A 26‑year‑old woman with attention‑deficit/hyperactivity disorder (ADHD) and generalized anxiety disorder (GAD) taking mixed amphetamine salts (20 mg extended‑release plus 10 mg immediate‑release) and sertraline 75 mg daily now has severe work‑related stress, marked procrastination, relapse of skin‑picking, lip‑biting, and an inflamed inner‑gum blister; what medication adjustments and therapeutic strategies should be recommended?

Immediate Medication Adjustment and Therapeutic Strategy

Reduce or discontinue the immediate-release amphetamine 10 mg dose, as the patient's skin-picking, lip-biting, and oral lesion are classic manifestations of amphetamine-induced stereotypic behaviors (body-focused repetitive behaviors) that worsen with higher total daily stimulant doses and peak plasma concentrations. 1, 2

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Understanding the Clinical Picture

This patient is experiencing stimulant-induced exacerbation of body-focused repetitive behaviors (BFRBs), not worsening anxiety. The relapse in skin-picking and new-onset compulsive lip-biting with tissue injury are stereotypic behaviors directly linked to amphetamine's dopaminergic effects, particularly at higher doses or with immediate-release formulations that create sharp plasma peaks. 1, 2

• The patient explicitly denies increased subjective anxiety and reports no panic attacks or emotional breakdowns, which argues against undertreated anxiety disorder. 3
• Her procrastination and task-completion difficulties are better explained by executive dysfunction from life overload (NP school clinicals, 6-month-old infant, two per diem jobs) rather than inadequate ADHD medication dosing. 1
• The 30 mg total daily amphetamine dose (20 mg ER + 10 mg IR) is within therapeutic range but the addition of IR dosing creates problematic plasma concentration spikes. 1, 4

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Primary Recommendation: Stimulant Regimen Modification

Step 1: Eliminate the Immediate-Release Dose

• Discontinue the 10 mg amphetamine IR immediately to eliminate the sharp plasma peak that is driving stereotypic behaviors. 1, 2
• The IR formulation causes rapid dopamine surges that can trigger or worsen BFRBs, particularly in patients under high stress. 2, 4
• Continue the 20 mg amphetamine ER as the sole stimulant dose, which provides more stable plasma levels over 8–9 hours without the problematic peak. 4

Step 2: Monitor for Resolution of Stereotypic Behaviors

• Assess skin-picking frequency, lip-biting, and oral lesion healing at 1-week and 2-week follow-up visits. 1
• If BFRBs persist after eliminating the IR dose, consider reducing the ER dose to 15 mg or switching to lisdexamfetamine 30–40 mg, which has a smoother pharmacokinetic profile due to its prodrug design. 1, 4

Step 3: Address ADHD Symptom Coverage if Needed

• If the patient reports inadequate afternoon ADHD control after stopping the IR dose, do not add back immediate-release amphetamine. 1
• Instead, increase the morning ER dose to 25–30 mg (maximum 50 mg daily for adults) or switch to lisdexamfetamine 50–70 mg for longer duration (up to 13–14 hours). 1, 4, 5
• Lisdexamfetamine's prodrug formulation reduces abuse potential and creates fewer adverse events by avoiding rapid plasma spikes. 1

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Sertraline Optimization for Anxiety

Current Dose Assessment

• Sertraline 75 mg is a subtherapeutic dose for generalized anxiety disorder; therapeutic range is 100–200 mg daily. 3
• The patient's anxiety is "managed well" per her report, but she is avoiding tasks and procrastinating, which may reflect residual anxiety symptoms masked by her busy schedule. 3

Recommendation

• Increase sertraline to 100 mg daily now, then reassess at 2 weeks. 3
• If anxiety symptoms remain at 4-week follow-up, titrate to 125–150 mg daily in 25 mg increments every 2 weeks until optimal response. 3
• Maximum dose is 200 mg daily; most patients with GAD require 100–150 mg for full remission. 3

Safety Considerations

• No significant pharmacokinetic interaction exists between amphetamines and sertraline; this combination is safe and well-established. 1, 2, 6
• Monitor for serotonin syndrome (agitation, confusion, tremor, hyperthermia, hyperreflexia) during the first 48 hours after any sertraline dose increase, though risk is low with this combination. 3, 2
• Sertraline can cause discontinuation syndrome if stopped abruptly; always taper by 25 mg every 1–2 weeks if discontinuation is needed. 3

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Addressing Executive Dysfunction and Procrastination

