Somatic Symptom Disorders and Sleep-Wake Disorders

Somatic Symptom Disorder

A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.
B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
1. Disproportionate and persistent thoughts about seriousness of one's symptoms.
2. Persistently high levels of anxiety about health or symptoms.
3. Excessive time and energy devoted to these symptoms or health concerns.
C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).
- Specify if:
With predominant pain: This specifier is for individuals whose somatic symptoms predominately involve pain.
Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months)
- Specify current severity:
Mild: Only one of the symptoms specified in Criterion B is fulfilled.
Moderate: Two or more of the symptoms specified in Criterion B are fulfilled.
Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom).

Illness Anxiety Disorder

A. Preoccupation with having or acquiring a serious illness.
B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition, the preoccupation is clearly excessive or disproportionate.
C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.
D. The individual performs excessive health-related behaviors or exhibits maladaptive avoidance.
E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time.
F. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.
- Specify whether:
Care seeking type: Medical care, including physician visits or undergoing tests and procedures, is frequently used.
Care-avoidant type: Medical care is rarely used.

Functional Neurological Symptom Disorder (Conversion Disorder)

A. One or more symptoms of altered voluntary motor or sensory function.
B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or mental disorder.
D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.
- Specify symptom type:
With weakness or paralysis
With abnormal movement
With swallowing symptoms
With speech symptom
With attacks or seizures
With anesthesia or sensory loss
With special sensory symptom
With mixed symptom
- Specify if:
Acute episode: Symptoms present for less than 6 months.
Persistent: Symptoms occurring for 6 months or more.
- Specify if:
With psychological stressor
Without psychological stressor

Psychological Factors Affecting Other Medical Conditions

A. A medical symptom or condition (other than a mental disorder) is present.
B. Psychological or behavioral factors adversely affect the medical condition in one of the following ways:
1. The factors have influenced the course of the medical condition as shown by close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the medical condition.
2. The factors interfere with the treatment of the medical condition.
3. The factors constitute additional well-established health risks for the individual.
4. The factors influence the underlying pathophysiology, precipitating or exacerbating symptoms or necessitating medical attention.
C. The psychological and behavioral factors in Criterion B are not better explained by another mental disorder.
- Specify current severity:
Mild: Increases medical risk.
Moderate: Aggravates underlying medical condition.
Severe: Results in medical hospitalization or emergency room visit.
Extreme: Results in severe, life-threatening risk.

Factitious Disorder Imposed on Self

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
B. The individual presents himself or herself to others as ill, impaired, or injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.
- Specify:
Single episode
Recurrent episode (two or more events of falsification of illness and/or induction of injury)

Factitious Disorder Imposed on Another

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception.
B. The individual presents another individual (victim) to others as ill, impaired, or injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.
- The perpetrator, not the victim, receives the diagnosis.
- Specify:
Single episode
Recurrent episodes (two or more events of falsification of illness and/or induction of injury)

Other Specified Somatic Symptom and Related Disorder

Used when symptoms characteristic of a somatic symptom and related disorder are present but do not meet the full criteria for any of the disorders in the somatic symptom and related disorders diagnostic class.

Unspecified Somatic Symptom and Related Disorder

Used when symptoms characteristic of a somatic symptom and related disorder are present but do not meet the full criteria for any of the disorders in the somatic symptom and related disorders diagnostic class. Should not be used unless there are decidedly unusual situations where there is insufficient information to make a more specific diagnosis.

Insomnia Disorder

A. A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
1. Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)
2. Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiving intervention.)
3. Early-morning awakening with inability to return to sleep.
B. The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral or other important areas of functioning.
C. The sleep difficulty occurs at least 3 nights per week.
D. The sleep difficulty is present for at least 3 months.
E. The sleep difficulty occurs despite adequate opportunity for sleep.
F. The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder.
G. The insomnia is not attributable to the psychological effects of a substance.
H. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.
- Specify if:
With mental disorder, including substance use disorders
With medical condition
With another sleep disorder
- Specify if:
Episodic: Symptoms last at least 1 month but less than 3 months.
Persistent: Symptoms last 3 months or longer.
Recurrent: Two (or more) episodes within the space of 1 year.

