Sleep-Wake Disorders
A 10-year-old boy is referred by his teacher for evaluation of his difficulty sitting still in school, which is interfering with his academic performance. The boy complains of an unpleasant "creepy-crawly" sensation in his legs and an urge to move them when sitting still that is relieved by movement. This symptom bothers him most of the day, but less when playing sports after school or watching television in the evening, and it generally does not bother him in bed at night. What aspect of his clinical presentation rules out a diagnosis of restless legs syndrome (RLS)? a. He is too young for a diagnosis of RLS. b. He does not have a sleep complaint. c, He does not complain of daytime fatigue or sleepiness. d. His symptoms occur in the daytime as much as or more than in the evening or at night. e. He does not have impaired social functioning.
His symptoms occur in the daytime as much as or more than in the evening or at night. Explanation: The diagnostic criteria for RLS specify that symptoms are worse in the evening or night, and in some individuals occur only in the evening or night. The symptoms can delay sleep onset and awaken the individual from sleep, resulting in significant sleep fragmentation and daytime sleepiness. RLS symptoms are accompanied by significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning. Although it is more common in adults, RLS can be diagnosed in children.
In DSM-IV, the diagnosis of breathing-related sleep disorder would be given to an individual complaining of excessive daytime sleepiness, with nocturnal polysomnography demonstrating episodic loss of ventilatory effort and result- ing apneic episodes occurring 10-20 times per hour, whose symptoms cannot be attributed to another mental disorder, a medication or substance, or another medical condition. What is the appropriate DSM-5 diagnosis for the same individual? A. Insomnia disorder. B. Narcolepsy. C. Obstructive sleep apnea hypopnea. D. Central sleep apnea. E. Other specified hypersomnolence disorder.
Central sleep apnea. Explanation: The diagnosis of central sleep apnea is made on the basis of five or more central apneic episodes per hour on polysomnography and absence of another sleep disorder. Unlike DSM-IV, DSM-5 codes central and obstructive sleep apnea syndromes as different diagnoses within a larger group of breathing-related sleep disorders that also includes sleep-related hypoventilation. Central apneas are characterized by a loss of respiratory drive rather than by mechanical obstruction.
A 67-year-old woman complains of insomnia. She does not have trouble falling asleep between 10 and 11 P.M., but after 1-2 hours she awakens for several hours in the middle of the night, sleeps again for 2-4 hours in the early morning, and then naps three or four times during the day for 1-3 hours at a time. She has a family history of dementia. On exam she appears fatigued and has deficits in short-term memory, calculation, and abstraction. What is the most likely diagnosis? a. Major neurocognitive disorder (NCD). b. Circadian rhythm sleep-wake disorder, irregular sleep-wake type, and un-specified NCD. c. Narcolepsy. d. Insomnia disorder. e. Major depressive disorder.
Circadian rhythm sleep-wake disorder, irregular sleep-wake type, and unspecified NCD. Explanation: The DSM-5 circadian rhythm sleep-wake disorders retained three of the DSM-IV subtypes—delayed sleep phase type, shift work type, and unspecified type—and expanded to include advanced sleep phase type and irregular sleep-wake type, whereas the jet lag type was removed. In this patient's presentation, there is no major sleep period and no discernible circadian rhythm to the sleep-wake cycle; her sleep is fragmented into five or six periods across the 24-hour day. Irregular sleep-wake type is commonly associated with NCDs, including major NCDs such as Alzheimer's disease, Parkinson's disease, and Huntington's disease, as well as NCDs in children. Insufficient data are provided to justify a diagnosis of major NCD or depression. This woman does not have narcolepsy, which is characterized by frequent irresistible urges to sleep, but also requires the presence of at least one of the following: 1) cataplexy, 2) hypocretin deficiency, or 3) characteristic abnormalities on nocturnal polysomnography or multiple sleep latency testing.