Realistic Expectations

• This patient is in an objectively overwhelming life phase: final semester of NP school with clinicals, caring for a 6-month-old infant, and working two per diem jobs (one requiring marketing). 1
• Her inability to finish tasks and procrastination are normal responses to cognitive overload, not necessarily medication failure. 1
• Stimulants improve attention and impulse control but do not create time or reduce workload. 1

Non-Pharmacologic Interventions (Essential)

• Refer for ADHD-specific cognitive-behavioral therapy (CBT) focusing on time management, task prioritization, and breaking large projects into smaller steps. 1, 7
• CBT for adult ADHD is the most extensively studied psychotherapy and shows increased effectiveness when combined with medication. 1, 7
• Consider mindfulness-based interventions (MBCT or MBSR) to address emotion regulation, executive function, and stress management; these help most with inattention symptoms and quality of life. 1, 7

Practical Strategies

• Encourage the patient to delegate or temporarily reduce non-essential responsibilities (e.g., reduce per diem hours, pause marketing role if possible). 1
• Implement external structure: use timers, checklists, and accountability partners to compensate for executive dysfunction during this high-stress period. 1
• Normalize that medication alone will not solve procrastination when the root cause is insufficient time and excessive demands. 1

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Monitoring Parameters

At 1-Week Follow-Up

• Assess frequency and severity of skin-picking and lip-biting. 1, 2
• Photograph the oral lesion to track healing. 2
• Evaluate ADHD symptom control using a standardized rating scale (e.g., Adult ADHD Self-Report Scale). 1
• Measure blood pressure and pulse to ensure cardiovascular stability after medication changes. 1, 2

At 2–4 Week Follow-Up

• Reassess anxiety symptoms and sertraline tolerability. 3
• Monitor for serotonin syndrome symptoms (agitation, tremor, hyperreflexia, hyperthermia). 3, 2
• Evaluate sleep quality and appetite, as amphetamines commonly cause insomnia and appetite suppression. 1, 2, 4
• Track weight, as amphetamines are associated with weight loss. 2, 8

Ongoing Monitoring

• Continue monthly follow-up during this high-stress period to adjust medications and provide supportive counseling. 1
• Screen for suicidality at every visit, particularly given the patient's anxiety history and SSRI use. 3, 1

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Common Pitfalls to Avoid

• Do not increase the amphetamine dose in response to procrastination and task-avoidance; this will worsen stereotypic behaviors and does not address the underlying problem of cognitive overload. 1, 2
• Do not add a benzodiazepine for anxiety; benzodiazepines reduce self-control and have disinhibiting effects in patients with ADHD. 1
• Do not assume the oral lesion is unrelated to medication; amphetamine-induced bruxism, jaw clenching, and repetitive oral behaviors are well-documented adverse effects. 2
• Do not prescribe bupropion as an alternative; bupropion is inherently activating and can exacerbate anxiety, agitation, and hyperactivity, making it inappropriate for this patient. 1
• Do not switch to atomoxetine unless stimulants fail after proper dose adjustment; atomoxetine has smaller effect sizes (0.7 vs. 1.0 for stimulants) and requires 6–12 weeks to achieve full effect. 1, 7

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Alternative Strategy if BFRBs Persist

If skin-picking and lip-biting do not resolve after eliminating the IR dose and optimizing sertraline:

• Switch to lisdexamfetamine 30–50 mg once daily, which has a smoother pharmacokinetic profile and lower peak plasma concentrations due to its prodrug design. 1, 4
• Consider adding N-acetylcysteine (NAC) 1200–2400 mg daily as an adjunct for BFRBs; NAC modulates glutamate and has evidence for reducing skin-picking and trichotillomania (though this is off-label and not cited in the provided evidence).
• Refer to dermatology or behavioral medicine for habit-reversal therapy, which is the gold-standard non-pharmacologic treatment for BFRBs. 1

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Summary Algorithm

1. Discontinue amphetamine IR 10 mg immediately to eliminate plasma peaks driving stereotypic behaviors. 1, 2
2. Continue amphetamine ER 20 mg once daily as sole stimulant. 4
3. Increase sertraline to 100 mg daily now, titrate to 150 mg if needed at 2–4 weeks. 3
4. Refer for ADHD-specific CBT and mindfulness-based interventions. 1, 7
5. Monitor BFRBs, anxiety, ADHD symptoms, and cardiovascular parameters at 1-week and 2-week follow-up. 1, 2
6. If BFRBs persist, reduce amphetamine ER to 15 mg or switch to lisdexamfetamine 30–50 mg. 1, 4
7. If ADHD symptoms worsen, increase amphetamine ER to 25–30 mg or switch to lisdexamfetamine 50–70 mg for longer duration. 1, 4, 5