Sleep disorders

Sleep disorders US Medical PG Question 1: A 45-year-old obese man presents to his primary care provider for an annual physical. The patient states that he has noticed increased sleepiness during the day at work over the past 6 months in addition to difficulty concentrating and worsening memory. He denies recent weight loss, and is not sure if he snores because he sleeps by himself. His past medical history is significant for hypertension and type II diabetes. Vital signs are T 98.6 F, HR 75 bpm, BP 140/90 mm Hg, RR 18/min. Physical exam reveals a 350 pound man. Jugular venous distension is difficult to evaluate due to excess tissue in the neck. There is no peripheral edema. Lung exam is normal. Routine CBC shows WBC count of 5000 cells/ml, platelet count of 350,000/mcL, hemoglobin of 18 gm/dL, and hematocrit of 54%. What is the most likely cause of his abnormal lab results?

• A. JAK2 mutation
• B. Malignancy
• C. Cor pulmonale
• D. Sleep apnea (Correct Answer)
• E. Diuretic overuse

Sleep disorders Explanation: ***Sleep apnea*** - The patient's **obesity**, daytime sleepiness, difficulty concentrating, and high hemoglobin/hematocrit are highly suggestive of **sleep apnea**. The chronic nocturnal hypoxia from sleep apnea triggers increased erythropoietin production, leading to **secondary polycythemia**. - While the patient isn't sure if he snores, the combination of his symptoms and elevated red blood cell parameters in an obese individual makes sleep apnea the most likely cause. *JAK2 mutation* - A **JAK2 V617F mutation** is characteristic of **polycythemia vera**, a myeloproliferative neoplasm, which typically presents with very high hemoglobin and hematocrit and can be associated with symptoms like fatigue and pruritus. However, **secondary polycythemia** due to sleep apnea is a more common cause of elevated red cell counts in an obese patient with these symptoms. - Unlike **secondary polycythemia**, which primarily affects red blood cell production, polycythemia vera often involves increases in all three blood cell lines (panmyelosis), though these are not seen here. *Malignancy* - While some **malignancies** can cause paraneoplastic syndromes leading to polycythemia (e.g., renal cell carcinoma producing erythropoietin), this is typically less common than sleep apnea as a cause of secondary polycythemia in an obese patient with these symptoms. - The patient's general signs and symptoms are more consistent with the chronic issues related to sleep-disordered breathing rather than a specific malignancy. *Cor pulmonale* - **Cor pulmonale** refers to right-sided heart failure due to chronic lung disease or pulmonary hypertension. While chronic hypoxia from severe lung disease can cause **secondary polycythemia**, the patient has a normal lung exam and no peripheral edema or overt signs of right heart failure. - Although sleep apnea can eventually lead to pulmonary hypertension and cor pulmonale, the primary cause of the polycythemia and presenting symptoms in this case is the hypoxia of sleep apnea itself, rather than advanced cor pulmonale. *Diuretic overuse* - **Diuretic overuse** can cause hemoconcentration and apparent increases in hemoglobin and hematocrit due to fluid loss, but it would typically be accompanied by other signs of dehydration or electrolyte abnormalities, and would not explain the patient's severe daytime sleepiness and cognitive issues. - The patient denies recent weight loss and has an elevated blood pressure, making severe dehydration from diuretic overuse less likely.

Sleep disorders US Medical PG Question 2: A 63-year-old man presents to his primary care physician complaining of excessive daytime sleepiness. He explains that this problem has worsened slowly over the past few years but is now interfering with his ability to play with his grandchildren. He worked previously as an overnight train conductor, but he has been retired for the past 3 years. He sleeps approximately 8-9 hours per night and believes his sleep quality is good; however, his wife notes that he often snores loudly during sleep. He has never experienced muscle weakness or hallucinations. He has also been experiencing headaches in the morning and endorses a depressed mood. His physical exam is most notable for his large body habitus, with a BMI of 34. What is the best description of the underlying mechanism for this patient's excessive daytime sleepiness?

