Sleep-Wake Disorders

Sleep-Wake Disorders Indian Medical PG Question 1: Which of the following is false about narcolepsy?

• A. Sudden loss of muscle tone (cataplexy)
• B. Cataplexy is a common symptom
• C. Typically occurs only during nighttime sleep (Correct Answer)
• D. Typical onset in the second decade of life

Sleep-Wake Disorders Explanation: ***Typically occurs only during nighttime sleep*** - Narcolepsy is characterized by **excessive daytime sleepiness** and sudden, uncontrollable urges to sleep during the day, not exclusively nighttime sleep. - Patients with narcolepsy often experience disrupted nocturnal sleep, including **frequent awakenings** and vivid dreams. *Sudden loss of muscle tone (cataplexy)* - This statement accurately describes **cataplexy**, a hallmark symptom of narcolepsy, which is a sudden, brief loss of **muscle tone** triggered by strong emotions. - Cataplexy is a key diagnostic feature, though not all individuals with narcolepsy experience it. *Cataplexy is a common symptom* - **Cataplexy is indeed common** in narcolepsy, particularly in Narcolepsy Type 1, where it is caused by a deficiency in **hypocretin (orexin)**. - It is a defining characteristic for diagnosing narcolepsy with cataplexy. *Typical onset in the second decade of life* - The onset of narcolepsy symptoms, including excessive daytime sleepiness and cataplexy, often occurs during **adolescence or early adulthood**, typically between the ages of 10 and 25. - This timing can significantly impact education and social development.

Sleep-Wake Disorders Indian Medical PG Question 2: Severe Obstructive sleep apnea is defined as AHI of greater than

• A. 15 events/hour
• B. 30 events/hour (Correct Answer)
• C. 25 events/hour
• D. 20 events/hour

Sleep-Wake Disorders Explanation: ***30 events/hour*** - A **severe form of obstructive sleep apnea (OSA)** is diagnosed when the Apnea-Hypopnea Index (AHI) is greater than or equal to **30 events per hour** [1]. - The AHI represents the average number of **apnea and hypopnea events** per hour of sleep [1]. *15 events/hour* - An AHI of **15 to 30 events/hour** typically defines **moderate sleep apnea**, not severe. - This level indicates a significant number of sleep disturbances, but less than what is categorized as severe. *25 events/hour* - An AHI of **25 events/hour** falls within the **moderate range** of OSA severity (15-30 events/hour). - It does not meet the criteria for severe OSA, which requires a higher AHI. *20 events/hour* - An AHI of **20 events/hour** also falls into the **moderate category** of OSA. - This value is above the threshold for mild OSA (5-15 events/hour) but below the threshold for severe OSA.

Sleep-Wake Disorders Indian Medical PG Question 3: A 32-year-old man comes to the physician complaining of excessive sleepiness for the past several months. He reports falling asleep while dealing with customers and had a near accident when he fell asleep while driving. The patient reports that he occasionally hears voices while falling asleep and finds himself "temporarily frozen" and unable to move upon awakening. Which of the following is the most appropriate treatment for this patient?

• A. Melatonin
• B. Modafinil (Correct Answer)
• C. Clonazepam
• D. Continuous positive airway pressure

Sleep-Wake Disorders Explanation: ***Modafinil*** - The patient's symptoms of **excessive daytime sleepiness** (EDS), **hypnagogic hallucinations** (hearing voices while falling asleep), and **sleep paralysis** are classic signs of **narcolepsy**. - **Modafinil** is a **non-amphetamine stimulant** that promotes wakefulness and is a first-line treatment for narcolepsy, improving alertness and reducing EDS. *Melatonin* - **Melatonin** is a hormone involved in regulating the **sleep-wake cycle** and is primarily used for **insomnia**, **jet lag**, or **circadian rhythm disorders**. - It is not effective for treating the hallmark symptoms of narcolepsy, such as cataplexy or excessive daytime sleepiness. *Clonazepam* - **Clonazepam** is a **benzodiazepine** that acts as a central nervous system depressant, primarily used for **anxiety disorders**, seizures, and some sleep disorders like **REM sleep behavior disorder**. - While it can help with some parasomnias, it would worsen daytime sleepiness in a patient with narcolepsy and is not a primary treatment for its core symptoms. *Continuous positive airway pressure* - **Continuous positive airway pressure (CPAP)** is the standard treatment for **obstructive sleep apnea (OSA)**, a condition characterized by recurrent upper airway collapse during sleep. - Although OSA can cause excessive daytime sleepiness, the patient's additional symptoms of hypnagogic hallucinations and sleep paralysis are not typical of OSA, making narcolepsy and its specific treatments more appropriate.

