Sleep Disorders: Diagnosis and Management

This assignment delves into the complexities of sleep disorders, encompassing their classification, underlying causes in various conditions like COPD and PTSD, and the multifaceted impact on individuals. It examines different management approaches, including pharmacotherapy (with specific drug examples) and behavioral therapies like Cognitive Behavioral Therapy for Insomnia (CBT-I). The discussion also touches upon the importance of signal analysis in sleep diagnostics and the interplay between obesity and obstructive sleep apnea.

ANXIETY AND SLEEP DISORDER 1
Anxiety and Sleep Disorder
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Word count: 3000

ANXIETY AND SLEEP DISORDER 2
Contents
Introduction......................................................................................................................................2
Anxiety............................................................................................................................................2
Aetiology......................................................................................................................................2
Pathophysiology...........................................................................................................................3
Diagnostic tools............................................................................................................................4
General Anxiety Disorder-7 (GAD-7).....................................................................................4
Beck Anxiety Inventory (BAI).................................................................................................5
DSM-IV-TR diagnostic tool.....................................................................................................5
Hospital Anxiety and Depression Scale (HADS).....................................................................5
Treatment.....................................................................................................................................6
Pharmacotherapy......................................................................................................................6
Non-pharmacologic therapy.....................................................................................................6
Sleep Disorder.................................................................................................................................7
Aetiology......................................................................................................................................7
Medical conditions...................................................................................................................7
Psychiatric conditions...............................................................................................................8
Environmental conditions.........................................................................................................8
Pathophysiology...........................................................................................................................8
Diagnostic tools............................................................................................................................9
Treatment...................................................................................................................................10
Non-pharmacological.............................................................................................................10
Pharmacological therapy........................................................................................................11
Management strategies for DF.......................................................................................................12
Counseling.................................................................................................................................12
Medication.................................................................................................................................13
Conclusion.....................................................................................................................................13
References......................................................................................................................................14

ANXIETY AND SLEEP DISORDER 3
Anxiety and Sleep Disorder
Introduction
Anxiety is a reaction to a fearful or stressful circumstance and might also occur due to
illness. In most cases, the symptoms of anxiety are short-lived and may not affect normal
function. Excessive anxiety might cause irrational thinking, behaviour problem and sleep
problems. Sleep disorders are caused by several other factors other than anxiety. Studies link
anxiety to environmental and genetic factors. This scholarly paper is based on a case study of DF
who is experiencing nightmares due to anxiety after being involved in an accident. It will
describe the aetiology and pathophysiology of anxiety and sleep disorder and the diagnostic tools
available. Additionally, the study will discuss agents available for the treatment of anxiety and
sleep disorder. Finally, the paper will propose reasonable management strategies for DF.
Anxiety
Aetiology
The initiation and expression of anxiety are linked to genetic, environmental, and
psychosocial factors. Even though empirical evidence links the occurrence of anxiety to genes,
no definitive gene has been identified as being the causative factor for anxiety disorder (1).
Anxiety might run in the family, which increases the chances of being inherited. Environmental
stresses that might cause anxiety include exposure to life stressors or breakup of an important
relationship. Stress might play a fundamental role in the expression and progression of anxiety.
The inability to cope with stressful events might increase the chances of stress in some
individuals. Childhood trauma is another environmental factor that can cause anxiety.

