Clinical Pharmacology and Therapeutics

ANXIETY 107
and daytime sleeping should be discouraged. Increased
daytime exercise improves sleep at night.
• Alcohol should be avoided because it causes rebound
restlessness and sleep disturbance after the initial sedation
has worn off. Tolerance and dependence develop rapidly.
It also causes dehydration (gueule de bois) and other
unpleasant manifestations of hangover.
SPECIAL PROBLEMS AND SPECIAL GROUPS
JET LAG
Jet lag consists of fatigue, sleep disturbances, headache and difficulty
in concentrating. It is due to mismatching of the body clock
(circadian dysrhythmia) against a new time environment with
its own time cues (Zeitgebers). Resetting the internal clock is hastened
by conforming to the new time regime. Thus, one should
rest in a dark room at night, even if not tired, and eat, work and
socialize during the day. Sufferers should not allow themselves
to sleep during the day (easier said than done!). Taking hypnotics
at night can make things worse if sleepiness is experienced
the next day. However, short-acting benzodiazepines may be
effective if taken before going to bed for two or three nights.
Melatonin is of uncertain usefulness but may help sleep
patterns, and improves daytime well-being if taken in the
evening. It is not generally available in the UK, although it is
in several other countries including the USA.
NIGHT WORK
Night work causes more serious sleep difficulties than jet lag
because hypnotics cannot be used for long periods. Moreover,
drug-induced sleep during the day precludes family and other
non-work activities. A better strategy is to allow the subject to
have a short, non-drug-induced sleep during the night shift.
This improves efficiency towards the end of the night shift and
reduces sleep needs during the day.
CHILDREN
The use of hypnotics in children is not recommended, except
in unusual situations (e.g. on the night before an anticipated
unpleasant procedure in hospital). Hypnotics are sometimes
used for night terrors. Children are, however, prone to experience
paradoxical excitement with these drugs. Promethazine,
an antihistamine which is available without a prescription, is
often used, but is of doubtful benefit.
ELDERLY
Anxiety and insomnia are prevalent in the elderly, for a variety
of psychological and physical reasons. As a rule, elderly
patients are more sensitive to the action of central nervous system
(CNS) depressant drugs than younger patients, and the
pharmacokinetics of these drugs are also altered such that their
action is more prolonged with increasing age. Hypnotics
increase the risk of falls and nocturnal confusion. Even shortacting
drugs can lead to ataxia and hangover the next morning.
In the treatment of insomnia, when short-term treatment
with drugs is considered necessary, short-acting hypnotics
should be used in preference to long-acting drugs but with
explanation from the outset that these will not be continued
long term. (Short-acting benzodiazepines have the greatest
abuse potential.) Insomnia occurring in the context of documented
psychiatric disorders or dementia may be better
treated with low doses of antipsychotic drugs.
Case history
A 42-year-old man with chronic depression presents to his
general practitioner with a long history of difficulty in sleeping
at night, associated with early morning waking. His general
practitioner had made the diagnosis of depression and
referred him some years previously for cognitive behavioural
therapy, but this had not resulted in significant improvement
of his symptoms. His difficulty in sleeping is now interfering
with his life quite significantly, so that he feels tired most
of the day and is having difficulty holding down his job as
an insurance clerk. The GP decides that he would benefit
from taking temazepam at night; he prescribes him this,
but says that he will only give it for a maximum of a month,
as he does not want his patient to become addicted.
Question 1
Is this the correct management?
Question 2
What would be a suitable alternative treatment?
Answer 1
No. Although the benzodiazepine might help in the short
term, it does not provide the patient with a long-term solution,
and does not tackle the root cause of his insomnia.
Answer 2
A more appropriate treatment would be with a regular
dose of a sedating antidepressant drug, for example amitriptyline
at night.
ANXIETY
Anxiety is fear and is usually a normal reaction. Pathological
anxiety is fear that is sufficiently severe as to be disabling. Such
a reaction may be a response to a threatening situation (e.g. having
to make a speech) or to a non-threatening event (e.g. leaving
one’s front door and going into the street). Episodes of paroxysmal
severe anxiety associated with severe autonomic symptoms
(e.g. chest pain, dyspnoea and palpitations) are termed panic
attacks and often accompany a generalized anxiety disorder.
GENERAL PRINCIPLES AND MANAGEMENT OF
ANXIETY
• Distinguish anxiety as a functional disturbance from a
manifestation of organic brain disease or somatic illness
(e.g. systemic lupus erythematosus).
• Assess the severity of any accompanying depression,
which may need treatment in itself.
• Most patients are best treated with cognitive therapy,
relaxation techniques and simple psychotherapy and
without drugs.
• Some patients are improved by taking regular exercise.
• In severely anxious patients who are given anxiolytic drugs,
these are only administered for a short period (up to two
to four weeks) because of the risk of dependence.