• A. Poor oropharyngeal tone (Correct Answer)
• B. Circadian rhythm sleep-wake disorder
• C. Deficiency of the neuropeptides, orexin-A and orexin-B
• D. Insufficient sleep duration
• E. Psychiatric disorder

Sleep disorders Explanation: ***Poor oropharyngeal tone*** - This patient's symptoms, including **excessive daytime sleepiness**, loud **snoring**, **morning headaches**, **obesity (BMI 34)**, and depressed mood, are all highly suggestive of **obstructive sleep apnea (OSA)**. - In OSA, poor oropharyngeal tone, often exacerbated by obesity, leads to the collapse of the upper airway during sleep, causing interrupted breathing and subsequent sleep fragmentation, which manifests as daytime sleepiness. *Circadian rhythm sleep-wake disorder* - This disorder typically involves a **misalignment between endogenous sleep-wake rhythms** and external environmental cues, often seen in shift workers or with jet lag. - While the patient previously worked as an overnight conductor, he has been retired for 3 years, and his symptoms are more aligned with chronic airway obstruction rather than a desynchronized internal clock. *Deficiency of the neuropeptides, orexin-A and orexin-B* - A deficiency in **orexin (hypocretin)** is the underlying mechanism for **narcolepsy type 1**, characterized by excessive daytime sleepiness, cataplexy (sudden loss of muscle tone triggered by strong emotions), and sleep paralysis/hypnagogic hallucinations. - This patient specifically denies muscle weakness or hallucinations, which makes narcolepsy less likely. *Insufficient sleep duration* - While insufficient sleep duration can cause excessive daytime sleepiness, the patient reports sleeping approximately **8-9 hours per night**, which is generally considered an adequate duration for adults. - The loud snoring and other symptoms point towards a **qualitative problem with sleep**, despite seemingly adequate hours. *Psychiatric disorder* - While **depressed mood** is present, it is often a **consequence or comorbidity of chronic sleep deprivation** and fragmented sleep rather than the primary cause of the patient's excessive daytime sleepiness and loud snoring. - Depression alone does not explain the physical signs like snoring and morning headaches without an underlying sleep disorder.

Sleep disorders US Medical PG Question 3: A mother brings her 7-year-old son to the pediatrician because she is worried about his sleep. She reports that the child has repeatedly woken up in the middle of the night screaming and thrashing. Although she tries to reassure the child, he does not respond to her or acknowledge her presence. Soon after she arrives, he stops screaming and appears confused and lethargic before falling back asleep. When asked about these events, the child reports that he cannot recall ever waking up or having any bad dreams. These events typically occur within four hours of the child going to sleep. The child’s past medical history is notable for asthma and type I diabetes mellitus. He uses albuterol and long-acting insulin. There have been no recent changes in this patient’s medication regimen. His family history is notable for obesity and obstructive sleep apnea in his father. Physical examination reveals a healthy male at the 40th and 45th percentiles for height and weight, respectively. Which of the following EEG waveforms is most strongly associated with this patient’s condition?

• A. Delta waves (Correct Answer)
• B. Theta waves
• C. Sleep spindles
• D. Beta waves
• E. Alpha waves

Sleep disorders Explanation: ***Delta waves*** - The child's symptoms (screaming, thrashing, unresponsiveness during waking, confusion afterward, and no recall) are characteristic of **sleep terror (pavor nocturnus)**, which is a **non-REM parasomnia**. - Sleep terrors typically occur during **slow-wave sleep (NREM stage 3/4 sleep)**, which is predominantly characterized by the presence of **delta waves** on an EEG. *Theta waves* - **Theta waves** are characteristic of **NREM stage 1 and 2 sleep**, which are lighter stages of sleep. - Sleep terrors are arousal disorders that originate from the deep stages of non-REM sleep, not the lighter stages where theta waves are prominent. *Sleep spindles* - **Sleep spindles** and **K-complexes** are characteristic EEG findings of **NREM stage 2 sleep**. - While stage 2 is part of NREM sleep, sleep terrors are specifically associated with the deeper NREM stage 3/4, which is dominated by delta waves, not sleep spindles. *Beta waves* - **Beta waves** are high-frequency, low-amplitude waves associated with **awake, alert, and active mental states**. - Their presence indicates wakefulness or active mental engagement and is not associated with any stage of sleep. *Alpha waves* - **Alpha waves** are characteristic of a state of **relaxed wakefulness**, often with closed eyes, and are a precursor to sleep onset. - They are not associated with the deep sleep stages where sleep terrors occur.

