Institute of Mental Health 2/26/21 Anxiety Disorders and Insomnia Dr Jared Ng Senior Consultant Institute of Mental Health 1 INTRODUCTION • Common presentation to primary care • Insomnia • Anxiety symptoms • Somatic symptoms • Can be a normal and healthy reaction to stress and is associated with the activation of the fight-orflight response 2 Restricted 1 Institute of Mental Health Anxiety and Depression 2/26/21 • Anxiety –Fear –Worry –Repetitive, intrusive, inappropriate • Depression –Loss of interest in things –Depressed mood –Irritability • Both –Physical complaints –More than 50% will present with somatic complaints 3 Common Symptoms Depressive Disorders Low mood Anhedonia Weight loss/gain Fear Panic Excessive worries Panic attacks Pain complaints Poor sleep Poor concentration Problems sleeping Anxiety Disorders Hypervigilance Compulsive acts Agoraphobia Fatigue, giddiness, GI complaints, headache, chest discomfort, poor appetite 4 Restricted 2 Institute of Mental Health 2/26/21 Differentiating… Worry Anxiety • Worries are limited to a specific, small number of realistic concerns • Last for a short period of time and goes away • Bouts of anxiety last for short periods of time • Able to control your worrying • Able to work or study and maintain social connection • Chronic and irrational worry • Out of proportion to the situation • Can last for weeks, months or longer • Your worrying is uncontrollable, extremely upsetting and stressful • Disruption to everyday activities and function 5 Differentiating… Depression • Hopelessness • Terminal insomnia • Diurnal variation • Worse in mornings • Psychomotor retardation Anxiety • • • • Initial insomnia Symptoms more constant Agitation Anhedonia less likely 6 Restricted 3 Institute of Mental Health 2/26/21 Cultural influences • Poor sleep • Anxiety • Physical presentations of anxiety states: ‘many many pain’, ‘can’t breathe’, ‘like forget to breathe’, ’head very hot’ • Psychological symptoms of anxiety states 7 ANXIETY DISORDERS BRIEF INTRODUCTION 8 Restricted 4 Institute of Mental Health 2/26/21 Exclude medical causes • Hyperthyroidism • Hypoglycaemia • Drug intoxication/withdrawal • Seizures • Respiratory diseases e.g. Asthma • Tumor e.g. Phaechromocytoma • And more! 9 Common • Generalized Anxiety Disorder (GAD) • Panic Disorder • Social Anxiety Disorder • Post Traumatic Stress Disorder (PTSD) • Phobias • *Obsessive Compulsive Disorder (OCD) 10 Restricted 5 Institute of Mental Health 2/26/21 Comorbidities • All anxiety and depressive disorders are highly co-morbid with other psychiatric diagnoses • 50% of patients will have 2 more disorders 11 Assessment • Review of symptoms • Stressors/trauma exposure • Developmental history • Medical history • School/NS/Occupational history • Family history of depression or other mental illnesses • Social history including stressors at home 12 Restricted 6 Institute of Mental Health 2/26/21 Assessment • Collateral information from caregiver/family members (if possible) 13 Assessment • Suicidality • Past or Ongoing Trauma • Differential diagnoses mimicking condition (particularly anxiety) • Psychiatric: Bipolar, Depression • Medical: hyperthyroidism, caffeine, asthma, epilepsy etc 14 Restricted 7 Institute of Mental Health Panic Attacks and Panic Disorders 2/26/21 • Discrete • Intense • Fear or discomfort • Peak in 10-15 minutes • Uncued and unpredictable • Persistent concerns • Worry about the consequences • Leading to change in behaviour 15 Agoraphobia • Persistent fear of specific situations • • • • Open spaces Driving Closed spaces Public places • If panic present, then probably panic disorder with agoraphobia • If no panic, then agoraphobia without panic disorder • Interferes with functioning 16 Restricted 8 Institute of Mental Health 2/26/21 • Do symptoms include fear, avoidance and anxious anticipation? • Specific phobia • Social phobia • Panic disorders 17 Social