DSM 5 Clinical Cases - Sleep-Wake Disorders

Sleep-Wake Disorders
DSM-5® Clinical Cases
Introduction
John W. Barnhill, M.D.
The pursuit of restful sleep is bedeviled by work and family pressures, long-distance
travel, and the ubiquitous presence of stimulants (e.g., coffee) and electronics (e.g., e-
mail). A good night’s sleep can be a casualty of a host of psychiatric disorders, includ-
ing anxiety, depression, and bipolar and psychotic disorders, as well as a variety of
nonpsychiatric medical conditions. Sleep problems may not simply be epiphenom-
ena but can precipitate, prolong, and intensify these other psychiatric and medical
conditions. All too often, however, the DSM-5 sleep-wake disorders exist as silent and
undiagnosed contributors to distress and dysfunction.
DSM-5 makes use of both a “lumping” and a “splitting” approach to the sleep dis-
orders. Insomnia disorder can exist autonomously, but DSM-5 encourages consider-
ation of comorbidity with both psychiatric and nonpsychiatric medical conditions. In
so doing, DSM-5 moves away from making a causal attribution (e.g., depression inev-
itably causes insomnia) and instead acknowledges the bidirectional interactions be-
tween sleep and other disorders. Clarification of an independent sleep disorder is also
a reminder to the clinician that the sleep problem may not resolve spontaneously but
instead may warrant independent psychiatric attention.
In addition to a broad clinical approach, DSM-5 features sleep disorders that re-
quire very specific physiological findings. For example, a patient may present with rest-
Copyright © 2015. American Psychiatric Publishing. All rights reserved.
less sleep and daytime fatigue. If the patient’s bed partner identifies unusually loud
snoring, sleep apnea would likely be considered. A DSM-5 diagnosis of obstructive
sleep apnea hypopnea requires not only clinical evidence but also a polysomnogram
that reveals at least five obstructive apneas or hypopneas per hour of sleep (or, if there
is no evidence of nocturnal breathing difficulties, 15 or more such apneic events per
hour).
Other sleep disorders can be diagnosed through either clinical evidence or a com-
bination of patient report, laboratory results, and sleep studies. For example, narco-
lepsy is defined by two required criteria. First, clinical report must indicate recurrent,
persistent episodes marked by irrepressible sleep or an irrepressible need for sleep.
The second criterion can be met in three ways: by recurrent episodes of cataplexy
(defined clinically); hypocretin deficiency (defined via cerebrospinal fluid levels
obtained through lumbar puncture); or specifically abnormal rapid eye movement
111
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112 Sleep-Wake Disorders: DSM-5® Selections
(REM) sleep latency as determined by nocturnal sleep polysomnography or a multi-

ple sleep latency test.
REM sleep behavior disorder and restless legs syndrome are new disorders within
the main text of DSM-5. For each, substantial evidence has clarified the physiological
basis, prevalence, and clinical relevance. Both are often comorbid with other psychiatric
and nonpsychiatric medical conditions (e.g., REM sleep behavior disorder comorbid
with narcolepsy and neurodegenerative disorders such as Parkinson’s disease; rest-
less legs syndrome comorbid with depression and cardiovascular disease).
The initial sleep assessment generally involves a retrospective patient report. Clini-
cians are accustomed to working with subjective reports, but a sleep complaint that is
impossible (“I haven’t slept in weeks”) can lead the clinician to think “insomnia” and
move on with other aspects of the evaluation. Increasingly robust diagnostic criteria
for the sleep-wake disorders are helpful for a variety of reasons, but they are especially
helpful as a reminder to the general clinician to explore common complaints that are
often underdiagnosed and that contribute to significant distress and dysfunction.
Suggested Readings
Edinger JD, Wyatt JK, Stepanski EJ, et al: Testing the reliability and validity of DSM-IV-TR and
ICSD-2 insomnia diagnoses: results of a multitrait-multimethod analysis. Arch Gen Psy-
chiatry 68(10):992–1002, 2011
Ohayon MM, Reynolds CF 3rd: Epidemiological and clinical relevance of insomnia diagnosis
algorithms according to the DSM-IV and the International Classification of Sleep Disor-
ders (ICSD). Sleep Med 10(9):952–960, 2009
Reite M, Weissberg M, Ruddy J: Clinical Manual for Evaluation and Treatment of Sleep Disor-
ders. Washington, DC, American Psychiatric Publishing, 2009
Case 1: Difficulty Staying Asleep

