Anxiety and Sleep Disorder Flashcards
What is an anxiety disorder?
Severe, excessive, persistent anxiety and irrational fears that impairs functioning with everyday living; pathological.
When anxiety is out of proportion to the actual danger or threat of the situation
State the anxiety disorders that are most amenable to treatment
1) Panic Disorder
2) Social Anxiety Disorder
3) Generalised Anxiety Disorder
4) Obsessive Compulsive Disorder
5) Post Traumatic Stress Disorder
What is the most prevalent Anxiety related disorder in SG?
OCD
The fear circuit is regulated by the ____ while the worry circuit is regulated by the ____
Amygdala
Cortico-Striatial-Thalamic-Cortical (CSTC) loop
State which brain circuit benzodiazepines have no effect on and what type of drugs are needed
Worry circuit
Serotonergic antidepressants are needed
State examples of medical conditions associated with anxiety (4 systems)
CVS: CHF, arrhythmia, MI, IHD
Respi: Asthma, COPD
Endocrine: HYPERthyroidism
Neuro: Stroke, derilium, dementia
List drug induced/ related causes of anxiety
(8 induce; 2 related)
1) Sympathomimetic
2) Stimulants (cocaine, amphetamine)
3) Methylxanthines (Theophylline, Caffeine)
4) Levothyroxine
5) Steriods
6) Antidepressants (SSRIs or TCAs: esp with initiation or rapid dose escalation)
7) Levodopa (dopamine agonist)
8) Beta agonist (e.g salbutamol)
9) Drug withdrawal (Caffeine, Nicotine, Antidepressant, Alcohol, Sedatives, Benzodiazepines)
10) Drug intoxication (Anticholinergic, Antihistamine, Digoxin)
Describe Panic Attack
A discrete period of intense fear/discomfort, in which ≥ 4 of the following Signs and Symptoms developed abruptly and reached a peak within 10mins (usually lasts no more than 20-30 min)
Palpitations, pounding heart, ↑PR
Sweating
Trembling/ shaking
Sensations of shortness of breath
Feeling of choking
Chest pain/ discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, lightheaded, faint
Derealization (feelings of unreal) or depersonalization (being detached from oneself)
Fear of losing control or going crazy
Fear of dying
Paresthesias (numbness or tingling sensations)
Chills or hot flushes
Describe presentation of Generalised Anxiety Disorder (3 pts)
Excessive anxiety/ worry for ≥ 6 months with functional impairment
≥ 3 of the following signs and symptoms:
o Restlessness or feeling keyed up or on edge
o Being easily fatigue
o Difficulty concentrating or mind going blank.
o Irritability
o Muscle tension
o Sleep disturbance (insomnia, restless unsatisfying sleep)
Signs and symptoms are not due to another mental condition or direct physiological effects of a substance (e.g. drugs)
Describe Panic Disorder
Both 1 and 2:
o (1) Recurrent unexpected panic attacks, and
o (2) ≥ 1 of the panic attacks has been followed by ≥ 1mth of ≥ 1 of the following:
- (a) Persistent anticipatory anxiety of having additional panic attacks
- (b) Worry about implications of the panic attack
- (c) Significant change in behaviour related to the panic attacks
Desrcibe Social Anxiety Disorder
- Marked and persistent fear for > 6 months of ≥ 1 social/performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others/peers. He/she fears that he/she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing
- The feared social/performance situations are avoided or endured with intense anxiety/distress
o The avoidance, anxious anticipation or distress in the feared situation(s) significantly impairs functioning - Symptoms are not due to another mental condition or direct physiological effects of a substance (e.g. drugs)
Describe OCD
Either Obsessions or Compulsions AND
o Obsessions= Recurrent and persistent thoughts/ impulses/ images that are experienced, at some time during the disturbance, as intrusive and inappropriate and causing marked anxiety/distress
o Compulsions =
(1) Repetitive behaviours (e.g. hand washing, checking) or mental acts (praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rigid rules.
(2) The behaviours or mental acts are aimed at preventing/reducing the distress but NOT connected in a realistic way with what they are designed to neutralize/prevent or are clearly excessive.
Person recognised that the obsessions/compulsions are excessive or unreasonable
The obsessions/ compulsions cause marked distress, are time consuming (take ≥ 1hr a day), or significantly impairs functioning
Describe PTSD
Subsequent persistence of symptoms for > 1 month after person was exposed to stressor, causing functional impairment
Symptoms:
- Intrusion symptoms (persistence re-experiencing of trauma) (1 symptom required)
- Avoidance of trauma related stimuli (1 symptom required)
- Negative alterations in cognition or mood (2 symptoms required)
- Alteration in arousal or reactivity (2 symptoms required)
Name the clinician rated scale administered in RCTs to assess Anxiety
Hamiliton Anxiety Scale (HAM-A)
State which drug is used (as adjunct) for anxiety and to help people sleep that does not cause dependence
Hydroxyzine
State the general pharmacological and non-pharmacological management of Anxiety related disorders
Non-Pharm (Key): Cognitive behavioural therapy to be used in combination with medications
Pharmacological:
SSRI (1st line), SNRI (2nd line), Clomipramine (TCA) (3rd line)
EXCEPT in OCD where Clomipramine is 2nd line
State the clinical benefit of Serotonergic agents as well as state the onset of effect as well as when full response is expected
o Effective for “excessive worrying” type of symptoms in anxiety
- Onset at least 1-2 months
- Full response generally 3 months
State the dosing approach to antidepressant dosing in Anxiety disorders
Start low go slow
Transient jitteriness in the initial 1-2 weeks of starting antidepressant.
