IC14 Anxiety and Sleep Disorders Flashcards
What is the patho for anxiety disorders?
- Dysregulation of NE, 5-HT
- ↓GABA
What are the 2 main general symptoms to look out for in anxiety disorders?
Remember 2 major symptoms:
-
Physical Symptoms
a. Muscle tense up, headache, butterfly in their stomach, tremors, palpitation, sweat, want to rush
b. Can be effectively treated with relaxation pills/BZD -
Worrying symptoms
a. Need serotonergic antidepressants
b. BZD will NOT work
What are the sx of general anxiety disorder as defined by DSM-5?
(1) Generalised Anxiety Disorder
- Excessive anxiety and worry
-
>=3 of the following Sx for >=6months:
o Restlessness
o Fatigue
o Difficulty concentrating
o Irritability
o Muscle tension
o Insomnia - Cause significant functional impairment
What are the sx of panic disorder as defined by DSM-5?
(2) Panic Disorder
- Recurrent unexpected panic attacks AND
- > =1 of the panic attacks are followed by >=1month of >=1 of the following:
o Persistent anticipatory anxiety
o Worry about implications of panic attack
o Significant change in behaviour related to the panic attack
What are the sx of social anxiety disorder as defined by DSM-5?
(3) Social Anxiety Disorder
- Marked and persistent fear of >=1 social/performance situations
- Humiliating and embarrassing
- >=6 months
- Avoid these feared situations
- Impairs functioning
What are the sx of obsessive compulsive disorder as defined by DSM-5?
(4) Obsessive-compulsive disorder
- Obsession: recurrent and persistent thoughts/impulses/images which are intrusive and inappropriate
- Compulsive: repetitive behaviours or mental acts; clearly excessive and unreasonable
- Marked distress
What are the sx of post traumatice stress disorder as defined by DSM-5?
(5) Post-traumatic stress disorder
- Exposed to stressor
- Persistently re-experience the trauma
- Avoidance
- Negative change to mood and cognitions
- Arousal and reactivity e.g. irritable, hypervigilance
- >=6months
- Impairs functioning
Out of all 5 anxiety disorders, which one has different duration to diagnose it? State the duration.
Panic Disorder: 1 month
The rest need to have sx for 6months
Which class of medications can be used for all anxiety disorders?
SSRIs
What are the pharm and non-pharm options for GAD?
GAD
Pharm (long term):
1) SSRI (Fluoxetine, sertraline)
2) Venlafaxine XR (SNRI)
3) Pregabalin
+ adjunctive BZD PRN 1-2 weeks
Non-pharm
1) CBT
2) Psychotherapy
3) Relaxation
4) Anxiety Management
What are the pharm and non-pharm options for PD?
PD
Pharm (long term):
1) SSRI (Fluoxetine, sertraline)
+ adjunctive BZD PRN 1-2 weeks
Non-pharm
1) CBT
What are the pharm and non-pharm options for SAD?
SAD
Pharm (long term):
1) SSRI (Fluoxetine, sertraline)
+ adjunctive BZD PRN 1-2 weeks
Non-pharm
1) Behavioural therapy
What are the pharm and non-pharm options for OCD?
GAD
Pharm (long term):
1) SSRI (Fluoxetine, sertraline)
2) Clomipramine (TCA)
3) SNRI
+ adjunctive BZD PRN 1-2 weeks
Non-pharm
1) CBT
2) Exposure and Response Prevention Therapy (ERT)
What are the pharm and non-pharm options for PTSD?
PTSD
Pharm (long term):
1) SSRI (Fluoxetine, sertraline)
+ adjunctive BZD PRN 1-2 weeks
Non-pharm
1) CBT (1st line)
Generally what is the pharm combination for anxiety disorders?
Serotonergic Antidepressant (long term) + Adjunctive BZDs (+ Non-pharm)
How does serotonergic antidepressants help with anxiety disorders?
- Antidepressants that promote 5-HT will offer efficacy for these anxiety disorders
- Effective for “worrying/apprehension” type of symptoms
- 6-12 weeks for onset of effects
How do you start the serotonergic antidepressants for any of the anxiety disorders?
When is the onset of effects?
When does the max effects occur?
What is the total duration of treatment?
What is the dose level for maintenance therapy?
- Initiation:
o at very low doses to minimize initial jitteriness, gradually titrate dose.
o Occurs in 1st 2 weeks
o Thus, reduce dose if patients complain of this - Onset of effects: 6-12 weeks
- Max. response: 3 months.
- Duration of treatment: at least 1 year in general, usually longer
- Maintenance:
o high end of the dose range
What are the possible adjunctives to serotonergic antidepressants for the anxiety disorders?
- BZDs (clonazepam, lorazepam),
- sedating antihistamine (hydroxyzine),
- Propranolol
What is the 2nd/3rd line for GAD long treatment?
Pregabalin (anticonvulsant) for GAD if SSRI/SNRI ineffective
What are the DDIs of antidepressants, BZDs, anticholinergics?
