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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
Q

What are 7 other (non-demographic) risk factors for insomnia?

A
  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
Q

What are 6 chronic illnesses where patints have a higher prevalence of insomnia than the general population?

A
  1. Diabetes
  2. CAD
  3. Hypertension
  4. Heart failure
  5. BPH
  6. COPD
27
Q

What are 4 forms of psychiatric illness that are correlated with insomnia/ sleeplessness?

A
  1. Anxiety
  2. Depression
  3. Manic episodes
  4. PTSD
28
Q

What are 4 of the less common diagnostic factors for insomnia?

A
  1. Daytime napping
  2. Enlarged tonsils or tonge
  3. Micrognathia and retrognathia
  4. Lateral narrowing of oropharynx
29
Q

How is a diagnosis of insomnia usually made?

A

usually through patient interview, looking for risk factors

30
Q

What are 2 investigations that may aid diagnosis of insomina?

A
  1. Sleep diaries
  2. Actigraphy - non-invasive method for monitoring motor activity
31
Q

When is polysomnopgraphy considerd to help diagnose insomnia? 2 situations

A

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
Q

What are 4 aspects of the short-term management of insomnia?

A
  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
Q

What are 3 aspects of good sleep hygiene?

A
  1. No screens before bed
  2. Limited caffeine intake
  3. Fixed bedtimes
34
Q

When is the only time you should consider hypnotics for insomnia?

A

if daytime impairment severe

35
Q

What are 5 adverse effects of hypnotics, that are sometimes (sparingly) used for insomnia?

A
  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
Q

How quickly can tolerance of the hypnotic effects of benzodiazepines for insomnia take place?

A

within a few days or weeks of regular use

37
Q

What are 2 options for hypnotics to treat insomnia?

A
  1. Benzodiazepines
  2. Non-benzodiazepines: zopiclone, zolpidem, zaleplon
38
Q

What is the guidance about use of diazepam for insomnia?

A

not recommended, but can be useful if insomnia is linked to daytime anxiety

39
Q

What are 3 types of non-benzodiazepine hypnotic drugs that can be used to treat insomnia in certain situations?

A
  1. Zopiclone
  2. Zolpidem
  3. Zaleplon
40
Q

What is the guidance about duration and dose of treatment with hypnotics for insomnia?

A

use lowest effective dose for shortest possible period

41
Q

What is the guidance if you prescribe a hypnotic for insomnia and there is no response?

A

do not prescribe another - make patient aware that repeat prescriptions aren’t usually given

42
Q

When should you review a patient after prescribing a hypnotic drug for insomnia and what referral should be considered?

A

after 2 weeks; consider referral for CBT

43
Q

What are 5 sedative drugs NOT recommended for managing insomnia?

A

antidepressants, antihistamines, choral hydrate, clomethiazole, barbiturates

GP (43 decks)

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