Insomnia And Anxiety In General Practice

Front 1

Mrs I is a 48yo patient of your practice who presents with a 2 week history of problems falling asleep and frequent waking during the night. She is feeling increasingly irritable and fatigued during the day. She has had increased stressors at work over the last month that has caused a flare of her rheumatoid arthritis.
Meds - Paracetamol 1g tds
- Prednisone 50mg nocte
- Zoloft 50mg nocte

What are the possible causes of her insomnia?

Back 1

- ?menopause
- ?pain from rheumatoid arthritis
- ?stress and worry from work
- ?worsening depression
- ?Zoloft (SSRI) at night
- ?Prednisone at night
- ?increased stimulant use - caffeine, cigs, alcohol
- ?waking due to nightmares/rumination over work
- ?others

Front 2

What are the possible effects of insomnia?

Back 2

- Daytime fatigue.
- Irritability.
- Decreased memory.
- Decreased concentration.

Front 3

What percentage of the population over 40 years of age complain of insomnia?

Back 3

30%.

Front 4

Who suffers from insomnia more? Males or females?

Back 4

Males.

Front 5

What percentage of insomnia patients have really severe symptoms?

Back 5

30%.

Front 6

What percentage of insomnia patients have a mental disorder?

Back 6

20%.

Front 7

What are the underlying diagnostic features of primary insomnia?

Back 7

- Behavioural conditioning and behaviours impairing sleep.
- Must have occurred at least 3 times a week for the past month.
- Other organic, psychiatric and drug-induced causes have been excluded.

Front 8

What are the general causes of secondary insomnia?

Back 8

- Stimulants such as caffeine (coffee/tea/cola/energy drinks/chocolate), amphetamines, nicotine or alcohol or withdrawal of drugs eg MJ.
- Obstructive sleep apnoea.
- Restless legs and limb movement disorders.
- Sleep phase disorders such as jet lag or shift work.

Front 9

What are the psychiatric causes of secondary insomnia?

Back 9

- Mood disorders.
- Anxiety disorders.
- Psychotic disorders.
- Manic phase of bipolar disorders.
- Acute or chronic stressors.
- Post traumatic stress disorder (PTSD).
- Panic attacks or nightmares.

Front 10

What are the medical causes of secondary insomnia?

Back 10

- Pain of any cause.
- Drug intoxication or withdrawal.
- Thyrotoxicosis.
- Chronic end organ failure.
- Gastric ulceration
- Prostatism
- Menopause
- Stroke or neurodegenerative.

Front 11

What are the drug causes of secondary insomnia?

Back 11

- Beta blockers.
- Theophylline.
- Stimulants like pseudoephedrine and decongestant nasal sprays.
- Thyroid hormones.
- Corticosteroids.
- SSRI/SNRI/NARI/MAOI antidepressants.

Front 12

What general advice should be given to a patient suffering form insomnia?

Back 12

- Sleep hygiene, reassurance and education.
- Avoid caffeine, nicotine, alcohol and late night exercise.
- “Worry” time set aside from bedtime.
- Limit bedroom to sleep and sex.
- Exercise daily in AM or late afternoon.
- Avoid sleeping in or daytime napping.
- Plan for bedtime - relaxing activities and tryptophan rich snacks such as milk or bananas.

Front 13

What relaxation therapies are there for treating insomnia? How are they implemented and how do they work?

Back 13

- Progressive muscle relaxation technique.
- Meditation training with visualisation.
- Needs regular and daily use over 4-8 weeks to be effective.
- Decreases somatic, cognitive and psychological arousal.
- Taught by teacher/class (eg Relaxation Centre of Qld), GP, psychologist or self directed by book or CD/tape.

Front 14

Describe sleep restriction therapy in treating insomnia.

Back 14

- Decrease the amount of times spent in bed to increase sleep efficiency.
- Requires keeping a sleep diary for 2 weeks then inducing a sleep deprivation by forcing to go to bed 3 hours later and slowly increasing bed time by 15 minutes a week. Waking is at the same time everyday.
- Requires a number of weeks of adjustment, discipline and specialist sleep clinics and physicians to be effective.

Front 15

Describe stimulus control therapy in treating insomnia.

Back 15

- Designed to reassociate bed and bedroom with rapid sleep onset.
- Going to bed only when sleepy.
- Bed is only for sleep and sex.
- If unable to go to sleep within 15 minutes of going to bed, then get up, go to another room and do something else until sleepy again before returning to bed. Repeat if needed.
- Regular rising in the morning and no daytime napping.

Front 16

Describe benzodiazepine actions in the treatment of insomnia.

Back 16

– Short acting and short course (eg Temazepam).
– Disturb sleep architecture.
– Tolerance to hypnotic activity.
– Rebound insomnia.
– Hangover effects.