Anxiety Disorder • Common • Fear of “public scrutiny” • Characterised by • Physiological symptoms • Blushing, sweating, tremours, palpitations, GI discomfort • Psychological symptoms • Anxiety, fear, embarrassment, avoidance • Disabling and often chronic • Can be very disruptive 18 Restricted 9 Institute of Mental Health 2/26/21 • Fear of seperation • Seperation anxiety • Recurrent and persistent thoughts or ritualistic behaviours or recurrent mental acts • OCD • Reexperiencing of highly traumatic events • PTSD? • History will tell • Loved one passed away recently • Bereavement • Grief 19 OCD • Feelings of anxiety accompanied by specific congnitive and behavioural symptoms • Thoughts • Compulsions • Lifelong; waxes and wanes • • • • • Common presentations Contamination Doubt Somatisation Need for symmetry 20 Restricted 10 Institute of Mental Health 2/26/21 • Pervasive anxiety symptoms and worries with a variety of situations and event • Generalised anxiety disorder • • • • Worry Insomnia Fatigue Poor concentration • Symptoms in response to a specific psychosocial stressors? • Adjustment disorder • Cannot classify? • Anxiety disorders- NOS • Prominent Secondary Gain issues ++++ • Malingering? 21 Adjustment Disorder • ~15% of new outpatient cases seen • Can take the form of • • • • Marital woes Domestic issues Job related stress Financial problems 22 Restricted 11 Institute of Mental Health 2/26/21 23 Treatment of Anxiety • Mild Anxiety – psychotherapy (first line) • Moderate Anxiety – psychotherapy (first line) then consider medications if no response • Severe Anxiety – medications + psychotherapy 24 Restricted 12 Institute of Mental Health 2/26/21 Treatment of Anxiety • Types of Psychotherapies used for Anxiety • CBT • Psychodynamic psychotherapy 25 Treatment of Anxiety • SSRIs have shown efficacy for anxiety • Other agents: • Tricyclic antidepressants (e.g. Imipramine, Clomipramine, Amitriptyline) • Venlafaxine (GAD, Social Phobia) • Mirtazapine • Pregabalin • B-blockers • Benzodiazepines (short term treatment) 26 Restricted 13 Institute of Mental Health 2/26/21 SSRI • Fluoxetine 20mg-60mg OM • Fluvoxamine 50-200mg ON • Sertraline 50-200mg OM • Escitalopram 5-20mg OM 27 INSOMNIA ASSESSMENT AND MANAGEMENT 28 Restricted 14 Institute of Mental Health What is insomnia? 2/26/21 Sleep-related issues • • • • Difficulty sleeping Restless sleep Waking up too soon Non-refreshing sleep Personal distress Functional impairment/Day-time consequences 29 Sleep Structure • 5 stages of sleep -Stage 1- drowsy period -Stage 2- drifting to deep sleep -Stage 3 and 4- deep sleep (NREM) -Stage 5- REM sleep • The cycle repeats (stage 3à5) • REM sleep becomes longer and longer 30 Restricted 15 Institute of Mental Health 2/26/21 31 Classifications • Dysomnias • Parasomnias • Others 32 Restricted 16 Institute of Mental Health 2/26/21 Dysomnias • Primary Insomnia • Primary Hypersomnia • Circadian Rhythm Sleep Disorder • Narcolepsy 33 Parasomnias • REM -Nightmare disorder • NREM -Sleep walking -Sleep talking -Night terrors • Others -Restless leg syndrome -Periodic limb movement disorder -Bruxism -Sleep paralysis 34 Restricted 17 Institute of Mental Health 2/26/21 Other Causes • Medical- OSA, Asthma, hyperthyroidism, CCF, GERD, COPD etc • Pain/discomfort • Psychiatric illness- depression, anxiety disorders • Substance use- smoking, alcohol, caffeine, medications 35 Assessment • Thorough sleep history: Routine, duration of sleep problem When do you sleep and wake up? Length of sleep Nightmares, dreams Refreshing sleep? What goes on in your head when you cannot sleep? • *Psychiatric and medical history • *Sleep diary • • • • • • 36 Restricted 18 Institute of Mental Health 2/26/21 • Initial Insomnia • e.g. anxiety Assessment • Middle Insomnia • e.g. medical illness, pain, depression, anxiety, substance use, medications • Terminal insomnia • e.g. major depression 37 Assessment • ‘Common things occurs more commonly’ • Exclude non-psychiatric causes- eg OSA, pain • Exclude Substance-related insomnia • Exclude major psychiatric illnesses • Exclude sleep misconceptions • Reminders: • * Be wary of drug-seeking behavior* • * Do not label everyone who asks for sleeping tablets as drug seekers.