Sleep disorders US Medical PG Question 4: A 21-year-old man presents to the clinic complaining of feeling tired during the day. He is concerned as his grades in school have worsened and he does not want to lose his scholarship. Upon further questioning, the patient describes frequently experiencing a dreamlike state before falling asleep and after waking up. He also has frequent nighttime awakenings where he finds himself unable to move. He denies snoring. The patient does not drink alcohol or abuse any other drugs. The patient's BMI is 21 kg/m2, and his vital signs are all within normal limits. What is this patient's diagnosis?

• A. Obstructive sleep apnea (OSA)
• B. Insomnia
• C. Alcohol withdrawal
• D. Delayed sleep phase syndrome (DSPS)
• E. Narcolepsy (Correct Answer)

Sleep disorders Explanation: ***Narcolepsy*** - The patient's symptoms of **excessive daytime sleepiness**, **hypnagogic/hypnopompic hallucinations** (dreamlike state before falling asleep and after waking up), and **sleep paralysis** (unable to move during nighttime awakenings) are the **classic tetrad of narcolepsy** (cataplexy is the 4th feature, not present here). - The absence of snoring, normal BMI, and lack of alcohol/drug use rule out other common causes of sleep disturbances, supporting the diagnosis of narcolepsy. - Narcolepsy is a **chronic sleep-wake disorder** caused by hypothalamic hypocretin (orexin) deficiency. *Obstructive sleep apnea (OSA)* - While OSA also causes **daytime sleepiness**, a key feature is **snoring**, which this patient denies. - OSA is often associated with obesity, but this patient has a **normal BMI of 21 kg/m²**. - OSA would not explain the hypnagogic hallucinations or sleep paralysis. *Insomnia* - Insomnia primarily involves difficulty initiating or maintaining sleep, leading to **insufficient sleep quantity or quality**. - This patient's symptoms are more specific, including episodes of sleep paralysis and vivid dreamlike states, rather than just general difficulty sleeping. - The hallmark features of narcolepsy distinguish this from simple insomnia. *Alcohol withdrawal* - Alcohol withdrawal can cause **sleep disturbances**, but it is typically accompanied by other symptoms like tremors, anxiety, autonomic hyperactivity, and potentially seizures, none of which are present. - The patient **explicitly denies drinking alcohol**, making this diagnosis highly unlikely. *Delayed sleep phase syndrome (DSPS)* - DSPS is a **circadian rhythm disorder** characterized by a delayed sleep-wake cycle, where individuals fall asleep and wake up later than desired. - While it can cause daytime fatigue if individuals are forced to wake up early, it does **not** involve the specific symptoms of hypnagogic/hypnopompic hallucinations or sleep paralysis seen in this patient. - DSPS is primarily a timing issue, not a neurological sleep disorder.

Sleep disorders US Medical PG Question 5: A 55-year-old man presents to the physician for the evaluation of excessive daytime sleepiness over the past six months. Despite sleeping 8–9 hours a night and taking a nap during the day, he feels drowsy and is afraid to drive. His wife complains of loud snoring and gasping during the night. His blood pressure is 155/95 mm Hg. BMI is 37 kg/m2. Oropharyngeal examination shows a small orifice and an enlarged tongue and uvula. The soft palate is low-lying. The examination of the nasal cavity shows no septal deviation or polyps. Examination of the lungs and heart shows no abnormalities. Polysomnography shows an apnea-hypopnea index of 20 episodes/h. The patient is educated about weight loss, exercise, and regular sleep hours and duration. Which of the following is the most appropriate next step in management?

