Insomnia — MCQs

10 questions

A 28-year-old woman who reports being a "nervous person" and experiences chronic tension, exhibits symptoms of both sympathetic and parasympathetic nervous system activation, and has insomnia is most likely to be suffering from which condition?

Disturbances in sleep due to depression are associated with which of the following?

A woman, who is 4 days postpartum, presented with tearfulness, mood swings, and occasional insomnia. What is the likely diagnosis?

Antidepressant drug used in nocturnal enuresis is:

Post-traumatic stress disorder is characterized by all except:

A child presents with complaints of bed wetting. What is the first line of treatment?

All are used in the treatment of nocturnal enuresis except?

In narcolepsy, the polysomnographic recording typically shows which of the following patterns?

All are true about delirium tremens, except:

Q10

All are true about delirium tremens, except:

Insomnia Indian Medical PG Practice Questions and MCQs

Question 1: A 28-year-old woman who reports being a "nervous person" and experiences chronic tension, exhibits symptoms of both sympathetic and parasympathetic nervous system activation, and has insomnia is most likely to be suffering from which condition?

A. Post-traumatic stress disorder
B. Generalized anxiety disorder (Correct Answer)
C. Obsessive-compulsive disorder
D. Agoraphobia

Explanation: ***Generalized anxiety disorder*** - This condition is characterized by **persistent and excessive worry** about various aspects of life, often accompanied by physical symptoms of autonomic arousal, such as muscle tension, nervousness, and sleep disturbances (insomnia). - The patient's description of being a "nervous person" and experiencing **chronic tension** and insomnia, along with symptoms of both sympathetic and parasympathetic activation, is highly consistent with GAD. *Post-traumatic stress disorder* - This disorder typically develops after exposure to a **traumatic event** and involves symptoms such as re-experiencing the trauma, avoidance, negative alterations in cognition and mood, and hyperarousal. - While it can involve hyperarousal and sleep disturbances, the absence of a specified traumatic event and the focus on "nervousness" and "chronic tension" makes GAD a more direct fit. *Obsessive-compulsive disorder* - OCD involves **recurrent, intrusive thoughts (obsessions)** and repetitive behaviors or mental acts (compulsions) performed to alleviate anxiety. - The symptoms described do not include typical obsessions or compulsions, making this diagnosis less likely. *Agoraphobia* - This is an anxiety disorder characterized by intense fear and avoidance of situations where escape might be difficult or help unavailable, often involving public places or crowds. - While agoraphobia can cause anxiety and autonomic symptoms, the primary description of chronic tension and generalized nervousness is not the hallmark feature of this condition.

Question 2: Disturbances in sleep due to depression are associated with which of the following?

A. Occasional vivid dreams
B. Changes in REM sleep architecture
C. Decreased REM (rapid eye movement) latency (Correct Answer)
D. Insomnia and fragmented sleep

Explanation: ***Decreased REM (rapid eye movement) latency*** - **Decreased REM latency** (shortened time from sleep onset to first REM period, typically <60 minutes vs normal ~90 minutes) is the **most specific and well-established polysomnographic finding** in major depressive disorder. - This neurobiological marker reflects dysregulation of sleep architecture and is used as a **biological marker** in depression research. - Other REM changes include **increased REM density** (more rapid eye movements per REM period) and **prolonged first REM period**. *Changes in REM sleep architecture* - While this statement is technically correct (decreased REM latency is a change in REM architecture), it is **too broad and non-specific**. - This option lacks the precision needed for a clinical diagnosis, as many psychiatric and medical conditions alter REM architecture. - The question asks for the specific disturbance most associated with depression, making **decreased REM latency** the superior answer. *Occasional vivid dreams* - Vivid dreams are **not a characteristic or diagnostic feature** of depression-related sleep disturbance. - More commonly associated with **REM rebound** (after REM suppression), **narcolepsy**, **PTSD**, or certain medications (e.g., beta-blockers, antidepressants). *Insomnia and fragmented sleep* - While **early morning awakening** (terminal insomnia), difficulty maintaining sleep, and fragmented sleep are common clinical symptoms of depression, they are **non-specific**. - These symptoms occur in many conditions and describe subjective sleep quality rather than the **objective neurophysiological marker** that decreased REM latency represents.

Question 3: A woman, who is 4 days postpartum, presented with tearfulness, mood swings, and occasional insomnia. What is the likely diagnosis?

A. Postpartum depression
B. Postpartum blues (Correct Answer)
C. Postpartum psychosis
D. Postpartum anxiety

Explanation: ***Postpartum blues*** - This condition presents with mild, transient symptoms like **tearfulness**, **mood swings**, and **insomnia** typically peaking around **4-5 days postpartum** and resolving within two weeks. - It is a very common, self-limiting condition impacting up to 80% of new mothers, attributed to drastic **hormonal shifts** post-delivery. *Postpartum depression* - Symptoms are similar to postpartum blues but are more **severe**, last longer (typically **beyond two weeks**), and significantly impair functioning. - It often includes feelings of **hopelessness**, pervasive sadness, loss of pleasure, and sometimes thoughts of harming oneself or the baby. *Postpartum psychosis* - This is a severe psychiatric emergency characterized by **hallucinations**, delusions, disorganized thinking, and bizarre behavior, usually within the first 2-3 weeks postpartum. - It is a rare condition requiring **urgent medical intervention** due to the high risk of harm to mother and baby. *Postpartum anxiety* - While anxiety can co-occur with postpartum blues or depression, primary postpartum anxiety specifically involves excessive and **uncontrollable worry** or fear, often about the baby's health or safety. - It does not typically present with the prominent **tearfulness** and **mood swings** characteristic of blues or depression.

