Anxiety + insomnia Flashcards
What do NICE define as the central feature of anxiety?
excessive worry about a number of different events associated with heightened tension
When considered a psychiatric diagnosis, what should you always look for?
potential physical cause
What are 3 alternative organic causes of anxiety disorders?
- Hyperthyroidism
- Cardiac disease
- Medication-induced anxiety
What are 5 medications that can trigger anxiety?
- Salbutamol
- Theophylline
- Corticosteroids
- Antidepressants
- Caffeine
What are the 4 steps to the interventions for generalised anxiety disorder?
- Step 1: education about GAD + active monitoring
- Step 2: low intensity psychological interventions
- Step 3: high intensity psychological interventions or drug treament
- Step 4: highly specialist input e.g. multi-agency teams
What are 3 examples of low-intensity psychological interventions for generalised anxiety disorder?
- Individual non-facilitated self help
- Individual guided self-help
- Psychoeduational groups
What are 2 examples of high-intensity psychological interventions for generalised anxiety disorder?
- Cognitive behavioural therapy
- Applied relaxation
What are the first line treatment, and second and third line drug treatments for GAD?
- Sertraline first line
- If ineffective: alternative SSRI or SNRI
- If can’t tolerate, offer pregabalin
What are 2 ways that management changes for GAD under 30 years?
- Warn patients of increased risk of suicidal thinking and self-harm with SSRIs and SNRIs
- Weekly follow up for first month
What are the 2 options for treatment of panic disorder in primary care?
- CBT or
- Drug treatment: SSRIs first line
What are the 5 steps to the stepwise management of panic disorder?
- Step 1: recognition and diagnosis
- Step 2: treatment in primary care
- Step 3: review and consideration of alternative treatments
- Step 4: review and referral to specialist mental health services
- Step 5: care in specialist mental health services
What is the first line drug management of panic disorder and what is the second line?
first line is SSRIs; if contra-indicated or no response after 12 weeks, then imipramine or clomipramine should be offered (TCAs)
When should you consider changing to second-line treatment after treatment with SSRIs for panic disorder?
after 12 weeks
What are 4 of the drug treatments that can be offered for GAD?
- SSRIs
- Buspirone (5-HT1A partial agonist)
- Beta-blockers
- Benzodiazepines - longer acting e.g. diazepam, clonazepam
What is GAD?
disproportionate, pervasive, uncontrollable and widespread worry and a range of somatic, cognitive and behavioural symptoms on a continuum of severity
What time period is GAD usually diagnosed following?
worry for more days than not, present for at least 6 months or‘most days for several months’
What are 6 anxiety disorders that are encompassed by generalised anxiety disorder?
- Acute stress disorder
- Obsessive-compulsive disorder
- Panic disorder
- Post-traumatic stress disorder
- Social phobia
- Specific phobias
What is insomnia defined as by DSM-V?
difficulty initiating or maintaining sleep, or early-morning awakening that leads to dissatisfaction with sleep quantity or quality
What are 2 types of insomnia?
acute or chronic
What is the typical course of acute insomnia?
usually related to a life event, resolves without treatment
When is a diagnosis of chronic insomnia made?
if person has trouble falling asleep or staying asleep at least three nights per week for 3 months or longer
What are 4 features of insomnia in the history?
- Decreased daytime functioning
- Decreased periods of sleep (delayed onset or awakening in night)
- Increased accidents due to poor concentration
- Often partner’s rest also suffers
Why is it important to identigy the aetiology of insomnia?
management can differ
What are 6 demographic risk factors associated with insomnia?
- Female gender
- Increased age
- Lower educational attainment
- Unemployment
- Economic inactivity
- Widowed, divorced or separated status
What are 7 other (non-demographic) risk factors for insomnia?
- Alcohol and substance abuse
- Stimulant usage
- Medicatiosn such as corticosteroids
- Poor sleep hygiene
- Chronic pain
- Chronic illness e.g. diabetes, hypertension
- Psychiatric illness - anxiety and depression, mania, PTSD
What are 6 chronic illnesses where patints have a higher prevalence of insomnia than the general population?
- Diabetes
- CAD
- Hypertension
- Heart failure
- BPH
- COPD
What are 4 forms of psychiatric illness that are correlated with insomnia/ sleeplessness?
- Anxiety
- Depression
- Manic episodes
- PTSD
What are 4 of the less common diagnostic factors for insomnia?
- Daytime napping
- Enlarged tonsils or tonge
- Micrognathia and retrognathia
- Lateral narrowing of oropharynx
How is a diagnosis of insomnia usually made?
usually through patient interview, looking for risk factors
What are 2 investigations that may aid diagnosis of insomina?
- Sleep diaries
- Actigraphy - non-invasive method for monitoring motor activity
When is polysomnopgraphy considerd to help diagnose insomnia? 2 situations
not routinely indicated, but may be considered in patients with:
- suspected OSA or periodic limb movement disorder or
- when insomnia poorly responsive to conventional treatment
What are 4 aspects of the short-term management of insomnia?
- Identify any potential causes e.g. mental/physical health issues or poor sleep hygiene
- Advise person not to drive while sleepy
- Advise good sleep hygiene: no screens before bed, limited caffeine intake, fixed bed times
- Only consider hypnotics if daytime impairment severe
What are 3 aspects of good sleep hygiene?
- No screens before bed
- Limited caffeine intake
- Fixed bedtimes
When is the only time you should consider hypnotics for insomnia?
if daytime impairment severe
What are 5 adverse effects of hypnotics, that are sometimes (sparingly) used for insomnia?
- Daytime sedation
- Poor motor co-ordination
- Cognitive impairment
- Concerns about accidents and injuries
- Tolerance to effects of benzos may be rapid
How quickly can tolerance of the hypnotic effects of benzodiazepines for insomnia take place?
within a few days or weeks of regular use
What are 2 options for hypnotics to treat insomnia?
- Benzodiazepines
- Non-benzodiazepines: zopiclone, zolpidem, zaleplon
What is the guidance about use of diazepam for insomnia?
not recommended, but can be useful if insomnia is linked to daytime anxiety
What are 3 types of non-benzodiazepine hypnotic drugs that can be used to treat insomnia in certain situations?
- Zopiclone
- Zolpidem
- Zaleplon
What is the guidance about duration and dose of treatment with hypnotics for insomnia?
use lowest effective dose for shortest possible period
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
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
What are 5 sedative drugs NOT recommended for managing insomnia?
antidepressants, antihistamines, choral hydrate, clomethiazole, barbiturates