ANXIETY AND SLEEP DISORDER 4
Physical disorders, use or withdrawal of a drug are all risk factors for anxiety disorder.
Physical disorders that can cause anxiety are heart disorders, hormonal disorders and lung
disorders. A variety of drugs have been linked to the increased risk of developing anxiety. Some
of the most critical drugs in the occurrence of anxiety are alcohol, caffeine, cocaine and
prescription drugs like corticosteroids (2). An individual who withdrawal from sedatives or
alcohol has a risk of presenting with anxiety disorders like restlessness.
Psychodynamic theory is the first theory that attempts to explain the aetiology of anxiety.
Psychodynamic theory elucidates anxiety as a conflict between ego and id. Natural impulsive
and aggressive drives might be experienced as unacceptable leading to repression. The repressed
drives might break through repression and cause automatic anxiety. Another theory that attempts
to explain the aetiology of anxiety is a cognitive theory. According to cognitive theory, anxiety is
the propensity to elevate the possibility of danger. As such, patients presenting with anxiety
disorders tend to avoid the events and places they think are dangerous. For instance, they avoid
heights and crowds (3).
Pathophysiology
Key brain parts including the amygdala and thalamus play a vital role in the occurrence
of anxiety disorders. These parts of the brain create the important prerequisites of the nervous
detection and response system. Thalamus offers the first real processing part to organise sensory
data gotten from the surrounding. The thalamus transmits information to cortical centres for
processing and then to amygdala for assessment of highly charged emotional information. It is
the amygdala that offers emotional valence (1). The interaction of these two parts allows the
organism to act swiftly on intricate but important events. An event or stimulus becomes an

ANXIETY AND SLEEP DISORDER 5
anxiety if the activity of fear-response network results in maladaptive distress or behaviour.
Thus, some events might not be interpreted as anxiety.
Besides, neurotransmitters play an important role in the occurrence and expression of
anxiety. The symptoms of anxiety are also evident due to the interaction of the brain, peptides
and neurotransmitters. Dopamine, serotonin and norepinephrine are some of the major mediators
of anxiety disorder symptoms. Gamma-aminobutyric acid (GABA) has also been characterised
by its involvement in the expression of anxiety (2). A sequence of reactions occurs before the
symptoms of anxiety are expressed. The hypothalamus receives signals from the amygdala. The
signals influence the nervous system to impact heart rate and blood pressure as well as stress-
associated changes. The amygdala further affects the HPA axis resulting in the secretion of stress
hormones. One of the most important stress hormones that are secreted is the cortisol (4).
Cortisol can damage the brain if it is escalated for extended periods. Apart from the brain,
cortisol might also damage other vital body organs. This aspect explains why anxiety should be
addressed early. The knowledge on how amygdala influences the fear response is important
because it offers valuable targets for current pharmacological treatments.
Diagnostic tools
General Anxiety Disorder-7 (GAD-7)
The GAD-7 is an effective tool for detecting general anxiety disorder in primary care
patients. There is also a short version of the GAD-7 which is the GAD-2. The GAD-2 comprises
of two questions that test whether a patient has anxiety. The self-reporting questionnaire enables
the expeditious detection of GAD. Clients are asked whether they have been troubled by any

ANXIETY AND SLEEP DISORDER 6
anxiety associated issue in the last two weeks and answer seven questions on a 4-point scale (5).
GAD-7 is applied due to its sensitivity.
Beck Anxiety Inventory (BAI)
The BAI diagnostic tool consists of 21 items that measure the severity of anxiety. The 21
items describe different signs of anxiety that occur in the general public. Patients are requested to
rate how much they are disturbed by symptoms of anxiety in the last one week. This diagnostic
tool uses a four-point scale from zero to three. Individuals whose scores are above 21 points are
deemed to have symptoms of anxiety. BAI is effective for evaluating the severity of different
anxiety disorders such as social phobia, panic disorder (6).
DSM-IV-TR diagnostic tool
DSM-IV-TR is used to diagnose generalised anxiety disorder and is organised into a 5-
part axial system (7). Axis one consists of clinical disorders commonly accompanied with mental
disorders. Axis two comprises of intellectual disabilities as well as personality disorders. The
other axes comprise of environmental, psychosocial, medical and childhood factors.
Hospital Anxiety and Depression Scale (HADS)
The HADS has two independent scales, one for depression and one for anxiety. The
design of this tool aims to prevent content overlap. Even though this tool offers great
psychometric scale for the two scales, the distinction of the scales is determined by the
participants of the study. This tool has a simple design, yet it is reliable. The use of the term
“hospital” suggests that the tool is suitable for hospital settings alone. However, HADS has been
successfully used in settings outside hospital such as in the community and primary care settings
(8).