Charles F. Reynolds III, M.D.
Aidan Jones, a 30-year-old graduate student in English, visited a psychiatrist to

discuss his difficulty staying asleep. The trouble began 4 months earlier, when he
started to wake up at 3:00 every morning, no matter when he went to bed, and then was
unable to fall back to sleep. As a result, he felt “out of it” during the day. This led him
to feel increasingly worried about how he was going to finish his doctoral dissertation
when he was unable to concentrate owing to exhaustion. At first he did not recall waking
up with anything in particular on his mind. As the trouble persisted, he found himself
dreading the upcoming day and wondering how he would teach his classes or focus
on his writing if he was getting only a few hours of sleep. Some mornings he lay awake
in the dark next to his fiancée, who was sleeping soundly. On other mornings he would
cut his losses, rise from bed, and go very early to his office on campus.
After a month of interrupted sleep, Mr. Jones visited a physician’s assistant at the
university’s student health services, where he customarily got his medical care. (He
suffered from asthma, for which he occasionally took inhaled 2-adrenergic receptor
agonists, and a year earlier he had had mononucleosis.) The physician’s assistant pre-
Sleep-Wake Disorders: DSM-5® Clinical Cases 113
scribed a sedative-hypnotic, which did not help. “Falling asleep was never the prob-
lem,” Mr. Jones explained. Meanwhile, he heeded some of the advice he read online. Al-
though he felt reliant on coffee during the day, he never drank it after 2:00 P.M. An avid
tennis player, he restricted his court time to the early morning. He did have a glass or
two of wine every night at dinner with his fiancée, however. “By dinnertime I start to
worry about whether I’ll be able to sleep,” he said, “and, to be honest, the wine helps.”
The patient, a slender and fit-appearing young man looking very much the part of
the young academic in a tweed jacket and tortoise-rimmed glasses, was pleasant and
open in his storytelling. Mr. Jones did not appear tired but told the evaluating psychi-
atrist, “I made a point to see you in the morning, before I hit the wall.” He did not look
sad or on edge and was not sure if he had ever felt depressed. But he was certain of the
nagging, low-level anxiety that was currently oppressing him. “This sleep problem has
taken over,” he explained. “I’m stressed about my work, and my fiancée and I have
been arguing. But it’s all because I’m so tired.”
Although this was his first visit to a psychiatrist, Mr. Jones spoke of a fulfilling 3-year
psychodynamic psychotherapy with a social worker while in college. “I was just look-
ing to understand myself better,” he explained, adding with a chuckle that as the son of
a child psychiatrist, he was accustomed to people assuming he was “crazy.” He recalled
always being an “easy sleeper” prior to his recent difficulties; as a child he was the first
to fall asleep at slumber parties, and as an adult he inspired the envy of his fiancée for
the ease with which he could doze off on an airplane.
Diagnosis
• Insomnia disorder
Discussion
Mr. Jones reports 4 months of feeling dissatisfied with his sleep most nights, with dif-
ficulty maintaining sleep and early morning awakening. He describes daytime
fatigue, difficulty concentrating, mild symptoms of anxiety, and interpersonal and
vocational impairment. He does not appear to qualify for diagnoses of other medical,
psychiatric, sleep, or substance use disorders. He meets the clinical criteria for DSM-5
insomnia disorder.
The case history suggests that the patient’s sleep disturbance began during a pe-
riod of heightened stress related to time pressures and that he has developed some
behaviors that may worsen or perpetuate his sleep disturbance. He worries about not
sleeping and creates a self-fulfilling prophecy. He may also be self-medicating with
caffeine to maintain alertness during the day and with wine to dampen arousal dur-
ing the evening.
Also noted is a medical history of asthma, for which Mr. Jones takes occasional
2-adrenergic receptor agonists. Because these medications may be stimulating, it
would be helpful to know when and how much of them he actually uses.
The patient reports a history of participating for 3 years in psychodynamic psycho-
therapy while in college. It would be helpful to know more about his mood and anx-
iety symptoms to determine whether his insomnia might be related to an earlier, and
perhaps recurrent, mood or anxiety disorder. Conversely, insomnia itself increases