Hypersomnolence Disorder

A. Self-reported excessive sleepiness (hypersomnolence) despite a main sleep period lasting at least 7 hours, with at least one of the following symptoms:
1. Recurrent periods of sleep or lapses into sleep within the sleep day.
2. A prolonged main sleep episode of more than 9 hours per day that is nonrestorative (i.e. unrefreshing).
3. Difficulty being fully aware after abrupt awakening.
B. The hypersomnolence occurs at least three times per week, for at least 3 months.
C. The hypersomnolence is accompanied by significant distress or impairment in cognitive, social, or other important areas of functioning.
D. The hypersomnolence is not better explained by and does not occur exclusively during the course of another sleep disorder.
E. The hypersomnolence is not attributable to the physiological effects of a substance.
F. Coexisting mental and medical disorders do not adequately explain the predominate complaint of hypersomnolence.
- Specify if:
With mental disorder, including substance use disorders
With medical condition
With another sleep disorder
- Specify if:
Acute: Duration of less than 1 month.
Subacute: Duration of 1-3 months.
Persistent: Duration of more than 3 months.
- Specify current severity:
Specify severity based on degree of difficulty maintaining daytime alertness as manifested by the occurrence of multiple attacks of irresistible sleepiness within any given day occurring, for example, while sedentary, driving, visiting with friends, or working.
Mild: Difficulty maintaining daytime alertness 1-2 days/week.
Moderate: Difficulty maintaining daytime alertness 3-4 days/week.
Severe: Difficulty maintaining alertness 5-7 days/week.

Narcolepsy

A. Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day. These must have been occurring at least three times per week over the past 3 months.
B. The presence of at least one of the following:
1. Episodes of cataplexy, defined as either (a) or (b), occurring at least a few times per month:
a. In individuals with long-standing disease, brief (seconds to minutes) episodes of sudden bilateral loss of muscle tone with maintained consciousness that are precipitated by laughter or joking.
b. In children or in individuals within 6 months of onset, spontaneous grimaces or jaw-opening episodes with tongue thrusting or a global hypotonia, without any obvious emotional triggers.
2. Hypocretin deficiency, as measured using cerebrospinal fluid (CSF) hypocretein-1 immunoreactivity values. Low CSF levels of hypocretein-1 must not be observed in the context of acute brain injury, inflammation, or infection.
3. Nocturnal sleep polysomnography showing rapid eye movement (REM) sleep latency less than or equal to 15 minutes, or a multiple sleep latency test showing a mean sleep latency less than or equal to 8 minutes and two or more sleep-onset REM periods.
- Specify whether:
Narcolepsy with cataplexy or hypocretin deficiency (type 1)
Narcolepsy without cataplexy and either without hypocretin deficiency or hypocretin unmeasured (type 2)
Narcolepsy with cataplexy or hypocretin deficiency due to a medical condition
Narcolepsy without cataplexy and without hypocretin deficincy due to a medical condition
- Specify current severity:
Mild: Need for naps only once or twice per day. Sleep disturbances, if present, is mild. Cataplexy, when present, is infrequent (occuring less than once per week).
Moderate: Need for multiple naps per day. Sleep may be moderately disturbed. Cataplexy, when present, occurs daily or every few days.
Severe: Nearly constant sleepiness and, often, highly disturbed nocturnal sleep (which may include excessive body movement and vivid dreams). Cataplexy, when present, is drug-resistant, with multiple attacks daily.

