How does the classification of pediatric sleep disorders differ between DSM-IV-TR to DSM-5?

Updated: Oct 09, 2018
  • Author: Sufen Chiu, MD, PhD; Chief Editor: Caroly Pataki, MD  more...
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Major scientific advances have altered the understanding of sleep disorders, which have resulted in major changes moving from Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition Text Revision (DSM-IV-TR) [2] to the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5). [3] The DSM-IV-TR divided sleep disorders into 3 categories: Dyssomnias, Parasomnias, and Medical Psychiatric Disorders.

These categorical differences were eliminated in the DSM-5 to encourage the understanding that medical disorders and sleep disorders are intertwined and primary causation is usually not important. The entire section has been renamed Sleep-Wake Disorders to highlight that etiology may be based in the inability to maintain alertness during the waking period. The definition of dyssomnia versus parasomnia is provided to highlight the developmental differences of sleep-wake disorders.

Patients with dyssomnias present with difficulty initiating or maintaining sleep or with excessive daytime somnolence. The DSM-IV-TR defined dyssomnias as primary disturbances in the quantity, quality, or timing of sleep. [2] These disorders are believed to be a consequence of central nervous system (CNS) abnormalities that alter the sleep process. Adolescents with and without substance use disorders represent a significant proportion of sleep-disordered youths. This is an excellent example how difficult it may be to distinguish a primary sleep disorder from those induced by medical conditions.

Parasomnias result in disruption of an existing state of sleep. Arousals, partial arousals, and sleep-stage transition impositions define this category. An alternative definition of these phenomena includes deviated behavioral or physiologic events that transpire during sleep, specific sleep stages, or sleep-wake transitions. Insomnia or excessive sleepiness is uncommon in parasomnias despite intrusion upon sleep; these symptoms are characteristic of dyssomnia.

Most parasomnias affect otherwise healthy youths and commonly subside over the course of adolescence. These disorders are typically viewed as transient developmental phenomena, though children with parasomnias have been found to display higher rates of sleep-onset delay, night awakenings, bedtime resistance, and reduced sleep duration compared to a community control group.

Medical-psychiatric–associated sleep disorders comprise the neuropsychiatric conditions that typically include sleep disturbances. This category has been eliminated in DSM-5 but should still be considered by the clinician when evaluating sleep disorders. The medical differential should include the following:

  • Attention deficit hyperactivity disorder (ADHD)

  • Gastroesophageal reflux disease (GERD)

  • Pervasive developmental disorders

  • Mental retardation

  • Down syndrome

  • Prader-Willi syndrome

  • Smith-Magenis syndrome

  • Tourette disorder

  • Nocturnal asthma

  • Depressive disorders

  • Anxiety disorders

  • Mania

  • Neuromuscular disorders

  • Nocturnal seizures

  • Kleine-Levin syndrome or periodic hypersomnia

  • Headaches

  • Blindness with associated sleep disorder

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