Psychiatric comorbidities with sleep disorders US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Psychiatric comorbidities with sleep disorders. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Psychiatric comorbidities with sleep disorders US Medical PG Question 1: A 24-year-old woman presents with a 3-month history of worsening insomnia and anxiety. She says that she has an important college exam in the next few weeks for which she has to put in many hours of work each day. Despite the urgency of her circumstances, she states that she is unable to focus and concentrate, is anxious, irritable and has lost interest in almost all activities. She also says that she has trouble falling asleep and wakes up several times during the night. She claims that this state of affairs has severely hampered her productivity and is a major problem for her, and she feels tired and fatigued all day. She denies hearing voices, abnormal thoughts, or any other psychotic symptoms. The patient asks if there is some form of therapy that can help her sleep better so that she can function more effectively during the day. She claims that the other symptoms of not enjoying anything, irritability, and anxiety are things that she can learn to handle. Which of the following approaches is most likely to address the patients concerns most effectively?
- A. Initiation of risperidone
- B. Psychotherapy only
- C. Trial of bupropion
- D. Phototherapy
- E. Initiation of mirtazapine (Correct Answer)
Psychiatric comorbidities with sleep disorders Explanation: ***Initiation of mirtazapine***
- The patient exhibits classic symptoms of **major depressive disorder**, including insomnia, anxiety, anhedonia (loss of interest), irritability, and fatigue, all of which would benefit from an antidepressant.
- **Mirtazapine** is particularly effective at lower doses for **insomnia** and **anxiety** due to its potent antihistaminergic properties, making it suitable given her chief complaint about sleep.
*Initiation of risperidone*
- **Risperidone** is an **antipsychotic** medication used for conditions like schizophrenia, bipolar disorder, or severe agitation, which is not indicated here given the absence of psychotic symptoms.
- Its use in this context would expose the patient to unnecessary side effects such as **extrapyramidal symptoms**, **metabolic syndrome**, and hyperprolactinemia.
*Psychotherapy only*
- While psychotherapy, particularly cognitive-behavioral therapy (CBT), is an important component of depression treatment, the severity and acute nature of her symptoms, especially the significant functional impairment and insomnia, suggest that **pharmacotherapy is also warranted** for a more effective and rapid response.
- Relying solely on psychotherapy might delay symptomatic relief, especially for her prominent **sleep disturbance** and **anxiety**.
*Trial of bupropion*
- **Bupropion** is an antidepressant that works primarily on **dopamine** and **norepinephrine** reuptake, and it tends to be **activating**, which could exacerbate the patient's existing **insomnia** and **anxiety**.
- It lacks the sedative properties that would directly address her primary concern regarding difficulty sleeping.
*Phototherapy*
- **Phototherapy** is primarily used for **seasonal affective disorder (SAD)**, which is not suggested by the patient's presentation; her symptoms have been ongoing for 3 months and are linked to significant stressors, not seasonal changes.
- While it can improve mood and sleep in SAD, it would not be the most appropriate or effective initial treatment for a non-seasonal major depressive episode with prominent insomnia and anxiety.
Psychiatric comorbidities with sleep disorders US Medical PG Question 2: A 45-year-old woman presents to her primary care physician with complaints of muscle pains, poor sleep, and daytime fatigue. When asked about stressors she states that she "panics" about her job, marriage, children, and finances. When asked to clarify what the "panics" entail, she states that it involves severe worrying. She has had these symptoms since she last saw you one year ago. What is the most likely diagnosis?
- A. Generalized anxiety disorder (Correct Answer)
- B. Social phobia
- C. Adjustment disorder
- D. Obsessive-compulsive disorder
- E. Panic disorder
Psychiatric comorbidities with sleep disorders Explanation: ***Generalized anxiety disorder***
- This patient presents with **chronic, excessive, and uncontrollable worry** about multiple life circumstances (job, marriage, children, finances), fulfilling the core diagnostic criterion for GAD.
- The associated symptoms of **muscle pains**, **poor sleep**, and **daytime fatigue** are common physical manifestations of GAD, and the duration of symptoms for over a year supports the diagnosis.
*Social phobia*
- **Social phobia**, or social anxiety disorder, involves intense fear and anxiety in **social situations** where one might be scrutinized or judged.
