Assessment: Discuss The Patient’s Mental Status Examination

Assessment: Discuss the patient’s mental status examination results

This case involves a seven-year-old boy, Dev Cordoba, presenting with significant anxiety, worry, sleep disturbances, enuresis, and behavioral concerns, as reported by both his mother and during a clinical interview. A thorough mental status examination (MSE) would evaluate Dev's appearance, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and judgment. Based on the case details, Dev appears anxious, worried, and cautious, with notable fears about being lost, separation from his family, and concerns about his father's absence. His affect is likely subdued or apprehensive, and he demonstrates difficulty focusing and concentrating at school, which correlates with reports of hyperfocus on his worries. His speech may be somewhat hesitant as he discusses fears and worries, and his thought process appears logical but preoccupied with safety, security, and loss. No hallucinations, delusions, or perceptual disturbances are described, and Dev's cognition seems appropriate for his age.

Supportive observations include his avoidance behavior, such as looking out the window during class, and his reported negative self-perception, exemplified by being called "Mr. Smelly" and feeling unloved. His sleep pattern shows difficulty falling asleep, frequent night wakings, and night terrors, indicative of heightened anxiety or trauma-related symptoms. His enuresis persists despite medical treatment, which may be a somatic manifestation of his psychological distress. Overall, the MSE reflects a child experiencing separation anxiety, generalized anxiety, and trauma-related symptoms likely linked to his father's death and ongoing family stressors.

Differential diagnoses

1. Separation Anxiety Disorder (SAD): This diagnosis is supported by Dev's intense worry about being separated from his mother and brother, frequent nightmares about being lost and unable to find his family, and physical symptoms such as stomach aches and headaches associated with separation fears. DSM-5-TR criteria specify excessive fear or anxiety concerning separation from attachment figures, lasting at least four weeks in children, with symptoms causing distress or impairment. Dev's persistent fears of losing his family, along with his reluctance to be away from his mother and his somatic complaints, align closely with SAD. The fact that these symptoms have persisted since early childhood and significantly interfere with his daily activities reinforces this diagnosis. The DSM-5-TR rules out other anxiety disorders because his fears are specifically tied to separation and loss, rather than generalized anxiety about multiple domains.

2. Post-Traumatic Stress Disorder (PTSD): The primary evidence supporting PTSD as a differential diagnosis is Dev's loss of his father due to military deployment and his subsequent inability to fully comprehend or process this loss, which may serve as a trauma. Symptoms such as nightmares, hypervigilance, and emotional dysregulation are characteristic of PTSD. DSM-5-TR criteria include exposure to a traumatic event, intrusive symptoms, avoidance, negative alterations in mood and cognition, and hyperarousal lasting more than a month. Although Dev does not explicitly report re-experiencing traumatic memories, his nightmares and fears of abandonment could reflect elements of trauma response. However, the absence of direct traumatic memories or flashbacks suggests PTSD might be less likely than other diagnoses.

3. Generalized Anxiety Disorder (GAD): Dev exhibits pervasive worry about multiple aspects of his life, including concerns about his mother, brother, school, and safety. DSM-5-TR defines GAD as excessive anxiety and worry occurring more days than not for at least six months, about a variety of activities, with difficulty controlling the worry. Symptoms include restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance. While Dev's worry is pervasive, his primary fears seem centered on separation and loss, and his anxiety appears more specific rather than generalized across all life areas, which somewhat distinguishes GAD from SAD or trauma-related disorders. Nonetheless, symptom overlap necessitates careful evaluation to rule out GAD as a primary diagnosis.

Comparison of DSM-5-TR diagnostic criteria

In diagnosing Dev, the DSM-5-TR criteria are critical to distinguish between these disorders. For SAD, criteria focus on excessive fear of being separated, impairment, and duration of at least four weeks. For PTSD, exposure to trauma followed by intrusive symptoms, avoidance, and hyperarousal are key, with symptoms lasting over a month. GAD requires pervasive, uncontrollable worry for over six months about various domains with associated physical symptoms. In Dev's case, the diagnostic criteria are most consistent with Separation Anxiety Disorder, given the duration, focus on separation fears, and associated somatic complaints. The absence of a traumatic event as defined by DSM-5-TR makes PTSD less likely, although trauma-related symptoms are present. The pattern of pervasive worry not limited to separation suggests GAD as a potential comorbid or secondary diagnosis. Applying DSM-5-TR criteria systematically rules out other diagnoses, honing in on SAD as the primary classification based on symptom duration, focus, and functional impairment.

Critical-thinking process for primary diagnosis

The primary diagnosis of Separation Anxiety Disorder is derived from a comprehensive analysis of Dev’s symptomatology in the context of DSM-5-TR criteria. Key features include his intense worry about his family’s safety, fear of being lost, nightly nightmares about separation, reluctance to go to school due to worries about his loved ones, and physical complaints such as stomachaches and headaches associated with separation fears. The traumatic loss of his father adds a complicated grief component, but his fear-based behaviors focus on separation anxiety per se. Negative self-appraisal, social withdrawal (being called "Mr. Smelly" and feeling unloved), and sleep disturbances further support SAD overtaking other differential diagnoses. The child's age, presentation, and duration of symptoms align with DSM-5-TR guidelines, leading to a confident primary diagnosis.

Plan for psychotherapy and treatment

The treatment plan for Dev should incorporate evidence-based interventions targeting separation anxiety and trauma. Cognitive-behavioral therapy (CBT), especially trauma-focused CBT adapted for children, is considered first-line. It would focus on gradual exposure to separation, cognitive restructuring to address maladaptive thoughts about safety and abandonment, and relaxation techniques. Play therapy can incorporate creative activities like LEGO building to improve emotional expression and resilience. Family therapy sessions involving his mother are crucial to improve communication, reinforce healthy coping strategies, and address parental concerns that may exacerbate Dev’s anxiety.

Pharmacologic options may include selective serotonin reuptake inhibitors (SSRIs), such as sertraline, if symptoms persist despite therapy or significantly impair functioning (Reynolds et al., 2017). Monitoring for side effects and gradual titration are essential. Nonpharmacologic treatments like mindfulness, relaxation training, and ensuring consistent routines contribute to symptom management. School-based interventions, such as accommodations for focus and anxiety, are important.

Health promotion activities include parent education on anxiety management, normalizing worries, and promoting emotional literacy. An educational strategy involves teaching Dev coping skills, such as diaphragmatic breathing and positive self-talk, tailored to his developmental level. Follow-up assessments should monitor symptom reduction, functional improvement, and adherence to therapy, with adjustments as needed.

Reflection notes and ethical considerations

If given a chance to revisit the session, I would incorporate more developmentally appropriate rapport-building activities early on, such as more play therapy to foster trust. Engaging Dev in expressive art or storytelling could facilitate emotional expression, especially given his age. A follow-up intervention would be a structured safety plan involving his mother to reinforce routines and emotional support at home, alongside ongoing therapy. Ethically, it is essential to consider confidentiality, informed consent, and the child's right to participate in treatment planning. Cultural factors, such as Dev's father's military background and his family's response to trauma, influence diagnosis and treatment. Addressing socioeconomic barriers to therapy access and considering cultural sensitivities around mental health are critical. Also, awareness of potential stigmatization in his community must guide culturally competent care. Emphasizing early intervention and prevention strategies, such as parental support groups, can mitigate long-term adverse outcomes (American Psychiatric Association, 2013).

References

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• American Academy of Child & Adolescent Psychiatry. (2018). Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 57(5), 370–378.
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