Sleep in Psychiatric Disorders — MCQs
Child wakes up at night sweating and terrified, does not remember the episode - diagnosis?
Sedation as an adverse effect is most commonly associated with which of the following atypical antipsychotics?
A patient complains of sadness of mood, increased lethargy, early morning awakening, loss of interest and reports no will to live and hears voices asking her to kill self. What is the diagnosis?
A 68-year-old lady thinks that she has committed a sin, she is not worthy to live in this world, she is also having anorexia and insomnia, she is suffering from -
Which of the following is least characteristic of mania?
The EEG pattern in REM sleep is:
Early morning awakening is a feature of -
Muller's manoeuvre is used to
A patient presents with symptoms of hyperthyroidism. Thyroid function tests would probably reveal:
Identify the sleep stage in the following Polysomnograph.
Sleep in Psychiatric Disorders Indian Medical PG Practice Questions and MCQs
Question 1: Child wakes up at night sweating and terrified, does not remember the episode - diagnosis?
- A. Narcolepsy
- B. Nightmares
- C. Night terrors (Correct Answer)
- D. Somnambulism
Explanation: ***Night terrors*** - **Night terrors** are characterized by partial arousals from **deep non-REM sleep** (typically N3 stage), often accompanied by loud screams, thrashing, and autonomic symptoms like sweating and tachycardia. - The child is very difficult to awaken or comfort during an episode and, crucially, has **no memory of the event** upon waking, which differentiates it from nightmares. *Narcolepsy* - **Narcolepsy** is a chronic neurological condition characterized by overwhelming daytime **sleepiness** and sudden attacks of sleep. - It often involves **cataplexy** (sudden loss of muscle tone triggered by strong emotions) and **hypnagogic/hypnopompic hallucinations**, which are not described. *Nightmares* - **Nightmares** are vivid, frightening dreams that occur during **REM sleep** and typically result in full awakening and the ability to **recall the dream content**. - While they cause fear and distress, episodes do not usually involve the terrified unresponsiveness or lack of recall seen in night terrors. *Somnambulism* - **Somnambulism** (sleepwalking) occurs during **deep non-REM sleep**, and affected individuals may perform complex actions while partially aroused. - While there is amnesia for the event, prominent features like **sweating and intense terror** are not typical components of sleepwalking.
Question 2: Sedation as an adverse effect is most commonly associated with which of the following atypical antipsychotics?
- A. Risperidone
- B. Olanzapine
- C. Quetiapine (Correct Answer)
- D. Aripiprazole
Explanation: ***Quetiapine*** - **Quetiapine** is known for its strong **H1 histamine receptor blockade**, which directly contributes to its prominent sedating effects. - This sedation is often dose-dependent and can be beneficial for patients with insomnia or agitation, but it is also a common complaint and reason for discontinuation. - Among the options listed, quetiapine is classically taught as the **most sedating** atypical antipsychotic. *Risperidone* - While risperidone can cause some sedation [1], it is generally less sedating than quetiapine or olanzapine and is more commonly associated with **extrapyramidal symptoms (EPS)**, especially at higher doses [1]. - Its mechanism of action primarily involves **D2 dopamine receptor blockade** and **5-HT2A serotonin receptor blockade** [1]. *Olanzapine* - **Olanzapine** also causes significant sedation [1] due to its strong antagonism of **H1 histamine receptors** and **alpha-1 adrenergic receptors**. - Clinically, olanzapine's sedative effects are comparable to quetiapine, though quetiapine is traditionally emphasized in exam contexts as the most sedating among these options. - Olanzapine is additionally notable for significant **metabolic side effects** like weight gain and dyslipidemia. *Aripiprazole* - **Aripiprazole** acts as a **partial agonist** at D2 dopamine receptors and 5-HT1A serotonin receptors, and an antagonist at 5-HT2A serotonin receptors, which results in minimal sedation. - It is often considered to be more **activating** or have a **neutral** effect on sedation compared to other atypical antipsychotics.
Question 3: A patient complains of sadness of mood, increased lethargy, early morning awakening, loss of interest and reports no will to live and hears voices asking her to kill self. What is the diagnosis?
