Sleep & Anxiety Disorders

Question 1

Wellness..

Answer 1

is based upon the integrated and coordinated function of many Neurotransmitter systems

Question 2

Disorder =

Answer 2

IMBALANCE SIGNIFICANTLY impairing Function and Quality of Life

Question 3

What are the research targets?

Answer 3

Molecular, Biochemical, Cellular, Neuronal, & Behaviour areas

Question 4

What are the meaningful outcomes?

Answer 4

functional status & QOL

Question 5

______ <–> ________

Answer 5

Mental

Physical Health

Question 6

What are the key features of NS?

Answer 6

BALANCE & Adaptation (when physical/mental health is good we are better able to adapt to things like COVID)

Question 7

What is 1 of the biggest reasons why we don’t know exact pathophys of the disorder?

Answer 7

because it contains MANY neurons with MANY connections

Question 8

What should Health Care Practitioners draw upon for optimal outcomes?

Answer 8

more than clinical & scientific skills
- combo of both pharmaceutical & other is ideal

Question 9

What are the factors for discussion?

Answer 9

• PRECISE pathophys is unknown
• Neuronal receptor mech’s are vital
• Evidence-based research is critical
• Definitions of illnes/disorders
• Overall impact of dysfunction
• Societal impact of disorders
• Outcome - focused perspectives

Question 10

What is imp. about Anxiety/Sleep Disorders?

Answer 10

• Co-occurrence is VERY HIGH (if anxiety is high, sleep is probs disrupted & vice versa)
• Overgeneralizing: An excess of “stimulating” neural flow relative to “Calming” neural flow
• Considerable overlap of symptoms, pathophys, persistence, & treatment approaches

Question 11

Autonomic (Involuntary) Nervous System:

Answer 11

• directs the action of skeletal muscle, cardiac muscle & gland secretion
• consists of SNS & PNS - balanced for optimal body function

Question 12

What underlies mental health conditions such as: Anxiety, Depression & Chronically feeling “Stressed”?

Answer 12

OVERACTIVE Sympathetic/UNDERACTIVE Parasympathetic

Question 13

What are the Neurochemical Models of Anxiety?

Answer 13

• NORADRENERGIC model
• GABA model
• SEROTONIN model

Question 14

NORADRENERGIC model:

Answer 14

ANS is HYPERsensitive or OVERactive –> excessive NE, Glutatmate, Locus Ceruleus (alarm center for brain) firing

Question 15

GABA model:

Answer 15

normalizing (HIGH) GABA can favorably impact 5HT, NE, DA

Question 16

Serotonin model:

Answer 16

increasing/normalizing Serotonin (5HT) reduces Locus Ceruleus firing & NE “excess”, hence reducing overstimulation

Question 17

What is the presentation of an Anxiety disorder?

Answer 17

• often present as PHYSIOLOGIC or SOMATIC COMPLAINTS (often pt doesn’t straight up say they have anxiety)
• Headaches, upset stomach, high BP, pain sensitivity
• IMPAIRMENT of sleep, ability to relax, & of appetite are common features
• PERSISTENT WORRIES about health & wellbeing of self & of others

Question 18

What is anxiety good?

Answer 18

allow us to prepare for or react to environmental changes
- part of us, should be ADAPTIVE & TRANSIENT (a healthy surge of STIMULATION)

Question 19

When is anxiety bad?

Answer 19

when EXCESSIVE
- becoming severe, persistent & impair function

Question 20

What type of arousal is anxiety?

Answer 20

psychologic/phyiologic

Question 21

What are high comorbidities of anxiety?

Answer 21

• medical illness
• depression
• schizophrenia
• bipolar disorder

Question 22

What is the etiology of increased anxiety/anxiety disorders?

Answer 22

1. Medical causes (CV, Endo, Neural, Resp etc,)
2. Psychiatric (Depn, SZP, BpD, Alz, Subst)
3. Drugs - Antidepressants, Bronchiodilators, Steroids, Thyroid, Stimulants, Herbals etc.
4. Drugs - withdrawal from Sedatives (rebound after discontinuing sedatives)
5. Life stressors
6. Endogenous factors (ex: why 1 fam is anxious & another isn’t)

Question 23

What is the Anxiety tx?

Answer 23

Thorough Assessment to define condition and focus reduction of Reversible factors must clarify Symptomatic target and Chronic vs. Transient nature of Symptoms

GOAL - reduce duration & severity of Sx & to improve overall functioning

Question 24

What are Anxiety’s symptoms?

Answer 24

1. Physical
   - restlessness, fatigue, muscle tension, sleep disturbances, irritability
2. Psychologic/cognitive
   - HIGH anxiety, worries hard to control, on EDGE, poor concentration

Question 25

What are the Physical symptoms for anxiety?

Answer 25

- Respond quickly to GABAa Agonists - Benzodiazepines - Antidepressants have superior LONG-TERM benefits, but can INCREASE PHYSICAL SYMPTOMS at 1st & benefits take time (*worse before better) - Rapid effectiveness of BZD contributes to DEPENDENCE liability, esp. with FAST ONSET & RAPID ELIMINATION ex: Lorazepam

Question 26

What are the Psychologic symptoms for anxiety?

