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Case Study: What’s Up With Suzanne?

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“I’m so busy that I barely have time to sleep! And when I do get to bed, I’m having trouble sleeping.”

Case: Suzanne, a 35-year-old mom of three, presents at your office for her annual physical.

Past medical history: Appendectomy, age 22. Seasonal allergies since childhood.

Family history: Both parents are being treated for hypertension and heart disease. Her sister has type 1 diabetes. Suzanne’s son was diagnosed with ADHD four years ago when he was 8 years old.

Social history: Full-time, fourth-year law student applying for Law Review; husband also works full-time. She has 6-year-old twin girls and a 12- year-old son. A live-in nanny takes care of the children during the week. “I’m so busy that I barely have time to sleep! And when I do get to bed, I’m having trouble sleeping.”

Review of systems: WNL.  She is sleeping and eating poorly. Notes that she frequently feels “anxious,” which is accompanied by tachycardia and sweating.

Medications: Antihistamines as necessary for seasonal allergy relief.

Physical examination: She appears restless, anxious, and somewhat agitated.

Height: 5’5”   Weight: 118 lb, down 12 lb since a year ago
Temperature is normal. BP 150/72, HR 120
HEENT: Pupils dilated and equally reactive to light
Breath sounds normal
Remainder of physical examination is within normal limits

Suzanne’s report of anxiety, tachycardia, and sleeplessness could be the result of her fast-paced and stressful lifestyle. And many of her physical findings could also be symptoms of hyperthyroidism. However, a thyroid panel ordered at the time of this visit was normal.

What is your diagnosis and how would you proceed?

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In the absence of hyperthyroidism, the clinical features of increased blood pressure and heart rate, weight loss, and dilated pupils are worrisome and may indicate a more complicated issue.

Further questioning reveals that Suzanne is currently vying for a staff position at the Law Review, which requires that she maintain top grades. In order to keep up with everything in her life—family, children, and schoolwork—she used to drink coffee to keep her focused while she studied late into the night. But as her alertness diminished, she has begun ‘borrowing’ her son’s amphetamine medication that he takes to control his ADHD. Because she is using the drug for something other than its intended medical purpose, this is technically considered abuse.

Stimulants such as amphetamines and methamphetamine are often prescribed for children and adults who exhibit symptoms of ADHD, including difficulty sustaining attention and maintaining self-control. Experts in the field say they help strengthen the parts of the brain involved in these functions by improving the utilization of dopamine, a key neurotransmitter.[1] Abusers feel it improves their energy, confidence, and productivity, all of which are tempting claims for a busy law students with three children at home. But this increased energy comes at a price. As with any drug, amphetamines can be habit forming, with a long list of side effects that include tachycardia, hypertension, anorexia, and weight loss—and even the risk of cardiac arrest for people with heart conditions.[2]

Perhaps Suzanne can be persuaded to try a series of stress-relief and time-management exercises rather than relying on amphetamines to maintain her productivity. These might include the following:

Regular Exercise. By exercising 30 minutes a day, mental clarity, focus, and well-being are enhanced. A good workout releases dopamine, serotonin, and norepinephrine in the brain.

Healthful Eating. A diet rich in whole grains, fresh fruits, and vegetables is beneficial, and will give you energy and decrease cravings. Avoid overindulging in caffeine and sugary products.

Ask for Help. If you are frazzled and overwhelmed, ask for help. Organize your day and be sure to include at least 15 minutes of “me-time.”

Practice Healthy Sleep Habits. Avoid caffeine after dinner. Take a hot shower or bath just before bed. Keep computers, cell phones, and tablets out of the bedroom. Some evidence suggests that the lights on these devices may suppress the release of the sleep-promoting hormone melatonin, making it take longer to fall asleep.[3] Sleep deprivation leads to irritability, anxiety, and depression—none of which benefit productivity.

Practice Healthy Coping Skills. Life can be stressful. Aim for balance by finding and utilizing a good support system. Avoid using alcohol as a reward for a trying day.

Learn to Prioritize. Suzanne’s family and school demands are overwhelming. Turning things down and learning to say ‘no’ may improve her ability to spend time with her family and focus on her schoolwork without the aid of amphetamines.

Updated on April 10, 2012
Published on April 2, 2012

References

  1. Volkow ND, Fowler JS, Wang G, et al. Mechanism of action of methylphenidate: insights from PET imaging studies. J Atten Disord. 2002:6(Suppl 1):S31–S43.
  2. InfoFacts: Stimulant ADHD Medications – Methylphenidate and Amphetamines. National Institute on Drug Abuse Website. http://www.drugabuse.gov/publications/infofacts/stimulant-adhd-medications-methylphenidate-amphetamines. Updated June 2009. Accessed March 20, 2012.
  3. National Sleep Foundation. 2011 Sleep in America Poll.® Communications Technology in the Bedroom. Arlington, VA: National Sleep Foundation; 2011. http://www.sleepfoundation.org/sites/default/files/sleepinamericapoll/SIAP_2011_Summary_of_Findings.pdf?utm_source=Media+Contacts&utm_campaign=9026f44afb-Press_Release_02_28_11_Poll_Release&utm_medium=email. Accessed March 20, 2012.