Anxiety and Insomnia: Overview of Anxiety

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Anxiety is defined as a state of apprehension, tension, or dread stemming from a real or perceived threat to a persons well-being. Sometimes the source of the threat can be identified, but often there may be no obvious, identifiable cause. The onset of anxiety may be:

Sudden and unexpected, possibly with an intense outbreak of symptoms Gradual and relatively mild, sometimes with overlooked symptoms

Everyone experiences situational anxiety from time to time, when faced with a stressful situation or event. However, individuals ability to cope with anxiety varies. Generally, situational anxiety can be handled without medical intervention. If anxiety becomes chronic, or begins to affect a persons ability to perform daily activities, medication can provide symptomatic relief to help the person cope with his/her emotional stressors. Both pharmacologic and nonpharmacologic therapies are important, because chronic or severe anxiety can lead to serious gastrointestinal, cardiovascular, and other physical disorders. Situational anxiety is not regarded as a major anxiety disorder because it is short term and does not usually disable the person. In contrast, other types of anxiety disorders are characterized by persistent, excessive, and/or irrational fear. Potential paths that anxiety can take are illustrated in the flowchart on this screen.

Anxiety and Insomnia: Types of Major Anxiety Disorders

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Types of major anxiety disorders are:

Generalized anxiety disorder (GAD)

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Excessive worry or fear that lasts 6 months or more Most common type of stress disorder, with symptoms that include:

Restlessness/nervousness Insomnia Fatigue Inability to concentrate

Elevated blood pressure Heart palpitations Dry mouth Diarrhea Urinary urgency

Panic disorder (watch the video on this screen for a description)

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Intense feelings of apprehension, fear, and impending doom Short attacks lasting less than 10 minutes, but can reoccur quickly Two stages:

Anticipatory anxiety: feelings of dread when thinking about upcoming challenges Physical symptoms: increased respirations and heart rate

Phobias
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Feelings of fear related to situations or objects Common phobias: snakes, spiders, closed places, heights Example of social anxiety disorder (social phobia) is fear of public speaking or performing in front of an audience (stage fright)

Obsessive-compulsive disorder (OCD)

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Recurrent, intrusive thoughts or repetitive behaviors Common example is excessive hand washing due to a fear of germs (Click to watch a video of a client describing his OCD behavior.)

Posttraumatic stress disorder (PTSD)

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Type of situational anxiety that occurs after experiencing or witnessing a traumatic life event such as war, physical or sexual abuse, natural disaster, or murder; may exhibit as nightmares or hallucinations that last for more than one month

Anxiety and Insomnia: Causes and Types of Insomnia

Insomnia is the inability to fall asleep or remain asleep. Insomnia and anxiety often go hand in hand. Clients who have problems sleeping frequently report symptoms of anxiety, and vice versa. Treating both conditions simultaneously may produce better sleep results than treating just the insomnia. A proper balance between sleeping and waking hours is necessary to maintain health. Many body functions operate on a 24-hour cycle, such as body temperature, hormone regulation, respiratory function, and blood pressure. If this cycle becomes impaired due to insomnia, pharmacotherapy may be necessary. However, nonpharmacologic measures should be tried before starting drug therapy. If medications for sleeplessness are used for a long period of time, they could worsen the insomnia or cause dependence. Insomnia can be primary or secondary. Secondary insomnia, caused by an underlying disease or disorder, is the most common. Primary insomnia is not associated with

another medical or psychological condition. Another way of classifying insomnia is according to duration:

Short-term insomnia, also called behavioral insomnia, can be caused by:

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Anxiety Stress Ingesting stimulants, such as caffeine Tobacco use Alcohol use Eating a high-protein or high-fat meal close to bedtime Medications containing central nervous system (CNS) stimulants Environmental factors, such as noise, light, or temperature Depression Manic disorders Chronic pain Other long-term medical or psychological conditions

Long-term insomnia may be caused by:

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Anxiety and Insomnia: Pathophysiology

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The limbic system plays a primary role in the experience and expression of human emotions, learning, and memory. Thus, the limbic system has been linked to the pathogenesis of anxiety and insomnia. Key parts of the limbic system include the amygdala, hippocampus, thalamus, and hypothalamus in the middle of the brain. A related component is the reticular activating system (RAS). The RAS is a system of nerve pathways that begin in the spinal cord and connect in the reticular formation, a group of neurons along the brainstem core. Following is a brief, functional description of some of these components:

The amygdala plays a key role in emotional and behavioral responses. The hippocampus is also involved in these responses, assisting with memory storage and retrieval.