Answer 26

- Some quick "easing" with BZD, not sustained (like temporary dulling of headache pain) - Antidepressants work more slowly but are treatment of choice for chronic anxiety symptoms - transient increase in symptoms may challenge adherence - Psychoeducation, psychotherapy, meditation, exercise, etc are often VITAL for optimal management (SHOULD BE MEDICATION + OTHER --> best answer for long-term)

Question 27

Benzodiazepines:

Answer 27

All have Muscle Relaxant, Anxiolytic, Sedative/Hypnotic, and Anticonvulsant properties All ↓ CNS Excitability via enhancing GABA {GABA Agonists} Onset speed correlates with Lipid Solubility Variable Half-Lives

Question 28

Benzodiazepines Slower Drug Elimination =

Answer 28

LONGER half-life......INCREASE hangover effect (might help them fall asleep, but might wake up feeling off)

Question 29

Benzodiazepines Faster Drug Elimination =

Answer 29

SHORTER half-life (Lorazepam, Diazepam).....INCREASE rebound symptoms, elevated risk of dependency

Question 30

Benzodiazepine dependency:

Answer 30

- UNAUTHORIZED dosage increase & potential for dependency is a concern - Lorazepam & Alprazolam - Short t1/2 - Diazepam - Rapid onset - Highest risk for Dependency with quick onset & accelerated clearance or metabolism (liver induction)

Question 31

What about Antidepressants for Anxiety?

Answer 31

mech not fully understood Modulation of 5HT, NE, and DA normalizes gene expression → → more BDNF, less CRF (↓ Cortisol) 5HT modulation ( Short & Long-term) NE modulation ( Indirect & Direct ) DA modulation ( Indirect & Direct) Antidepressants don't work super fast

Question 32

Sleep Disorders:

Answer 32

Insomnia may be related to Endogenous, Situational, Medical, Psychiatric, or Pharmacologic factors - transient, short-term (up to 3 weeks) or chronic insomnia - improvement WITHOUT MEDICATION is ideal

Question 33

Subtypes of Sleep Disorders:

Answer 33

- difficulty in falling asleep - difficulty in maintaining sleep - or non-restorative sleep

Question 34

“ Normal “ Sleep Cycles & Circadian Rhythm

Answer 34

- stage 3 & 4 are REM - delta sleep - most RESTORATIVE sleep, difficult to arouse, muscle atonia (3&4)

Question 35

What do most sleep medications do?

Answer 35

alter sleep cycles

Question 36

Wakefulness/alertness associated with...

Answer 36

- NE - DA - ACH - Histamine - Substance P - Corticotropin Releasing Factor --> CORTISOL

Question 37

What are Sleep Hygiene & Stimulus Control?

Answer 37

1. Establish REGULAR TIMES to wake up & got to sleep 2. Sleep only as much as needed to feel rested 3. Go to bed only when sleepy (avoid long periods of wakefulness in bed) 4. If you do not fall asleep within 20-30 mins, leave the bed & do something relaxing 5. Avoid daytime naps 6. Schedule worry time during the day. Do not take your troubles to bed 7. Exercise routinely, but not close to bedtime 8. Minimize sensory stimulation in the bedroom (light, sound, temp, etc) 9. Reduce use of alcohol, caffeine, & nicotine - esp. in the evening 10. Avoid large quantities of liquids in the evening 11. Do something relaxing & enjoyable before bedtime (Address these 1st BEFORE adding medications to pt)

Question 38

What are the reversible causes of insomnia treatment?

Answer 38

- Situational (stressors, jet lag, shift work) - Medical (CV, pain, pregnancy etc.) - Psychiatric - all disorders, incl substance abuse - Medications (ex on slides)

Question 39

What are the treatment targets in insomnia?

Answer 39

Address Reversible Causes & Utilize Sleep Hygiene techniques! - before adding medications Enhance (restore) GABA, Serotonin Inhibit (normalize) Histamine, Ach, NE, Da, Substance P, CRF - Cortisol

Question 40

What are the current treatments of insomnia?

Answer 40

- through assessment, non-pharm techniques (ex: stress, sleep hygiene), careful use of sedative hypnotics) - BZD - GABAa agonists - NonBenzo GABAa agonists - Zopiclone etc - Antihistamines - Antidepressants (esp if pt has or is prone to depression) incl. Trazodone (least disruptive to sleep - don't cause bad impact on sleep) - Melatonin & related agonists, Valerian (natural compounds)

Question 41

What is an ex of a medication that helps sleep but also causes sleep problems?

Answer 41

Benzodiazepines - GABAa agonists - suppress REM sleep - when they stop taking it, their REM has been suppressed so they have REM REBOUND --> it causes lots of dreams etc. - lasts a few nights - can be done but has to be slowly & carefully

Question 42

Dimenhydinate (Gravol)

Answer 42

- most effective for motion sickness - an Antihistamine, also Anticholinergic - acts as a CNS depressant, often causing drowsiness & sedation as SE's (*good for pt with upset stomach & has sleep problems but should be monitored) - off-label use as a sleep aid

Question 43

Sleep / Anxiety Disorders & Pharmacists:

Answer 43

Educate about: - non-drug strategies - importance of thorough assessment & of appropriate pharmacologic strategies - appropriate time-frames for response, & minimizing SE's Promote: - ADHERENCE to a therapeutic plan, incl. "Do not increase dose without discussing with prescriber"