- The patient's reported worries are broad and not limited to social interactions, making social phobia less likely.
*Adjustment disorder*
- **Adjustment disorder** is characterized by emotional or behavioral symptoms developing within **three months of an identifiable stressor**, not diffuse chronic worry.
- The symptoms in adjustment disorder typically resolve within **six months** after the stressor or its consequences have ended, whereas this patient's symptoms are chronic and pervasive.
*Obsessive-compulsive disorder*
- **Obsessive-compulsive disorder (OCD)** involves recurrent, intrusive **obsessions** (thoughts, urges, images) and/or **compulsions** (repetitive behaviors or mental acts) performed to reduce anxiety.
- While the patient experiences severe worrying, there's no mention of specific obsessions or compulsive behaviors aimed at neutralizing those anxieties.
*Panic disorder*
- **Panic disorder** is characterized by recurrent, unexpected **panic attacks**—sudden surges of intense fear or discomfort accompanied by physical and cognitive symptoms.
- While the patient uses the term "panics," she clarifies it involves "severe worrying," not discrete, intense, and short-lived panic attacks.
Psychiatric comorbidities with sleep disorders US Medical PG Question 3: A 24-year-old man is brought to your emergency department under arrest by the local police. The patient was found naked at a busy intersection jumping up and down on top of a car. Interviewing the patient, you discover that he has not slept in 2 days because he does not feel tired. He reports hearing voices. The patient was previously hospitalized 1 year ago with auditory hallucinations, paranoia, and a normal mood. What is the most likely diagnosis?
- A. Schizophrenia
- B. Bipolar disorder
- C. Brief psychotic disorder
- D. Schizotypal disorder
- E. Schizoaffective disorder (Correct Answer)
Psychiatric comorbidities with sleep disorders Explanation: ***Schizoaffective disorder***
- This patient demonstrates the **hallmark feature** of schizoaffective disorder: **psychotic symptoms occurring both during AND independent of mood episodes**.
- **Current presentation**: Clear **manic episode** (decreased need for sleep, grandiose/disinhibited behavior, psychomotor agitation) with psychotic features (auditory hallucinations).
- **Previous hospitalization**: **Psychotic symptoms (hallucinations, paranoia) in the absence of a mood episode** ("normal mood"), requiring hospitalization for at least 2 weeks - this is the **key diagnostic criterion** for schizoaffective disorder.
- The diagnosis requires an **uninterrupted period of illness** with both psychotic symptoms (meeting Criterion A for schizophrenia) and a major mood episode, PLUS psychotic symptoms for **≥2 weeks without prominent mood symptoms**.
*Bipolar disorder*
- In bipolar disorder with psychotic features, psychotic symptoms occur **exclusively during mood episodes** (manic, hypomanic, or depressive).
- This patient's previous hospitalization with psychosis but **"normal mood"** indicates psychotic symptoms independent of mood episodes, which **rules out** bipolar disorder and points to schizoaffective disorder.
- While the current presentation shows mania with psychosis, the longitudinal course is critical for diagnosis.
*Schizophrenia*
- Schizophrenia involves **continuous psychotic symptoms** without prominent mood episodes dominating the clinical picture.
- This patient has **prominent manic symptoms** (decreased sleep, grandiose behavior, agitation) that are central to the current presentation, making schizophrenia less likely.
- The presence of full mood episodes that occupy a **substantial portion** of the illness duration favors schizoaffective disorder over schizophrenia.
*Brief psychotic disorder*
- Brief psychotic disorder involves psychotic symptoms lasting **<1 month** with full return to baseline functioning.
- This patient has a **recurrent course** with hospitalization 1 year ago, indicating a chronic/recurring condition rather than a brief, self-limited episode.
*Schizotypal disorder*
- This is a **personality disorder** characterized by social deficits, cognitive/perceptual distortions, and eccentric behavior, but **NOT overt psychotic episodes**.
- Does not involve acute psychotic breaks with severe symptoms like hallucinations requiring hospitalization or manic episodes.
