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PR3153 FINALS > IC14 Anxiety and Sleep Disorders > Flashcards

IC14 Anxiety and Sleep Disorders Flashcards

1
Q

What are the 5 main classes of anxiety disorders?

A
  1. Generalised anxiety d/o (GAD)
  2. Social anxiety d/o (SAD)
  3. Panic d/o (PD)
  4. Obsessive compulsive d/o (OCD)
  5. Post traumatic stress d/o (PTSD)
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2
Q

Which parts of the brain regulate the fear and worry circuits?

A

Fear: amygdala
Worry: cortico-striatal-thalamic-cortical loop

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3
Q

Which 2 neurotransmitters are important in anxiety disorders?

A

Serotonin and GABA

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4
Q

What are the 4 classes of medical conditions that are associated with anxiety?

A
  1. CV (HF)
  2. Endocrine (hyperthyroidism)
  3. Neurologic (dementia, delirium)
  4. Pulmonary (asthma, COPD)
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5
Q

What are the 7 drugs/classes of drugs that can induce anxiety

A
  1. Sympathomimetics (pseudoephedrine)
  2. Stimulants (amphetamines)
  3. Theophylline
  4. Caffeine
  5. Corticosteroids (esp systemic)
  6. Antidepressants (SSRIs, TCAs)
  7. Beta-agonists (salbutamol)
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6
Q

What other drug-related causes can induce anxiety? (2)

A

Drug withdrawal (alcohol, caffeine, benzos, nicotine)
Drug intoxication (anticholinergics, antihistamines)

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7
Q

What is the DSM-5 definition for GAD?

A

Excessive anxiety and worry occurring for ≥ 6 months
At least 3 of the following 6 sx: restlessness, being on edge, easily fatigued, irritability, muscle tension and sleep disturbance
Symptoms cause functional impairment

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8
Q

What is the DSM-5 definition for PD?

A

Recurrent unexpected panic attacks with more than 1 month of persistent anticipatory anxiety

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9
Q

What is the DSM-5 definition of SAD?

A

Marked and persistent fear of social or performance situations where the person is exposed to possible scrutiny by others

The feared social situations are avoided or endured with intense anxiety and stress and the avoidance, anxious anticipation or distress significantly impairs functioning

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10
Q

What is the DSM-5 definition of OCD?

A

Obsessions: recurrent and persistent thoughts, impulses or images that are experienced being intrusive and inappropriate in nature, and the patient can relate these thoughts as products of their own mind

Compulsions: repetitive behaviours (eg. handwashing) or mental acts (eg. repeating words, counting) aimed at preventing or reducing distress but not connected in a realistic way, or are clearly excessive

Pt can recognise that these are excessive and time-consuming (take up more than 1h a day, or significantly impairs functioning)

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11
Q

What is the DSM-5 definition of PTSD?

A

Person exposed to some form of trauma (eg. death, sexual violence) and the traumatic events are persistently re-experienced, causing avoidance of the stimuli

This negatively alters cognition, mood, arousal and reactivity, resulting in functional impairment

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12
Q

What non-pharmacological management method can be used for anxiety?

A

CBT (but use in combination w meds)

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13
Q

Which antidepressants can be used in anxiety?

A

All serotonergic antidepressants can be useful (SSRIs, SNRIs, clomipramine)

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14
Q

Which antidepressants should and should not be used in OCD specifically?

A

Don’t use SNRI (NE stimulation can worsen compulsions)

Use SSRI > clomipramine > venlafaxine

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15
Q

What should be taken note regarding starting dose and initial side effects for antidepressant therapy for anxiety disorders?

A
  • Starting dose must be low as the medications take a while to take effect
  • There may be transient jitteriness in the initial 1-2 weeks of starting the antidepressant
  • Benzodiazepines may be considered as an adjunct therapy
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16
Q

Which symptoms do antidepressants help with and how long does it take to work?

A

Worry symptoms
Onset of at least 1-2 months, full response generally seen at 3 months

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17
Q

Which symptoms do benzodiazepines help with?

A

Physical symptoms of anxiety like muscle tension

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18
Q

What is the onset of action for benzodiazepines and how long should they be used for?

A

Fast onset of action (within 30 mins for lorazepam)
Short-term treatment (a few weeks to 3-4 months)

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19
Q

How should be benzodiazepines be stopped and why?

A

Gradually tapered, risk of dependence

20
Q

Which benzodiazepines are preferred in anxiety disorders?

A

High potency benzodiazepines (clonazepam, lorazepam, alprazolam XR)

21
Q

Which one other medication can be used in GAD and what is it’s MOA?

A

Pregabalin
Increases levels of enzymes that produce GABA

22
Q

What is the usual dosing for alprazolam?

