Your patient reports he feels discouraged by his failure to find a job. He
watches television or goes out drinking in the evening and rarely falls asleep
before 3 a.m. You determine he has not only depression, but also inadequate
sleep hygiene and a delayed sleep phase disorder.
This patient should receive all three diagnoses, says Michael Sateia, M.D.,
a professor of psychiatry and chief of sleep medicine at Dartmouth Medical
As this case suggests, multiple factors often contribute to difficulty
sleeping, noted Sateia, who was editor of the recently published second
edition of the International Classification of Sleep Disorders Diagnostic
and Coding Manual (ICSD-2), published in 2005 by the American Academy of
Sleep Medicine. The new edition replaces ICSD-1, published in 1990
and revised in 1997.
Since sleep symptoms frequently accompany psychiatric illness, Sateia said,
psychiatrists should find ICSD-2 helpful in making a comprehensive
"Psychiatrists traditionally have viewed insomnia as a symptom of
depression, but insomnia often has a life of its own," he said. It may
persist, even after mood improves. It requires treatment beyond the standard
treatment for depression, particularly hypnotic medication and/or
"If not treated," he added, "insomnia may boost the
likelihood of the depression's recurrence."
Many sleep diagnoses outside the insomnia category also are highly relevant
to psychiatry, he pointed out. As many as 50 percent of people with chronic
schizophrenia have obstructive sleep apnea. Circadian rhythm sleep disorders
have a high association with mood disorders. Some antidepressant medications
trigger or increase periodic leg movements in sleep.
ICSD-2 represents consensus opinion from more than 100 sleep
specialists worldwide. Its descriptions and criteria for sleep disorders,
Sateia asserted, "are as rooted in evidence as available knowledge
The 300-page manual covers more than 80 discrete disorders, organized in
eight categories. Unlike DSM-IV-TR, ICSD-2 does not use an axial
system; it focuses only on the diagnosis of sleep disorders.
"While ICSD-2 enables psychiatrists who specialize in the
treatment of sleep disorders to make finer distinctions than is possible in
DSM-IV-TR, DSM-IV-TR's sleep disorders section continues to be useful
for the general psychiatrist," according to Michael First, M.D., cochair
and editor of DSM-IV-TR and a research psychiatrist with the New York
State Psychiatric Institute in New York City.
"The diagnostic codes in DSM-IV-TR were recently updated so
as to be compatible with new International Classification of Diseases
(ICD-9-CM) codes introduced as a result of ICSD-2," First
said. The codes are posted at<www.aasmnet.org/PDF/CrosswalkCard.pdf>.
Some disorders are grouped according to a common complaint; these include
insomnia, hypersomnia, parasomnia, and sleep-related movement disorder.
Others, such as circadian rhythm sleep disorders, are classified by presumed
etiology. Still others are classified according to the organ system from which
Separate sections deal with disorders that involve isolated symptoms, such
as sleep talking, and longer and shorter than normal sleep duration.
Appendices review sleep disorders associated with medical disorders, such as
sleep-related epilepsy or headaches, along with psychiatric and behavioral
disorders frequently encountered in the differential diagnosis of sleep
For each disorder, ICSD-2 includes alternative names and describes
essential and associated features, demographics, predisposing and
precipitating factors, and familial patterns. It reports onset, course, and
complications, as well as pathology and pathophysiology, and includes
polysomnographic and other objective findings, diagnostic criteria, and
Each section also addresses unresolved issues, further directions, and
differential diagnosis, concluding with a concise bibliography. Most pediatric
presentations are incorporated into the text for individual sleep disorders;
three presentations unique to childhood are listed separately.
The new code for behavioral insomnia of childhood—a disorder child
psychiatrists might encounter—has sparked consternation among some
pediatric sleep specialists. This ICSD-2 disorder combines two
ICSD-1 disorders, sleep onset association disorder and limit-setting
sleep disorder. Its coding was downgraded to a "V" or"
problem" code usually reserved for lifestyle issues.
"A V code means insurance companies are unlikely to reimburse for
this diagnosis," said Judith Owens, M.D., an associate professor of
pediatrics at Brown Medical School. "That may serve as a barrier to care
for families of some children with this disorder."
It also creates a pocketbook issue for practitioners, said Owens, who
estimates that about 30 percent of the children in her pediatric sleep clinic
have behavioral insomnia.
This disorder typically presents in the first or second year of life and
probably involves a dysfunction in the child's ability to consolidate and
self-regulate sleep, Owens explained, making it similar to psychophysiological
insomnia in adults. Treatment involves teaching parents strategies to modify
the child's behavior and improve the home sleep environment.
While pediatric sleep practitioners are campaigning to repeal this coding
decision, work already has begun on ICSD-3. John Winkelman, M.D.,
Ph.D., an assistant professor of psychiatry at Harvard Medical School, chairs
a task force on this issue.
Copies of ICSD-2 may be purchased at<www.aasmnet.org>.▪