Sleep Disorders in Psychiatric Conditions — MCQs
Which of the following statements is MOST accurate regarding REM sleep?
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?
Which of the following structures is the primary regulator of circadian rhythms in the body?
Which neurotransmitter deficit is MOST consistently implicated as the primary mechanism in the pathophysiology of depression?
Post-traumatic stress disorder is characterized by all except:
Hypnagogic hallucinations are seen in ?
Drug of choice for night terrors:
Chronic disorder characterized by compulsive use of drugs, resulting in physical, psychological, and social harm, and continued use despite evidence that it is harmful is called.
In narcolepsy, the polysomnographic recording typically shows which of the following patterns?
Early morning awakening is a feature of -
Sleep Disorders in Psychiatric Conditions Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following statements is MOST accurate regarding REM sleep?
- A. Slow waves on EEG
- B. Low muscle tone (Correct Answer)
- C. Decrease in BP
- D. Dreams
Explanation: ***Low muscle tone*** - **Muscle atonia** (near-complete loss of skeletal muscle tone) is one of the **defining physiological characteristics** of **REM sleep**. - This **muscle paralysis** prevents individuals from acting out their dreams and is a consistent, measurable feature of REM sleep. - Along with rapid eye movements and desynchronized EEG, **muscle atonia** is one of the three hallmark features that define REM sleep. *Dreams* - While **vivid dreams** are commonly associated with **REM sleep** and dream recall is highest during this stage, not all REM periods result in recalled dreams. - Dream recall varies significantly between individuals and circumstances. - Dreams can also occur during **NREM sleep**, though they are typically less vivid and less frequently recalled. *Slow waves on EEG* - **Slow waves** are characteristic of **deep non-REM sleep (N3 stage)**, not REM sleep. - During REM sleep, the **EEG** shows a **low-voltage, mixed-frequency pattern** resembling wakefulness (desynchronized EEG). *Decrease in BP* - During **REM sleep**, blood pressure often **fluctuates** and can even **increase** due to autonomic instability, rather than consistently decreasing. - The cardiovascular system exhibits **irregularities** in both heart rate and blood pressure during REM sleep.
Question 2: 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 3: Which of the following structures is the primary regulator of circadian rhythms in the body?
- A. Ventromedial nucleus
- B. Supraoptic nucleus
- C. Suprachiasmatic nucleus (Correct Answer)
- D. Dorsomedial nucleus
Explanation: ***Suprachiasmatic nucleus*** - The **suprachiasmatic nucleus (SCN)** is the primary **circadian pacemaker** in mammals, regulating various daily rhythms including the sleep-wake cycle, hormone secretion, and body temperature. - It receives direct input from the retina about light exposure, allowing it to synchronize the body's internal clock with the external light-dark cycle. *Ventromedial nucleus* - The **ventromedial nucleus (VMN)** of the hypothalamus is primarily involved in regulating **satiety** and is often referred to as the "satiety center." - Damage to the VMN can lead to **hyperphagia** (overeating) and obesity, rather than disturbances in daily rhythms. *Supraoptic nucleus* - The **supraoptic nucleus (SON)**, along with the paraventricular nucleus, is responsible for producing **vasopressin (ADH)** and **oxytocin**. - These hormones are then transported to the posterior pituitary for release, influencing water balance and social bonding, respectively, not daily rhythms. *Dorsomedial nucleus* - The **dorsomedial nucleus (DMN)** of the hypothalamus is involved in various functions including **feeding, drinking, and activity levels**. - While it can influence aspects of activity, it is not the primary regulator of the **circadian rhythm** itself; it receives input from the SCN.
Question 4: Which neurotransmitter deficit is MOST consistently implicated as the primary mechanism in the pathophysiology of depression?
- A. Norepinephrine
- B. GABA
- C. Serotonin (Correct Answer)
- D. Dopamine
Explanation: ***Serotonin (decreased levels)*** - The **monoamine hypothesis** of depression suggests that a functional deficit of neurotransmitters is central to its pathophysiology, with **serotonin (5-HT) most consistently highlighted as the primary driver**. - Reduced levels of serotonin in the synaptic cleft lead to impaired neurotransmission, affecting **mood**, **sleep**, **appetite**, and **cognitive functions**. - Most **selective serotonergic antidepressants (SSRIs)** target this pathway as first-line treatment, underscoring serotonin's central role. *Norepinephrine (decreased levels)* - **Norepinephrine** is another monoamine neurotransmitter implicated in depression, and its deficiency contributes to depressive symptoms. - Low norepinephrine levels are linked to symptoms like **fatigue**, **difficulty concentrating**, and **anhedonia**. - However, while important, **decreased serotonin is more consistently emphasized as the primary pathophysiological mechanism** in most contemporary models of depression. *GABA (reduced levels)* - **GABA (gamma-aminobutyric acid)** is the primary inhibitory neurotransmitter in the brain; reduced levels are associated more strongly with **anxiety disorders** and seizure disorders. - While GABAergic system dysfunction can contribute to certain depressive symptoms, it is not considered a primary mechanism for the core pathophysiology of depression. *Dopamine (increased levels)* - **Increased dopamine levels** are more commonly associated with conditions like **schizophrenia** (mesolimbic pathway) and **mania**, not depression. - Conversely, **decreased** dopamine levels (particularly in the mesocortical pathway) are linked to anhedonia and lack of motivation in depression, making this option factually incorrect.
