Anxiety disorders insomnia with, treatment

Once chronic insomnia has developed, it hardly ever spontaneously resolves without treatment or intervention. The toll of chronic insomnia can be very high and the frustration it produces may precipitate a clinical depression or an anxiety disorder. Insomnia is also associated with decreased productivity in the workplace and more frequent use of medical services. Einally, substance abuse problems may result from the inappropriate use of alcohol or sedatives to induce sleep or caffeine and other stimulants to maintain alertness during the day. 

Modulation of GABA receptors is also beneficial in the treatment of several neuropsychiatric conditions, including anxiety disorders, insomnia, and agitation. The mechanisms are not well understood but may work through a general inhibition of neuronal activity. Benzodiazepines and ethanol use the same mechanism to influence GABA receptors. This property is the basis for ethanol detoxification with benzodiazepines (Grobin et ah, 1998). 

The definition of desired therapeutic and side effects in the case of the benzodiazepines very much depends on the clinical problem in question. The sedative and hypnotic actions are desired effects in the treatment of insomnia, but undesired effects in the treatment of anxiety disorders. Effects that are usually undesired include daytime drowsiness, potentiation of the sedative effects of ethanol, and anterograde amnesia. They are mediated via the benzodiazepine site of GABAa receptors, since they can be antagonized with flumazenil. 

In the treatment of children and adolescents with anxiety disorders clinicians have a wide variety of pharmacologic options beyond the antidepressants (Shader and Greenblatt, 1995 Lydiard et ah, 1996 Riddle et ah, 1999). The benzodiazepines (BZs), with their favorable safety profile and quick onset of action, are attractive alternatives for the treatment of acute anxiety. While the clinical effectiveness of buspirone has not been proven in children, buspirone is used alone or in combination with other drugs in the treatment of anxiety disorders. The antihistamines are often used to treat insomnia and may reduce acute mild agitation. Zolpidem (Ambien) is occasionally used for its sedative properties. This chapter reviews the structure, proposed mechanisms of action, pharmacodynamic principles, and pharmacokinetic principles of these drugs. 

Anxiety and insomnia are prevalent symptoms with multiple etiologies. Effective treatments are available, but they vary by diagnosis. In most instances, the best course of action is to treat the underlying disorder rather than reflexively to institute treatment with a nonspecific anxiolytic. 

Khat may interact with drugs used in treatment of other diseases and produce emotional and mental disorders. For example, when combined with niridazole—a drug used in treating schistosomiasis (a parasitic disease endemic throughout Asia, Africa, and tropical America)—severe anxiety reactions, insomnia, and even psychoses may develop. Also, khat would be likely to react with other stimulants such as alcohol, coffee, or cigarettes, causing palpitations and agitation. 

In human studies, there is some evidence that withdrawal signs such as nervousness, anxiety and vertigo occur following sub-chronic administration of zopiclone but the frequency and intensity of the withdrawal effects are greater after conventional 1,4-benzodiazepines. No rebound effects have been seen in patients with insomnia who received zolpidem daily for 7-180 days. By contrast, after 3 weeks of abercamil treatment of patients with generalized anxiety disorder possible signs of withdrawal resulted, the incidence of these withdrawal effects being related to doses of abercamil administered. 

Patients with mild symptoms of alcohol withdrawal do not generally require medication therapy. Benzodiazepines, like diazepam or alprazolam, are the treatment of choice for patients with severe alcohol withdrawal syndromes like delirium tremens. Barbiturates can also be used for this disorder, but are often less prescribed because they are not as safe as benzodiazepines. Both barbiturates and benzodiazepines are effective in treating the anxiety, tremor, insomnia, and hand tremors associated with delirium tremens. 

Escitalopram was efficacious in patients with major depressive disorder in short-term, placebo-controlled trials, three of which included citalopram as an active control, and in a 36-week study in the prevention of relapse in depression (7). It has also been used to treat generalized anxiety disorder, panic disorder, and social anxiety disorder. Results also suggest that, at comparable doses, escitalopram demonstrates clinically relevant and statistically significant superiority to placebo treatment earlier than citalopram. The most common adverse events associated with escitalopram include nausea, insomnia, disorders of ejaculation, diarrhea, dry mouth, and somnolence. Only nausea occurred in more than 10% of patients taking escitalopram. 

A 27-year-old married woman developed symptoms of generalized anxiety disorder and was given buspirone 30 mg/day (32). During treatment she felt depressed and decided to take St John s wort. Two months later she started to have nervousness, aggressiveness, hyperactivity, insomnia, blurred vision, and very short periods of confusion and disorientation. The symptoms were consistent with serotonin syndrome. St John s wort was withdrawn and her symptoms resolved after 1 week. 

Valerian is promoted in the United States primarily as a sedative-hypnotic for treatment of insomnia, and as an anxiolytic for restlessness and sleeping disorders associated with anxiety (4,7). 

The adverse events profile for escitalopram is similar to that observed with Ri-citalopram in both major depression and anxiety disorders. Discontinuation rates due to adverse events were similar in patients receiving escitalopram or placebo in several trials. Nausea and ejaculatory problems were reported in both fully published trials in patients with major depression. In addition, diarrhea, insomnia, dry mouth, headache, and upper respiratory tract infections were experienced by patients receiving escitalopram, although the incidence of these events was not significantly higher than in patients receiving placebo. The recommended dose of escitalopram for the treatment of major depression is 10 mg/day, which, depending on the individual patient response, may be titrated up to 20 mg/day. 

In contrast to panic disorder, the somewhat more subtle and persistent symptoms of GAD do not always command immediate attention. Although patients with GAD may present with a primary complaint of anxiety, they are more likely to complain of a physical ailment or another psychiatric condition or symptoms, for example, depression or insomnia. As such, many patients with GAD will seek treatment from a primary care physician long before recognizing the need for mental health care despite readily acknowledging that they have been anxious virtually all of their lives. 

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