the risk for either new-onset or recurrent episodes of mood, anxiety, or substance use
disorders. It might also be helpful to explore Mr. Jones’s family history of mood, anx-
iety, substance use, or sleep disorders.
A 2-week sleep-wake diary would be helpful in evaluating Mr. Jones’s sleep issues,
including the amount of time spent in bed, his lifestyle (timing of physical and mental
activities that could increase arousal and interfere with sleep), the timing and use of
substances that can act on the central nervous system, and other medical issues (e.g.,
asthma attacks). A history from Mr. Jones’s fiancée could be informative with respect to
his sleep-related pathologies, such as apnea, loud snoring, leg jerks, or partial arousals
from sleep (non-REM or REM parasomnias).
In addition to having Mr. Jones keep a sleep-wake diary, it would be useful to have
him document the severity of his current sleep complaint by use of a self-report in-
ventory such as the Insomnia Severity Index (ISI) or the Pittsburgh Sleep Quality In-
dex (PSQI). These instruments provide useful baselines or benchmarks against which
to measure change over time. In addition, the use of brief self-report measures of af-
fective state, such as the Patient Health Questionnaire 9-item depression scale (PHQ-9)
or the Generalized Anxiety Disorder 7-item scale (GAD-7), would allow the clinician
to further assess for coexisting or supervening mental disorders.
Formal sleep laboratory testing (polysomnography) does not appear to be indi-
cated for Mr. Jones. However, if further information emerged from history or diary, it
could be appropriate to obtain testing for a breathing-related sleep disorder or for pe-
riodic limb movement disorder. Another diagnostic possibility is a circadian rhythm
sleep disorder, such as an advanced sleep phase syndrome (unlikely, however, given
the relatively young age of the patient).
As illustrated by this case, DSM-5 has moved away from categorizing “primary”
or “secondary” forms of insomnia disorder. Instead, DSM-5 mandates concurrent
specification of coexisting conditions (medical, psychiatric, and other sleep disor-
ders), for two reasons: 1) to underscore that the patient has a sleep disorder warrant-
ing independent clinical attention, in addition to the medical or psychiatric disorder
also present, and 2) to acknowledge bidirectional and interactive effects between sleep
disorders and coexisting medical and psychiatric disorders.
This reconceptualization reflects a paradigm shift in the field of sleep disorders

medicine. The shift is away from making causal attributions between coexisting dis-
orders (“a” is due to “b”), because there are often limited empirical data to support
such attribution and because optimal treatment planning requires attention to both
“a” and “b” (because the co-occurrence of each may make the other worse).
Thus, the differential diagnosis of sleep-wake complaints necessitates a multidi-
mensional approach, with consideration of coexisting conditions. Such conditions are
the rule, not the exception. Finally, the DSM-5 classification of insomnia disorder and
other sleep-wake disorders includes dimensional as well as categorical assessment,
for several reasons: 1) to capture severity, 2) to facilitate measurement-based clinical
care, 3) to capture behaviors that may contribute to the pathogenesis and perpetua-
tion of sleep-wake complaints, and 4) to allow correlation with and exploration of un-
derlying neurobiological substrates.
Suggested Readings
Chapman DP, Presley-Cantrell LR, Liu Y, et al: Frequent insufficient sleep and anxiety and de-
pressive disorders among U.S. community dwellers in 20 states, 2010. Psychiatr Serv
64(4):385–387, 2013
Reynolds CF 3rd: Troubled sleep, troubled minds, and DSM-5. Arch Gen Psychiatry 68(10):990–
991, 2011
Reynolds CF 3rd, O’Hara R: DSM-5 sleep-wake disorders classification: overview for use in
clinical practice. Am J Psychiatry 170(10):1099–1101, 2013
Case 2: Anxious and Sleepy

