The fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) won’t be published by the American Psychiatric Association APA) for a few years (May 2013). However, developing the roadmap of psychiatric diagnoses is a huge initiative as feedback is being sought from over 600 global experts. The DSM provides the standard classification of mental disorders used by mental health and other health professionals for diagnostic and research purposes. In addition, insurance companies use the DSM diagnoses to determine which psychiatric conditions will be covered by health insurance.
Over the years since the last DSM was published (1994), new research has been published on many psychiatric conditions. New research leads to new opinions on the identification and treatment of disorders. Sleep disorders, many of which often plague shift workers, have received a significant amount of attention in recent years and as a result, the current draft of the DSM-5 includes information that shift workers and their employers should be aware of. The recommendations for revisions to the DSM are posted on the APA’s web site for the manual www.DSM5.org. Public review and written comments are welcome. Comments will be reviewed and considered by the DSM-5Work Groups.
The sleep disorder work group is recommending greater inclusion of sleep disorders. This is being proposed primarily as a way to educate non-expert sleep clinicians (such as psychiatrists and general medical physicians) about sleep disorders that have mental as well as medical/neurological aspects.
Among the changes being recommended the significant ones impacting shift workers include:
1. Adding obstructive sleep apnea hypopnea syndrome to the DSM-5: this disorder was previously contained under the sleep disordered breathing category. Obstructive sleep apnea is associated with snoring, obesity, increased waist girth, and male gender. Central sleep apnea is most strongly associated with advanced age, heart failure, and diabetes. Cardiac problems associated with obstructive and central apnea are different.
- Obstructive sleep apnea is associated with ventricular ectopy which is often experienced as a strong or skipped heart beat resulting from abnormal electrical activation originating in the ventricles (heart’s lower chambers) before a normal heartbeat would occur. Studies have indicated that sleep apnea promotes ventricular ectopy.
- Central sleep apnea is more strongly associated with atrial fibrillation. During atrial fibrillation, the heart’s two upper chambers (the atria) quiver instead of beating effectively. Blood isn’t pumped completely out of the chambers, so it may pool and clot. If a piece of a blood clot in the atria leaves the heart and becomes lodged in an artery in the brain, a stroke results. About 15 percent of strokes occur in people with atrial fibrillation.
People with coronary artery disease whose blood oxygen is lowered by sleep disordered breathing may be at risk of ventricular arrhythmias and nocturnal sudden death. CPAP treatment may reduce this risk. Sleep disordered breathing, including apnea, may cause coronary artery disease and hypertension.
2. Adding primary central sleep apnea to the DSM-5. See 1. above. Point is to separate obstructive and central sleep apnea as the risk factors and outcomes for each are different.
3. Adding restless leg syndrome to the DSM-5. According to the DSM web site the rationale is that RLS is a sufficiently common syndrome to merit elevation to an independent category. In national and international studies the prevalence of RLS appears to be between 7-10% of the population, depending upon age and gender.
4. Including circadian rhythm, delayed sleep phase, advanced sleep phase, irregular sleep wake rhythm and free-running sleep disorders in the DSM-5 as separate subtypes. The rationale for this proposed change is based on new data indicating not only the differences in clinical characteristics, but also the underlying pathophysiology and in some cases, genetic basis for the different types of circadian rhythm sleep disorders.
To read more about other primary sleep disorders, follow the links below:
Primary Sleep Disorders
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