1. (D): Tricyclic antidepressants are the treatment of choice for sleep paralysis and cataplexy because they appear to act mainly through blockade of norepinephrine reuptake or serotonin reuptake and not due to anticholinergic effects. Gabapentin increases slow wave sleep but does not have any effect on cataplexy. Rarely midbrain tumors have been seen to cause cataplexy. (Aldrich 1999, p. 171)

2. (A): PLMS are seen in many normal, especially older sleepers with usually movements of the leg, but rarely of the arms, but may be abnormal if PLMS occur at least four in sequence with the duration of movements occurring for 0.5 to 5 seconds each. PLMS can accompany narcolepsy or idiopathic hypersomnia. PLMS >40 per hour have both a sensitivity and specificity of 81% for the diagnosis of restless leg syndrome. (Daube 2002, p. 510)

3. (B): Actigraphy is an inexpensive useful method for longitudinal assessment, comprising days or weeks, of sleep wake pattern. It can differentiate individuals with normal sleep pattern from those with insomnia including sleep state misperception and inadequate sleep hygiene, circadian rhythm sleep disorder. It is unable to diagnose sleep apnea, PLMS, or bruxism. (Chokroverty 2005, p. 248)

4. (B): MSLT is test of quantifying physiologic sleepiness during wakefulness and to determine the occurrence of REM sleep near sleep onset. It consists of four or five 20-minute rest periods in bed in a dark room spaced 2 hours apart. The sleep latency is defined as the time between lights out and beginning of any stage of sleep. After sleep onset has occurred, patient is allowed to sleep for 15 minutes to assess if REM stage occurs. It is important to confirm that adequate amount of sleep must be obtained for 1 to 2 weeks before the study to ensure that the patient is not voluntarily sleep deprived. (Daube 2002, p. 496)

5. (B): MSLT is test of quantifying physiologic sleepiness during wakefulness and to determine the occurrence of REM sleep near sleep onset. If no sleep occurs during the first 20 minutes in bed, sleep latency is recorded as 20 minutes. EEG, EOG, submental EMG, and ECG data are recorded. Oxygen saturation is not a part of MSLT. For each nap, sleep latency and the occurrence of REM sleep are noted. The presence of REM in two or more naps is considered abnormal. (Daube 2002, p. 495)

6. (B): REM sleep without atonia is scored EEG and EOG suggest REM sleep, but the chin EMG shows muscle artifact rather than the expected. This usually takes the form of a marked increase in phasic twitches but sometimes sustains tonic muscle activity. This is seen with purposeful movements, such as punching in the air during this type of sleep. This is characteristic of REM behavior disorder. (Daube 2002, p. 500)

7. (D): REM sleep is defined by a relatively low amplitude mixed frequency EEG similar to stage 1 sleep, in combination with markedly decreased tone in chin EMG and episodic bursts of rapid eye movements. (Daube 2002, p. 499)

8. (A): The most helpful treatments for PLMS are those for restless leg syndrome: levodopa and dopamine agonists, opiates, and benzodiazepines. Imipramine is not effective in PLMS. (Aldrich 1999, p. 182)

9. (D): Confusional arousals are characterized by a sudden arousal from sleep associated with complex behaviors without full alertness. Most commonly occur during the first third of the night in slow wave sleep. The episodes usually last just few seconds to several minutes. Patients are usually amnesic of the event. These are not associated with tachycardia, flushing, mydriasis, and sweating that is typically seen in sleep terrors. (Aldrich 1999, p. 261)

10. (B): Sleep terrors are episodes of agitation and fear arising abruptly from sleep during which the patient is unresponsive. These episodes are associated with high autonomic activation with tachycardia, flushing, mydriasis, and sweating. These spells usually arise within the first few hours of sleep, in the first third of the night and arise out of slow wave sleep. (Aldrich 1999, p. 265)

11. (C): Sleep talking consists of just a few words to a few sentences during sleep. Sleep talking is common. Approximately 90% of sleep talking occurs in NREM sleep and rest occurs in REM sleep. The cause of sleep talking is unknown. Genetic predisposition is commonly seen. (Aldrich 1999, p. 269)

12. (C): Sleep paralysis is a common feature of narcolepsy, however, isolated sleep paralysis is seen commonly in adolescents, occurring at least in up to 15%. It is a manifestation of REM intrusion into wakefulness. Patients often report inability to lift even a finger during the episodes. The absence of daytime sleepiness distinguishes isolated sleep paralysis from narcolepsy. (Aldrich 1999, p. 270)

13. (D): Sleep bruxism refers to grinding or clenching of the teeth during sleep. Bruxism occurs at all ages and affects men and women equally. It occurs during arousals at all stages of sleep including REM sleep. Periodontal pain and tension headaches are common complaints in these patients. Tooth damage can usually be prevented with a dental guard, which reduces symptoms in 80% to 90% of patients, but does not eliminate bruxing. (Aldrich 1999, p. 279)