- A. Schizophrenia
- B. Major depressive disorder plus psychosis (Correct Answer)
- C. Schizoaffective disorder
- D. Schizotypal personality disorder
Explanation: ***Major depressive disorder plus psychosis*** - The patient presents with classic symptoms of **major depressive disorder**, including persistent sadness, **anhedonia (loss of interest)**, **lethargy**, and **early morning awakening**. - The presence of **auditory hallucinations** (hearing voices asking her to kill herself) indicates **psychotic features** accompanying the severe depression, leading to the diagnosis of major depressive disorder with psychotic features. *Schizophrenia* - While schizophrenia involves psychosis, the primary presentation here is a prominent **depressive syndrome** rather than the typical **positive symptoms (delusions, hallucinations)**, **negative symptoms (alogia, avolition)**, and **disorganized thought** processes characteristic of schizophrenia. - The depressive symptoms are too pervasive and central to the clinical picture to be solely schizophrenia. *Schizoaffective disorder* - This disorder requires a period of **at least two weeks of psychotic symptoms** (hallucinations or delusions) **without prominent mood symptoms**, which is not described. - In this case, the **psychotic symptoms are congruent with the depressed mood** (e.g., voices urging self-harm, reflecting hopelessness), rather than independent. *Schizotypal personality disorder* - This is a pervasive pattern of **social and interpersonal deficits** marked by acute discomfort with, and reduced capacity for, close relationships, as well as by **cognitive or perceptual distortions** and eccentricities of behavior. - It does not involve persistent, severe depressive episodes with overt psychotic symptoms as described, nor significant functional impairment to the extent seen here.
Question 4: A 68-year-old lady thinks that she has committed a sin, she is not worthy to live in this world, she is also having anorexia and insomnia, she is suffering from -
- A. Endogenous depression (Correct Answer)
- B. Dissociative disorder
- C. Exogenous depression
- D. Neurotic depression
Explanation: ***Endogenous depression*** - This older classification term describes **severe depressive symptoms** that arise without a clear external precipitating factor and are characterized by **melancholic/biological features**. - The patient presents with classic features: profound guilt (\"committed a sin\"), worthlessness (\"not worthy to live\"), and significant **vegetative symptoms** including **anorexia** and **insomnia**. - These symptoms align with what is now termed **Major Depressive Disorder with Melancholic Features** in modern classification (DSM-5/ICD-11). - The endogenous nature suggests a **biological/biochemical basis** rather than purely reactive symptoms. *Dissociative disorder* - This disorder involves disruption of **consciousness, memory, identity, or perception** (e.g., dissociative amnesia, depersonalization). - The core features presented—guilt, worthlessness, anorexia, insomnia—are **mood and vegetative symptoms**, not dissociative phenomena. - While depression and dissociation can co-occur, this presentation is primarily a **mood disorder**. *Exogenous depression* - Also called **reactive depression**, this type is triggered by an **identifiable external stressor** (e.g., bereavement, job loss, trauma). - The question provides **no history of external precipitant**, and the severity of guilt and biological symptoms suggests an endogenous process. - Modern equivalent would be depression clearly linked to a psychosocial stressor. *Neurotic depression* - This outdated term historically referred to **milder depression** with prominent **anxiety features** and thought to be related to personality factors. - The patient's presentation is **too severe**—profound guilt, worthlessness, and marked vegetative symptoms indicate a more severe depressive episode. - This better fits **melancholic/endogenous depression** rather than a neurotic-level disorder.
Question 5: Which of the following is least characteristic of mania?