* • * Crucial to use clinical judgment* 38 Restricted 19 Institute of Mental Health 2/26/21 Treatment • Bio-Psycho-Social Model 39 Sleep hygiene (Often all that the patient needs) • Healthy lifestyle- exercise, diet • Avoid caffeine/alcohol/smoking • Avoid eating/ drinking before sleep • Do relaxing activities before sleeping • ‘Bed is for sleeping & sex only’ • Not to go to bed unless tired • Avoid afternoon naps • Relaxation • Keep environment comfortable • Bed-time routine 40 Restricted 20 Institute of Mental Health 2/26/21 Sleep hygiene Unfortunately, most of our patients usually want more than lifestyle advice ……. 41 Treatment • Medical conditions that contribute to insomnia need to be addressed and treated. • If there is suspicion of substance abuse- psychoed, assess motivation to change, refer to addiction specialist (NAMS) 42 Restricted 21 Institute of Mental Health Treatment 2/26/21 • If the cause is a mental illness- treat mental illness. • Use of sedative anti-depressant should be considered- Fluvoxamine, Mirtazapine, Venlafaxine, Trazodone, Amitriptylline • New anti-depressant: Agomelatine • Combination treatment: Fluoxetine and Hydroxyzine, augmentation with antipsychotics (needs specialist follow-up as its off-label use) 43 Treatment • Antihistamines: Hydroxyzine, Promethazine Maleate • *CAUTION: anti-cholinergic and antihistaminergic SE, best avoided in elderly* • Daytime drowsiness, cholinergic effects, & paradoxical excitement 44 Restricted 22 Institute of Mental Health Treatment 2/26/21 • Melatonin • Used in developmental delays, autism, neurological impairment, blindness, ADHD, jet lag • Main effect on suprachiasmatic nucleus; weak hypnotic • Adverse effects largely unknown; hypotension, bradycardia, nausea, headache, asthma, exacerbation of arthritis • Not regulated, so formulation vary 45 Treatment • Benzodiazepines (BZDs) • Use of BZD is best avoided. Often last treatment option: • • • • Risk of dependence Risk of falls Risk of cognitive deficits Risk of co-consumption with alcohol 46 Restricted 23 Institute of Mental Health Treatment 2/26/21 • Benzodiazepines (BZDs) • There is a place for BZD use! • Short-half-life for sleep onset, longerhalf-life for sleep maintenance; also parasomnias • Adverse effects: Sedation, rebound insomnia, cognitive impairment, amnesia, impaired respiratory function; marked abuse potential 47 Benzodiazepine • Limitation in primary care setting • Depends on duration of action • Short Acting: Midazolam, Nimetazepam • Intermediate Acting: Alprazolam, Lorazepam • Longer Acting: Diazepam, Clonazepam • Short acting drugs should be avoided • Intermediate acting drugs are useful in sleep initiation/maintenance • Long acting drugs are useful in anxiety disorder 48 Restricted 24 Institute of Mental Health Z-drugs 2/26/21 Similar addictive potential to BZD Fast acting Shorter half-life Often marketed as superior to BZD NICE- no difference between BZD and Z- drugs in terms of adverse effect, addicti potential and efficacy • Zopiclone and Zolpidem • • • • • • Zolpidem acts up to 6hrs • Zopiclone acts up to 8hrs, metallic/bitter taste • Adverse effects: Headache, retrograde amnesia, few residual next-day effects 49 Treatment • CRSD- bright light therapy, melatonin, psychotherapy, medications • Parasomnias- often need sleep studies and should be treated by psychiatrists/ neurologists • TCM?Jamu?Ayurveda?Herbal? • Psychotherapy- relaxation techniques for anxiety, CBT, sleep scheduling for CRSD, sleep restriction • Music therapy/Aromatherapy? 50 Restricted 25 Institute of Mental Health 2/26/21 Questions? 51 Restricted 26
