Slaapstoornissen Flashcards
Wat is de dsm criteria voor insomnia?
307.42 (F51.01) 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 caregiver 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 (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).
G. The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
H. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.
Specify if:
• With non–sleep disorder mental comorbidity, including substance use disorders
• With other medical comorbidity
• With other sleep disorder
• Coding note: The code 307.42 (F51.01) applies to all three specifiers. Code also the relevant associated mental disorder, medical condition, or other sleep disorder immediately after the code for insomnia disorder in order to indicate the association.
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.
Note: Acute and short-term insomnia (i.e., symptoms lasting less than 3 months but otherwise meeting all criteria with regard to frequency, intensity, distress, and/or impairment) should be coded as an other specified insomnia disorder.
Wat zijn diagnostische kenmerken van insomnia?
Moeite met in slaap komen of in slaap blijven. Combinatie van deze twee symptomen komt het meeste voor. De diagnosie is gebaseerd op de subjectieve perceptie van het individu en de caretakers report.
Nonrestorative sleep: lage kwaliteit van slaap waardoor iemand niet uitgerust wakker wordt. Als deze klacht bestaat in isolatie (zonder probleem met in slaap komen of blijven) maar wel met alles andere diagnostische criteria, wordt de diagnose NOS-insomnia of unspecified insomnia gemaakt.
De ernst beoordelen:
Na 20-30 minuten nog niet in slaap en 20-30 minuten nog wakker na het wakker worden en 30 minuten voor de geplande tijd wakker worden
diagnose moet gereserveerd zijn voor mensen die significante distress gedurende de dag hebben, niet iedereen die slecht slaap heeft erdoor problemen.
Wat is de prevalentie van insomnia?
1/3 van de volwassenen laat symptomen zien, 10-15% heeft daytime impairments en 6-10% heeft de stoornis. Meest prevalente slaapstoornis. Meer vrouwen. 40-50% hebben een comorbide stoornis.
Onset is meestal in vroege volwasenheid. Het kan situationeel, persistent of herhalend zijn. Geconditioneerde arousal kan ervoor zorgen dat het persistent wordt. De hoge prevalentie in oudere volwassenen komt meestal door de lichamelijk problemen die komen met ouder worden.
Wat zijn risicofactoren van insomnia?
- Levensgebeurtenissen
- Dagelijke stress
- Slechte slaapgewoontes
- Anxiety or worry prone
- Omgeving (licht etc)
- Genetisch: meer bij eerstegraads familie en eeneiige tweelingen
Wat zijn de differentiele diagnoses bij insomnia?
- Situational/acute insomnia: als alle criteria er is behalve dat het geen 3 maanden duurt wordt ook weer de insomnia NOS diagnose gegeven.
- Restless legs
- Breathing related sleep disorders
- Narcopelsie
- Parasomnias
- Substance medication induces sleep disorder: bvb insommia wat alleen voorkomt bij het gebruik van de substantie
Hoe is de relatie met comorbide stoornissen bij insomnia?
De relatie met comorbide stoornissen is vaak bi-directioneel. Het een veroorzaakt het ander en andersom.
Wat is de dsm criteria van hypersonmnolence 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 same day.
2. A prolonged main sleep episode of more than 9 hours per day that is nonrestorative
(i.e., unrefreshing).
3. Difficulty being fully awake 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, occupational, 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.g., narcolepsy, breathing-related sleep disorder, circadian rhythm sleep-wake disorder, or a parasomnia).
E. The hypersomnolence is not attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication).
Hypersomnolence Disorder 369
F. Coexisting mental and medical disorders do not adequately explain the predominant
complaint of hypersomnolence.
Specify if:
With mental disorder, including substance use disorders
With medical condition
With another sleep disorder
Coding note: The code 307.44 (F51.11) applies to all three specifiers. Code also the
relevant associated mental disorder, medical condition, or other sleep disorder immediately after the code for hypersomnolence disorder in order to indicate the association.