Maurice M. Ohayon, M.D., D.Sc., Ph.D.
Bernadette Kleber was a 34-year-old divorced, unemployed white mother of

three school-age children. She was living with a new companion. Ms. Kleber presented
to a psychiatrist for anxiety and sleepiness.
Ms. Kleber had experienced anxiety much of her life, but she had become much
more worried and stressed since the birth of her first child 10 years before. She said
she was “okay at home” but anxious in social situations. She avoided having to inter-
act with new people, fearing that she would be embarrassed and judged. For exam-
ple, she wanted to lose the weight that she had gained since the births of her children
(current body mass index [BMI] 27.7) but was afraid of the ridicule that might accom-
pany her efforts at the gym. She had gradually withdrawn from situations in which
she might be forced to meet new people, and this made it almost impossible for her
to interview for a new job, much less work in one. She had been successfully treated
for social phobia 5 years earlier with psychotherapy, a selective serotonin reuptake in-
hibitor (SSRI) antidepressant, and clonazepam 0.25 mg twice daily, but her symptoms
had returned over the prior year. She denied increasing the dose of either medication
or taking any other medication (prescribed or over the counter) for anxiety. Although
excited about her new relationship, she was worried her new girlfriend would leave her
if she did not “tune up my act.”
She denied periods of significant depression, although she said she had experi-
enced multiple periods of feeling frustrated with her limited effectiveness. She also
denied all manic symptoms.
The psychiatrist then asked Ms. Kleber about her “sleepiness.” She said she slept
more than anyone she knew. She said she typically slept at least 9 hours per night but
then took two naps for 5 additional hours during the day. She did not recall a problem
until the end of high school, when she started falling asleep around 8:00 or 9:00 P.M.
and dozing every afternoon. When she tried to go to college, she realized how much
more sleep she needed than her friends and eventually dropped out because she
could not stay awake in class. Despite the naps, she typically fell asleep when visiting
friends or family and when reading or watching TV. She quit driving alone for fear of
falling asleep at the wheel. Late afternoon naps were not restorative and had no ap-
parent impact on her falling asleep at night.
Raising a family was difficult, especially because mornings were Ms. Kleber’s worst
period. For at least half an hour after waking, she was disoriented and confused, mak-
ing it difficult to get her children to school. Throughout the day, she said she felt “scat-
tered and inattentive.”
Snoring had appeared 5 years earlier. Her companion was unsure whether Ms. Kleber
also had breathing pauses during her sleep. Ms. Kleber denied having ever experi-
enced sleep paralysis or abruptly falling asleep in the middle of a sentence. Although
she would fall asleep while socializing, it would generally occur during a lull in the
conversation while she was in a quiet spot in the corner of a couch. She denied falling
down when she fell asleep. She reported experiencing hypnopompic hallucinations
several times per year since she was a teenager.
On examination, Ms. Kleber was an overweight woman who was cooperative and
coherent. She was concerned about her anxiety but preoccupied with her sleep prob-
lem. She denied depression, suicidality, psychosis, and memory complaints. Her in-
sight and judgment appeared intact.
Her physical examination was essentially noncontributory. Her medical history was
significant only for hypercholesterolemia and occasional migraine headaches. Ms. Kle-
ber did have some muscular complaints, such as weakness in her legs and pain in her
left arm; these were related to exertion. She has smoked marijuana occasionally to help
with her pain but denied that the marijuana was an important contributor to her sleep-
iness. She denied a history of head trauma and unusual illnesses. She denied a family
history of sleep or mood problems, although multiple relatives were “anxious.”
Ms. Kleber was referred for sleep studies. Polysomnography showed an apnea
hypopnea index of 3 events per hour. The next day, she underwent a multiple sleep
latency test (MSLT), which indicated a mean sleep latency of 7 minutes with one sleep-
onset REM period during the testing. A lumbar puncture was done to assess cerebro-
spinal fluid (CSF) levels of hypocretin-1; the level appeared in the normal range.
Diagnoses
• Social phobia
• Hypersomnolence disorder
Discussion
Ms. Kleber appears to have several DSM-5 diagnoses that warrant clinical attention.
She has been diagnosed with social phobia in the past, and its recurrence seems to
have led to this psychiatric consultation. She has gained weight since the birth of her
children, and her obesity exacerbates her social avoidance and puts her at risk for
sleep disturbances and medical complications. Obesity is not a diagnosis in the main
text of DSM-5, but it is listed in the DSM-5 chapter “Other Conditions That May Be a
Focus of Clinical Attention.” Ms. Kleber’s anxiety and weight issues might both war-
rant independent clinical attention, but it is her sleep problems that appear to most
profoundly affect her life.
Ms. Kleber sleeps too much. The sleep is not restful or restorative. Because of the
sleep problems, she can barely function as a mother and she indicates that she cannot
keep or maintain a job, drive independently, or socialize with friends. She is worried
she will lose her new romantic partner. The excess sleep and sleepiness have appar-
