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Monograph (CME Posttest and Evaluation) - Redefining Insomnia: State-of-the-Science in Insomnia Management


INSTRUCTIONS: Select the most appropriate response. To receive credit, participants must earn a score of 70% or higher. You have two attempts to pass this posttest. If you fail to score at least 70% after two attempts, you will not receive any CME credit for this activity.

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1. Sleep is regulated by circadian and homeostatic factors. Which of the following is true about the circadian rhythm?
 
A: It determines the amount of sleep
B: It ceases to function with absence of sunlight
C: It provides a strong propensity to sleep once a day, between 2:00 am and 6:00 am
D: It determines the timing of sleep
E: It creates a propensity to sleep based on one's accrued "sleep debt"

2. A 62-year-old man presents with excessive daytime sleepiness. He estimates that he actually sleeps about 5 hours per night, and it is affecting his concentration during the day, causing irritability. His past medical history is negative, he takes no medications, and his health and mood is otherwise good. While ruling out other sleep disorders, he and his wife both say that he moves his legs much of the night. He says whenever he lies down, he feels great agitation in his legs and he has to get up and move around to feel better. He's up much of the night due to this, and often has to fall asleep in a recliner with legs only partially elevated. There is no snoring or other sleep abnormality. 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

3. A 43-year-old woman presents with chronic insomnia. Cognitive behavioral therapy (CBT) is prescribed to treat the condition. The patient reports that the psychologist told her that the bed was to be associated with sleep only, and as such, she was to use the bed only for sleep or sex. She was told to get into bed only when tired. If she could not fall asleep within 20 minutes, she was to get out of the bed and do something relaxing until she felt tired enough to sleep. This is an example of which CBT?
 
A: Stimulus control therapy
B: Paradoxical intention therapy
C: Relaxation therapy
D: Sleep restriction therapy
E: Sleep hygiene education

4. The only medications approved for indefinite, long-term hypnotic use with proven efficacy in treating both sleep-onset and sleep-maintenance insomnias are the intermediate half-life non-benzodiazepine benzodiazepine-receptor agonists (NBBRAs). Which of the following is an intermediate half-life NBBRA?
 
A: Zolpidem CR
B: Temazepam
C: Ramelteon
D: Eszopiclone
E: Both A and D

5. A 50-year-old woman with no significant past medical history presents with problems sleeping at night that has been going on for months. It takes her at least three hours to fall asleep at night, almost every night. She then sleeps through the night without difficulty. She gets about four hours of sleep per night. The review of systems is negative: she has no other medical, sleep, or mental health problems, and she is not on any medications. What is the next step?
 
A: Order a polysomnogram
B: Determine etiology (ie, psychophysiologic insomnia, inadequate sleep hygiene)
C: Determine 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

6. Cognitive Behavioral Therapies (CBTs) should be the first choice of PCPs when dealing with chronic insomnia because:
 
A: They are safer
B: They are less expensive
C: They are at least comparable to pharmacologic therapy
D: They have been shown to be effective and lasting in improving sleep latency, quality, duration, and continuity in 50% to 75% of patients
E: All of the above

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 most commonly used over-the-counter pharmacologic agents to treat insomnia
C: Alcohol in moderation is recommended to treat insomnia due to the good quality of sleep patients can finally achieve
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. A 53-year-old man comes in with difficulty sleeping. It has been going on for the past two weeks since he hurt his lower back. It is difficult for him to fall asleep, but once he does so, he stays asleep. He feels the problem is related to his back pain. There are no other sleep, medical, or psychiatric issues. Besides aspirin, he takes no medications. The sleep disturbance occurs despite adequate opportunities for sleep, and it is negatively affecting his work. How should one classify this insomnia?
 
A: A chronic, sleep-maintenance insomnia due to a mental disorder
B: A transient, sleep-onset insomnia due to a drug or substance
C: A short-term, sleep-offset insomnia due to inadequate sleep hygiene
D: A transient, sleep-maintenance psychophysiologic insomnia
E: A short-term, sleep-onset insomnia due to a medical condition

9. When treating a patient who has a psychiatric illness and chronic insomnia, an evidence-based "off label" (non-FDA-approved) strategy in treating the insomnia might be to:
 
A: Prescribe the antidepressant trazodone if the patient has comorbid depression since it has been shown in some trials to treat insomnia better than placebo
B: Prescribe an antipsychotic if the patient is older and delirious, like haloperidol or risperidone
C: Prescribe the antidepressant nortriptyline since it has excellent evidence to support its use for insomnia
D: Prescribe a low-dose barbiturate like phenobarbital or chloral hydrate
E: Prescribe the benzodiazepine flurazepam, which carries with it no risk of residual daytime sedation and accidents

10. A 32-year-old female was worked up for insomnia and was found to follow the popular "3P" model of: predisposition; precipitating factors; and perpetuating behaviors. Diagnosis was made of a primary chronic psychophysiologic insomnia -- with both sleep-onset and sleep-maintenance difficulties -- but she failed her cognitive behavioral therapy. Which of the following statements is true about pharmacologic hypnotics?
 
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: As a benzodiazepine, zolpidem CR would create more tolerance, dependence, abuse, and cause more residual sedation
C: Eszopiclone is the only FDA-approved hypnotic that works as a melatonin-receptor agonist
D: Ramelteon is not indicated since there is a sleep-maintenance component to the patient's insomnia
E: Both benzodiazepines and non-benzodiazepine benzodiazepine receptor agonists have been found safe to use in pregnancy