Anxiety and Insomnia Flashcards
What is anxiety?
Anxiety is a feeling of fear, worry, and uneasiness,
independent to externals events; or an overreaction to
a situation that is only subjectively seen as menacing.
Clinical manifestation
Psychological: apprehension and fear;
Somatic symptoms: palpitations, chest pain, shortness
of breath, dizziness, loss of libido, headache, tremor
Causes
- Gene some are born more anxious than others.
- ENVO (Environment) bad experiences in the past or big life-changes such as, becoming unemployed or moving house, pregnancy, changing job, etc
- Drugs like amphetamines, LSD or ecstasy etc.
Clinical types and manifestation
- Generalised anxiety disorder Affecting 4% population -excessive anxiety lacking any clear reason or focus;
- Obsessive compulsive disorder 2% population - compulsive ritualistic behaviour driven by
irrational anxiety resulting in distress e.g. fear of contamination etc; - Panic disorder 1% population - sudden episodic attacks of overwhelming fear with somatic symptoms e.g. sweating, tachycardia, chest pains, trembling, choking;
- Phobias 0.8% population - strong anxiety/fear of a specific object/situation (e.g. snakes, flying, social interactions etc);
- Acute stress reactions - response to extreme physical or psychological stress
- Post-traumatic stress disorder - anxiety triggered by recall of past stressful experiences; e.g. veteran’s syndrome
- Mixed anxiety and depressive disorder - anxiety + depression
Common Causes
• There is no one cause for anxiety disorders.
Several factors can play a role
– Genetics
– Brain biochemistry
– Overactive “fight or flight” response
» Can be caused by too much stress
– Life circumstances
– Personality
» People who have low self-esteem and poor coping
skills may be more prone
• Certain drugs, both recreational and medicinal, can
lead to symptoms of anxiety due to either side effects or withdrawal from the drug.
• In very rare cases, a tumor of the adrenal gland
(pheochromocytoma) may be the cause of anxiety
Dysfunction of neurotransmission
Limbic system • Amygdalae • Hippocampus (“seahorse”) • Cingulate gyrus • Parahippocampal gyrus • Hypothalamus • Mamillary bodies • Anterior nucleus of thalamus Decreased serotonergic (5-HT) neurotransmission; Reduced availability of GABA; with sub-sensitivity of postsynaptic GABAA receptors; Over-activity of noradrenergic system; Excessive activity in excitatory glutamatergic neurons;
Anxiety Treatment
- Psychological e.g. relaxation techniques, desensitization therapy
- Pharmacological anxiolytic drugs e.g. benzodiazepines
anti-depressant drugs e.g. SSRI’s, MAOI’s antipsychotic drugs β antagonists e.g. propranolol - Psychosurgery in extreme cases of non-responsive OCD
(Obsessive Compulsive disorder)
Cognitive-behavioral therapy (CBT)
Guided by empirical research, CBT focuses on the
development of personal coping strategies that target
solving current problems and changing unhelpful patterns in cognitions (e.g. thoughts, beliefs, and attitudes), behaviors, and emotional regulation.
Cognitive-behavioral therapy (CBT)
• Teaches patient to react differently to situations and
bodily sensations that trigger anxiety
• Teaches patient to understand how thinking patterns that
contribute to symptoms
• Patients learn that by changing how they perceive
feelings of anxiety, the less likely they are to have them
• Examples: Hyperventilating, writing down list of top fears
and doing one of them once a week, spinning in a chair
until dizzy; after awhile patients learned to cope with the
negative feelings associated with them and replace them
with positive ones
Exercise
- Benefits: symbolic meaning of the activity, the distraction from worries, mastery of a sport, effects on self image, biochemical and physiological changes associated with exercise, symbolic meaning of the sport
- Helps by expelling negative emotions and adrenaline out of your body in order to enter a more relaxed, calm state to deal with issues and conflicts
Benzodiazepines
• Mechanism – selective agonist on GABAA receptors; – enhance the responses to GABA by facilitating the opening of GABA-activated chloride channels; – inhibits neuronal excitability; • Pharmacological effects – reduction of anxiety and aggression; – all are sedative and some are hypnotic (artificial sleep) at high dose; – at high dose some are muscle relaxants; – some are anticonvulsant; – but not analgesic or antipsychotic; – anterograde amnesia; • Indications – (significant) anxiety disorders – transient disabling insomnia – acute seizures (first line treatment) – pre-medication & sedation – muscle spasm – alcohol withdrawal • ADR – respiratory distress & arrest » usually only life threatening with other CNS depressant , e.g. alcohol – CNS effects are common – » some sedation/drowsiness (useful for inducing sleep (“hypnotic drugs” )) » ataxia – e.g. can affect driving; short t1/2 helpful ! » confusion, amnesia » tolerance & dependence • Cautions – liver disease – avoid alcohol – avoid in pregnancy • Contraindications – respiratory depression – myasthenia gravis • Drug interactions – potentiate other CNS depressants – erythromycin, ketoconazole, fluconazole, (inhibit metabolism of benzodiazepine)
Benzodiazepines
table slide 13
Benzodiazepine withdrawal
• Withdrawal of benzodiazepines – abrupt withdrawal can cause
» insomnia, anxiety, disturbed sleep, vivid dreams
» severe cases - confusion, convulsion, psychosis
– often misinterpreted as recurrence of original symptoms
– occurs within hours – up to 3 weeks (depending on t1/2)
e.g. lorazepam: intense withdrawal symptoms begin a few hours
• Advice:
– avoid prolonged treatment: restricting use < 4 weeks
– Gradual withdrawal over 4-8 week is desirable
– first switching to a longer acting benzodiazepine
– dose reduction 2 mg diazepam equivalents every 2 weeks
– may take months or a year!
Benzodiazepine Toxicity
• Effects include: excessive sedation, respiratory
depression and coma.
• Romazicon (flumazenil) is antidote. Has shorter duration
than many benzos so repeated dosing may be necessary. For overdose, give 0.2mg over 30 seconds, wait 30 seconds, then 0.3mg over 30 seconds, then 0.5mg every 60 seconds up to max. of 3mg.
Buspirone
• Mechanism Buspirone
– 5HT1A partial agonist
– presynaptic inhibition of 5HT release
– delayed anxiolytic effect (receptor desensitisation theory)
• Pharmacokinetics
– well absorbed
– first pass metabolism in the liver
– half life is short 2-4h
• Indications
– generalized anxiety disorders
– anxiolytic with slow onset of action (1-2 weeks)
– ineffective for panic attacks
• ADR
– nausea, dizziness, headache, restlessness
– c.f. benzodiazepines- no ataxia, sedation, withdrawal effects
What is Insomnia?
• The perception of inadequate or poor-quality sleep
accompanied by significant distress or impaired function;
• Insomnia and anxiety often occur together
• You might suffer from insomnia if:
– It takes you more than 30 to 45 minutes to get to sleep
– You wake up during the night If you wake up early and
cannot get back to sleep
– You wake up feeling un-refreshed in the morning
– You can only get to sleep with the aid of sleeping
aids or alcohol
• Incidence increases with age; by 50 years old, 25%
population has insomnia, by 65 years old 30-40%
Types of insomnia
• Transient insomnia
» <4/52, triggered by excitement or stress, occurs when away from home
• Short-term
» 4/52-6/12, ongoing stress at home or work, medical problems, psychiatric illness
» Lasts from a few nights to a few weeks
» Caused by worry over a stressful situation
• Chronic
» Poor sleep every night or most nights for > 6/12,
psychological factors (prevalence 9%)
» Lasts months or even years
» Caused by general anxiety, medications, chronic pain, etc
