Anxiety and Insomnia

Question 1

Which part of the brain is implicated in anxiety disorders?

Answer 1

Fear - amygdala;
Worry - cortico-striatal-thalamic-cortical (CSTC) loop

Question 2

Explain the dysregulation in neurotransmitters in anxiety disorders.

Answer 2

1) NE - fight-or-flight;
2) Serotonin - reduced, hence less inhibition of amygdala outputs -> more fear.
3) GABA -> need more to inhibit amygdala output.

Question 3

S&S of anxiety and worry (>= 6 mo for GAD diagnosis)

Answer 3

1. Restlessness
2. Being easily fatigue
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance (insomnia, restless unsatisfying sleep)

Question 4

List 3 features of Social Anxiety Disorder.

Answer 4

1. Fear of social/performance situations, may avoid them.
2. Fear of humiliation or embarrassment.
3. Duration > 6 mo.

Question 5

What is Obesessive-Compulsive Disorder?

Answer 5

Obsession: recurrent, persistent thoughts/impulses/images.
Compulsion: repetitive behaviours or mental acts which are clearly excessive. Aimed at preventing the distress.

Patient at some point recognizes that the obsessions/compulsions are excessive or unreasonable.

Question 6

What is PTSD?

Answer 6

Exposed to traumatic event, which they persistently re-experience it.
Avoidance behaviour of trauma-related stimuli.

Question 7

List the agents suitable for treatment of GAD.

Answer 7

SSRIs
Venlafaxine XR
Pregabalin

TCAs, beta-blockers

Question 8

List the agents suitable for treatment of Panic Disorder.

Answer 8

SSRIs (Fluoxetine, Paroxetine, Sertraline)
TCAs

Question 9

List the agents suitable for treatment of Social Anxiety Disorder.

Answer 9

SSRIs (Fluvoxamine, Parox, Sertraline)
MAOIs/RIMAs
May consider MAOIs + BZDs

Question 10

List the agents suitable for treatment of OCD.

Answer 10

SSRIs (Fluoxetine, Fluvoxamine, Paroxetine, Sertraline)
Clomipramine (TCA)

Question 11

List the agents suitable for treatment of PTSD.

Answer 11

SSRIs (Paroxetine, Sertraline)
TCAs

More imptly: CBT

Question 12

when will the patient start benefitting from the anxiolytic?

Answer 12

Onset: 1-2 mo
Full response generally @ 3 mo
Expect to be treated for at least 1-2 years, long-term.

Question 13

Classification of insomnia as a symptom

Answer 13

Acute - Transient (<1 wk)
Acute - short-term (<4 wks)
Chronic (>4 wks)

Question 14

When should I use hypnotics (x7-10d, max 2-4 wks)?

Answer 14

Sleep difficulties for more than 1 week, but less than 4 weeks.

Question 15

List 5 non-pharmacological treatment for insomnia (1st-line).

Answer 15

Avoid:
- Caffeine
- Nicotine
- Alcohol
- Drinking fluids after dinner
- Environments - active after 5pm
- Daytime Naps

Establish a routine for getting ready for bed.
Regular physical activities.

Question 16

Special dosing for Zolpidem (Stillnox)

Answer 16

Adults > 18 yrs: 10mg HS PRN.
Females Half Dose.

Question 17

[Side Effects] Anticholinergics

Answer 17

Dry mouth
Constipation
Nausea
Dry Skin

Pupil dilation
Urinary retention

Question 18

what is the Contraindication for Lemborexant?

Answer 18

Administration for patient w/ Narcolepsy, severe Hepatic impairment, moderate-strong CYP3A inhibitor/inducer.

Question 19

Compare the SE profile of BZD and Z-Hypnotics.

Answer 19

Both has sedation.
Z-hypnotic has less N/V, dizziness, dry mouth, headache.

Z-hypnotics - complex sleep behaviours (sleep-walking).
Zopiclone - taste disturbance.

Question 20

List the SE profile for Trazodone.

Answer 20

Same as SSRIs.
Sedation
Orthostatic hypotension
Priapism

Question 21

Before giving BZD, what should you ensure?

Answer 21

• No severe renal/hepatic impairment.
• Pregnancy / breastfeeding
• Hx of drug/alcohol abuse or psychiatric disorders.

Avoid prolonged usage. Taper off gradually.
BZD + Opioids = increased mortality.