Panic disorder US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Panic disorder. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Panic disorder US Medical PG Question 1: A 55-year-old man with a history of myocardial infarction 3 months ago presents with feelings of depression. He says that he has become detached from his friends and family and has daily feelings of hopelessness. He says he has started to avoid strenuous activities and is no longer going to his favorite bar where he used to spend a lot of time drinking with his buddies. The patient says these symptoms have been ongoing for the past 6 weeks, and his wife is starting to worry about his behavior. He notes that he continues to have nightmares that he is having another heart attack. He says he is even more jumpy than he used to be, and he startles very easily. Which of the following is the most likely diagnosis in this patient?
- A. Major depressive disorder
- B. Post-traumatic stress disorder (Correct Answer)
- C. Acute stress disorder
- D. Alcohol withdrawal
- E. Midlife crisis
Panic disorder Explanation: ***Post-traumatic stress disorder***
- The patient's symptoms, including **nightmares** about another heart attack, **hypervigilance** (being jumpy and easily startled), **avoidance behaviors** (strenuous activities, bar), **detachment**, and feelings of **hopelessness**, are characteristic of **PTSD** following a traumatic event like a myocardial infarction.
- The symptoms have persisted for **6 weeks**, exceeding the 1-month duration required for a PTSD diagnosis.
*Major depressive disorder*
- While feelings of **hopelessness** and **detachment** are present, the pervasive **recurrent nightmares**, **hypervigilance**, and **avoidance specifically related to the traumatic event** (MI) point more strongly to PTSD.
- A diagnosis of MDD would not fully encompass the trauma-specific symptoms described.
*Acute stress disorder*
- This diagnosis is considered when symptoms similar to PTSD (intrusion, negative mood, dissociation, avoidance, arousal) occur within **3 days to 1 month** after a traumatic event.
- Since the patient's symptoms have been ongoing for **6 weeks**, exceeding the 1-month timeframe, acute stress disorder is ruled out.
*Alcohol withdrawal*
- Symptoms of alcohol withdrawal typically include **tremors, hallucinations, seizures, and delirium**, often developing rapidly after a reduction in alcohol intake.
- The patient's symptoms of **nightmares related to his MI**, **hypervigilance**, and emotional detachment are not characteristic of alcohol withdrawal.
*Midlife crisis*
- This is a non-clinical term describing a period of **emotional turmoil and self-doubt** that may occur in middle age, often involving questioning life choices and goals.
- While the patient is in midlife, his specific symptom constellation, particularly the trauma-related nightmares and hypervigilance, aligns with a diagnosable mental health condition rather than a general life transition.
Panic disorder US Medical PG Question 2: An 18-year-old man presents to the student health department at his university for recurrent palpitations. The patient had previously presented to the emergency department (ED) for sudden onset palpitations five months ago when he first started college. He had a negative cardiac workup in the ED and he was discharged with a 24-hour Holter monitor which was also negative. He has no history of any medical or psychiatric illnesses. The patient reports that since his initial ED visit, he has had several episodes of unprovoked palpitations associated with feelings of dread and lightheadedness though he cannot identify a particular trigger. Recently, he has begun sitting towards the back of the lecture halls so that he can “quickly escape and not make a scene” in case he gets an episode in class. Which of the following is the most likely diagnosis?
- A. Social phobia
- B. Specific phobia
- C. Adjustment disorder
- D. Panic disorder (Correct Answer)
- E. Somatic symptom disorder
Panic disorder Explanation: ***Panic disorder***
- The patient experiences **recurrent, unprovoked panic attacks** characterized by palpitations, feelings of dread, and lightheadedness, which align with the diagnostic criteria for panic disorder.
- His behavior of sitting at the back of lecture halls to "quickly escape" indicates **avoidance behaviors** and **anticipatory anxiety** related to potential future attacks, a hallmark of panic disorder.
*Social phobia*
- This condition is characterized by **fear or anxiety about social situations** where the individual might be scrutinized or judged, which is not the primary driver of the patient's symptoms or avoidance behavior.
- While he avoids public situations, his motivation is fear of a panic attack, not fear of social judgment.
*Specific phobia*
- This involves an **intense, irrational fear of a specific object or situation** (e.g., heights, spiders, flying), which does not fit the generalized, unprovoked nature of the patient's panic attacks.
- The patient's symptoms are not tied to a single, clearly defined phobic stimulus.