Question 4: Antidepressant drug used in nocturnal enuresis is:

A. Imipramine (Correct Answer)
B. Fluoxetine
C. Trazodone
D. Sertraline

Explanation: ***Imipramine*** - **Imipramine**, a **tricyclic antidepressant (TCA)**, is frequently used off-label for **nocturnal enuresis** in children [1]. - Its mechanism of action in enuresis is thought to involve a combination of anticholinergic effects (which relax the bladder detrusor muscle) and central nervous system effects (which may increase bladder capacity and arousal from sleep) [1]. *Fluoxetine* - **Fluoxetine** is a **selective serotonin reuptake inhibitor (SSRI)** and is primarily used for depression, anxiety disorders, and OCD [2]. - It is not indicated for the treatment of nocturnal enuresis and does not have the same bladder-relaxing or arousal-modulating properties as imipramine in this context. *Trazodone* - **Trazodone** is a **serotonin antagonist and reuptake inhibitor (SARI)**, commonly prescribed for depression and insomnia due to its prominent sedative effects. - It is not used for nocturnal enuresis and its mechanism of action does not confer benefits for bladder control. *Sertraline* - **Sertraline** is another **selective serotonin reuptake inhibitor (SSRI)** used for a wide range of psychiatric conditions, including depression, anxiety, and panic disorder [2]. - Like fluoxetine, it is not an appropriate treatment for nocturnal enuresis and lacks the specific known effects beneficial for this condition.

Question 5: Post-traumatic stress disorder is characterized by all except:

A. Flashback and nightmare
B. Re-experiencing stressful events
C. Exposure to traumatic events
D. It doesn't develop after 6 months of stress (Correct Answer)

Explanation: ***It doesn't develop after 6 months of stress*** - This statement is **FALSE** and is therefore the correct answer to this "EXCEPT" question. - **PTSD can develop at any time** following a traumatic event, including months or even years later - there is no upper time limit for symptom onset. - The **DSM-5 includes a "delayed expression" specifier** for cases where full diagnostic criteria are not met until at least 6 months after the trauma. - While most cases develop within **3 months of the traumatic event**, delayed onset is well-documented and clinically recognized. - This distinguishes PTSD from **Acute Stress Disorder**, which by definition occurs within 3 days to 4 weeks after trauma exposure. *Flashback and nightmare* - **Flashbacks** (dissociative reactions where the person feels the traumatic event is recurring) and **nightmares** are core symptoms of PTSD. - These belong to the **re-experiencing/intrusion symptom cluster** (Criterion B in DSM-5). - These involuntary recollections cause significant distress and are hallmark features of the disorder. *Re-experiencing stressful events* - **Re-experiencing symptoms** are one of the four main symptom clusters required for PTSD diagnosis. - This includes intrusive memories, traumatic nightmares, flashbacks, and intense psychological/physiological reactions to trauma reminders. - These symptoms reflect the **inability to integrate the traumatic memory** properly, leading to involuntary reactivation. *Exposure to traumatic events* - **Criterion A: Exposure to actual or threatened death, serious injury, or sexual violence** is the essential prerequisite for PTSD diagnosis. - This exposure can be through direct experience, witnessing, learning it happened to a close other, or repeated/extreme exposure to aversive details. - Without documented trauma exposure, PTSD cannot be diagnosed regardless of symptom presentation.

Question 6: 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

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.

Question 7: All are used in the treatment of nocturnal enuresis except?

A. Voiding of urine before sleeping (Correct Answer)
B. Imipramine
C. Alarm setup
D. Maintenance of calendar of day night wetting

Explanation: ***Voiding of urine before sleeping*** - **Voiding before sleep** is a **general hygiene measure and preventive advice** rather than a specific therapeutic intervention for nocturnal enuresis. - While it may reduce bladder volume at bedtime, it does **not address the underlying pathophysiology** of nocturnal enuresis (arousal deficit, nocturnal polyuria, or detrusor overactivity). - It is **routine advice** given to all children, not a targeted treatment modality for curing enuresis. *Imipramine* - **Imipramine**, a tricyclic antidepressant, is an established **pharmacological treatment** for nocturnal enuresis. - Its mechanisms include: **anticholinergic effects** (increasing bladder capacity and functional bladder capacity), **alpha-adrenergic effects** (increasing bladder outlet resistance), and **antidiuretic effects**. - Typical dosing: **25-50 mg at bedtime**, with success rates of 40-60%. *Alarm setup* - **Bed-wetting alarms** are the **first-line behavioral therapy** with the highest long-term cure rates (60-70% success). - Works through **classical conditioning**: the alarm triggers when moisture is detected, training the child to either wake to void or develop nocturnal bladder control. - Requires **8-12 weeks** of consistent use and has the lowest relapse rates among treatments. *Maintenance of calendar of day night wetting* - **Voiding diary/calendar** is an essential **behavioral intervention** for monitoring and managing nocturnal enuresis. - Helps identify patterns, track treatment progress, and provides **positive reinforcement** through visual feedback. - Part of comprehensive behavioral management alongside fluid restriction and scheduled voiding during daytime.

