Diagnostic Features

The essential feature of Substance-Induced Sleep Disorder is a prominent disturbance in sleep that is sufficiently severe to warrant independent clinical attention (Criterion A) and is judged to be due to the direct physiological effects of a substance (i.e., a drug of abuse, a medication, or toxin exposure) (Criterion B). Depending on the substance involved, one of four types of sleep disturbance may be noted. Insomnia and Hypersomnia Types are most common, and Parasomnia Type is seen less often. A Mixed Type may also be noted when more than one type of sleep disturbance is present and none predominates. The disturbance must not be better accounted for by a mental disorder (e.g., another Sleep Disorder) that is not substance induced (Criterion C). The diagnosis is not made if the sleep disturbance occurs only during the course of a delirium (Criterion D). The symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion E). This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention.

A Substance-Induced Sleep Disorder is distinguished from a primary Sleep Disorder and from Insomnia or Hypersomnia Related to Another Mental Disorder by considering the onset and course. For drugs of abuse, there must be evidence from the history, physical examination, or laboratory findings of Dependence, Abuse, intoxication, or withdrawal.

Substance-Induced Sleep Disorder arises only in association with intoxication or withdrawal states, whereas the primary Sleep Disorders may precede the onset of substance use or occur during times of sustained abstinence. Because the withdrawal state for some substances with long half-lives (e.g., some benzodiazepines) can be relatively protracted, the onset of the sleep disturbance can occur up to 4 weeks after cessation of substance use but is usually seen within days of abstinence. Another consideration is the presence of features that are atypical of primary Sleep Disorders (e.g., atypical age at onset or course). In contrast, factors that suggest that the sleep disturbance is better accounted for by a primary Sleep Disorder include persistence of the sleep disturbance for more than about a month after the end of intoxication or acute withdrawal; the development of symptoms that are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or a history of a prior primary Sleep Disorder.

Subtypes and Specifiers

The subtypes listed below can be used to indicate which of the following symptom presentations predominates. The clinical presentation of the specific Substance-Induced Sleep Disorder may resemble that of the analogous primary Sleep Disorder. However, the full criteria for the analogous primary Sleep Disorder do not need to be met to assign a diagnosis of Substance-Induced Sleep Disorder.

Insomnia Type. This subtype refers to a sleep complaint characterized primarily by difficulty falling asleep, difficulty maintaining sleep, or a feeling of nonrestorative sleep.

Hypersomnia Type. This subtype is used when the predominant complaint is one of excessively long nocturnal sleep or of excessive sleepiness during waking hours.

Parasomnia Type. This subtype refers to a sleep disturbance characterized primarily by abnormal behavioral events that occur in association with sleep or sleep-wake transitions.

Mixed Type. This subtype should be used to designate a substance-induced sleep problem characterized by multiple types of sleep symptoms but no symptom clearly predominates.

The context of the development of the sleep symptoms may be indicated by using one of the following specifiers:

With Onset During Intoxication. This specifier should be used if criteria are met for intoxication with the substance and symptoms develop during the intoxication syndrome.

With Onset During Withdrawal. This specifier should be used if criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, a withdrawal syndrome.

Recording Procedures

The name of the Substance-Induced Sleep Disorder begins with the specific substance (e.g., alcohol, methylphenidate, thyroxine) that is presumed to be causing the sleep disturbance. The diagnostic code is selected from the listing of classes of substances provided in the criteria set for Substance-Induced Sleep Disorder. For substances that do not fit into any of the classes (e.g., thyroxine), the code for “Other Substance” should be used. In addition, for medications prescribed at therapeutic doses, the specific medication can be indicated by listing the appropriate E-code. The name of the disorder (e.g., Caffeine-Induced Sleep Disorder) is followed by the subtype indicating the predominant symptom presentation and the specifier indicating the context in which the symptoms developed (e.g., 292.89 Caffeine-Induced Sleep Disorder, Insomnia Type, With Onset During Intoxication). When more than one substance is judged to play a significant role in the development of the sleep disturbance, each should be listed separately (e.g., 292.89 Cocaine-Induced Sleep Disorder, Insomnia Type, With Onset During Intoxication; 291.89 Alcohol-Induced Sleep Disorder, Insomnia Type, With Onset During Withdrawal). If a substance is judged to be the etiological factor but the specific substance or class of substance is unknown, the category 292.89 Unknown Substance-Induced Sleep Disorder may be used.

