiple times, leading to concerns for his safety, especially if he’s near stairs or sharp objects.

Nightmare Disorder

Alicia has frequent, vivid nightmares in which she’s chased or trapped, often waking up abruptly, drenched in sweat, and terrified. These nightmares make it hard for her to return to sleep, and she often finds herself lying awake for hours afterward. The fear of having another nightmare causes Alicia to dread going to bed, which impacts her daytime mood, leaving her tired and anxious.

Rapid Eye Movement Sleep Behavior Disorder

Jack’s spouse reports that he often thrashes around or talks loudly during his dreams. Sometimes, he even “acts out” the dream by moving his limbs, as if he’s defending himself or running. This behavior has caused both minor injuries and disrupted sleep for Jack and his spouse, who is worried about the intensity of his movements. When Jack wakes up, he often remembers parts of his dreams vividly, especially when they involve aggressive or action-filled scenarios.

Restless Leg Syndrome

In the evenings, Charlotte experiences uncomfortable sensations in her legs, like tingling and an urge to move. These sensations become more intense when she’s sitting or lying down, making it difficult for her to relax or fall asleep. Charlotte finds that moving her legs temporarily eases the discomfort, but it returns as soon as she stops. Her sleep is often interrupted, and she feels exhausted and irritable during the day, which affects her ability to focus at work.

Rebound Insomnia

Sleep problems reappear, sometimes worse—may occur when the medication (sleeping pills) is withdrawn.

Pica

Diagnostic Criteria

A. The individual repeatedly consumes nonnutritive, nonfood items (e.g., dirt, chalk, paper) for at least one month.

B. The behavior is considered abnormal based on the individual's developmental stage (i.e., not appropriate for age).

C. The behavior is not explained by cultural or social practices that might normally involve eating nonfood items.

Specifier:

• In Remission: The criteria for the disorder were previously met, but symptoms have not occurred for an extended period.

Rumination Disorder

Diagnostic Criteria

A. The individual repeatedly regurgitates food for at least one month, which may be re-chewed, re-swallowed, or spit out.

B. The regurgitation is not due to any gastrointestinal or medical condition (e.g., gastroesophageal reflux, pyloric stenosis).

C. The behavior does not occur only during anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder.

D. If the regurgitation occurs with another mental disorder (e.g., intellectual disability or neurodevelopmental disorder), it is severe enough to need further clinical attention.

Specifier:

• In Remission: The criteria for rumination disorder were previously met, but symptoms have not occurred for an extended period.

Avoidant/Restrictive Food Intake Disorder

Diagnostic Criteria

A. Eating/Feeding Disturbance: There is a persistent eating or feeding issue, such as lack of interest in eating, avoidance due to food’s sensory characteristics, or worry about negative outcomes from eating. This results in at least one of the following:

• Significant weight loss or, in children, lack of expected growth.

• Noticeable nutritional deficiency.

• Dependence on enteral feeding or nutritional supplements.

• Interference with psychosocial functioning.

B. Not Due to Food Availability or Cultural Practice: The disturbance is not due to a lack of food or culturally acceptable practices.

C. Exclusion of Anorexia and Bulimia: The behavior does not occur exclusively during anorexia or bulimia, nor is there body weight or shape disturbance.

D. Exclusion of Medical or Mental Conditions: The disturbance is not due to another medical condition or mental disorder. If present alongside another condition, it is severe enough to require extra clinical attention.

Specifier:

• In Remission: The criteria for the disorder were previously met but have not been met for a sustained period.

Anorexia Nervosa

Diagnostic Criteria

A. Persistent restriction of energy intake leads to significantly low body weight, considering age, sex, growth expectations, and health status.

B. There is an intense fear of gaining weight or becoming fat, or a consistent pattern of behavior that prevents weight gain despite being underweight.

C. Disturbance in self-perception of body weight or shape, where self-worth is disproportionately influenced by weight/shape, or there is a lack of recognition of the severity of low weight.

Specifiers:

• Partial Remission: Criterion A (low weight) not met, but Criterion B (fear of weight gain) or Criterion C (distortion in body image) still present.

