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

Bettina Bernstein, DO


August 17, 2022

The presence of asthma can interact with anxiety symptoms such that it can be confusing to determine the driving factors.[9] Family history and air pollution exposure can be risk factors for asthma.[10,11] Asthma can also increase the risk for other internalizing disorders, such as depression.[12] Successful treatment of anxiety may help reduce the frequency and intensity of asthma symptoms.[13,14] Treatment of anxiety with corticosteroids is also standard preventive therapy for asthma.[15]

Caregiver responses to an anxious child should not be overlooked. The caregiver of a child with asthma is typically more involved and may adjust their behaviors to minimize the child's distress. This can extend to family accommodation or overprotection when the child reacts with distress to situations that trigger anxiety, which can interfere with the child gaining mastery over the anxiety. If acute asthma symptoms are not present, alternatives to medications such as bronchodilators, which can increase heart rate and anxiety, should be considered.[16]

Anxiety can be defined as an internal fear, worry, or nervousness that often includes a subjective feeling of distress, accompanied by heightened sympathetic nervous system arousal.[17] The feeling of distress can be intense and out of proportion to the situation the person is experiencing. The state of anxiety can result from an imagined or exaggerated perception of danger, and the typical reaction is avoidance of anything that might trigger the feeling of danger.

Anxiety can be adaptive when it signals the need to respond to an unsafe environment or during developmental stages when anxiety is typically observed, such as stranger anxiety by age 18 months and again by age 3 years. Excessive anxiety or anxiety that occurs without any known realistic trigger can hold a youth back from participation in everyday activities. Anxiety disorder, especially when chronic, can be associated with lower academic performance, maladaptive interpersonal functioning, depression, substance abuse, ADHD, conduct disorder, suicidal behaviors, self-harm, and even suicide.

As in this case, a comprehensive and thorough history-taking and physical examination should be performed when the patient has somatic symptoms. Although the cause of the symptoms may turn out to be anxiety, general medical conditions can accompany or drive symptoms. Examples of medical conditions that can mimic or cause anxiety symptoms include hyperthyroidism, hyperparathyroidism, pheochromocytoma, vestibular dysfunctions, seizure disorders, cardiac conditions, and pulmonary disorders such as asthma, as in this patient.[7]

Awareness of culture-bound syndromes is important. For example, taijin kyofusho, which occurs in Japanese and Korean cultures, is a syndrome in which a person is concerned about doing something or presenting an appearance that would offend or embarrass others and thus differs from social anxiety disorder.[18]

Some symptoms of ADHD, such as inattention, may resemble anxiety. However, if a child has symptoms of inattention only in anxiety-provoking situations, such as when called on to answer a question in class, this indicates that a diagnosis of ADHD is not primary.[2]

Although some of the criteria for generalized anxiety disorder were present in this case, including excessive and unrealistic emotional reactions, such as feeling overwhelmed, afraid, or worried in the context of everyday activities, the patient's symptoms were not triggered by a specific event or situation. This suggests that panic disorder is the more accurate diagnosis.[5,19]

General principles of anxiety treatment include addressing symptoms early to prevent the development of chronic anxiety, which can interfere with the achievement of age-appropriate developmental skills and can increase risk for other disorders, owing to potentially disabling symptoms such as insomnia.[20] Cognitive-behavioral therapy (CBT), exposure therapy, and acceptance and mindfulness-based therapy are well-known, effective, and evidence-based treatments for anxiety disorders.[21] CBT has the strongest evidence for the treatment of panic disorder.[22] Exposure therapy requires the identification of a specific trigger for anxiety symptoms, which appear not to be consistently present in the patient in this case.

Manualized programs include a psychoeducation component, real-life exposure, and social skills training, such as the Coping Cat program. This program is very appealing to children because it involves playing a video game that builds skills and also provides an intrinsic reward for participation.[23] Approaches that can be delivered effectively using the internet or virtual reality can be helpful for youth who are reluctant to engage in outpatient therapy or during periods when spikes in COVID-19 cases require patients to stay at home.[24]


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