Case Overview
Miss S is an 18-year-old high school student whose recent behavior has changed substantially from her earlier academic and social functioning. Historically, she was described as capable, engaged, physically healthy, and a positive influence on younger siblings. Over approximately eight months, however, her school performance declined, conflict with teachers and family increased, sleep became disrupted, and she became socially withdrawn from peers. Her father also reported irritability, verbal aggression, rule-breaking, late-night absences, theft of money, and concern about possible substance use, although Miss S denied drug use.
The case also contains important attachment and loss experiences. Miss S’s biological mother left when she was young, her grandmother—whom she regarded as her primary source of love and understanding—later died, and her relationship with her father and stepmother deteriorated. About 18 months before assessment, Miss S re-established contact with her biological mother. She now fears losing that relationship and has become preoccupied with the idea of living with her mother. She also reports gambling behavior, including use of false identification to enter casinos, with the stated goal of winning enough money to obtain a home for herself and her mother. These details suggest that the presenting problem cannot be reduced to one symptom or one diagnosis.
Presenting Problems and Initial Formulation
The most prominent reported symptoms include intense fear of separation from her mother, persistent worry that others will prevent contact with her, irritability, family conflict, academic decline, social withdrawal, sleep disturbance, and a narrowing of future goals around remaining close to her mother. These symptoms may be consistent with separation-anxiety phenomena, but a responsible clinical formulation must also consider depression, trauma-related responses, gambling problems, disruptive behavior, substance use, grief, sleep disruption, and other psychiatric or psychosocial conditions.
The case history also raises questions about safety and functioning. Miss S is leaving home late at night, using false identification, gambling, stealing money, and engaging in risky relationships with older men. Those behaviors require direct assessment rather than being treated as secondary details. A clinician would need to ask about coercion, exploitation, sexual safety, self-harm, suicidality, substance use, violence, housing plans, financial risk, and whether any adult relationship places her in danger. Confidentiality is important, but at age 18 the clinician should still explain clearly the limits of confidentiality where imminent safety concerns or abuse are involved.
Assessment and the Use of Screening Tools
The original case states that the Zung Self-Rating Depression Scale contains 30 items. That is incorrect. The Zung SDS is a 20-item self-report instrument used to screen depressive symptoms. Each item is rated on a four-point scale, producing a raw score from 20 to 80; some scoring systems convert the raw score to an index. Because different publications use raw and index cutoffs differently, the meaning of a reported score of 65 depends on which scoring method was used. A score in that range may indicate clinically significant or moderate-to-marked depressive symptoms on an index scale, but the SDS is a screening instrument rather than a stand-alone diagnosis (Zung, 1965).
For Miss S, the depression screen should therefore be interpreted as evidence that depressive symptoms deserve further assessment, not proof of a depressive disorder. A full interview should examine mood, pleasure, energy, concentration, appetite, sleep, guilt, hopelessness, self-harm thoughts, and the temporal relationship between symptoms and her family stressors. Because her sleep problems may also be related to late-night activity, anxiety, gambling, or substance use, the clinician should avoid assuming that one symptom has only one cause.
Separation Anxiety and DSM-5-TR Considerations
Separation anxiety disorder is characterized by developmentally inappropriate and excessive fear or anxiety concerning separation from major attachment figures. Symptoms may include persistent worry about losing the attachment figure, reluctance to leave or be alone, refusal to sleep away from the attachment figure, nightmares about separation, or physical symptoms when separation is anticipated. In childhood, symptoms must persist for at least four weeks; in adults, DSM guidance generally requires a longer duration, typically at least six months (Merck Manual Professional Edition, 2026).
Miss S is 18, so adult-duration guidance is relevant. Her reported fear of losing her mother, desire to remain physically close, and distress around possible separation may fit part of this picture. However, the case should not present separation anxiety disorder as definitively established without a full diagnostic interview. The clinician needs to determine whether the anxiety is excessive for her developmental context, whether the fear is the primary driver of impairment, and whether another condition better explains the symptoms.
The old multiaxial format shown in the original essay should also be removed. DSM-5 eliminated the DSM-IV Axis I–V system. Personality disorders, medical conditions, psychosocial stressors, and functional impairment are still clinically important, but they are not documented as separate diagnostic axes. Likewise, the Global Assessment of Functioning score is no longer the standard DSM-5 method for summarizing impairment. A modern case formulation should instead describe symptoms, diagnoses under consideration, medical and psychosocial factors, and functional impairment directly (American Psychiatric Association, 2022).
Differential Diagnosis
Several alternatives and comorbid conditions require consideration. Major depressive disorder or another depressive condition may be relevant because Miss S has academic decline, social withdrawal, sleep disturbance, irritability, and an elevated depression-screening score. At the same time, these symptoms may arise from anxiety, grief, family conflict, or disrupted sleep rather than a primary depressive disorder.
Trauma- and stressor-related conditions also deserve assessment because the case includes early parental separation, the death of a highly significant caregiver, family instability, and fear of losing another attachment figure. Persistent complex grief is not established from the available information, but the loss of her grandmother appears psychologically important. The clinician should explore intrusive memories, avoidance, hyperarousal, guilt, emotional numbing, and whether specific losses continue to shape her current behavior.
