IC15 Anxiety and Sleep Disorder

Question 1

definition of anxiety disorder

Answer 1

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

Question 2

define Generalised Anxiety Disorder (GAD)

Answer 2

excessive anxiety and worries ≥6 mths

Question 3

define Panic Disorder (PD)

Answer 3

panic attack + anticipatory anxiety

Question 4

define Social Anxiety Disorder (SAD)

Answer 4

• fear of being scrutinised or humiliated by others in public, okay to be alone
• Differential dx: paranoid (in schizophrenia)

Question 5

define Obsessive Compulsive Disorder (OCD)

Answer 5

• 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

Question 6

define Post Traumatic Stress Disorder (PTSD)

Answer 6

• re-experiencing of trauma, persistent avoidance, increased arousal
• must have a trauma (either experienced/ witness)

Question 7

pathophysiology of anxiety

Answer 7

• “fear circuit” (regulated by amygdala — helps to recall things) and “worry-circuit”

Question 8

types of neurochemical that are dysregulated in the fear/worry circuit

Answer 8

norepinephrine, serotonin, GABA

Question 9

medical conditions causing anxiety

Answer 9

CV (HF); endocrine (hyperthyroidism); neurologic (dementia, delirium); pulmonary (asthma, COPD)

Question 10

Drug-induced anxiety

Answer 10

1. Sympathomimetics: pseudoephedrine
2. Stimulants: amphetamines, cocaine
3. Theophylline, caffeine
4. Thyroid hormone: levothyroxine
5. CS: prednisolone
6. Antidepressants
7. Dopamine agonist: levodopa
8. Beta-adrenergic agonists: salbutamol
9. Drug withdrawal: caffeine, alcohol, sedatives, benzodiazepines, antidepressants, nicotine
10. Drug intoxication: anticholinergics, antihistamines, digoxin

Question 11

define panic attack

Answer 11

discrete period of intense fear/discomfort that develop abruptly and reach a peak within 10mins (usually not longer than 20-30mins)

Question 12

Gold standard assessment tool for anxiety in RCT

Answer 12

HAM-A

Question 13

Non-pharm for anxiety

Answer 13

CBT (1st line esp for PTSD, combi with all meds)
Psychotherapy
Relaxation
Anxiety management
(OCD) Exposure and Responsive Prevention

Question 14

Pharm tx for anxiety

Answer 14

1. SSRI, SNRI (venlafaxine), clomipramine (TCA)
   (OCD: SSRI > clomipramine > SNRI)
2. Pregabalin (for GAD)

Question 15

Adjunct tx for anxiety

Answer 15

1. BZD (lorazepam, clonazepam, diazepam, alprazolam) short term PRN 1-2 weeks
2. sedating antihistamine (hydroxyzine) for GAD

Question 16

approach to dosing for anxiety

Answer 16

start low go slow
- maintenance dose may be high end of the range (higher than depression dose)

Question 17

onset and full response of serotonergic antidepressants for anxiety

Answer 17

• Onset: at least 1-2mths
• Full response: ~3mths (advise pt to be patient with tx)

Question 18

adjunct BZD is used in anxiety for…

Answer 18

for physical sx of anxiety (eg muscle tension), fast onset of action (within 30mins)

Question 19

MOA of pregbalin

Answer 19

binding to alpha2-delta subunits at presynaptic voltage gated Ca channels → inhibits excitatory neurotransmission

Question 20

why is lorazepam the safest?

Answer 20

does not undergo liver CL, does not accumulate during liver impairment

Question 21

DDI of benzodiazepines and antidepressants

Answer 21

• 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)

Question 22

physiology of melatonin

Answer 22

melatonin secretion increased during sleep and is suppressed by bring light

Question 23

sleep promoting NT

Answer 23

GABA

Question 24

wakefulness promoting NT

Answer 24

NE, DA, acetylcholine, histamine, orexin

Question 25

most impt sleep period

Answer 25

NERM (non rapid eye movements) — stage 3 &4 = restorative/delta sleep

Question 26

normal adult need how many hours of sleep?

