Focused SOAP Note SAD

Focused SOAP Note

Patient Information: The patient is a 9-year old boy

SUBJECTIVE.

CC: Patient feels “worried”

HPI: XX is a 9-year-old boy who presents with anxiety and worry. The patient reports that he is worried and anxious most of the time. The patient also has difficulties sleeping and is afraid of being left alone in his room at night. He has also been having nightmares (with the said nightmares being themed around losing and being unable to find his mother or brother). He has difficulties in school in terms of being unable to relate well with other children and has gotten in trouble in the past for throwing things. He does not like staying in school for lengthy periods of time and is often worried about his mum dying or failing to turn up to pick him at school. Most times, he complains of headaches or stomach aches – especially when he is in school and wants to go back home. The client also wets the bed at night and has lost a number of pounds over the last few weeks.

Current Medications: None. The client was referred by the family pediatrician who believes there is nothing physically wrong with the 9-year-old.

Allergies: NKA

PMHx: Patient’s immunizations are current.

Substance Use History: The client does not have any history of substance abuse/use.

Soc Hx: Client is in grade 4. He appears to be experiencing difficulties in as far as his relationship with other children in school/class is concerned.

Fam Hx: The patient lives with his mother and younger brother. His father was a military man and was killed at war. No history of mental illness among fist degree relatives.

OBJECTIVE.

Mental Status Exam (MSE): Patient is well-groomed. However, in as far as hygiene is concerned, there is a faint ammonia-like foul smell (most likely as a consequence of poor hygiene). His posture is appropriate. He is, however, constantly disrupted and appears to be finding it difficult to concentrate on a single task (our engagement) for a lengthy time period. There is no evidence of psychomotor agitation or retardation. In as far as mood is concerned, the client appears tense. The client’s thought content could be defined as being delusional. His insight is fair. His judgment is also fair.

ASSESMENT.

1. Separation Anxiety Disorder (SAD): The primary diagnosis in this case would be separation anxiety disorder. The client presents with a number of symptoms that are consistent with the manifestation of the said disorder under DSM-5. It would be prudent to note that as Vaughan, Coddington, Ahmed, and Erel (2016) observe, this happens to be one of the most common disorders among children of school-going age. More specifically, in the words of the authors, some of SAD’s many consequences are inclusive of, but they are not limited to, “excessive worry, sleep problems, distress in social and academic settings, and a variety of physical symptoms” (Vaughan, Coddington, Ahmed, and Erel, 2016, p. 311). As per DSM-5 criteria, persons presenting with SAD often demonstrate anxiety or fear that could be deemed excessive about imminent separation from certain attachment figures such as parents. The said anxiety or fear has to be evidenced by a minimum of three symptoms – out of a total of 8 symptoms. The client in this case presents with 4 of the highlighted symptoms. To begin with, the client presents with what has been defined as “persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death” under DSM-5 (Goldstein and DeVries, 2016, p. 236). It has been indicated that when in school, the client keeps worrying about the wellbeing of his mom and younger brother. As his mother indicates, the client is often worried that she will die or will not show up to pick him at school. Secondly, as per DSM-5 criteria, persons suffering from SAD are likely to present “persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings” (Goldstein and DeVries, 2016, p. 236). In the present scenario, the client wants to go back home from school all the time. Third, as per the DSM-5 criteria, persons suffering from SAD are likely to report constant or routine nightmares which have a separation theme (Goldstein and DeVries, 2016). According to the client, he often dreams of losing and being unable to find his mom as well as brother. Fourth, under DSM-5, SAD is associated with “repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated” (Goldstein and DeVries, 2016. p. 237). In the present scenario, the client’s mother reports that the client often presents excuses to avoid school, i.e. by claiming headaches as well as stomachaches.