Sleep-Wake Disorders Indian Medical PG Question 4: A 7-year-old girl is reported by the parents as waking up in the night screaming, and she sits up in bed frightened. She does not respond to questions and after 2 or 3 minutes she goes back to sleep. She has no memory of these events the following morning. Which of the following is the most likely diagnosis?

• A. Nightmare
• B. Sleep terrors (Correct Answer)
• C. Narcolepsy
• D. Nocturnal seizures

Sleep-Wake Disorders Explanation: ***Sleep terrors*** - **Sleep terrors** are characterized by abrupt awakenings, intense fear and screaming, autonomic arousal, and unresponsiveness, typically occurring during **NREM sleep** in the first third of the night. - The child will have **no memory** of the event the next morning, which is a key diagnostic feature, and they often return to sleep quickly afterward. *Nightmare* - **Nightmares** occur during **REM sleep**, usually in the latter half of the night, and the individual can often recall vivid and frightening details upon waking. - Unlike sleep terrors, individuals experiencing nightmares are typically **responsive to comfort** and fully alert after waking. *Narcolepsy* - **Narcolepsy** is a chronic neurological condition characterized by overwhelming daytime sleepiness and irresistible urges to sleep, often accompanied by **cataplexy**. - It does not involve nocturnal screaming episodes or unresponsiveness followed by a quick return to sleep with no memory. *Nocturnal seizures* - **Nocturnal seizures** can cause nocturnal awakenings with confusion or unusual behaviors, but they often involve **stereotyped movements**, sometimes with motor manifestations or post-ictal confusion that lasts longer than a few minutes. - While there might be no memory of the event, the screaming and frightened demeanor without typical seizure activity make sleep terrors a more likely diagnosis.

Sleep-Wake Disorders Indian Medical PG Question 5: A child presents with complaints of bed wetting. What is the first line of treatment?

• A. Bed alarm technique (Correct Answer)
• B. Motivational therapy
• C. Oxybutynin
• D. Desmopressin

Sleep-Wake Disorders Explanation: ***Bed alarm technique*** - The **bed alarm technique** is considered the most effective first-line treatment for **nocturnal enuresis** in children. - It works through **classical conditioning**, training the child to wake up in response to bladder fullness. *Motivational therapy* - **Motivational therapy** can be a useful adjunct to other treatments, but it is not typically the sole **first-line therapy** due to varying effectiveness. - It focuses on building the child's confidence and encouraging dryness but does not directly address the physiological aspects of bedwetting. *Oxybutynin* - **Oxybutynin** is an anticholinergic medication that can reduce bladder contractions and increase bladder capacity. - It is usually reserved for cases where **bedwetting alarms** and **desmopressin** have been ineffective, or when there is an identifiable **overactive bladder component**. *Desmopressin* - **Desmopressin** is an antidiuretic hormone analogue that reduces urine production during the night. - While effective, it is often considered a **second-line treatment** after behavioral interventions like the bed alarm, or when rapid but temporary improvement is desired.

Sleep-Wake Disorders Indian Medical PG Question 6: What is the primary characteristic feature of Klein-Levin syndrome?

• A. Insomnia
• B. Anxiety
• C. Depression
• D. Hypersomnia (Correct Answer)

Sleep-Wake Disorders Explanation: ***Hypersomnia*** - **Hypersomnia** is the cardinal and primary characteristic feature of Klein-Levin syndrome, characterized by recurrent episodes of excessive sleepiness lasting days to weeks. - During these episodes, individuals may sleep for **16 to 20 hours a day** and are extremely difficult to awaken. - Episodes are often accompanied by **cognitive disturbances** (confusion, derealization), **behavioral changes** (apathy, hyperphagia, hypersexuality), but **hypersomnia remains the defining feature**. - Normal functioning returns between episodes. *Insomnia* - **Insomnia** (difficulty falling or staying asleep) is the opposite of the key symptom seen in Klein-Levin syndrome. - Klein-Levin syndrome is a disorder of excessive sleep, not sleep deprivation. *Anxiety* - **Anxiety** may occur as a secondary feature or during the distress of episodes, but it is not the primary characteristic feature. - The core pathology manifests as profound sleep disturbance, not an anxiety disorder. *Depression* - **Depression** is sometimes observed during or after episodes of Klein-Levin syndrome, but it is not the primary defining feature. - The diagnostic hallmark is the **recurrent hypersomnia with associated cognitive and behavioral symptoms**, not mood disturbance.

