Focused SOAP Note for Anxiety PTSD and OCD
Subjective
CC: The patient (Dev) says, “I worry about my mom and brother when I’m at school. All I can think about is what they’re doing and if they’re OK. And besides, nobody likes me there. They call me Mr. Smelly.”
HPI: The 7-year-old boy with his mom presents to Dr. Jenny with excessive worry, anxiety, and a sad mood. The boy says he feels worried most of the time. He worries about his mother and little brother. The patient is sad and feels bad for being called names at school. His mother says he gets in trouble at home and school for throwing things. Also, the patient has sleeping problems. He gives excuses like headaches and stomach aches to leave school for home. The patient feels bad and sad for his daddy never coming home and is afraid of losing his mom or brother. His hygiene is pathetic; he doesn’t bathe, wets bed, and has nightmares every night. He dies doing anything to hurt himself or others.
Family and Social Hx: No FHX mental disorder; patient is bullied at school and called names; patient has no friends at school.
Substance Abuse: No
Allergies: No
Medication: Patient takes DDVAP for bedwetting.
Reproductive Hx: Patient is 7 years old and has no children.
Review of Systems:
- General: In the past 3 weeks, the patient has lost 3 pounds. He denies fatigue or fever.
- HEENT: Patient denies ear pain, headache, nose bleed, itchy eyes, or running nose. Also, no difficulty swallowing or mouth pain is reported.
- Musculoskeletal: Patient denies body, or muscle pain.
- Cardiovascular: Patient denies difficulty breathing, or cough.
- Neurological: Steady gain but denies dizziness, or headache.
- Respiratory: Patient denies unusual heart rate and chest pain.
- Skin: Patient denies skin rashes or skin itches.
Objective
Diagnostic Result: Urinalysis would be done to R/O any medical condition relating to the patient’s Urinary Incontinence, i.e., Enuresis.
Assessment
Mental Status Examination
Patient is a 7-year-old Caucasian boy. He is fair-minded, oriented, and alert to his name, date, and month. He is able to maintain direct eye contact with the clinician. He answers questions clearly and timely. Patient’s speech is clear, coherent, and audible. Patient clearly remembers recent memories and experiences. However, he appears worried, sad, and in a bad mood when thinking about his mom and small brother. He denies visual and auditory hallucinations, homicidal, or suicidal thoughts.
Differential Diagnosis
The three possible diagnoses, from highest to lowest priority, include PTSD, ADHD, and separation anxiety disorder (SAD).
PTSD: To be diagnosed with PTSD, a person must have been exposed to an event that involved the actual or possible injury, violence, or threat to death. An individual who directly experiences trauma or witnesses another person being exposed to a traumatic event feels afraid and worried (Foa et al., 2018). However, experiencing constant nightmares, excessive worry, bad emotions, or negative thoughts disrupt a child’s daily activities match PTSD’s diagnostic criteria. In this case, the 7-year-old patient lost his dad 2-years ago. He thinks that the dad abandoned them, a feeling that is traumatic. He experiences excessive worry ABOUT losing his mom and little brother. Also, he experiences nightmares. These recurrent, intrusive, and involuntary distressing memories of trauma match the DSM-5 criteria for diagnosing PTSD in children. Thus, the clinician should prioritize assessing the patient for PTSD and formulating a treatment plan that suits PTSD treatment.
ADHD: This mental disorder results from a person’s inability to concentrate, maintain attention, or stay focused (Rigler, et al., 2016). The DSM-5 diagnostic criteria for ADHD classify this condition as a persistent pattern of hyperactivity-impulsivity and inattention that interferes with the child’s development and functioning. In this case, the patient finds it difficult to concentrate on teachers, does not stay focused in school, finds it difficult to sleep, gets in trouble for throwing things at school, and does not enjoy school time.
SAD: Separation anxiety is the fear that children have of being away from their parents, family, and caregivers (Park & Kim, 2020). This disorder is a common part of children’s development. In DSM-5 diagnostic criteria, separation and anxiety disorder is diagnosed with people who experience unusual anxiety and fear of separating from individuals they are strongly attached to or related with, either family or carers. In this case, the patient worries about his mom and brother when at school. Every time, the child wants to go home and always gives excuses so he can go home and spend time with his mom and brother. As a result, he has a difficult time concentrating or staying focused at school.
Plan
The patient’s diagnosis would inform the treatment plan. His differential diagnosis includes PTSD, ADHD, and SAD. The treatment would consist of a combination of psychotherapy and medications. Using CBT, the patient would attend therapeutic sessions with the clinician. This approach will facilitate effective treatment for the patient’s excessive worry, anxiety, and sadness. Studies by Lebowitz et al. (2020) posit that approximately two-thirds of children treated using CBT heal from their primary diagnosis after treatment. The other psychotherapeutic approach to include in the patient’s treatment plan is family therapy. The clinician will organize a family therapy session with the mother of the patient to help improve their relationship. To advance the patient-mother relationship, the clinician will use the child-directed interaction (CDI) intervention. The CDI strategies to include would be attention, warmth, and praise. If the patient recovers within eight (8) weeks, medication will not be used. However, if medication is considered necessary, the clinician would administer Prozac 10 mg once daily for PTSD. This treatment will be reviewed in two months during the patient’s next appointment.
Reflection
During the patient interview, I noted that the patient’s mom feels guilty and blames herself for the boy’s current state. She states that she told Dev that his dad was on vacation despite him having been killed while working with the military. This misinformation makes her son believe in having been abandoned by their father. The patient’s mom appears to have given up on him. Despite knowing that he is called names at school, she does not encourage him to shower. Given the patient’s age of 7 years, he is a child and unable to make decisions. It is her mom’s responsibility to correct, guide, and counsel him. To address this case, the beneficence principle would be considered. Using CBT, the clinician will significantly assist the patient and his mother through individual and family therapy.
References
Foa, E. B., Asnaani, A., Zang, Y., & Capaldi, S. Y. (2018). Psychometrics of the Child PTSD Symptom Scale for DSM-5 for trauma-exposed children and adolescents. Journal of Clinical Child & Adolescent Psychology, 47(1), 38-46.
Lebowitz, E. R., Marin, C., Martino, A., Shimshoni, Y., & Silverman, W. K. (2020). Parent-based treatment as efficacious as cognitive-behavioral therapy for childhood anxiety: A randomized noninferiority study of supportive parenting for anxious childhood emotions. Journal of the American Academy of Child & Adolescent Psychiatry, 59(3), 362-372.
Park, S. C., & Kim, Y. K. (2020). Anxiety Disorders in the DSM-5: changes, controversies, and future directions. Anxiety Disorders, 187-196.
Rigler, T., Manor, I., Kalansky, A., Shorer, Z., Noyman, I., & Sadaka, Y. (2016). New DSM-5 criteria for ADHD—Does it matter? Comprehensive Psychiatry, 68, 56-59.