Specific Substances

Substance-Induced Sleep Disorder most commonly occurs during intoxication with the following classes of substances: alcohol; amphetamine and related substances; caffeine; cocaine; opioids; and sedatives, hypnotics, and anxiolytics. Sleep disturbances are also seen less commonly with intoxication with other types of substances. Substance-Induced Sleep Disorder can also occur in association with withdrawal from the following classes of substances: alcohol; amphetamine and related stimulants; cocaine; opioids; and sedatives, hypnotics, and anxiolytics. Each of the Substance-Induced Sleep Disorders produces EEG sleep patterns that are associated with, but cannot be considered diagnostic of, the disorder. The EEG sleep profile for each substance is further related to the stage of use, whether intoxication, chronic use, or withdrawal following discontinuation of the substance.

Alcohol. Alcohol-Induced Sleep Disorder typically occurs as the Insomnia Type. During acute intoxication, alcohol typically produces an immediate sedative effect, with increased sleepiness and reduced wakefulness for 3-4 hours. This is accompanied by an increase in stages 3 and 4 non-rapid eye movement (NREM) sleep and reduced rapid eye movement (REM) sleep during EEG sleep studies. Following these initial effects, the individual has increased wakefulness, restless sleep, and, often, vivid and anxiety-laden dreams for the rest of the sleep period. EEG sleep studies show that, in the second half of sleep after alcohol ingestion, stages 3 and 4 sleep is reduced, wakefulness is increased, and REM sleep is increased. Alcohol can aggravate Breathing-Related Sleep Disorder by increasing the number of obstructive apnea events. With continued habitual use, alcohol continues to show a short-lived sedative effect for several hours, followed by sleep continuity disruption for several hours.

During Alcohol Withdrawal, sleep is grossly disturbed. The individual typically has extremely disrupted sleep continuity, accompanied by an increase in the amount and intensity of REM sleep. This is often accompanied by an increase in vivid dreaming and, in the most extreme example, constitutes part of Alcohol Withdrawal Delirium. After acute withdrawal, individuals who have chronically used alcohol may continue to complain of light, fragmented sleep for weeks to years. EEG sleep studies confirm a persistent deficit in slow-wave sleep and persistent sleep continuity disturbance in these cases.

Amphetamines and related stimulants. Amphetamine-Induced Sleep Disorder is characterized by insomnia during intoxication and by hypersomnia during withdrawal. During the period of acute intoxication, amphetamine reduces the total amount of sleep, increases sleep latency and sleep continuity disturbances, increases body movements, and decreases REM sleep. Slow-wave sleep tends to be reduced. During withdrawal from chronic amphetamine use, individuals typically experience hypersomnia, with both prolonged nocturnal sleep duration and excessive sleepiness during the daytime. REM and slow-wave sleep may rebound to above baseline values. Multiple Sleep Latency Tests (MSLTs) may show increased daytime sleepiness during the withdrawal phase as well.

Caffeine. Caffeine-Induced Sleep Disorder typically produces insomnia, although some individuals may present with a complaint of hypersomnia and daytime sleepiness related to withdrawal. Caffeine exerts a dose-dependent effect, with increasing doses causing increased wakefulness and decreased sleep continuity. Polysomnography may show prolonged sleep latency, increased wakefulness, and a decrease in slow-wave sleep. Consistent effects on REM sleep have not been described. Abrupt withdrawal from chronic caffeine use can produce hypersomnia. Some individuals may also experience hypersomnia between daytime doses of caffeine, as the immediate stimulant effect wanes.

Cocaine. As with other stimulants, cocaine typically produces insomnia during acute intoxication and hypersomnia during withdrawal. During acute intoxication, the total amount of sleep may be drastically reduced, with only short bouts of very disrupted sleep. Conversely, withdrawal after a cocaine binge is often associated with extremely prolonged sleep duration.

