Critical Thinking Case Studies

Jean Ivey, DSN, CRNP

A 10-Year-Old with Anxiety And History of Asthma

Kathleen A. Troup, Anthony Roberson
Case Presentation
ames is a 10-year-old Caucasian male who was brought to the authors psychiatric mental health outpatient clinic by his parents with the complaint of he is having trouble swallowing. His parents provided much of the clinical picture and history, since James did not voluntarily offer much conversation during the session. His father stated that James had strep throat about a month or two ago, and he noted that as time went on, James was not swallowing. Further, James was holding saliva in his mouth, only eating soft foods (for example, mashed potatoes, ice cream), and expressing more fears of choking. His father also recalled a past incident when James had swallowed a whole ice cube and feared choking. James will not eat meat, vegetables, or anything that needs to be chewed or that has texture. He repeatedly refers to that feeling in his throat and chest. His mother reported that James does not sleep well because he fears that he is going to die in his sleep from choking. James has had two attacks within four days related to his sense of not being able to breathe and swallow.
Kathleen A. Troup, MSN, RN, PMHNPBC, is a Faculty Member, University of Alabama at Birmingham, School of Nursing, Birmingham, AL. Anthony Roberson, PhD, PMHNP-BC, is an Assistant Professor, University of Alabama at Birmingham, Capstone College of Nursing, Tuscaloosa, AL.

During the first episode, James reported feeling like I was going to faint. Of the second incident he said, My heart is pounding, and I am sweaty, and I cant breathe good. His parents described him as making shallow, rapid, panting vocalizations. The use of his rescue inhaler did not relieve his symptoms. Both episodes resulted in emergency department (ED) visits where the physical findings (X-rays, cardiac and respiratory monitoring, pulmonary functions) were all normal. There was no evidence of cranial nerve (II-XII) dysfunction. Complete physical examination revealed no abnormal findings in head, neck, or thorax. The ED physician subsequently referred James to his long-time pediatrician for a follow-up visit, where James physical findings were again in the normal and expected range. The pediatrician prescribed alprazolam 0.25 mg one tablet three times a day as necessary and referred James to the authors psychiatric mental health practice for an evaluation.

for the past two years, his grades are good, and there are no reported behavioral problems. His parents report that James has stopped socializing with his friends, and that he seldom goes out of the house. Previously, he was interested in sports, especially football, but no longer expresses an interest in trying out for the school sports teams. His father reports a history of asthma, as well as an anxiety disorder and panic attacks, for which James takes a benzodiazepine (alprazolam) when necessary.

Physical Examination
General: T 98.4 F; P 80; R 16; BP 104/62. James has lost about 10 pounds since his fear of choking began. His build is average and is at the 50% for height, weight, and body mass index. Head and neck: No external deformities or lesions, no masses palpated. No discomfort reported with palpation of face, jaw, or neck. No abnormalities of lips, tongue, or gums. No dysphagia or chest discomfort with swallowing. No abnormalities in dentition. No hoarseness or difficulty with articulation. No excessive saliva noted; patient swallows without difficulty upon request. Respiratory: Bilateral vesicular breath sounds, no wheezing, rales, rubs, or dullness. No cough. Cardiovascular: Regular rhythm, normal rate, no murmurs. Neurological: Cranial nerves II-XII intact.

Family/Social History
James lives with his father and mother in a local urban area. Both parents are employed full-time. His parents are concerned and supportive. James has one younger brother (7 years old). No family relationship stressors are indicated. James is in the fifth grade in the public school system. His pediatrician diagnosed attention deficit hyperactivity disorder (ADHD) several years ago and prescribed methylphenidate. However, James has not taken the medication

Critical Thinking Case Studies is designed to test your problem-solving and decision-making abilities. Instructions: Read the symptom(s) above. Then outline how you would assess and manage the problem. Finally, compare your rationale and decision to that listed in the shaded area. Please submit material to: Pediatric Nursing; East Holly Avenue/Box 56; Pitman, NJ 08071-0056; (856) 589-7463 (fax) PEDIATRIC NURSING/May-June 2011/Vol. 37/No. 3 133

Critical Thinking Case Studies

What Is Your Assessment?