ANXIETY AND SLEEP DISORDER 7
Treatment
Pharmacotherapy and non-pharmacotherapy are the main approaches to the management
and treatment of anxiety. The treatments of anxiety are personalised based on the symptoms of
the patient, health status, age, comorbid and preferences.
Pharmacotherapy
Prescription drugs that are used for managing general anxiety disorders are hydroxyzine,
buspirone, benzodiazepines, pregabalin, benzodiazepines and antidepressants (9).
Antidepressants are more preferred than benzodiazepines for the management of general anxiety
disorder because their side effects are tolerable and lack risk of dependency. They are also
efficient in managing comorbid conditions. However, benzodiazepines are the most effective
drugs in managing the symptoms of anxiety in the short-term (1). Benzodiazepines are the most
effective drugs for the management of anxiety symptoms in the short-term. Individuals who are
experiencing sleep disturbances can control the problem using benzodiazepines. In case a patient
has anxiety symptoms but does not present with depression symptoms, they are advised to use
pregabalin and buspirone. Even though hydroxyzine is effective in managing anxiety disorders, it
is unsuitable for in the long-term because of its side effects.
Non-pharmacologic therapy
Stress management, exercises, psychoeducation and psychotherapy, are classified as non-
pharmacological therapy (1). Education is designed to address relevant information on general
anxiety disorder as well as its management. The most effective education advises patients to
withdraw stimulants. They are informed how to avoid alcohol, caffeine and diet pills. Cognitive-
behavior therapy (CBT) is an effective psychological therapy for patients with general anxiety

ANXIETY AND SLEEP DISORDER 8
disorder (10). In the short-term, CBT focuses on educating clients how to resume the activities
they have been avoiding due to anxiety. Most patients with anxiety have reported success after
using CBT.
Sleep Disorder
Aetiology
Sleep disorders increase with age and are common among adults. The most common
types of sleep disorders are insomnia, sleep-related breathing disorders and restless legs
syndrome (RLS) (11). The causes of sleep disorders can be classified as psychological, medical
and environmental. People with sleep disorders always exhibit or complain about concomitant
signs such as daytime sleepiness. In some cases, a bed partner might detect hallmark symptoms
of sleep disturbances.
Medical conditions
Congestive heart failure and ischemia are the cardiac conditions that might result in the
occurrence of sleep disorder. Besides, neurological illnesses such as dementia, stroke, peripheral
nerve damage and degenerative conditions may lead to disordered sleep. Endocrine problems
impacting sleep are associated with menopause, hyperthyroidism as well as pregnancy.
Pulmonary illnesses such as COPD and asthma have been linked to disordered sleep (12).
Several gastrointestinal conditions are also responsible for the occurrence of sleep disorder.
Various substances such as caffeine and alcohol may cause insomnia.

ANXIETY AND SLEEP DISORDER 9
Psychiatric conditions
Most psychiatric disorders tend to co-occur with other medical conditions. Depression is
among the medical conditions that cause alterations to the normal sleep patterns. Empirical
evidence suggests that about 40 percent of the people with depression also have insomnia.
Likewise, PTSD and anxiety disorders increase the risk of sleep disturbances (13). Even the
prescribed drugs that are used to manage these psychiatric conditions increase the chances of
sleep disorder. For instance, antidepressants tend to interfere with normal sleep pattern.
Environmental conditions
Certain environmental factors might predispose an individual to sleep disturbances. Life-
threatening events have been found to cause insomnia. The work structure including shifts and
working hours might result in changes in altitude. Environmental noise and extremely warm
temperatures might lead to sleep deprivation (14).
Pathophysiology
Sleep is influenced and controlled by the suprachiasmatic nucleus in the brain. This
nucleus control circadian rhythm. Sleep is divided into two main categories depending on muscle
contractions and movement of the eyes. The first type of sleep is rapid-eye-movement (REM)
sleep. REM sleep is characterised by the movement of eyes and dreaming, but the body is always
paralysed. The second type of sleep is Non-REM (NREM) sleep (15). This type of sleep
comprises of stages one to four. Stage one is a transition point between wake and sleep. People
get a lot of sleep in stage two. The other two stages, three and four are clustered together and
termed as deep sleep or delta sleep.

