Anxiety and Sleep Disorder

Question 1

What is an anxiety disorder?

Answer 1

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

Question 2

State the anxiety disorders that are most amenable to treatment

Answer 2

1) Panic Disorder

2) Social Anxiety Disorder

3) Generalised Anxiety Disorder

4) Obsessive Compulsive Disorder

5) Post Traumatic Stress Disorder

Question 3

What is the most prevalent Anxiety related disorder in SG?

Answer 3

OCD

Question 4

The fear circuit is regulated by the ____ while the worry circuit is regulated by the ____

Answer 4

Amygdala

Cortico-Striatial-Thalamic-Cortical (CSTC) loop

Question 5

State which brain circuit benzodiazepines have no effect on and what type of drugs are needed

Answer 5

Worry circuit

Serotonergic antidepressants are needed

Question 6

State examples of medical conditions associated with anxiety (4 systems)

Answer 6

CVS: CHF, arrhythmia, MI, IHD

Respi: Asthma, COPD

Endocrine: HYPERthyroidism

Neuro: Stroke, derilium, dementia

Question 7

List drug induced/ related causes of anxiety

(8 induce; 2 related)

Answer 7

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)

Question 8

Describe Panic Attack

Answer 8

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

Question 9

Describe presentation of Generalised Anxiety Disorder (3 pts)

Answer 9

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)

Question 10

Describe Panic Disorder

Answer 10

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

Question 11

Desrcibe Social Anxiety Disorder

Answer 11

• 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)

Question 12

Describe OCD

Answer 12

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

Question 13

Describe PTSD

Answer 13

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)

Question 14

Name the clinician rated scale administered in RCTs to assess Anxiety

Answer 14

Hamiliton Anxiety Scale (HAM-A)

Question 15

State which drug is used (as adjunct) for anxiety and to help people sleep that does not cause dependence

Answer 15

Hydroxyzine

Question 16

State the general pharmacological and non-pharmacological management of Anxiety related disorders

Answer 16

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

Question 17

State the clinical benefit of Serotonergic agents as well as state the onset of effect as well as when full response is expected

Answer 17

o Effective for “excessive worrying” type of symptoms in anxiety
- Onset at least 1-2 months
- Full response generally 3 months

Question 18

State the dosing approach to antidepressant dosing in Anxiety disorders

Answer 18

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

Question 19

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.

Answer 19

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.

Question 20

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

Answer 20

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)

Question 21

State the 2 short acting Benzodiazepines used for Anxiety disorders

Answer 21

Lorazepam, Alprazolam

Question 22

Which Benzodiazepine associated with the most deaths and abuse?

Answer 22

Alprazolam

Question 23

State the treatment goals of Anxiety disorders (2)

Answer 23

Remission of symptoms, functional recovery

Question 24

Which neurotransmitter(s) is/are sleep promoting?

Answer 24

GABA

Question 25

In Non-rapid eye movement sleep, stages 3 and 4 are known as what kind of sleep?

Answer 25

Restorative sleep

Question 26

Benzodiazepine increases time in ____ but decreases time in _____?

Answer 26

Deeper sleep (stage 2); restorative sleep (stage 3 and 4)

Question 27

State the various classifications of Insomnia, likely causes for each classification and management

Answer 27

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

Question 28

State how you would counsel a patient regarding sleep hygiene (7; 9 if feeling ambitious)

Answer 28

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

Question 29

What ADR is specific to Zopiclone?

Answer 29

Taste disturbance

Question 30

State usual dose of Zopidem and when dosing should be adjusted

Answer 30

10mg HS PRN

Halve dose for: Females, Elderly and Debilitated

Question 31

List the Z-hypnotics

Answer 31

Zolpidem, Zopiclone

Question 32

State rare ADR of Z-Hypnotics

Answer 32

Complex sleep behaviour (e.g sleep walking)

Question 33

State CIs of Lemborexant (3)

Answer 33

1) Narcolepsy
2) Severe hepatic impairment
3) Moderate-strong CYP3A inducer/inhibitor

Question 34

State the most well tolerated hypnotic for patients > 55 y.o

Answer 34

Circadin

Question 35

State contraindications of Benzodiazepine and Z-hypnotics (4)

Answer 35

1) Narrow angle glaucoma
2) Respiratory depression (basically patients with prob breathing e.g sleep apnea incl)
3) Unstable myasthnia gravis
4) Hypersensitivity

Question 36

State the groups of patients in which Antihistamines should be used in caution (7)

Answer 36

BPH, Urine retention, angle closure glaucoma, pyloroduodenal obstruction, epilepsy, QTc prolonging patient (for hydroxyzine), CAD (for promethazine)

Question 37

ADR of Benzodiazepines (3)

Answer 37

Sedation, drowsiness, amnesia

Question 38

Which Benzodiazepine is almost always reserved for Panic disorders only?

Answer 38

Alprazolam

Question 39

Which drug is FDA approved for ALL anxiety disorders?

Answer 39

Paroxetine