Insomnia and Anxiety Management Lecture

The flashcards cover key concepts related to insomnia and anxiety management, including definitions, treatment approaches, and important considerations for patient care.

Insomnia

A sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early.

Short-term insomnia

A type of insomnia lasting less than 3 months.

Long-term insomnia

Insomnia that persists for 3 months or longer.

Three P’s model of insomnia

A framework for understanding insomnia that includes predisposing, precipitating, and perpetuating factors.

Cognitive Behavioral Therapy for Insomnia (CBTI)

A first-line treatment for insomnia that focuses on changing thoughts and behaviors related to sleep.

Sedating Antihistamines

Medications like diphenhydramine that cause sedation by blocking H1 receptors; may cause daytime drowsiness.

Diazepam

A benzodiazepine prescribed for short-term management of insomnia, known for its sedative effects.

Sleep hygiene

Practices that promote healthy sleep behavior, such as maintaining a consistent sleep schedule and creating a comfortable sleep environment.

Generalized Anxiety Disorder (GAD)

A mental health condition characterized by excessive, uncontrollable worry about various aspects of life.

GAD-7

A screening tool used to assess the severity of anxiety symptoms.

SSRIs (Selective Serotonin Reuptake Inhibitors)

A class of antidepressants commonly used in the treatment of anxiety disorders.

Cognitive Restructuring

A CBT technique that involves identifying and challenging unhelpful thoughts and beliefs about sleep.

Sleep Restriction Therapy

A CBTI method that limits time in bed to match actual sleep duration, aimed at improving sleep efficiency.

Orexin antagonists

Medications like Daridorexant that reduce wake signaling, enabling restorative sleep.

Cognitive distortions

Negative thought patterns that contribute to insomnia and anxiety, often addressed in CBT.

Patient counseling

Guidance provided to patients regarding the use of medications and non-pharmacological strategies for managing insomnia and anxiety.

Melatonin

A hormone that regulates sleep-wake cycles, sometimes used as a supplement for insomnia.

Breathing exercises

Techniques used in relaxation training to reduce physical tension and anxiety before bedtime.

Pharmacological management

Treatment of insomnia and anxiety disorders through the use of medications.

What are the main learning outcomes for insomnia?

"Outline risk factors pharmacological strategies and counselling for insomnia management."

What are the main learning outcomes for anxiety?

"Outline risk factors pharmacological strategies and counselling for anxiety management."

What resources are useful for insomnia management?

"NICE guidance and Clinical Knowledge Summaries (CKS)."

Who is Anthony in the insomnia case?

"A 21-year-old pharmacy student with asthma and insomnia prescribed diazepam."

Why might Anthony wake early at 4 a.m.?

"Could be asthma-related steroid effects hunger or lifestyle factors."

Why is Anthony’s asthma unlikely to cause his early waking?

"Asthma symptoms usually occur late at night and improve by early morning when endogenous steroids peak."

Why is Anthony’s BMI unlikely to be causing his insomnia?

"His BMI is normal; sleep apnoea occurs mainly in high BMI."

Why are steroids unlikely to be the cause of Anthony’s insomnia?

"Steroids taken in the morning have limited effect on next-morning sleep; he falls asleep easily."

Is insomnia a symptom or a disorder?

"It can be both: a symptom of another condition or a primary disorder."

What does the term ‘insomnia’ derive from?

"Latin: ‘in somnus’ meaning ‘without sleep’; Somnus was the Roman god of sleep."

Why is sleep socially significant?

"Sleep is universal yet under-discussed; lack of sleep is seen as stress or illness."

Why is asking about sleep important in healthcare?

"It reveals underlying stress mental health or physiological issues often overlooked."

Which population do we commonly ask about sleep?

"Infants—parents are often asked ‘are they sleeping well?’"

How can insomnia manifest?

"Difficulty falling asleep staying asleep early waking or poor quality sleep."

What’s the difference between short-term insomnia and insomnia disorder?

"Short-term insomnia has identifiable cause; insomnia disorder persists ≥3 months without cause."

What proportion of adults experience some form of sleep problem weekly?

"Most adults experience some sleep problem about once a week."

How does age affect sleep needs?

"Sleep needs decrease with age; older adults need less sleep than children."

What are the main risk factors for insomnia?

"Older age female sex, anxiety/stress, poor lifestyle, family history

What is the 3Ps model of insomnia?

"Predisposing precipitating and perpetuating factors."

Give examples of predisposing factors for insomnia.

"Age female sex anxiety high sleep focus."

Give examples of precipitating factors for insomnia.

"Stress lifestyle caffeine alcohol environment."

Give examples of perpetuating factors for insomnia.

"Worry about sleep staying in bed awake irregular sleep patterns."

How do perpetuating factors worsen insomnia?

"They create negative associations with bed and maintain sleep difficulty."

What can result from chronic insomnia?

"Cognitive decline agitation irritability appetite changes."

How do risk factors for insomnia change with age?

"Predisposing stay constant; precipitating factors increase midlife; perpetuating dominate later."

Why is Anthony’s insomnia likely precipitated rather than predisposed?

"He’s young with acute stressors from university rather than chronic biological predisposition."

What drug was prescribed to Anthony?

"Diazepam a benzodiazepine."

What is the mechanism of diazepam?

"Enhances GABAergic transmission causing sedation."

List common side effects of diazepam.

"Drowsiness weakness dizziness confusion blurred vision."

Why are elderly patients at higher risk from diazepam?

"Increased risk of falls fractures and prolonged sedation."

What causes dependence with diazepam?

"Neural adaptation—brain creates more GABA receptors; withdrawal causes anxiety and tremor."

