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Sleep-Wake Disorders — DSM-5-TR Companion Reference
Summarized and paraphrased from DSM-5-TR (American Psychiatric Association, 2022). This file is for orientation and education; verify exact criteria wording, codes, and recording procedures against the official DSM-5-TR before any formal clinical, legal, insurance, or research use.
Chapter Overview
This chapter covers 10 disorders or disorder groups: insomnia disorder, hypersomnolence disorder, narcolepsy, breathing-related sleep disorders, circadian rhythm sleep-wake disorders, NREM sleep arousal disorders, nightmare disorder, REM sleep behavior disorder, restless legs syndrome, and substance/medication-induced sleep disorder. The unifying theme is dissatisfaction with the quality, timing, or amount of sleep together with daytime distress or impairment, which the manual treats as a core feature shared by all of these conditions. The chapter is organized to facilitate differential diagnosis of sleep-wake complaints and to clarify when referral to a sleep specialist for polysomnography is appropriate.
The classification balances "lumping" and "splitting": DSM-IV's three insomnia categories were lumped into one insomnia disorder with comorbidity specifiers, while narcolepsy was split into separately coded types (type 1 with cataplexy or hypocretin deficiency; type 2 without). The manual notes its approach is simpler and less differentiated than the International Classification of Sleep Disorders, 3rd edition (ICSD-3), and shows superior interrater reliability. Biological validators matter here more than in most DSM chapters: CSF hypocretin-1 for narcolepsy, polysomnography for the breathing-related disorders, and periodic limb movements for restless legs syndrome.
Coding convention (dual F-codes and G-codes). The manual prints ICD-10-CM codes from two blocks. F-codes (mental and behavioral disorders) are used for insomnia disorder (F51.01), hypersomnolence disorder (F51.11), NREM sleep arousal disorders (F51.3/F51.4), nightmare disorder (F51.5), and the substance/medication-induced sleep disorders (F10.182–F19.982). G-codes (diseases of the nervous system) are used for narcolepsy (G47.411–G47.429), breathing-related disorders (G47.31–G47.37), circadian rhythm sleep-wake disorders (G47.20–G47.26), REM sleep behavior disorder (G47.52), restless legs syndrome (G25.81), and the other-specified/unspecified categories (G47.00/G47.09, G47.10/G47.19, G47.8/G47.9). Record exactly the code printed for each disorder; do not substitute between blocks.
Disorders in this chapter
| Disorder | ICD-10-CM code(s) | One-line "what it is" |
|---|---|---|
| Insomnia Disorder | F51.01 | Dissatisfaction with sleep quantity/quality: trouble initiating, maintaining, or early awakening, with daytime distress/impairment |
| Hypersomnolence Disorder | F51.11 | Excessive sleepiness despite ≥7 h sleep: sleep lapses, >9 h nonrestorative sleep, or difficulty being fully awake |
| Narcolepsy | G47.411 / G47.419 / G47.421 / G47.429 | Recurrent irrepressible sleep need with cataplexy and/or hypocretin deficiency (type 1) or PSG/MSLT findings (type 2) |
| Obstructive Sleep Apnea Hypopnea | G47.33 | Repeated upper-airway obstruction during sleep with apneas/hypopneas on PSG |
| Central Sleep Apnea | G47.31 / R06.3 / G47.37 | Central apneas from ventilatory-control instability: idiopathic, Cheyne-Stokes breathing, or opioid-related |
| Sleep-Related Hypoventilation | G47.34 / G47.35 / G47.36 | Elevated CO2 during sleep: idiopathic, congenital central alveolar, or comorbid (obesity, pulmonary, opioids) |
| Circadian Rhythm Sleep-Wake Disorders | G47.21–G47.26, G47.20 | Misalignment between endogenous circadian rhythm and the required sleep-wake schedule |
| NREM Sleep Arousal Disorders | F51.3 / F51.4 | Sleepwalking and sleep terrors: incomplete awakenings from deep NREM sleep with amnesia |
| Nightmare Disorder | F51.5 | Repeated extended dysphoric, well-remembered dreams (usually REM, second half of night) |
| REM Sleep Behavior Disorder | G47.52 | Dream-enactment vocalization/motor behavior during REM with REM sleep without atonia |
| Restless Legs Syndrome | G25.81 | Urge to move legs with unpleasant sensations, worse at rest and in the evening/night |
| Substance/Medication-Induced Sleep Disorder | F10.182–F19.982 (class-dependent) | Insomnia, daytime sleepiness, parasomnia, or mixed type caused by a substance/medication |
| Other Specified / Unspecified Insomnia | G47.09 / G47.00 | Insomnia symptoms not meeting full criteria, with/without a recorded reason |
| Other Specified / Unspecified Hypersomnolence | G47.19 / G47.10 | Hypersomnolence symptoms not meeting full criteria, with/without a recorded reason |
| Other Specified / Unspecified Sleep-Wake Disorder | G47.8 / G47.9 | Other sleep-wake symptoms not meeting full criteria for any specific disorder |
Parts of this chapter reference
| Part | Scope |
|---|---|
| 21-sleep-wake-insomnia-hypersomnia-narcolepsy-breathing.md | Insomnia disorder, hypersomnolence disorder, narcolepsy, and the breathing-related sleep disorders (obstructive sleep apnea hypopnea, central sleep apnea, sleep-related hypoventilation) |
| 21-sleep-wake-circadian-parasomnias-and-movement.md | Circadian rhythm sleep-wake disorders, NREM sleep arousal disorders, nightmare disorder, REM sleep behavior disorder, restless legs syndrome, and general conversation principles |
| 21-sleep-wake-substance-medication-induced-and-other.md | Substance/medication-induced sleep disorder and the other specified and unspecified sleep-wake categories |
Cross-Cutting Considerations
Sleep-wake complaints and suicidal thoughts or behavior
A review of multiple studies found that insomnia may increase the risk of suicidal thoughts, suicidal behavior, and death even after adjustment for depression, and that nightmares increase the risk of suicidal thoughts and behavior. In one college-student study, 31.3% of those with sleep problems had suicidal thoughts, while 82.7% of those with suicidal thoughts had sleep problems. An American Academy of Sleep Medicine review concluded that in teenagers, fewer than 8 hours of sleep is associated with increased risk of self-harm, suicidal thoughts, and suicidal behavior. Ask about sleep directly in suicide risk assessment (see 01-safety-and-boundaries.md).
When to refer for a sleep study (PSG / MSLT)
- Suspected obstructive sleep apnea (snoring + observed pauses/gasping + daytime sleepiness) — PSG or out-of-center sleep testing.
- Suspected narcolepsy or hypersomnolence disorder — nocturnal PSG followed by MSLT, on adequate sleep and off REM-altering medications.
- Suspected central sleep apnea, sleep-related hypoventilation, or treatment-emergent central apnea.
- REM sleep behavior disorder — PSG with video and EMG to document REM sleep without atonia; also to rule out seizures or OSA mimicking parasomnias.
- Adult-onset sleepwalking/sleep terrors without childhood history, or parasomnias with atypical features or injury.
- Restless legs syndrome with uncertain diagnosis (PLMS support) or suspected periodic limb movement disorder.
- Insomnia in older adults where comorbid sleep apnea is likely.