ently occurred daily since she neared the end of high school. Ms. Kleber’s symptoms
are indicative of DSM-5 hypersomnolence disorder. Criteria include symptoms at least
3 days per week for at least 3 months (Ms. Kleber has had symptoms almost daily for
over 15 years). The nocturnal sleep duration (9 hours) alone might not suggest a prob-
lem, but her total daily sleep duration of 14 hours is typical of hypersomnolence, as are
her inertia upon awakening and her unexpected lapses into sleep.
It is important to rule out other explanations for her somnolence. Ms. Kleber smokes
marijuana and uses a benzodiazepine for anxiety. She insists that her use is either oc-
casional (the marijuana) or at a low, stable dose (the clonazepam), and that her symp-
toms predated her use of either. Although both can be sedating, they do not appear to
be causative agents. She has pain and headaches, so it would be useful to tactfully in-
quire further about her possible use of pain medications, which can be sedating. She
also describes demoralization about her lack of effectiveness, which should prompt a
consideration of depression, which can lead to excessive amounts of nonrestorative
sleep. At the moment, none of these possibilities seems likely.
There are multiple sleep disorders that can lead to excessive sleep and/or daytime
somnolence. Ms. Kleber’s obesity, excessive sleepiness, and snoring should prompt a
consideration of sleep apnea, and a sleep study was certainly indicated. Polysomnog-
raphy yielded an apnea hypopnea index of 3 events per hour, which is in the normal
range and indicates that Ms. Kleber does not have a sleep-related breathing disorder.
Ms. Kleber should also be evaluated for narcolepsy, which is characterized by re-
current periods of an irrepressible need to sleep, lapsing into sleep, or napping within
the same day. Ms. Kleber’s clinical picture is suggestive. Not only does she fall asleep
abruptly, but she has relatively frequent hypnopompic hallucinations. Although gen-
erally considered normal, hypnopompic hallucinations can reflect sleep-onset REM
intrusions and are, therefore, suggestive of narcolepsy. To satisfy requirements for
DSM-5 narcolepsy, the individual should demonstrate cataplexy, CSF hypocretin de-
ficiency, or a reduction of REM sleep latency during nocturnal polysomnography or
an MSLT. Ms. Kleber’s MSLT showed a mean sleep latency of 7 minutes with only one
sleep-onset REM period during the testing. The sleep latency is brief; however, to
qualify for narcolepsy, she would need at least two early REM periods during the study.
Levels of CSF hypocretin-1 appeared in the normal range, which rules out narcolepsy-
cataplexy/hypocretin deficiency syndrome. Unless her episodes of falling asleep are
viewed as cataplexy, Ms. Kleber would not qualify for a narcolepsy diagnosis. At this
point, then, Ms. Kleber qualifies only for DSM-5 hypersomnolence disorder in addition
to her social phobia.
Suggested Readings
Karasu SR, Karasu TB: The Gravity of Weight: A Clinical Guide to Weight Loss and Mainte-
nance. Washington, DC, American Psychiatric Publishing, 2010
Ohayon MM, Reynolds CF 3rd: Epidemiological and clinical relevance of insomnia diagnosis
algorithms according to the DSM-IV and the International Classification of Sleep Disor-
ders (ICSD). Sleep Med 10(9):952–960, 2009
Ohayon MM, Dauvilliers Y, Reynolds CF 3rd: Operational definitions and algorithms for ex-
cessive sleepiness in the general population: implications for DSM-5 nosology. Arch Gen
Psychiatry 69(1):71–79, 2012
Case 3: Sleepiness
Brian Palen, M.D.
Vishesh K. Kapur, M.D., M.P.H.
César Lopez, a 57-year-old Hispanic man, presented for reevaluation of his anti-
depressant medication. He described several months of worsening fatigue, daytime
sleepiness, and generally “not feeling good.” He lacked the energy to do his usual ac-
tivities, but he still enjoyed them when he did participate. He had been having some
trouble focusing on his work as an information technology consultant and was worried
that he would lose his job. An SSRI antidepressant had been started 2 years earlier, re-
sulting in some improvement of symptoms, and Mr. Lopez insisted he was adherent to
this medication.
He denied stressors. In addition to having been diagnosed with depression, he had
hypertension, diabetes, and coronary artery disease. He complained of heartburn as
well as erectile dysfunction, for which he had not been medically evaluated.
Mr. Lopez was born in Venezuela. He was married and had two grown children. He
did not consume tobacco or alcohol but did drink several servings of coffee each day
to help maintain alertness.
On physical examination, he was 5 feet 10 inches tall, weighed 235 pounds, and had
a BMI of 34. His neck circumference was 20 inches. His respiratory rate was 90, and
his blood pressure was 155/90. No other abnormalities were present.
On mental status examination, the patient was a heavyset, cooperative man who ap-
peared tired but was without depressed mood, anxiety, psychosis, or cognitive decline.
More focused questioning revealed that Mr. Lopez not only had trouble staying
awake at work, but also occasionally nodded off while driving. He slept 8–10 hours
nightly but had frequent awakenings, made nightly trips to the bathroom (nocturia),
and often woke with a choking sensation and sometimes with a headache. He had
snored since childhood, but he added, “All the men in my family are snorers.” Before
she elected to sleep nightly in their guest bedroom, his wife said he snored very loudly
and intermittently stopped breathing and gasped for air.
Mr. Lopez was sent for a sleep study (polysomnography). Results included the fol-
lowing:
• Apnea hypopnea index: 25 events per hour

