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Healthinmind/Mental Health Disorders The symptoms of sleep disorders logically must fall into one of
three categories: too much sleep, too little sleep, and something
amiss in the sleep process. Similarly, the causes of sleep disorders
must fall into one of three categories: 1) primary sleep disorders,
in which only the sleep process is disturbed (see below), 2) sleep
disorders that are part of a mental disorder (see below), and 3)
sleep disorders that have a known physiological cause (a medical
condition or a substance- related problem, which we discuss together
on this site, see below). The broadest DSM-IV
categories are distinguished first according to their causes and,
within the causes, according to their symptoms. The
primary sleep disorders are defined by exclusion; that is, they are
not caused by other mental or physical disorders; the primary
problem is with sleep. The symptoms of primary sleep disorder are
divided into two classes. The first are called "Dyssomnias,"
which are problems with too little, too much, too low quality, or
badly timed sleep. The second are called "Parasomnias," a
class that includes abnormal events during sleep or while falling
asleep or awaking. To read about these subclasses, click on the
names below. 2) Sleep Disorders Related to Another Mental Disorder DSM-IV distinguishes only two disorders within this class, the Insomnia and Hypersomnia types. The behavioral manifestations required for making these diagnoses are nearly identical to those required for diagnoses of Primary Insomnia and Primary Hypersomnia, respectively. (see above) The difference is that, in the categories here, the sleep disorder is judged to be related to another mental disorder--the most likely candidates are Major Depressive Disorder, Generalized Anxiety Disorder, and Adjustment Disorder with Anxiety. The sleep disorder must be a source of sufficient distress or impairment to justify an independent diagnosis, in addition to the diagnosis of the other mental disorder. Further, it cannot be judged to be a consequence of another sleep disorder, the use of a substance, or a general medical condition. The treatments of these two sleep disorders must be combined with treatment of the other mental disorder; the successful treatment of either is likely to help with the symptoms of the other. 3) Other Sleep Disorders All the behavioral manifestations of the different types of sleep disorders--dyssomnias and parasomnias of all types--can be judged to be primary, related to another mental disorder, related to a general medical condition or substance-related. General medical conditions and substance-related conditions can be combined into a still more general "physiologically caused" category, yielding three in all: primary conditions, conditions with a "mental" basis, or conditions with a physical basis. Thus a fundamental task of a clinician presented with the symptoms of a sleep disorder is to determine as accurately as humanly possible the type of cause underlying the disorder. If the root cause is past or present exposure to a substance, the emphasis has to be on protecting the patient from the consequences of the use of or withdrawal from the substance. Then, if the sleep disorder persists, attention can be focused on the sleep problem. A similar situation exists if the sleep symptoms arise from a general medical condition or from another mental disorder; the pre-existing disorder may have to be the first focus of attention. Only in the case of the primary sleep disorders can exclusive attention be paid to the sleep disorder. Even in that case the clinician should remain alert to the possibility that something was overlooked, and the disorder was not primary after all. Some patients with psychopathology want to hide symptoms, and are surprisingly good at it. The diagnostic problem is extremely complex because of the very large number of substance-related or medical conditions that can underlie sleep disorders. Among the substances that can induce sleep disorders during the intoxication phase are alcohol, amphetamine and other stimulants, anxiolytics, caffeine, cocaine, hypnotics, nicotine, opiods, and sedatives. Most can also cause sleep disorders during the withdrawal phase. Any medical condition that causes severe pain is a candidate for causing a sleep problem; two with which one of the authors of this web site (WAH) is all too familiar are hip pain (cured by a hip replacement) and shoulder pain (cured by a shoulder operation). In neither case, however, did the sleep problem meet the criterion that it was "sufficiently severe to warrant independent clinical attention." The medication prescribed for pain also helped with the sleep problem, which, therefore, did not receive "independent" clinical attention. Insomnia Visit SleepNet for practical information on sleep problems. Last updated 12/19/03 |
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