*Adjustment disorder*
- This diagnosis is typically made when individuals experience **emotional or behavioral symptoms in response to an identifiable stressor**, arising within three months of the onset of the stressor.
- While starting college is a stressor, the patient's panic attacks are recurrent and unprovoked, evolving into a pattern beyond a typical adjustment response, and he has a negative cardiac workup.
*Somatic symptom disorder*
- This involves **distressing somatic symptoms accompanied by excessive thoughts, feelings, or behaviors related to the symptoms**, such as disproportionate thoughts about the seriousness of one's symptoms or high levels of anxiety about health.
- Although the patient experiences physical symptoms (palpitations), the presence of clear panic attacks, dread, and avoidance behavior points more specifically to panic disorder rather than a primary focus on the somatic symptoms themselves.
Panic disorder US Medical PG Question 3: A 32-year-old farmer is brought to the emergency department by his wife. The patient was reportedly anxious, sweaty, and complaining of a headache and chest tightness before losing consciousness on route to the hospital. Which of the following is mechanistically responsible for this patient's symptoms?
- A. Reversible inhibition of acetylcholinesterase
- B. Competitive inhibition of acetylcholine at post-junctional effector sites
- C. Binding of acetylcholine agonists to post-junctional receptors
- D. Irreversible inhibition of acetylcholinesterase (Correct Answer)
- E. Inhibition of presynaptic exocytosis of acetylcholine vesicles
Panic disorder Explanation: ***Irreversible inhibition of acetylcholinesterase***
- The farmer's symptoms (anxiety, sweating, headache, chest tightness, loss of consciousness) are characteristic of **organophosphate poisoning**, which causes a cholinergic crisis due to accumulation of acetylcholine.
- Organophosphates are common in **pesticides** and act by irreversibly inhibiting **acetylcholinesterase**, leading to prolonged stimulation of cholinergic receptors.
*Reversible inhibition of acetylcholinesterase*
- Reversible acetylcholinesterase inhibitors, such as **physostigmine** or **neostigmine**, typically have a shorter duration of action and might cause similar symptoms but are less likely to lead to such severe, acute presentations in an accidental exposure scenario for a farmer.
- These agents are often used therapeutically and would not typically cause prolonged loss of consciousness in this context unless in very high intentional doses.
*Competitive inhibition of acetylcholine at post-junctional effector sites*
- This mechanism describes the action of **anticholinergic drugs** (e.g., atropine), which would block acetylcholine's effects and cause symptoms like dry mouth, dilated pupils, and tachycardia, opposite to what is observed here.
- Such agents would alleviate, not cause, the cholinergic symptoms seen in this patient.
*Binding of acetylcholine agonists to post-junctional receptors*
- While direct agonists (e.g., pilocarpine, methacholine) would mimic acetylcholine and cause cholinergic symptoms, organophosphate poisoning operates by preventing acetylcholine breakdown, rather than directly binding as an exogenous agonist.
- The context of a farmer and sudden, severe symptoms points more strongly to pesticide exposure and acetylcholinesterase inhibition.
*Inhibition of presynaptic exocytosis of acetylcholine vesicles*
- This mechanism is characteristic of **botulinum toxin**, which blocks the release of acetylcholine from presynaptic terminals, leading to muscle paralysis and weakness.
- The patient's symptoms are those of cholinergic excess, not cholinergic blockade or deficiency at the neuromuscular junction.
Panic disorder US Medical PG Question 4: A 25-year-old woman presents with a history of recurrent attacks of unprovoked fear, palpitations, and fainting. The attacks are usually triggered by entering a crowded place or public transport, so the patient tries to avoid being in public places alone. Besides this, she complains of difficulties in falling asleep, uncontrolled worry about her job and health, fear to lose the trust of her friends, and poor appetite. She enjoys dancing and has not lost a passion for her hobby, but recently when she participated in a local competition, she had an attack which made her stop her performance until she calmed down and her condition improved. She feels upset due to her condition. She works as a sales manager and describes her work as demanding with multiple deadlines to be met. She recently broke up with her boyfriend. She does not report any chronic medical problems, but she sometimes takes doxylamine to fall asleep. She has a 4-pack-year history of smoking and drinks alcohol occasionally. On presentation, her blood pressure is 110/60 mm Hg, heart rate is 71/min, respiratory rate is 13/min, and temperature is 36.5°C (97.7°F). Her physical examination is unremarkable. Which of the following medications can be used for the acute management of the patient’s attacks?
