Phil’s Case: The Impact of the Client’s Age on Diagnosis

Subject:	Psychiatry
Pages:	3
Words:	1664
Reading time:	6 min
Study level:	Master

Introduction

Phil is a 15-year-old male Hispanic patient who has been experiencing sadness and angry during the last four months. No specific information about the biological problems or challenges is mentioned. No physical traumas and other physiological concerns are reported and noticed by the doctor. Biological problems of this patient may be associated with stress-related hormone and chemical imbalance when norepinephrine and serotonin change their rhythms.

Psychological Problems

The patient reports feelings of sadness and anger over the last four months. He cannot sleep well because of the impossibility of forgetting his father new fiancé. The boy has lost hope that his family could be reunited, and the father would come back to his mother and three sisters. Nothing brings him happiness, and he is upset that no one can understand this situation.

Social Problems

The patient is not interested in hanging out with his friends, playing sports, and educating. He does not like being pushed by his mother to leave the house. During the last several weeks, he got into verbal arguments with teachers, friends, and the principal. Phil postpones his driver’s education plans, sports activities, and other cooperation in groups due to his poor interest in any activity.

Spiritual Problems

Before the divorce, Phil admired communication with people and sharing the same religious beliefs. After the divorce, he has lost his trust in the church and does not consider faith the center of life. Religion is not a strong factor for the boy to support and find sound solutions. The introduction to the father’s fiancé negatively affected the boy and made his refuses his beliefs.

Assessment

This 15-year-old patient has many symptoms of separation anxiety disorder, explaining the decision to use the Screen for Child Anxiety Related Emotional Disorders. This inventory is commonly used to screen children and adolescents for various anxiety disorders (Behrens et al., 2019). Clinicians and psychiatrists are indented users of this inventory, and their task is to involve pediatric patients and their parents. There are 41 items in this test for children and the same integrated context for parents (Behrens et al., 2019). It is effective for children aged between 8 and 18 years, which meets the characteristics of this case.

Diagnostic Impressions

Signs and Symptoms

The primary diagnosis for this patient is separation anxiety disorder, and the secondary disorders are oppositional defiant disorder and social anxiety disorder. In the table below, the signs and symptoms of the chosen disorder will be mentioned in the client report section (American Psychiatric Association, 2013):

309.21 (F93.0) Separation anxiety disorder	DSM Criteria	Client Report
A	Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached.	Father leaves the family; Phil is concerned about his new fiancé.
1	Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.	Phil feels sad and angry because of his family being separated.
2	Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.	Phil is worried about the future marriage.
3	Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.	The future wedding is an untoward event that separated the father from his first family.
4	Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.	The child is upset when his mother offers him to leave the house.
5	Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.	Phil thinks that not all people could understand his family’s problem.
6	Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.	Phil cries at night and has a hard time getting to sleep.
7	Repeated nightmares involving the theme of separation.	No information about nightmares is given.
8	8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.	The patient looks physically healthy.
B	The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.	Last four months.
C	The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.	Academic achievements have been decreased; Cooperation with fellows is low; Driver’s classes are cancelled; Verbal arguments at schools emerge.
D	The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.	No history.
313.81 (F91.3) Oppositional defiant disorder
A	A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.	Phil is angry and sad about his father marriage; Teachers admit Phil’s argumentative/defiant behavior at school.
B	The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g., family, peer group, work colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioning.	Phil was good at school; He liked doing sports and communicating; He is now not interested in education; He neglects the church; He does not want to initiate his driver’s education.
C	The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.	No other mental disorders.
300.23 (F40.10) Social anxiety disorder
A	Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech).	Phil does not want to leave his home; He is not interested in interacting with peers; He does not communicate; He has stopped going for sports.
B	The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).	Phil has no one to talk about his parents’ divorce; He rejects the role of the church; He does not want someone to pity him;
C	The social situations almost always provoke fear or anxiety.	Phil is anxious about the necessity to talk about his family problems with anyone.
D	The social situations are avoided or endured with intense fear or anxiety.	No fear.
E	The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.	Not accurate for this case.
F	The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.	Last four months.
G	The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.	No relevant information.
H	The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.	No relevant information.
I	The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.	No history of past mental health issues.
J	If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.	No other medical conditions.

Other DSM Conditions Considered

Other DSM conditions for consideration include depression and insomnia disorder to explain Phil’s behavioral changes. On the one hand, both conditions could be appropriate because the patient demonstrated verbal temper outbursts from time to time (depression) and reported sleeping problems during the last months (insomnia). On the other hand, these could not be the correct diagnoses because parents’ divorce is the major trigger of behavioral changes.

Consideration of Theories and Factors

The psychoanalytic theory of personality can explain normal and abnormal development through inner forces that could affect human behavior. The mind consists of conscious and unconscious parts, and Phil’s feelings of sadness and anger prove the possibility of several diagnoses. According to Freud’s theory, separation anxiety disorder should be viewed from the id, ego, and superego perspectives and the imbalance of outside factors and Phil’s expectations. The same theory explains social anxiety disorder and oppositional defiant disorder as the response to the environment that he does not like (a family without a father).

Multicultural or Social Justice Considerations

The boy is the only male who remains in his family after his father decides to leave with a new fiancé. He feels responsible for the women in his family and cannot understand his father. He does not find it socially just to live in an incomplete family. He cannot think about sports or cars and has no one to talk to about this situation.

Treatment Recommendations

Key Issues

Anger management (women in a family should not suffer from Phil’s inability to manage his emotions);
Academic performance as a part of human development (driving license, high degrees, and sports achievements play an important role in forming a male image in a family).

Recommendations for Individual Counseling

Phil should learn how to manage his family changes and deal with his anger. Cognitive behavioral therapy is recommended to enhance generalization, analyze naturalistic settings, and solve problems (Freidl et al., 2017). Selective serotonin reuptake inhibitors intake is another safe treatment method for patients to deal with depression, anxiety, and other behavioral problems (Freidl et al., 2017). Combining these approaches is highly recommended to achieve positive changes in a short period.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5^th ed.). American Psychiatric Association.

Behrens, B., Swetlitz, C., Pine, D. S., & Pagliaccio, D. (2019). The screen for child anxiety related emotional disorders (SCARED): Informant discrepancy, measurement invariance, and test–retest reliability. Child Psychiatry & Human Development, 50(3), 473-482. Web.

Freidl, E. K., Stroeh, O. M., Elkins, R. M., Steinberg, E., Albano, A. M., & Rynn, M. (2017). Assessment and treatment of anxiety among children and adolescents. FOCUS, 15(2), 144–156. Web.