- A. Disorientation (Correct Answer)
- B. Pressure of speech
- C. Decreased need for sleep
- D. Grandiose delusions
Explanation: ***Disorientation*** - While psychotic features can occur in severe mania, **disorientation** (confusion about time, place, or person) is not a typical or primary symptom. - It suggests a more profound cognitive disturbance or an organic cause (such as delirium), which is less characteristic of an uncomplicated manic episode. - The presence of disorientation should prompt evaluation for medical causes. *Decreased need for sleep* - **Decreased need for sleep** is a hallmark symptom of a manic episode and one of the core diagnostic criteria. - Individuals with mania feel energetic and rested despite sleeping very little (often 2-3 hours or less). - This is distinct from insomnia—patients don't feel tired or have difficulty sleeping; rather, they simply don't need much sleep. *Pressure of speech* - **Pressure of speech**, characterized by rapid, loud, and difficult-to-interrupt speech, is a core diagnostic feature of mania. - It reflects the underlying racing thoughts (flight of ideas) and increased psychomotor activity typical of manic episodes. - Speech may be tangential, circumstantial, or filled with puns, jokes, and theatrical references. *Grandiose delusions* - **Grandiose delusions** (delusions of grandeur), such as believing one has special powers, extraordinary wealth, or a special relationship with famous figures, are common psychotic features in severe mania. - These delusions are mood-congruent and consistent with the elevated mood, inflated self-esteem, and impaired judgment seen in manic episodes.
Question 6: The EEG pattern in REM sleep is:
- A. High amplitude, slow waves
- B. Low amplitude, slow waves
- C. High amplitude, rapid waves
- D. Low amplitude, rapid waves (Correct Answer)
Explanation: ***Low amplitude, rapid waves*** - REM sleep is characterized by an **EEG pattern** that is very similar to wakefulness, featuring **desynchronized, low amplitude, high frequency (rapid) waves**. - This pattern reflects high brain activity despite the body being in a state of muscle paralysis (**atonia**), and is often referred to as **paradoxical sleep**. *High amplitude, slow waves* - This EEG pattern, indicative of **delta waves**, is characteristic of **deep non-REM (NREM) sleep** stages 3 and 4 (or N3 in newer classifications). - It signifies a highly synchronized brain state where neuronal firing is slow and highly rhythmic, unlike the active brain state of REM sleep. *Low amplitude, slow waves* - While low amplitude waves can be seen in wakefulness or some lighter NREM stages, the presence of **slow waves** does not align with the highly active and desynchronized nature of REM sleep. - Slow waves are more typical of deeper sleep stages or general drowsiness. *High amplitude, rapid waves* - Although REM sleep involves **rapid waves (high frequency)**, they are typically of **low amplitude**. High amplitude waves suggest synchronization, whereas REM is characterized by desynchronization. - **High amplitude rapid waves** are not a typical EEG characteristic of any sleep stage; rapid waves usually imply lower amplitude due to desynchronization.
Question 7: Early morning awakening is a feature of -
- A. Mania
- B. Psychosis
- C. Anxiety neurosis
- D. Depression (Correct Answer)
Explanation: ***Depression*** - **Early morning awakening** (or terminal insomnia) is a classic symptom of major depressive disorder, where patients wake up several hours before their usual time and cannot return to sleep. - This symptom is often accompanied by other features like **anhedonia**, feelings of worthlessness, fatigue, and **psychomotor retardation** or agitation. *Mania* - Patients experiencing **mania** often have a significantly reduced need for sleep but do not typically report early morning awakening as a distressful symptom. - They may go days with very little sleep, feeling energetic and not tired, which differs from the insomnia associated with depression. *Psychosis* - **Psychotic disorders** can disrupt sleep patterns due to hallucinations, delusions, or disorganized thinking, leading to various sleep disturbances. - However, **early morning awakening** is not a specific or hallmark symptom of psychosis; rather, sleep architecture can be severely fragmented and irregular. *Anxiety neurosis* - **Anxiety neurosis** (now often termed generalized anxiety disorder or panic disorder) can cause sleep initiation difficulties due to racing thoughts and worries. - While anxiety can cause **insomnia**, it more commonly manifests as difficulty falling asleep or nocturnal awakenings, rather than the characteristic early morning awakening seen in depression.