Following a traumatic brain injury resulting in blindness, a 50-year-old man develops waxing and waning daytime sleepiness interfering with daytime activity. Serial actigraphy (a method of measuring human activity/rest cycles) demonstrates that the time of onset of the major sleep period occurs progressively later day after day, with a normal duration of the major sleep period. What is the most likely diagnosis? A. Circadian rhythm sleep-wake disorder, unspecified type. B. Circadian rhythm sleep-wake disorder, delayed sleep phase type. C. Circadian rhythm sleep-wake disorder, non-24-hour sleep-wake type. D. Pineal gland injury. E. Malingering.
Circadian rhythm sleep-wake disorder, non-24-hour sleep-wake type. Explanation: Non-24-hour sleep-wake type circadian rhythm sleep disorder is common in individuals with blindness. The endogenous sleep-wake cycle is longer than 24 hours and is not entrained by light cues, resulting in onset of sleepiness at later and later times of day. When the onset of sleepiness occurs at night, there is low interference with normal daytime activities; however, as the onset of sleepiness cycles toward the daytime hours there is greater impairment in social-occupational function. In DSM-IV, this disorder was included in the "unspecified" type of circadian rhythm sleep disorder.
A 50-year-old emergency department nurse complains of sleepiness at work interfering with her ability to function. She recently switched from the 7 A.M.- 4 P.M. day shift to the 11 P.M.-8 A.M. night shift in order to have her afternoons free. Even with this schedule change, she finds it difficult to sleep in the mornings at home, has little energy for recreational activities or household chores in the afternoon, and feels exhausted by the middle of her overnight shift. What is the most likely diagnosis? A. Normal variation in sleep secondary to shift work. B. Circadian rhythm sleep-wake disorder, shift work type. C. Bipolar disorder. D. Insomnia disorder. E. Hypersomnolence disorder.
Circadian rhythm sleep-wake disorder, shift work type. Explanation: The criteria for circadian rhythm sleep-wake disorder, shift work type, are a gradual reversion from conventional daylight hours as the main period of occupational engagement, difficulty sleeping in the day, and sleepiness at night during the work shift. The daylight sleeping problem might be mistaken for insomnia and the work shift sleepiness problem for hypersomnolence, but the presence of both symptoms in this context clarifies the diagnosis. The daytime and nighttime symptoms must be clinically significant in terms of distress or impairment in function, which is largely a clinical judgment, and the boundary between normal variation in sleep and sleepiness due to shift work versus the shift work type of circadian rhythm sleep-wake disorder is not sharply demarcated. Bipolar disorder may be destabilized by shift work that interferes with stable circadian rhythms and adequate sleep at nighttime, but mania resulting from such destabilization does not generally manifest as complaints of sleepiness or insomnia.
Which of the following is necessary to make a diagnosis of insomnia disorder? a. Difficulty being fully awake after awakening. b. Difficulty with sleep initiation or sleep maintenance, or early-morning awakening with inability to return to sleep. c. Absence of a coexisting mental disorder. d. Documented insufficient opportunity for sleep. e. Persistence of sleep difficulties despite use of sedative-hypnotic agents.
Difficulty with sleep initiation or sleep maintenance, or early-morning awakening with inability to return to sleep. Explanation: The key features of insomnia disorder in DSM-5 are dissatisfaction with sleep quality, trouble initiating or maintaining sleep, or early-morning awakening or, in children, resistance to going to bed, and distress or impairment in daytime functioning, despite adequate opportunity to sleep, with the problem occurring frequently and persisting for at least 3 months. An important change from DSM-IV is the possibility of making an independent diagnosis of insomnia disorder even when another disorder such as major depressive disorder might include sleep disturbance as a diagnostic feature. In such a case, both diagnoses would be appropriate, and the comorbid psychiatric disorder listed as a clinical comorbid condition specifier (i.e., "With non-sleep disorder mental comorbidity").
Which of the following is a core feature of insomnia disorder? A. Depressed mood. B. Dissatisfaction with sleep quantity or quality. C. Cognitive impairment. D. Abnormal behaviors during sleep. E. Daytime fatigue.
Dissatisfaction with sleep quantity or quality. Explanation: Individuals with insomnia disorder typically present with sleep-wake complaints of dissatisfaction regarding the quality, timing, or amount of sleep. Resulting distress and impairment are core features.
