Audio Case Studies (CME Posttest and Evaluation) - Redefining Insomnia: State-of-the-Science in Insomnia Management
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A 32-year-old married female with 2 children follows up for her insomnia, which continues to disrupt her life. She developed the problem 1 year ago after a bout of depression, which has since resolved. She was diagnosed with psychophysiologic insomnia, following the popular 3P model of: Predisposition, Precipitating factors, and Perpetuating behaviors. Her chronic primary insomnia includes both sleep-onset and sleep-maintenance difficulties. She has now failed 2 trials of cognitive behavioral therapy (CBT). Which of the following statements is true about pharmacologic hypnotic options for this patient?
A:
Triazolam can be used for both sleep-onset and sleep-maintenance insomnia, and side effects of withdrawal and cognitive impairment are rare and mild
B:
Both benzodiazepines and non-benzodiazepine benzodiazepine-receptor agonists (NBBRAs) are contraindicated during pregnancy
C:
Zolpidem CR is not a possible treatment option since there is a sleep-maintenance component to the patient's insomnia
D:
Ramelteon is not indicated because it is for sleep-offset insomnia only
E:
As a benzodiazepine, eszopiclone would create more tolerance, dependence, abuse, and cause more residual sedation
2.
A 52-year-old female with no significant past medical history presents with a chronic, sleep-onset insomnia. Medical and psychiatric disorders as well as other sleep disorders have been ruled out. She refused CBT due to lack of coverage with her insurance. Which of the following medications have short half-lives, indicating them for sleep-onset insomnia?
A:
Zaleplon
B:
Ramelteon
C:
Temazepam
D:
Zolpidem immediate release
E:
B and D
3.
Which of the following is true about off-label (non-FDA-approved) prescription medication strategies used by some to treat insomnia?
A:
The antidepressant trazodone is superior to zolpidem and zaleplon in treating insomnia
B:
Antipsychotics are best if the patient is older and delirious
C:
Antidepressants like nortriptyline do not have good evidence to support their use for insomnia
D:
Barbiturates like chloral hydrate are safe alternatives to NBBRAs
E:
The benzodiazepines flurazepam and quazepam carry no risk of residual daytime sedation and accidents
4.
A 64-year-old male presents with excessive daytime sleepiness. He is in bed for 7 hours per night on average but never feels refreshed in the morning. It is affecting his concentration during the day, causing irritability. His past medical history is negative except for obesity, dyslipidemia, and hypertension. The dyslipidemia and hypertension are well controlled on a statin and ACE inhibitor. While ruling out other sleep disorders, he and his wife both say that he snores so loudly that they cannot sleep in the same bed anymore. There is no other sleep abnormality nor any other medical or psychiatric disorders. What is your diagnosis/classification?
A:
Obstructive sleep apnea
B:
Restless legs syndrome
C:
Insomnia due to a medical condition
D:
Insomnia due to a mental disorder
E:
Insomnia due to a drug or substance
5.
A 19-year-old female comes in with difficulty falling asleep for the past 2 weeks. She reports that duration of sleep is not a problem. There are no other sleep, medical, or psychiatric issues. Besides aspirin, she takes no medications and rarely drinks alcohol, although she did just start smoking cigarettes this month. The sleep disturbance occurs despite adequate opportunities for sleep, and her schoolwork has been negatively affected as a result. How would you classify this insomnia?
A:
A chronic, sleep-maintenance insomnia due to a mental disorder
B:
A short-term, sleep-onset insomnia due to a drug or substance
C:
A short-term, sleep-offset insomnia due to restless legs syndrome
D:
A transient, sleep-maintenance psychophysiologic insomnia
E:
A chronic, sleep-onset insomnia due to a medical condition
6.
A 43-year-old female presents with chronic insomnia. Cognitive behavioral therapy is prescribed to treat the condition. The patient reports that the psychologist uses a form of therapy that has included biofeedback, progressive muscle relaxation, mental imagery, and meditation. She says he is "targeting an insomnia that he feels is largely due to my heightened arousal." This is an example of what CBT?
A:
Stimulus control therapy
B:
Paradoxical intention therapy
C:
Relaxation therapy
D:
Sleep restriction therapy
E:
Sleep hygiene education
7.
Which of the following statements is true about nonprescription drugs used by patients to self-medicate for their insomnia?
A:
Melatonin is the best nonprescription option due to its FDA regulation and lack of impurities or concentration variability
B:
Antihistamines like diphenhydramine are the only recommended over-the-counter pharmacologic agent used to treat insomnia
C:
Alcohol leads to tolerance, dependence, and a potential for abuse, liver toxicity, and disrupted sleep architecture
D:
Of herbal remedies, only chamomile has good evidence to support its use as a mild hypnotic
E:
Of herbal remedies, only kava kava has good evidence to support its use as a mild hypnotic
8.
Which of the following is true about zolpidem CR and eszopiclone?
A:
Both are for long-term, indefinite use
B:
They can be used to treat both sleep-onset and sleep-maintenance insomnias
C:
Both are NBBRAs
D:
They have intermediate half-lives
E:
All of the above
9.
Cognitive behavioral therapy is recommend as the first choice of primary care physicians (PCPs) when dealing with chronic insomnia because it is safer, less expensive, at least as comparable to pharmacologic therapy, and effective and lasting in improving sleep latency, quality, duration, and continuity in 50% to 75% of patients. Which of the following is a limitation of CBT?
A:
It is time consuming
B:
It is felt to be impractical by many patients and sleep professionals
C:
Some CBTs have reported a low adherence rate
D:
If insurance does not pay for CBT, it could be more expensive than medications
E:
All of the above
10.
A 61-year-old male with no significant past medical history presents with problems sleeping at night, persisting for months since his wife died. It takes him at least 3 hours to fall asleep at night, almost every night. He gives himself 7 hours in bed with the room both dark and quiet. After falling asleep, he sleeps through the night without difficulty. He gets approximately 4 hours of sleep per night. The review of systems is negative; he has no other medical or sleep disorders, and he is not on any medications. His insomnia has caused him to miss several days of work lately because he has been too tired, although he admits sometimes it is because he is sad about his wife and does not want to "deal with the world." What is the next step?
A:
Order a polysomnogram
B:
Work up the possibility of depression in order to classify the etiology of insomnia
C:
Confirm the insomnia by determining if there are daytime consequences, and confirm that there are adequate opportunities for sleep
D:
Diagnose circadian rhythm sleep disorder and consult a sleep specialist
E:
Prescribe a hypnotic and have her follow up in 1 month