• Oxygen desaturation index: 20 events per hour
• Nadir oxygen saturation: 82%
• % Time with oxygen saturation 90%: 8%
• Arousal index: 35 events per hour
• Sleep stage (%):

% Time in stage N1 sleep: 20%
% Time in REM sleep: 10%
Diagnosis
• Obstructive sleep apnea hypopnea, moderate severity
Discussion
Mr. Lopez presents for a reevaluation of his treatment for depression, but his present-
ing symptoms are much more notable for fatigue and sleepiness than for a mood dis-
order. The patient’s history of loud snoring and episodes of choking and gasping
suggest that his most likely underlying problem is obstructive sleep apnea hypopnea
(OSAH).
Although OSAH affects about 3% of the overall population, rates are much higher
in people with pertinent risk factors. Mr. Lopez, for example, is above age 50, is obese
with a large neck circumference, and has a family history notable for “all the men”
being snorers. Snoring is a particularly sensitive indicator for OSAH, especially when
very loud, occurring more than 3 days per week, and accompanied by episodes of
choking and gasping. As seen in Mr. Lopez, patients with OSAH also frequently re-
port nocturia, heartburn, sexual dysfunction, and morning headaches, reflecting the
multisystem effects of this disorder.
OSAH is characterized by the repetitive collapse (apnea) or partial collapse (hypop-
nea) of the pharyngeal airway during sleep. Relaxation of the pharyngeal muscles dur-
ing sleep allows soft tissue in the back of the throat to block the pharyngeal airway. The
resultant decrease in airflow can cause significant reductions in blood oxygen saturation.
The increased work of breathing through an occluded airway stimulates brief arousals
to allow resumption of normal breathing. This pattern can repeat itself hundreds of
times throughout the night, resulting in significantly fragmented sleep patterns.
Sleep studies (polysomnography) quantify sleep in multiple ways, but DSM-5 fo-
cuses specifically on the apnea hypopnea index (AHI), which is a measure of the
number of complete breathing pauses (apneas) and partial breathing events (hypop-
neas) that last for at least 10 seconds per hour of sleep. If patients have at least 15 ob-
structive apneas or hypopneas per hour (an AHI of 15), they meet criteria regardless
of associated symptoms. With at least five such episodes (an AHI of 5), patients must
also have either nocturnal breathing disturbances or daytime sleepiness or fatigue.
The AHI is also the determinant of the severity of OSAH. Mild cases are associated
with an AHI of less than 15 (which, by definition, includes some sort of symptoms).
Mr. Lopez’s 25 events per hour fall in the moderate range of 15–30. OSAH is consid-
ered to be severe if the AHI is greater than 30.
Although not specifically related to DSM-5 criteria, Mr. Lopez’s polysomnography
is notable for abnormal sleep architecture, with a reduction of the percentage of time
spent in REM and stage N3 sleep. It demonstrates elevated amounts of time spent
with oxygen saturation below 90%, and his arousal index, which measures cortical
arousals per hour, is 35, far above the 20 that is the high range of normal.
OSAH is similar to many DSM-5 diagnoses in that if untreated, it can have a seri-
ously negative impact on quality of life. OSAH is unusual within DSM-5, however, in
that its diagnosis is heavily based on the results of a test rather than on clinical obser-
vation. As exemplified in the case of Mr. Lopez, many people with this disorder do
not get promptly diagnosed, leading to extended periods of not receiving adequate
treatment. Interestingly, one of the most “objective” of psychiatric diagnoses is only
considered during a sensitive clinical assessment.
Suggested Readings
Peppard PE, Szklo-Coxe M, Hla KM, Young T: Longitudinal association of sleep-related breath-
ing disorder and depression. Arch Intern Med 166(16):1709–1715, 2006
Schwartz DJ, Karatinos G: For individuals with obstructive sleep apnea, institution of CPAP
therapy is associated with an amelioration of symptoms of depression which is sustained
long term. J Clin Sleep Med 15(6):631–635, 2007
Sharafkhaneh A, Giray N, Richardson P, et al: Association of psychiatric disorders and sleep
apnea in a large cohort. Sleep 28(11):1405–1411, 2005
Young T, Palta M, Dempsey J, et al: The occurrence of sleep-disordered breathing among mid-
dle-aged adults. N Engl J Med 328(17):1230–1235, 1993
Young T, Shahar E, Nieto FJ, et al: Predictors of sleep-disordered breathing in community dwelling
adults: the Sleep Heart Health Study. Arch Intern Med 162(8):893–900, 2002
Case 4: Feeling Itchy, Creepy, and Crawly

