Family History: (10 points)
S.S. is a 13-year-old cisgender male who lives with both parents in Watchung, NJ. He is an only child, conceived through IVF using a donor egg. His mother experienced multiple miscarriages before his birth. Both parents work in IT from home, with the father occasionally traveling. They report a happy 25-year marriage.
Family Psychiatric History:
Maternal side: S.S.’s maternal grandmother (72 years old) and maternal uncle (50 years old) have schizophrenia. This suggests a potential genetic predisposition to psychiatric disorders on the maternal side.
Paternal side: No reported psychiatric illnesses.
Medical History: Both paternal grandparents (75 and 70 years old) have hypertension, diabetes, and arthritis, indicating potential familial risk for these conditions.
It’s worth noting that since S.S. was conceived using a donor egg, there may be additional genetic factors from the donor’s side that are unknown. This information gap could be significant for assessing potential genetic predispositions.
Social /Developmental History: (20 points)
Psychomotor Development: S.S. achieved his developmental milestones at appropriate levels. He has shown some anxiety-related behaviors, such as hand-wringing when anxious and past transient tics with vocal grunting in 4th grade.
Cognitive Development: S.S. is described as a “superior student” who scores near-perfectly on standardized tests. He is in all honors classes and spent his summer learning algebra, demonstrating advanced cognitive abilities for his age.
Interpersonal Development: S.S. reports having a group of 12 close friends from cross-country running, indicating good social skills. He also has neighborhood friends and feels understood by his parents, suggesting positive relationships with peers and family.
Emotional Development: S.S. experiences anxiety and obsessive thoughts, which have intensified recently. He reports feeling empty and sad, particularly when he can’t meet his high standards. These emotional struggles are impacting his daily functioning and self-esteem.
Moral Development: While not explicitly addressed, S.S.’s concern about potentially offending friends or causing harm (even imaginary) suggests a developing sense of moral responsibility and empathy.
Harm to Self or Others: S.S. reports passive suicidal thoughts without plan or intent, stemming from frustration with his intrusive thoughts. He denies any homicidal ideation.
Trauma History: No reported history of trauma or abuse.
Habits: S.S. is described as a good sleeper and eater. He has limited technology use, with an Apple watch but no phone, suggesting controlled media exposure.
Child’s Strengths & Successes: S.S. is academically gifted, participates in cross-country running, has a supportive friend group, and maintains close relationships with his parents.
Child’s Media Diet: Limited to Apple watch use for brief communications, suggesting a controlled media environment.
Environmental Supports: S.S. has supportive parents who are attentive to his needs and seeking help for his challenges. He lives in a stable home environment with both parents present.
School History and Current Issues Impacting Functioning: (5 points)
S.S. is currently in 8th grade and enrolled in all honors classes. He is an honor student labeled as gifted. His anxiety began in 4th grade, initially centered around his grades. Currently, his obsessive thoughts are impacting his ability to focus during the school day, potentially affecting his academic performance. Despite these challenges, he does not have an IEP or 504 plan, suggesting that his academic performance remains strong. S.S. aspires to attend a charter high school specializing in Math, Science, and Engineering, indicating high academic ambitions.
Assessment Instruments Used for Diagnosis: (4 points)
PHQ-9: Score = 3, indicating no depression
GAD-7: Score = 14, indicating moderate anxiety
While not administered, the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) is recommended to assess the progression of OCD tendencies.
Assessment: DSM-5 Diagnosis and Differential Diagnosis: (5 points)
Primary Diagnosis:
Obsessive-Compulsive Disorder (OCD) (F42)
Generalized Anxiety Disorder (GAD) (F41.1)
Differential Diagnosis:
Tic Disorder: Considered due to past history of transient tics, but current presentation aligns more closely with OCD symptoms.
Adjustment Disorder: While S.S. is experiencing distress, the duration and nature of his symptoms are more consistent with OCD and GAD than an adjustment reaction.
Rationale:
S.S. presents with persistent, intrusive thoughts that he finds difficult to control, a hallmark of OCD. These thoughts interfere with his daily functioning and cause significant distress. His need for reassurance, perfectionism, and fear of causing harm (even when implausible) are typical OCD presentations in children (Farrell et al., 2022).