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: Hypnagogic hallucinations are seen in ?
- A. Schizophrenia
- B. Depression
- C. Mania
- D. Narcolepsy (Correct Answer)
Explanation: ***Narcolepsy*** - **Hypnagogic hallucinations** are vivid, often terrifying perceptual experiences that occur right as a person is falling asleep (sleep onset). They are a common symptom of **narcolepsy**. - Other key symptoms of narcolepsy include **excessive daytime sleepiness**, **cataplexy** (sudden loss of muscle tone triggered by strong emotions), and **sleep paralysis**. *Schizophrenia* - While hallucinations are a hallmark of **schizophrenia**, they are typically **auditory** and occur in a clear state of consciousness, not specifically at sleep onset. - Schizophrenia is characterized by a broader range of symptoms including **delusions**, disorganization of thought, and negative symptoms. *Depression* - Depression can involve sleep disturbances like **insomnia** or **hypersomnia**, but it is generally not associated with hypnagogic hallucinations. - Core symptoms relate to **mood disturbance**, anhedonia, and vegetative symptoms. *Mania* - Mania, a feature of bipolar disorder, can lead to **reduced need for sleep** and racing thoughts, but not typically hypnagogic hallucinations. - Psychotic features like hallucinations can occur in severe mania, but they are not characteristically tied to sleep onset.
Question 7: Drug of choice for night terrors:
- A. Tricyclic antidepressant
- B. Meprobamate
- C. Diazepam
- D. Clonazepam (Correct Answer)
Explanation: ***Clonazepam*** - **Clonazepam**, a benzodiazepine, is the **drug of choice** for night terrors due to its ability to suppress Stage 3 and 4 **slow-wave sleep**, where night terrors occur. - Its sedative and anxiolytic effects help to calm the patient and reduce the frequency and severity of these episodes. *Tricyclic antidepressant* - While some **tricyclic antidepressants** (TCAs) have sedative properties, they are generally not the first-line treatment for night terrors. - Their side effect profile and potential to alter other sleep stages make them less suitable than benzodiazepines for this specific parasomnia. *Meprobamate* - **Meprobamate** is an anxiolytic and sedative drug that is largely historical and has been replaced by safer and more effective alternatives like benzodiazepines. - It has a higher risk of dependence and side effects compared to modern treatments for sleep disorders. *Diazepam* - **Diazepam** is another benzodiazepine, but **clonazepam** is generally preferred for night terrors due to its longer half-life and specific efficacy in suppressing slow-wave sleep. - While diazepam could offer some relief, clonazepam is considered more effective for sustained management of this condition.
Question 8: Chronic disorder characterized by compulsive use of drugs, resulting in physical, psychological, and social harm, and continued use despite evidence that it is harmful is called.
- A. Substance intoxication
- B. Drug addiction (Correct Answer)
- C. Drug abuse
- D. Drug dependence
Explanation: ***Drug addiction*** - This definition accurately describes **drug addiction** as a chronic disorder involving compulsive drug use despite harmful consequences across physical, psychological, and social domains. - Key components include the **compulsive nature** of use, the **harmful outcomes**, and the persistence of use even with awareness of these harms. *Substance intoxication* - **Substance intoxication** refers to the acute, reversible effects of a substance on the central nervous system, leading to clinical changes in perception, mood, and behavior. - It does not encompass the chronic, compulsive use or the long-term physical, psychological, and social harms characteristic of addiction. *Drug abuse* - **Drug abuse** is a pattern of harmful use of a psychoactive substance, but it doesn't necessarily include the compulsive, chronic nature and the concept of continued use despite acknowledging harm that defines addiction. - The term "abuse" is often considered outdated in favor of "substance use disorder" in clinical contexts to better reflect the chronic disease model. *Drug dependence* - **Drug dependence** refers to a physiological state where the body adapts to a substance, leading to **withdrawal symptoms** if the substance is stopped and **tolerance** to its effects. - While it is a component of addiction, it does not fully capture the compulsive drug-seeking behavior or the broader psychological and social harms that define addiction itself.
Question 9: 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 10: 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.
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