Psychiatric comorbidities with sleep disorders US Medical PG Question 4: A 71-year-old woman comes to her doctor because she is having trouble staying awake in the evening. Over the past year, she has noticed that she gets tired unusually early in the evenings and has trouble staying awake through dinner. She also experiences increased daytime sleepiness, fatigue, and difficulty concentrating. She typically goes to bed around 9 PM and gets out of bed between 2 and 3 AM. She does not have any trouble falling asleep. She takes 30-minute to 1-hour daytime naps approximately 3 times per week. She has no history of severe illness and does not take any medication. Which of the following is the most likely diagnosis?
- A. Non-REM sleep arousal disorder
- B. Depressive disorder
- C. Delayed sleep phase disorder
- D. Advanced sleep phase disorder (Correct Answer)
- E. Insomnia disorder
Psychiatric comorbidities with sleep disorders Explanation: ***Advanced sleep phase disorder***
- The patient's early evening fatigue, difficulty staying awake through dinner, and habitual bedtime of 9 PM with waking between 2-3 AM are classic symptoms of **advanced sleep phase disorder**.
- This condition involves a consistent advance of the **major sleep episode**, occurring significantly earlier than desired and resulting in early morning awakening.
*Non-REM sleep arousal disorder*
- This disorder is characterized by recurrent episodes of **incomplete awakening** from sleep, often accompanied by behaviors like sleepwalking or sleep terrors.
- The patient's symptoms are primarily related to timing of sleep, not **arousals** from sleep.
*Depressive disorder*
- While **sleep disturbance** (insomnia or hypersomnia) is common in depression, the specific pattern of early sleep onset and early morning awakening without difficulty falling asleep points away from a primary depressive disorder here.
- The patient does not describe other critical symptoms of depression such as anhedonia, low mood, or feelings of worthlessness.
*Delayed sleep phase disorder*
- This disorder involves a **delay** in the timing of the major sleep episode, meaning individuals go to bed and wake up much later than conventional times.
- The patient's symptoms are the **opposite** of delayed sleep phase disorder, as she is going to bed and waking up earlier.
*Insomnia disorder*
- Characterized by **difficulty falling asleep**, staying asleep, or early morning awakenings with inability to return to sleep, leading to significant distress or impairment.
- The patient explicitly states she has **no trouble falling asleep**, which rules out primary insomnia as the main issue.
Psychiatric comorbidities with sleep disorders US Medical PG Question 5: A 57-year-old man comes to the physician because of a 3-month history of fatigue, difficulty swallowing, and weight loss. He has smoked 1 pack of cigarettes daily for 30 years. He is 173 cm (5 ft 8 in) tall, and weighs 54 kg (120 lb); BMI is 18 kg/m2. Upper gastrointestinal endoscopy shows an exophytic tumor at the gastroesophageal junction. The patient is diagnosed with advanced esophageal adenocarcinoma. Palliative treatment is begun. Two months later, he complains of difficulty sleeping. His husband says that the patient does not get out of bed most days and has lost interest in seeing his friends. Mental status examination shows a blunted affect, slowed speech, and poor concentration. This patient is at increased risk of developing which of the following findings on polysomnography?
- A. Increased periodic sharp-wave discharge
- B. Decreased REM sleep latency (Correct Answer)
- C. Increased slow-wave sleep-cycle duration
- D. Decreased REM sleep duration
- E. Increased spike-and-wave discharge
Psychiatric comorbidities with sleep disorders Explanation: ***Decreased REM sleep latency***
- This patient's symptoms of **fatigue**, **anhedonia**, **sleep disturbance**, **blunted affect**, **slowed speech**, and **poor concentration** are highly suggestive of **major depressive disorder**.
- **Depression** is associated with **decreased REM sleep latency** (shorter time to enter REM sleep) and **increased REM density** (more rapid eye movements during REM).
*Increased periodic sharp-wave discharge*
- **Periodic sharp-wave discharges** on EEG are characteristic of **Creutzfeldt-Jakob disease**, which is a **neurodegenerative prion disease**, not depression.
- The patient's presentation does not align with the neurological signs typical of CJD.
*Increased slow-wave sleep-cycle duration*
- **Slow-wave sleep (SWS)**, or deep sleep, is typically **decreased** in patients with depression.
- An increase in SWS duration would be an unusual finding in the context of major depressive disorder.