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 daytime alertness 5–7 days/week.
Wat is de criteria van narcolepsie?
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.
Narcolepsy 373
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) hypocretin-1
immunoreactivity values (less than or equal to one-third of values obtained in
healthy subjects tested using the same assay, or less than or equal to 110 pg/mL).
Low CSF levels of hypocretin-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:
347.00 (G47.419) Narcolepsy without cataplexy but with hypocretin deficiency: Criterion B requirements of low CSF hypocretin-1 levels and positive polysomnography/
multiple sleep latency test are met, but no cataplexy is present (Criterion B1 not met).
347.01 (G47.411) Narcolepsy with cataplexy but without hypocretin deficiency:
In this rare subtype (less than 5% of narcolepsy cases), Criterion B requirements of
cataplexy and positive polysomnography/multiple sleep latency test are met, but CSF
hypocretin-1 levels are normal (Criterion B2 not met).
347.00 (G47.419) Autosomal dominant cerebellar ataxia, deafness, and narcolepsy: This subtype is caused by exon 21 DNA (cytosine-5)-methyltransferase-1 mutations and is characterized by late-onset (age 30–40 years) narcolepsy (with low or
intermediate CSF hypocretin-1 levels), deafness, cerebellar ataxia, and eventually dementia.
347.00 (G47.419) Autosomal dominant narcolepsy, obesity, and type 2 diabetes:
Narcolepsy, obesity, and type 2 diabetes and low CSF hypocretin-1 levels have been
described in rare cases and are associated with a mutation in the myelin oligodendrocyte glycoprotein gene.
347.10 (G47.429) Narcolepsy secondary to another medical condition: This subtype is for narcolepsy that develops secondary to medical conditions that cause infectious (e.g., Whipple’s disease, sarcoidosis), traumatic, or tumoral destruction of
hypocretin neurons.
Coding note (for ICD-9-CM code 347.10 only): Code first the underlying medical condition (e.g., 040.2 Whipple’s disease; 347.10 narcolepsy secondary to Whipple’s disease).
Specify current severity:
Mild: Infrequent cataplexy (less than once per week), need for naps only once or twice
per day, and less disturbed nocturnal sleep.
Moderate: Cataplexy once daily or every few days, disturbed nocturnal sleep, and
need for multiple naps daily.
Severe: Drug-resistant cataplexy with multiple attacks daily, nearly constant sleepiness, and disturbed nocturnal sleep (i.e., movements, insomnia, and vivid dreaming).
Wat is de criteria van obstructive sleep apnea?
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 (including a
sleep disorder) and is not attributable to another medical condition.
2. Evidence by polysomnography of 15 or more obstructive apneas and/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.
Wat zijn diagnostische kenmerken van slaap apneu?
Obstructive sleep apnea hypopnea is the most common breathing-related sleep disorder.
It is characterized by repeated episodes of upper (pharyngeal) airway obstruction (apneas
and hypopneas) during sleep. Apnea refers to the total absence of airflow, and hypopnea refers to a reduction in airflow. Each apnea or hypopnea represents a reduction in breathing
of at least 10 seconds in duration in adults or two missed breaths in children and is typically associated with drops in oxygen saturation of 3% or greater and/or an electroencephalographic arousal. Both sleep-related (nocturnal) and wake-time symptoms are common.
The cardinal symptoms of obstructive sleep apnea hypopnea are snoring and daytime
sleepiness.
Obstructive sleep apnea hypopnea in adults is diagnosed on the basis of polysomnographic findings and symptoms. The diagnosis is based on symptoms of 1) nocturnal
breathing disturbances (i.e., snoring, snorting/gasping, breathing pauses during sleep), or
2) daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities to
sleep that are not better explained by another mental disorder and not attributable to another medical condition, along with 3) evidence by polysomnography of five or more obstructive apneas or hypopneas per hour of sleep (Criterion A1). Diagnosis can be made in
the absence of these symptoms if there is evidence by polysomnography of 15 or more obstructive apneas and/or hypopneas per hour of sleep (Criterion A2).