Question 8: In narcolepsy, the polysomnographic recording typically shows which of the following patterns?

A. REM intrusion during inappropriate periods (Correct Answer)
B. An absence of REM sleep in midcycle
C. Extreme muscular relaxation
D. Spike-and-wave EEG recording

Explanation: ***REM intrusion during inappropriate periods*** - In narcolepsy, the hallmark polysomnographic finding is **sleep-onset REM periods (SOREMPs)** - the occurrence of REM sleep within 15 minutes of sleep onset. - The **Multiple Sleep Latency Test (MSLT)** in narcolepsy typically shows **≥2 SOREMPs** along with a mean sleep latency of ≤8 minutes. - Clinically, this **REM sleep intrusion** manifests as **sudden, irresistible sleep attacks** during the day, **cataplexy** (sudden muscle weakness triggered by strong emotions), **sleep paralysis**, and **hypnagogic/hypnopompic hallucinations**. - These represent features of REM sleep (muscle atonia, dreams) occurring at inappropriate times. *An absence of REM sleep in midcycle* - This statement is incorrect as narcolepsy is characterized by an **abnormal presence and early onset of REM sleep**, not its absence. - Individuals with narcolepsy enter REM sleep much faster than normal (often within minutes rather than the typical 90 minutes). *Extreme muscular relaxation* - While **cataplexy** (present in Type 1 narcolepsy) involves sudden loss of muscle tone due to REM-related atonia during wakefulness, this is a clinical symptom rather than a continuous polysomnographic finding. - Polysomnography focuses on **sleep architecture** and the timing of **REM sleep onset**, not general muscle relaxation patterns. *Spike-and-wave EEG recording* - **Spike-and-wave patterns** on EEG are characteristic of **absence seizures** (a form of epilepsy), not narcolepsy. - Narcolepsy is a primary **sleep disorder** with distinct polysomnographic features related to **REM sleep dysregulation**, not epileptiform activity.

Question 9: All are true about delirium tremens, except:

A. Clouding of consciousness
B. Visual hallucinations
C. Normal sleep-wake cycle (Correct Answer)
D. Coarse tremors

Explanation: ***Normal sleep wake cycle*** - Delirium tremens is characterized by a **disrupted sleep-wake cycle**, often with **insomnia** and **nocturnal exacerbation** of symptoms, making a normal sleep-wake cycle an incorrect statement. - The brain's regulatory mechanisms for sleep are significantly impaired due to the withdrawal of alcohol's suppressive effects. *Clouding of consciousness* - **Clouding of consciousness** is a hallmark feature of delirium tremens, representing a reduced awareness of the environment and impaired attention. - Patients often present with **disorientation** regarding time, place, and person. *Visual hallucinations* - **Visual hallucinations** are very common in delirium tremens, often described as vivid, frightening, and involving small animals or insects. - These hallucinations contribute to the patient's **agitation** and fear. *Coarse tremors* - **Coarse tremors**, particularly of the hands and face, are a classic physical sign of alcohol withdrawal and an integral part of delirium tremens. - These tremors are due to the **overactivity of the sympathetic nervous system** as the inhibitory effects of alcohol wear off.

Question 10: All are true about delirium tremens, except:

A. Coarse tremors
B. Visual hallucinations
C. Normal sleep wake cycle (Correct Answer)
D. Clouding of consciousness

Explanation: ***Normal sleep wake cycle*** - Delirium tremens is characterized by **significant disruption of the sleep-wake cycle**, often leading to severe *insomnia* and **nocturnal exacerbation** of symptoms. - Patients typically experience **vivid dreams, nightmares**, and struggles distinguishing dreams from reality due to the altered state of consciousness. *Clouding of consciousness* - **Clouding of consciousness** is a hallmark feature of delirium tremens, manifesting as difficulty with attention, decreased awareness of surroundings, and impaired cognitive function. - This symptom contributes to the patient's disorientation and inability to process information logically. *Coarse tremors* - **Coarse tremors** are a classic physical sign of alcohol withdrawal, including delirium tremens, affecting the hands, tongue, and sometimes the entire body. - These tremors are typically **generalized**, rapid, and can be quite severe, often worsening with anxiety or motor activity. *Visual hallucinations* - **Visual hallucinations** are common and often frightening in delirium tremens, ranging from *fleeting images* to vivid, complex scenes of animals or people. - These hallucinations, along with **tactile (e.g., bugs crawling on skin)** and *auditory hallucinations*, contribute to the patient's extreme distress and agitation.

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