IC15 Anxiety and Sleep Disorder Flashcards
definition of anxiety disorder
severe, excessive, persistent anxiety and irrational fears that impairs functioning with everyday life
- anxiety is out of proportion to the actual danger or threat of the situation
define Generalised Anxiety Disorder (GAD)
excessive anxiety and worries ≥6 mths
define Panic Disorder (PD)
panic attack + anticipatory anxiety
define Social Anxiety Disorder (SAD)
- fear of being scrutinised or humiliated by others in public, okay to be alone
- Differential dx: paranoid (in schizophrenia)
define Obsessive Compulsive Disorder (OCD)
- obsessional thoughts/ impulses that causes anxiety + compulsive behaviours to relieve that anxiety
- obsession/ compulsion/ both → no need to have both to classify as OCD
- obsession/compulsion that cause marked distress are time consuming (≥1 hr per day) or significantly impairs functioning
define Post Traumatic Stress Disorder (PTSD)
- re-experiencing of trauma, persistent avoidance, increased arousal
- must have a trauma (either experienced/ witness)
pathophysiology of anxiety
- “fear circuit” (regulated by amygdala — helps to recall things) and “worry-circuit”
types of neurochemical that are dysregulated in the fear/worry circuit
norepinephrine, serotonin, GABA
medical conditions causing anxiety
CV (HF); endocrine (hyperthyroidism); neurologic (dementia, delirium); pulmonary (asthma, COPD)
Drug-induced anxiety
- Sympathomimetics: pseudoephedrine
- Stimulants: amphetamines, cocaine
- Theophylline, caffeine
- Thyroid hormone: levothyroxine
- CS: prednisolone
- Antidepressants
- Dopamine agonist: levodopa
- Beta-adrenergic agonists: salbutamol
- Drug withdrawal: caffeine, alcohol, sedatives, benzodiazepines, antidepressants, nicotine
- Drug intoxication: anticholinergics, antihistamines, digoxin
define panic attack
discrete period of intense fear/discomfort that develop abruptly and reach a peak within 10mins (usually not longer than 20-30mins)
Gold standard assessment tool for anxiety in RCT
HAM-A
Non-pharm for anxiety
CBT (1st line esp for PTSD, combi with all meds)
Psychotherapy
Relaxation
Anxiety management
(OCD) Exposure and Responsive Prevention
Pharm tx for anxiety
- SSRI, SNRI (venlafaxine), clomipramine (TCA)
(OCD: SSRI > clomipramine > SNRI) - Pregabalin (for GAD)
Adjunct tx for anxiety
- BZD (lorazepam, clonazepam, diazepam, alprazolam) short term PRN 1-2 weeks
- sedating antihistamine (hydroxyzine) for GAD
approach to dosing for anxiety
start low go slow
- maintenance dose may be high end of the range (higher than depression dose)
onset and full response of serotonergic antidepressants for anxiety
- Onset: at least 1-2mths
- Full response: ~3mths (advise pt to be patient with tx)
adjunct BZD is used in anxiety for…
for physical sx of anxiety (eg muscle tension), fast onset of action (within 30mins)
MOA of pregbalin
binding to alpha2-delta subunits at presynaptic voltage gated Ca channels → inhibits excitatory neurotransmission
why is lorazepam the safest?
does not undergo liver CL, does not accumulate during liver impairment
DDI of benzodiazepines and antidepressants
- Alcohol and other CNS depressants
- Anticholinergic
- MAOIs and SSRI/TCA combination
- Benzodiazepines + opioids = increased mortality (CNS depression)
- Most benzodiazepines are metabolised by CYP3A4 (except lorazepam)
physiology of melatonin
melatonin secretion increased during sleep and is suppressed by bring light
sleep promoting NT
GABA
wakefulness promoting NT
NE, DA, acetylcholine, histamine, orexin
most impt sleep period
NERM (non rapid eye movements) — stage 3 &4 = restorative/delta sleep
normal adult need how many hours of sleep?
7hr
Insomnia definition
inability to initiate/maintain sleep a/w daytime problems (fatigue, impaired concentration/ memory)
Insomnia disorder
insomnia becomes a disorder if it impairs function: sleep complaint occurs ≥3 nights/week and present for ≥3mths
Acute Transient insomnia (duration and mx)
<1 week
mx: sleep hygiene
Acute Short term insomnia (duration and mx)
<4 weeks
mx: Sleep hygiene, short course PRN hypnotic (7-10days/ 1-2 weeks)
Chronic insomnia (duration and mx)
> 4 weeks (≥3 nights/week)
mx: Investigate and manage underlying causes/ conditions, sleep hygiene
- Discourage long-term use of hypnotics
Non-pharm for insomnia
- CBT
- Relaxation training
- Sleep restriction therapy
- Stimulus control therapy
- Sleep hygiene
Sleep hygiene eg
- Avoid caffeine, nicotine and alcohol esp later in the day
- Avoid heavy meals within 2 hrs of bedtime
- Avoid drinking fluids after dinner
- Avoid environments that will make you really active after 5pm
- Establish a routine for getting ready to go to bed
- Avoid taking daytime naps
- Pursue regular physical activities
Indication of fast-acting anxiolytics/ sedatives/ hypnotics
ADJUNCT for SHORT-TERM RELIEF of distressful insomnia/anxiety
- PRN dosing at lowest effective dose and short course (1-2 weeks)
Types of hypnotics (5)
- Benzodiazepines (Lorazepam, Diazepam)
- Z-hypnotics (zolpidem, zopiclone)
- Antihistamine (hydroxyzine, promethazine)
- melatonin
- lemborexant
Zolpidem vs zopiclone
Zolpidem: shorter half life, less hangover, female half dose
Zopiclone: longer half life (preferred)
- similar risk of dependence as BZD
SE of BZD
sedation, drowsiness, muscle weakness, ataxia, amnesia
- minimise risk of dependence by taking short course 1-2 weeks PRN
SE of Z-hypnotics (zolpidem, zopiclone)
complex sleep behaviours (sleep walking)
- zopiclone: taste disturbances
SE of sedating antihistamine
anticholinergic SE (dry mouth, constipation, blurred vision)
CI of promethazine
Promethazine not use for <2yo (cause death)
MOA of lemborexant
orexin (OX1 and OX2) receptor antagonist
SE of lemborexant
somnolence
CI of lemborexant
narcolepsy (orexin deficiency - feels slpy during the day), moderate-strong CYP3A inhibitor/inducer, liver impairment
off label drugs for insomnia
- trazodone (antidepressants)
- antipsychotics
Benzodiazepines & Z-hypnotics should not be administered in
- acute narrow angle glaucoma
- respiratory depression
- myasthenia gravis
Anticholinergics should be cautioned in
prostatic hypertrophy, urinary retention, angle closure glaucoma, epilepsy
Additional precautions for Benzodiazepine use
- Hx of drug/alcohol abuse or psychiatric disorders (eg depression, psychosis)
- Prolonged usage (then abrupt discontinuation) should be avoided — need gradual dose tapering
- Benzodiazepines + opioids = increased mortality
antihistamine used for anxiety vs insomnia
anxiety: hydroxyzine
insomnia: hydroxyzine, promethazine
