Cognitive-Behavioral Therapy for Insomnia — MCQs
Disturbances in sleep due to depression are associated with which of the following?
Electroconvulsive therapy is not useful in which of the following conditions?
Which of the following treatments cannot be used for management of Obsessive Compulsive Disorder (OCD)?
Best therapy suited to teach daily life skill to a mentally challenged child:
Bruxism most commonly occurs during which phase of sleep?
What is a feature of narcolepsy?
Benzodiazepines are used in the treatment of somnambulism because they?
Hypnagogic hallucination is defined as a hallucination experienced during which state?
Kleine-Levin syndrome is characterized by which of the following?
A person hears voices before falling asleep, with a history of falls and daytime sleep attacks. What is the probable diagnosis?
Cognitive-Behavioral Therapy for Insomnia Indian Medical PG Practice Questions and MCQs
Question 1: 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 2: Electroconvulsive therapy is not useful in which of the following conditions?
- A. Panic attacks (Correct Answer)
- B. Depression
- C. Seizures
- D. Delirium
Explanation: ***Panic attacks*** - ECT has **no established role** in the treatment of panic disorder or panic attacks. - **First-line treatments** include SSRIs, benzodiazepines, and cognitive behavioral therapy (CBT). - ECT is not indicated for **anxiety-predominant disorders** and there is no evidence supporting its use in panic attacks. *Depression* - ECT is a **highly effective** treatment for **severe major depression**, particularly: - **Treatment-resistant depression** (failed multiple antidepressant trials) - **Psychotic depression** (depression with psychotic features) - **Severe melancholic or catatonic depression** - Depression with **high suicide risk** requiring rapid response - ECT is considered one of the most effective treatments in psychiatry for severe depression. *Seizures* - ECT **induces controlled therapeutic seizures** to achieve psychiatric benefits, but it is **not a treatment for epilepsy** or seizure disorders. - The therapeutic effect in psychiatric conditions is mediated through the induced seizure and its neurobiological effects. - ECT does **not treat or prevent epileptic seizures**; patients with epilepsy can safely receive ECT with appropriate precautions. *Delirium* - ECT can be used in **highly selected cases** of refractory delirium, particularly: - Delirium with **severe agitation** unresponsive to medical management - Delirium in the context of **catatonia** - While not a first-line treatment, ECT **has documented efficacy** in specific refractory cases of delirium when conventional treatments have failed.
Question 3: Which of the following treatments cannot be used for management of Obsessive Compulsive Disorder (OCD)?
- A. Fluoxetine
- B. Carbamazepine (Correct Answer)
- C. Cognitive Behaviour Therapy
- D. Clomipramine
Explanation: ***Carbamazepine*** - **Carbamazepine** is an **anticonvulsant** and **mood stabilizer** primarily used for epilepsy and bipolar disorder. - It does not have established efficacy for the treatment of **Obsessive-Compulsive Disorder (OCD)**. *Fluoxetine* - **Fluoxetine** is a **Selective Serotonin Reuptake Inhibitor (SSRI)** and is a **first-line pharmacotherapy** for OCD. - SSRIs, including fluoxetine, are effective in reducing the severity of **obsessions and compulsions**. *Cognitive Behaviour Therapy* - **Cognitive Behavioural Therapy (CBT)**, specifically **Exposure and Response Prevention (ERP)**, is the **gold standard psychotherapy** for OCD. - It involves gradually exposing patients to feared situations or thoughts while preventing their ritualistic responses. *Clomipramine* - **Clomipramine** is a **tricyclic antidepressant (TCA)** that has potent inhibitory effects on **serotonin reuptake**. - It is one of the **most effective medications** for OCD, often used when SSRIs are insufficient.