- A. Imipramine
- B. Clonazepam (Correct Answer)
- C. Metoprolol
- D. Bupropion
- E. Nifedipine
Panic disorder Explanation: ***Clonazepam***
- **Clonazepam** is a **benzodiazepine** that acts rapidly to provide acute relief from severe anxiety symptoms, such as those experienced during a **panic attack**.
- Its fast onset of action and anxiolytic properties make it suitable for interrupting the acute, distressing symptoms of **panic disorder**.
*Imipramine*
- **Imipramine** is a **tricyclic antidepressant** (TCA) and is used for long-term management of panic disorder and depression, but its onset of action is too slow for acute symptom relief.
- TCAs have significant **anticholinergic side effects** and cardiotoxicity, making them less suitable for immediate use in an acute panic attack.
*Metoprolol*
- **Metoprolol** is a **beta-blocker** that can help manage the physical symptoms of anxiety, such as palpitations and tremors, but it does not address the underlying psychological component of panic.
- Beta-blockers are generally not recommended as monotherapy for panic attacks as they do not treat the core anxiety, though they can be useful for performance anxiety.
*Bupropion*
- **Bupropion** is an **atypical antidepressant** primarily used for depression and smoking cessation, but it can sometimes worsen anxiety in patients.
- It works by inhibiting the reuptake of norepinephrine and dopamine, and its stimulant-like effects are not suitable for acute panic relief.
*Nifedipine*
- **Nifedipine** is a **calcium channel blocker** used to treat hypertension and angina, and it has no direct role in the management of panic attacks.
- While it affects cardiovascular function, it does not alleviate the anxiety and fear component of a panic attack.
Panic disorder US Medical PG Question 5: A previously healthy 24-year-old woman comes to the physician because of recurrent episodes of a choking sensation, palpitations, diffuse sweating, and shortness of breath over the past 3 months. These episodes occur without warning and last for about 10 minutes before gradually resolving. One episode occurred while at a shopping center, and she now avoids busy areas for fear of triggering another. She has been evaluated in the emergency department twice during these episodes; both times her ECG showed normal sinus rhythm and serum cardiac enzymes and thyroid hormone levels were normal. She does not currently have symptoms but is concerned that the episodes could occur again at any time and that there may be something wrong with her heart. She does not smoke or drink alcohol. Her only medication is an oral contraceptive. Vital signs are within normal limits. Physical examination shows no abnormalities. Urine toxicology screening is negative. Which of the following is the most appropriate next step in management?
- A. Administer lorazepam
- B. Administer propranolol
- C. D-dimer measurement
- D. Echocardiography
- E. Prescribe fluoxetine (Correct Answer)
Panic disorder Explanation: ***Prescribe fluoxetine***
* The patient's presentation with recurrent, unprovoked episodes of **choking sensation, palpitations, sweating, and shortness of breath**, lasting about 10 minutes, and leading to avoidance behavior (agoraphobia), is highly consistent with **panic disorder with agoraphobia**.
* **Selective serotonin reuptake inhibitors (SSRIs)** like fluoxetine are first-line pharmacologic treatments for panic disorder, demonstrating efficacy in reducing the frequency and severity of panic attacks.
*Administer lorazepam*
* **Lorazepam** is a **benzodiazepine** that can provide rapid relief of acute panic symptoms due to its anxiolytic effects.
* However, it is typically used for **acute symptom management** or short-term bridging therapy due to the risk of **dependence, tolerance, and withdrawal**, and is not considered a first-line long-term solution for panic disorder.
*Administer propranolol*
* **Propranolol** is a **beta-blocker** that can alleviate some physical symptoms of anxiety, such as palpitations and tremor, by blocking adrenergic receptors.
* It is more commonly used for **performance anxiety** or specific phobias and does not address the core psychological components of panic disorder or the avoidance behaviors associated with agoraphobia.
*D-dimer measurement*
* **D-dimer measurement** is used to rule out **thrombotic events** such as deep vein thrombosis (DVT) or pulmonary embolism (PE).
* The patient's symptoms are episodic, resolve spontaneously, and are not continuous or worsening, and previous ED evaluations for cardiovascular issues were normal, making a thrombotic event unlikely in this context.
*Echocardiography*
* **Echocardiography** is an imaging test to evaluate the **structure and function of the heart**.