*Decreased REM sleep duration*
- While sleep architecture is altered in depression, total **REM sleep duration** is often **increased**, or at least not significantly decreased, in proportion to other sleep stages.
- The more characteristic finding is a shorter time to reach REM sleep, not necessarily a reduction in its total duration.
*Increased spike-and-wave discharge*
- **Spike-and-wave discharges** are characteristic patterns seen on EEG in patients with **epilepsy**, particularly **absence seizures**.
- There is no clinical or historical information to suggest an epileptic disorder in this patient.
Psychiatric comorbidities with sleep disorders US Medical PG Question 6: A 21-year-old female is brought to the emergency department by her roommate. Her roommate says that the patient has been acting “strangely” for the past 10 days. She has noticed that the patient has been moving and talking on the phone at all hours of the night. She doesn’t think that the patient sleeps more than one to two hours a night. She also spends hours pacing up and down the apartment, talking about “trying to save the world.” She also notices that the patient has been speaking very fast. When asking the patient if anything seems different, the patient denies anything wrong, only adding that, “she’s made great progress on her plans." The patient said she has felt like this on one occasion 2 years ago, and she recalled being hospitalized for about 2 weeks. She denies any history of depression, although she said about a year ago she had no energy and had a hard time motivating herself to go to class and see her friends for months. She denies hearing any voices or any visual hallucinations. What is the most likely diagnosis in this patient?
- A. Bipolar II disorder
- B. Bipolar I disorder (Correct Answer)
- C. Major depressive disorder
- D. Persistent Depressive Disorder
- E. Schizoaffective disorder
Psychiatric comorbidities with sleep disorders Explanation: ***Bipolar I disorder***
- The patient exhibits clear symptoms of a **manic episode**, including decreased need for sleep, grandiosity ("saving the world"), pressured speech, and increased goal-directed activity, which are characteristic of Bipolar I disorder.
- The history of a prior hospitalization for similar symptoms ("felt like this on one occasion 2 years ago, and she recalled being hospitalized") and self-reported depressive episodes ("she had no energy... for months") further supports the diagnosis of Bipolar I disorder, which requires at least one manic episode.
*Bipolar II disorder*
- Bipolar II disorder involves at least one **hypomanic episode** and at least one major depressive episode.
- The severity of the patient's current symptoms, including significant functional impairment and a prior hospitalization for similar symptoms, indicates a **manic episode**, not a hypomanic episode.
*Major depressive disorder*
- This diagnosis is characterized solely by **major depressive episodes** without any history of manic or hypomanic episodes.
- The patient's presentation clearly includes symptoms of **mania**, ruling out a sole diagnosis of major depressive disorder.
*Persistent Depressive Disorder*
- This disorder is characterized by **chronic, mild depressive symptoms** lasting at least two years.
- The patient's current presentation of severe manic symptoms and past episodes of clear mania differentiates her condition from persistent depressive disorder.
*Schizoaffective disorder*
- Schizoaffective disorder involves a period of uninterrupted illness during which there is a **major mood episode (depressive or manic) concurrent with symptoms of schizophrenia**, such as hallucinations or delusions, for at least two weeks in the absence of a major mood episode.
- The patient **denies hearing any voices or visual hallucinations**, making schizoaffective disorder less likely; her symptoms are primarily mood-related.
Psychiatric comorbidities with sleep disorders US Medical PG Question 7: A 30-year-old woman presents to her family doctor requesting sleeping pills. She is a graduate student and confesses that she is a “worry-a-holic,” which has been getting worse for the last 6 months as the due date for her final paper is approaching. During this time, she feels more on edge, irritable, and is having difficulty sleeping. She has already tried employing good sleep hygiene practices, including a switch to non-caffeinated coffee. Her past medical history is significant for depression in the past that was managed medically. No current medications. The patient’s family history is significant for her mother who has a panic disorder. Her vital signs are within normal limits. Physical examination reveals a mildly anxious patient but is otherwise normal. Which of the following is the most effective treatment for this patient’s condition?