The GAD diagnosis is supported by his excessive worry about multiple areas of his life, including academics, sports performance, and social interactions. His GAD-7 score of 14 indicates moderate anxiety levels, corroborating this diagnosis.
While tic disorder was considered due to past transient tics, the current presentation is more aligned with OCD symptoms. Adjustment disorder was ruled out due to the chronic nature and specific symptom profile of S.S.’s presentation.
Conceptual Formulation and Treatment Plan: (25 points)
Conceptual Formulation:
S.S. is a gifted 13-year-old male presenting with symptoms of OCD and GAD. His high intelligence and perfectionism may contribute to his anxiety and obsessive thoughts. There’s a family history of schizophrenia on the maternal side, suggesting a potential genetic vulnerability to psychiatric disorders. His symptoms began around age 8, which is consistent with typical onset for pediatric OCD.
Strengths: High intelligence, academic success, supportive family, engagement in extracurricular activities (cross-country), and positive peer relationships.
Areas to Address: Intrusive thoughts, anxiety, perfectionism, and emerging passive suicidal ideation.
Risks: Family history of mental illness, high standards leading to self-criticism, and potential for academic decline if symptoms worsen.
Protective Factors: Supportive parents, good insight, willingness to seek help, and strong social support.
Treatment Plan:
Medication Management:
Continue Zoloft 25 mg daily, with potential for dose adjustment based on response and side effects.
Rationale: SSRIs like Zoloft are first-line pharmacological treatments for pediatric OCD and anxiety disorders (De Nadai et al., 2022).
Labs: Baseline complete blood count and liver function tests before starting SSRI treatment.
Education: Provide information to S.S. and his parents about potential side effects, expected timeline for improvement, and the importance of consistent medication use.
Psychotherapy:
Initiate Cognitive-Behavioral Therapy with Exposure and Response Prevention (CBT-ERP), which is the gold standard treatment for pediatric OCD (Farrell et al., 2022).
Consider incorporating elements of Acceptance and Commitment Therapy (ACT) to address perfectionism and anxiety (Bergman, 2019).
Family-based interventions to educate parents on supporting S.S. and reducing accommodation of OCD behaviors.
Evidence-Based Practice Guidelines:
The American Academy of Child and Adolescent Psychiatry (AACAP) recommends CBT-ERP as the first-line treatment for pediatric OCD, with SSRIs as an adjunct for moderate to severe cases.
A combination of CBT and SSRIs has shown superior efficacy compared to either treatment alone in pediatric anxiety disorders (De Nadai et al., 2022).
Intensive, brief CBT formats (e.g., FAST CBT) have shown promise for rapid symptom reduction in pediatric OCD (Farrell et al., 2022).
Virtual delivery of intensive CBT has demonstrated effectiveness for pediatric anxiety and OCD, offering a flexible treatment option (Instride Health, 2024).
Measurable Short-Term Treatment Goals:
Reduce GAD-7 score by at least 4 points within 8 weeks of treatment initiation.
Decrease time spent on obsessive thoughts by 25% within 12 weeks, as measured by patient self-report and parent observation.
Improve school focus by reducing instances of distraction due to intrusive thoughts, aiming for a 30% reduction within 10 weeks.
Community Resources:
Refer to a local OCD support group for adolescents to provide peer support and additional coping strategies.
Connect with school counselor to discuss potential academic accommodations if needed, without implementing a formal 504 plan at this time.
Provide information on mindfulness and relaxation apps suitable for adolescents to supplement therapy techniques.
Format/Grammar/Spelling/Turnitin. (5 points)
[Note: This section would typically involve a careful review of the entire document for formatting, grammar, and spelling. As an AI, I don’t produce actual documents that could be run through Turnitin, but in a real academic setting, this would be an important step to ensure originality and proper citation.]
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Case Conceptualization and Treatment Plan for S.S.
S.S. is a 13-year-old cisgender male presenting with significant anxiety and obsessive-compulsive symptoms that are impacting his academic and social functioning. He experiences intrusive thoughts centered around daily events, fears of causing harm, and a need for constant reassurance. While S.S. excels academically and demonstrates strong social connections, his anxiety and obsessive thoughts cause him significant distress and interfere with his daily life.
