CASE STUDY 1

Tracy is a 37-year-old, married 9th grade teacher. She presents to her primary care physician with the chief complaint of feeling overwhelmed and fatigued. Tracy reports that she is having difficulty grading homework and keeping her lesson plans current. Most recently, her principal admonished her for delinquent paperwork and her limited involvement in extracurricular activities. She reported that she was distracted during conversations and forgetting appointments. Tracy finds it nearly impossible to meet the demands of her job and manage the schedule of her eight-year-old son. “I know women with more responsibility and less support than me who get through their days much easier.” She had been relying on two glasses of wine on most nights to relieve her generalized anxiety.

Tracy's medical history is remarkable for mild exercise-induced asthma. She had one full-term pregnancy. She takes no chronic medications. She quit smoking while in college and tries to limit her caffeine intake to three cups of coffee per day.

As an adolescent, Tracy was seen by a therapist because of conflict with her parents. She did well in school but her parents complained that, in light of her high achievement scores, she rarely applied herself, appeared lazy and her grades were average. In her adult life, Tracy has never sought psychiatric care, but three years ago, presenting with the same complaints, her primary care doctor prescribed a 20 mg daily dose of Prozac. She discontinued the medication after eight months, discerning only mild improvement. Tracy emerges from an intact family. Her mother suffers from fibromyalgia and her brother has struggled with alcohol dependency and several drunk driving arrests for most of his adult life. Tracy's husband is an engineer. He is generally supportive, but has discouraged his wife from starting to work on a Masters degree, fearing that this added responsibility would be too burdensome for her.

Initially, Tracy underwent an extensive medical workup. Given her fatigue, her physician considered hypothyroidism and anemia. Neither was borne out through routine blood work. Further cardiac and neurological testing was unremarkable and her physician concluded that she did not have a physical condition. Tracy agreed to limit her alcohol intake, but her sobriety did not improve her functioning. Although Tracy denied feeling sad or hopeless, her physician suspected that she was depressed. A course of Effexor XR was initiated, but consonant with her previous Prozac experience, Tracy did not notice symptom improvement and had difficulty tolerating the sexual side effects.

Earlier in the academic semester, one of Tracy’s students with whom she identified was diagnosed with ADHD. The child had a positive response to medication treatment and Tracy became intrigued about the disorder. During a web search, she found an article outlining the phenomenon of adult ADHD. The site included a self-evaluation form. Tracy and her husband completed the form and both endorsed many of the symptoms. Armed with this information, she returned to her doctor.

The form Tracy filled out was the Adult Self-Report Rating Scale (ASRS). The ASRS assesses symptoms of inattention, distractibility and hyperactivity, and Tracy scored high for the first two symptoms. Together with her physician, and buoyed by the experience of her student, Tracy and her doctor started a trial of an amphetamine-based psychostimulant.

Tracy returned in one month and reported that she was better able to focus and concentrate. She took medication early each morning and was able to start her day more easily. She noted that she was more successful at keeping up to date with her work and was gratified that she was more punctual to meetings. Tracy’s husband reported that her mood was more stable. She was not forgetting her son’s activities and was better able to organize her home. Both partners agreed that the family was functioning more harmoniously. Notably, Tracy was tolerating the medication far better than any psychotropic she had previously taken; in the past, the diminished libido which resulted from the anti-depressants put an additional strain on her marriage. To the delight of her physician, Tracy’s clinical improvement was sustained consistently after the initiation of treatment.