Anxiety and Insomnia

Anxiety
1. Generalized anxiety disorder
  1. Difficult to control anxiety lasting 6+ months
  2. Restlesness, fatigue, muscle tension, inability to focus, dread, sleep disturbances, BP elevation, heart palpations, respiratory change, dry mouth
2. Panic disorder
  1. Intense feelings of immediate apprehension, fearfulness, terror, or impending doom, accompanied by ANS activity
3. Phobias
  1. Fearful feelings attached to situations or objects
  2. Social anxiety disorder: Fear of being judged, ridiculed, or embarrassed by other
  3. Performance anxiety: Dread, nervousness, or apprehension that comes from performing or speaking in public
  4. Sweating, tachycardia, trembling, bowel cramping
4. Obsessive compulsive disorder
  1. Concurrent, intrusive thoughts or repetitive behaviors
5. Post traumatic stress disorder
  1. Extreme situational anxiety that develops in response to rexperiencing a previous life event
  2. War, physical/sexual abuse, rape & domestic violence, natural disasters, homicidal situations
  3. Risk of attempted suicide is high
6. Caused by:
  1. Limbic system
    1. Emotional expression, learning, memory
    2. Signals ultimately reach hypothalamus
      1. Resulting emotions: anxiety, fear, anger, aggression, remorse, depression, sexual drive, euphoria
  2. Hypothalamus
    1. Unconscious responses to extreme stress, such as high BP, elevated RR, and dilated pupils
      1. "Fight or flight" ANS response
  3. Reticular formation
    1. Connects w/ hypothalamus
    2. Neurons in the brainstem
      1. Response to stimulation: heightened alertness and arousal
        Response to inhibitions: Drowiness
  4. Reticular activating system
    1. Brainstem to thalamus
      1. 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
7. Pt. should be discouraged from medication until anxiety interferes w/ADLs
  1. When meds are indicated, drugs are called anxiolytics
    1. CNS agents, like antidepressants & CNS depressants
    2. Seizure meds
    3. Emotional/mood disorder drugs
    4. Antihypertensives and antidysrhythmics
Insomnia
1. Sleep is needed
  1. Self repair
  2. Protective mechanism
  3. Electrical signaling of brain
  4. Circadian rhythm is the daily fluctuation of body temp, BP, hormone lvls, and respiration
    1. Disruption occurs when travelling through time zones or alternating day and night shifts
2. Caused by:
  1. Short term insomnia
    1. Hectic lifestyle
      1. Inability to resolve life conflicts
        Worrying about work, marriage, children
  2. Narcolepsy
    1. Overwhelming daytime drowsiness and sudden attacks of sleep.
  3. Substances and meds
    1. Stimulants, such as coffee
      1. 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
  4. Enivronment
    1. Too much light
      1. Uncomfortable room temp (especially if it's too warm)
        Snoring
        Recurring nightmares
  5. Long term insomnia
    1. Depression
      1. Manic disorders
        Chronic pain
3. Nonpharmacologic methods of treatment should be tried first
  1. Long term use of sleep meds are likely to worsen insomnia.
    1. Long term use can also cause dependence
      1. Rebound insomnia when drug is discontinued
        Anxiety & insomnia become markedly worse
        Older patients are more likely to experience drug-related problems
4. Diagnosed by EEG
  1. REM and non-REM sleep can be identified
  2. REM brain waves similar to patient that is awake, but drowsy
  3. Pt. deprived of stage 3 NREM sleep experience depression, apathy, and fatigue
    1. Stage 3 associated w/repair and restoration of physical body
    2. REM sleep associated with memory, learning, memory, and ability to adjust to environment
      1. 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

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