Family History
S.S. has a significant family history of mental illness. His maternal grandmother and uncle both have schizophrenia, indicating a potential genetic predisposition to mental health disorders. While S.S. was conceived via donor egg, the lack of information regarding the donor’s medical history leaves a gap in understanding potential genetic influences.
Social/Developmental History
Strengths:
High Intelligence: S.S. is described as gifted and excels academically.
Strong Social Connections: He has a supportive group of friends and enjoys positive relationships with his parents.
Motivation and Drive: S.S. is goal-oriented, as evidenced by his desire to attend a competitive high school.
Areas for Intervention:
Intrusive Thoughts and Obsessions: S.S. experiences distressing intrusive thoughts related to harm, daily events, and performance.
Anxiety: He exhibits moderate anxiety as measured by the GAD-7, impacting his daily functioning.
Perfectionism: S.S.’s need for perfection contributes to his anxiety and distress, particularly in competitive environments.
Limited Coping Skills: S.S. struggles to manage his anxiety and intrusive thoughts, leading to avoidance and reassurance-seeking behaviors.
Assessment
GAD-7: Score of 14 indicates moderate anxiety.
PHQ-9: Score of 3 suggests no significant depressive symptoms currently.
CY-BOCS: This assessment, though not yet administered, is recommended to assess the severity and nature of S.S.’s OCD symptoms.
DSM-5 Diagnosis
Obsessive-Compulsive Disorder (OCD): S.S.’s presentation aligns with the diagnostic criteria for OCD, characterized by persistent intrusive thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) aimed at reducing anxiety.
Generalized Anxiety Disorder (GAD): S.S.’s excessive worry and anxiety about various aspects of his life, coupled with his GAD-7 score, support this diagnosis.
Differential Diagnoses
Tic Disorder: S.S.’s history of transient tics and current hand-wringing warrants consideration, although these behaviors appear linked to anxiety.
Adjustment Disorder: While S.S.’s symptoms have been present for several years, exploring any recent stressors or transitions that might be exacerbating his anxiety is essential.
Conceptual Formulation
S.S.’s anxiety and OCD likely stem from a combination of factors, including a potential genetic predisposition, his perfectionistic tendencies, and learned coping mechanisms. His intrusive thoughts and anxiety create a cycle of distress, leading to avoidance and reassurance-seeking behaviors that further reinforce his anxieties.
Treatment Plan
Medication Management:
Sertraline (Zoloft) 25mg: Continue at the current dosage, monitoring for effectiveness and side effects. Dosage adjustments may be necessary based on S.S.’s response and tolerability.
Rationale: SSRIs like Sertraline are considered first-line treatment for both OCD and GAD in children and adolescents (AACAP, 2019).
Therapy:
Cognitive Behavioral Therapy (CBT): CBT will focus on identifying and challenging negative thought patterns, developing coping mechanisms for anxiety and intrusive thoughts, and gradually reducing avoidance behaviors (Franklin et al., 2020).
Exposure and Response Prevention (ERP): A specific type of CBT highly effective for OCD, ERP involves gradually exposing S.S. to his feared situations or thoughts while preventing his usual compulsions, helping him learn to manage anxiety and reduce the power of obsessions (McGuire et al., 2016).
Family Involvement:
Psychoeducation: Educate S.S.’s parents about OCD, GAD, and the treatment process.
Support and Communication: Encourage open communication and support within the family to help S.S. feel understood and supported.
School Collaboration:
Communication with School: Collaborate with S.S.’s school to ensure his academic needs are met and provide support during his treatment.
Community Resources:
Anxiety and Depression Association of America (ADAA): Provides information, resources, and support groups for individuals with anxiety and OCD.
International OCD Foundation (IOCDF): Offers resources, support, and treatment provider referrals for individuals with OCD and their families.
Measurable Short-Term Goals:
S.S. will demonstrate a decrease in the frequency and intensity of intrusive thoughts as measured by the CY-BOCS.
S.S. will report a reduction in anxiety levels as measured by the GAD-7.
S.S. will utilize at least two new coping skills to manage anxiety and intrusive thoughts.
S.S. will engage in at least one enjoyable activity without significant interference from anxiety or obsessions.
Prognosis:
With appropriate treatment and support, S.S. has a good prognosis. Early intervention, consistent therapy attendance, medication adherence, and family involvement are crucial for successful treatment outcomes.