In a stressful situation, the amygdala relays messages of anxiety or fear to the hypothalamus. The hypothalamus helps coordinate unconscious responses to stress (fight or flight), such as:
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Increased blood pressure Increased respiratory rate Increased heart rate Dilated pupils

The hypothalamus relays messages to the reticular formation, which is connected to the RAS. The RAS is responsible for regulating states of consciousness and awareness, thereby affecting sleeping and waking patterns:
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Stimulation of the RAS creates alertness, enabling the mind to focus. Inhibition of the RAS promotes drowsiness and sleep. In other words, when signals are prevented from passing through the RAS, there is reduced brain activity.

Pharmacotherapy: Drug Classes for Treating Anxiety and Insomnia

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Central nervous system (CNS) agents are medications that affect activity in the brain and spinal cord. CNS agents that slow the activity in the brain are often referred to as CNS depressants. CNS agents in the following classes may be used to treat anxiety and/or insomnia symptoms:

Antidepressants
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Selective serotonin reuptake inhibitors (SSRIs) Tricyclic antidepressants (TCAs) Atypical antidepressants, such as serotonin norepinephrine reuptake inhibitors (SNRIs) Monoamine oxidase inhibitors (MAOIs)

Benzodiazepines Barbiturates Nonbenzodiazepine and nonbarbiturate CNS depressants

Pharmacotherapy: Antidepressants

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Of the various classes of antidepressants, SSRIs are used most often to treat anxiety disorders. TCAs and SNRIs may also be prescribed. However, MAOIs are seldom used today because adverse effects frequently occur with their use. The two primary mechanisms of action of antidepressants are:

Slowing the reuptake of serotonin and norepinephrine

Blocking the enzymatic breakdown of norepinephrine

Click to review the mechanisms of action of antidepressants. Antidepressants approved for treating anxiety disorders include:

Drug Classes SSRIs

Generic Names escitalopram oxalate fluoxetine hydrochloride fluvoxamine paroxetine

Trade Names Lexapro GAD

Disorders

Prozac

OCD

Luvox Paxil

OCD, social anxiety disorder GAD, OCD, panic disorder, PTSD, social anxiety disorder GAD, OCD, panic disorder, PTDS, social anxiety disorder GAD

sertraline hydrochloride SNRIs duloxetine hydrochloride venlafaxine TCAs clomipramine hydrochloride

Zoloft

Cymbalta

Effexor Anafranil

GAD OCD

Click to review detailed descriptions of the drugs escitalopram oxalate and fluoxetine hydrochloride. Common adverse effects of antidepressants include insomnia, nervousness, agitation, nausea, dry mouth, dizziness, and fatigue. On a more serious level, antidepressants come

with a black box warning. Clients should be monitored closely for warning signs of suicide when therapy is initiated and dosages are changed.

Pharmacotherapy: Benzodiazepines

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Benzodiazepines are the drugs of choice for GAD and short-term treatment of insomnia:

Generic Names Anxiety therapy alprazolam chlordiazepoxide hydrochloride clorazepate dipotassium diazepam lorazepam oxazepam Insomnia therapy estazolam flurazepam hydrochloride quazepam temazepam triazolam

Trade Names Xanax Librium Tranxene Valium Ativan Serax ProSom Dalmane Doral Restoril Halcion

To learn more, click to review the prototype drugs diazepam and lorazepam. The mechanism of action of benzodiazepines is similar for all the drugs in this class. However, the onset and duration of action do differ between medications. Benzodiazepines work by binding to gamma-aminobutyric acid (GABA) receptors. This action increases the effect of GABA, an inhibitory neurotransmitter in the brain. For a more detailed explanation, watch the video on this screen. All benzodiazepines have similar adverse effects, which may include drowsiness, sedation, dizziness, headache, confusion, amnesia, blurred vision, hypotension, and ataxia.

Benzodiazepines are contraindicated in clients with acute narrow-angle glaucoma, pregnancy, and lactation. The main route of administration is oral. However, diazepam and lorazepam may also be administered IM or IV.