2. Generalized Anxiety Disorder (GAD): In basic terms, GAD, according to Gale and Millichamp (2016), could be defined as tension or worry that appears excessive with regard to daily undertakings – with the said tension or worry largely overwhelming a person and preventing them from focusing on key day-to-day activities. Indeed, under DSM-5, one presenting symptom of GAD happens to be worry and anxiety that occurs most days and that affects a person for a period of more than 6 months. The client in the present scenario reports being worried (about just everything) most of the time. Secondly, as per the DSM-5 diagnostic criteria, the worry ought to be overwhelming and difficult for a person to control. It is clear in this case that the client is unable to control the way he feels. Third, the DSM-5 criteria lists a total of six symptoms which are associated with the said worry or and anxiety. Three of these ought to be present for a person to be diagnosed with GAD. The said symptoms are inclusive of “restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)” (Goldstein and DeVries, 2016, p. 412). The client presents with only two of these, i.e. sleep disturbance, irritability (as indicated by his throwing of objects around), and difficulty concentrating (which resulted in his sitting position in class being changed). However, under the DSM-5, for a person to be diagnosed with GAD, the disturbance observed must not be associated with any other mental disorder such as separation anxiety (Goldstein and DeVries, 2016). In the present scenario, there are clear indications that the client has significant fear of being separated from a major attachment figure, i.e. his mother and/or brother.

3. Post-Traumatic Stress Disorder (PTSD): According to Kolaitis (2017), “many children and adolescents are exposed to different types of trauma, e.g. abuse or various disasters” (p. 77). The DSM-5 diagnostic criteria comes in handy in efforts to diagnose PTSD. To begin with, as per the said criteria, for a person to be diagnosed with PTSD, he ought to have been exposed to, or witnessed an event (in certain formats) that could be deemed traumatic (Goldstein and DeVries, 2016). In the present scenario, we could hypothesize that the death of the client’s father (and hence his permanent absence from his life) is the traumatic event. Secondly, such an individual ought to have displayed certain intrusion symptoms that could be traced back to the said event. The said intrusive symptoms could be inclusive of dreams with a theme closely aligned to the traumatic event and distress following exposure to scenarios that mimic the traumatic event. In the present case, the client has recurrent dreams themed around losing and being unable to find certain attachment figures. Also, separation from the said figures (as he was separated from his dad) triggers distress. Next, as per the DSM-5 criteria, persons suffering from PTSD could also avoid any stimuli they link to the traumatic event. In the present scenario, the client appears to avoid going to school as he could be associating separation from his mother while in school to the fact that his dad went and never came back. Although the client also projects some irritable behaviors (such as throwing a book at a classmate) and problems with concentration, he does not display any self-destructive behavior. This diagnosis could, however, be ruled out owing to the fact that the distress that the client is experiencing happens to be more inclined towards the effects of separation with his father when he was at the age of 5. Indeed, the client points out that his classmates do not appear to understand just how somebody feels when their father leaves and never comes back. For this reason, he appears to be worried that he could lose his mother the very same way he lost his father. In his own words, “what if my mom doesn’t come home too?”

Plan.

There are various treatment strategies that could be embraced in attempts to treat SAD. In the present scenario, psychotherapy will be combined with medication.

Psychotherapy: More specifically, the specific form of psychotherapy to be deployed will be CBT. In essence, the goal of treatment in this case will be to ensure that the client develops the relevant skills in relation his ability to manage, handle, as well as face uncertainty and/or separation fears. On the other hand, the client’s mother will also be equipped with the relevant skills on how to promote the client’s independence (age-related) and provide meaningful emotional support going forward.

Medication: Owing to the fact that the symptoms associated with the said condition are interfering with the client’s daily life, CBT will combined with the appropriate medications – specifically selective serotonin reuptake inhibitors (SSRIs).

Health Promotion Activities: The client and his mother will be advised to ensure that they adhere to the plan of treatment, i.e. in relation to taking the medications as advised and keeping therapy appointments. There may also be need to modify the client’s diet and ensure that foods that help reduce anxiety are included in his diet. The said foods could be inclusive of salmon, turmeric, and chamomile. These foods could come in handy in anxiety reduction owing to the fact that they have anti-inflammatory as well as antioxidant properties.

Reflection Notes

If I were to conduct the session again, I would seek to find out more from the client on how exactly the separation with his dad affected his life and whether he still thinks about him a lot. I would also seek to establish whether there are any events or occurrences that make the symptoms that the client presents with worse or better. There would also been need to find out from the client’s mother whether there are any other significant life changes that have occurred in the recent past that could have had an impact on his symptoms. There would also be need to find out if the client has any other observed mental health issues.