A 9-year-old girl is brought to the office by her mother for evaluation of frequent stomach aches. The mother says that her daughter has always had a "sensitive stomach" but that it has gotten worse since she started going to a new school a few months ago. The girl has been missing class due to being in the nurse's office multiple times per week. The patient's symptoms improve when her mother comes to get her. In response to the doctor's questions about the girl's peer relationships, the mother replies, "She has friends but never enjoys sleepovers." When the patient is at a friend's house, she often complains of stomach pain and nausea. She occasionally has nightmares about being left alone and wakes up crying. Although both parents are healthy, the patient says she worries about them "dying of a terrible illness, like cancer." Abdominal examination shows no abnormalities. Which of the following is the most likely diagnosis in this patient?

Question

A 9-year-old girl is brought to the office by her mother for evaluation of frequent stomach aches.  The mother says that her daughter has always had a "sensitive stomach" but that it has gotten worse since she started going to a new school a few months ago.  The girl has been missing class due to being in the nurse's office multiple times per week.  The patient's symptoms improve when her mother comes to get her.  In response to the doctor's questions about the girl's peer relationships, the mother replies, "She has friends but never enjoys sleepovers."  When the patient is at a friend's house, she often complains of stomach pain and nausea.  She occasionally has nightmares about being left alone and wakes up crying.  Although both parents are healthy, the patient says she worries about them "dying of a terrible illness, like cancer."  Abdominal examination shows no abnormalities.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

Although separation anxiety is common in young children and in older children at times of change or stress, this patient's distress is excessive and impairing when she is separated from her mother. Her inability to sleep away from home, abdominal pain when separated from her mother, worries about losing her parents, and nightmares about being left alone are consistent with separation anxiety disorder. Children with this disorder commonly experience physical symptoms (eg, headaches, stomach aches, nausea) when separation occurs or is anticipated, and have repeated nightmares involving the theme of separation. According to DSM-5, symptoms must be present for ≥4 weeks in children and ≥6 months in adults. (Choice A) This girl's symptoms predate the stressor of starting a new school. In addition, adjustment disorders are not diagnosed when symptoms better meet the criteria for another disorder. As in this patient, stressful events often exacerbate symptoms of another disorder. (Choice B) Patients with dependent personality disorder fear being left alone and seek out others to support and assume responsibility for them. However, personality disorders are not diagnosed in children as their personalities are still developing. (Choice C) Generalized anxiety disorder involves chronic anxiety regarding multiple issues. This patient's symptoms occur in the context of separation, making separation anxiety disorder the appropriate diagnosis. (Choice D) This child's fears focus on her parents becoming ill, causing her to be left alone. Illness anxiety disorder is diagnosed in individuals who excessively worry about having a specific illness themselves. (Choice F) Social anxiety disorder is considered when anxiety and avoidance of social settings are due to worry about being viewed negatively by others. This child fears separation from her parents, not social rejection. (Choice G) Patients with somatic symptom disorder have an ongoing preoccupation with physical symptoms; their anxiety is primarily related to their physical symptoms and health. This child's somatic symptoms are an expression of anxiety due to separation from attachment figures. Educational objective: Separation anxiety disorder consists of excessive and distressing anxiety (≥4 weeks in children, ≥6 months in adults) due to separation from attachment figures. Children with this disorder often experience physical symptoms and nightmares. __________ References: Pediatric-onset and adult-onset separation anxiety disorder across countries in the World Mental Health Survey. (http://www.ncbi.nlm.nih.gov/pubmed/26046337) Assessment and treatment of anxiety disorders in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/25980507)

A 9-Year-Old Girl Is Brought to the Office by Her