W21 Anxiety and Insomnia

Question 1

What are the psychological symptoms of anxiety and insomnia? (4)

Answer 1

• Irritability
• Restlessness
• A sense of dread
• Difficulty with concentration

Question 2

What are the physical symptoms of anxiety and insomnia? (8)

Answer 2

• Tiredness
• Fast or irregular heartbeat
• Muscle aches and tension
• Trembling
• Dry mouth
• Excessive sweating
• Feeling sick
• Pins & needles

Question 3

Hypnotics and anxiolytics:
What are some examples of benzodiazepines used as hypnotics?

Answer 3

• Most anxiolytics (‘sedatives’) will induce sleep when given at night and most hypnotics will sedate when given during the day.
• Short-acting hypnotics - sleep onset insomnia, less sedation, for elderly
• Long-acting hypnotics - poor sleep maintenance, when anxiolytic effect is needed during the day
  Elderly: benzodiazepines and Z-drugs should be avoided in the elderly as they are at greater risk of becoming ataxic and confused, leading to falls and injury.

Benzodiazepines as hypnotics:
* Nitrazepam and Flurazepam (long-acting)
* Loprazolam, lormetazepam and temazepam - (short-acting no hangover effect)
* Diazepam- for insomnia associated with day-time anxiety - single dose at night Z-drugs:
* Zolpidem and zopiclone- short duration of action, NOT for long-term use

Question 4

Benzodiazepines (Schedule 4 Part 1 drugs)
What is their role?
What are some examples?
MHRA/CHM advice?
Overdose signs?
Driving advice?

Answer 4

• Act at benzodiazepine receptors which are associated with (GABA) receptors.
• For short-term relief (2-4 weeks) of anxiety or insomnia that is severe, disabling or causing the patient distress and not for mild anxiety.
• Diazepam
• Alprazolam
• Chlordiazepoxide
• Clobazam
• Lorazepam

MHRA/CHM advice: Benzodiazepines and opioids: reminder of risk of potentially fatal respiratory depression
* Patients should be informed of the signs and symptoms of respiratory depression and sedation

Contra-indications:
* Pulmonary insufficiency, respiratory weakness, not used alone for psychosis or depression
* Obsessional states, phobic states
* Sleep apnoea syndrome

Signs of overdose:
* Drowsiness, ataxia, dysarthria, nystagmus,
respiratory depression and coma

Driving and skilled tasks:
* May cause drowsiness, impair judgement
and increase reaction time

Question 5

Anxiolytics: What is meant by ‘paradoxical effects’?

Answer 5

A paradoxical increase in hostility, aggression, anxiety may be reported.
Adjust dose.

Question 6

Anxiolytics
Dependence and withdrawal:
What is Withdrawal syndrome?

Answer 6

• Withdrawal should be gradual as abrupt withdrawal may produce confusion, toxic psychosis, convulsions
• May develop at any time up to 3 weeks after stopping a long-acting benzodiazepine or within a day in short-acting ones.
• Insomnia, anxiety, loss of appetite, weight loss, tremor, perspiration, tinnitus and perceptual disturbances

Question 7

Withdrawal protocol for long-term benzodiazepines:

Answer 7

 Transfer patient, one dose at a time to an equivalent daily dose of diazepam taken ON
 Reduce diazepam dose by 1-2mg every 2-4 weeks (up to 1/10th of the dose every 1-2 weeks for higher doses)
 Reduce diazepam further in smaller steps of 500 mcg towards the end then stop completely.

Question 8

Anxiolytics- What are some examples of other treatments? (8)

Answer 8

• Buspirone (serotonin 5HT1A receptor agonist)
  -Response to treatment takes up to 2 weeks
  -Low dependence and abuse potential
• Beta-blockers
  -Used for palpitations and tremor
• Barbiturates
  -Avoid in elderly
• Clomethiazole
  -Useful hypnotic for elderly because of its freedom from hangover
• Antihistamines
  -Occasional insomnia- may cause headache, psychomotor impairment and anti-muscarinic effects
• Alcohol
  -Poor hypnotic because the diuretic action interferes with sleep
• Melatonin
  -Pineal hormone. Licensed for short term insomnia for >55 Years old
• SSRIs/ SNRIs/ Pregabalin

Question 9

Quiz
1. Suggest a withdrawal protocol for a patient on Temazepam 30mg daily
2. A patient is on Alprazolam 10mg daily for the treatment of panic disorders. Calculate the equivalent dose of diazepam.

Answer 9

1. Transfer patient to an equivalent daily dose of Diazepam taken ON
   = 15mg Diazepam
   Reduce by 1-2mg every 2-4 weeks (up to 1/10th of the dose every 1-2 weeks for higher doses)
   * Reduce diazepam further in smaller steps of 500mcg towards the end then stop completely
2. Diazepam 5mg is equivalent to Alprazolam 0.250mg
   So Alprazolam 10mg (x40) = 200mg Diazepam