Eating Disorders;

Sleep Disorders

Anorexia Nervosa         Bulimia Nervosa    

Primary Insomnia      Primary Hypersomnia       Narcolepsy

Breathing-Related Sleep Disorder       Circadian Rhythm Sleep Disorder

Nightmare Disorder      Sleep Terror Disorder

Sleepwalking Disorder     Insomnia Related to [Axis I or Axis II disorder]

Hypersomnia Related to [Axis I or Axis II disorder]

Sleep Disorder Due to a General Medical Condition

Substance-Induced Sleep Disorder

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Eating Disorders

Anorexia Nervosa

• The patient will not maintain a minimum body weight (for example, 85% of expected weight for height and age).

• Despite being underweight, the patient intensely fears becoming fat.

• Self-perception of the body is abnormal, shown by at least 1 of:
  --Unduly emphasizes weight or shape in self-evaluation
  --Denies seriousness of low weight
  --Has a distorted perception of own body shape or weight

• Due to weight loss, a female patient has missed at least 3 consecutive periods (or periods occur only when she is given hormones).

Specify whether:

Binge-Eating/Purging Type. During an anorectic episode, the patient often purges (vomits, uses laxatives or diuretics) or eats in binges.

Restricting Type. No bingeing or purging during an anorectic episode. This is the more usual type.

Bulimia Nervosa

• The patient repeatedly eats in binges. In a binge episode the patient has both of:
  --Consumes much more food than most people would in similar circumstances and in a similar period of time
  --Feels that the eating is out of control

• The patient repeatedly controls weight gain by inappropriate means such as: fasting, self-induced vomiting, excessive exercise or abuse of laxatives, diuretics or other drugs.

• On average, both of the above behaviors (binge eating and inappropriate control) have occurred at least twice a week for at least 3 consecutive months.

• Weight and body shape unduly affect the patient's self-evaluation.

• These symptoms do not occur solely during episodes of Anorexia Nervosa.

Specify whether:

Purging type: The patient often induces vomiting or misuses diuretics or laxatives. This is the more common type.

Nonpurging type: The patient fasts or exercises excessively but does not often induce vomiting or misuse diuretics or laxatives.

Sleep Disorders

Primary Insomnia

• For at least a month the patient's main complaint has been trouble going to sleep, staying asleep or feeling unrested.

• The insomnia, or resulting daytime fatigue, causes clinically important distress or impairs work, social or personal functioning.

• It does not occur solely in the course of Breathing-Related or Circadian Rhythm Sleep Disorder, Narcolepsy or a parasomnia.

• It does not occur solely in the course of another mental disorder (such as a delirium, Generalized Anxiety Disorder, Major Depressive Disorder).

• These symptoms are not directly caused by a general medical condition or substance use, including medications and drugs of abuse.

Primary Hypersomnia

• For at least a month (or less, if it is recurrent) the patient's main complaint has been excessive sleepiness. This has been shown by either of:
  -Prolonged sleep
  -Sleeping during the day, almost daily

• This sleepiness causes clinically important distress or impairs work, social or personal functioning.

• Neither insomnia nor an inadequate amount of sleep explains it better.

• It doesn't occur solely during another sleep disorder (such as Breathing-Related or Circadian Rhythm Sleep Disorder, Narcolepsy or a parasomnia).

• Another mental disorder doesn't explain it better.

• These symptoms are not directly caused by a general medical condition or substance use, including medications and drugs of abuse.

Specify if Recurrent: For at least 2 years, periods of hypersomnia lasting 3 days or more have occurred several times a year.

Narcolepsy

• Each day for 3 months or more the patient has had irresistible attacks of refreshing sleep.

• The patient experiences either or both of:
  -Cataplexy (sudden, brief loss of muscle tone bilaterally, usually associated with intense emotion)
  -Intrusions of REM sleep into transitions between waking and sleeping, as shown by either of:
       - Hypnagogic or hypnopompic hallucinations or
       - Sleep paralysis at the beginning or end of sleep

• These symptoms are not directly caused by a general medical condition or substance use, including medications and drugs of abuse.

Breathing-Related Sleep Disorder

• The patient experiences disruption of sleep that causes excessive insomnia or sleepiness.

• The clinician judges this disruption to be caused by a breathing problem related to sleep such as central or obstructive sleep apnea or central alveolar hypoventilation syndrome.

• Another mental disorder does not better explain this behavior.

• The symptoms are not directly caused by a general medical condition or substance use, including medications and drugs of abuse.

Coding Note

On Axis III, also code Sleep-Related Breathing Disorder. For example,

Axis III 780.57 Obstructive Sleep Apnea

Circadian Rhythm Sleep Disorder

• There is a persisting or repeating mismatch between a patient's sleep-wake pattern and the sleep-wake demands of that patient's environment.

• The mismatch leads to excessive insomnia or sleepiness.

• This problem causes clinically important distress or impairs work or social life.

• It doesn't occur solely during another mental disorder or Sleep Disorder.

• It is not directly caused by a general medical condition or substance use, including medications and drugs of abuse.

Specify:

Delayed Sleep Phase Type. The patient repeatedly has trouble getting to sleep and trouble awakening on time.

Jet Lag Type. Alertness and sleepiness occur at inconvenient times of day after traveling across more than one time zone.

Shift Work Type. Because of night shift work or frequently changing job shifts, the patient experiences excessive sleepiness during major periods of wakefulness or insomnia during major sleep period.

Unspecified Type.

Nightmare Disorder

• The patient repeatedly awakens with detailed recall of long, frightening dreams. These usually occur in the second half of the sleep or nap period and concern threats to security, self-esteem or survival.