* Given that the patient's ECG was normal, cardiac enzymes were normal, and she has experienced several such episodes without cardiac dysfunction, further cardiac workup like echocardiography is unlikely to reveal an underlying cardiac cause and would be an unnecessary investigation at this point.
Panic disorder US Medical PG Question 6: A 23-year-old man comes to the emergency department with palpitations, sweating, and shortness of breath that began 10 minutes ago. He says, “Please help me, I don't want to die.” He has experienced several similar episodes over the past 2 months, which occurred without warning in situations including open spaces or crowds and resolved gradually after 5 to 10 minutes. He has been staying at home as much as possible out of fear of triggering another episode. He has no history of serious illness and takes no medications. He drinks 3 bottles of beer daily. He appears anxious and has a flushed face. His pulse is 104/min, respirations are 12/min, and blood pressure is 135/82 mm Hg. Cardiopulmonary examination shows no abnormalities. An ECG shows sinus tachycardia. Which of the following is the most appropriate initial step in management?
- A. Oral propranolol
- B. Oral venlafaxine
- C. Oral buspirone
- D. Long-term ECG monitoring
- E. Oral alprazolam (Correct Answer)
Panic disorder Explanation: ***Oral alprazolam***
- This patient is experiencing an acute panic attack, characterized by sudden onset of intense fear, physical symptoms (palpitations, sweating, shortness of breath), and a fear of losing control or dying. **Benzodiazepines like alprazolam** are the most appropriate initial treatment for rapid symptom relief due to their fast onset of action.
- The patient's history of recurrent, uncued episodes, fear of future attacks, and subsequent avoidance behaviors (staying at home) are consistent with a diagnosis of **panic disorder**.
*Oral propranolol*
- **Beta-blockers like propranolol** can help manage some physical symptoms of anxiety (e.g., palpitations, tremor) by blocking adrenergic receptors. However, they are not effective in directly reducing the psychological distress or fear associated with acute panic attacks.
- Propranolol might be considered for **performance anxiety** or generalized anxiety with prominent physical symptoms but is not first-line for acute panic.
*Oral venlafaxine*
- **Venlafaxine**, a serotonin-norepinephrine reuptake inhibitor (SNRI), is a first-line treatment for **panic disorder** for long-term management and prevention of future attacks.
- However, its onset of action is slow (several weeks), making it unsuitable for immediate relief during an **acute panic attack**.
*Oral buspirone*
- **Buspirone** is an anxiolytic that is used for generalized anxiety disorder. It has a slow onset of action and is less effective for acute panic attacks.
- It does not provide the rapid, potent anxiolytic effects needed for an urgent presentation of **panic symptoms**.
*Long-term ECG monitoring*
- While an **ECG is appropriate during an acute presentation** to rule out cardiac causes, and the current ECG shows only sinus tachycardia, long-term ambulatory ECG monitoring (Holter monitor) is not the initial step for managing an acute panic attack in the absence of other cardiac symptoms or pathology.
- The patient's symptoms are highly suggestive of a **psychiatric condition (panic attack)**, and cardiac causes have already been largely ruled out by the initial ECG and unremarkable cardiopulmonary exam.
Panic disorder US Medical PG Question 7: A 36-year-old woman comes to the physician because of an 8-month history of occasional tremor. The tremor is accompanied by sudden restlessness and nausea, which disrupts her daily work as a professional violinist. The symptoms worsen shortly before upcoming concerts but also appear when she goes for a walk in the city. She is concerned that she might have a neurological illness and have to give up her career. The patient experiences difficulty falling asleep because she cannot stop worrying that a burglar might break into her house. Her appetite is good. She drinks one glass of wine before performances "to calm her nerves" and otherwise drinks 2–3 glasses of wine per week. The patient takes daily multivitamins as prescribed. She appears nervous. Her temperature is 36.8°C (98.2°F), pulse is 92/min, and blood pressure is 135/80 mm Hg. Mental status examination shows a full range of affect. On examination, a fine tremor on both hands is noted. She exhibits muscle tension. The remainder of the neurological exam shows no abnormalities. Which of the following is the most likely explanation for this patient's symptoms?
- A. Atypical depressive disorder
- B. Adjustment disorder
- C. Generalized anxiety disorder (Correct Answer)
- D. Panic disorder
- E. Essential tremor
Panic disorder Explanation: ***Generalized anxiety disorder***
- The patient exhibits persistent and excessive worry about various life circumstances (performance, burglaries, general anxiety), accompanied by physical symptoms like **restlessness**, muscle tension, and sleep disturbances, which are hallmark features of **Generalized Anxiety Disorder (GAD)**.