• A. Continuous positive airway pressure (Correct Answer)
• B. Upper airway neurostimulation
• C. Supplemental oxygen
• D. Oral appliances
• E. Upper airway surgery

Sleep disorders Explanation: ***Continuous positive airway pressure*** - This patient presents with symptoms and polysomnography findings consistent with **moderate to severe obstructive sleep apnea (OSA)** (apnea-hypopnea index of 20 episodes/h). **CPAP is the first-line treatment** for such cases. - CPAP works by **delivering pressurized air** via a mask, creating a pneumatic splint that prevents the collapse of the upper airway during sleep, thereby reducing apneas and hypopneas. *Upper airway neurostimulation* - This therapy involves stimulating the **hypoglossal nerve** to activate upper airway muscles, improving airway patency. - However, it is generally considered a **second-line treatment** for patients with moderate to severe OSA who **cannot tolerate or fail CPAP therapy**. *Supplemental oxygen* - While oxygen therapy can reduce nocturnal desaturation, it **does not address the underlying airway obstruction** that causes apneas and hypopneas. - It might even **worsen apnea by blunting the ventilatory drive**, making it an inappropriate primary treatment for OSA. *Oral appliances* - **Mandibular advancement devices (MADs)** can be effective for **mild to moderate OSA**, or for patients with severe OSA who cannot tolerate CPAP. - They work by repositioning the jaw and tongue forward to enlarge the pharyngeal space, but CPAP is generally more effective for the severity described. *Upper airway surgery* - Various surgical procedures, such as **uvulopalatopharyngoplasty (UPPP)**, aim to remove excess tissue in the pharynx to enlarge the airway. - Surgery is typically reserved for patients who **fail or cannot tolerate CPAP and oral appliances** and are carefully selected based on anatomical considerations.

Sleep disorders US Medical PG Question 6: A 40-year-old man with a past medical history of major depression presents to the clinic. He is interested in joining a research study on depression-related sleep disturbances. He had 2 episodes of major depression within the last 2 years, occurring once during the summer and then during the winter of the other year. He has been non-compliant with medication and has a strong desire to treat his condition with non-pharmacological methods. He would like to be enrolled in this study that utilizes polysomnography to record sleep-wave patterns. Which of the following findings is likely associated with this patient’s psychiatric condition?

• A. Increased REM sleep latency
• B. Associated with a seasonal pattern
• C. Decreased REM sleep latency (Correct Answer)
• D. Increased slow wave sleep
• E. Late morning awakenings

Sleep disorders Explanation: ***Decreased REM sleep latency*** - Patients with major depression exhibit characteristic alterations in sleep architecture, most notably a **decreased REM latency** (shortened time from sleep onset to the first REM period). - Normal REM latency is typically 90 minutes, but in depression it may be reduced to **45-60 minutes or less**. - This is one of the most **consistent and well-established polysomnographic findings** in major depressive disorder. - Other REM sleep changes include **increased REM density** (more frequent rapid eye movements) and a shift of REM sleep to the first half of the night. *Increased REM sleep latency* - This is the **opposite** of what occurs in depression. - **Decreased REM sleep latency** (shorter time to reach REM sleep) is the hallmark finding, not increased latency. - Increased REM latency might be seen in other conditions or with certain medications, but not in untreated major depression. *Associated with a seasonal pattern* - While the patient had episodes in summer and winter, the question asks specifically about **polysomnography findings**, not clinical subtypes or patterns. - Seasonal pattern is a **clinical specifier** for major depressive disorder (as in seasonal affective disorder), not a polysomnographic finding. - The seasonal pattern itself is a diagnostic feature, not something detected on sleep studies. *Increased slow wave sleep* - Depression is associated with **decreased slow-wave sleep (SWS)**, not increased. - SWS (stage N3, deep sleep) is typically **reduced** in patients with major depression. - This decrease in restorative deep sleep contributes to the poor sleep quality, daytime fatigue, and cognitive difficulties in depressed patients. *Late morning awakenings* - Major depression classically presents with **early morning awakening** (terminal insomnia), not late morning awakening. - Patients typically wake 2-3 hours earlier than desired and cannot return to sleep. - Late morning awakenings or hypersomnia may occur in **atypical depression**, but early morning awakening is the more typical pattern in melancholic depression.

