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Anxiety + insomnia Flashcards

1
Q

What do NICE define as the central feature of anxiety?

A

excessive worry about a number of different events associated with heightened tension

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2
Q

When considered a psychiatric diagnosis, what should you always look for?

A

potential physical cause

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3
Q

What are 3 alternative organic causes of anxiety disorders?

A
  1. Hyperthyroidism
  2. Cardiac disease
  3. Medication-induced anxiety
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4
Q

What are 5 medications that can trigger anxiety?

A
  1. Salbutamol
  2. Theophylline
  3. Corticosteroids
  4. Antidepressants
  5. Caffeine
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5
Q

What are the 4 steps to the interventions for generalised anxiety disorder?

A
  1. Step 1: education about GAD + active monitoring
  2. Step 2: low intensity psychological interventions
  3. Step 3: high intensity psychological interventions or drug treament
  4. Step 4: highly specialist input e.g. multi-agency teams
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6
Q

What are 3 examples of low-intensity psychological interventions for generalised anxiety disorder?

A
  1. Individual non-facilitated self help
  2. Individual guided self-help
  3. Psychoeduational groups
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7
Q

What are 2 examples of high-intensity psychological interventions for generalised anxiety disorder?

A
  1. Cognitive behavioural therapy
  2. Applied relaxation
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8
Q

What are the first line treatment, and second and third line drug treatments for GAD?

A
  1. Sertraline first line
  2. If ineffective: alternative SSRI or SNRI
  3. If can’t tolerate, offer pregabalin
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9
Q

What are 2 ways that management changes for GAD under 30 years?

A
  1. Warn patients of increased risk of suicidal thinking and self-harm with SSRIs and SNRIs
  2. Weekly follow up for first month
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10
Q

What are the 2 options for treatment of panic disorder in primary care?

A
  1. CBT or
  2. Drug treatment: SSRIs first line
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11
Q

What are the 5 steps to the stepwise management of panic disorder?

A
  1. Step 1: recognition and diagnosis
  2. Step 2: treatment in primary care
  3. Step 3: review and consideration of alternative treatments
  4. Step 4: review and referral to specialist mental health services
  5. Step 5: care in specialist mental health services
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12
Q

What is the first line drug management of panic disorder and what is the second line?

A

first line is SSRIs; if contra-indicated or no response after 12 weeks, then imipramine or clomipramine should be offered (TCAs)

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13
Q

When should you consider changing to second-line treatment after treatment with SSRIs for panic disorder?

A

after 12 weeks

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14
Q

What are 4 of the drug treatments that can be offered for GAD?

A
  1. SSRIs
  2. Buspirone (5-HT1A partial agonist)
  3. Beta-blockers
  4. Benzodiazepines - longer acting e.g. diazepam, clonazepam
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15
Q

What is GAD?

A

disproportionate, pervasive, uncontrollable and widespread worry and a range of somatic, cognitive and behavioural symptoms on a continuum of severity

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16
Q

What time period is GAD usually diagnosed following?

A

worry for more days than not, present for at least 6 months or‘most days for several months’

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17
Q

What are 6 anxiety disorders that are encompassed by generalised anxiety disorder?

A
  1. Acute stress disorder
  2. Obsessive-compulsive disorder
  3. Panic disorder
  4. Post-traumatic stress disorder
  5. Social phobia
  6. Specific phobias
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18
Q

What is insomnia defined as by DSM-V?

A

difficulty initiating or maintaining sleep, or early-morning awakening that leads to dissatisfaction with sleep quantity or quality

19
Q

What are 2 types of insomnia?

A

acute or chronic

20
Q

What is the typical course of acute insomnia?

A

usually related to a life event, resolves without treatment

21
Q

When is a diagnosis of chronic insomnia made?

A

if person has trouble falling asleep or staying asleep at least three nights per week for 3 months or longer

22
Q

What are 4 features of insomnia in the history?