- The symptoms have been present for **8 months**, exceed the diagnostic duration for GAD (at least 6 months), and are not clearly tied to a specific stressor or episodic panic attacks.
*Atypical depressive disorder*
- Atypical depression is characterized by mood reactivity, increased appetite/weight gain, hypersomnia, leaden paralysis, and interpersonal rejection sensitivity.
- This patient reports difficulty sleeping (*insomnia*) and primarily presents with anxiety symptoms, not depressive mood.
*Adjustment disorder*
- **Adjustment disorder** involves emotional or behavioral symptoms in response to an identifiable stressor, occurring within 3 months of the stressor's onset, and usually resolving within 6 months after the stressor or its consequences have ceased.
- The patient's symptoms are chronic (8 months), excessive, and not solely linked to *one* identifiable recent stressor, but rather a pervasive pattern of worry.
*Panic disorder*
- **Panic disorder** is characterized by recurrent unexpected **panic attacks** with sudden onset of intense fear and physical symptoms (e.g., palpitations, dyspnea, dizziness).
- While she experiences sudden restlessness and nausea related to performances, these are specific triggers and not unexpected, unprovoked panic attacks. The primary pattern is persistent worry, not recurrent panic attacks.
*Essential tremor*
- **Essential tremor** is a neurological condition causing an *action tremor*, often visible when performing daily tasks, and typically improves with alcohol.
- While she has a tremor that improves with alcohol, the presence of marked and pervasive psychological symptoms like severe worrying, restlessness, and insomnia point to an underlying anxiety disorder, not solely an isolated neurological tremor.
Panic disorder US Medical PG Question 8: A 32-year-old man comes to the physician because of a 2 month history of difficulty sleeping and worsening fatigue. During this time, he has also had difficulty concentrating and remembering tasks at work as well as diminished interest in his hobbies. He has no suicidal or homicidal ideation. He does not have auditory or visual hallucinations. Vital signs are normal. Physical examination shows no abnormalities. Mental status examination shows a depressed mood and flat affect with slowed thinking and speech. The physician prescribes sertraline. Three weeks later, the patient comes to the physician again with only minor improvements in his symptoms. Which of the following is the most appropriate next step in management?
- A. Augment with aripiprazole and continue sertraline
- B. Provide electroconvulsive therapy
- C. Continue sertraline for 3 more weeks (Correct Answer)
- D. Change medication to duloxetine
- E. Augment with phenelzine and continue sertraline
Panic disorder Explanation: ***Continue sertraline for 3 more weeks***
- Antidepressants like **sertraline** typically require **4 to 6 weeks** to reach their full therapeutic effect.
- Since only three weeks have passed with minor improvements, the patient should continue the medication to allow time for the drug to work fully.
*Augment with aripiprazole and continue sertraline*
- **Augmentation** with an atypical antipsychotic like aripiprazole is considered if there is **no significant improvement after an adequate trial** (at least 6-8 weeks) of antidepressant monotherapy.
- It is too early to consider augmentation as the patient has not completed a sufficient trial of sertraline.
*Provide electroconvulsive therapy*
- **Electroconvulsive therapy (ECT)** is reserved for **severe, treatment-resistant depression**, depression with psychotic features, or when rapid response is required (e.g., severe suicidality).
- The patient's symptoms, while bothersome, do not meet criteria for severe, treatment-resistant depression or acute emergencies warranting ECT.
*Change medication to duloxetine*
- Changing antidepressants is usually considered if there is **minimal or no response** after an adequate trial of the initial medication.
- Switching medications before allowing sufficient time for the current treatment to work is premature and may delay effective treatment.
*Augment with phenelzine and continue sertraline*
- **Phenelzine** is a **monoamine oxidase inhibitor (MAOI)**, and using it in combination with an **SSRI like sertraline** is contraindicated due to the risk of **serotonin syndrome**.
- MAOIs are generally reserved for **refractory depression** due to their dietary restrictions and potential for severe drug interactions.
