Introduction
Miss S is an 18-year-old high school student whose recent functioning has changed substantially from an earlier pattern of academic engagement, family responsibility, and social participation. Over roughly eight months, she has experienced academic decline, conflict with teachers and caregivers, disrupted sleep, social withdrawal, irritability, rule-breaking, theft of money, late-night absences, and risky behavior. Her history also includes major attachment disruptions: her biological mother left during childhood, her grandmother—described as a central source of affection and security—died, and she later re-established contact with her mother. Miss S now appears intensely preoccupied with preserving that relationship and fears losing access to her mother. Separation anxiety disorder is therefore a reasonable diagnostic consideration, but the available information does not justify treating it as established. Assessment must also consider depression, trauma- and stressor-related conditions, gambling problems, substance use, grief, sleep disturbance, exploitation risk, and disruptive behavior. A contemporary formulation should describe symptoms and functional impairment directly rather than use the obsolete DSM-IV multiaxial Axis I–V system (American Psychiatric Association, 2022).
Diagnostic Considerations
Separation anxiety disorder involves developmentally inappropriate and excessive fear concerning separation from major attachment figures. In DSM-5 and DSM-5-TR, the diagnosis is no longer restricted to disorders beginning before age eighteen; the criteria were revised to recognize adult presentations, and adult symptoms typically need to persist for about six months or longer to reduce overdiagnosis of transient fears (American Psychiatric Association, 2013; American Psychiatric Association, 2022). Miss S reports intense concern about losing her mother, a desire to remain physically close, and distress about people who might interfere with that relationship. Those features fit part of the diagnostic picture, but clinical assessment must establish whether the anxiety is excessive relative to her developmental context, persistent enough, and responsible for significant impairment. It is also necessary to determine whether the fear is better explained by another condition. At age eighteen, wanting renewed contact with an absent parent can be understandable. The diagnosis depends not on the existence of attachment but on the intensity, duration, avoidance, distress, and functional consequences associated with separation.
Differential Diagnosis
The case requires a broad differential diagnosis because several reported behaviors extend beyond separation anxiety. Miss S has academic decline, social withdrawal, irritability, disrupted sleep, family conflict, theft, gambling, and possible substance-use concerns. Depression should be assessed through mood, anhedonia, energy, concentration, appetite, sleep, guilt, hopelessness, and suicidal thinking rather than inferred from one screening score. The Zung Self-Rating Depression Scale contains twenty items, not thirty, and any score must be interpreted using the scoring method reported; it is a screening instrument rather than a stand-alone diagnosis (Zung, 1965). Trauma- and stressor-related conditions also merit evaluation because early parental separation, bereavement, family instability, and fear of another loss may shape current behavior. Gambling deserves direct assessment because Miss S reportedly uses false identification to enter casinos and imagines gambling winnings as a route to living with her mother. Substance use should be explored nonjudgmentally as well. A denial does not prove use or nonuse, and screening should be based on history, risk, and clinical findings rather than accusation.
Safety and Functional Assessment
Safety and functional assessment should take priority over premature diagnostic certainty. Miss S is leaving home late at night, stealing money, gambling illegally, and reportedly interacting with older men, so a clinician should ask directly about coercion, exploitation, sexual safety, violence, self-harm, suicidal thoughts, housing plans, financial risk, and substance exposure. Because she is eighteen, treatment should respect her legal autonomy while clearly explaining confidentiality and the circumstances in which safety concerns may require disclosure or emergency action. The clinician should also assess daily functioning: school attendance, missed assignments, sleep schedule, friendships, family relationships, finances, transportation, and capacity to make safe decisions. Standardized measures can support assessment but should not replace the interview. The American Psychiatric Association’s current adult severity measure for separation anxiety asks about fear, avoidance, physical arousal, early departure from situations, preparation for separation, and reliance on coping aids during the previous seven days, illustrating that clinically relevant separation anxiety involves a pattern of thoughts, feelings, behaviors, and impairment rather than one attachment preference (American Psychiatric Association, 2022).
Psychological and Family Treatment
Treatment planning should begin with the confirmed problems rather than assume that one intervention will address every behavior. Cognitive behavioral therapy is well supported across anxiety disorders and commonly combines psychoeducation, cognitive restructuring, coping skills, and graduated exposure to feared situations (Merck Manual Professional Edition, 2026). For Miss S, exposure would not mean cutting her off from her mother. The goal would be to help her tolerate ordinary periods of separation, test catastrophic predictions, and maintain the relationship without organizing school, sleep, finances, or safety around preventing distance. Family work may be useful if Miss S agrees and if relationships are safe, particularly to reduce escalation with her father and stepmother and clarify boundaries around money, curfews, gambling, and communication. School support can address attendance, incomplete work, graduation planning, and reintegration with peers. Gambling or substance problems, if confirmed, require their own evidence-based interventions. Relaxation or breathing strategies may reduce physiological arousal, but they should support engagement rather than become rituals used to avoid every feared separation.
Medication and Monitoring
Medication should not be prescribed solely because Miss S has anxiety symptoms or an elevated depression-screening score. A qualified clinician would first establish the principal diagnosis, symptom severity, comorbidities, safety risks, medical history, substance use, treatment preference, and response to psychotherapy. Psychotherapy—particularly CBT with exposure-based elements—is a core treatment for anxiety disorders, while medication may be considered when symptoms are severe, persistent, or insufficiently responsive to appropriate psychological treatment (Merck Manual Professional Edition, 2026). If depressive symptoms are substantial, they should be evaluated on their own diagnostic criteria rather than assumed to be secondary to separation anxiety. Progress should be measured through meaningful functioning as well as symptom ratings. Useful goals might include more regular sleep, improved school attendance, reduced gambling, safer decision-making, less family conflict, increased peer contact, and greater ability to tolerate ordinary separation from her mother. Treatment should be revised when new information emerges, especially if substance use, trauma, exploitation, mood instability, or self-harm risk becomes more prominent than the initial attachment concern.
Conclusion
In conclusion, Miss S presents with a complex pattern of attachment fear, loss, family conflict, academic deterioration, sleep disturbance, depressive symptoms, gambling, and risky behavior. Separation anxiety disorder is a plausible consideration because her distress centers partly on preserving access to her biological mother, but diagnosis requires evidence that the fear is developmentally excessive, persistent, impairing, and not better explained by another condition. Current DSM guidance recognizes separation anxiety in adults and generally expects a longer duration in adult presentations, while the older DSM-IV multiaxial structure is no longer used (American Psychiatric Association, 2013; American Psychiatric Association, 2022). The most defensible plan therefore begins with comprehensive safety and differential assessment, followed by treatment matched to the problems actually confirmed. CBT, gradual exposure, school support, consensual family work, and targeted intervention for gambling or substance use may all be relevant. The clinical goal is broader than reducing anxiety: Miss S needs support in rebuilding safe, age-appropriate functioning while maintaining important relationships without relying on avoidance, conflict, financial risk, or dangerous attempts to prevent separation.
References
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