A
  1. Decreased daytime functioning
  2. Decreased periods of sleep (delayed onset or awakening in night)
  3. Increased accidents due to poor concentration
  4. Often partner’s rest also suffers
23
Q

Why is it important to identigy the aetiology of insomnia?

A

management can differ

24
Q

What are 6 demographic risk factors associated with insomnia?

A
  1. Female gender
  2. Increased age
  3. Lower educational attainment
  4. Unemployment
  5. Economic inactivity
  6. Widowed, divorced or separated status
25
What are 7 other (non-demographic) risk factors for insomnia?
1. Alcohol and substance abuse 2. Stimulant usage 3. Medicatiosn such as corticosteroids 4. Poor sleep hygiene 5. Chronic pain 6. Chronic illness e.g. diabetes, hypertension 7. Psychiatric illness - anxiety and depression, mania, PTSD
26
What are 6 chronic illnesses where patints have a higher prevalence of insomnia than the general population?
1. Diabetes 2. CAD 3. Hypertension 4. Heart failure 5. BPH 6. COPD
27
What are 4 forms of psychiatric illness that are correlated with insomnia/ sleeplessness?
1. Anxiety 2. Depression 3. Manic episodes 4. PTSD
28
What are 4 of the less common diagnostic factors for insomnia?
1. Daytime napping 2. Enlarged tonsils or tonge 3. Micrognathia and retrognathia 4. Lateral narrowing of oropharynx
29
How is a diagnosis of insomnia usually made?
usually through patient interview, looking for risk factors
30
What are 2 investigations that may aid diagnosis of insomina?
1. Sleep diaries 2. Actigraphy - non-invasive method for monitoring motor activity
31
When is polysomnopgraphy considerd to help diagnose insomnia? 2 situations
not routinely indicated, but may be considered in patients with: 1. suspected OSA or periodic limb movement disorder or 2. when insomnia poorly responsive to conventional treatment
32
What are 4 aspects of the short-term management of insomnia?
1. Identify any potential **causes** e.g. mental/physical health issues or poor sleep hygiene 2. Advise person **not to drive** while sleepy 3. Advise **good sleep hygiene**: no screens before bed, limited caffeine intake, fixed bed times 4. Only consider **hypnotics** if daytime impairment severe
33
What are 3 aspects of good sleep hygiene?
1. No screens before bed 2. Limited caffeine intake 3. Fixed bedtimes
34
When is the only time you should consider hypnotics for insomnia?
if daytime impairment **severe**
35
What are 5 adverse effects of hypnotics, that are sometimes (sparingly) used for insomnia?
1. Daytime sedation 2. Poor motor co-ordination 3. Cognitive impairment 4. Concerns about accidents and injuries 5. Tolerance to effects of benzos may be rapid
36
How quickly can tolerance of the hypnotic effects of benzodiazepines for insomnia take place?
within a few days or weeks of regular use
37
What are 2 options for hypnotics to treat insomnia?
1. Benzodiazepines 2. Non-benzodiazepines: zopiclone, zolpidem, zaleplon
38
What is the guidance about use of diazepam for insomnia?
not recommended, but can be useful if insomnia is linked to daytime anxiety
39
What are 3 types of non-benzodiazepine hypnotic drugs that can be used to treat insomnia in certain situations?
1. Zopiclone 2. Zolpidem 3. Zaleplon
40
What is the guidance about duration and dose of treatment with hypnotics for insomnia?
use lowest effective dose for shortest possible period
41
What is the guidance if you prescribe a hypnotic for insomnia and there is no response?
do not prescribe another - make patient aware that repeat prescriptions aren't usually given
42
When should you review a patient after prescribing a hypnotic drug for insomnia and what referral should be considered?
after 2 weeks; consider referral for CBT
43
What are 5 sedative drugs NOT recommended for managing insomnia?
antidepressants, antihistamines, choral hydrate, clomethiazole, barbiturates

GP (43 decks)

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