3.5 Eating, Sex and Sleep
Week 3
Sleep
,DSM-5 Criteria → Insomnia Disorder
A A predominant complaint of dissatisfaction with sleep quantity or quality, associated
with one (or more) of the following symptoms:
1. Difficulty initiating sleep. (In children, this may manifest as difficulty initiating
sleep without caregiver intervention.)
2. Difficulty maintaining sleep, characterized by frequent awakenings or
problems returning to sleep after awakenings. (In children, this may
manifest as difficulty returning to sleep without caregiver intervention.)
3. Early-morning awakening with inability to return to sleep.
B The sleep disturbance causes clinically significant distress or impairment in social,
occupational, educational, academic, behavioral, or other important areas of
functioning.
C The sleep difficulty occurs at least 3 nights per week.
D The sleep difficulty is present for at least 3 months.
E The sleep difficulty occurs despite adequate opportunity for sleep.
F The insomnia is not better explained by and does not occur exclusively during the
course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep
disorder, a circadian rhythm sleep-wake disorder, a parasomnia).
G The insomnia is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication).
H Coexisting mental disorders and medical conditions do not adequately explain the
predominant complaint of insomnia.
Subtype ● With non-sleep disorder mental comorbidity, including substance abuse
disorders
● With other mental comorbidity
● With other sleep disorder
Subtype ● Episodic: Symptoms last at least one month but less than 3 months.
● Persistent: Symptoms last 3 months or longer.
● Recurrent: Two (or more) episodes within the space of 1 year.
Note Acute and short-term insomnia (i.e., symptoms lasting less than 3 months but
otherwise meeting all criteria with regard to frequency, intensity, distress, and/or
impairment) should be coded as an other specified insomnia disorder.
Note The diagnosis is given whether it occurs as an independent condition or is
comorbid with another disorder
Diagnostic features
● Essential feature → dissatisfaction with sleep quantity or quality by difficulty initiating
or maintaining sleep
, ● Different manifestations occur at different times of the sleep period
○ Sleep onset insomnia (initial insomnia) → difficulty initiating sleep at bedtime
○ Sleep maintenance insomnia (middle insomnia) → frequent or prolonged
awakenings throughout the night
○ Late insomnia → early morning awakening and inability to return to sleep
● Difficulty maintaining is most common, then difficulty initiating, combination of the two is
most common overall
● Sleep complaints often vary over time
● Nonrestorative sleep → complaint of poor sleep quality, individual is not well rested
upon awakening despite adequate duration is common complaint usually co-occurring
with other symptoms
○ If this is the only symptom → other specified insomnia disorder or unspecified
● Quantitative data to quantify insomnia severity
○ Difficulty initiating → greater than 20-30 mins
○ Difficulty maintaining → time awake greater than 20-30 mins
○ There is no standard definition of early morning awakening → at least 30 mins
before scheduled time and before total sleep time reaches 6.5 hours, depends on
time gone to bed, could reflect age dependent changes
● Associated with daytime impairments → fatigue, daytime sleepiness, especially among
older when comorbid with other medical condition, impairment in cognitive performance,
mood disturbances
Associated features supporting diagnosis
● Preoccupation with sleep and distress due to the inability to sleep may lead to vicious
cycle
● Maladaptive sleep habits and cognitions may occur, may worsen the condition
● Some report better sleep when they are away from their own bedrooms and usual
routines
● Symptoms of anxiety/depression may be present, excessive focus on the perceived
effects of sleep loss on daytime functioning
● Self report inventories may show elevated depression & anxiety, worrisome cognitive
style, emotion focused & internalizing style of conflict resolution, somatic focus
● Often require more effort to maintain cognitive performance
Prevalence
● ⅓ of adults report symptoms
● 10-15% experience daytime impairments
● 6-10% have symptoms that meet the criteria
● More prevalent among females
● Often comorbid condition of another disorder (40-50%)
