Psychiatry Case Challenge: Nightmares and Poor Grades in a Third Grader Allergic to Cats

Bettina Bernstein, DO


August 17, 2022

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


The mother of a 9-year-old boy reports that her child "cannot catch his breath." He has a 5-year history of asthma triggered by colds and allergies to cat dander and pollen, which responds to inhaled albuterol and fluticasone propionate. When the patient was 5 years old, he had an emergency department (ED) visit for an acute asthma attack triggered by a cold. He began preventive fluticasone therapy at age 8 years, with a good response. He has not had any surgeries or overnight hospitalizations.

The child is a slender, self-identified cisgender male. His mother reports that he weighed 7 lb 11 oz (3.49 kg) at birth and that she had a full-term, uneventful pregnancy and vaginal delivery. He babbled by age 2 months, sat by 6 months, walked by 1 year, was fully toilet trained and spoke three-word sentences by 2.5 years, and was able to ride a bicycle by 6 years. He began preschool at age 3 years and kindergarten at 6 years, and is academically on grade level for third grade. The patient lives with his biological parents, who are married, and a 6-year-old sister in an urban setting not far from an airport.

Neither the patient nor his caregivers report any traumatic events, such as abuse of any kind, neglect, witnessing domestic or community violence, or sudden losses. The only stressor was the COVID-19 pandemic, which the patient is not concerned about currently. The past 2 years were challenging at times for the family owing to the pandemic; however, they know no one who died of COVID-19, they were able to manage financially, and the patient attended school virtually for about 18 months. During that time, he played online games and used videochat apps with his friends.

For the past 6 months, he has been regularly attending school in person. His teacher has not had any serious behavioral concerns; however, when school was virtual, his mother noticed that the patient was occasionally shy and would answer questions only if the teacher directly addressed him. His mother adds that he has always been a quiet child, is able to make one or two close friends, and gets along well with others, but in a larger social situation, he tends to talk to people he knows and does not mingle with others. The patient reports that lately his grades have gone down and suspects that it might be because of Spanish class. Part of his grade is based on introducing himself in Spanish to an unfamiliar student, and he says that he does not like to talk to people he does not know well. He reports such interactions as stressful to him.

The patient also says that he occasionally wakes up in the middle of the night for no reason and is frightened and feels that he cannot breathe. He has nightmares in which his parents are in the hospital and he is alone. Afterward, he sometimes crawls into his parents' or his sister's bed and is able to fall asleep. On the night before an important test at school, he also has difficulty falling asleep. He worries that he will not get a good grade and will disappoint his parents.

When questioned further about his anxiety, the patient says that he also has "that feeling" during recess, which he describes as "a tightness" in his chest. He has used his asthma inhaler but it seems to have no effect. He sometimes feels even more tightness after using the inhaler and his heart beats rapidly, which increases his sense of breathlessness. These periods of tightness last about 10 minutes. At those times, he goes to the school nurse's office. He feels slightly better after he sits for a while and is then able to return to class, but he misses playing with his friends at recess. When questioned about other situations that might cause anxiety, he says that he is slightly worried about an upcoming school play. However, the tightness sensations often occur out of the blue.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.