| DSM-5 Sleep-wake disorders
Sleep-wake disorders encompass 10 disorders or disorder groups. Items in bold are covered as part of the NCCPA PANCE/PANRE Psychiatry Blueprint and include narcolepsy and the parasomnias. The two important categories of parasomnias include the NREM sleep arousal disorders (of which I have included sleepwalking and sleep terrors) and the REM sleep behavior disorders, of which I have included nightmare disorder. Sleep-wake disorders are covered as part of the PAEA EOR™ Psychiatry Topic List. Included are brief descriptions of insomnia disorder and hypersomnolence disorder, as well as restless legs syndrome, because they are important to know, but they are not included as part of the PANCE/PANRE Psychiatry Blueprint. |
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| Insomnia disorder
Breathing-related sleep disorders |
Parasomnias:
Restless legs syndrome Substance/medication-induced sleep disorder |
PANCE/PANRE Sleep-wake disorders
| Narcolepsy | A sleep disorder characterized by uncontrollable sleep attacks. The sufferer may lapse directly into REM sleep, often at inopportune times. |
| Parasomnias | Parasomnias are dissociated sleep states which are partial arousals during the transitions between wakefulness, NREM sleep, and REM sleep, and their combinations.
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| Narcolepsy
Patient will present as → a 19-year-old female complaining of an irresistible urge to sleep at sudden times throughout the day. This has disturbed her school functioning. She sometimes feels like she “is paralyzed” for several minutes when she wakes up. She “passed out” one day at school when she was startled by her boyfriend. Excessive daytime sleepiness + cataplexy (sudden loss of muscle tone with strong emotion, often laughter)
DX: Polysomnography + next-day multiple sleep latency test (MSLT) — mean sleep latency ≤ 8 minutes with ≥ 2 sleep-onset REM periods
TX: Scheduled naps + sleep hygiene, plus wake-promoting medication — modafinil first-line (pitolisant, solriamfetol alternatives)
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| Parasomnias
DX: Clinical (history from bed partner/parents) — polysomnography when the events are atypical, injurious, or suggest REM sleep behavior disorder or seizures
TX: Reassurance + safety measures — most childhood NREM parasomnias resolve with age
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| Restless leg syndrome
DX: Clinical — URGE criteria (Urge · Rest worsens · Gets better with movement · Evening predominance)
TX: Iron repletion when indicated + trigger removal; alpha-2-delta ligands (gabapentin enacarbil, gabapentin, pregabalin) are now preferred first-line
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| Insomnia disorder
Patient will present as → a 39-year-old female presents with difficulty falling asleep, frequent awakenings, and unrefreshing sleep for four months. She reports daytime fatigue, irritability, and poor concentration, affecting her work. She denies symptoms of other sleep or mood disorders. Exam is unremarkable. She is diagnosed with insomnia disorder. Management includes cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment. She is advised on sleep hygiene strategies, including maintaining a regular sleep schedule, limiting screen time before bed, avoiding caffeine in the afternoon, and creating a relaxing bedtime routine. Short-term pharmacotherapy with low-dose trazodone may be considered if behavioral measures alone are ineffective. The patient is counseled to avoid over-the-counter sedatives due to potential dependence and side effects. Follow-up is scheduled in four weeks to assess progress and adjust treatment as needed. Dissatisfaction with sleep ≥ 3 nights/week for ≥ 3 months, despite adequate opportunity to sleep
DX: DSM-5 — sleep dissatisfaction ≥ 3 nights/week for ≥ 3 months with adequate opportunity for sleep and daytime consequences
TX: CBT for insomnia (CBT-I) is first-line — before any medication
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Patient will present as → a 25-year-old male presents with excessive daytime sleepiness for six months, despite sleeping 9-10 hours nightly. He reports long naps that do not relieve fatigue and difficulty concentrating, but denies cataplexy or hallucinations. Exam is unremarkable. Polysomnography is normal, and MSLT shows mean sleep latency <8 minutes without sleep-onset REM, consistent with hypersomnolence disorder. Management includes sleep hygiene, a structured sleep schedule, and consideration of modafinil. Follow-up is arranged to monitor treatment response. Hypersomnolence disorderExcessive daytime sleepiness DESPITE ≥ 7 hours of main sleep — long, non-refreshing naps and severe sleep inertia
DX: DSM-5 — excessive sleepiness despite main sleep ≥ 7 hours with ≥ 1 of: recurrent naps · non-refreshing sleep > 9 h · sleep inertia, occurring ≥ 3×/week for ≥ 3 months with impairment
TX: Wake-promoting agents — modafinil first-line
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| Circadian rhythm sleep-wake disorders
Patient will present as → a 16-year-old who cannot fall asleep before 2 a.m. and cannot wake for school, yet sleeps normally and wakes refreshed at noon on weekends — delayed sleep-wake phase. His grandfather has the mirror image, sleeping 7 p.m. to 3 a.m. Sleep is NORMAL when allowed to occur on the body's own schedule — the timing, not the sleep, is the problem
DX: Clinical — persistent misalignment between the internal clock and required schedule, with insomnia or sleepiness and impairment
TX: Timed light exposure + timed melatonin to shift the clock
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References: Merck Manual