From the Guidelines
The patient's chronic fatigue, insomnia, and anxiety require a comprehensive approach, prioritizing cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment, as recommended by the American College of Physicians 1.
Current Situation
The patient is experiencing persistent fatigue, insomnia, and anxiety, despite undergoing Cognitive Behavioral Therapy for Insomnia (CBTI) and taking Dexedrine for ADHD management. The fatigue has lasted for several months, with the patient getting about 6.5 hours of sleep per night.
Key Issues
- Chronic fatigue
- Insomnia
- Anxiety
- ADHD
Management Plan
- Refer the patient to a sleep specialist at UCSF, with the initial appointment potentially via Zoom, to further investigate sleep issues 1.
- Repeat laboratory tests to understand elevated testosterone levels, with additional hormone tests, including testosterone precursors.
- Test Iron, B12, and Vitamin D levels, with all labs conducted fasted and early morning before 10 AM.
- Continue CBTI for insomnia management, as it is a strongly recommended initial treatment for chronic insomnia disorder 1.
- Track sleep patterns and monitor progress.
- For anxiety, send questionnaires to quantify symptoms and discuss anxiety management with the patient's psychiatrist, with BuSpar suggested as a potential medication option.
- Maintain the current exercise regimen, including strength training and protein intake.
Follow-up and Education
- Schedule a follow-up appointment in 4-6 weeks to reassess the patient's condition and discuss any improvements.
- Educate the patient about the connection between ADHD, anxiety, and sleep issues, including how different ADHD phenotypes may affect sleep and anxiety.
From the FDA Drug Label
Buspirone hydrochloride tablets are indicated for the management of anxiety disorder or the short-term relief of the symptoms of anxiety. The patient's anxiety symptoms, such as racing thoughts and anxiety before bed, may be managed with buspirone, as it is indicated for the management of anxiety disorder. However, the effectiveness of buspirone for long-term use has not been demonstrated in controlled trials 2.
- The patient's symptoms, including anxiety, worry, and insomnia, align with the symptoms of Generalized Anxiety Disorder (GAD).
- Buspirone may be considered as a potential medication for the patient's anxiety, but it is essential to consult with the patient's psychiatrist who manages their Dexedrine before making any decisions.
From the Research
Fatigue and Sleep Issues
- The patient presents with ongoing fatigue and sleep issues, despite undergoing Cognitive Behavioral Therapy for Insomnia (CBTI) and taking Dexedrine for ADHD management 3.
- Fatigue can be due to a broad spectrum of diseases, including decompensation of already known conditions, sleep disorders, depression, and excessive psychosocial stress 4.
- The patient's symptoms of anxiety, depression, and stress do not appear to impair the effectiveness of CBTI, and CBTI may even improve these symptoms 3.
Diagnosis and Treatment
- A comprehensive history and physical examination are essential in guiding the workup and diagnosis of fatigue 5, 6.
- The patient's fatigue can be classified as secondary to other medical conditions, physiologic, or chronic, and treatment should prioritize comorbidities and symptoms based on severity 6.
- Cognitive behavioral therapy, exercise therapy, and acupuncture may help with some of the fatigue associated with chronic conditions 6.
- The patient's insomnia and anxiety symptoms can be addressed through continued CBTI and potential medication, such as BuSpar, if recommended by their psychiatrist 3, 7.
Management and Follow-up
- A structured plan for regular physical activity, including stretching and aerobic exercise, can help improve fatigue symptoms 5.
- The patient should be educated on the connection between ADHD, anxiety, and sleep issues, as well as the various phenotypes of ADHD and their potential impact on sleep and anxiety 3.
- Regular follow-up visits are recommended to monitor the patient's condition and discuss any changes or improvements 5, 6.