Sleep-Wake Disorders Indian Medical PG Question 7: Which of the following statements about narcolepsy is false?

• A. Day dreaming (Correct Answer)
• B. Cataplexy
• C. Sudden sleep and decreased REM latency
• D. Hypnagogic hallucinations

Sleep-Wake Disorders Explanation: ***Day dreaming*** - While people with narcolepsy experience excessive daytime sleepiness, **daydreaming** is a normal cognitive process and not a characteristic symptom of narcolepsy. - Narcolepsy involves **irresistible urges to sleep** or sudden sleep attacks, which are distinct from simply daydreaming. *Hypnagogic hallucinations* - These are **vivid, often frightening hallucinations** that occur as a person is falling asleep. - They are a common symptom of narcolepsy, along with hypnopompic hallucinations (occurring upon waking). *Cataplexy* - **Cataplexy** is a sudden, brief loss of voluntary muscle tone, often triggered by strong emotions like laughter or anger. - It is a hallmark symptom of **Type 1 narcolepsy** and is caused by the intrusion of REM sleep atonia into wakefulness. *Sudden sleep and decreased REM latency* - Individuals with narcolepsy experience **sudden and irresistible sleep attacks** during the day. - They also have **decreased REM latency**, meaning they enter REM sleep much faster than usual, often within minutes of falling asleep.

Sleep-Wake Disorders Indian Medical PG Question 8: Which of the following statements about narcolepsy is false?

• A. Loss of muscle tone
• B. Hallucination
• C. Cataplexy
• D. Sleep architecture normal (Correct Answer)

Sleep-Wake Disorders Explanation: ***Sleep architecture normal*** ✓ **This is the FALSE statement** - Narcolepsy is characterized by **abnormal sleep architecture**, specifically an **abbreviated latency to REM sleep** (often <15 minutes, compared to normal 90 minutes). - Patients experience **fragmented nighttime sleep** with frequent awakenings and difficulty maintaining continuous sleep. - Sleep studies show **disrupted sleep-wake cycles** and **premature entry into REM sleep**. *Loss of muscle tone* - TRUE statement - **Loss of muscle tone** is the defining feature of **cataplexy**, a hallmark symptom of narcolepsy type 1. - Sudden emotional triggers (laughter, surprise, anger) lead to muscle weakness or paralysis without loss of consciousness. - This reflects neurological dysfunction affecting muscle control regulation during wakefulness. *Hallucination* - TRUE statement - **Hypnagogic hallucinations** (upon falling asleep) and **hypnopompic hallucinations** (upon waking) are common in narcolepsy. - These vivid, dream-like experiences occur during sleep-wake transitions due to intrusion of REM sleep phenomena into wakefulness. - Can involve visual, auditory, or tactile sensations. *Cataplexy* - TRUE statement - **Cataplexy** is a hallmark symptom of **narcolepsy type 1** (narcolepsy with cataplexy). - Involves sudden, brief episodes of bilateral muscle weakness or paralysis triggered by strong emotions. - Results from loss of hypocretin (orexin) neurons in the hypothalamus.

Sleep-Wake Disorders Indian Medical PG Question 9: Which of the following parasomnias is characterized by sudden arousal from deep NREM sleep with intense fear and no memory of the event?

