A 35-year-old man comes to the office due to persistent fatigue and insomnia for the past 3 weeks. The patient was fired from his job as an insurance salesman a month ago due to poor sales and has since felt increasingly tired. He has no difficulty falling asleep but, "for no reason," awakens at 4 AM most nights. The patient's wife has told him he snores occasionally, although he has not awakened short of breath. He says, "I liked going to the gym with my friends, but now I just don't want to anymore. I'm at home a lot now, but I don't have the energy to play with my kids." The patient feels pressured to look for new job opportunities but is so unfocused that he has not been able to complete any applications. Medical history is significant for hypertension treated with enalapril. Weight is 81 kg (178.6 lb) and height is 180.3 cm (5 ft 11 in). Vital signs are within normal limits. Physical examination and laboratory studies show no abnormalities. The patient moves slowly and appears withdrawn. Polysomnography is recommended to assess for sleep abnormalities. This patient is most likely to have which of the following findings?

Question

A 35-year-old man comes to the office due to persistent fatigue and insomnia for the past 3 weeks.  The patient was fired from his job as an insurance salesman a month ago due to poor sales and has since felt increasingly tired.  He has no difficulty falling asleep but, "for no reason," awakens at 4 AM most nights.  The patient's wife has told him he snores occasionally, although he has not awakened short of breath.  He says, "I liked going to the gym with my friends, but now I just don't want to anymore.  I'm at home a lot now, but I don't have the energy to play with my kids."  The patient feels pressured to look for new job opportunities but is so unfocused that he has not been able to complete any applications.  Medical history is significant for hypertension treated with enalapril.  Weight is 81 kg (178.6 lb) and height is 180.3 cm (5 ft 11 in).  Vital signs are within normal limits.  Physical examination and laboratory studies show no abnormalities.  The patient moves slowly and appears withdrawn.  Polysomnography is recommended to assess for sleep abnormalities.  This patient is most likely to have which of the following findings?

Quizplus · Accepted Answer

This patient's 3-week history of low energy, sleep disturbance, decreased interest, and impaired concentration, as well as the finding of psychomotor slowing on mental status examination, is consistent with major depressive disorder (MDD). Sleep abnormalities are a core symptom of depression and may include difficulty falling asleep, interrupted sleep, early morning awakening, and hypersomnia. major depressive disorder A characteristic polysomnographic finding in MDD is decreased REM sleep latency (the time from sleep onset until the start of the first REM sleep period), which is considered a biomarker for depression. Other sleep findings in depressed patients include decreased slow-wave sleep and increased REM sleep duration and density, as well as disruptions in sleep continuity. Sleep disturbances in MDD typically return to normal with antidepressant treatment. (Choice B) Increased periodic limb movements during sleep (ie, involuntary jerking movements of the legs) may cause nighttime arousals, which typically lead to excessive daytime somnolence. Periodic limb movement disorder would not explain this patient's marked depressive symptoms. (Choice C) Slow-wave sleep (also known as deep sleep) is decreased, not increased, in MDD. (Choice D) Loss of normal REM sleep atonia is a feature of REM sleep behavior disorder, a parasomnia characterized by dream-enactment behaviors. (Choice E) Sleep-related hypoventilation and apneas on polysomnography are characteristic of obstructive sleep apnea (OSA). These patients commonly have a history of observed breathing pauses, snoring, and gasping for air, as well as excessive daytime sleeping rather than early morning awakening. Although this patient has some risk factors for OSA (eg, male, hypertension, snoring), he has a normal BMI and no evidence of interrupted breathing. MDD is a better explanation for his 3-week history of symptoms. Educational objective: Sleep disturbance is a core symptom of depression. Polysomnographic findings in major depressive disorder include decreased REM latency and slow-wave sleep, as well as increased REM sleep duration and REM sleep density. References: The neurobiological mechanisms and treatments of REM sleep disturbances in depression. (http://www.ncbi.nlm.nih.gov/pubmed/26412074) REM sleep dysregulation in depression: state of the art. (http://www.ncbi.nlm.nih.gov/pubmed/23391633)

A 35-Year-Old Man Comes to the Office Due to Persistent