2. Anxiety and sleep disorders

Limbic system is responsible for

emotional

expression

learning

memory

Hypothalamus is associated with

autonomic nervous system and the “Fight or Flight” response

What is connected to the hypothalamus

Reticular formation

Stimulation of Reticular formation causes what 

alertness/arousal

Inhibition of Reticular formation causes what 

drowsiness/induction of sleep

Reticular activating system (RAS)

part of the reticular formation, regulate the sleep-wake cycle

Cingulate gyrus

Part of the limbic system responsible for:

formation and processing of emotions

What does the hypothalamus do in anxiety

Activates the sympathetic nervous system

Causes release of corticosteroids

What does the Locus coeruleus do in anxiety

Releases norepinephrine to activate flight or flight responses

Thalamus

Helps regulate consciousness, sleep, and alertness

Hippocampus

Maintains long term storage of memory related to emotions

Amygdala

Recognizes harmful stimuli

generates an emotional response such as anxiety or fear

Important neurotransmitters 

• Norepinephrine (Excitatory and inhibitory)

• Serotonin (inhibitory)

• Histamine (H1,H2: Excitatory ; H3: inhibitory)

• GABA (inhibitory, majority of postsynaptic inhibition in the brain)

how long does anxiety persist until its not normal

Longer than 6 months

Types of anxiety disorders

• Generalized Anxiety Disorder (GAD)

• Panic Disorder

• Phobias

• Separation anxiety disorder

Other disorders close to anxiety 

• Obsessive-Compulsive Disorder (OCD)

• Post-Traumatic Stress Disorder (PTSD)

Essentials of diagnosis for anxiety

• Persistent excessive anxiety or chronic fear and associated behavioral disturbances.

• Somatic symptoms refer to the autonomic nervous system (e.g., dyspnea, palpitations, paresthesia).

• Not limited to an adjustment disorder.

• Not a result of physical disorders, other psychiatric conditions (e.g., schizophrenia), or drug abuse (e.g., cocaine)

Insomnia

Inability to fall asleep and/or stay asleep

• Cause of insomnia is commonly associated with anxiety disorders

Disorders associated with excessive daytime sleepiness

• Narcolepsy

• Obstructive sleep apnea (OSA)

• Restless legs syndrome (RLS)

Medication for insomnia and anxiety 

• Sedative–hypnotic

• Anxiolytics

Sedative–hypnotic

a drug with the ability to produce a calming effect at lower doses and the ability to induce sleep at higher doses

Anxiolytics

Drugs that have an ability to reduce anxiety symptoms by altering levels of two important neurotransmitters in the brain: norepinephrine and serotonin

Commonly used classes (5)

• Benzodiazepines: short term/ immediate- term

• Nonbenzodiazepine: buspirone (Anxiolytics), Z -drugs (insomnia only)

• Antidepressants

• Barbiturates: rarely used

• First generation antihistamines: hydroxyzine

Benzodiazepines

Bind to GABA receptors in the brain, enhancing the effects to produce a calming effect

Anxiety FDA approved benzodiazepines

Alprazolam (Xanax)

Diazepam

Lorazepam

Clonazepam

Insomnia FDA approved benzodiazepines

Temazepam: sleep onset and sleep maintenance

Estazolam

Triazolam: sleep onset

When are benzodiazepines useful

short periods of time, should not be used as maintenance
treatment for anxiety

Adverse effects of benzodiazepines (7)

drowsiness, sedation, lethargy, somnolence, confusion, headache,
respiratory depression

Use benzodiazepines cautiously in 

older adults and pregnant women

• increase fall risk, potential cognitive impairments, teratogenic

Reversal agent of benzodiazepines overdose

Flumazenil

Benzodiazepines are

strong central nervous system depressants with significant abuse potential

Antidepressant to treat anxiety and Insomnia

SSRIs

• first line pharmacological treatment for anxiety and depression

• Safest of the 3 classes

SSRIs also treat

eating disorders, panic disorders, and OCD

Common SSRIs

• fluoxetine (Prozac; Sarafem; Prozac Weekly)

• Citalopram (Celexa)

• Escitalopram (Lexapro)

• Paroxetine (Paxil; Pexevl)

• Sertraline (Zoloft)

• Fluvoxamine (Luvox)

Atypical antidepressant

• Selective Norepinephrine Reuptake Inhibitors (SNRIs)

• Serotonin Modulator

Selective Norepinephrine Reuptake Inhibitors (SNRIs)

Duloxetine and venlafaxine

Serotonin Modulator

Trazodone (Oleptro)

Tricyclic antidepressants (TCAs

Doxepin (FDA approved for insomnia at low dose)

imipramine

amitriptyline

Mirtazapine

Which of the following drugs is a selective serotonin reuptake inhibitor (SSRI)?

Fluoxetine

Which of the following drugs is a serotonin norepinephrine reuptake inhibitor (SNRI)?

Venlafaxine

Non- benzodiazepine drugs 

Z- drugs 

First- generation antipsychotic drugs

Hydroxyzine

Z-drugs

FDA-approved for insomnia:

• Zolpidem (Ambien, Ambien CR, Intermezzo)

• Zaleplon (Sonata)

• Eszopiclone (Lunesta)

First- generation antipsychotic drugs

Hydroxyzine (Atarax, Vistaril)

buspirone (BuSpar),
meprobamate

nothing

What does Hydroxyzine do

Non-selectively blocks central and peripheral histamine H1 receptors, also
referred to as a first-generation antihistamine (highly anticholinergic)

• Has no black box warning, no abuse potential

• may be used with caution in pregnancy and should be avoided in lactation

Other medications

• Antiseizure medications: valproic acid

• Beta Blockers: propranolol

• Melatonin receptor drugs: ramelteon is a melatonin receptor agonist

• Barbiturates: phenobarbital, secobarbital
  

What do Barbiturates do 

Bind to, enhance the activity of, and mimic GABA

• Tolerance/overdoes is a problem ( no specific drug for reversal)

Which of the following drugs are FDA approved for insomnia?

Doxepin

Zolpidem