Specific attention to disturbed sleep occurring in association with snoring or breathing
pauses and physical findings that increase risk of obstructive sleep apnea hypopnea (e.g.,
central obesity, crowded pharyngeal airway, elevated blood pressure) is needed to reduce
the chance of misdiagnosing this treatable condition.
Wat zijn geassoiceerde kenmerken die de diagnose van slaap apneu ondersteunen?
Because of the frequency of nocturnal awakenings that occur with obstructive sleep apnea
hypopnea, individuals may report symptoms of insomnia. Other common, though nonspecific, symptoms of obstructive sleep apnea hypopnea are heartburn, nocturia, morning
headaches, dry mouth, erectile dysfunction, and reduced libido. Rarely, individuals may
complain of difficulty breathing while lying supine or sleeping. Hypertension may occur
in more than 60% of individuals with obstructive sleep apnea hypopnea.
Wat is de prevalentie van slaap apneu?
Obstructive sleep apnea hypopnea is a very common disorder, affecting at least 1%–2% of
children, 2%–15% of middle-age adults, and more than 20% of older individuals. In the
general community, prevalence rates of undiagnosed obstructive sleep apnea hypopnea
may be very high in elderly individuals. Since the disorder is strongly associated with obesity, increases in obesity rates are likely to be accompanied by an increased prevalence of
this disorder. Prevalence may be particularly high among males, older adults, and certain
racial/ethnic groups. In adults, the male-to-female ratio of obstructive sleep apnea hypopnea ranges from 2:1 to 4:1. Gender differences decline in older age, possibly because of an
increased prevalence in females after menopause. There is no gender difference among
prepubertal children.
Wat zijn risico en prognostische factoren van slaap apneu?
Genetic and physiological. The major risk factors for obstructive sleep apnea hypopnea
are obesity and male gender. Others include maxillary-mandibular retrognathia or micrognathia, positive family history of sleep apnea, genetic syndromes that reduce upper
airway patency (e.g., Down’s syndrome, Treacher Collin’s syndrome), adenotonsillar hypertrophy (especially in young children), menopause (in females), and various endocrine
syndromes (e.g., acromegaly). Compared with premenopausal females, males are at increased risk for obstructive sleep apnea hypopnea, possibly reflecting the influences of sex
hormones on ventilatory control and body fat distribution, as well as because of gender
differences in airway structure. Medications for mental disorders and medical conditions
that tend to induce somnolence may worsen the course of apnea symptoms if these medications are not managed carefully.
Obstructive Sleep Apnea Hypopnea 381
Obstructive sleep apnea hypopnea has a strong genetic basis, as evidenced by the significant familial aggregation of the apnea hypopnea index. The prevalence of obstructive
sleep apnea hypopnea is approximately twice as high among the first-degree relatives of
probands with obstructive sleep apnea hypopnea as compared with members of control
families. One-third of the variance in the apnea hypopnea index is explained by shared familial factors. Although genetic markers with diagnostic or prognostic value are not yet
available for use, eliciting a family history of obstructive sleep apnea hypopnea should increase the clinical suspicion for the disorder.
Wat zijn cultuur gerelateerde diagnostische issues bij slaap apneu?
There is a potential for sleepiness and fatigue to be reported differently across cultures. In
some groups, snoring may be considered a sign of health and thus may not trigger concerns. Individuals of Asian ancestry may be at increased risk for obstructive sleep apnea
hypopnea despite relatively low BMI, possibly reflecting the influence of craniofacial risk
factors that narrow the nasopharynx.
Wat zijn gender gerelateerde issues bij slaap apneu?
Females may more commonly report fatigue rather than sleepiness and may underreport
snoring
Wat zijn diagnostische markers van slaap apneu?