• Full Remission: No criteria met for a sustained period.

Severity Based on BMI:

• Mild: BMI ≥ 17 kg/m²

• Moderate: BMI 16–16.99 kg/m²

• Severe: BMI 15–15.99 kg/m²

• Extreme: BMI < 15 kg/m²

Bulimia Nervosa

Diagnostic Criteria

A. Binge Eating Episodes:

1. Consuming an amount of food within a discrete period (e.g., 2 hours) that is larger than what most people would eat in similar circumstances.

2. Experiencing a loss of control over eating during these episodes (e.g., feeling unable to stop or control intake).

B. Inappropriate Compensatory Behaviors: Engaging in actions to prevent weight gain, such as self-induced vomiting, laxative or diuretic misuse, fasting, or excessive exercise.

C. Frequency: Binge eating and compensatory behaviors occur at least once a week for 3 months.

D. Self-Evaluation Influenced by Body Shape/Weight: Self-worth is heavily dependent on body shape and weight.

E. Not Exclusively During Anorexia Episodes: These behaviors are not exclusive to episodes of anorexia nervosa.

Remission Specifiers:

• Partial Remission: Some criteria met, but not all, for a sustained period.

• Full Remission: No criteria met for a sustained period.

Severity Based on Frequency of Compensatory Behaviors:

• Mild: 1–3 episodes per week

• Moderate: 4–7 episodes per week

• Severe: 8–13 episodes per week

• Extreme: 14 or more episodes per week

Binge-Eating Disorder

Diagnostic Criteria

A. Recurrent Binge Eating Episodes:

1. Eating a larger-than-normal amount of food within a limited time (e.g., 2 hours).

2. Feeling a lack of control over eating during the episode (e.g., feeling unable to stop).

B. Associated Features (three or more of the following):

1. Eating much faster than normal.

2. Eating until feeling uncomfortably full.

3. Eating large amounts of food even when not physically hungry.

4. Eating alone due to embarrassment over the quantity of food eaten.

5. Feeling disgusted, depressed, or very guilty after eating.

D. Occurs, on average, at least once a week for 3 months.

E. No Compensatory Behaviors: Binge eating is not followed by compensatory actions (e.g., vomiting) and does not occur exclusively within anorexia or bulimia nervosa episodes.

Remission Specifiers:

• Partial Remission: Binge eating episodes reduce to less than one per week for a sustained period.

• Full Remission: No criteria have been met for a sustained period.

Severity Based on Frequency of Episodes:

• Mild: 1–3 episodes per week.

• Moderate: 4–7 episodes per week.

• Severe: 8–13 episodes per week.

• Extreme: 14 or more episodes per week.

Insomnia Disorder

Diagnostic Criteria

A. Difficulty with sleep quality or quantity, with one or more of the following symptoms:

1. Difficulty falling asleep (for children, this may require caregiver intervention).

2. Difficulty staying asleep (frequent awakenings or difficulty returning to sleep without help).

3. Waking up too early and being unable to return to sleep.

B. The sleep disturbance significantly impairs social, occupational, academic, or other important areas of functioning.

C. Occurs at least three nights per week.

D. Present for at least three months.

E. The difficulty occurs despite having adequate time and opportunity for sleep.

Specifiers:

1. With non–sleep disorder mental comorbidity: Includes mental health issues or substance use disorders.

2. With other medical comorbidity: Accompanied by a medical condition.

3. With other sleep disorder: Accompanied by another sleep-related issue.

Duration Specifiers:

• Episodic: Lasts at least 1 month but less than 3 months.

• Persistent: Lasts 3 months or longer.

• Recurrent: Two or more episodes in a year.

Note: If symptoms meet the criteria but last less than three months, the diagnosis should be coded as Other Specified Insomnia Disorder.