- A. Buspirone (Correct Answer)
- B. Diazepam
- C. Desensitization therapy
- D. Relaxation training
- E. Bupropion
Psychiatric comorbidities with sleep disorders Explanation: ***Buspirone***
- This patient's symptoms of **generalized anxiety** (excessive worry, difficulty sleeping, irritability, on edge for 6 months) without panic attacks or phobias, and a history of depression, make buspirone a suitable choice.
- **Buspirone** is a non-benzodiazepine anxiolytic that is effective for **generalized anxiety disorder** and has a lower risk of dependence compared to benzodiazepines, making it a good option for chronic use.
*Diazepam*
- **Diazepam** is a benzodiazepine, primarily used for acute anxiety or short-term management due to its **rapid onset of action**.
- Its potential for **dependence and withdrawal symptoms** makes it less ideal for chronic anxiety management, especially in a patient with a predisposition to depression and requesting "sleeping pills".
*Desensitization therapy*
- **Desensitization therapy** (a form of exposure therapy) is primarily used for **phobias** and **post-traumatic stress disorder**, where specific triggers are identified.
- The patient's presentation of generalized, pervasive worry, rather than a fear of specific situations, suggests this would not be the most effective initial treatment.
*Relaxation training*
- While beneficial as an adjunct, **relaxation training** alone is generally not sufficient as the **most effective monotherapy** for generalized anxiety disorder, especially given the severity and duration of the patient's symptoms.
- The patient has already tried **sleep hygiene practices**, indicating that behavioral interventions alone might not be enough to manage her anxiety.
*Bupropion*
- **Bupropion** is an antidepressant primarily used for **major depressive disorder** and **smoking cessation**.
- It is generally **not efficacious for anxiety disorders** and can sometimes exacerbate anxiety due to its stimulating effects.
Psychiatric comorbidities with sleep disorders US Medical PG Question 8: 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
Psychiatric comorbidities with 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.
Psychiatric comorbidities with sleep disorders US Medical PG Question 9: An 11-year-old boy is brought to the physician by his mother because of teacher complaints regarding his poor performance at school for the past 8 months. He has difficulty sustaining attention when assigned school-related tasks, does not follow the teachers' instructions, and makes careless mistakes in his homework. He often blurts out answers in class and has difficulty adhering to the rules during soccer practice. His mother reports that he is easily distracted when she speaks with him and that he often forgets his books at school. Physical examination shows no abnormalities. The patient is started on the appropriate first-line therapy. This boy is at increased risk for which of the following conditions?
- A. Elevated blood pressure (Correct Answer)
- B. Serotonin syndrome
- C. Increased BMI
- D. Prolonged QT interval
- E. Decreased perspiration
Psychiatric comorbidities with sleep disorders Explanation: ***Elevated blood pressure***
- This boy's symptoms are highly suggestive of **ADHD** (Attention-Deficit/Hyperactivity Disorder), which is commonly treated with **stimulant medications** like methylphenidate or amphetamines.
- Stimulants can cause **cardiovascular side effects**, including **elevated blood pressure** and heart rate, warranting regular monitoring.
*Serotonin syndrome*
- **Serotonin syndrome** is a risk associated with medications that increase serotonin levels, such as **SSRIs** or MAO inhibitors, which are not typically first-line for ADHD.
- Characterized by altered mental status, autonomic dysfunction, and neuromuscular abnormalities, symptoms not directly caused by stimulant therapy.
*Increased BMI*
- Medications for ADHD, particularly stimulants, are more commonly associated with **decreased appetite** and **weight loss**, not an increased BMI.
- **Appetite suppression** leading to difficulty gaining weight is a known side effect in children taking these medications.
*Prolonged QT interval*
- While some psychiatric medications can prolong the QT interval (e.g., certain antipsychotics or TCAs), **stimulants** used for ADHD are generally not a primary cause of this.
- **ECG monitoring** may be considered for patients with pre-existing cardiac conditions, but it's not a common direct side effect for healthy individuals on stimulants.
*Decreased perspiration*
- Stimulant medications for ADHD can sometimes lead to **increased sweating** (hyperhidrosis) as a side effect, rather than decreased perspiration.
- **Autonomic nervous system changes** due to stimulants can include enhanced sympathetic activity, which can manifest as increased sweating.
Psychiatric comorbidities with sleep disorders US Medical PG Question 10: 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
Psychiatric comorbidities with 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.
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