Polysomnography provides quantitative data on frequency of sleep-related respiratory
disturbances and associated changes in oxygen saturation and sleep continuity. Polysomnographic findings in children differ from those in adults in that children demonstrate
labored breathing, partial obstructive hypoventilation with cyclical desaturations, hypercapnia and paradoxical movements. Apnea hypopnea index levels as low as 2 are used to
define thresholds of abnormality in children.
Arterial blood gas measurements while the individual is awake are usually normal, but
some individuals can have waking hypoxemia or hypercapnia. This pattern should alert the
clinician to the possibility of coexisting lung disease or hypoventilation. Imaging procedures
may reveal narrowing of the upper airway. Cardiac testing may show evidence of impaired
ventricular function. Individuals with severe nocturnal oxygen desaturation may also have elevated hemoglobin or hematocrit values. Validated sleep measures (e.g., multiple sleep latency test [MSLT], maintenance of wakefulness test) may identify sleepiness.
Wat zijn functionele gevolgen van slaap apneu?
More than 50% of individuals with moderate to severe obstructive sleep apnea hypopnea
report symptoms of daytime sleepiness. A twofold increased risk of occupational accidents
has been reported in association with symptoms of snoring and sleepiness. Motor vehicle
crashes also have been reported to be as much as sevenfold higher among individuals with
elevated apnea hypopnea index values. Clinicians should be cognizant of state government requirements for reporting this disorder, especially in relationship to commercial
drivers. Reduced scores on measures of health-related quality of life are common in individuals with obstructive sleep apnea hypopnea, with the largest decrements observed in the
physical and vitality subscales.
Wat is de eerste differentiele diagnoses bij slaap apneu?
Primary snoring and other sleep disorders. Individuals with obstructive sleep apnea
hypopnea must be differentiated from individuals with primary snoring (i.e., otherwise asymptomatic individuals who snore and do not have abnormalities on overnight polysomnography). Individuals with obstructive sleep apnea hypopnea may additionally report
nocturnal gasping and choking. The presence of sleepiness or other daytime symptoms
not explained by other etiologies suggests the diagnosis of obstructive sleep apnea hypopnea, but this differentiation requires polysomnography. Definitive differential diagnosis
between hypersomnia, central sleep apnea, sleep-related hypoventilation, and obstructive
sleep apnea hypopnea also requires polysomnographic studies.
Obstructive sleep apnea hypopnea must be differentiated from other causes of sleepiness, such as narcolepsy, hypersomnia, and circadian rhythm sleep disorders. Obstructive
sleep apnea hypopnea can be differentiated from narcolepsy by the absence of cataplexy,
sleep-related hallucinations, and sleep paralysis and by the presence of loud snoring,
gasping during sleep, or observed apneas in sleep. Daytime sleep episodes in narcolepsy
are characteristically shorter, more refreshing, and more often associated with dreaming.
Obstructive sleep apnea hypopnea shows characteristic apneas and hypopneas and oxygen desaturation during nocturnal polysomnographic studies. Narcolepsy results in multiple sleep-onset rapid eye movement (REM) periods during the MSLT. Narcolepsy, like
obstructive sleep apnea hypopnea, may be associated with obesity, and some individuals
have concurrent narcolepsy and obstructive sleep apnea hypopnea. A diagnosis of narcolepsy does not exclude the diagnosis of obstructive sleep apnea hypopnea, as the two conditions may co-occur.
Wet melke differentiele diagnoes moet nog meer rekening worden gehouden?
Insomnia disorder. For individuals complaining of difficulty initiating or maintaining
sleep or early-morning awakenings, insomnia disorder can be differentiated from obstructive sleep apnea hypopnea by the absence of snoring and the absence of the history, signs,
and symptoms characteristic of the latter disorder. However, insomnia and obstructive
sleep apnea hypopnea may coexist, and if so, both disorders may need to be addressed
concurrently to improve sleep.