ANXIETY AND SLEEP DISORDER 10
Distractions in the patterns of REM or NREM sleep occur in individuals who develop
sleep disorders. There are intricate sequences of biological processes that influence the sleep-
wake cycles. The suprachiasmatic nucleus that has been mentioned in a previous paragraph is
considered to be the body’s anatomical timekeeper. This nucleus is responsible for the secretion
of melatonin, which occurs after every 24 hours (16). When subjected to bright light, pineal
gland releases low amounts of melatonin. Thus, the level of this secretion is low during the
daytime. Some neurotransmitters play a fundamental role in sleep. These neurotransmitters are
serotonin, norepinephrine and acetylcholine. Conversely, dopamine is linked to wakefulness
(14). Other neurotransmitters that are associated with wakefulness are hypocretin, histamine and
substance P. It is evident that cognitive, physiologic and cortical arousal is critical in the
pathophysiology of sleep disorders.
Diagnostic tools
Various tools are used to diagnose sleeping disorders. The primary tool that is used to
diagnose sleep disorders is a polysomnography (PSG). This tool records electroencephalogram
(EEG), electromyogram (EMG), electrooculogram (EOG) and electrocardiogram (ECG) (17).
Other aspects that are recorded include oximetry, airflow, abdominal and thoracic movements.
The onset of sleep, sleep levels, arousal, eye movements, heart rhythm, respiratory effort and
arrhythmias are also recorded. ECG is useful for detecting phenotyping and apnoea sleep
sections. It is also useful for rhythm measurements and HR. PSG can be used to monitor sleep at
home (18). Daytime sleep is also monitored to determine the extent of sleep disorder in a
patient. However, daytime sleep might be monitored when the patient manifests significant
symptoms of sleep disorders. Multiple sleep latency tests (MSLT) and maintenance of

ANXIETY AND SLEEP DISORDER 11
wakefulness test (MWT) are the primary techniques for measuring daytime sleep (1). Epworth
Sleepiness Scale (ESS) is another tool that is used to assess sleepiness. The ESS comprises of a
simple questionnaire that forecasts subjective sleepiness.
Treatment
Non-pharmacological
Losing weight is among the most effective non-pharmacological techniques of managing
sleep apnea (19). Patients are guided to set goals for weight loss, which might entail daily
exercises and diet management. Some patient with sleep disorders might be sleepwalkers.
Providers may establish approaches to alleviate the problem of sleepwalking in these patients.
This approach would also prevent the risk of getting hurt at night. Another treatment method is
light-phase shift therapy. This therapy is appropriate for sleep disorders linked to circadian
rhythm abnormalities. The sleep pattern can be normalised by exposing patients to bright light
(14).
Cognitive behavioural therapy (CBT) is another treatment technique that is widely used
for sleep disorders. Specifically, CBT is used for the treatment of insomnia. However, CBT is
only effective in the short-term and might not be effective in some patients. One study involving
160 adults experiencing insomnia revealed that CBT is effective. The patients exhibited
substantial recovery in time wake and sleep latency (20). The combination of CBT with other
treatments such as zolpidem is more effective than CBT alone. The recent treatments comprise
the use of software programs to record sleep behaviour and cycles. This non-pharmacological
therapy entails wearing a wrist band or motion detection technology integrated into a
smartphone. The software program gathers information that can be used to determine quality and

