Sleep Related Hypoventilation DSM-5 327.24 (G47.34), 327.25 (G47.35), 327.26 (G47.36)
DSM-5 Category: Sleep-Wake Disorders
Introduction
Sleep-Related Hypoventilation is a DSM -5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), diagnosis involving inadequate respiratory effort during sleep. There are multiple causative factors at work in this disorder (American Psychiatric Association, 2013). Respiration is a semi-autonomic activity, meaning that our autonomic, or involuntary nervous system maintains respiration according to our oxygen demands, in turn dictated by factors including activity level- e.g., sprinting up an incline requires more oxygen intake and CO2 removal than sitting quietly in a chair. However, we have a degree of voluntary control over our respiration when awake and alert, When sleeping, and unable to deliberately influence our respiratory rate and depth, our autonomic nervous system typically takes control and maintains our respiration at nominal levels. In Sleep Related Hypoventilation disorder, that mechanism breaks down.
This disorder may be cormorbid with sleep apnea, but it is a discreet disorder. Sleep apnea involves repeated episodes of cessation of respiration, consequential Hypercapnia (increased blood levels of CO2), and awakening to reflexively breathe. Other individuals experience breathing difficulties during onset of sleep, but this is typically caused by autonomic arousal, such as anxiety, or a heavy meal before bed. An individual will stop breathing and awaken with a sudden start,and sometimes a feeling of suffocation. The respiratory cessation is very brief, and maybe related to a hypersensitive suffocation response. A few brief seconds of apnea is normally experienced by most individuals at the onset of sleep but for an anxious individual, this may induce a panic response, and they awaken gasping for breath. In Hypoventilation, respiration is maintained, but shallow breaths are taken for a period of more than 10 seconds. This may result in awakening, and objective measures will indicate reduced oxygen levels, increased CO2 levels, and either an abnormally elevated or slowed hear rate.
Symptoms of Sleep-Related Hypoventilation
Sleep apnea causes restlessness, poor quality sleep, snoring, headaches, tiredness during the day and heart arrhythmia. Heart failure is a possible complication when oxygen levels in the blood are chronically too low. According to the DSM-5, persons with Sleep Related Hypoventilation will present with abnormally high C02 levels due to respiratory insufficiency, which is attributable to another sleep disorder. The abnormal CO2 levels will be detected during a polysomnography study. There are three specifiers with different DSM -5 numerical codes: 1. 327.24 Idiopathic Hypoventilation, in which there is not specifically identifiable cause, 2. 327.25 Congenital central alveolar hypoventilation, which occurs perinatally, with sleep related apnea, respiratory insufficiency, or cyanosis, and 3. 327.26 comorbid sleep related hypoventilation, which occurs due to a medical condition, or use of ethanol, opiates or benzodiazepines, all of which have the potential to produce respiratory depression. Severity may also e specified and there is an Obesity related hypoventilation subtype disorder. (American Psychiatric Association, 2013).
Incidence and Prevalence
The DSM -5 describes the incidence of Idiopathic Hypoventilation as : very uncommon” but does not define this more specifically. (American Psychiatric Association, 2013).However, the incidence of the Obesity related subtype of hypoventilation is presumed to increase, given increased rates of obesity and morbid obesity in the United States and throughout the world (Mokhlesi B, 2010).The Congenital central alveolar type is of unknown prevalence, but 'rare”, and co-morbid sleep related hypoventilation is “ much more common” (American Psychiatric Association, 2013). The prevalence of Sleep related Hypoventilation disorder increases with age, and is mostly seen in persons over 50. (Fayyaz, Lessnau & Mosenifar, 2014)
Risk Factors
The DSM-5 notes that use of CNS ( Central nervous System) depressants is associated with respiratory depression. Alcohol, Tricyclic antidepressants, benzodiazepines, and opiates are probably the most commonly used, (Weiss, 2013) the latter two either by prescription or illicit diversion. Idiopathic sleep related hypoventilation is typically due to a a lack of response to normal response to C02 indicative of neurological abnormalities in the Pons and medulla oblongata. Co-morbid medical conditions can also be responsible for hypoventilation such as a primary pulmonary disorder- e.g, emphysema or COPD (Chronic Obstructive Pulmonary Disease). In one study, 43% of n=53 patients with COPD had sleep related Hypoventilation. (Fayyaz, Lessnau & Mosenifar, 2014).Another cause can be thyroid insufficiency, a neuromuscular disorder such as a cervical spinal cord injury, or chest wall disorder, Congenital central alveolar hypoventilation is a condition in which there is lack of autonomic sensitivity and responsiveness to C02, resulting in a lack of respiratory drive. (American Psychiatric Association, 2013). Sleep related hypoventilation can also be related to obesity, of which the incidence has increased in the United States (Mokhlesi, 2010).