Sleep disorders US Medical PG Question 7: A 25-year-old male presents to his primary care physician with a chief complaint of anxiety and fatigue. The patient states that during this past week he has had final exams and has been unable to properly study and prepare because he is so exhausted. He states that he has been going to bed early but has been unable to get a good night’s sleep. The patient admits to occasional cocaine and marijuana use. Otherwise, the patient has no significant past medical history and is not taking any medications. On physical exam you note a tired and anxious appearing young man. His neurological exam is within normal limits. The patient states that he fears he will fail his courses if he does not come up with a solution. Which of the following is the best initial step in management?

• A. Polysomnography
• B. Sleep hygiene education (Correct Answer)
• C. Alprazolam
• D. Melatonin
• E. Zolpidem

Sleep disorders Explanation: ***Sleep hygiene education*** - This is the **best initial step** because it addresses lifestyle factors that commonly contribute to **insomnia and fatigue**, especially during periods of stress like final exams. - Helping the patient establish **regular sleep patterns**, avoid stimulants, and create a conducive sleep environment can significantly improve sleep quality without medication. *Polysomnography* - This is a diagnostic test typically reserved for when a **primary sleep disorder** like sleep apnea or restless legs syndrome is suspected. - Given the patient's acute stressor (final exams) and **drug use**, lifestyle interventions should be tried first before pursuing expensive and invasive testing. *Alprazolam* - This is a **benzodiazepine** that can be used for acute anxiety or insomnia, but it carries a risk of **dependence, tolerance, and withdrawal**. - It is not a first-line treatment for a patient experiencing sleep difficulties primarily due to stress and poor sleep habits, and its use should be avoided in those with a history of substance abuse. *Melatonin* - Melatonin can be helpful for **circadian rhythm disorders** or jet lag, but its efficacy for primary insomnia is limited and inconsistent. - While it has fewer side effects than prescription hypnotics, **sleep hygiene education** is still a more fundamental and effective initial approach for this patient. *Zolpidem* - This is a **non-benzodiazepine hypnotic** often prescribed for short-term insomnia, but it has potential side effects like **next-day drowsiness** and can be abused, especially in individuals with a history of substance use. - **Sleep hygiene** should always be optimized first, especially in a young patient whose sleep issues are clearly linked to stress and lifestyle.

Sleep disorders US Medical PG Question 8: A 17-year-old high school student comes to the physician because of a 6-month history of insomnia. On school nights, he goes to bed around 11 p.m. but has had persistent problems falling asleep and instead studies at his desk until he feels sleepy around 2 a.m. He does not wake up in the middle of the night. He is worried that he does not get enough sleep. He has significant difficulties waking up on weekdays and has repeatedly been late to school. At school, he experiences daytime sleepiness and drinks 1–2 cups of coffee in the mornings. He tries to avoid daytime naps. On the weekends, he goes to bed around 2 a.m. and sleeps in until 10 a.m., after which he feels rested. He has no history of severe illness and does not take medication. Which of the following most likely explains this patient's sleep disorder?

