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

Bettina Bernstein, DO


August 17, 2022

For the patient in this case, CBT alone was not sufficient to address his intense baseline anxiety. To enable a patient to participate in therapy, medication with a favorable safety profile, such as a selective serotonin reuptake inhibitor, can be helpful. Although addictive medications such as benzodiazepines are effective, they should be avoided, owing to the risk for dependence and misuse.[21] A recent double-blind study concluded that children do not require adjunctive antianxiety medications.[25]

Future directions of research include combining CBT with approaches that use the diving reflex to improve the balance of parasympathetic to sympathetic nervous system inputs. Panic disorder is known to be provoked by stimuli such as carbon dioxide in lactate-induced panic attacks, due to the increase in stimulation from the sympathetic nervous system. Other approaches include the use of alpha agonists to modulate the adrenergic system to reduce sympathetic overactivation, as well as the use of glutamatergic modulators (eg, memantine, minocycline, and D-cycloserine).[26] In addition, supplements and herbal preparations such as lavender, valerian, and threonine can reduce the associated increase in sympathetic nervous system activation that occurs with anxiety and that sustains its dysphoric physical and emotional symptoms.[27]

During a brief initial period, the patient in this case missed 1 day of school after he had chest pains and went to the ED, and again missed 1 day of school after he had been home for a week-long holiday and had difficulty returning to school. However, he had a good response after 6 weeks of weekly outpatient individual and family therapy, which included the use of CBT and adjunctive medication (sertraline). He reported reduced severity of anxiety, from 4 or 5 to 1 or 2, with 5 indicating the most intense feeling of anxiety. His academic functioning at school improved and he made the honor roll. In addition, the intensity and frequency of his asthma symptoms diminished, and he no longer needed to use a rescue inhaler.


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