Development and course
, ● Onset can occur at any time but first episode is most common in young adulthood, less
frequently in childhood or adolescence, can occur during menopause, late life onset is
associated with onset of other conditions
● Can be situational, persistent or recurrent
○ Often the insomnia resolves once an event has subsided
○ For those vulnerable → can persist after the event
○ Factors that precipitate insomnia can be different to those that perpetuate it
● Chronicity ranges from 45% to 75%
○ Light sleepers have a higher chance of persistent sleep problems
● More prevalent among middle age and older adults
○ Difficulties change depending on age → difficulties initiating more common in
young adults, difficulties maintaining more common among middle aged & older
○ Higher prevalence in older can be explained by higher incidence of other health
problems
● In children & adolescents could be caused & maintained by irregular sleep schedules,
psychological & medical factors
● Polysomnography is not very useful to the diagnosis of insomnia, but is to the differential
diagnosis
Risk and prognostic factors
● These risk factors increase vulnerability, but sleep disturbances are more likely to occur
in a precipitating life event or stress
● Temperamental → anxiety or worry-prone personality or cognitive styles, increased
arousal predisposition, tendency to repress emotions
● Environmental → noise, light, uncomfortably high or low temperature, high altitude
● Genetic & physiological → female gender & advancing age, familial disposition
● Course modifiers → poor sleep hygiene practices (caffeine consumption, irregular
sleep schedules)
Gender-related diagnostic issues
● More prevalent among females than males (linked to childbirth and menopause) but
older women show better preservation of sleep continuity and slow-wave sleep
Diagnostic markers
● Polysomnography usually shows impairments of sleep continuity, increased stage 1,
decreased stage 3 and 4 sleep
● Severity of impairments does not always match individuals clinical presentation or
subjective complaint → individuals underestimate sleep duration and overestimate
wakefulness
● Insomnia usually have greater high frequency electroencephalography power relative to
good sleepers during sleep onset and non REM sleep (increased cortical arousal)
● Individuals with insomnia have lower sleep propensity and do not typically show
increased daytime sleepiness in lab compared to those without disorder
Week 3
Sleep
,DSM-5 Criteria → Insomnia Disorder
A A predominant complaint of dissatisfaction with sleep quantity or quality, associated
with one (or more) of the following symptoms:
1. Difficulty initiating sleep. (In children, this may manifest as difficulty initiating
sleep without caregiver intervention.)
2. Difficulty maintaining sleep, characterized by frequent awakenings or
problems returning to sleep after awakenings. (In children, this may
manifest as difficulty returning to sleep without caregiver intervention.)
3. Early-morning awakening with inability to return to sleep.
B The sleep disturbance causes clinically significant distress or impairment in social,
occupational, educational, academic, behavioral, or other important areas of
functioning.
C The sleep difficulty occurs at least 3 nights per week.
D The sleep difficulty is present for at least 3 months.
E The sleep difficulty occurs despite adequate opportunity for sleep.
F The insomnia is not better explained by and does not occur exclusively during the
course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep
disorder, a circadian rhythm sleep-wake disorder, a parasomnia).
G The insomnia is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication).
H Coexisting mental disorders and medical conditions do not adequately explain the
predominant complaint of insomnia.
Subtype ● With non-sleep disorder mental comorbidity, including substance abuse
disorders
● With other mental comorbidity
● With other sleep disorder
Subtype ● Episodic: Symptoms last at least one month but less than 3 months.
● Persistent: Symptoms last 3 months or longer.
● Recurrent: Two (or more) episodes within the space of 1 year.
Note Acute and short-term insomnia (i.e., symptoms lasting less than 3 months but
otherwise meeting all criteria with regard to frequency, intensity, distress, and/or
impairment) should be coded as an other specified insomnia disorder.