Obstructive Sleep Apnea Hypopnea

A. Either (1) or (2):
1) Evidence by polysomnography of at least five obstructive apneas or hypopneas per hour of sleep and either of the following sleep symptoms:
a. Nocturnal breathing disturbances: snoring, snorting/gasping, or breathing pauses during sleep.
b. Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities to sleep that is not better explained by another mental disorder and is not attributable to another medical condition.
2. Evidence by polysomnography of 15 or more obstructive apneas or hypopneas per hour of sleep regardless of accompanying symptoms.
- Specify current severity:
Mild - Apnea hypopnea index is less than 15.
Moderate - Apnea hypopnea index is 15-30.
Severe- Apnea hypopnea index is greater than 30.

Central Sleep Apnea

A. Evidence by polysomnography of five or more central apneas per hour of sleep.
B. The disorder is not better explained by another current sleep disorder.
- Specify whether:
Idiopathic central sleep apnea: Characterized by repeated episodes of apneas and hypopneas during sleep caused by variability in respiratory effort but without evidence or airway obstruction.
Cheyne-Stokes breathing: A pattern of periodic cresendo-decresendo variation in tidal volume that results 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: The pathogenesis of this subtype is attributed to the effects of opioids on the respiratory rhythm generators in the medulla as well as the differential effects on hypoxic versus hypercapnic respiratory drive.
- Specify current severity:
Severity of central sleep apnea is graded according to the frequency of the breathing disturbances as well as the extent of associated oxygen desaturation and sleep fragmentation that occur as a consequence of repetitive respiratory disturbances.

Sleep-Related Hypoventilation

A. Polysomnography demonstrates episodes of decreased respiration associated with elevated CO2 levels.
B. The disturbance is not better explained by another sleep disorder.
- Specify whether:
Idiopathic hypoventilation: This subtype is not attributable to any readily identified condition.
Congenital central alveolar hypoventilation: This subtype is a rare congenital disorder in which the individual typically presents in the perinatal periods with shallow breathing, or cyanosis and apnea during sleep.
Comorbid sleep-related hypoventilation: This subtype occurs as a consequence of a medical condition.
- Specify current severity:
Severity is graded according to the degree of hypoxemia and hypercarbia present during sleep and evidence of end organ impairment due to these abnormalities. The presence of blood gas abnormalities during wakefulness is an indicator of greater severity.

Circadian Rhythm Sleep-Wake Disorders

A. A persistent or recurrent pattern of sleep disruption 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 an individual's physical environment or social or professional schedule.
B. The sleep disturbance leads to excessive sleepiness or insomnia, or both.
C. The sleep disturbance causes clinically significant distress or impairment in social, occupational, and other important areas of functioning.
- Specify whether:
Delayed sleep phase type: A 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.
Specify if:
Overlapping with non-24 hour sleep-wake type: Delayed sleep phase type may overlap with another circadian rhythm sleep-wake disorder, non-24-hour sleep-wake type.
Advanced sleep phase type: A 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: A temporally disorganized sleep-wake pattern, such that the timing of sleep and wake periods is variable throughout, such that the timing of sleep and wake periods is variable throughout the 24-hour period.
Non-24-hour sleep-wake type: A pattern of sleep-wake cycles that is not synchronized to the 24-hour environment, with a consistent daily drift (usually to later and later times) of sleep on-set and wake times.
Shift work type: Insomnia during the major sleep period and/or excessive sleepiness during the major awake period associated with a shift work schedule.
Unspecified type
- Specify if:
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

A. Recurrent episodes of incomplete awakening from sleep, usually occurring during the first third of the major sleep episode, accompanied by either one 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 (only a single visual scene) dream imagery is recalled.
C. Amnesia for the episodes is present.
D. The episodes cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance.
F. Coexisting mental and medical disorders do not explain the episodes of sleepwalking or sleep terrors.
- Specify whether:
Sleepwalking type
- Specify if:
With sleep-related eating
With sleep-related sexual behavior (sexsomnia)
Sleep terror type