Comorbidity
Sleep hypoventilation disorder is comorbid with a multitude of medical conditions according to the DSM -5. As previously noted, this can include COPD, cervical spinal cord injury, obesity, Alcohol, opiate,or benzodiazepine use, and obstructive sleep Apnea. (American Psychiatric Association, 2013). It should be noted that respiratory depression can occur even with prescribed benzodiazepines and opiates, taken as directed. The potential for respiratory depression is even greater when these drugs are abused, or mixed with one another, especially benzodiazepines (Weiss, 2013) and alcohol.
Treatment for Sleep-Related Hypoventilation
The DSM-5 does not specify treatment options for this disorder, Treatment options depend on the etiology of the hypoventilation disorder, Substance abuse counseling, either inpatient or outpatient, with adjunctive follow up through a 12-step self help group e.g. AA (Alcoholics Anonymous) or NA (Narcotics Anonymous) is indicated if the hypoventilation disorder can be attributed to abuse of alcohol, opiates, or benzodiazepines. If COPD or other respiratory difficulty are contributing factors, smoking cessation is indicated to ameliorate symptoms. If the hypoventilation disorder is obesity related, weight loss is indicated, and can be facilitated by CBT (Cognitive Behavioral Therapy) (Cooper,Doll, Hawker, Byrne, Bonner, Eeley, O’Connor, & Fairburn, 2010)or an appropriate support group,such as OA (Overeaters Anonymous) or Weight Wwatchers.
Impact on Functioning
Sleep related hypoventilation disorder can have a serious impact on one's health. Chronic high level of blood CO2 and low blood oxygen levels can result in constriction of pulmonary blood vessels producing pulmonary hypertension, and right sided heat failure. Cardiac arrhythmia and cognitive impairment can result. (American Psychiatric Association, 2013). Overall quality of life can decline, increased health care expenses are incurred, and life span can be significantly shortened. (Mokhlesi, 2010).
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th Edition). Washington, DC.
Cooper,Z., Doll, H.A., Hawker, D.M., Byrne, S., Bonner, G., Eeley, E., O’Connor, M.E., and Fairburn, C.G. (2010) Testing a new cognitive behavioral treatment for obesity: A randomized controlled trial with three-year follow-up Behavioral Research and Therapy. 48(8): 706–713. doi: 10.1016/j.brat.2010.03.008 PMCID: PMC2923743
Fayyaz, J., Lessnau , K. and Mosenifar, Z. (2014). Hypoventilation Syndromes. Medscape. Retrieved February 28, 2014 from http://emedicine.medscape.com/article/304381-overview
Mokhlesi B, (2010). Obesity Hypoventilation Syndrome: A state of the art review. Respiratory care (55). 10. 1347-1362. Retrieved February 28, 2014 from www.ncbi.nlm.nih.gov/pubmed/20875161
Weiss, .B. D., (2013). Extended release and long acting opioid analgesics: Risk and Mitigating Factors. CME Bulletin. (12). 3. Retrieved March 1, 2014 from http://www.aafp.org/dam/AAFP/documents/cme/bulletins/rems.pdf
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