Hypersomnolence Disorder

Diagnostic Criteria

A. Self-reported excessive sleepiness despite having at least 7 hours of main sleep, along with one of the following:

1. Recurrent periods of sleep or frequent lapses into sleep within the same day.

2. Prolonged main sleep episode of more than 9 hours that is unrefreshing.

3. Difficulty being fully awake after sudden awakening.

B. Occurs at least three times per week, for a minimum of 3 months.

Specifiers:

1. With mental disorder: Including cases with co-occurring substance use.

2. With medical condition: Accompanied by a medical issue.

3. With another sleep disorder: Alongside another sleep-related disorder.

Duration Specifiers:

• Acute: Lasts less than 1 month.

• Subacute: Lasts 1–3 months.

• Persistent: Lasts more than 3 months.

Severity Specifiers (based on daytime alertness difficulty):

• Mild: Difficulty 1–2 days per week.

• Moderate: Difficulty 3–4 days per week.

• Severe: Difficulty 5–7 days per week, with episodes occurring in settings such as when driving, at work, or socializing.

Narcolepsy

Diagnostic Criteria

A. Primary Symptom: Recurrent, irrepressible need to sleep, lapses into sleep, or naps within the same day, occurring at least three times per week over the past three months.

B. At least one of the following is also present:

1. Cataplexy Episodes:

   • (a) In individuals with long-standing narcolepsy: brief episodes (seconds to minutes) of sudden, bilateral muscle tone loss while conscious, often triggered by laughter or joking.

   • (b) In children or recent onset cases (within 6 months): spontaneous grimaces, jaw-opening with tongue thrusting, or generalized hypotonia without obvious emotional triggers.

2. Hypocretin Deficiency: Measured via cerebrospinal fluid (CSF) hypocretin-1 levels, which are either ≤1/3 of normal levels or ≤110 pg/mL. This deficiency must not occur due to brain injury, inflammation, or infection.

3. Abnormal REM Sleep Patterns:

   • Either REM latency ≤15 minutes on nocturnal polysomnography

   • Or a mean sleep latency ≤8 minutes on a multiple sleep latency test (MSLT), with two or more sleep-onset REM periods.

Specify Subtypes:

• Narcolepsy without cataplexy but with hypocretin deficiency (G47.419): Low CSF hypocretin levels; no cataplexy but abnormal sleep studies.

• Narcolepsy with cataplexy but without hypocretin deficiency (G47.411): Cataplexy present, normal hypocretin levels, and abnormal sleep study (rare).

• Autosomal Dominant Cerebellar Ataxia, Deafness, and Narcolepsy (G47.419): Rare, due to DNA methyltransferase-1 mutations with symptoms of late-onset narcolepsy, ataxia, deafness, and eventual dementia.

• Autosomal Dominant Narcolepsy, Obesity, and Type 2 Diabetes (G47.419): Narcolepsy co-occurs with obesity and type 2 diabetes and has been linked to a specific gene mutation.

• Narcolepsy Secondary to Another Medical Condition (G47.429): Narcolepsy resulting from medical conditions that damage hypocretin neurons, such as Whipple’s disease, trauma, or tumors.

Specify Severity:

• Mild: Infrequent cataplexy (<1 episode/week), need for naps 1–2 times/day, mild nocturnal disturbances.

• Moderate: Daily or near-daily cataplexy, significant nocturnal sleep disruption, multiple naps required daily.

• Severe: Drug-resistant cataplexy, multiple daily attacks, almost constant sleepiness, with marked nocturnal disruptions (insomnia, vivid dreams, excessive movements).

Obstructive Sleep Hypopnea

Diagnostic Criteria

A. Criteria: Either (1) or (2):

1. At least five obstructive apneas or hypopneas per hour of sleep, along with one of the following symptoms:

   • Nocturnal Breathing Disturbances: Such as snoring, snorting or gasping, or breathing pauses during sleep.

   • Daytime Symptoms: Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities to sleep, which is not better explained by another mental disorder or medical condition.

2. Polysomnography Evidence:

   • 15 or more obstructive apneas and/or hypopneas per hour of sleep, regardless of accompanying symptoms.

Specify Current Severity

• Mild: Apnea-hypopnea index (AHI) is less than 15.

• Moderate: Apnea-hypopnea index (AHI) is 15–30.

• Severe: Apnea-hypopnea index (AHI) is greater than 30.