Note The diagnosis is given whether it occurs as an independent condition or is
comorbid with another disorder
Diagnostic features
● Essential feature → dissatisfaction with sleep quantity or quality by difficulty initiating
or maintaining sleep
, ● Different manifestations occur at different times of the sleep period
○ Sleep onset insomnia (initial insomnia) → difficulty initiating sleep at bedtime
○ Sleep maintenance insomnia (middle insomnia) → frequent or prolonged
awakenings throughout the night
○ Late insomnia → early morning awakening and inability to return to sleep
● Difficulty maintaining is most common, then difficulty initiating, combination of the two is
most common overall
● Sleep complaints often vary over time
● Nonrestorative sleep → complaint of poor sleep quality, individual is not well rested
upon awakening despite adequate duration is common complaint usually co-occurring
with other symptoms
○ If this is the only symptom → other specified insomnia disorder or unspecified
● Quantitative data to quantify insomnia severity
○ Difficulty initiating → greater than 20-30 mins
○ Difficulty maintaining → time awake greater than 20-30 mins
○ There is no standard definition of early morning awakening → at least 30 mins
before scheduled time and before total sleep time reaches 6.5 hours, depends on
time gone to bed, could reflect age dependent changes
● Associated with daytime impairments → fatigue, daytime sleepiness, especially among
older when comorbid with other medical condition, impairment in cognitive performance,
mood disturbances
Associated features supporting diagnosis
● Preoccupation with sleep and distress due to the inability to sleep may lead to vicious
cycle
● Maladaptive sleep habits and cognitions may occur, may worsen the condition
● Some report better sleep when they are away from their own bedrooms and usual
routines
● Symptoms of anxiety/depression may be present, excessive focus on the perceived
effects of sleep loss on daytime functioning
● Self report inventories may show elevated depression & anxiety, worrisome cognitive
style, emotion focused & internalizing style of conflict resolution, somatic focus
● Often require more effort to maintain cognitive performance
Prevalence
● ⅓ of adults report symptoms
● 10-15% experience daytime impairments
● 6-10% have symptoms that meet the criteria
● More prevalent among females
● Often comorbid condition of another disorder (40-50%)
Development and course
, ● Onset can occur at any time but first episode is most common in young adulthood, less
frequently in childhood or adolescence, can occur during menopause, late life onset is
associated with onset of other conditions
● Can be situational, persistent or recurrent
○ Often the insomnia resolves once an event has subsided
○ For those vulnerable → can persist after the event
○ Factors that precipitate insomnia can be different to those that perpetuate it
● Chronicity ranges from 45% to 75%
○ Light sleepers have a higher chance of persistent sleep problems
● More prevalent among middle age and older adults
○ Difficulties change depending on age → difficulties initiating more common in
young adults, difficulties maintaining more common among middle aged & older
○ Higher prevalence in older can be explained by higher incidence of other health
problems
● In children & adolescents could be caused & maintained by irregular sleep schedules,
psychological & medical factors
● Polysomnography is not very useful to the diagnosis of insomnia, but is to the differential
diagnosis
Risk and prognostic factors
● These risk factors increase vulnerability, but sleep disturbances are more likely to occur
in a precipitating life event or stress
● Temperamental → anxiety or worry-prone personality or cognitive styles, increased
arousal predisposition, tendency to repress emotions
● Environmental → noise, light, uncomfortably high or low temperature, high altitude
● Genetic & physiological → female gender & advancing age, familial disposition
● Course modifiers → poor sleep hygiene practices (caffeine consumption, irregular
sleep schedules)
Gender-related diagnostic issues
● More prevalent among females than males (linked to childbirth and menopause) but
older women show better preservation of sleep continuity and slow-wave sleep
Diagnostic markers
● Polysomnography usually shows impairments of sleep continuity, increased stage 1,
decreased stage 3 and 4 sleep
● Severity of impairments does not always match individuals clinical presentation or
subjective complaint → individuals underestimate sleep duration and overestimate
wakefulness
● Insomnia usually have greater high frequency electroencephalography power relative to
good sleepers during sleep onset and non REM sleep (increased cortical arousal)
● Individuals with insomnia have lower sleep propensity and do not typically show
increased daytime sleepiness in lab compared to those without disorder