James initially exhibited signs and symptoms consistent with a diagnosis of an acute asthmatic attack. Shortness of breath is a symptom that occurs at the onset of the asthma attack, followed by those related to hypoxia pounding heart, chest pain, dizziness, tremulousness, sweating, the sensation of choking, and the fear of smothering or dying. However, at each visit to the ED, James findings were consistently normal. When the repeated visits did not yield a diagnosis, the pediatrician took the appropriate measures of assessing James respiratory function in the office. This evaluation ruled out physiologic causes independent of those that may have prompted the trips to the ED. The pediatrician then began alprazolam 0.25 mg three times a day as necessary, and the attacks did not recur. James is exhibiting signs and symptoms consistent with the diagnosis of panic disorder without agoraphobia as defined by the DSM-IVTR (American Psychiatric Association [APA], 2000). To make this diagnosis, a patient must meet the criteria for having a panic attack and have an absence of agoraphobia. A panic attack is defined as a discrete period of intense fear or discomfort, in which four or more symptoms develop abruptly and reached a peak within ten minutes (APA, 2000, p. 209). James exhibited more than four of the specified symptoms a) pounding heart, b) sweating, c) trembling, d) sensations of shortness of breath or smothering, e) a feeling of choking, f) chest pain, g) feeling dizzy, and h) fear of dying. All of these symptoms are consistent with those of an asthma attack. If they were manifest at the time of presentation to the ED, a diagnosis of acute asthma would likely be made in a child, especially if there had been a history of the same. Although it is important to emphasize that all episodes of respiratory distress should be viewed as actual airway obstruction until proven otherwise or relieved by appropriate interventions, knowledge of the signs and symptoms of anxiety gives the practitioner additional tools in considering other possible diagnoses. There is evidence that children with co-morbid anxiety disorders have an increased focus on symptoms and illness episodes (Kaplan & Sadock, 2007). Children may be 134

unable to distinguish between actual or perceived attacks, especially since there are similarities in signs and symptoms of anxiety and asthma. The repeated incidence of attacks with symptoms can create a vicious circle of fear the anticipation of an attack creates anxiety, and the anxiety produces symptoms mimicking asthma (Katon, Richardson, Lozano, & McCauley, 2004). There is also the possibility that the physiologic response to anxiety may trigger actual airway obstruction. The anxiety attack, or panic attack, may be the alarm reaction triggered by the sense of impending respiratory distress or suffocation (Pine, 1997). In a study of children with anxiety disorders, respiratory dysfunction (measures of tidal volume, minute ventilation, and end-tidal CO2) and severity of somatic symptoms are positively correlated (Katon et al., 2004). Because the link between anxiety and respiratory disorders is so strong, it is important to be aware of the influence one exerts on the other. In addition, these refractory symptoms can lead to the excessive use of oral alpha-2 agonists. These have a high side effect profile, including tremors, insomnia, and an overall exacerbation of anxiety (Kaplan & Sadock, 2007), and the cycle continues. Asthma is one of the most common chronic illnesses in children (Richardson et al., 2006). Anxiety disorders are the most common psychiatric illness diagnosed in children, affecting as many as 20% of children and adolescents (Birmaher et al., 2003). A quick diagnosis is crucial when assessing adolescents presenting with symptoms of asthma, but when findings are equivocal, it is equally crucial to consider the presence of a co-morbid disorder, such as anxiety or panic disorder.

The Rest of the Story

Panic disorders respond well to all three major classes of antidepressants selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOs), but SSRIs are preferred because of better tolerability (Lehne, 2010). The currently available SSRIs are citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Prozac WeeklyTM), paroxetine (Paxil, Paxil CR), and sertraline (Zoloft). The choice of medication should be made on the basis of low side effect profile; per-

haps consideration should be given to the positive response by a firstdegree relative with anxiety disorder. It is recommended that the dosing of any medication be kept as low as possible while monitoring the presence of side effects closely. Any increase in the dosing should be based on response and tolerance (Lehne, 2010). A lack of efficacy after four to six weeks may be an indication to increase the dosage of the SSRI (Birmaher et al., 2003). James was started on fluoxetine 10 mg every day, the low end of the dosing range, in an attempt to avoid possible side effects. James was continued on alprazolam 0.25 mg one tablet three times a day as necessary for anxiety. Although it was recommended that he continue with this dosing of the benzodiazepine, the plan of care included gradually decreasing the dosing of the alprazolam as the effects of the SSRI were being realized. Benzodiazepines relieve the immediate feelings of anxiety, but they are not recommended for long-term therapy because of the risk of dependence and severe withdrawal symptoms. SSRIs target specific neurotransmitters related to anxiety and can produce more consistent control of anxiety (Lehne, 2010). Full therapeutic effect of an SSRI is usually noticed over a period of 4 to 6 weeks (Kaplan & Sadock, 2007). At that time, the need for continued benzodiazepines or an increased does of the SSRI can be evaluated. Although fluoxetine is approved for use in the pediatric population (older than 7 years of age), the black box warning regarding increased risk of suicide in children and adolescents remains. The risk of suicide with SSRI use is higher when compared to placebo in children, adolescents, and young adults; however, it should be noted that the population addressed are those treated for depressive disorders. As with most other psychiatric disorders, concurrent psychotherapy often produces more dramatic and long-standing remission of anxiety disorders (Otto, Smits, & Reese, 2004). Therefore, James was referred to individual therapy in which the focus of treatment was cognitive behavioral therapy (CBT), in which patients are helped to see the distortions in thinking that maintain their symptoms. In these cases, they recognize the onset of anxiety states along with their undesirable responses to anxiety. Patients can learn alternative ways of coping, perhaps through

