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

Bettina Bernstein, DO


August 17, 2022


Posttraumatic stress disorder was excluded by the absence of a traumatic event reported as a trigger for anxiety symptoms.[1]Attention-deficit/hyperactivity disorder (ADHD) was ruled out, as the only potential symptom of ADHD — the patient's impaired academic performance in Spanish — appeared directly related to anxiety triggered by the requirement to introduce himself to an unfamiliar person.[2] Moreover, he had no symptoms of hyperactivity or inattention at school or at home.

The patient and his caregivers reported no rule-breaking behavior, chronic irritability, or oppositional or defiant behavior. Thus, conduct disorder was excluded.[3]

Although the patient had some performance-related anxiety and worries about the well-being of family members from time to time, generalized anxiety disorder was a less likely diagnosis because his most frequent and disabling symptoms centered around dysphoric physical symptoms.[4] The asthma inhaler did not relieve his symptoms, and side effects of the inhaler, such as increased heart rate, may have worsened the anxiety symptoms.

Panic disorder best explains this patient's symptoms and presentation. It is characterized by frequent, severe episodes of anxiety and physical symptoms that occur with no identified trigger and can include discomfort such as stomachaches, chest pain or heart palpitations, breathlessness, and dizziness or presyncope.[5] Panic attacks can occur at any time, including while sleeping. Although the patient in this case does not exhibit a sense of terror, impending doom, or death, he shows many of the discomforts associated with panic attacks.

Anxiety disorders are common. They occur in as many as 5% of children younger than 12 years and in as many as 19% of children and adolescents younger than 18 years.[6] The presentation of anxiety can vary with age, beginning with separation anxiety, generalized worries, and somatic discomfort in younger children and specific phobias, panic disorder, and social anxiety in older youths.

Panic disorder often starts in childhood, and the severity of symptoms by adolescence can be disabling in nearly 45% of youths. Risk factors for anxiety disorders include a family history of anxiety; physical illness, including pulmonary disorders such as asthma; and cardiac disease, especially conditions such as mitral valve prolapse and regurgitation.[5,7] Studies have also found that anxiety disorders are associated with an earlier history of a shy temperament and tendency to become anxious or fearful in social situations, as was true for the patient in this case.[8]


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