• A. Inadequate sleep hygiene
• B. Irregular sleep-wake disorder
• C. Psychophysiologic insomnia
• D. Delayed sleep-wake disorder (Correct Answer)
• E. Advanced sleep-wake disorder

Sleep disorders Explanation: ***Delayed sleep-wake disorder*** - This patient exhibits a consistent pattern of **delayed sleep onset** and **delayed wake time**, particularly evident on weekends when he can follow his natural circadian rhythm (going to bed at 2 AM and waking at 10 AM). - The symptoms, including difficulty falling asleep at conventional times, difficulty waking for school, and daytime sleepiness, are classic for **delayed sleep-wake phase disorder**, where an individual's internal clock is misaligned with societal expectations. *Inadequate sleep hygiene* - While aspects like studying in bed are **poor sleep hygiene**, the core issue is not simply bad habits but a fundamental misalignment of his **circadian rhythm** as evidenced by his consistent late sleep onset and wake times when allowed. - The patient's ability to sleep well and feel rested on weekends when he can follow his natural rhythm suggests that hygiene alone isn't the primary cause. *Irregular sleep-wake disorder* - This disorder is characterized by a **lack of a discernible sleep-wake rhythm**, with sleep periods fragmented and scattered throughout the 24-hour day. - The patient, however, demonstrates a clear, albeit delayed, sleep schedule; he sleeps in one consolidated block and feels rested when allowed to do so. *Psychophysiologic insomnia* - This condition involves heightened arousal and **anxiety surrounding sleep**, leading to difficulty falling asleep at night and often improved sleep in novel environments or away from home. - While he expresses worry about not getting enough sleep, his sleep issues are primarily due to a shifted circadian phase, not just anxiety about sleep itself, and he sleeps restfully when allowed to follow his delayed rhythm. *Advanced sleep-wake disorder* - This disorder is characterized by a **habitually early sleep onset** and **early morning awakening**, typically several hours earlier than desired or conventional times. - The patient, in contrast, consistently struggles to fall asleep until very late hours and desires a later wake time.

Sleep disorders US Medical PG Question 9: A 5-year-old boy is brought to the physician by his parents because of 2 episodes of screaming in the night over the past week. The parents report that their son woke up suddenly screaming, crying, and aggressively kicking his legs around both times. The episodes lasted several minutes and were accompanied by sweating and fast breathing. The parents state that they were unable to stop the episodes and that their son simply went back to sleep when the episodes were over. The patient cannot recall any details of these incidents. He has a history of obstructive sleep apnea. He takes no medications. His vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?

• A. Restless legs syndrome
• B. Nightmare disorder
• C. Sleepwalking disorder
• D. Insomnia disorder
• E. Sleep terror disorder (Correct Answer)

Sleep disorders Explanation: ***Sleep terror disorder*** - This patient's presentation with sudden nocturnal screaming, agitation, autonomic arousal (sweating, fast breathing), and subsequent **amnesia** for the event is classic for **sleep terror disorder**. - The inability of parents to awaken or comfort the child, followed by the child returning to sleep and having **no recall**, are key diagnostic features. *Restless legs syndrome* - Characterized by an irresistible urge to move the legs, often accompanied by uncomfortable sensations, typically occurring or worsening during periods of **rest** or **inactivity**, and partially or totally relieved by movement. - This condition does not involve screaming, intense fear, or amnesia for a sleep event. *Nightmare disorder* - Nightmares are typically **vivid, frightening dreams** from which the individual awakens fully alert and often recalls the dream in detail. - Unlike sleep terrors, nightmares occur during **REM sleep** (usually later in the night), and the child is usually consolable after waking. *Sleepwalking disorder* - Involves complex motor behaviors, such as walking, while still asleep, without full consciousness. - While it can occur during NREM sleep and involves partial amnesia, it typically **does not feature screaming, intense fear, or significant autonomic arousal** as the predominant symptom. *Insomnia disorder* - Defined by persistent difficulty with **sleep initiation, duration, consolidation, or quality**, despite adequate opportunity for sleep, leading to daytime impairment. - It does not involve acute episodes of screaming or terror during sleep as described.