Opioids. During acute short-term use, opioids typically produce an increase in sleepiness and in subjective depth of sleep. REM sleep is typically reduced by acute administration of opioids, with little overall change in wakefulness or total sleep time. With continued administration, most individuals become tolerant to the sedative effects of opioids and may begin to complain of insomnia. This is mirrored by increased wakefulness and decreased sleep time in polysomnographic studies. Withdrawal from opioids is typically accompanied by hypersomnia complaints, although few objective studies have documented this finding.

Sedatives, hypnotics, and anxiolytics. Drugs within this class (e.g., barbiturates, benzodiazepines, meprobamate, glutethimide, and methyprylon) have similar, but not identical, effects on sleep. Differences in duration of action and half-life may affect sleep complaints and objective measures of sleep. In general, barbiturates and the older nonbarbiturate, nonbenzodiazepine drugs more consistently produce tolerance, dependence, and severe withdrawal, but these phenomena can be noted with benzodiazepines as well.

During acute intoxication, sedative-hypnotic drugs produce the expected increase in sleepiness and decrease in wakefulness. Polysomnographic studies confirm these subjective effects during acute administration, as well as a decrease in REM sleep and an increase in sleep-spindle activity. Chronic use (particularly of barbiturates and the older nonbarbiturate, nonbenzodiazepine drugs) may cause tolerance with the resulting return of insomnia. If the individual then increases the dose, daytime hypersomnia may occur. Sedative-hypnotic drugs can aggravate Breathing-Related Sleep Disorder by increasing the frequency and severity of obstructive sleep apnea events.

The abrupt discontinuation of chronic sedative-hypnotic use can lead to withdrawal insomnia. In addition to decreased sleep duration, withdrawal can produce increased anxiety, tremulousness, and ataxia. Barbiturates and the older nonbarbiturate, nonbenzodiazepine drugs are also associated with a high incidence of withdrawal seizures, which are much less frequently observed with benzodiazepines. Typically, sedative-hypnotic drugs with short durations of action are most likely to produce complaints of withdrawal insomnia, whereas those with longer durations of action are more often associated with daytime hypersomnia during active use. However, any sedative-hypnotic drug can potentially cause either daytime sedation or withdrawal insomnia. Withdrawal from sedative-hypnotic agents can be confirmed by polysomnographic studies, which show reduced sleep duration, increased sleep disruption, and REM sleep “rebound.”

Other substances. Other substances may produce sleep disturbances. Common examples include medications that affect the central or autonomic nervous systems (including adrenergic agonists and antagonists, dopamine agonists and antagonists, cholinergic agonists and antagonists, serotonergic agonists and antagonists, antihistamines, and corticosteroids). Clinically, such medications are prescribed for the control of hypertension and cardiac arrhythmias, chronic obstructive pulmonary disease, gastrointestinal motility problems, or inflammatory processes.

Differential Diagnosis

Sleep disturbances are commonly encountered in the context of Substance Intoxication or Substance Withdrawal. A diagnosis of Substance-Induced Sleep Disorder should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the sleep disturbance is judged to be in excess of that usually associated with the intoxication or withdrawal syndrome and when the disturbance is sufficiently severe to warrant independent clinical attention. For example, insomnia is a characteristic feature of Sedative, Hypnotic, or Anxiolytic Withdrawal. Sedative-, Hypnotic-, or Anxiolytic-Induced Sleep Disorder should be diagnosed instead of Sedative, Hypnotic, or Anxiolytic Withdrawal only if the insomnia is more severe than that usually encountered with Sedative, Hypnotic, or Anxiolytic Withdrawal and requires special attention and treatment. If the substance-induced sleep disturbance occurs exclusively during the course of a delirium, the sleep disturbance is considered to be an associated feature of the delirium and is not diagnosed separately. In substance-induced presentations that contain a mix of different types of symptoms (e.g., sleep, mood, and anxiety), the specific type of Substance-Induced Disorder to be diagnosed depends on which type of symptoms predominates in the clinical presentation.