A

0.25-0.5mg TDS

23
Q

What is alprazolam’s duration of action?

A

Short, hence XR formulation available

24
Q

How is clonazepam usually dosed?

25
Q

How is diazepam usually dosed?

26
Q

How is lorazepam usually dosed?

A

1-3mg a day in divided doses

27
Q

How is lorazepam metabolised and what is its duration of action?

A

Glucuronidation (others mostly by oxidation)
Short duration of action

28
Q

Which two benzodiazepines do not have active metabolites?

A

Alprazolam (no major ones)
Lorazepam (none)

29
Q

What are the 5 significant DDIs with anxiety pharmacotherapy?

A
  1. Alcohol and other CNS depressants
  2. Anticholinergics cause excessive SE
  3. MAOI and SSRI/TCA combination can cause serotonin syndrome
  4. Antidepressants w CYP450 interactions
  5. Benzodiazepine + opioid combination results in increased mortality
30
Q

What are sleep promoting and wakefulness promoting neurotransmitters?

A

Sleep: GABA
Wakefulness: DA, NE, ACh, histamine, orexin

31
Q

Which portions of NREM are important?

A

Stages 3 and 4
“delta” or restorative sleep

32
Q

How can insomnia be classified according to duration and what is the recommended management strategy?

A

Transient acute (< 1 week) → sleep hygiene

Short-term acute (< 4 weeks) → short PRN course of hypnotics for 7-10 days

Chronic (> 4 weeks) → secondary to an underlying psychiatric and/or medical problem, investigate and manage underlying cause

33
Q

How are pharmaco meds indicated for insomnia?

A

Fast-acting anxiolytics/sedatives/hypnotics intended as ADJUNCTS for short-term relief of distressful insomnia (1-2 weeks)

Limited to PRN dosing at lowest effective dose

34
Q

Non-pharmacological treatment is first-line in insomnia.
What are 7 non-pharmacological management points for insomnia?

A
  1. Avoid the use of caffeine-containing products, nicotine and alcohol, especially later in the day
  2. Avoid heavy meals within 2 hours of bedtime
  3. Avoid drinking fluids after dinner
  4. Avoid environments that will make you really reactive after 5pm
  5. Establish a routine for getting ready to go to bed
  6. Avoid taking daytime naps but if they have to be taken, try to do so before 3pm and that total napping time does not exceed 1h
  7. Pursue regular physical activities like walking or gardening but avoid vigorous exercise close to bedtime
35
Q

Non-pharmacological treatment is first-line in insomnia.
What are 7 non-pharmacological management points for insomnia?

A
  1. Avoid the use of caffeine-containing products, nicotine and alcohol, especially later in the day
  2. Avoid heavy meals within 2 hours of bedtime
  3. Avoid drinking fluids after dinner
  4. Avoid environments that will make you really reactive after 5pm
  5. Establish a routine for getting ready to go to bed
  6. Avoid taking daytime naps but if they have to be taken, try to do so before 3pm and that total napping time does not exceed 1h
  7. Pursue regular physical activities like walking or gardening but avoid vigorous exercise close to bedtime
36
Q

What are the 4 drugs/classes of drugs that fall under hypnotics?

A
  1. Benzodiazepines
  2. Z-hypnotics
  3. Antihistamines
  4. Lemborexant
37
Q

What are benzodiazepines MOA and side effects (3)?

A

Potentiates GABA
SE: sedation, drowsiness, amnesia

38
Q

How should benzodiazepine dose be limited, given its risk for dependence?

A

Limit to 2 weeks PRN short course at lowest effective dose

39
Q

What are Z-hypnotics side effects?

A

Complex sleep behaviours (sleep-walking)
Zopiclone: taste disturbance

40
Q

Which Z-hypnotic dose should be adjusted in which special population?

A

Zolpidem dose half for females

41
Q

What is the main side effect of antihistamines?

A

Anticholinergic SE

42
Q

What is the main side effect of lemborexant?

A

Somnolence

43
Q

In which populations are lemborexant contraindicated?

A
  1. Narcolepsy
  2. Severe hepatic impairment
  3. Moderate to strong CYP3A4 inhibitor/inducers
44
Q

Which two other medications can be used as off-label hypnotics?

A

Antidepressants (trazodone)
Antipsychotics (dirty drug, antagonism at a few other receptors)

45
Q

In which populations should benzodiazepines and Z-hypnotics not be administered? (3)

A
  1. Respiratory depression
  2. Narrow angle glaucoma
  3. Myasthenia gravis
46
Q

In which populations should antihistamines not be administered (3) and why?

A
  1. Prostatic hypertrophy
  2. Urinary retention
  3. Angle closure glaucoma

Due to anticholinergic SE

PR3153 FINALS (8 decks)

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