Central Sleep Apnea

Diagnostic Criteria

A. Evidence by polysomnography of five or more central apneas per hour of sleep.

B. Differential Diagnosis:

• The disorder is not better explained by another current sleep disorder.

Specify Whether:

• Idiopathic Central Sleep Apnea (327.21 [G47.31]):

  • Characterized by repeated episodes of apneas and hypopneas during sleep due to variability in respiratory effort without evidence of airway obstruction.

• Cheyne-Stokes Breathing (786.04 [R06.3]):

  • A pattern of periodic crescendo-decrescendo variation in tidal volume resulting in central apneas and hypopneas at a frequency of at least five events per hour, accompanied by frequent arousal.

• Central Sleep Apnea Comorbid with Opioid Use (780.57 [G47.37]):

  • Pathogenesis attributed to the effects of opioids on respiratory rhythm generators in the medulla, as well as differential effects on hypoxic versus hypercapnic respiratory drive.

Specify Current Severity:

• Severity is graded according to:

  • Frequency of breathing disturbances.

  • Extent of associated oxygen desaturation.

  • Degree of sleep fragmentation resulting from repetitive respiratory disturbances.

Sleep-Related Hypoventilation

Diagnostic Criteria

A. Polysomnography Findings: Episodes of decreased respiration associated with elevated CO2 levels.

• Note: In the absence of objective CO2 measurement, persistent low levels of hemoglobin oxygen saturation not associated with apneic or hypopneic events may indicate hypoventilation.

B. Differential Diagnosis:

• The disturbance is not better explained by another current sleep disorder.

Specify Whether:

• Idiopathic Hypoventilation (327.24 [G47.34]):

  • This subtype is not attributable to any readily identified condition.

• Congenital Central Alveolar Hypoventilation (327.25 [G47.35]):

  • A rare congenital disorder typically presenting in the perinatal period with shallow breathing, cyanosis, or apnea during sleep.

• Comorbid Sleep-Related Hypoventilation (327.26 [G47.36]):

  • Occurs as a consequence of a medical condition, such as:

    • Pulmonary disorders (e.g., interstitial lung disease, chronic obstructive pulmonary disease).

    • Neuromuscular or chest wall disorders (e.g., muscular dystrophies, postpolio syndrome, cervical spinal cord injury, kyphoscoliosis).

    • Medications (e.g., benzodiazepines, opiates).

    • Obesity (Obesity Hypoventilation Disorder): Reflects a combination of increased work of breathing due to reduced chest wall compliance, ventilation-perfusion mismatch, and variably reduced ventilatory drive. Usually characterized by:

      • Body mass index (BMI) of greater than 30.

      • Hypercapnia during wakefulness (pCO2 greater than 45), without other evidence of hypoventilation.

Specify Current Severity:

• Severity is graded based on:

  • Degree of hypoxemia (low blood oxygen levels).

  • Degree of hypercarbia (elevated CO2 levels) during sleep.

  • Evidence of end-organ impairment due to these abnormalities (e.g., right-sided heart failure).

  • Presence of blood gas abnormalities during wakefulness is an indicator of greater severity.

Circadian Rhythm Sleep-Wake Disorders

Diagnostic Criteria

• A. A persistent or recurrent pattern of sleep disruption primarily due to an alteration of the circadian system or misalignment between the endogenous circadian rhythm and the individual's required sleep-wake schedule due to physical environment, social, or professional factors.

• B. Sleep Disruption Symptoms leads to excessive sleepiness, insomnia, or both.

• C. The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify the Type:

• Delayed Sleep Phase Type (307.45 [G47.21]):

  • Pattern of delayed sleep onset and awakening times, with an inability to fall asleep and awaken at a desired or conventionally acceptable earlier time.

  • Specify if:

    • Familial: A family history of delayed sleep phase is present.

    • Overlapping with non-24-hour sleep-wake type.

• Advanced Sleep Phase Type (307.45 [G47.22]):

  • Pattern of advanced sleep onset and awakening times, with an inability to remain awake or asleep until the desired or conventionally acceptable later sleep or wake times.

