Discussion Unit 6 Case Study: Samsam Meets Criteria

Discussion Unit 6 Case Study Samsam Meets Criteria For The Second M

Sam R. is a 16-year-old African American high school student who has recently relocated to a new town due to his father’s job transfer. He experiences feelings of sadness, social withdrawal, and avoidance behaviors, particularly around public speaking and social interactions in his new school environment. These symptoms align with a clinical diagnosis of Social Anxiety Disorder, also known as Social Phobia. The ICD-10 code for this disorder is F40.1.

My rationale for diagnosing Sam with Social Anxiety Disorder (F40.1) is based on his persistent fear and avoidance of social situations that involve potential scrutiny — especially public speaking, which causes significant distress and physical symptoms such as embarrassment and tongue-tied speech. He has avoided oral reports and class participation, often feigning illness to escape these scenarios. Such symptoms are hallmark indicators of social anxiety, as they interfere with his academic performance and social integration. Prior to arriving at this diagnosis, other conditions, such as generalized anxiety disorder (F41.1) or major depressive disorder (F32), should be considered but predominantly ruled out due to the specific focus on social situations and the absence of pervasive negative mood, anhedonia, or pervasive worry. Additionally, a diagnosis of social phobia captures the contextual and situational nature of his anxiety rather than a more generalized or mood-based disorder.

When considering treatment options and family counseling, it is essential to identify the 'identified patient' (IP) to meet insurance mandates and facilitate targeted intervention. Typically, the patient who manifests the primary symptoms and impairment that warrant clinical attention is identified as the IP. In Sam’s case, since his social anxiety symptoms are significantly impairing his functioning and academic performance, he would be established as the IP. To differentiate this from potential secondary or family-wide issues, a comprehensive assessment including clinical interviews, behavioral observations, and collateral information from parents and teachers should be employed. This allows clinicians to determine if the presenting problem primarily affects Sam or if familial dynamics contribute to his symptoms.

Moreover, engaging both Sam and his parents in treatment planning ensures that family factors are considered, particularly in addressing avoidance behaviors and social skill development. Emphasizing cognitive-behavioral therapy (CBT) techniques, such as exposure and cognitive restructuring, can help reduce anxiety symptoms. For insurance purposes, documenting the severity of Sam’s symptoms, their impact on functioning, and the diagnostic criteria essential for the diagnosis will support reimbursement and treatment authorization.

References

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