DDI:
-
↑CNS depressant:
a. Alcohol (separate 4-6hrs part), BZD, antidepressants, BZD + opioids = death - Excessive anticholinergic effects (esp. anticholinergics)
- Serotonin syndrome: Opioids like tramadol, hydromorphone, MAOIs, SSRIs, SNRIs, TCAs
- CYP3A4 inducers and inhibitors (BZDs are metabolised by CYP3A4)
- Others in IC10
e.g. increase risk of bleeding with SSRI antidepressants, use agomelatine instead
Describe insomnia and what is the duration for one to be diagnosed with insomnia?
- Inability to maintain sleep, have daytime problems that impair functions
- At least 3 nights/wk for >=3months
What is the patho of insomnia?
Pathophysiology:
- Keep awake: NE, DA, acetylcholine, histamine, orexin
- Helps with sleep: GABA, melatonin
What are the stages of insomnia and how would you generally manage them?
- Acute (due to acute stressors): sleep hygiene +/- hypnotic PRN x7-10days
- Chronic (due to underlying condition): treat underlying condition + sleep hygiene + DISCOURAGE long term hypnotics
What is 1st line/standard of care of insomnia?
Non-pharm –> sleep hygiene
Others: CBT for insomnia (CBT-I), behavioral interventions (stimulus control etc)
- Avoid drinking caffeine, alcohol, later in the day
- Avoid taking daytime naps
What is 1st line for PTSD?
CBT (non-pharm)
What is the place in therapy of pharm treatment in insomnia?
Pharmacological Therapy:
- Pharmacological Options as adjuncts (never give for sleep only)
- Fast acting anxiolytics/hypnotics/sedatives/ antipsychotics as adjuncts for short term relief –> help relax and sleep
- PRN, lowest effective dose, short course (1-2wks)
What are the possible pharm options for insomnia?
- BZDs
- Z-hypnotics
- Sedating antihistamines e.g. hydroxyzine/promethazine
- melatonin
- lemborexant
- off label use: trazadone, antipsychotics
How does BZDs help with insomnia?
How should BZDs be taken?
Benzodiazepines e.g. Lorazepam, Diazepam
- Not as monotherapy but Adjunct to antidepressant for MDD or anxiety disorders;
- Quick onset for “physical/somatic” aspects of symptoms (insomnia & tension)
- Prefer short course (1-2 weeks), PRN, short to intermediate-acting benzodiazepine
What is the ADRs of BZDs?
What should be avoided when taking BZDs?
- ADRs: sedation, drowsiness, amnesia
- Precautions: Avoid in persons with 1) substance abuse, 2) respiratory depression, acute narrow angle glaucoma, myasthenia gravis
- Interaction: 3) Benzodiazepines + Opioids = risk of profound CNS depression and death
- 4) Avoid abrupt discontinuation –> Gradually taper off if BZD had been used daily for weeks/months, to avoid rebound anxiety or withdrawal seizures in susceptible patients
What are some examples of z-hypnotics?
Zolpidem, zopiclone
How does z-hypnotics differ from BZDs in terms of its help in anxiety disorders?
Z-hypnotics e.g. Zolpidem, Zopiclone
- Helpful to relieve insomnia (very specific) but not anxiety (meaning does NOT help relax the muscle);
while BZDs help relieve all physical symptoms (insomnia and muscle tension)
What are the ADRs of z-hypnotics?
ADRs:
- taste disturbances/metallic taste,
- sedation
- complex sleep behaviours like sleep-walking
What to avoid when using z-hypnotics?
- to apply same cautions as benzodiazepines (high abuse potential)
- Precautions: Avoid in persons with substance abuse, respiratory depression, acute narrow angle glaucoma, myasthenia gravis
What are the ADRs of antihistamines?
ADRs:
- Significant anticholinergic SE,
- delirium, (emergency)
- acute urinary retention, (emergency)
- sedation
What are the drug examples of antihistamines that can be used for insomnia?
Sedating antihistamines e.g. hydroxyzine, promethazine
What precautions need to be taken when taking antihistamines?
- Precautions: cautioned in prostatic hypertrophy, urinary retention, angle closure glaucoma, pyloroduodenal obstruction, epilepsy, QTc interval prolongation (with Hydroxyzine), coronary artery disease (with Promethazine).
When should melatonin be used for insomnia?
Melatonin
- Preferred hypnotic if >55 years. Generally well tolerated. Given 1-2hrs before bedtime.
- Safest sleeping pill not much SE but not very effective, but has a role in rebuilding their sleep cycle
What is an example of a orexin receptor antagonist?
What is the ADRs?
What should be avoided when using this med?
Lemborexant (orexin receptor antagonist):
- ADRs: somnolence
- Avoid in narcolepsy (chronic neurological disorder), moderate/strong 3A inhibitors/inducers, severe liver impairment
- Useful, lower risk of dependence