Kathy P. Parker, Ph.D., R.N.
Dingxiang Meng was a 63-year-old Chinese-born man who was referred for a
psychiatric consultation for depression and excessive somatic complaints. He had a
history of psychotic depressions for which he had been admitted twice in the prior
decade. He was evaluated as an outpatient in the renal unit of a small hospital during
his routine hemodialysis.

At the time of the evaluation, Mr. Meng said he felt “itchy, creepy, and crawly,” like
“worms were crawling underneath the skin.” These symptoms had fluctuated over the
prior few years but had worsened in recent weeks, and he felt like he was “going crazy.”
He said he was worried and often tired but said he always laughed when playing
with his grandchildren or when visiting with people from his home country. He did
not display a thought disorder. A review of the chart indicated that Mr. Meng’s physical
complaints had been conceptualized at various times as akathisia, peripheral neurop-
athy, and “psychosomatic” and “psychotically ruminative” symptoms. He had been
euthymic and off all psychiatric medications for 2 years at the time of this evaluation.
Mr. Meng said his physical symptoms were worse at night when he tried to sit still
or lie down. He said the discomfort was only in his legs. Rubbing them helped, but
the greatest relief came from standing up and pacing. Dialysis was especially difficult
because of “being strapped to a machine for hours.” He also complained of daytime

sleepiness and fatigue. In the course of the interview, Mr. Meng twice jumped up from
receiving the dialysis. One of the nurses mentioned that he often asked to cut short
his dialysis, generally looked tired, and always seemed to be “jumping around.”
Mr. Meng had been diagnosed with diabetes soon after his immigration to the
United States 15 years earlier. He developed progressive renal insufficiency and had
begun hemodialysis 7 years earlier. He was divorced, with two adult children and
three young grandchildren. He spoke little English; all interviews were done using a
Mandarin interpreter. He lived with one of his children.
Diagnosis
• Restless legs syndrome
Discussion
Mr. Meng presents with depression, fatigue, a creepy sensation of “worms” crawling
under his skin, and an intense urge to move. It was not clear to earlier examiners
whether his hospitalizations for “psychotic depression” were related to these physical
sensations. These sensations were diagnosed in multiple ways over the years: as aka-
thisia, peripheral neuropathy, and “psychosomatic” and “psychotically ruminative”
symptoms.
Instead of these diagnoses, Mr. Meng most likely has restless legs syndrome (RLS).
A newly independent diagnosis in DSM-5, RLS is characterized by an urge to move
the legs, usually accompanied by disagreeable sensations. Mr. Meng’s symptoms are
typical. The symptoms are improved by movement and are most intense in the evening
or when the person is in some sort of sedentary situation (such as dialysis). The symp-
toms are frequent, chronic, and distressing.
RLS is a particularly common problem for people with end-stage renal disease
(ESRD) who are undergoing dialysis. Usually, but not always, the condition is associ-
ated with periodic limb movements: stereotypical movements involving extension of
the big toe with partial flexing of the ankle, knee, and sometimes hip. Mr. Meng’s day-
time sleepiness could be related to a delayed sleep onset but also to a reduction in the
quality of his sleep; RLS is associated with both problems. ESRD and dialysis are ad-
equate explanations for the RLS (which often has no explanation), but a search should
be made for such contributors as anemia, folate deficiency, and uremia. Although ob-
viously not applicable to Mr. Meng, pregnancy is also associated with RLS.
It is not clear why the RLS diagnosis was delayed, especially since RLS is such a
common finding in dialysis units. Mr. Meng’s history of psychotic depressions might
have led the treating team to assume that his complaints were psychological. Such an
understanding might have led to the diagnosis of “psychosomatic” symptoms, im-
plying that his physical symptoms were attributable to some sort of psychological
disorder or conflict. Not only does that appear to be a misunderstanding of Mr. Meng’s
complaints, it is a misuse of the term psychosomatic, which is better conceptualized as
the branch of psychiatry that focuses on comorbidity between psychiatric and medical
illnesses; using that definition, it is meaningless to describe someone as “psychoso-

