Obstructive Sleep Apnea Hypopnea DSM-5 327.23 (G47.33)

Obstructive Sleep Apnea Hypopnea DSM-5 327.23 (G47.33)

DSM-5 Category: Breathing Related Sleep Disorders


Obstructive sleep apnea hypopnea (OSAH) is a disturbance in breathing during sleep. A diagnosis is based on the number of episodes of partial or complete upper airway collapse while sleeping measured through overnight monitoring. Nocturnal breathing disturbances are measured via a polysomnography – a test that monitors biophysiological change during sleep, including the brain, eye movements, and heart rhythms. Nocturnal sleep disturbances include snoring, gasping, and breathing pauses. A diagnosis is made when five or more apneas or hypopneas are identified in an hour. The sleep disturbances can also cause daytime impairments including sleepiness, fatigue and unrefreshing sleep. The incidence of sleep apnea in the US population is around 17% (Marin et al., 2012). Sleep apnea in children is often a result of developmental issues related to the growth of the nasopharynx and tonsils, which self-resolve in childhood as the child grows. In adolescence and adulthood, sleep apnea is strongly related with lifestyle diseases, especially obesity and hypotension.

Symptoms of OSAH

Obstructive sleep apnoea hypopnea symptoms include measurements of the number of apneas and hypopneas per hour, sleep fragmentation, nocturnal breathing disturbances, reduced stages in deep sleep, and daytime impairment. Apnea or hypopnea in adults is defined as breathing disturbances of at least 10 seconds or two missed breaths in children. These breathing disturbances are most often marked by snoring and daytime sleepiness.

For a diagnosis of sleep apnea under DSM-5, either criterion 1 or 2 must be met (APA, 2013):

1. Evidence by polysomnography of at least five obstructive apneas or hypopneas per hour of sleep and either of the following sleep symptoms:

a. Nocturnal breathing disturbances: snoring, snorting/gasping, or breathing pauses during sleep.

b. Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities to sleep that is not better explained by another mental disorder (including a sleep disorder) and is not attributable to another medical condition.

2. Evidence by polysomnography of 15 or more obstructive apneas and/or hypopneas per hour of sleep regardless of accompanying symptoms.

The sleep apnea severity index is as follows: Mild: Apnea hypopnea index is less than 15.

Moderate: Apnea hypopnea Index is 15-30. Severe: Apnea hypopnea index is greater than 30

The frequent disruptions of sleep can lead to insomnia, heartburn, reduced libido, and erectile dysfunction.

Risk Factors of Obstructive Sleep Apnea Hypopnea 

Obstructive sleep apnea is associated with many of the lifestyle diseases, especially obesity, cardiovascular disease and diabetes. Hypertension is prevalent in 60% of persons who have obstructive sleep apnea, according to the DSM-5 (APA, 2013). Obesity and weight gain are associated with hypertension, and strongly correlated with sleep apnea. Both these risks make persons with OSAH at higher risk of cardiovascular disease. Arterial hypertension is present in cases of sleep apnea and is a sign of early cardiovascular damage. It is also associated with arrhythmias, stroke and sudden cardiac events.

Sleep apnea is more common in males. The DSM-5 identifies two increased risk factors in males: the impact of sex hormones on ventilator control and body fat distribution, and gender differences in airway structure. The risk of sleep apnea increases with age. Untreated sleep apnoea has been associated with mortality, cardiovascular disease, stroke, diabetes and depression (Kendzerska, 2014).

Obesity is a major risk factor for OSAH. The severity of obstructive sleep apnea has been related to calorie-dense foods high in fat and carbohydrates in children and adolescents (Beebe, Miller, Kirk, Daniels, & Amin). A crowded pharyngeal airway is another risk.

In children, sleep apnoea can be harder to identify. Snoring typically begins in childhood. Frequent awakening and bedwetting can be a sign of sleep disturbances. Increased drowsiness and irritation during the day is often a sign that nocturnal sleep is being disturbed.

Among physical causes, maxillary-mandibular retrognathia is a frequent cause of sleep apnea. Retrognathia is when either the upper (maxilla) or lower (mandible) jaws are recessed or small causing obstruction of the airway path. Retrognathia is more often a cause of sleep apnea in women. Men are more apt to have large tonsils that obstruct breathing. Obstruction of the upper airway can be caused by genetic factors such as Down’s syndrome.

Treatment of OSAH

Continuous positive airway pressure (CPAP) is the most effective treatment for obstructive sleep apnea. CPAP involves wearing a mask that props open the airway and circulates air pressure during the night. Improvements have been shown across diverse sleep conditions (e.g., sleeping while watching an event, restless sleep) and quality of life measures after six months of CPAP treatment. Improvements in quality of life include in daily in functioning, social interactions, and emotional functioning. In addition, a lower incidence of hypertension was found in persons who were treated with continuous positive airway pressure (CPAP) (Marin et al., 2012). Treatments should last for at least 6 months. Below a treatment threshold, which may be longer for some patients, sleep apnea symptoms can return when treatment is stopped.

Cranial facial structure abnormalities can require surgery. Participants in a survey of maxillomandibular advancement (MMA) over 53 studies, or 627 adults, reported improvements in OSAH symptoms and quality of life (Hotly & Guilleminault, 2010). MMA is a surgical procedure that involves moving the lower and upper jaw forward. Concomitantly, the tongue may be operated on to remove obstructions to the airway.

Given the strong association of OSAH with obesity and other lifestyle diseases, a change in lifestyle is recommended. Abdominal fat volume is highly correlated with OSAH. The DSM-5 reports that weight loss can produce spontaneous resolution of sleep apnea. Since eating is associated with poor sleep and hormone imbalances, a cycle leading to growing health problems and even mortality through sudden cardiac arrest is begun once the weight gain triggers sleep apnea. A small weight loss can produce immediate results. Sleep and weight loss issues should both be addressed in any weight loss or behavioral therapy plan to identify the underlying causes of the weight gain. Consistency across diet, exercise and sleep schedules can help reduce emotion and anxiety-driven eating habits. Any weight loss should be accompanied by monitoring of changes in the cranial facial structure to gain a more precise understanding of how weight gain affects the cranial facial structure of each individual.


American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Avlonitou, E., Kapsimalis, F., Varouchakis, G., Vardavas, C. I., & Behrakis, P. (2012). Adherence to CPAP therapy improves quality of life and reduces symptoms among obstructive sleep apnea syndrome patients. Sleep and Breathing, 16(2), 563-569.

Beebe, D. W., Miller, N., Kirk, S., Daniels, S. R., & Amin, R. (2011). The association between obstructive sleep apnea and dietary choices among obese individuals during middle to late childhood. Sleep medicine, 12(8), 797-799.

Holty, J. E. C., & Guilleminault, C. (2010). Maxillomandibular advancement for the treatment of obstructive sleep apnea: a systematic review and meta-analysis. Sleep medicine reviews, 14(5), 287-297.

Kendzerska, T., Mollayeva, T., Gershon, A. S., Leung, R. S., Hawker, G., & Tomlinson, G. (2014). Untreated obstructive sleep apnea and the risk for serious long-term adverse outcomes: a systematic review. Sleep medicine reviews, 18(1), 49-59.

Marin, J. M., Agusti, A., Villar, I., Forner, M., Nieto, D., Carrizo, S. J., ... & Jelic, S. (2012). Association between treated and untreated obstructive sleep apnea and risk of hypertension. Jama, 307(20), 2169-2176.

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