Panic attacks. Nocturnal panic attacks may include symptoms of gasping or choking
during sleep that may be difficult to distinguish clinically from obstructive sleep apnea hypopnea. However, the lower frequency of episodes, intense autonomic arousal, and lack of
excessive sleepiness differentiate nocturnal panic attacks from obstructive sleep apnea hypopnea. Polysomnography in individuals with nocturnal panic attacks does not reveal the
typical pattern of apneas or oxygen desaturation characteristic of obstructive sleep apnea
hypopnea. Individuals with obstructive sleep apnea hypopnea do not provide a history of
daytime panic attacks.
Attention-deficit/hyperactivity disorder. Attention-deficit/hyperactivity disorder in children may include symptoms of inattention, academic impairment, hyperactivity, and internalizing behaviors, all of which may also be symptoms of childhood obstructive sleep
apnea hypopnea. The presence of other symptoms and signs of childhood obstructive
sleep apnea hypopnea (e.g., labored breathing or snoring during sleep and adenotonsillar
hypertrophy) would suggest the presence of obstructive sleep apnea hypopnea. Obstructive sleep apnea hypopnea and attention-deficit/hyperactivity disorder may commonly
co-occur, and there may be causal links between them; therefore, risk factors such as enlarged tonsils, obesity, or a family history of sleep apnea may help alert the clinician to
their co-occurrence.
Substance/medication-induced insomnia or hypersomnia. Substance use and substance
withdrawal (including medications) can produce insomnia or hypersomnia. A careful history is usually sufficient to identify the relevant substance/medication, and follow-up
shows improvement of the sleep disturbance after discontinuation of the substance/medication. In other cases, the use of a substance/medication (e.g., alcohol, barbiturates, benzodiazepines, tobacco) has been shown to exacerbate obstructive sleep apnea hypopnea.
An individual with symptoms and signs consistent with obstructive sleep apnea hypopnea should receive that diagnosis, even in the presence of concurrent substance use that is
exacerbating the condition.
Wat is de comorbiditeit bij slaap apneu?
Systemic hypertension, coronary artery disease, heart failure, stroke, diabetes, and increased
mortality are consistently associated with obstructive sleep apnea hypopnea. Risk estimates vary from 30% to as much as 300% for moderate to severe obstructive sleep apnea
hypopnea. Evidence of pulmonary hypertension and right heart failure (e.g., cor pulmonale, ankle edema, hepatic congestion) are rare in obstructive sleep apnea hypopnea and
when present indicate either very severe disease or associated hypoventilation or cardiopulmonary comorbidities. Obstructive sleep apnea hypopnea also may occur with increased frequency in association with a number of medical or neurological conditions (e.g.,
cerebrovascular disease, Parkinson’s disease). Physical findings reflect the co-occurrence of
these conditions.
As many as one-third of individuals referred for evaluation of obstructive sleep apnea
hypopnea report symptoms of depression, with as many of 10% having depression scores
consistent with moderate to severe depression. Severity of obstructive sleep apnea hypopnea, as measured by the apnea hypopnea index, has been found to be correlated with severity of symptoms of depression. This association may be stronger in males than in
females.
Wat is de criteria voor central slaap apneu?
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:
327.21 (G47.31) Idiopathic central sleep apnea: Characterized by repeated episodes of apneas and hypopneas during sleep caused by variability in respiratory effort
but without evidence of airway obstruction.
786.04 (R06.3) Cheyne-Stokes breathing: A pattern of periodic crescendodecrescendo 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.
780.57 (G47.37) 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.
Coding note (for 780.57 [G47.37] code only): When an opioid use disorder is present, first
code the opioid use disorder: 305.50 (F11.10) mild opioid use disorder or 304.00 (F11.20)
moderate or severe opioid use disorder; then code 780.57 (G47.37) central sleep apnea
comorbid with opioid use. When an opioid use disorder is not present (e.g., after a onetime heavy use of the substance), code only 780.57 (G47.37) central sleep apnea comorbid with opioid use.