• A. Night terrors (Correct Answer)
• B. Sleepwalking
• C. Excessive daytime sleepiness (narcolepsy)
• D. Bruxism (teeth grinding)

Sleep-Wake Disorders Explanation: ***Night terrors*** - Night terrors are a **parasomnia** that occurs during **NREM sleep**, specifically during stage N3 (slow-wave sleep). - They are characterized by **sudden arousal from sleep** accompanied by screaming, intense fear, and autonomic activation, with **no recall of the event** upon waking. - This combination of features (arousal from deep sleep + intense fear + amnesia) distinguishes night terrors from other NREM parasomnias. *Sleepwalking* - Somnambulism is also a parasomnia occurring during **NREM stage N3** (slow-wave sleep). - However, it involves **complex motor behaviors** during sleep rather than the sudden fearful arousal characteristic of night terrors. - Unlike night terrors, there is usually no associated screaming or expression of intense fear during the episode. *Excessive daytime sleepiness (narcolepsy)* - **Narcolepsy** is a chronic neurological condition characterized by overwhelming daytime drowsiness and sudden sleep attacks. - It involves dysregulation of **REM sleep** processes, including direct entry into REM sleep (sleep-onset REM periods). - This is not a parasomnia and is not associated with NREM sleep phenomena. *Bruxism (teeth grinding)* - Bruxism can occur during **both NREM and REM sleep** but is most frequently observed during lighter NREM stages (N1 and N2). - It involves rhythmic jaw muscle activity without the arousal, fear response, or amnesia seen in night terrors. - While it occurs during NREM sleep, it lacks the characteristic sudden arousal with terror.

Sleep-Wake Disorders Indian Medical PG Question 10: A 25-year-old medical student who failed his exam tells his friends, "I didn't want to pass anyway. The exam was poorly designed and doesn't test real clinical knowledge." This is an example of which defense mechanism?

• A. Denial
• B. Projection
• C. Displacement
• D. Rationalization (Correct Answer)

Sleep-Wake Disorders Explanation: ***Rationalization*** - **Rationalization** involves constructing a logical justification for actions or attitudes that otherwise would be unacceptable, thereby avoiding feelings of guilt or shame. - The man in the scenario uses logical reasons to explain his actions, preventing him from feeling guilty about them. *Denial* - **Denial** is a defense mechanism where a person refuses to accept or acknowledge a reality or facts of a situation, usually a painful or threatening one. - In this case, the man is not denying his actions but rather finding reasons to excuse them. *Projection* - **Projection** is when an individual attributes their own unacceptable thoughts, feelings, or qualities to another person. - The man is creating excuses for his own behavior, not attributing his feelings or actions to someone else. *Displacement* - **Displacement** involves redirecting unacceptable urges or feelings from their original target to a less threatening one. - The man is not shifting his emotions to a different object or person; instead, he is justifying his own actions.

Sleep-Wake Disorders Flashcard 1 of 10

Question: _____ Test provides 40-minute test sessions at 2-hour intervals across the day where the patient is instructed to try to remain awake (in narcolepsy)

Answer: Maintenance of Wakefulness

Sleep-Wake Disorders Flashcard 2 of 10

Question: _____ scale is used to assess daytime sleepiness

Answer: Epworth

Sleep-Wake Disorders Flashcard 3 of 10

Question: What disorder of sleep is seen in autism spectrum disorder?_____

Answer: Insomnia

Sleep-Wake Disorders Flashcard 4 of 10

Question: The _____ (ESS) is used in the assessment of daytime sleepiness.

Answer: Epworth Sleepiness Scale

Sleep-Wake Disorders Flashcard 5 of 10

Question: _____ is the most common sleep complaint.

Answer: Insomnia

Sleep-Wake Disorders Flashcard 6 of 10

Question: The primary symptoms of narcolepsy are excessive daytime _____ and sleep attacks

Answer: sleepiness

Sleep-Wake Disorders Flashcard 7 of 10

Question: A total of _____ nap opportunities of 20 mintues each are provided at 2 hour intervals throughout the day for Multiple sleep latency test (MSLT)

Answer: 5

Sleep-Wake Disorders Flashcard 8 of 10

Question: Benzodiazepines are useful for treating _____ and sleepwalking by decreasing N3 and REM sleep

Answer: night terrors

Sleep-Wake Disorders Flashcard 9 of 10

Question: _____ is associated with cataplexy, which is the loss of all muscle tone following a strong emotional stimulus (e.g. laughter)

Answer: Narcolepsy

Sleep-Wake Disorders Flashcard 10 of 10

Question: The sleep disturbance should be present for atleast _____ nights per week, for atleast 3 months to diagnose insomnia disorder

Answer: 3