A 44-year-old man comes to the office due to fatigue for the past 6 months. He says, "I've fallen asleep at work a few times, and I really have to push myself to concentrate. I can't seem to get a good night's sleep either because I keep waking up." The patient feels guilty that he has been spending less time with his kids due to feeling tired and states his mood has been low the past week. He worries that his wife is annoyed with him because he has not been helping with household chores as much and keeps her up at night due to his snoring. The patient drinks 3 or 4 beers a week and does not use tobacco or illicit drugs. Medical history is noncontributory. Blood pressure is 146/94 mm Hg and pulse is 78/min and regular. BMI is 32 kg/m². Which of the following is the most likely diagnosis?

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11ec160b_3631_fe11_9249_df0375a34658_MD0001_00 This patient's snoring, repetitive awakenings, excessive daytime tiredness, elevated blood pressure, obesity, and male sex are strongly suggestive of obstructive sleep apnea (OSA). Other associated features include sleep-related apnea/choking spells and morning headaches. OSA may also present with depressive symptoms, such as low mood, decreased energy, and impaired concentration, and should be ruled out before diagnosing a primary depressive disorder. The patient's bed partner should be asked about snoring, as well as breathing pauses and nocturnal gasping or choking. Diagnosis is confirmed by polysomnography demonstrating obstructive respiratory events. (Choice A) This patient has insufficient symptoms for a diagnosis of major depressive disorder because he has had low mood for a week and does not describe anhedonia. His sleep disturbance, fatigue, and impaired concentration began prior to his mood changes and are better explained by untreated OSA. (Choice B) Narcolepsy may also cause excessive daytime sleepiness. However, it typically presents in younger patients and is associated with cataplexy, hypnagogic/hypnopompic hallucinations, and sleep paralysis. (Choice D) The combination of restless sleep and excessive daytime somnolence in a patient with multiple risk factors for OSA is less consistent with primary insomnia, which would be appropriate when sleep-related symptoms are not better explained by another sleep disorder, psychiatric disorder, or drugs/medications. (Choice E) Although symptoms of somatic symptom disorder may include daily, severe fatigue, this patient does not appear to have health-related anxiety (eg, fears about the medical seriousness of physical symptoms), which is necessary for diagnosis. Educational objective: Obstructive sleep apnea is characterized by sleep-related apnea/choking spells, loud snoring, disrupted sleep, excessive daytime somnolence, and symptoms that may overlap with depression (eg, low mood, fatigue, impaired concentration). __________ References: Depressive symptoms before and after treatment of obstructive sleep apnea in men and women. (http://www.ncbi.nlm.nih.gov/pubmed/25902824)

A 44-Year-Old Man Comes to the Office Due to Fatigue