384 Sleep-Wake Disorders
Note: See the section “Diagnostic Features” in text.
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
Wat is de criteria voor sleep-related hypoventilation?
A. Polysomnograpy demonstrates episodes of decreased respiration associated with elevated CO2 levels. (Note: In the absence of objective measurement of CO2, persistent
low levels of hemoglobin oxygen saturation unassociated with apneic/hypopneic
events may indicate hypoventilation.)
B. The disturbance is not better explained by another current sleep disorder.
Specify whether:
327.24 (G47.34) Idiopathic hypoventilation: This subtype is not attributable to any
readily identified condition.
327.25 (G47.35) Congenital central alveolar hypoventilation: This subtype is a rare
congenital disorder in which the individual typically presents in the perinatal period with
shallow breathing, or cyanosis and apnea during sleep.
327.26 (G47.36) Comorbid sleep-related hypoventilation: This subtype occurs as a
consequence of a medical condition, such as a pulmonary disorder (e.g., interstitial
lung disease, chronic obstructive pulmonary disease) or a neuromuscular or chest wall
disorder (e.g., muscular dystrophies, postpolio syndrome, cervical spinal cord injury,
kyphoscoliosis), or medications (e.g., benzodiazepines, opiates). It also occurs with
obesity (obesity hypoventilation disorder), where it reflects a combination of increased
work of breathing due to reduced chest wall compliance and ventilation-perfusion mismatch and variably reduced ventilatory drive. Such individuals usually are characterized by body mass index of greater than 30 and hypercapnia during wakefulness (with
a pCO2 of greater than 45), without other evidence of hypoventilation.
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 (e.g., rightsided heart failure). The presence of blood gas abnormalities during wakefulness is an
indicator of greater severity.
Wat is de criteria voor rhytm sleep-waker disorder?
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 disruption 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.
Coding note: For ICD-9-CM, code 307.45 for all subtypes. For ICD-10-CM, code is based
on subtype.
Specify whether:
307.45 (G47.21) 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.
307.45 (G47.22) 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.
307.45 (G47.23) Irregular sleep-wake type: A temporally disorganized sleep-wake
pattern, such that the timing of sleep and wake periods is variable throughout the 24-
hour period.
Circadian Rhythm Sleep-Wake Disorders 391
307.45 (G47.24) 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 onset and wake times.
307.45 (G47.26) Shift work type: 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).
307.45 (G47.20) 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
Wat is de criteria voor non-rapid eye movement disorder?
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 (e.g., 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 (e.g., a
drug of abuse, a medication).
F. Coexisting mental and medical disorders do not explain the episodes of sleepwalking
or sleep terrors.
Coding note: For ICD-9-CM, code 307.46 for all subtypes. For ICD-10-CM, code is based
on subtype.
Specify whether:
307.46 (F51.3) Sleepwalking type
Specify if:
With sleep-related eating
With sleep-related sexual behavior (sexsomnia)
307.46 (F51.4) Sleep terror type
Wat is de criteria voor 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.g., a drug of abuse, a medication).
E. Coexisting mental and medical disorders do not adequately explain the predominant
complaint of dysphoric dreams.
Specify if:
During sleep onset
Specify if:
With associated non–sleep disorder, including substance use disorders
With associated other medical condition
With associated other sleep disorder
Coding note: The code 307.47 (F51.5) applies to all three specifiers. Code also the
relevant associated mental disorder, medical condition, or other sleep disorder immediately after the code for nightmare disorder in order to indicate the association.
Specify if:
Acute: Duration of period of nightmares 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.
Wat is de criteria voor rapid aye 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.
408 Sleep-Wake Disorders
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 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 mental and medical disorders do not explain the episodes.