Answer 26

7hr

Question 27

Insomnia definition

Answer 27

inability to initiate/maintain sleep a/w daytime problems (fatigue, impaired concentration/ memory)

Question 28

Insomnia disorder

Answer 28

insomnia becomes a disorder if it impairs function: sleep complaint occurs ≥3 nights/week and present for ≥3mths

Question 29

Acute Transient insomnia (duration and mx)

Answer 29

<1 week mx: sleep hygiene

Question 30

Acute Short term insomnia (duration and mx)

Answer 30

<4 weeks mx: Sleep hygiene, short course PRN hypnotic (7-10days/ 1-2 weeks)

Question 31

Chronic insomnia (duration and mx)

Answer 31

>4 weeks (≥3 nights/week) mx: Investigate and manage underlying causes/ conditions, sleep hygiene - Discourage long-term use of hypnotics

Question 32

Non-pharm for insomnia

Answer 32

- CBT - Relaxation training - Sleep restriction therapy - Stimulus control therapy - Sleep hygiene

Question 33

Sleep hygiene eg

Answer 33

1. Avoid caffeine, nicotine and alcohol esp later in the day 2. Avoid heavy meals within 2 hrs of bedtime 3. Avoid drinking fluids after dinner 4. Avoid environments that will make you really active after 5pm 5. Establish a routine for getting ready to go to bed 6. Avoid taking daytime naps 7. Pursue regular physical activities

Question 34

Indication of fast-acting anxiolytics/ sedatives/ hypnotics

Answer 34

ADJUNCT for SHORT-TERM RELIEF of distressful insomnia/anxiety - PRN dosing at lowest effective dose and short course (1-2 weeks)

Question 35

Types of hypnotics (5)

Answer 35

1. Benzodiazepines (Lorazepam, Diazepam) 2. Z-hypnotics (zolpidem, zopiclone) 3. Antihistamine (hydroxyzine, promethazine) 4. melatonin 5. lemborexant

Question 36

Zolpidem vs zopiclone

Answer 36

Zolpidem: shorter half life, less hangover, female half dose Zopiclone: longer half life (preferred) - similar risk of dependence as BZD

Question 37

SE of BZD

Answer 37

sedation, drowsiness, muscle weakness, ataxia, amnesia - minimise risk of dependence by taking short course 1-2 weeks PRN

Question 38

SE of Z-hypnotics (zolpidem, zopiclone)

Answer 38

complex sleep behaviours (sleep walking) - zopiclone: taste disturbances

Question 39

SE of sedating antihistamine

Answer 39

anticholinergic SE (dry mouth, constipation, blurred vision)

Question 40

CI of promethazine

Answer 40

Promethazine not use for <2yo (cause death)

Question 41

MOA of lemborexant

Answer 41

orexin (OX1 and OX2) receptor antagonist

Question 42

SE of lemborexant

Answer 42

somnolence

Question 43

CI of lemborexant

Answer 43

narcolepsy (orexin deficiency - feels slpy during the day), moderate-strong CYP3A inhibitor/inducer, liver impairment

Question 44

off label drugs for insomnia

Answer 44

- trazodone (antidepressants) - antipsychotics

Question 45

Benzodiazepines & Z-hypnotics should not be administered in

Answer 45

1. acute narrow angle glaucoma 2. respiratory depression 3. myasthenia gravis

Question 46

Anticholinergics should be cautioned in

Answer 46

prostatic hypertrophy, urinary retention, angle closure glaucoma, epilepsy

Question 47

Additional precautions for Benzodiazepine use

Answer 47

1. Hx of drug/alcohol abuse or psychiatric disorders (eg depression, psychosis) 2. Prolonged usage (then abrupt discontinuation) should be avoided — need gradual dose tapering 3. Benzodiazepines + opioids = increased mortality

Question 48

antihistamine used for anxiety vs insomnia

Answer 48

anxiety: hydroxyzine insomnia: hydroxyzine, promethazine