Panic disorder US Medical PG Question 9: A 52-year-old man presents with a 1-month history of a depressed mood. He says that he has been “feeling low” on most days of the week. He also says he has been having difficulty sleeping, feelings of being worthless, difficulty performing at work, and decreased interest in reading books (his hobby). He has no significant past medical history. The patient denies any history of smoking, alcohol use, or recreational drug use. A review of systems is significant for a 7% unintentional weight gain over the past month. The patient is afebrile and his vital signs are within normal limits. A physical examination is unremarkable. The patient is prescribed sertraline 50 mg daily. On follow-up 4 weeks later, the patient says he is slightly improved but is still not feeling 100%. Which of the following is the best next step in the management of this patient?
- A. Switch to a different SSRI
- B. Continue sertraline (Correct Answer)
- C. Add buspirone
- D. Switch to an MAOI
- E. Add aripiprazole
Panic disorder Explanation: ***Continue sertraline***
- Many antidepressants, including SSRIs like sertraline, require **4-6 weeks at a therapeutic dose** to achieve their full effect. Since the patient reports slight improvement after 4 weeks, continuing the current medication allows more time for optimal response.
- The goal is for the patient to feel "100%", which often takes longer than one month. **Gradual improvement** after initial therapy suggests the medication is working, but needs more time.
*Switch to a different SSRI*
- Switching to another SSRI is typically considered if there is **no improvement or significant intolerance** after an adequate trial (at least 4-6 weeks) at a therapeutic dose of the initial SSRI.
- This patient has shown *slight improvement*, indicating that sertraline may still be effective with more time.
*Add buspirone*
- Buspirone is an **anxiolytic medication** sometimes used as an augmentation strategy for depression, particularly if anxiety is a prominent symptom.
- However, it's generally added *after* an initial antidepressant has failed to achieve a full response, and typically *after* optimizing the dose and duration of the primary antidepressant.
*Switch to an MAOI*
- **Monoamine oxidase inhibitors (MAOIs)** are older antidepressants with a more challenging side effect profile and significant drug-drug and drug-food interactions.
- They are typically reserved for patients who have **failed multiple trials of other antidepressants** due to their safety concerns.
*Add aripiprazole*
- Aripiprazole, an **atypical antipsychotic**, is sometimes used as an augmentation strategy for **treatment-resistant depression**.
- This approach is usually considered when trials of several different antidepressant classes have failed or when the depression has not responded adequately to optimized antidepressant therapy.
Panic disorder US Medical PG Question 10: A 36-year-old woman complains of difficulty falling asleep over the past 4 months. On detailed history taking, she says that she drinks her last cup of tea at 8:30 p.m. before retiring at 10:30 p.m. She then watches the time on her cell phone on and off for an hour before falling asleep. In the morning, she is tired and makes mistakes at work. Her husband has not noticed excessive snoring or abnormal breathing during sleep. Medical history is unremarkable. She has smoked 5–7 cigarettes daily for 7 years and denies excess alcohol consumption. Her physical examination is normal. Which of the following is the best initial step in the management of this patient’s condition?
- A. Ropinirole
- B. Continuous positive airway pressure
- C. Modafinil
- D. Paroxetine
- E. Proper sleep hygiene (Correct Answer)
Panic disorder Explanation: ***Proper sleep hygiene***
- The patient's history of difficulty falling asleep, using a cell phone before bed, and tea consumption close to bedtime points towards **poor sleep hygiene** as a primary contributor to her insomnia.
- Addressing these behavioral factors first with **sleep hygiene education** is the most appropriate initial step before considering pharmacologic interventions.
*Ropinirole*
- **Ropinirole** is a dopamine agonist primarily used to treat **Parkinson's disease** and **restless legs syndrome**.
- There are no indications in the patient's presentation, such as an irresistible urge to move the legs, that would suggest restless legs syndrome.
*Continuous positive airway pressure*
- **Continuous positive airway pressure (CPAP)** is the standard treatment for **obstructive sleep apnea (OSA)**.
- The patient's husband has not noticed snoring or abnormal breathing during sleep, making OSA less likely as the primary cause of her insomnia.
*Modafinil*
- **Modafinil** is a wakefulness-promoting agent used to treat **narcolepsy** and other disorders characterized by excessive daytime sleepiness.
- The patient's primary complaint is difficulty *falling asleep* (**insomnia**), not excessive daytime sleepiness, and there's no evidence of narcolepsy.
*Paroxetine*
- **Paroxetine** is a selective serotonin reuptake inhibitor (SSRI) used to treat **depression** and **anxiety disorders**, and sometimes insomnia associated with these conditions.
- There is no mention of symptoms of depression or anxiety in the patient's history that would warrant immediate antidepressant use for her sleep difficulties.
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