Which of the following metabolic changes is the cardinal feature of sleep-related hypoventilation? A. Insulin resistance. B. Hypoxia. C. Hypercapnia. D. Low arterial hemoglobin oxygen saturation. E. Elevated vasopressin.
Hypercapnia. Explanation: Sleep-related hypoventilation is diagnosed using polysomnography showing sleep-related hypoxemia and hypercapnia that is not better explained by another breathing-related sleep disorder. The documentation of increased arterial pCO2 levels to greater than 55 mmHg during sleep or a 10 mmHg or greater increase in pCO2 levels (to a level that also exceeds 50 mmHg) during sleep in comparison to awake supine values, for 10 minutes or longer, is the gold standard for diagnosis. However, obtaining arterial blood gas determinations during sleep is impractical, and noninvasive measures of pCO2 have not been adequately validated during sleep and are not widely used during polysomnography in adults. Prolonged and sustained decreases in oxygen saturation (oxygen saturation of less than 90% for more than 5 min- utes with a nadir of at least 85%, or oxygen saturation of less than 90% for at least 30% of sleep time) in the absence of evidence of upper airway obstruction are often used as an indication of sleep-related hypoventilation; however, this finding is not specific, as there are other potential causes of hypoxemia, such as that due to lung disease.
Which of the following sleep disturbances is associated with chronic opiate use? A. Excessive daytime sleepiness. B. Insomnia. C. Periodic limb movements in sleep. D. Obstructive sleep apnea hypopnea. E. Parasomnias.
Insomnia. Explanation: Although acute opiate intoxication tends to lead to sedation, habituation may result in eventual complaints of insomnia. Opiates may also decrease respiratory drive, resulting in central sleep apneas.
In addition to requiring recurrent sleep attacks, the diagnostic criteria for narcolepsy require the presence of cataplexy, hypocretin deficiency, or characteristic abnormalities on sleep polysomnography or multiple sleep latency testing. Which of the following is a defining characteristic of cataplexy? A. It is sudden. B. It is induced by suggestion. C. It occurs unilaterally. D. It persists for hours. E. It is accompanied by hypertonia.
It is sudden. Explanation: The definition of cataplexy differs according to patient characteristics. In individuals with long-standing narcolepsy, cataplexy is defined as brief (seconds to minutes) episodes of sudden bilateral loss of muscle tone with maintained consciousness that are precipitated by laughter or joking. In children or in individuals within 6 months of onset, cataplexy takes the form of spontaneous grimaces or jaw-opening episodes with tongue thrusting or a global hypotonia, without any obvious emotional triggers.
A 51-year-old man presents with symptoms of chronic fatigue and excessive worrying about current life stressors. He has a strong family history of depression and a past history of a major depressive episode, with some improvement while maintained on antidepressants. On weekday nights, it takes him several hours to fall asleep, and he then has difficulty getting up to go to work in the morning, experiencing sleepiness for the first few hours of awake time. On weekends, he awakens later in the morning and feels less fatigue and sleepiness. Which of the following diagnoses apply? a. Major depressive disorder, in partial remission. b. Generalized anxiety disorder. c. Insomnia disorder. d. Major depressive disorder in partial remission and circadian rhythm sleep-wake disorder, delayed sleep phase type. e. Major depressive disorder in partial remission; generalized anxiety disorder; circadian rhythm sleep-wake disorder, delayed sleep phase type; and insomnia disorder.
Major depressive disorder in partial remission and circadian rhythm sleep-wake disorder, delayed sleep phase type. Explanation: In this case, both diagnoses should be coded, even though insomnia can be considered as a symptom of major depressive disorder. Circadian rhythm sleep-wake disorder, delayed sleep phase type, is characterized by delayed onset (usually more than 2 hours) of the major sleep period in relation to the desired sleep and wake times appropriate to the individual's personal and occupational obligations, with resulting symptoms of tiredness and insomnia complaints. When allowed to set their own schedule, individuals with this condition have normal (for age) quality and quantity of sleep.
