A 12-year-old girl is brought to the office by her mother due to worsening grades and repeated absences from school associated with frequent stomachaches. Her mother says, "She never had a problem before starting middle school 6 months ago. She used to walk to elementary school, but the middle school is farther away. Now, I have to take her to school myself because she refuses to get on the bus. As soon as we get close to the school, her stomach hurts and she says she's going to vomit. If she goes to school, she calls during every break to see if I'm okay. I keep telling her that I'm fine." The patient is worried that her mother will have an accident and not be able to pick her up from school and says, "I won't know what happened to her." The patient denies problems with her appetite or energy levels but has trouble concentrating in class because she is worried about getting to the phone in her locker. She denies being bullied or having other issues at school. Family history is significant for cardiovascular disease and anxiety in her father and obsessive-compulsive disorder in her maternal aunt. Physical examination is normal. Which of the following is the most likely diagnosis?

Question

A 12-year-old girl is brought to the office by her mother due to worsening grades and repeated absences from school associated with frequent stomachaches.  Her mother says, "She never had a problem before starting middle school 6 months ago.  She used to walk to elementary school, but the middle school is farther away.  Now, I have to take her to school myself because she refuses to get on the bus.  As soon as we get close to the school, her stomach hurts and she says she's going to vomit.  If she goes to school, she calls during every break to see if I'm okay.  I keep telling her that I'm fine."  The patient is worried that her mother will have an accident and not be able to pick her up from school and says, "I won't know what happened to her."  The patient denies problems with her appetite or energy levels but has trouble concentrating in class because she is worried about getting to the phone in her locker.  She denies being bullied or having other issues at school.  Family history is significant for cardiovascular disease and anxiety in her father and obsessive-compulsive disorder in her maternal aunt.  Physical examination is normal.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's fear of separation with excessive concern that something bad will happen and reluctance to leave her mother are suggestive of separation anxiety disorder. It is more common in children under age 12 but can occur at any age. Some degree of separation anxiety is normal at age 9-18 months. This anxiety commonly recurs when children start school or transition in some way. In this case, the girl has to travel farther away from home to attend middle school, which has precipitated her anxiety. In children and adolescents, separation anxiety is often associated with somatic symptoms (eg, stomachaches), nightmares, and difficulty sleeping and may lead to school avoidance, as seen in this patient. In adults, separation anxiety may represent a persistent disorder from childhood or can develop suddenly, especially after a traumatic or life-changing event. Separation anxiety becomes pathological when it is persistent, impedes a child's development, or causes significant functional impairment. (Choice A) Adjustment disorder develops as a response to a stressful event and causes impairment in functioning. However, adjustment disorder is not diagnosed when the patient's condition is better explained by a more specific disorder (eg, in this case, separation anxiety). (Choice B) In dependent personality disorder, fears of separation are due to an excessive need to be taken care of, with difficulty being alone and making decisions. This patient, however, is resisting separation due to a fear of something happening to her mother. Personality disorders are not commonly diagnosed in children, whose personalities are still developing. (Choice C) Generalized anxiety disorder involves excessive worries about multiple issues, which is not the case with this patient. Her anxiety is focused on separation. (Choice D) Preoccupation with safety and checking behaviors can be seen in obsessive-compulsive disorder. However, this girl's behavior is due to her fear of separation from her mother, making separation anxiety the central issue. (Choice F) In somatic symptom disorder, patients are preoccupied with their somatic symptoms, with concern that they could have a serious illness. In contrast, in separation anxiety disorder, physical symptoms (eg, stomachaches, hyperventilation, headaches) occur only when separation is anticipated. Unlike someone with somatic symptom disorder, this patient does not exhibit excessive preoccupation with her symptoms. Educational objective: Separation anxiety disorder is most commonly seen in infants and toddlers but can occur at any age and is often associated with transition or change. It is characterized by a marked fear of separation from a loved one and may present as school or work absences. References: Separation anxiety: at the neurobiological crossroads of adaptation and illness. (http://www.ncbi.nlm.nih.gov/pubmed/26487808) Pediatric-onset and adult-onset separation anxiety disorder across countries in the World Mental Health Survey. (http://www.ncbi.nlm.nih.gov/pubmed/26046337)

A 12-Year-Old Girl Is Brought to the Office by Her