  • Specify if:

    • Familial: A family history of advanced sleep phase is present.

• Irregular Sleep-Wake Type (307.45 [G47.23]):

  • A temporally disorganized sleep-wake pattern, with variable timing of sleep and wake periods throughout the 24-hour period.

• Non-24-Hour Sleep-Wake Type (307.45 [G47.24]):

  • Pattern of sleep-wake cycles that are not synchronized to the 24-hour environment, with consistent daily drift (usually to later times) of sleep onset and wake times.

• Shift Work Type (307.45 [G47.26]):

  • Insomnia during the major sleep period and/or excessive sleepiness (including inadvertent sleep) during the major awake period, associated with a shift work schedule (i.e., requiring unconventional work hours).

• Unspecified Type (307.45 [G47.20])

Specify Duration:

• Episodic: Symptoms last at least 1 month but less than 3 months.

• Persistent: Symptoms last 3 months or longer.

• Recurrent: Two or more episodes occur within the space of 1 year.

Non-Rapid Eye Movement Sleep Arousal Disorders

Diagnostic Criteria

A. Recurrent Episodes of Incomplete Awakening from sleep, usually occurring during the first third of the major sleep episode, accompanied by either of the following:

1. Sleepwalking: Repeated episodes of rising from bed during sleep and walking about. While sleepwalking, the individual 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.

2. Sleep Terrors: Recurrent episodes of abrupt terror arousals from sleep, usually 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. There is relative unresponsiveness to efforts of others to comfort the individual during the episodes.

B. No or little (e.g., only a single visual scene) dream imagery is recalled.

C. Amnesia for the episodes is present.

Specify

• Sleepwalking Type

  • Specify if:

  • With sleep-related eating

  • With sleep-related sexual behavior (sexsomnia)

• Sleep Terror Type

Nightmare Disorder

Diagnostic Criteria

A. Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security, or physical integrity and that generally occur during the second half of the major sleep episode.

B. On awakening from the dysphoric dreams, the individual rapidly becomes oriented and alert.

Specify

• During Sleep Onset

• With Associated Non–Sleep Disorder:
  Including substance use disorders

• With Associated Other Medical Condition

• With Associated Other Sleep Disorder

Specify Duration

• Acute: Duration of the period of nightmares is 1 month or less.

• Subacute: Duration of the period of nightmares is greater than 1 month but less than 6 months.

• Persistent: Duration of the period of nightmares is 6 months or greater.

Specify Current Severity

Severity can be rated by the frequency with which the nightmares occur:

• Mild: Less than one episode per week on average.

• Moderate: One or more episodes per week but less than nightly.

• Severe: Episodes nightly.

Rapid Eye Movement Sleep Behavior Disorder

Diagnostic Criteria

A. Repeated episodes of arousal during sleep associated with vocalization and/or complex motor behaviors.

B. These behaviors arise during rapid eye movement (REM) sleep and therefore usually occur more than 90 minutes after sleep onset, are more frequent during the later portions of the sleep period, and uncommonly occur during daytime naps.

C. Upon awakening from these episodes, the individual is completely awake, alert, and not confused or disoriented.

D. Evidence of REM Sleep Behavior Disorder:
Either of the following:

1. REM sleep without atonia on polysomnographic recording.

2. A history suggestive of REM sleep behavior disorder and an established synucleinopathy diagnosis (e.g., Parkinson’s disease, multiple system atrophy).

E. The behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (which may include injury to self or the bed partner).

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

G. Coexisting Disorders:
Coexisting mental and medical disorders do not explain the episodes.

Restless Leg Syndrome

Diagnostic Criteria

A. An urge to move the legs, usually accompanied by or in response to uncomfortable and unpleasant sensations in the legs, is characterized by all of the following:

1. The urge to move the legs begins or worsens during periods of rest or inactivity.

2. The urge to move the legs is partially or totally relieved by movement.

3. The urge to move the legs is worse in the evening or at night than during the day, or occurs only in the evening or at night.

B. The symptoms in Criterion A occur at least three times per week and have persisted for at least 3 months.