Question 4: Best therapy suited to teach daily life skill to a mentally challenged child:
- A. Contingency management (Correct Answer)
- B. Cognitive reconstruction
- C. Self instruction
- D. CBT (Cognitive behavior therapy)
Explanation: ***Contingency management*** - This therapy involves consistently **rewarding desired behaviors** and withholding rewards for undesirable ones, which is highly effective for teaching new skills to individuals with intellectual disabilities. - It uses principles of **operant conditioning** to shape behavior through positive reinforcement, making it suitable for acquiring daily living skills. *Cognitive reconstruction* - This technique focuses on identifying and changing **maladaptive thought patterns**, which typically requires a higher level of cognitive function. - It is generally not the primary or most effective approach for teaching concrete daily life skills to individuals with significant **cognitive limitations**. *Self instruction* - This involves teaching individuals to guide their own behavior using **internal verbal cues** or self-talk. - While beneficial for some, it often requires a certain degree of **abstract thinking** and memory, making it less suitable as a standalone method for those with profound cognitive challenges in acquiring basic skills. *CBT (Cognitive behavior therapy)* - CBT integrates cognitive and behavioral strategies to address emotional and behavioral problems by modifying **thoughts, feelings, and behaviors**. - While beneficial for a range of psychological issues, its emphasis on **cognitive restructuring** makes it less directly applicable or the most effective first-line therapy for teaching concrete, functional daily living skills to mentally challenged children.
Question 5: Bruxism most commonly occurs during which phase of sleep?
- A. REM sleep
- B. NREM Stage I
- C. NREM Stage II (Correct Answer)
- D. NREM Stage III
Explanation: **Explanation:** **Sleep Bruxism** is a sleep-related movement disorder characterized by the involuntary grinding or clenching of teeth. **Why NREM Stage II is correct:** While bruxism can occur in any stage of sleep, it is most frequently observed during **NREM Stage II (Light Sleep)**. Statistically, about 80% of bruxism episodes occur during NREM sleep, with the vast majority clustered in Stage II. These episodes are often associated with "micro-arousals"—brief shifts in sleep depth where the sympathetic nervous system activity increases, leading to rhythmic masticatory muscle activity (RMMA). **Analysis of Incorrect Options:** * **REM Sleep (A):** Although bruxism can occur during REM, it is less common. REM-related bruxism is often associated with more severe clinical symptoms and may be linked to obstructive sleep apnea. * **NREM Stage I (B):** This is a transitional phase of very light sleep. While grinding can occur here, the frequency is significantly lower than in Stage II. * **NREM Stage III (D):** Also known as Slow Wave Sleep (SWS) or deep sleep. Parasomnias like sleepwalking (somnambulism) and night terrors typically occur here, but bruxism is less frequent in this stage compared to Stage II. **High-Yield Clinical Pearls for NEET-PG:** * **Treatment of Choice:** The first-line management is usually **stress reduction** and **dental guards (occlusal splints)** to prevent tooth wear. * **Pharmacotherapy:** If severe, **Benzodiazepines** (like Clonazepam) or muscle relaxants may be used short-term. * **Association:** Bruxism is frequently associated with stress, anxiety, and other sleep disorders like Obstructive Sleep Apnea (OSA). * **Key Distinction:** Do not confuse bruxism (Stage II) with **Sleep Terrors/Somnambulism**, which are classic **Stage III (N3)** phenomena.
Question 6: What is a feature of narcolepsy?
- A. Insomnia
- B. Hypersomnia during the day (Correct Answer)
- C. Bruxism
- D. Somnambulism
Explanation: **Explanation:** **Narcolepsy** is a chronic neurological disorder characterized by the brain's inability to regulate sleep-wake cycles normally. The hallmark feature is **excessive daytime sleepiness (EDS)** or hypersomnia, where patients experience an irrepressible need to sleep or "sleep attacks" regardless of the amount of sleep they get at night. This occurs due to the loss of orexin (hypocretin)-producing neurons in the hypothalamus, which are responsible for maintaining wakefulness. **Analysis of Options:** * **Option B (Correct):** Hypersomnia is the primary symptom. Patients often enter REM sleep directly from wakefulness (SOREMPs), leading to refreshing but short naps. * **Option A:** Insomnia refers to difficulty initiating or maintaining sleep. While narcoleptics may have fragmented nocturnal sleep, the defining diagnostic feature is daytime hypersomnia. * **Option C:** Bruxism (teeth grinding) is a sleep-related movement disorder, not a primary feature of narcolepsy. * **Option D:** Somnambulism (sleepwalking) is a NREM parasomnia. Narcolepsy is primarily associated with REM sleep dysregulation. **High-Yield Clinical Pearls for NEET-PG:** * **The Classic Tetrad:** 1. Excessive Daytime Sleepiness, 2. **Cataplexy** (sudden loss of muscle tone triggered by emotions—most specific sign), 3. Sleep Paralysis, and 4. Hypnagogic/Hypnopompic hallucinations. * **Diagnosis:** Gold standard is the **Multiple Sleep Latency Test (MSLT)** showing a mean sleep latency <8 minutes and ≥2 SOREMPs. * **Treatment:** Modafinil (first-line for EDS); Sodium Oxybate (effective for both EDS and cataplexy).