Nightmare Disorder

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.
C. The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The nightmare symptoms are not attributable to the physiological effects of a substance.
E. Coexisting mental disorders and medical conditions do not adequately explain the predominant and complaint of dysphoric dreams.
- Specify if:
During sleep onset
With mental disorder, including substance use disorders
With medical condition
With another sleep dsiorder
- Specify if:
Acute: Duration of period of nightmare is 1 month or less.
Subacute: Duration of period of nightmares is greater than 1 month but less than 6 months.
Persistent: Duration of 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

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. Either of the following:
1. REM sleep without atonia or polysomnographic recording.
2. A history suggestive of REM sleep behavior disorder and an established synucleinopathy diagnosis.
E. The behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
F. The disturbance is not attributable to the psychological effects of a substance or another medical condition.
G. Coexisting mental disorders and medical conditions do not explain the episodes.

Restless Legs Syndrome

A. An urge to move the legs, usually accompanied by or in response to uncomfortable and unpleasant sensations in the legs, 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.
C. The symptoms in Criterion A are accompanied by significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
D. The symptoms in Criterion A are not attributable to another mental disorder or medical condition and are not better explained by a behavioral condition.
E. The symptoms are not attributable to the psychological effects of a drug of abuse or medication.

Substance/Medication-Induced Sleep Disorder

A. A prominent and severe disturbance in sleep.
B. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2):
1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to or withdrawal from a medication.
2. The involved substance/medication is capable of producing the symptoms in Criterion A.
C. The disturbance is not better explained by a sleep disorder that is not substance/medication-induced.
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- Specify whether:
Insomnia type: Characterized by difficulty falling asleep or maintaining sleep, frequent nocturnal awakenings, or nonrestorative sleep.
Daytime sleepiness type: Characterized by predominant complaint of excessive sleepiness/fatigue during waking hours or, less commonly, a long sleep period.
Parasomnia type: Characterized by abnormal behavioral events during sleep
Mixed type: Characterized by a substance/medication-induced sleep problem characterized by multiple types of sleep symptoms, but no symptom clearly predominates.
- Specify:
With onset during intoxication
With onset during withdrawal
With onset after medication use

Other Specified Insomnia Disorder

Characteristics of insomnia are sleeplessness that cause clinically significant distress that does not meet the full criteria for any sleep disorder already described. Used in situations in which the clinician chooses to specify the reason that the individual does not qualify for other another diagnosis.

Unspecified Insomnia Disorder

Characteristics of insomnia are sleeplessness that cause clinically significant distress that does not meet the full criteria for any sleep disorder already described. Used in situations in which the clinician chooses not to specify the reason that the individual does not qualify for other another diagnosis.

Other Specified Hypersomnolence Disorder

This category applies to presentations in which symptoms characteristic of hypersomnolence disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for hypersomnolence disorder or any of the disorders in the sleep-wake disorders diagnostic class. Used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for hypersomnolence disorder or any specific sleep-wake disorder.

Unspecified Hypersomnolence Disorder

This category applies to presentations in which symptoms characteristic of hypersomnolence disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for hypersomnolence disorder or any of the disorders in the sleep-wake disorders diagnostic class. Used in situations in which the clinician chooses not to communicate the specific reason that the presentation does not meet the criteria for hypersomnolence disorder or any specific sleep-wake disorder.

Other Specified Sleep-Wake Disorder

This category applies to presentations in which symptoms characteristic of a sleep-wake disorder that cause clinically significant distress or impairment predominate but do not meet the full criteria for any of the disorders in the sleep-wake disorders diagnostic class and do not qualify for a diagnosis of other specified insomnia disorder or other specified hypersomnolence disorder. Used when the clinician chooses to specify the reason that the presentation does not meet the criteria.

Unspecified Sleep-Wake Disorder

This category applies to presentations in which symptoms characteristic of a sleep-wake disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the sleep-wake disorders diagnostic class and do not qualify for a diagnosis of unspecified insomnia disorder or unspecified hypersomnolence disorder. The unspecified
sleep-wake disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific sleep-wake disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis.