Psychiatric Annals

Guest Editorial Free

This issue: Sleep Disorders

Imran S. Khawaja, MD, FAASM; Thomas D. Hurwitz, MD

This issue of Psychiatric Annals presents a timely review of sleep disorders in light of the new editions of both the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) and the International Classification of Sleep Disorders, third edition (ICSD-3).1,2

Sleep disturbance is disproportionately prevalent in our psychiatric practices.3 Not only is there frequent comorbidity of sleep and psychiatric disorders, but evidence suggests that this influences the course and outcome of patients’ conditions. For instance, the presence of insomnia can complicate the severity of an illness and even increase the possibility of suicide.4 Treating the disorders simultaneously would seemingly improve the outcome of both conditions.5,6 Therefore, it is imperative for mental health providers to have a good understanding of sleep disorders.

In the first article, the authors describe the important developments for diagnosis of insomnia disorder based on DSM-5 and ICSD-3 criteria. Difficulty initiating or maintaining sleep is one of the most common symptoms of patients with psychiatric illness. Clear evidence is emerging to support consideration of insomnia as a comorbid disorder rather than a secondary process, and that treatment of both the psychiatric disorder and insomnia simultaneously provides positive benefit for both conditions.

The next article, “Obstructive Sleep Apnea: An Update for Mental Health Providers,” provides an overview of this sleep disorder. Not only is this a common disorder in the general population, but the authors underscore the association between it and depressive illness. The psychiatrist might be the first provider to consider it in a given patient, and its confirmation and therapy can greatly assist in treatment. The article describes clinical symptoms common in sleep apnea, differential diagnosis, and updated treatment options. The authors also provide tips on helping patients improve adherence with the use of continuous positive airway pressure.

In the article, “Hypersomnolence Disorders in DSM-5: A Review for Clinicians,” the authors review the topic of excessive daytime sleepiness (EDS), which includes narcolepsy and idiopathic hypersomnia. Updated information on pathophysiology of these disorders is reviewed. The symptom of EDS is a frequent complaint of psychiatric patients, often associated with their psychiatric illness or pharmacotherapy. Mental health providers must be able to assess these symptoms, consider the possibility of a comorbid hypersomnia disorder, and know how to refer patients for further consultation and testing.

“The Review on Parasomnias: An Update” explores parasomnias—the fascinating group of behavioral disturbances that occur in the twilight zone between sleep and wakefulness. Parasomnias can resemble and overlap with common nocturnal experiences of patients with posttraumatic stress disorder, panic and other anxiety disorders, psychosis, and substance use disorders. They can cause serious distress and have been associated with substantial bodily injury. It is most important for psychiatrists to be familiar with these phenomena that have often been mistakenly attributed to psychiatric disorders.

The final article takes a look at restless leg syndrome (RLS)—now designated as Willis-Ekbom disease (WED). RLS/WED is a relatively common disorder, and may even be more frequent in psychiatric patients on antipsychotic medications and antidepressant medications as these medications can cause akathisia and worsen and/or mimic the symptoms.

WED/RLS can adversely affect quality of life, and it must be recognized and treated to fully benefit the affected individual.

We are thankful to the contributing authors for this issue; all are prominent educators, researchers, and clinicians. We are hopeful that you will find these articles informative and relevant to your clinical practice.


  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013
  2. American Academy of Sleep Medicine. International Classification of Sleep Disorders: Diagnostic and Coding Manual. 3rd edition. Westchester, IL: American Academy of Sleep Medicine; 2014.
  3. Malik S, Kanwar A, Sim LA, et al. The association between sleep disturbances and suicidal behaviors in patients with psychiatric diagnoses: a systematic review and meta-analysis. Syst Rev. 2014;3:18. doi:10.1186/2046-4053-3-18 [CrossRef]
  4. Pigeon WR, Pinquart M, Conner K. Meta-analysis of sleep disturbance and suicidal thoughts and behviors. J Clin Psychiatry. 2012;73(9):1160–1167. doi:10.4088/JCP.11r07586 [CrossRef]
  5. Norra C, Richter N. [Sleep disturbances and suicidality: relationships and clinical implications]. Fortschr Neurol Psychiatr. 2013;81(10):561–569.
  6. Baglioni C, Spiegelhalder K, Nissen C, Riemann D. Clinical implications of the causal relationship between insomnia and depression: how individually tailored treatment of sleeping difficulties could prevent the onset of depression. EPMA J. 2011;2(3):287–293. doi:10.1007/s13167-011-0079-9 [CrossRef]


About The Guest Editors

Imran S. Khawaja, MD, FAASM, is Board Certified in Psychiatry and Sleep Medicine by the American Board of Psychiatry and Neurology. Dr. Khawaja is the Medical Director of the Minnesota Regional Sleep Disorders Center at Hennepin County Medical Center, Minneapolis, which is one of the oldest training programs in the field of Sleep Medicine. He is also an Associate Professor of Neurology at University of Minnesota School of Medicine.

He attended medical school at the King Edward Medical University, Lahore, Pakistan. He completed his residency in Psychiatry from Westchester Medical Center/New York Medical College, Valhalla, NY, and his fellowship in Sleep Medicine from the Mayo Clinic, Rochester, MN.

Dr. Khawaja has fellow status with the American Academy of Sleep Medicine. He also received a Bush Foundation medical fellowship in 2008 to complete his training in Sleep Medicine and expand sleep medicine services at the Minneapolis VA Medical Center. He worked at the Minneapolis VA Medical Center from 2005–2013.

Dr. Khawaja has a special interest in striving to better understand the relationship between sleep disorders and psychiatric conditions.

Thomas D. Hurwitz, MD, is the Director of the Sleep Medicine Clinic at the Minneapolis VA Health Care System, and an Assistant Professor of Psychiatry at the University of Minnesota Medical School. He has been a sleep medicine clinician and educator since 1980, originally at the Minnesota Regional Sleep Disorders Center.


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