Question 8: Muller's manoeuvre is used to
- A. To remove foreign body from ear
- B. To find degree of obstruction in sleep disordered breathing (Correct Answer)
- C. To remove laryngeal foreign body
- D. To find out opening of mouth
Explanation: ***To find degree of obstruction in sleep disordered breathing*** - **Muller's manoeuvre** is a diagnostic technique where the patient attempts to inspire forcefully against a **closed mouth and nostrils** while an endoscope observes the upper airway. - This maneuver helps to simulate the negative intraluminal pressure that occurs during sleep, making it useful in identifying the **site and severity of airway obstruction** in patients with sleep-disordered breathing. *To remove foreign body from ear* - Removing foreign bodies from the ear typically involves **irrigation**, specialized instruments (e.g., alligator forceps), or suction, not a breathing maneuver. - This option is unrelated to the physiological assessment of airway obstruction. *To remove laryngeal foreign body* - The primary methods for removing laryngeal foreign bodies are the **Heimlich maneuver** (abdominal thrusts) or direct laryngoscopy and removal. - Muller's manoeuvre is a diagnostic procedure, not a therapeutic one for foreign body extraction. *To find out opening of mouth* - Measuring the **opening of the mouth** is typically done with a ruler or specific instruments to assess jaw mobility (e.g., for temporomandibular joint disorders or trismus). - This is a simple measurement and does not involve the complex physiological assessment of the upper airway that Muller's manoeuvre provides.
Question 9: A patient presents with symptoms of hyperthyroidism. Thyroid function tests would probably reveal:
- A. Increased T4, Increased T3, decreased TSH (Correct Answer)
- B. Increased T4, normal T3, and increased TSH
- C. Increased T3, T4, and increased TSH
- D. Decreased T3 and T4, increased TSH
Explanation: ***Increased T4, Increased T3, decreased TSH*** - In **primary hyperthyroidism**, the thyroid gland overproduces thyroid hormones (**T3 and T4**), leading to elevated levels [1]. - The high levels of T3 and T4 then **feedback negatively** on the pituitary gland, suppressing the release of **TSH** [1]. *Increased T4, normal T3, and increased TSH* - This pattern is inconsistent with primary hyperthyroidism, as elevated T3 and T4 should suppress TSH. - An isolated increase in T4 with normal T3 can occur in **subclinical hyperthyroidism** or **thyroxine (T4) resistance**, but increased TSH would suggest pituitary dysfunction or resistance to thyroid hormones. *Increased T3, T4, and increased TSH* - Elevated T3 and T4 accompanied by **increased TSH** is a rare presentation, usually indicating **TSH-secreting pituitary adenoma** (secondary hyperthyroidism) or **thyroid hormone resistance** [1], [2]. - In typical hyperthyroidism, high thyroid hormone levels would suppress TSH. *Decreased T3 and T4, increased TSH* - This profile is characteristic of **primary hypothyroidism**, where an underactive thyroid gland produces insufficient T3 and T4 [1]. - The low thyroid hormone levels stimulate the pituitary to release **more TSH** in an attempt to stimulate thyroid hormone production [1].
Question 10: Identify the sleep stage in the following Polysomnograph.
- A. NREM stage 2 (Correct Answer)
- B. NREM stage 3
- C. REM
- D. NREM stage 1
Explanation: ***NREM stage 2*** - The **EEG** shows prominent **sleep spindles** (bursts of 12-14 Hz waves) and **K-complexes** (high-amplitude biphasic waves), which are characteristic features of NREM stage 2 sleep. - The EOG channels indicate slow eye movements or an absence of rapid eye movements, consistent with NREM sleep, while the **EMG shows moderate muscle tone**, higher than in REM sleep but lower than wakefulness. *NREM stage 3* - This stage is characterized by **delta waves**, which are slow waves with high amplitude (0.5-2 Hz, often >75 μV) on the EEG, comprising 20% or more of the epoch, and are not significantly visible here. - While muscle tone is still present, the EEG would primarily show widespread **slow-wave activity**, distinguishing it from the sleep spindles and K-complexes seen in the image. *REM* - **Rapid eye movements** would be clearly visible on the EOG channels, which are not prevalent in this polysomnograph. - The **EMG would show very low muscle tone** (atonia), which is not the case here, and the EEG would largely consist of low-voltage, mixed-frequency activity, similar to wakefulness. *NREM stage 1* - This stage is typically characterized by a **disappearance of alpha waves** from the EEG and the presence of **theta waves** (4-7 Hz). - While there may be slow eye movements on the EOG, **sleep spindles and K-complexes are absent** in NREM stage 1, making it distinct from the presented polysomnograph.
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