A 14-year-old girl frequently wakes in the morning with clear recollection of very frightening dreams. Once she awakens, she is normally alert and oriented, but the dreams are a persistent source of distress. Her mother reports that the girl sometimes murmurs or groans but does not talk or move during the period before waking. Her history is otherwise notable for having been homeless and living with her mother in a series of temporary shelter accommodations for 1 year when she was 10 years old. What is the most likely diagnosis? A. Unspecified anxiety disorder. B. Rapid eye movement (REM) sleep behavior disorder. C. Non-rapid eye movement sleep arousal disorders. D. Posttraumatic stress disorder. E. Nightmare disorder.
Nightmare disorder. Explanation: Nightmare disorder is characterized by repeated nightmares, which are extended, dysphoric, and well-remembered dreams occurring mostly in the second half of the major sleep episode and which usually involve threats to one's survival, security, or physical integrity. On awakening, the af- fected individual returns quickly to a normal level of consciousness with normal orientation, but the dreams cause persistent distress and/or impairment in function. Coexisting medical and mental disorders do not adequately explain the predominant complaint of dysphoric dreams. In children, nightmare disorder occurs most often after exposure to severe psychosocial stressors. Nightmares occur during REM sleep, when skeletal muscle tone decreases, so vocalization and body movement does not occur, except possibly at the very end of the REM sleep period. Nightmare disorder is common in childhood, and may continue to occur in women into adulthood, but is less common in men in adulthood. In contrast to nightmares, sleep terrors are associated with non-REM deep-stage sleep, generally occur earlier in the major sleep period, and are characterized by poor recall, only partial arousal, and confusion and disorientation at the end of the terror event. Amnesia for the event is common after the end of the sleep period. REM sleep behavior disorder is characterized by violent dream enactment or other complex motor behavior during sleep, and it is most common in middle-aged or older, male patients. Nightmares can occur in posttraumatic stress disorder (PTSD) as part of the "reexperiencing" phenomena but are insufficient alone to make a diagnosis of PTSD.
Which of the following sleep disturbances or disorders occurs during rapid eye movement (REM) sleep? A. Nightmare disorder. B. Confusional arousals. C. Sleep terrors. D. Obstructive sleep apnea hypopnea. E. Central sleep apnea.
Nightmare disorder. Explanation: Nightmares occur during REM sleep, which makes up a larger part of the sleep cycle later in the sleep period. Confusional arousals and sleep terrors are non-REM sleep phenomena. Obstructive sleep apneas and especially central sleep apneas tend to occur in deeper stages of sleep but can occur in lighter sleep as well, and they are not REM related.
A 56-year-old college professor complains of having difficulty sleeping for more than 5 hours per night over the past few weeks, leaving her feeling tired in the daytime. She awakens an hour or two before her intended waking time in the morning, experiencing restless sleep with frequent awakenings until it is time to get up. She does not have initial insomnia and is not depressed. The patient attributes the sleep trouble to intrusive thoughts that arise, after she initially awakens momentarily, about the need to complete an overdue academic project. What is the most appropriate diagnosis? A. Adjustment disorder with anxious mood. B. Obsessive-compulsive personality disorder. C. Insomnia disorder. D. Other specified insomnia disorder (brief insomnia disorder). E. Unspecified insomnia disorder.
Other specified insomnia disorder (brief insomnia disorder). Explanation: According to DSM-5, "The other specified insomnia disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for insomnia disorder or any specific sleep-wake disorder. This is done by recording 'other specified insomnia disorder' followed by the specific reason (e.g., brief insomnia disorder)." In this case we do not have sufficient evidence to justify a diagnosis of adjustment disorder or obsessive-compulsive personality disorder. The patient has an insomnia problem but does not meet the duration criterion for insomnia disorder. She can be given the diagnosis of other specified insomnia disorder because the clinician can specify the way in which her disorder differs from one of the DSM-5 insomnia diagnoses. If the clinician lacked specifying information or had reason to choose not to provide specification, the diagnosis would be unspecified insomnia disorder.
