Case history
- Background information;
Miss S is 18 years old high school female student, she has had great potential and was a cheerleader in elementary school. She was neatly dressed in jeans and t-shirt with multiple piercing in her ears and full sleeves tattoos. She was physically fit and not have any severe physical disease. Her father was suspicious that she might be using drugs, but miss S refused that she was not using any drug. Her father reported that no one else was suffering from psychotic disorder from his family.
Miss S had the father, step mother and three half younger siblings and she was role model for her siblings. In the past, she was kind and helping a child at home. Her mother ran away with another man and got divorced when miss S was five years old, and miss S was brought up by her father and grandmother. Miss S believed that only her grandmother loved her and understood her, no one liked her after her grandmother’s death. She did not have a good relationship with her stepmother and father. She was not getting along with her father after her grandmother’s death. However, she was coping with her siblings, and she was also a very good student and leader at elementary school.
Over last eight months, Miss S’s English teacher and her class counsellor had complained of being annoyed and showing negative demeanours and violent at school. She failed her 9th-grade exams and midterm exams. Her teachers were afraid that she would not be able to graduate if she will not work hard. Miss S blamed her teachers for giving them the ridiculous and moronic syllabus, and she also believed that her teacher deliberately gave that light material so that, she would not be able to succeed. She had not any interaction or relationship with her peer group.
Her father reported that he also noticed that her problematic behaviour is escalating every day and he was receiving her complains every week from her school and home. Her father said that they had many issues with miss S at home as she did not listen to her mother if she argues with S she suddenly walk out and did not answer her. Miss S also showed negative demeanours at home such as screaming, violent and irritating behaviours. Her father also stated that she had shown several emotional temper tantrums at family occasions and parties when she was with her family. In addition to, her father also notes that Miss S had the online relationship with old men and she usually went of home at nights and came back at 2 or 3 am for not complying family rules. Miss S insulted and irritated her the, and she also stole her money and when her father asked she blew up, screamed and get off from the room.
When miss S was asked to share her problems, she suddenly became agitated and said hello but not made eye contact. She demanded that ask her father to leave the session so that she will tell her story. Her father got angry and abruptly leave the room. After leaving her father, she became happy for annoying her father. She said that “there is no point of being here” because she believed that, her English teacher had personal issues with her and her parent wants her to follow the family rules. She refused to interact with her father and teacher healthily. She said that her father did not care about her. She anxiously told that she needs someone’s help. Eighteen months ago, she met with her biological mother, and she forgave her after listening to her story. Miss S wants to live with her mother, but her mother was impoverished and worked at slot for her living hood. She went to meet her mother every day and played slot to reduce anxiety. She also made fake id and played casino. She secretly shared and requested to keep it secret from her father; miss S said that she played casino to win significant amount to have money for purchasing her place. Then she will stay with her mother.
Description of presenting problems
Ever since miss S had met her mother she became restless and had a great fear of losing her again. She believed that if her father knew about her mother, he would never allow her to meet with her mother. Miss S problematic behaviour started when she met with her mother and she had fear of separation, and for this, she refused to do things that bring separation. She became aggressive, and lack school performance and she also had sleep problems. She was unable to sleep at nights, and her teacher reported that she slept in class during lectures. She remained alone after her grandmother’s death; she did not want live alone again. She never mentioned any other plans except to buy a place to live with her mother. She never talked about her career, future or personal life.
After examining case history, “Zung Self Rating Depression Scale” (SDS) was used to assess feelings, and depressive thoughts of Miss S. this scale contained on 30 items which assess affective, somatic and psychological symptoms of Miss S. The test was self-administered and had maximum time completion of 10 minutes. There were three ranges of assessing the depressive state of a client that varies from mild depression (20- 44) and mildly depressed ranged from (45 – 59) while moderately depressed lied between (60–69) and severely depressed lay onward 70.
- Diagnosis
Miss S scored 65 on “Zung Self rating Depressive Scale” which indicated that Miss S was moderately depressed. However, she had anxious thoughts and excessive fear of separation from her mother. She thought that everyone confronted her and would not allow her to meet with her mother. She had persistent thoughts about separation from her mother. The number of events from Miss S’s life was thoroughly discussed to increase understanding about her problems and self-compassion and identify the problematic area to provide treatment.