References:
American Academy of Child and Adolescent Psychiatry (AACAP). (2019). Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 58(1), 106-128.
Franklin, M. E., Smits, J. A., & Williston, S. K. (2020). Cognitive-behavioral therapy for anxiety disorders: A practical guide. Guilford Publications.
McGuire, J. F., Przeworski, A., & Lewin, A. B. (2016). Individual and family-based cognitive behavioral therapy for pediatric obsessive-compulsive disorder: A review. Clinical Child and Family Psychology Review, 19(1), 57-78.
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Number of sources: 5
Paper instructions:
Using the information on additional materials, to
RUBRIC
Family History: (10 points)
Has anyone else in the family (including grandparents, aunts, uncles, and cousins) had a psychiatric illness (including substance abuse)? How about other medical illnesses with a possible familial component (This includes not only classic “genetic” illnesses but also things such as cardiovascular disease and many types of cancer.) Are any aunts or uncles mentioned genetically related to the patient? Is the patient adopted? Included is a genogram
Family Psychiatric History:
Maternal and Paternal sides of the family
Social /Developmental History: (20 points)
A wide variety of information about the patient falls into this category. Several methods of organization are possible. One reasonable approach is as follows and documented with references to norms or deviation from the norms-That means all the following must be referenced from the literature:
Psychomotor
Cognitive
Interpersonal
Emotional
Moral development
Harm to self or others
Trauma History
Habits
Child’s Strengths & Successes
Child’s media diet
Environmental Supports
Please make sure that the deficiencies are addressed in the conceptualization and treatment plan.
School history and current issues impacting functioning (5 points)
Assessment instruments used for diagnosis or other related problems: 2 instruments are to be administered and scores obtained and used in the treatment plan (4 points)
Assessment: DSM-5 Diagnosis and Differential Diagnosis and rationale. Provide references. (5 points)
Conceptual Formulation and Treatment Plan: (25 points)
1. Presentation of a conceptual formulation of your case- must include the synthesis of the case in conceptual terms, support for your diagnosis, identification of the strengths, and what areas need to be addressed as part of the treatment and prognosis for this case. Please include a Risks and Protective Factors
2. In the treatment plan, you must include medication management including dosage and rationale, any labs that need to be ordered, and education for the family and patient. (5 points)-must be referenced.
3. Included is EBP and practice guidelines from the AACAP Practice Guidelines that are the most up-to-date on the APA website or EBP articles for treatment interventions and medication management from Cochrane or systematic reviews or research-based article that are less than 5 years old to support your interventions and medications. (4 different references required) (5 points)
4. Measurable short-term treatment goals that relate back to the conceptual formulation. (3 points)
5. Community resources for health promotion and treatment needed for positive treatment outcomes (2 points)
Format/Grammar/Spelling/Turnitin. (5 points).
Chief Complaint: “I get a lot of thought that I cannot stop. I feel empty, and the thoughts mess up my grades, and I won’t have a future.”
Mother and father “S.S. gets bothered/ disturbed by recurring thoughts about day-to-day small incidents and things that are part of one’s daily life. He constantly debates his liking when it comes to sports or any other extracurricular activities. These thoughts are recurring, and he cannot ignore them most of the time. This stops him from doing things and makes him very sad. He has lots of anxiety and keeps worrying about the past and future. He is a perfectionist and a very bright student, and he likes to ace everything else. For example, he started participating in cross country and would not like to be 2nd or lose a race. That makes him sad. Many times, he says, “I’m sad or depressed.” This has been happening for a while but has increased recently. He had a few therapy sessions last year, but that didn’t help him.