A Substance-Induced Sleep Disorder is distinguished from a primary Sleep Disorder and from Insomnia or Hypersomnia Related to Another Mental Disorder by the fact that a substance is judged to be etiologically related to the symptoms.

A Substance-Induced Sleep Disorder due to a prescribed treatment for a mental disorder or general medical condition must have its onset while the person is receiving the medication (or during withdrawal, if there is a withdrawal syndrome associated with the medication). Once the treatment is discontinued, the sleep disturbance will usually remit within days to several weeks (depending on the half-life of the substance and the presence of a withdrawal syndrome). However, as discussed above, some form of sleep problem can persist at decreasing intensity for months following Sedative, Hypnotic, or Anxiolytic Withdrawal. With these exceptions, if symptoms persist beyond 4 weeks, other causes for the sleep disturbance should be considered. Not infrequently, individuals with a primary Sleep Disorder use medications or drugs of abuse to relieve their symptoms. If the clinician judges that the substance is playing a significant role in the exacerbation of the sleep disturbance, an additional diagnosis of a Substance-Induced Sleep Disorder may be warranted.

A Substance-Induced Sleep Disorder and Sleep Disorder Due to a General Medical Condition can also be difficult to distinguish. Both may produce similar symptoms of insomnia, hypersomnia, or (more rarely) a Parasomnia. Furthermore, many individuals with general medical conditions that cause a sleep complaint are treated with medications that may also cause disturbances in sleep. The chronology of symptoms is the most important factor in distinguishing between these two causes of sleep disturbance. For instance, a sleep disturbance that clearly preceded the use of any medication for treatment of a general medical condition would suggest a diagnosis of Sleep Disorder Due to a General Medical Condition. Conversely, sleep symptoms that appear only after the institution of a particular medication or substance would suggest a Substance-Induced Sleep Disorder. In a similar way, a sleep disturbance that appears during treatment for a general medical condition but that improves after the medication is discontinued suggests a diagnosis of Substance-Induced Sleep Disorder. If the clinician has ascertained that the disturbance is due to both a general medical condition and substance use, both diagnoses (i.e., Sleep Disorder Due to a General Medical Condition and Substance-Induced Sleep Disorder) are given. When there is insufficient evidence to determine whether the sleep disturbance is due to a substance (including a medication) or to a general medical condition or is primary (i.e., not due to either a substance or a general medical condition), Parasomnia Not Otherwise Specified or Dyssomnia Not Otherwise Specified would be indicated.

Diagnostic criteria for Substance-Induced Sleep Disorder

A. A prominent disturbance in sleep that is sufficiently severe to warrant independent clinical attention.
B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2):
(1) the symptoms in Criterion A developed during, or within a month of, Substance Intoxication or Withdrawal
(2) medication use is etiologically related to the sleep disturbance

C. The disturbance is not better accounted for by a Sleep Disorder that is not substance induced. Evidence that the symptoms are better accounted for by a Sleep Disorder that is not substance induced might include the following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non-substance-induced Sleep Disorder (e.g., a history of recurrent non-substance-related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the sleep symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention.

Code [Specific Substance]-Induced Sleep Disorder:

(291.89 Alcohol; 292.89 Amphetamine; 292.89 Caffeine; 292.89 Cocaine; 292.89 Opioid; 292.89 Sedative, Hypnotic, or Anxiolytic; 292.89 Other [or Unknown] Substance)

Specify type:

Insomnia Type: if the predominant sleep disturbance is insomnia

Hypersomnia Type: if the predominant sleep disturbance is hypersomnia

Parasomnia Type: if the predominant sleep disturbance is a Parasomnia

Mixed Type: if more than one sleep disturbance is present and none predominates

Specify if:

With Onset During Intoxication: if the criteria are met for Intoxication with the substance and the symptoms develop during the intoxication syndrome

With Onset During Withdrawal: if criteria are met for Withdrawal from the substance and the symptoms develop during, or shortly after, a withdrawal syndrome