Start antidepressant at with low dose; consider Benzodiazepine as adjunct
Maintenance doses may be at higher end of dosing range
State the role of Benzodiazepines in managing Anxiety disorders, the type of benzodiazepines preferred, their onset of action as well things to be done when stopping.
Generally for short term (3-4 month) PRN use, gradual taper before discontinuing (↓ in steps of Diazepam 2mg, ~q2-3 wks)
Fast onset of action (within 30min)
Short acting but potent ones preferred.
State the PK characteristics of the following Benzodiazepines (wrt Duration of Action, Metabolism reaction undergone in liver, presence/ absence of active metabolite and dosing range incl max dose where applicable):
a) Alprazolam
b) Lorazepam
c) Diazepam
d) Clonazepam
a) Alprazolam (Short acting, Oxidation, No active metabolite, 0.25-5mg BD/TDS, max dose 4-6mg/day)
b) Lorazepam (Short acting, Glucuronidation, No active metabolite, 1-3mg/day in divided doses, max 6-8mg/day)
c) Diazepam (Long acting, Oxidation, Has active metabolites, 2-10mg BD/QDS)
d) Clonazepam (long acting, Oxidation/Nitroreduction, has active metabolites, 0.5mg BD, max dose 4mg/day)
State the 2 short acting Benzodiazepines used for Anxiety disorders
Lorazepam, Alprazolam
Which Benzodiazepine associated with the most deaths and abuse?
Alprazolam
State the treatment goals of Anxiety disorders (2)
Remission of symptoms, functional recovery
Which neurotransmitter(s) is/are sleep promoting?
GABA
In Non-rapid eye movement sleep, stages 3 and 4 are known as what kind of sleep?
Restorative sleep
Benzodiazepine increases time in ____ but decreases time in _____?
Deeper sleep (stage 2); restorative sleep (stage 3 and 4)
State the various classifications of Insomnia, likely causes for each classification and management
Acute (transient = < 1 wk; short term = < 4 wks)
- Cause: Acute stressor
- Management: Sleep hygiene +- short PRN course of hypnotic (up to 2-4 wks)
Chronic (sleep difficulties ≥ 3 nights/week for ≥ 1 month)
- Cause: underlying psychiatric and/or medical problems
- Management: Sleep hygiene + identify and manage underlying conditions + discourage long term use of hypnotics
State how you would counsel a patient regarding sleep hygiene (7; 9 if feeling ambitious)
1) Avoid caffeine-containing products, nicotine and alcohol especially late in the day
2) Avoid heavy meals within 2 hours of bedtime
3) Avoid drinking fluids after dinner to avoid frequent nighttime urination
4) Avoid environments that will make you active after 5pm (e.g noisy environments)
5) Establish a routine for getting ready to go to bed, wake up at same time everyday including weekends
6) Avoid taking daytime naps. If naps needed, take before 3pm and nap for less than 1 hour
7) Regular physical activity (e.g walking or gardening) but avoid vigorous exercises too close to bedtime
8) Relaxation techniques before and while in bed to help sleep
9) Create conducive environment to sleep
What ADR is specific to Zopiclone?
Taste disturbance
State usual dose of Zopidem and when dosing should be adjusted
10mg HS PRN
Halve dose for: Females, Elderly and Debilitated
List the Z-hypnotics
Zolpidem, Zopiclone
State rare ADR of Z-Hypnotics
Complex sleep behaviour (e.g sleep walking)
State CIs of Lemborexant (3)
1) Narcolepsy
2) Severe hepatic impairment
3) Moderate-strong CYP3A inducer/inhibitor
State the most well tolerated hypnotic for patients > 55 y.o
Circadin
State contraindications of Benzodiazepine and Z-hypnotics (4)
1) Narrow angle glaucoma
2) Respiratory depression (basically patients with prob breathing e.g sleep apnea incl)
3) Unstable myasthnia gravis
4) Hypersensitivity
State the groups of patients in which Antihistamines should be used in caution (7)
BPH, Urine retention, angle closure glaucoma, pyloroduodenal obstruction, epilepsy, QTc prolonging patient (for hydroxyzine), CAD (for promethazine)
ADR of Benzodiazepines (3)
Sedation, drowsiness, amnesia
Which Benzodiazepine is almost always reserved for Panic disorders only?
Alprazolam
Which drug is FDA approved for ALL anxiety disorders?
Paroxetine