A 74-year-old woman has a history of daytime sleepiness interfering with her ability to carry out her daily routine. She reports that it has become progressively worse over the past year. Polysomnography reveals sleep apnea without evidence of airway obstruction with two or three apneic episodes per hour. What is the most appropriate diagnosis? A. Central sleep apnea. B. Other specified sleep-wake disorder (atypical central sleep apnea). C. Unspecified sleep-wake disorder. D. Rapid eye movement (REM) sleep behavior disorder. E. Circadian rhythm sleep-wake disorder.
Other specified sleep-wake disorder (atypical central sleep apnea). Explanation: The patient does not meet full criteria for central sleep apnea because her apneic episodes occur at a frequency of fewer than five per hour. This deviation from diagnostic criteria can be specified. Therefore, "other specified" rather than "unspecified" sleep-wake disorder is the appropriate diagnosis.
Which of the following symptoms is most likely to indicate the presence of hypersomnolence disorder? A. Sleep inertia. B. Nonrefreshing sleep in main sleep episode. C. Automatic behavior. D. Frequent napping. E. Headache.
Sleep inertia. Explanation: Sleep inertia is a period of impaired performance and reduced vigilance, following waking from the main episode of sleep or from a nap that persists for several minutes or more. Although some patients with hypersomnolence disorder have one or more of the other symptoms listed, these symptoms are not as specific to hypersomnolence disorder as is sleep inertia.
An obese 52-year-old man complains of daytime sleepiness, and his partner confirms that he snores, snorts, and gasps during nighttime sleep. What polysomnographic finding is needed to confirm the diagnosis of obstructive sleep apnea hypopnea? a. No polysomnography is necessary. b. Polysomnographic evidence of at least 5 apnea or hypopnea episodes per hour of sleep. c. Polysomnographic evidence of at least 10 apnea or hypopnea episodes per hour of sleep. d. Polysomnographic evidence of at least 15 apnea or hypopnea episodes per hour of sleep. e. Polysomnographic evidence of resolution of apneas/hypopneas with application of continuous positive airway pressure.
Polysomnographic evidence of at least 5 apnea or hypopnea episodes per hour of sleep. Explanation: The diagnostic criteria for obstructive sleep apnea hypopnea are as follows: A. Either (1) or (2): Evidence by polysomnography of at least five obstructive apneas or hypopneas per hour of sleep and either of the following sleep symptoms: Nocturnal breathing disturbances: snoring, snorting/gasping, or breathing pauses during sleep. Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities to sleep that is not better explained by another mental disorder (including a sleep disorder) and is not attributable to another medical condition. Evidence by polysomnography of 15 or more obstructive apneas and/ or hypopneas per hour of sleep regardless of accompanying symptoms.
A 28-year-old woman who is in her thirty-fourth week of pregnancy reports that for the past few weeks she has experienced restlessness and difficulty falling asleep at the onset of the sleep period, as well as daytime fatigue. She works during the day and has not changed her schedule. She states that as she becomes increasingly tired, she feels more irritable and depressed. What sleep disorder is suggested by the onset of these symptoms in the third trimester of pregnancy? A. Circadian rhythm sleep-wake disorder, delayed sleep phase type. B. Insomnia disorder. C. Rapid eye movement (REM) sleep behavior disorder. D. Restless legs syndrome. E. Hypersomnolence disorder.
Restless legs syndrome. Explanation: The onset of symptoms late in pregnancy is a common feature of restless legs syndrome; the prevalence of restless legs syndrome in pregnant women is two to three times higher than that in the general population. In this case, one would want to know more about the patient's sense of restlessness in order to determine whether she has the unpleasant sensations and urge to move her legs, with relief of the unpleasant sensations after moving, that are the hallmark of the disorder.
Which of the following classes of psychotropic drugs may result in rapid eye movement (REM) sleep without atonia and REM sleep behavior disorder? A. Selective serotonin reuptake inhibitors. B. Benzodiazepines. C. Phenothiazines. D. Second-generation antipsychotics. E. Monoamine oxidase inhibitors.
