Sleep-Wake Disorders
Circadian Rhythm Sleep-Wake Disorder
ICD-10-CM: G47.20
1. Criteria
DSM Criteria
Criterion A
- There is a persistent or recurrent pattern of sleep disruption due primarily to alteration of the circadian system or misalignment between the endogenous circadian rhythm and the sleep-wake schedule required by the person's environment.
DSM Criteria
Criterion B
- The sleep disruption leads to excessive sleepiness, insomnia, or both.
DSM Criteria
Criterion C
- The sleep disturbance causes clinically significant distress or impairment.
2. Context
- Circadian rhythm sleep-wake disorder is a mismatch between the person's internal clock and the sleep schedule that their life requires. Patients often say they can sleep, just not at the time they need to, and that distinction is often what separates circadian problems from primary insomnia.
- Clock mismatch: The central issue is timing. The sleep pattern may work biologically, but it is misaligned with social or occupational demands.
- Subtype matters: Delayed sleep-wake phase, advanced phase, irregular sleep-wake rhythm, non-24-hour type, and shift-work type can look quite different in practice.
- History first: A careful sleep schedule history and sleep diary are often more helpful than a generic sleep complaint alone.
- Clinical focus: Most useful first tool for seeing the actual pattern across days and weeks.
3. Validated scales
Sleep diary
Most useful first tool for seeing the actual pattern across days and weeks.
Actigraphy
Helpful when trying to document sleep timing and circadian pattern objectively.
Epworth Sleepiness Scale
Useful if daytime sleepiness is prominent.
4. FDA approved treatments
FDA-approved medication relevant to circadian disorders
Tasimelteon has FDA labeling for non-24-hour sleep-wake disorder in blind adults. Other circadian interventions are often behavioral, light-based, or used off-label.
Common off-label medications
Interventional psychiatry modalities
- Light therapy and schedule-based interventions are more central here than interventional psychiatry procedures.
- TMS, ketamine, and ECT are not standard treatments for circadian rhythm sleep-wake disorders.
- Care often depends on subtype-specific chronotherapy and behavioral planning.
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