Front 17

What is a non-benzodiazepine drug that can be used to treat insomnia?

Back 17

Stilnox (zolpidem).

Front 18

How does zolpidem (stilnox) work in treating insomnia?

Back 18

Targets specific GABA receptors.

Front 19

What are the characteristics of zolpidem (stilnox) in treating insomnia?

Back 19

– ?Do not disturb sleep architecture
– ?Decreased dependence and rebound
– ?Less side effects
– Rapid acting and potent with amnesic effects, some reports of delusions and hallucinations.

Front 20

What pharmacological options are there for treating insomnia?

Back 20

- Short acting benzos.
- Zolpidem (stilnox).
- Antidepressants.
- Antihistamines.
- Herbal preparations.

Front 21

What are the preferred antidepressants to use for insomnia?

Back 21

Amitriptyline and Doxepin (TCAs).

SSRIs may work if insomnia is due to depression but often will make sleep worse during the first 2-4 weeks.

Front 22

What side effect might be problematic with antihistamines in terms of treating insomnia?

Back 22

Hangover.

Front 23

What herbal preparations might be considered for treating insomnia?

Back 23

- Valerian.
- Hops.
- Skullcap.
- Passionflower.
- Kava.

Little evidence to support use but may work with some patients.

Front 24

What is the management plan for panic disorder?

Back 24

- Ongoing assessment of the disorder.
- Education and information - nature of anxiety and fight/flight response, nature of panic attacks, role of hyperventilation, address concerns e.g. fear of death.
- Do not engage in avoidance of uncomfortable situations as this can lead to complicated agoraphobia.
- Slow breathing and relaxation training.
- Avoid medication if possible. SSRIs might work though.
- Specialist referral is needed.

Front 25

What is the management of agoraphobia?

Back 25

- Ongoing assessment
- Education - nature of anxiety and fight/flight response, role of hyperventilation, common fears addressed
- Training strategies - slow breathing exercise and relaxation training
- Graded exposure to fears - plans small steps toward overcoming feared situation eg travelling with someone else on quiet train until fear not occurring then move toward more challenging fears
- Avoid medication and refer if needed.

Front 26

Specific phobias occur in what percentage of the population?

Back 26

8%, but only 1% present for treatment.

Front 27

What is social phobia?

Back 27

Social phobia is the fear of being scrutinised or being evaluated negatively by other people.

May include - eating or drinking in public, speaking in public, writing in the presence of others, using public toilets or being fearful of saying foolish things with others.

Front 28

What is a specific phobia?

Back 28

It is a persistent and irrational fear and avoidance of a particular object or situation. May include heights, closed spaces, water, poisonous insects, spiders, snakes etc.

Front 29

What is the management plan for phobias?

Back 29

- Ongoing assessment
- Education and Information
- Training strategies - relaxation and slow breathing exercises.
• Graded exposure to fear situations.
• Avoid medication and refer if needed.

Front 30

What is the management plan of generalised anxiety disorder?

Back 30

- Ongoing assessment
- Education and information
- Training and strategies - slow breathing exercises, progressive muscular relaxation, planning activities that are enjoyable and relaxing, structured problem solving, graded exposure if specific anxieties, regular physical exercise.
- Avoid sedatives and specialist referral if needed.

Front 31

What is the definition of generalised anxiety disorder?

Back 31

GAD (generalised anxiety disorder) is characterised by persistent, generalised and excessive feelings of anxiety without a specific precipitant and a tendency to worry excessively.

Front 32

What is an acute stress reaction?

Back 32

A transient condition that develops in response to a traumatic event. Symptoms develop within mins and dissipate within hours or days (ICD-10) or develop within 4 weeks of event and last from 2 days to 4 weeks (DSM-IV).

Front 33

What are typical symptoms of an acute stress reaction?

Back 33

- 'Dazed'.
- Reduced level of consciousness.
- Agitation or overactivity.
- Withdrawal.
- Anxiety symptoms.
- Narrowing of focus/attention.
- Disorientation.
- Depression.
- Amnesia.

Front 34

What is the management plan of an acute stress reaction?

Back 34

- Help with removal of any ongoing trauma.
- Facilitate debriefing about the event.
- Education and normalise reaction and feelings.
- Encourage to talk with family and friends.
- Reassure symptoms will settle in a short time.
- Increase social supports.
- Relaxation - breathing, exercise or pleasant activities.
- Avoid alcohol and drugs as coping strategies.
- Regular follow-up.

Front 35

What is post-traumatic stress disorder (PTSD) and what are its typical symptoms?

Back 35

PTSD is the development of a long lasting anxiety response following a traumatic or catastrophic event.