Question 7: Benzodiazepines are used in the treatment of somnambulism because they?
- A. Increase the duration of NREM stages III and IV
- B. Increase the duration of REM sleep
- C. Decrease the duration of NREM stages III and IV (Correct Answer)
- D. Decrease the duration of REM sleep
Explanation: **Explanation:** **Somnambulism (Sleepwalking)** is a parasomnia that occurs during **NREM Stage N3 (Stage III and IV)**, also known as slow-wave sleep (SWS) or deep sleep. This is the stage characterized by high-arousal thresholds and rhythmic delta waves. **Why the correct answer is right:** Benzodiazepines (such as Diazepam or Alprazolam) are effective in treating somnambulism because they **suppress and decrease the duration of NREM Stage III and IV sleep**. By reducing the time a patient spends in these deep sleep stages, the physiological window in which sleepwalking occurs is minimized, thereby reducing the frequency of episodes. **Why the incorrect options are wrong:** * **Option A:** Increasing NREM Stage III and IV would theoretically increase the risk and frequency of sleepwalking episodes, as the disorder originates in these stages. * **Option B & D:** While Benzodiazepines are known to **decrease REM sleep** (Option D), this is not the primary reason they are used for somnambulism. Somnambulism is an NREM disorder; REM-related disorders include Nightmares and REM Sleep Behavior Disorder (RBD). Therefore, the effect on NREM is the clinically relevant mechanism here. **High-Yield Clinical Pearls for NEET-PG:** * **Timing:** Sleepwalking typically occurs during the **first third** of the night (when NREM sleep is most abundant). * **Amnesia:** Patients usually have complete amnesia regarding the episode the following morning. * **Management:** The first line of management is usually **safety precautions** and sleep hygiene. Pharmacotherapy (Benzodiazepines) is reserved for refractory or dangerous cases. * **Differential:** Unlike sleepwalking, **Nightmares** occur during REM sleep, usually in the later part of the night, and the patient has vivid recall.
Question 8: Hypnagogic hallucination is defined as a hallucination experienced during which state?
- A. While falling asleep (Correct Answer)
- B. While awakening
- C. After head trauma
- D. After a convulsion
Explanation: **Explanation:** **Hypnagogic hallucinations** are vivid, dream-like sensory perceptions (usually visual or auditory) that occur during the transition from wakefulness to sleep. The term is derived from the Greek words *hypnos* (sleep) and *agogos* (leading to). 1. **Why Option A is correct:** Hypnagogic hallucinations occur specifically **while falling asleep**. They are considered a physiological phenomenon but are classically associated with the tetrad of **Narcolepsy**, where REM sleep components (like dreaming) intrude into the wakeful state. 2. **Why the other options are incorrect:** * **Option B (While awakening):** Hallucinations occurring during the transition from sleep to wakefulness are termed **Hypnopompic** hallucinations (*"pomp"* as in "pomp out of bed"). * **Option C (After head trauma):** Hallucinations following trauma are usually part of post-traumatic delirium or organic brain syndrome, not specifically classified by the sleep-wake transition. * **Option D (After a convulsion):** This is the **post-ictal state**, where a patient may experience confusion or "post-ictal psychosis," but these are not termed hypnagogic. **High-Yield Clinical Pearls for NEET-PG:** * **Narcolepsy Tetrad:** 1. Excessive Daytime Sleepiness (most common), 2. Cataplexy (most specific), 3. Sleep Paralysis, and 4. Hypnagogic/Hypnopompic hallucinations. * **Mnemonic:** **GO**ing to sleep = Hypna**GO**gic; **PO**pping out of bed = Hypno**PO**mpic. * These hallucinations are generally considered **pseudo-hallucinations** because the individual often maintains insight into their unreality once fully awake.