Sleep disorders US Medical PG Question 10: A previously healthy 36-year-old man is brought to the physician by a friend because of fatigue and a depressed mood for the past few weeks. During this time, he has not been going to work and did not show up to meet his friends for two bowling nights. The friend is concerned that he may lose his job. He spends most of his time alone at home watching television on the couch. He has been waking up often at night and sometimes takes 20 minutes to go back to sleep. He has also been drinking half a pint of whiskey per day for 1 week. His wife left him 4 weeks ago and moved out of their house. His vital signs are within normal limits. On mental status examination, he is oriented to person, place and time. He displays a flattened affect and says that he “doesn't know how he can live without his wife.” He denies suicidal ideation. Which of the following is the next appropriate step in management?

• A. Prescribe a short course of alprazolam
• B. Hospitalize the patient
• C. Initiate cognitive behavioral therapy (Correct Answer)
• D. Initiate disulfiram therapy
• E. Prescribe a short course of duloxetine

Sleep disorders Explanation: ***Initiate cognitive behavioral therapy*** - The patient exhibits features of **adjustment disorder with depressed mood**, characterized by significant distress or impairment in functioning in response to an identifiable stressor (wife leaving). - **Cognitive behavioral therapy (CBT)** is an effective first-line treatment for adjustment disorders, helping patients develop coping strategies and restructure negative thought patterns. *Prescribe a short course of alprazolam* - **Alprazolam**, a benzodiazepine, can provide temporary relief for anxiety but does not address the underlying issues of adjustment disorder and carries risks of **dependence** and withdrawal. - It would be inappropriate as a sole initial treatment and could exacerbate his **alcohol use**. *Hospitalize the patient* - The patient denies **suicidal ideation** and does not present with acute psychosis or severe impairment that would warrant **hospitalization**. - His orientation and ability to engage in conversation further suggest an outpatient approach is safe and appropriate. *Initiate disulfiram therapy* - **Disulfiram** is used for alcohol dependence to deter drinking, but the patient's current alcohol use is a recent development in response to stress, not necessarily full-blown **alcohol dependence** requiring disulfiram. - Addressing the underlying **adjustment disorder** is the priority, which may in turn reduce his alcohol consumption. *Prescribe a short course of duloxetine* - **Duloxetine** is an antidepressant that is not indicated for **adjustment disorder** as a first-line treatment, especially given the short duration and clear precipitating factor. - **Psychotherapy**, like CBT, is generally the preferred initial intervention for adjustment disorders.

Sleep disorders Flashcard 1 of 10

Question: Depression is associated with _____ total REM sleep

Answer: increased

Sleep disorders Flashcard 2 of 10

Question: _____ disorder is characterized by inconsolable periods of terror with screaming in the middle of the night (stage N3 sleep)

Answer: Sleep terror

Sleep disorders Flashcard 3 of 10

Question: Insomnia can be treated in multiple nonpharmacologic ways, including establishing good sleep _____

Answer: hygiene

Sleep disorders Flashcard 4 of 10

Question: Neuro/Psych_____ may be used to treat parasomnias in children, such as sleep walking and night terrors

Answer: Benzodiazepines

Sleep disorders Flashcard 5 of 10

Question: What is the primary neurotransmitter that inhibits REM sleep?

Answer: norepinephrine (NE)

Sleep disorders Flashcard 6 of 10

Question: What sleep changes are common in the elderly?

Answer: less REM and slow-wave sleep more latency and awakenings

Sleep disorders Flashcard 7 of 10

Question: stage N3

Answer: deep sleep, sleepwalking, night terrors, bedwetting

Extra Information: delta waves

Sleep disorders Flashcard 8 of 10

Question: REM

Answer: dreaming, loss of motor tone, high brain activity

Extra Information: beta waves (like being fully awake)

Sleep disorders Flashcard 9 of 10

Question: What three drugs are associated with reduced REM and Stage N3 sleep?

Answer: alcohol, benzodiazepines, barbituates

Sleep disorders Flashcard 10 of 10

Question: How often do REM cycles occur during normal sleep?

Answer: about every 90 minutes