Gambling behavior is another important area. Miss S reports repeated casino gambling, use of false identification, and a belief that gambling will provide the money needed to create a home with her mother. The assessment should examine frequency, financial losses, chasing losses, concealment, inability to stop, borrowing or stealing money, and the degree to which gambling is interfering with school and relationships.
Substance use should be assessed directly and nonjudgmentally because her father suspects drug use and her sleep schedule and behavior have changed. A denial alone does not prove use or nonuse. Screening should include alcohol, cannabis, stimulants, opioids, sedatives, nicotine, and other substances as clinically appropriate. The case also calls for assessment of oppositional or conduct-related behavior, but those labels should not be applied merely because an adolescent argues with family members or violates rules.
Treatment Priorities
The first treatment priority is a comprehensive assessment rather than immediate commitment to a single diagnosis. Safety, depression severity, self-harm risk, exploitation risk, gambling, substance use, sleep, family conflict, and school impairment should all be evaluated. If urgent safety concerns are present, those take precedence over routine outpatient psychotherapy goals.
For separation-anxiety symptoms, cognitive behavioral therapy is a well-established approach. CBT can help the patient identify anxious predictions, test beliefs gradually, develop coping skills, and practice age-appropriate separation rather than avoiding it. Exposure should be planned and collaborative rather than forced. The goal is not to cut Miss S off from her mother but to help her maintain attachment without organizing her entire functioning around preventing separation.
Relaxation and breathing strategies can help reduce acute physiological arousal, but they should not become the only intervention because repeatedly using relaxation to escape every anxious situation may reinforce avoidance. Psychoeducation should explain the relationship among anxiety, avoidance, sleep, mood, and behavior while avoiding stigmatizing language.
Family and School Intervention
Family work may be useful because conflict with her father and stepmother is part of the maintaining environment. Family sessions can improve communication, clarify boundaries, reduce escalation, and help caregivers distinguish supportive behavior from attempts to control anxiety through reassurance or restriction. Because Miss S is 18, treatment should respect her legal autonomy and obtain her consent regarding family participation except where safety law requires otherwise.
The relationship with her biological mother should be discussed realistically. Reconnection may provide emotional support, but the plan to secure housing through gambling is unsafe and unlikely to resolve the deeper attachment fear. Therapy can help Miss S separate the understandable desire for connection from risky strategies intended to guarantee that connection.
School support can also be important. A counselor or appropriate school professional can help address attendance, sleep-related classroom problems, missed assignments, peer isolation, and planning for graduation. The goal should be restoration of functioning rather than punishment for symptoms. Clear communication among Miss S, the school, and treatment providers should occur only with appropriate consent and respect for privacy.
Medication Considerations
Medication is not automatically required for separation anxiety disorder. Psychotherapy, particularly CBT with gradual exposure, is generally central. Merck Manual notes CBT as the principal treatment for separation anxiety disorder, with medication used much less commonly. If depressive or anxiety symptoms are severe, persistent, or insufficiently responsive to psychotherapy, a qualified prescriber may consider medication based on the full diagnosis, risks, benefits, age, comorbidities, and patient preference.
The original essay states that antidepressants simply treat symptoms in the short term. That is too broad. Antidepressants may provide clinically meaningful benefit for some anxiety and depressive disorders, but they also require appropriate monitoring and should be part of an individualized treatment plan. Miss S should not be prescribed medication solely on the basis of a screening score.
Expected Goals and Monitoring
Treatment goals should be measurable and connected to functioning. Possible goals include improved sleep, regular school attendance, reduced conflict, decreased gambling, safer decision-making, increased peer or family communication, improved academic engagement, and greater ability to tolerate ordinary periods of separation from her mother. Progress should be reviewed regularly rather than assumed from attendance alone.
Repeated symptom measures can be useful, but the same scoring method must be used consistently. Clinical improvement should also be assessed through school functioning, family relationships, risky behavior, and the patient’s own goals. If symptoms worsen or new safety concerns emerge, the formulation and treatment plan should be revised rather than simply intensifying the same intervention.
Conclusion
Miss S presents with a complex combination of attachment fear, grief, family conflict, academic decline, sleep disturbance, depressive symptoms, gambling, and other risky behavior. Separation anxiety disorder is one plausible diagnostic consideration, especially given her intense fear of losing contact with her mother, but the case does not support treating that diagnosis as established without fuller assessment. Depression, trauma-related responses, gambling problems, substance use, and other conditions also need to be evaluated.
A modern treatment plan should therefore move away from the outdated DSM multiaxial framework and toward an integrated formulation. CBT, gradual exposure, psychoeducation, family work, school support, and targeted treatment of gambling or other comorbid problems may all be relevant. The aim is not merely to reduce anxiety but to restore safe, age-appropriate functioning while helping Miss S maintain important relationships without relying on avoidance, conflict, or risky behavior.
References
American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.).
Merck Manual Professional Edition. (2026). Separation Anxiety Disorder.
Zung, W. W. K. (1965). A self-rating depression scale. Archives of General Psychiatry, 12, 63–70.
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