Diagnosis in DSM V
Furthermore, five above AXIS criteria from “DSM V” would be helpful to understand thoroughly and diagnose Miss S.
Former Axis I: -309.21 (F93.0) Separation Anxiety Disorder
- Developing inappropriate persistent fear and anxiety of separation from mother figure.
- Persistent and excessive worry about having an untoward event that causes separation from the attachment figure.
Criteria A characteristic Symptoms
The fear, anxiety or avoidance is persistent, lasting at least for four weeks.
Criteria B Social interpersonal Dysfunctioning
Disturbed interpersonal relationships, unable to communicate with her parents and teachers
Criteria C 4 at least weeks of active symptoms, more than eight months of persistence of symptoms criteria met
Criteria D
Autism Spectrum Disorder, Hallucination or Delusional disorder concerning separation in psychotic disorder ruled out.
Criteria E disturbance is not due to direct physiological or substance abuse effect.
Criteria F no history of Autism or other psychotic disorders.
Former Axis II: Personality disorder or mental retardation Null
Former Axis III: General Medical Condition No
Former Axis IV: psychological and Environmental factors
- Significant fear and anxiety of losing mother
- the impairment in social interpersonal and academic life.
Differential Diagnosis
Separation anxiety developed after the distressing event of divorce and death of her grandmother.
Criteria for Anxiety disorder has not met.
Global Assessment of Functioning Scale (GAF):
61-70 some mild symptoms or some difficulty in social, school functioning, but functioning pretty well and has some meaningful relationships.
3. Intervention
Psychiatrists and psychologists utilise some medication and therapies to help patients deal with anxiety positively. Some therapies were used with miss S as well.
3.1. Therapies
At first, most commonly used therapies such as deep breathing and relaxation were used to calm her down.
3.1.1. Cognitive Behavior Therapy
In cognitive therapy, children were skilled to provoke disturbing or anxious thoughts by using coping strategies. In cognitive behaviour therapy, the patient was treated with three phases of education, application and relapse inhibition. With cognitive behaviour therapy patient taught to recognise anxious and fearful event and then discuss it in detail to provoke anxiety and develop coping strategies to cope with anxious events. At last, the patient was asked to evaluate the effects of coping strategies.
3.1.2. Counseling
Counseling considered as most effective non-drug therapeutic technique to change patient’s negative thoughts into positives.
3.1.3. Psychoeducational intervention technique
The above mentioned technique counselling and psychoeducational approach both utilised with the conjunction of other therapeutic techniques. It allows to educate patient and family about the disorder and increase knowledge about disorder and patient’s condition.
3.1.4. Behavior therapy
Behavior therapy also is known as exposure-based technique. In this therapy, systematic desensitisation, participant modelling and emotive imagery were used to decrease her fear and anxiety. This therapy focused on individual’s behaviour and carefully exposed an individual to reduce anxiety over time.
3.1.4.1 Contingency management
Contingency management is another behaviour technique and usually used with adults anxiety patients. It involves reward system with substantial or verbal reinforcement, and it requires parent’s involvement with patients. In this therapy, children supposed to fulfil several tasks and parents supposed to give her some reward for achieving a task.
3.1.5. Parent-child interaction therapy
Parent-child interaction therapy is most effective therapy to treat separation anxiety disorder, and it also revolves around three phases such as
- Child-directed interaction
Focused on parent-child relationship building and it allows the parent to interact with the child with warm touch, attention and praise. It also helps to strengthen patient’s feeling of safety.
- Bravery directed interaction
It teaches parents to learn about causes of the anxious behaviour of their children. It also increases awareness among parents about their children’s feelings and emotional state.
- Parent-directed interaction
It helps to manage poor behaviours of a patient. It allows the parents to be friendly communicate with children and discuss their problems.
The school environment is an essential key to effective treatment. Class counsellor and teachers should motivate patient to communicate with class fellows and teachers. It will help the patient to establish social relationships and avoid anxious thoughts.
3.2. Medication
There is not any specific medicine for separation anxiety disorder; some antidepressants suggested to patients if symptoms got worsened and other techniques being in effect. No medicines were prescribed to a patient. Medication only helps to cure symptoms in short time. Patients should also educate about side effects of antidepressants drug use.