Question 9: Kleine-Levin syndrome is characterized by which of the following?
- A. Insomnia
- B. Depression
- C. Anxiety
- D. Hypersomnia (Correct Answer)
Explanation: **Explanation:** **Kleine-Levin Syndrome (KLS)**, often referred to as "Sleeping Beauty Syndrome," is a rare, relapsing-remitting neurological disorder primarily affecting adolescent males. 1. **Why Hypersomnia is Correct:** The hallmark of KLS is **recurrent episodes of severe hypersomnia**, where patients may sleep for 15 to 21 hours a day. During these episodes, patients are difficult to arouse and exhibit cognitive disturbances (like derealization), irritability, and compulsive behaviors. 2. **Why Other Options are Incorrect:** * **Insomnia:** This is the inability to sleep. KLS is characterized by the polar opposite—excessive sleep duration. * **Depression & Anxiety:** While patients may experience mood changes or "flat affect" during an episode, these are secondary symptoms or part of the post-episode recovery phase. They are not the defining diagnostic criteria for the syndrome itself. 3. **Clinical Pearls for NEET-PG:** * **The Classic Triad:** Hypersomnia, Hyperphagia (compulsive overeating), and Hypersexuality (disinhibition). * **Demographics:** Most common in adolescent males (Male:Female ratio is approx. 3:1). * **Course:** Episodes typically last days to weeks and recur several times a year. Between episodes, patients usually have normal sleep and mood. * **Management:** * *Acute episodes:* Supportive care. * *Prophylaxis:* **Lithium** is the most effective treatment for reducing the frequency and severity of episodes. Carbamazepine or Valproate are second-line options. * **Differential Diagnosis:** Must be distinguished from Kluver-Bucy Syndrome (which involves temporal lobe damage and lacks the periodic sleep episodes).
Question 10: A person hears voices before falling asleep, with a history of falls and daytime sleep attacks. What is the probable diagnosis?
- A. Narcolepsy (Correct Answer)
- B. Schizophrenia
- C. Delusion
- D. Insomnia
Explanation: ### Explanation The clinical presentation described is a classic "textbook" case of **Narcolepsy**, characterized by the tetrad of symptoms resulting from the brain's inability to regulate sleep-wake cycles. **1. Why Narcolepsy is correct:** The diagnosis is confirmed by the presence of three key features mentioned in the stem: * **Daytime sleep attacks:** Overwhelming sleepiness leading to unintended naps. * **History of falls:** This indicates **Cataplexy**, a sudden loss of muscle tone often triggered by strong emotions (like laughter or surprise), causing the patient to collapse while remaining conscious. * **Voices before falling asleep:** These are **Hypnagogic hallucinations** (sensory experiences at sleep onset). If they occur upon awakening, they are called *hypnopompic* hallucinations. **2. Why the other options are incorrect:** * **Schizophrenia:** While it involves auditory hallucinations, these occur during clear consciousness throughout the day, not specifically at the transition to sleep. It lacks the sleep-related symptoms and cataplexy. * **Delusion:** This is a fixed, false belief. Hearing voices is a hallucination (perception), not a delusion (thought content). * **Insomnia:** This refers to difficulty initiating or maintaining sleep, which is the opposite of the "sleep attacks" seen here. **3. High-Yield Clinical Pearls for NEET-PG:** * **Pathophysiology:** Associated with a deficiency of **Hypocretin (Orexin)** in the lateral hypothalamus. * **REM Abnormality:** Narcolepsy is essentially REM sleep intruding into wakefulness. On Polysomnography, it shows a **decreased REM latency** (Sleep-onset REM periods or SOREMPs). * **Treatment:** * For daytime sleepiness: **Modafinil** (First-line) or Amphetamines. * For cataplexy: **Sodium Oxybate** or REM-suppressing drugs (SSRIs/TCAs). * **Mnemonic:** Remember **CHESS** (Cataplexy, Hallucinations, Excessive daytime sleepiness, Sleep paralysis, Sleep fragmentation).
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