Selective serotonin reuptake inhibitors. Explanation: Many widely prescribed medications, including tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and beta-blockers, may result in polysomnographic evi- dence of REM sleep without atonia and in frank REM sleep behavior disorder. It is not known whether the medications per se result in REM sleep behavior disorder or they unmask an underlying predisposition.
What is the key abnormality in sleep physiology in rapid eye movement (REM) sleep behavior disorder? A. REM starts earlier than normal in the sleep cycle. B. There is more REM sleep than normal. C. Delta wave activity is increased. D. Skeletal muscle tone is preserved during REM sleep. E. Total sleep time is greater than normal.
Skeletal muscle tone is preserved during REM sleep. Explanation: REM sleep without atonia is a sine qua non for the diagnosis of REM sleep behavior disorder. Normally there is loss of muscle tone during REM sleep, so no voluntary motor activity occurs, but when muscle atonia is not present, the dreaming individual "enacts" his or her actions in the ongoing dream. In an individual with an established synucleinopathy diagnosis, a history suggestive of REM sleep behavior disorder, even in the absence of polysomnographic evidence of REM sleep without atonia, is adequate to make the diagnosis of REM sleep behavior disorder.
What is the difference between sleep terrors and nightmare disorder? a. In nightmare disorder, arousal or awakening from the nightmare is incomplete, whereas sleep terrors result in complete awakening. b. In sleep terrors, episodes are concentrated in the final hours of the sleep period, whereas nightmares occur mostly early in the sleep period. c. Sleep terrors are characterized by clear recall of vivid dreams with frightening content, whereas nightmares are not recalled. d. Sleep terrors occur during rapid eye movement (REM) sleep, whereas nightmares occur in non-REM sleep. e. Sleep terrors are precipitous but incomplete awakenings from sleep beginning with a panicky scream or cry, with little recall, whereas nightmares are characterized by full arousal and vivid recall.
Sleep terrors are precipitous but incomplete awakenings from sleep beginning with a panicky scream or cry, with little recall, whereas nightmares are characterized by full arousal and vivid recall. Explanation: Sleep terrors are a non-REM sleep phenomenon and therefore tend to occur in the early period of sleep when non-REM sleep predominates; autonomic arousal, fearful crying out, incomplete awakening, and little recall or total amnesia characterize the episodes. Nightmares are REM sleep phenomena and therefore tend to be more prominent in the later part of the sleep period, and may be vividly recalled. Arousal after a nightmare tends to be to full consciousness.
Which of the following is a type of non-rapid eye movement (REM) sleep arousal disorder in DSM-5? A. REM sleep behavior disorder. B. Sleep terrors. C. Nightmare disorder. D. Fugue. E. Obstructive sleep apnea hypopnea.
Sleep terrors. Explanation: DSM-5 includes sleep terrors and sleepwalking in the diagnostic category of non-REM sleep arousal disorders. Sleep terrors are associated with a sense of terror and distress, but with incomplete awakening and poor recall, and they tend to occur early in the major sleep period, when non-REM sleep predominates. REM sleep behavior disorder episodes occur in REM sleep, which is predominantly in the later part of the sleep episode, with complex behaviors that are often recalled as "acting out" of a dream, sometimes violently. Nightmares are also a REM sleep phenomenon. Patients with nightmare disorder awaken and rapidly reorient and achieve full alertness, in contrast to those with sleep terrors. Fugue states are not sleep disorders.
Which of the following is a specific subtype of non-rapid eye movement sleep arousal disorder, sleepwalking type? A. Rapid eye movement (REM) sleep behavior disorder. B. Sleep-related seizure disorder. C. Sleep-related sexual behavior (sexsomnia). D. Complex motor behavior during alcoholic blackout. E. Nocturnal panic attack.
Sleep-related sexual behavior (sexsomnia). Explanation: The essential feature of sleepwalking is repeated episodes of complex motor behavior initiated during sleep, including rising from bed and walking about. Sleep-related sexual behavior and sleep-related eating are recognized as specific subtypes. Sleepwalking arises in non-REM sleep, not during REM sleep. Sleepwalking episodes can begin with a confusional arousal but progress to more complex motor behaviors and ambulation. Alcoholic blackouts do not occur during sleep or unconsciousness but involve loss of memory for events during the drinking episode. Sleep-related seizures are in the differential diagnosis of non-REM sleep arousal disorders but tend to be more stereotypic rather than complex motor behaviors.
