IC14 Anxiety and Sleep Disorders

Question 1

What are the 5 main classes of anxiety disorders?

Answer 1

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)

Question 2

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

Answer 2

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

Question 3

Which 2 neurotransmitters are important in anxiety disorders?

Answer 3

Serotonin and GABA

Question 4

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

Answer 4

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

Question 5

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

Answer 5

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

Question 6

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

Answer 6

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

Question 7

What is the DSM-5 definition for GAD?

Answer 7

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

Question 8

What is the DSM-5 definition for PD?

Answer 8

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

Question 9

What is the DSM-5 definition of SAD?

Answer 9

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

Question 10

What is the DSM-5 definition of OCD?

Answer 10

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)

Question 11

What is the DSM-5 definition of PTSD?

Answer 11

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

Question 12

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

Answer 12

CBT (but use in combination w meds)

Question 13

Which antidepressants can be used in anxiety?

Answer 13

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

Question 14

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

Answer 14

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

Use SSRI > clomipramine > venlafaxine

Question 15

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

Answer 15

• 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

Question 16

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

Answer 16

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

Question 17

Which symptoms do benzodiazepines help with?

Answer 17

Physical symptoms of anxiety like muscle tension

Question 18

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

Answer 18

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

Question 19

How should be benzodiazepines be stopped and why?

Answer 19

Gradually tapered, risk of dependence

Question 20

Which benzodiazepines are preferred in anxiety disorders?

Answer 20

High potency benzodiazepines (clonazepam, lorazepam, alprazolam XR)

Question 21

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

Answer 21

Pregabalin
Increases levels of enzymes that produce GABA

Question 22

What is the usual dosing for alprazolam?

Answer 22

0.25-0.5mg TDS

Question 23

What is alprazolam’s duration of action?

Answer 23

Short, hence XR formulation available

Question 24

How is clonazepam usually dosed?

Answer 24

0.5mg BD

Question 25

How is diazepam usually dosed?

Answer 25

2-10mg BD

Question 26

How is lorazepam usually dosed?

Answer 26

1-3mg a day in divided doses

Question 27

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

Answer 27

Glucuronidation (others mostly by oxidation) Short duration of action

Question 28

Which two benzodiazepines do not have active metabolites?

Answer 28

Alprazolam (no major ones) Lorazepam (none)

Question 29

What are the 5 significant DDIs with anxiety pharmacotherapy?

Answer 29

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

Question 30

What are sleep promoting and wakefulness promoting neurotransmitters?

Answer 30

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

Question 31

Which portions of NREM are important?

Answer 31

Stages 3 and 4 "delta" or restorative sleep

Question 32

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

Answer 32

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

Question 33

How are pharmaco meds indicated for insomnia?

Answer 33

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

Question 34

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

Answer 34

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

Question 35

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

Answer 35

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

Question 36

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

Answer 36

1. Benzodiazepines 2. Z-hypnotics 3. Antihistamines 4. Lemborexant

Question 37

What are benzodiazepines MOA and side effects (3)?

Answer 37

Potentiates GABA SE: sedation, drowsiness, amnesia

Question 38

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

Answer 38

Limit to 2 weeks PRN short course at lowest effective dose

Question 39

What are Z-hypnotics side effects?

Answer 39

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

Question 40

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

Answer 40

Zolpidem dose half for females

Question 41

What is the main side effect of antihistamines?

Answer 41

Anticholinergic SE

Question 42

What is the main side effect of lemborexant?

Answer 42

Somnolence

Question 43

In which populations are lemborexant contraindicated?

Answer 43

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

Question 44

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

Answer 44

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

Question 45

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

Answer 45

1. Respiratory depression 2. Narrow angle glaucoma 3. Myasthenia gravis

Question 46

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

Answer 46

1. Prostatic hypertrophy 2. Urinary retention 3. Angle closure glaucoma Due to anticholinergic SE