How should diazepam be prescribed for insomnia?

"Short-term (≤7 days) with counselling about drowsiness and dependency."

What is ‘diversion’ in drug misuse?

"When prescribed medicines are sold or given to others for non-medical use."

Why might the GP have chosen diazepam?

"Long half-life helps early waking; known anxiolytic effects."

Which OTC antihistamines are used for insomnia?

"Diphenhydramine and promethazine."

Why is promethazine not recommended for insomnia?

"Risk of misuse sedation of children and limited efficacy evidence."

Why is diphenhydramine not recommended?

"Limited efficacy next-day drowsiness cognitive impairment risk."

What herbal sleep aids exist?

"Valerian chamomile passionflower—mild sedatives with limited evidence."

What are orexin antagonists?

"New hypnotics blocking orexin receptors; hospital-only (red drugs) in some regions."

Why are orexin antagonists restricted?

"Limited long-term data; monitored in hospitals for safety beyond 12 months."

What does ‘formulary’ mean in UK pharmacy?

"A list of locally approved drugs developed by clinicians for regional prescribing consistency."

What are combination nighttime painkillers?

"Paracetamol with diphenhydramine; not recommended for insomnia due to overdose risk."

How does paracetamol reduce anxiety?

"May lower anxiety via central serotonergic modulation."

Why is melatonin prescription-only in the UK?

"Regulated for adults ≥55 or children with ASD/ADHD; limited efficacy in younger adults."

How effective is melatonin?

"Adds ~10 minutes of sleep in neurotypical adults; more benefit in neurodiverse patients."

What non-drug approach is first-line for insomnia?

"Cognitive Behavioural Therapy for Insomnia (CBT-I)."

Why is CBT-I preferred over drugs?

"Addresses underlying behaviours avoids dependence and improves long-term sleep."

What are the key elements of CBT-I?

"Stimulus control sleep restriction cognitive restructuring relaxation and sleep hygiene."

What is sleep restriction therapy?

"Limiting time in bed to actual sleep time to increase sleep efficiency."

What is stimulus control in CBT-I?

"Restricting bed use to sleep only; get out of bed if awake >20 minutes."

What is the purpose of fixed sleep/wake times?

"To strengthen circadian rhythm and improve sleep consistency."

Why are naps discouraged in CBT-I?

"They reduce sleep drive and delay night-time sleep onset."

What is cognitive restructuring in insomnia?

"Challenging unhelpful beliefs about sleep (e.g. catastrophising poor sleep)."

What is relaxation therapy for insomnia?

"Progressive muscle relaxation and deep breathing to reduce arousal."

What is guided imagery used for?

"Visualization to reduce anxiety or manage nightmares before sleep."

What sleep tracking tools are used in CBT-I?

"Sleep diaries Insomnia Severity Index (ISI) Epworth Sleepiness Scale."

What does ISI measure?

"Subjective severity of insomnia symptoms and impact on daily function."

What lifestyle factors improve sleep?

"Exercise daylight exposure limiting caffeine/alcohol regular meals."

What’s the recommendation on caffeine for insomnia?

"Avoid caffeine and energy drinks after noon."

Why avoid alcohol before sleep?

"Disrupts REM sleep and causes early waking."

What is the advice about screen use and sleep?

"Blue light less impactful than engagement—avoid stimulating content before bed."

What is an optimal sleep environment?

"Dark cool quiet safe bedroom with minimal disturbances."

What limitations does CBT-I have?

"Doesn’t account for chronic illness shift work caregiving or behavioural non-adherence."

What should pharmacists recommend first for insomnia?

"Rule out medical causes offer CBT-I and sleep hygiene reassess before medication."

What assessment scales measure sleepiness?

"Epworth Sleepiness Scale (ESS) and ISI for severity."

What is the first-line therapy for chronic insomnia?

"CBT-I (Cognitive Behavioural Therapy for Insomnia)."

What key behaviours form part of sleep hygiene?

"Regular schedule quiet/dark room no caffeine/alcohol before bed avoid screens."

How long should CBT-I be tried before medication?

"Typically 4–6 weeks with follow-up and sleep diary review."

When should pharmacological therapy for insomnia be considered?

"If CBT-I and sleep hygiene fail or insomnia is severe/short-term."

What are the pharmacological options for insomnia?

"Short-term benzodiazepines Z-drugs melatonin (specific groups) or orexin antagonists."

What counselling should accompany hypnotic prescribing?

"Use short-term avoid alcohol caution driving avoid abrupt withdrawal."

What is generalised anxiety disorder (GAD)?

"Chronic excessive worry lasting ≥6 months difficult to control with somatic symptoms."

What is the NICE-recommended tool for GAD diagnosis?

"GAD-7 questionnaire assessing anxiety severity over 2 weeks."

What score thresholds apply for GAD-7?

"0–4 minimal 5–9 mild 10–14 moderate 15–21 severe."

What somatic symptoms occur in GAD?

"Tension palpitations sweating tremor dizziness dyspnoea cold hands/feet."

What cognitive symptoms occur in GAD?

"Excessive worry poor concentration rumination indecisiveness."

What behavioural symptoms occur in GAD?

"Avoidance reassurance-seeking restlessness."

What conditions can overlap with GAD?

"Depression substance use physical illness (COPD asthma diabetes)."

What is the DSM-V criterion for GAD duration?

"Excessive worry for most days over 6 months."

How can chronic stressors lead to GAD?

"Prolonged stress activates HPA axis and sympathetic nervous system maintaining anxiety."

What are the main risk factors for GAD?

"Family history trauma childhood shyness chronic stress female sex poor coping style."