Which of the following conditions is commonly associated with rapid eye movement (REM) sleep behavior disorder? A. Attention-deficit/hyperactivity disorder. B. Synucleinopathies. C. Tourette's syndrome. D. Sleep terrors. E. Epilepsy.
Synucleinopathies. Explanation: Based on findings from individuals presenting to sleep clinics, most individuals (50%) with initially "idiopathic" REM sleep behavior disorder will eventually develop a neurodegenerative disease—most notably, one of the synucleinopathies (Parkinson's disease, multiple system atrophy, or major or mild neurocognitive disorder with Lewy bodies). REM sleep behavior disorder often predates any other sign of these disorders by many years (often more than a decade). Nocturnal seizures may perfectly mimic REM sleep behavior disorder, but the behaviors are generally more stereotyped. Polysomnographic monitoring employing a full electroencephalographic seizure montage may differentiate the two. REM sleep without atonia is not present on polysomnographic monitoring.
A psychiatric consultation is requested for evaluation and help with management of severe insomnia in a 65-year-old man, beginning the day after elective hip replacement surgery and continuing for 2 days. On evaluation the patient acknowledges heavy drinking until the day before surgery, and he appears to be in alcohol withdrawal, with autonomic instability, confusion, and tremor. Why would a diagnosis of substance/medication-induced sleep disorder be inappropriate in this situation? a. The insomnia is an understandable emotional reaction to the anxiety provoked by having surgery. b. The insomnia is not causing functional impairment. c. The insomnia has not been documented with polysomnography or actigraphy. d. The insomnia is occurring during acute alcohol withdrawal. e. The insomnia might be related to post operative pain.
The insomnia is occurring during acute alcohol withdrawal. Explanation: A substance/medication-induced sleep disorder diagnosis should be made instead of a diagnosis of substance withdrawal only when the sleep disturbance symptoms "predominate in the clinical picture" and are "sufficiently severe to warrant clinical attention." Otherwise, a diagnosis of substance withdrawal is more appropriate. Pain and emotional stress may result in insomnia and should certainly be considered in the differential diagnosis of this patient's problems. Functional impairment may be hard to judge in a medically hospitalized patient, but it can sometimes be understood in terms of the patient's ability to participate appropriately with care. Polysomnography and actigraphy are useful tools in sleep disorder diagnosis in general, but they are not required to make this particular diagnosis.
An 80-year-old man has a history of myocardial infarction and had coronary artery bypass graft surgery 8 years ago. He plays tennis three times a week, takes care of his grandchildren 2 afternoons each week, generally enjoys life, and manages all of his activities of daily living independently; however, he complains of excessively early morning awakening. He goes to sleep at 9:00 P.M. and sleeps well, with nocturia once nightly, but wakes at 3:30 A.M. although he would like to rise at 5:00 A.M. He does not endorse daytime sleepiness as a problem. His physical examination, mental status, and cognitive function are normal. What is the most likely sleep-wake disorder diagnosis? A. Insomnia disorder. B. Rapid eye movement (REM) sleep behavior disorder. C. Restless legs syndrome. D. Obstructive sleep apnea hypopnea. E. The man is a short sleeper, which is not a DSM-5 diagnosis.
The man is a short sleeper, which is not a DSM-5 diagnosis. Explanation: Although he complains about his sleep timing and endorses early awakening as a complaint, this man has no other features of impairment to justify a diagnosis of insomnia disorder. Many older adults are short sleepers. This man has no evidence of functional impairment such as excessive day- time sleepiness interfering with activities.
Which of the following substances is associated with parasomnias? A. Cannabis. B. Zolpidem. C. Methadone. D. Cocaine. E. Mescaline.
Zolpidem. Explanation: Benzodiazepine receptor agonists, especially at high doses, may cause parasomnias. These would be classified as a zolpidem-induced sleep disorder, with onset during intoxication, parasomnia type.
