Anxiety and Insomnia

Anxiety and Insomnia

1. Anxiety

   • Generalized anxiety disorder
     • Difficult to control anxiety lasting 6+ months
     • Restlesness, fatigue, muscle tension, inability to focus, dread, sleep disturbances, BP elevation, heart palpations, respiratory change, dry mouth
   • Panic disorder
     • Intense feelings of immediate apprehension, fearfulness, terror, or impending doom, accompanied by ANS activity
   • Phobias
     • Fearful feelings attached to situations or objects
     • Social anxiety disorder: Fear of being judged, ridiculed, or embarrassed by other
     • Performance anxiety: Dread, nervousness, or apprehension that comes from performing or speaking in public
     • Sweating, tachycardia, trembling, bowel cramping
   • Obsessive compulsive disorder
     • Concurrent, intrusive thoughts or repetitive behaviors
   • Post traumatic stress disorder
     • Extreme situational anxiety that develops in response to rexperiencing a previous life event
     • War, physical/sexual abuse, rape & domestic violence, natural disasters, homicidal situations
     • Risk of attempted suicide is high
   • Caused by:
     • Limbic system
       • Emotional expression, learning, memory
       • Signals ultimately reach hypothalamus
         • Resulting emotions: anxiety, fear, anger, aggression, remorse, depression, sexual drive, euphoria
     • Hypothalamus
       • Unconscious responses to extreme stress, such as high BP, elevated RR, and dilated pupils
         • "Fight or flight" ANS response
     • Reticular formation
       • Connects w/ hypothalamus
       • Neurons in the brainstem
         • Response to stimulation: heightened alertness and arousal
           • Response to inhibitions: Drowiness
     • Reticular activating system
       • Brainstem to thalamus
         • Sleeping/wakefulness, alters the entire cerebral cortex
           • Focuses attention by transmitting signals to higher centers of brainstem
           • If signals are prevented from passing through: No emotion related signals
           • If signals from hypothalamus pass through: Signals go to integrative brain centers, causing anxiety and fear, and a restless/interrupted sleeping pattern
   • Pt. should be discouraged from medication until anxiety interferes w/ADLs
     • When meds are indicated, drugs are called anxiolytics
       • CNS agents, like antidepressants & CNS depressants
       • Seizure meds
       • Emotional/mood disorder drugs
       • Antihypertensives and antidysrhythmics

2. Insomnia

   • Sleep is needed
     • Self repair
     • Protective mechanism
     • Electrical signaling of brain
     • Circadian rhythm is the daily fluctuation of body temp, BP, hormone lvls, and respiration
       • Disruption occurs when travelling through time zones or alternating day and night shifts
   • Caused by:
     • Short term insomnia
       • Hectic lifestyle
         • Inability to resolve life conflicts
           • Worrying about work, marriage, children
     • Narcolepsy
       • Overwhelming daytime drowsiness and sudden attacks of sleep.
     • Substances and meds
       • Stimulants, such as coffee
         • Tobacco
           • Alcohol might stimulate sleep, but it causes vivid dreams and frequent awakenings that may prevent restful sleep
             • Large meals, especially ones high in protein and fat, right before bed
               • B/c of increased metabolic rate needed for digestion
     • Enivronment
       • Too much light
         • Uncomfortable room temp (especially if it's too warm)
           • Snoring
             • Recurring nightmares
     • Long term insomnia
       • Depression
         • Manic disorders
           • Chronic pain
   • Nonpharmacologic methods of treatment should be tried first
     • Long term use of sleep meds are likely to worsen insomnia.
       • Long term use can also cause dependence
         • Rebound insomnia when drug is discontinued
           • Anxiety & insomnia become markedly worse
           • Older patients are more likely to experience drug-related problems
   • Diagnosed by EEG
     • REM and non-REM sleep can be identified
     • REM brain waves similar to patient that is awake, but drowsy
     • Pt. deprived of stage 3 NREM sleep experience depression, apathy, and fatigue
       • Stage 3 associated w/repair and restoration of physical body
       • REM sleep associated with memory, learning, memory, and ability to adjust to environment
         • Required to keep psyche functioning normally
           • When deprived of it, pt. experiences a sleep debt.
             • Frightened, irritable, paranoid, emotionally disturbed, impaired judgment, slowed reaction time
               • Speculated that due to lack of dreaming, pt. makes up for it by daydreaming and fantasizing throughout day