CPAN Case of the Month – March 2023
March's case of the month
Each month, PCPs call CPAN with a wide variety of mental health questions. Find out how CPAN helped a pediatrician with their 6-year-old patient with ADHD.
Patient: 17-year-old with anxiety
Reason for CPAN Consultation: PCP requested assistance with worsening symptoms.
The adolescent was an established patient, described as a “high achiever” in several areas of her life: she was successful in multiple sports, did well academically and had a positive friend group.
The PCP had previously treated for her for anxiety after her parents divorced. She was referred to therapy and when several sessions in therapy alone were not effective, the PCP suggested a trial medication: Prozac 20 mg. After several months, the PCP increased the 25 mg, which was reported to have helped.
The patient returned shortly after with worsening symptoms in the last 2-4 weeks, including “low motivation” to get out and do things. She was spending more time in her room, staying up at night and only sleeping 4-5 hours. She spent less time with friends and family, describing feeling uncomfortable when out of her room or when she goes out with friends. She now avoided those situations. The patient described feeling “dissociated” and described that as feeling like she was “in a dream.” She said she felt “unable to focus on her surroundings,” and it only occurred when she was around several people and away from her house.
While the patient was not suicidal, she described her mood as anxious and down. The decrease in sleep was unwelcome and not associated with any increase in energy or goal-oriented activity.
The CPAN psychiatrist believed the patient had symptoms of depression. However, the negative symptoms and unusual sensations were related to anxiety and could be subtle symptoms of a panic attack. CPAN encouraged the PCP to reassure the patient that these were common and treatable.
In addition to reassurance, the CPAN psychiatrist and PCP discussed increasing the medication to 50 mg daily to better control the baseline level of anxiety. Additionally, they discussed using Propranolol as needed to help before she goes out in public to reduce the likelihood of panic.
There were no contraindications to Propranolol, and the doctors both agreed to start 10 mg as needed daily and could increase to 20 mg as tolerated.