• The patient quickly becomes alert and oriented upon awakening.

• These experiences (or resulting sleep disturbance) cause clinically important distress or impair work, social or personal functioning.

• They don't occur solely during another mental disorder (such as Posttraumatic Stress Disorder or a delirium).

• The symptoms are directly caused by a general medical condition or substance use, including medications and drugs of abuse.

Sleep Terror Disorder

• On numerous occasions, the patient awakens abruptly, usually during the first third of sleep and usually beginning with a scream of panic.

• During each episode the patient shows evidence of marked fear and autonomic arousal, such as rapid breathing, rapid heartbeat and sweating.

• During the episode, the patient responds poorly to the efforts of others to provide comfort.

• The patient cannot recall any dream in detail at the time and cannot recall the whole episode later.

• These symptoms cause clinically important distress or impair work, social or personal functioning.

• These symptoms are not directly caused by a general medical condition or substance use, including medications and drugs of abuse.

Sleepwalking Disorder

• On numerous occasions, the patient arises and walks about, usually during the first third of sleep.

• During sleepwalking, the patient stares blankly, can be awakened only with difficulty and responds poorly to others' attempts at communication.

• Although there may be a brief period of confusion upon first awakening from the episode, within a few minutes the patient's behavior and mental activity are unimpaired.

• After the episode or the next morning, the patient has no memory for the episode.

• These symptoms cause clinically important distress or impair work, social or personal functioning.

• The symptoms are not directly caused by a general medical condition or substance use, including medications and drugs of abuse.

Insomnia Related to [Axis I or Axis II disorder]

• For at least a month, the patient's main complaint has been trouble going to sleep, staying asleep or feeling unrested.

• The insomnia causes daytime fatigue or impairs daytime functioning.

• The insomnia (or daytime sequel) causes clinically important distress or impairs work, social or personal functioning.

• Although it is serious enough to warrant clinical attention, the clinician believes another Axis I or II disorder (such as Generalized Anxiety or Major Depressive or Adjustment Disorder) causes it.

• Another Sleep Disorder (such as a parasomnia, Narcolepsy or Breathing-Related Sleep Disorder) does not explain the symptoms better.

• The insomnia is not directly caused by a general medical condition or substance use, including medications and drugs of abuse.

Hypersomnia Related to [Axis I or Axis II disorder]

• For at least a month the patient's main complaint has been excessive sleepiness. This has occurred almost daily and has been shown by either or both of:
  -Prolonged sleep or
  -Sleeping during the day, almost daily

• This sleepiness causes clinically important distress or impairs work, social or personal functioning.

• Although it is serious enough to warrant clinical attention, the clinician believes another Axis I or II disorder (such as Dysthymia or Major Depressive Disorder) causes it.

• The symptoms are not directly caused by a general medical condition or substance use, including medications and drugs of abuse.

• Neither inadequate sleep or another sleep disorder (such as a parasomnia, Narcolepsy or Breathing-Related Sleep Disorder) explains the symptoms better.

• The insomnia is not directly caused by a general medical condition or substance use, including medications and drugs of abuse.

Sleep Disorder Due to a General Medical Condition

• The patient has a sleep problem serious enough to warrant clinical attention.

• History, physical exam or laboratory findings suggest a general medical condition that seems likely to have directly caused this problem.

• The sleep problem causes clinically important distress or impairs work, social or personal functioning.

• It isn't better explained by another mental disorder (such as Adjustment Disorder, with a serious medical condition as the stressor).

• The problem is not due to Narcolepsy or a Breathing-Related Sleep Disorder.

• It doesn't occur solely during a delirium.

Based on predominant symptoms, specify:

     780.52 Insomnia Type
     780.54 Hypersomnia Type
     780.59 Parasomnia Type
     780.59 Mixed Type (there is more than one type and none predominates)

Coding Note

Use the name of the actual general medical condition in the Axis I name.

Code the general medical condition itself on Axis III.

Substance-Induced Sleep Disorder

• The patient has a sleep problem serious enough to warrant clinical attention.

• History, physical exam or laboratory data substantiate that either
  -These symptoms have developed within a month of Substance Intoxication or Withdrawal, or
  -Medication use has caused the symptoms

• No other Sleep Disorder better accounts for these symptoms.*

• The symptoms don't occur solely during a delirium.

• The symptoms cause clinically important distress or impair work, social or personal functioning.

Codes for Substance-Induced Sleep Disorders

291.8 Alcohol

292.89 Amphetamine (or Amphetamine-Like Substance), Caffeine, Cocaine, Opioid, Sedative, Hypnotic, or Anxiolytic, Other [or Unknown] Substance

Depending on the dominant symptomatology, specify whether:

     Insomnia Type
     Hypersomnia Type
     Parasomnia Type
     Mixed Type (there is more than one type and none predominates)

If criteria are met for intoxication or withdrawal with the particular substance and symptoms develop during that phase, specify:

     With Onset During Intoxication
     With Onset During Withdrawal

Coding Notes

*No other sleep disorder must better account for the symptoms than does substance abuse. Historical information could suggest that this is the case:

a. Sleep disorder symptoms precede the onset of substance abuse.

b. There have been previous episodes of a sleep disorder not related to substance abuse.

c. The symptoms are much worse than you would expect for the amount and duration of the substance abuse.

d. Sleep disorder symptoms continue long (at least a month) after substance abuse or withdrawal stops.

The diagnosis of a Substance-Induced Sleep Disorder should be made only when the symptoms considerably exceed what you would expect from an ordinary case of Intoxication or Withdrawal from that specific substance.

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