matic.” Because Mr. Meng was taking antipsychotic medication for at least some of the
time that he was also symptomatic, it does make some sense that akathisia was con-
sidered. Newer antipsychotic medications (i.e., the atypical antipsychotics) are rarely
implicated in akathisia, however, and his symptoms persisted 2 years after the discon-
tinuation of all psychiatric medication. Peripheral neuropathy tends to cause pain,
burning, and numbness in the extremities, which is not exactly Mr. Meng’s actual
complaint.
Perhaps of most concern are the chart notes that indicate that Mr. Meng’s restless
legs were a manifestation of “psychotic rumination.” Communication difficulties may
have contributed to this understanding, but it is possible that Mr. Meng’s two psychi-
atric admissions for “psychotic depression” might have actually been precipitated by
the somatic preoccupations, anxiety, and dysphoria caused by an undiagnosed case of
RLS—a disorder that, although new to DSM-5 as a diagnosis, has long been found to
be troublesome and is frequently comorbid with a number of medical illnesses.
Suggested Readings
Araujo SM, de Bruin VM, Nepomuceno LA, et al: Restless legs syndrome in end-stage renal dis-
ease: clinical characteristics and associated comorbidities. Sleep Med 11(8):785–790, 2010
Hening W, Allen RP, Tenzer P, Winkelman JW: Restless legs syndrome: demographics, presen-
tation, and differential diagnosis. Geriatrics 62(9):26–29, 2007
La Manna G, Pizza F, Persici E, et al: Restless legs syndrome enhances cardiovascular risk and
mortality in patients with end-stage kidney disease undergoing long-term haemodialysis
treatment. Nephrol Dial Transplant 26(6):1976–1983, 2011
Li Y, Walters AS, Chiuve SE, et al: Prospective study of restless legs syndrome and coronary
heart disease among women. Circulation 126(14):1689–1694, 2012
Oka Y, Ioue Y: Secondary restless legs syndrome [in Japanese]. Brain Nerve 61(5): 539–547, 2009
Winkelman JW, Chertow GM, Lazarus JM: Restless legs syndrome in end-stage renal disease.
Am J Kidney Dis 28(3):372–378, 1996

DSM 5 Clinical Cases - Sleep-Wake Disorders

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DSM 5 Clinical Cases - Sleep-Wake Disorders

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Sleep-Wake Disorders

DSM-5® Clinical Cases

(REM) sleep latency as determined by nocturnal sleep polysomnography or a multi-

Case 1: Difficulty Staying Asleep

Aidan Jones, a 30-year-old graduate student in English, visited a psychiatrist to

perhaps recurrent, mood or anxiety disorder. Conversely, insomnia itself increases

This reconceptualization reflects a paradigm shift in the field of sleep disorders

Case 2: Anxious and Sleepy

Bernadette Kleber was a 34-year-old divorced, unemployed white mother of

• Apnea hypopnea index: 25 events per hour

• Sleep stage (%):

Case 4: Feeling Itchy, Creepy, and Crawly

his routine hemodialysis.

because of “being strapped to a machine for hours.” He also complained of daytime

illnesses; using that definition, it is meaningless to describe someone as “psychoso-

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