Pharmacotherapy: Barbiturates

Although barbiturates were once widely prescribed for anxiety and insomnia, this class of drug is now seldom used to treat these conditions. The potential risks for serious side effects, including client dependency, plus the availability of newer drugs, have decreased the use of barbiturates. Barbiturates sometimes used to treat anxiety and insomnia are:

Generic Names

Trade Names

butabarbital sodium mephobarbital pentobarbital sodium phenobarbital phenobarbital sodium secobarbital sodium

Butisol Sodium Mebaral Nembutal Sodium Solfoton Luminal Seconal Sodium

Click to review the prototype drug phenobarbital. Barbiturates can depress CNS function at all levels. Their mechanism of action is to bind to GABA receptors. As a result, the inhibitory effect of GABA is intensified throughout the brain. At low doses, barbiturates decrease anxiety and cause drowsiness; at moderate doses they induce sleep. One of the most common adverse effects is residual sedation (hangover effect). More serious adverse effects may include respiratory depression, apnea, laryngospasm, and coma. Barbiturates are contraindicated in clients with severe respiratory disease, liver dysfunction, uncontrolled pain, or a history of previous addiction. Barbiturates are also contraindicated for clients who are pregnant or lactating. Routes of administration are oral, intramuscular, and intravenous.

Pharmacotherapy: Miscellaneous Drugs for Anxiety and Insomnia

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Miscellaneous drugs used to treat anxiety and insomnia are:

Generic Names Anxiety Therapy Insomnia buspirone hydrochloride eszopiclone

Trade Names BuSpar

Drug Classifications anxiolytic

Lunesta

sedative-hypnotic

Therapy

zaleplon

Sonata

anxiolytic; sedativehypnotic; nonbenzodiazepine anxiolytic; sedativehypnotic; nonbenzodiazepine

zolpidem

Ambien

Buspirone:

The mechanism of action is an agonist effect on dopamine receptors in the brain. Common adverse effects may include dizziness, headache, drowsiness, and nausea. This drug is contraindicated in clients who are lactating, and used with caution in pregnant clients or those who have liver or renal impairment. The route of administration is oral.

Zolpidem

The mechanism of action is enhancement of GABA in the brain. Adverse effects may include dizziness, drowsiness or fatigue, and irritability. This drug is contraindicated in clients with suicidal ideation, those in labor or obstetric delivery, and children under 18 years of age. The route of administration is oral. For more details, click to review zolpidem.

Nursing Role: Assessment

As the nurse, before administering any medications for anxiety or insomnia you should:

Be familiar with the clients medical diagnoses. Identify the client. Obtain a health history, including medications (prescription, over-the-counter, and herbal). Identify if any drugs currently being taken have adverse effects of anxiety or insomnia.

Obtain a sleep history. Assess stressors. This includes identifying factors that may trigger feelings of anxiety or inhibit sleep.

Assess any coping patterns. Ask the client what he/she has already tried in an effort to reduce anxiety or insomnia. Identify which of these factors have worked and which have not worked.

Assess the potential for drug abuse or drug dependence. Review the chart and clarify any unclear orders. Obtain baseline vital signs and weight. Assess the clients risk for falls.

Nursing Role: Planning and Client Education

During the planning stage of the nursing process, you will work with clients to establish goals and outcomes related to managing their anxiety and/or insomnia. During this time,

you should provide education about signs and symptoms related to adverse reactions from medications, and when to seek medical attention for them. Caution clients not to discontinue taking their prescription without discussing it with their health care provider. Abruptly stopping medications may lead to rebound anxiety and insomnia. It is also appropriate to discuss potential complementary treatments with clients, such as counseling, meditation, relaxation techniques, and yoga. Teach clients the aspects of good sleep habits, such as:

Avoiding caffeine several hours prior to the usual bedtime Getting regular exercise Avoiding long naps during the day Keeping a regular schedule for sleeping and waking Avoiding eating heavy meals and drinking alcohol just prior to bedtime Avoiding drinking a large amount of fluid just before bedtime

Nursing Role: Implementation

During the implementation phase, when medication is administered for anxiety or insomnia, you should:

Assess for the desired therapeutic effect of the medication Monitor laboratory studies as indicated/ordered Assess for adverse effects and report them to the health care provider, including:
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Excessive drowsiness Respiratory depression

Monitor the clients:

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Vital signs and weight Neurological status, checking for signs of confusion, dizziness, or unresponsiveness Emotional status, checking for signs of depression Intake of stimulants, such as caffeine

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Nursing Role: Evaluation

During the evaluation stage of the nursing process, you will have an active part in appraising the effectiveness of pharmacotherapy. When evaluating how well the goals for your client have been met, you will need to consider the expected outcomes of administering anxiety and insomnia medications.

The goals of therapy include:

The client will experience the desired therapeutic effect (decreased anxiety and improved ability to sleep). The client will be free from adverse effects. The client will be able to verbalize an understanding of the drugs use, adverse effects, and contraindications or precautions. The client will demonstrate knowledge of appropriate self-administration of medication regarding dose, time, and when to notify the health care provider.