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• DSM-V Work Group Reports (Apr. 2009)
• Sleep-Wake Disorders Work Group Report

Report of the DSM-V Sleep-Wake Disorders Work Group

April 2009
Charles F. Reynolds III, M.D.

The workgroup has continued twice monthly teleconference calls and met in person February 23-24, 2009.  Both the teleconference calls and the face-to-face meeting have included participation by advisors. 

We continue our review of each of the DSM-IV sleep-wake and circadian rhythm disorders, working with our advisors to update texts to reflect advances in epidemiology, pathophysiology, genetics, imaging, and treatment research, as appropriate. We expect our initial review of all disorders to be completed by mid summer, 2009.   We are following the evidence criteria stipulated by DSM-V in our deliberations for recommending the designation of new disorders.  

We are also focusing on the identification of appropriate dimensional measures of severity of symptom burden and associated distress and impairment.  We have recommended to the DSM-V Task force the inclusion of 1-2 items from the Pittsburgh Sleep Quality Index (PSQI; Buysse et al., 1989) to measure sleep quality as part of a more general superordinate dimensional assessment strategy.  We also continue to follow the work of NIH PROMIS investigators in developing and testing informative items for self-report measurement of sleep-wake disturbances.  A third dimensional measure with good performance characteristics is the ISI, or Insomnia Severity Index, developed by Charles Morin. 

The following summarizes recent work on various sleep-wake disorders by work group members and advisors:

1. Primary insomnia:  We are working to determine if quantitative diagnostic criteria are justified, e.g., occurrence of insomnia 3 or more times weekly, duration of one month or longer.  In addition, we are examining the performance characteristics of DSM-IV sleep wake diagnostic criteria, as ascertained in a nearly concluded trial sponsored by NIMH.
2. Breathing-related sleep disorder text and criteria are being updated.  It is likely we will include information in the text to help readers interpret the results of polysomnographic testing.
3. Circadian rhythm sleep disorder text and criteria are being updated.  The workgroup is considering recommending elevation of “advanced sleep phase syndrome” from its current NOS status.
4. Restless legs syndrome has received an exhaustive review.  The workgroup is considering recommending elevation of RLS from its current NOS status.
5. Parasomnia disorders text and diagnostic criteria are being updated.  The workgroup is considering recommending the elevation of REM sleep behavior disorder from its current NOS status.  The group is considering the inclusion of a new disorder for DSM-V, Confusional Arousal Disorder, consistent with the International Classification of Sleep Disorders-II.  This section of the DSM is being re-written to capture the concept of a spectrum of arousal disorders, encompassing confusional arousal, sleep walking, sleep terrors, nightmares, and REM sleep behavior disorder.
6. Insomnia comorbid with either another mental disorder or with a substance abuse disorder is being reviewed.
7. As noted in our second progress report of October 12, 2008, DSM-IV “primary hypersomnia” lumps together a rather heterogeneous group of disorders.  Work is being done to clarify the text to make this area less confusing for clinicians.  Updates of the text for narcolepsy-cataplexy are very likely to be needed to reflect scientific progress since DSM-IV. 

In terms of field trials, we are considering to nominate primary insomnia and insomnia comorbid with another mental disorder as candidates for further assessment of performance reliability and validity.  This decision will be taken after a review of the NIMH–funded diagnostic performance data and in light of other analyses currently being pursued, to attempt better quantification of diagnostic criteria for insomnia disorders. 

I note that in all of this work members and advisers are compiling the key primary source data papers that represent significant scientific advances in our understanding of the various sleep wake disorders since DSM-V.  We are also mindful that our work needs to be useful to non-sleep disorder clinicians and to primary care clinicians.