ANXIETY AND SLEEP DISORDER 12
duration of sleep (14). The information can be used to suggest methods of refreshing the sleep. A
device can even include an alarm that is designed to prevent disturbing the patient from sleep.
Pharmacological therapy
Different medications have been introduced to treat sleep disorders. Drug therapy is
mainly used to manage sleep disturbances in the short-term. Hypnotic drugs are recommended
for short-term use such as two weeks. Nevertheless, for patients with chronic insomnia, hypnotic
drugs may be used for long, but monitoring is needed to make sure patients use drugs
appropriately. Hypnotic drugs also have addictive effects (21). Chloral hydrate is occasionally
used due to safety concerns and undesirable side effects.
Over-the-counter drugs have also been adopted for the management of sleep disorders.
These include drugs that inhibit the histamine type 1 receptor. Over-the-counter drugs are less
costly and assist certain patients to address sleep disorders. Patients should use such drugs with
precaution because of their anticholinergic properties. Besides, many of these medicines take
long to act, and their sedative impacts persist for more than one day.
The most current drugs for treating sleep disorders are zaleplon and zolpidem. The U.S.
Food and Drug Administration (FDA) approve these two drugs. FDA has also recommended
eszopiclone for long-term use in the treatment of insomnia. These drugs have been approved due
to their effectiveness and low risk of adverse side effects. Other drugs that have been approved
by FDA are Tasimelteon and Suvorexant (14). These drugs are administered based on the
condition of the patient, efficacy and prosperity to induce side effects.

ANXIETY AND SLEEP DISORDER 13
Management strategies for DF
DF can use both pharmacological and non-pharmacological interventions to get better
sleep. The patient started experiencing sleep disturbances after an accident. Thus, the treatment
approaches should not interfere with her current condition of DF. Counseling will be important
for DF to sleep better.
Counseling
DF should first consider her diet as well as physical activity. No specific diet can be used
to manage insomnia. However, DF should avoid large portions of meals and spicy foods at least
three hours before proceeding to sleep. DF should keep away items that result in sleep
disturbance like caffeine and alcohol. Caffeine is contained in certain drinks such as coffee and
tea and should be avoided late in the day. Alcohol which is contained in alcoholic drinks might
create the illusion of better sleep, but it negatively impacts sleep architecture. Nicotine, which
can be compared with caffeine is a stimulant and should be avoided few hours before sleep time
(22). A good practice for DF is to avoid taking these substances in the afternoon because their
stimulating effect might persist into the night. DF can consume foods that contain tryptophan
because they have higher chances of inducing sleep. An example of good food is warm milk.
Additionally, DF can embrace relaxation techniques just before bedtime (23). DF should
exercise daily to improve her condition. Evidence suggests that strenuous exercises during the
day might lead to comfortable sleep. DF should avoid strenuous exercises at least three hours
before bedtime. Such exercises might result in initial insomnia. The client should avoid any
stimulating activity three hours before bedtime. For instance, DF should avoid tense movies and
thrillers. The patient should further embrace a regular sleeping and waking time. She should

ANXIETY AND SLEEP DISORDER 14
avoid naps because they can have an adverse impact on her sleeping patterns. In case, DF starts
struggling to sleep she should get up and wait for sleep to come (14).
Medication
The best medication for DF to get better sleep is zolpidem. The duration of action of
zolpidem is six to eight hours, and the daily dose range is five to ten mg. Several specific reasons
make zolpidem appropriate for DF. The pathway for the drug is oxidation and has short-
moderate duration (24). Zolpidem has no impact on sleep architecture and is has the potential of
sedation.
Conclusion
Sleep disorders and anxiety are normal occurrences that are prevalent in the society.
These problems tend to disappear after a short time, but they might be long-lived in some
patients. As indicated in the case study, anxiety might lead to sleep disturbances. Early detection
and treatment of sleep disorders and anxiety are needed to prevent significant adverse outcomes.
Both pharmacological and non-pharmacological treatments have been found effective for
managing these problems. DF is advised to modify her lifestyle and use zolpidem to get better
sleep.

ANXIETY AND SLEEP DISORDER 15
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