Symptoms include:
- Images.
- Dreams or flashbacks of event.
- Avoidance of cues which remind of event.
- Amnesia around the event.
- Intense arousal and anxiety on re-exposure.
- Depressed or irritable mood.
- Social withdrawal.
- Concentration and memory difficulties.
- Nightmares and disturbed sleep.
- Easily startled.

Better outcomes with early medication and specialist referral.

Front 36

SNRI (Venlafaxine) has a particularly strong role in what anxiety disorder?

Back 36

GAD.

Front 37

Describe Drew's treatment of mood disorders.

Back 37

- Adequate and restful sleep.
- Healthy, regular nutrition including breakfast. Some evidence of the importance of omega-3 oils in serotonin production (fatty fish and linseed/flaxseed oil).
- Regular (daily) physical exercise to dissipate catecholamines and increase endorphin release.
- Increasing social contacts and avoid withdrawal.
- Engage in enjoyable and relaxing activities.
- Engage in some type of formal relaxation technique daily such as breathing exercises, progressive muscular relaxation or guided meditation.

Front 38

HEADSS - Adolescent health

Back 38

H – Home

E – Education, Employment, Eating, Exercise

A – Activities, Hobbies and Peer relationships

D – Drugs and Depression

S – Sex, Sexuality and STIs

S – Suicide and mental health

Front 39

What do you need to review with a patient with long-term benzodiazepine use?

Back 39

− Review the therapeutic objective.
− Discuss the problems of long-term use.
− Assess dosage, pattern of use and use of other psychoactive drugs.
− Assess adverse effects.
− Assess symptoms of dependency/withdrawal.
− Assess history of depression.
− Assess medical problems.

Front 40

What are the potential effects of long-term benzodiazepine use in older people for insomnia?

Back 40

- Increased frequency of confusion.
- Drowsiness.
- Memory loss.
- Unsteadiness.
- Falls.
- Incontinence.

Front 41

In sleep studies, most benzodiazepines lose their hypnotic efficacy after approximately ___ consecutive nights.

Back 41

In sleep studies, most benzodiazepines lose their hypnotic efficacy after approximately 14 consecutive nights.

Front 42

What are zopiclone and zolpidem?

Back 42

Non-benzodiazepine hypnotics.

Front 43

What is the Five-Point Plan to managing insomnia in older people?

Back 43

1. Discuss and agree on the therapeutic objectives of the patient.
2. Assess the complaint: insomnia is a symptom.
3. Treat or improve the management of underlying symptoms.
4. Educate the patient about good sleeping habits.
5. The use of hypnotics should not be first-line therapy for insomnia.

Front 44

What are the common symptoms of benzodiazepine withdrawal?

Back 44

- Sweating.
- Feeling ill.
- Dizziness.
- Blurred vision.
- Irritabiliy.
- Lack of concentration.
- Feeling anxious and dperessed.
- Sleeplessness.

Front 45

When is insomnia considered to be chronic?

Back 45

When symptoms are present for at least one month and occur more than 3 times per week.

Front 46

What is the most efficacious treatment of insomnia?

Back 46

CBT, which improves total sleep time ana general sleep quality and reducing sleep latency times and waking after sleep onset. More importantly, it shifts cognitions about sleep into a more positive framework.

Front 47

What is delayed sleep phase syndrome?

Back 47

A circadium rhythm sleep disorder where patient presents with inability to sleep until approximately 2am but then achieves a consolidated sleep. Found in 7% of young adults and often associated with a mood disorder.

Front 48

What is advanced sleep phase syndrome?

Back 48

An abnormally early sleep onset between 6 and 8pm and waking between 1am and 3am. Found in older adults and less likely to be associated with a mood disorder.

Front 49

What are predisposing factors to insomnia?

Back 49

- Familial predisposition.
- Learnt behaviour.
- Unrecognised and untreated anxiety.
- Worrisome thoughts.
- Elevated stress response with metabolic consequences.

Front 50

What are the precipitating factors for insomnia?

Back 50

Acute response to stressors from relationships, family and work, as well as economic, environmental and circadium rhythm factors (including jet lag). For most people, sleep returns to normal when the stressor or other factor is removed.

Front 51

What are the perpetuating factors for insomnia?

Back 51

Psychological factors:
- Misattributions about the causes of insomnia.
- Catastrophising about sleep needs.
- Expectations of a bad night's sleep.
- Anxiety, stress or depression.

Behavioural factors:
- Irregular getting up time.
- No structure to the day or night (such as having no regular employment).
- Staying in bed for long periods when awake.
- Long naps.
- No 'wind down time' before bed.

Front 52

How might exercise improve insomnia?

Back 52

Exercise reduces muscle tension and physiological arousal, promotes better sleep and improves mood.

Front 53

What relaxation techniques might be involved in treating insomnia?

Back 53

- Progressive muscle relaxation.
- Focused breathing strategies.
- Imagery training.
- Meditation.
- Hypnosis.