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Miss S Heath care Case Study

Case history

  1. 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 a t-shirt with multiple piercings on her ears and full sleeves tattoos. She was physically fit and did 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 drugs. Her father reported that no one else was suffering from a psychotic disorder in his family.

Miss S had a father, stepmother, and three half-younger siblings and she was a role model for her siblings. In the past, she was kind and helped 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 the last eight months, Miss S’s English teacher and her class counselor had complained of being annoyed and showing negative demeanors and violence 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 behavior is escalating every day and he was receiving her complaints 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 demeanors at home such as screaming, and violent and irritating behaviors. 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 an online relationship with old men and she usually went home at night and came back at 2 or 3 am for not complying with family rules. Miss S insulted and irritated her, and she also stole her money 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 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 in 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 a slot for her living hood. She went to meet her mother every day and played slot to reduce anxiety. She also made fake IDs and played casino. She secretly shared and requested to keep it secret from her father; miss S said that she played casino to win a 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 behavior 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 lacked school performance and she also had sleep problems. She was unable to sleep at night, 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 their case history, “Zung Self Rating Depression Scale” (SDS) was used to assess their feelings, and depressive thoughts of Miss S. this scale contained 30 items that 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 ranging from (45 – 59) while moderately depressed lied between (60–69) and severely depressed lay onward 70.

  1. Diagnosis

Miss S scored 65 on the “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 of her problems and self-compassion and identify the problematic area to provide treatment.

Diagnosis in DSM V

Furthermore, the 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 the 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 effects.

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 the death of her grandmother.

Criteria for Anxiety disorder have not been met.

Global Assessment of Functioning Scale (GAF):

61-70 some mild symptoms or some difficulty in social, and school functioning, but functioning pretty well and has some meaningful relationships.

3. Intervention

Psychiatrists and psychologists utilize some medications and therapies to help patients deal with anxiety positively. Some therapies were used with miss S as well.

3.1. Therapies

At first, the 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 behavior therapy, the patient was treated with three phases education, application, and relapse inhibition. With cognitive behavior therapy patients is taught to recognise the 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 patients’ negative thoughts into positives.

3.1.3. Psychoeducational intervention technique

The above-mentioned technique counseling and psychoeducational approach are both utilized in conjunction with other therapeutic techniques. It allows to educate of patients and family about the disorder and increases knowledge about the disorder and the patient’s condition.

3.1.4. Behavior therapy

Behavior therapy also is known as an exposure-based technique. In this therapy, systematic desensitization, participant modeling, and emotive imagery were used to decrease her fear and anxiety. This therapy focused on an individual’s behavior and carefully exposed an individual to reduce anxiety over time. Contingency management

Contingency management is another behavior technique and is usually used with adult anxiety patients. It involves a reward system with substantial or verbal reinforcement, and it requires parents’ involvement with patients. In this therapy, children are supposed to fulfill several tasks, and parents are supposed to give them some reward for achieving a task.

3.1.5. Parent-child interaction therapy

Parent-child interaction therapy is the most effective therapy to treat separation anxiety disorder, and it also revolves around three phases as

  1. 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 the patient’s feeling of safety.

  1. Bravery directed interaction

It teaches parents to learn about the causes of the anxious behavior of their children. It also increases awareness among parents about their children’s feelings and emotional states.

  1. Parent-directed interaction

It helps to manage the poor behaviors 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 counsellors 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 are suggested to patients if symptoms got worsened and other techniques are in effect. No medicines were prescribed to a patient. Medication only helps to cure symptoms in a short time. Patients should also educate about the side effects of antidepressant drug use.



American Psychiatric Association. (2013). Diagnostic and Statistical Manual of mental disorders (5th ed.). Washington, DC: Author





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