PEDIATRIC NURSING/May-June 2011/Vol. 37/No. 3

A 10-Year-Old with Anxiety and History of Asthma relaxation techniques and self-awareness of coping skills (Evans et al., 2005). CBT is particularly effective in the treatment of panic disorder as a first-line therapy when pharmacologic treatment is less than efficacious or when patients want to discontinue the use of pharmacologic agents (Otto et al., 2004). James was seen for follow-up assessments at two-, four-, and sixweek intervals after starting the fluoxetine. The two-week visit was scheduled primarily for the purpose of assessing James for any adverse side effects to the fluoxetine and to encourage him to continue treatment (pharmacological and psychotherapy). At this visit, James continued to express fears of choking while eating and had made very little changes in his diet. It was recommended that he continue on fluoxetine 10 mg every day and alprazolam 0.25 mg three times a day as necessary for anxiety. The four-week follow-up visit focused more on assessing the specific signs and symptoms related to the anxiety. James mother reported he was less anxious and that he had begun to eat more solid foods, although preferring to eat the softer foods most of the time. She also reported a decrease in his complaints of not being able to breathe, and he had expressed decreased fears of choking and dying over the past two weeks. James continued in psychotherapy and had attended a total of three visits to date. He was continued on fluoxetine with a dosing increase to 20 mg every day. He continued on the alprazolam, but the dosing had been decreased on his own to 0.25 mg twice a day as necessary. The six-week follow-up visit revealed the most significant changes. James was eating all foods he had previously enjoyed, including steak, pizza, hamburgers, and various vegetables and fruits. He expressed no fears of choking or dying, and his sleep was really good. He had once again decreased the use of alprazolam to one tablet three to four times a week and continued on the fluoxetine 20 mg every day. He is scheduled to be seen monthly for the next three to four months, then once every three to six months or as necessary if the symptoms are stabilized. James also continues in individual psychotherapy, which has been a crucial element in the overall treatment process. It is planned to discontinue the alprazolam on the next visit and continue with fluoxetine 20 mg every day for at least one year.
Evans, W., Foa, E., Gur, R., Hendin, H., OBrien, C., Seligman, M., & Walsh, B. (2005). Treating and preventing adolescent mental health disorders: What we know and what we dont know. New York: Oxford University Press, Inc. Kaplan, H.I., & Sadock, B.J. (2007). Synopsis of psychiatry: Behavioral sciences/clinical psychiatry (10th ed.). Philadelphia: Lippincott, Williams & Wilkins. Katon, W., Richardson, L., Lozano, P., & McCauley, E. (2004). The relationship of asthma and anxiety disorders. Psychosomatic Medicine, 66, 349-355. Lehne, R. (2010). Pharmacology for nursing care (7th ed.). St. Louis, MO: Saunders Elsevier. Leupoldt, A., Ehnes, F., & Dahme, B. (2006). Emotions and respiratory functions in asthma: A comparison of findings in everyday life and laboratory. British Journal of Health Psychology, 11, 185198. Otto, M.W., Smits, J.A.J., & Reese, H.E. (2004). Cognitive behavioral therapy for the treatment of anxiety disorders. Journal of Clinical Psychiatry, 65, 3441. Pine, D. (1997). Childhood anxiety disorders. Current Opinion in Pediatrics, 9, 329338. Richardson, L., Lozano, P., Russo, J., McCauley, E., Bush, T., & Katon, W. (2006). Asthma symptom burden: Relationship to asthma severity and anxiety and depression symptoms. Pediatrics, 118, 1042-1051.

Implications for Practice

The number of children suffering from anxiety disorders with physical manifestations may be much more prevalent than currently recognized. An unpleasant or anxious mood is associated with diminished respiratory function in laboratory settings and in normal living conditions (Leupoldt, Ehnes, & Dahme, 2006). The subjective nature of this entity makes continued research on the relationship of anxiety and respiratory distress necessary before the mechanisms can be defined with certainty. Although there is a need for increased studies, there is enough evidence to warrant that health care professionals be aware of the link when considering their differential diagnoses. The child or adolescent identified as having a possible anxiety disorder should be referred to a child and adolescent mental health practitioner for thorough evaluation, diagnosis, and treatment. References
American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Birmaher, B., Axelson, D., Monk, K., Kalas, C., Clark, D., Ehmann, M., Brent, D. (2003). Fluoxetine for the treatment of childhood anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 42(4), 415-423

Additional Reading
Baron, C., & Marcotte, J-E. (1994). Role of panic attacks in the intractability of asthma in children. Pediatrics, 94, 108110.

PEDIATRIC NURSING/May-June 2011/Vol. 37/No. 3

135

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.