History of Present Psychiatric Illness
S.S. 13-year-old cisgender male domiciled with his parents in Watchung, NJ. He is an only child. He was referred by his parents for psychiatric evaluation due to anxiety which started in 4th grade over his grade. Mom notes that he is an honor student and is labeled as gifted. The mother notes that he has been getting intrusive thoughts since he was eight years old, questioning himself and checking. He will be running cross country this year. Dad reports that he is concerned that S.S.’s thoughts are more intrusive. He obsesses over his sprinting, affecting his ability to focus during the school day. He gets obsessive intrusive thoughts about inadvertently causing harm. The mother reports that he asks her if he broke a window at a neighbor’s house even though it did not happen. He requires intensive reassurance at the end of the day that he did nothing wrong. His parents feel that it “interrupts his day to day life,” and he worries that this is affecting him so much that he wonders if he will succeed with these intrusive thoughts. He told his mom that he wonders if life is “worth living” due to his thoughts, which make him depressed. He was an only child. He was born in the USA. Both parents work in IT from home, and Dad rarely travels. The parents have been married for 25 years. Mom reports that it is a good marriage. Parents report that it was a happy marriage. Mom had multiple miscarriages, and she had IVF with a donor egg. Mom was 36 when he was born. His parents reported that he was a perfect child. He is a superior student and scores “near perfect tests on standardized tests.” No separation issues were reported. Mom reports transient tics with vocal grunting in 4th grade for a few months. Mom notes that he will wring his hands later when he is anxious. Parents report past two months, they see a climax in the OCD patterns. He does not have OCD with symmetry, germs, food, oself-carere. No evidence of PANDAS due to Strep or URI. Last year he had two sessions of therapy and then two sessions with another therapist. His parents report that he is a good sleeper and a good eater. He tells mom that he likes girls but does not have time for them but asks mom about girls he likes. He is in all honors classes and is currently in 8th grade. He spent his summer learning algebra. He wants to attend a charter high school for Math, Science, and engineering. It is a magnet school in the public high school that accepts top students. He likes math and science. He reports that he loves his parents and is close to them. He feels that “they understand me the most.” He has a group of friends and reports that he has 12 close friends who run cross country with him, and “we are supportive of each other.” He hangs out with kids in the neighborhood. He has an apple watch but no phone. His parents told him that “it would be a distraction.” He does not text or chat. He uses his watch to call friends or briefly text. He admits to obsessive thoughts and thinking, “I could have done better, and these thoughts have no value.” He reports that he cannot stop the thoughts, and he cannot push them away. He denies sexual or religious thoughts. He overthinks conversations and whether he offended his friends. He reports that he gets obsessive and needs to learn “everything about sports, and it gets obsessive.”
He reports passive suicidal thoughts with no plan or intent for the past few weeks due to not being able to stop the thoughts and fearing they would distract him, but he would never harm himself.
He has a few sessions of therapy but did not like it because “they just told me to breathe and did not understand it.” Anxiety from age 7-8 whereby he did rituals and had to touch things repeatedly. No hospitalizations. The parents report that he has overall health is good. No history of trauma or abuse. He achieved his developmental milestones at appropriate developmental levels. S.S is an only child. He lives with two married parents who are in IT. He has many friends and is “a leader.” No IEP or 504 plan at school.
MSE
Appearance Appropriate, Casually Groomed, Good Hygiene
Attitude Cooperative, Pleasant, Good Eye Contact
Psychomotor Activity Normal, No Abnormal Movements
Affect Normal Range , Congruent to Mood, Appropriate to Context
Mood Anxious, Unhappy
Speech Clear, Normal Volume, Rate, Rhythm, Spontaneous
Thought Process Normal, Linear
Thought Content & Perceptions Normal
Orientation Awake, Alert, and Oriented to Person, Place, and Time
Memory Recent and Remote Memory Intact
Insight Good, Age Appropriate
Judgement Good, Age Appropriate
Concentration Good, Age Appropriate
Behavior Normal
Attention Attentive
Suicidality Denies
Homicidally Denies
AIMS / EPS Not Applicable
Assessment Instrument Used
PHQ-9 =3 which indicates no depression
GAD-7 score = 14 moderate anxiety
Though not completed a Children Yale-Brown Obsessive Compulsive Scale can help assess his progression of OCD tendencies.
Family History
His parents denied any medical or mental health concerns. S.S. mother is 49 y/o and his father is 50 y/o. His maternal grandmother and grandfather are 72y/o and 73 y/o respectively. His maternal grandmother and his uncle (50 y/o) have schizophrenia. His paternal grandfather and grandmother are 75 y/o and 70 y/o respectively. They both have hypertension, diabetes, and arthritis. The patient was conceived via a donor egg. The parents did not want to disclose more about the donor which would be of significance to note any genetic loading or other risks that the patient may be predisposed of.
Dx: OCD, GAD.
Differential tic d/o, adjustment disorder
Zoloft 25 mg was started and he was referred to therapy
