An 8-year-old boy is brought into his primary care physician by his mother because of stomach aches following a cross country move 3 months ago. His mother expresses concern because since the move her son has been insisting on sleeping in his parent’s bed and even when he is taken back to his own bed, he returns to his parent’s bed during the night. He reports concerns that there are shadows in his room that scare him and he is fearful that he will be kidnapped from his room and never see his parents ever again. Many hours are spent each night trying to convince him to sleep in his own room, and he is having trouble getting to school on time because he is fatigued from not getting enough sleep. He has been having recurring nightmares of being kidnapped from the home and wakes up crying even when he sleeps in his parent’s bed. While in the home he likes to be close to his mother which is a source of frustration for her because she reports that she feels like she cannot get a moment alone. Tim is reluctant to go out and meet other children without his mother being present and he has not made new friends in the neighborhood.
Which of the following is the most likely diagnosis?
- A) Agoraphobia
- B) Delusional disorder
- C) Dependent personality disorder
- D) Separation anxiety disorder
- E) Social anxiety disorder
D) Separation anxiety disorder
Separation anxiety disorder is an anxiety disorder with a constellation of behaviors which centers around fearfulness of losing one’s primary attachment figure. The behaviors must be present for at least 4 weeks in a child/adolescent patient. There must be at least 3 of the following: distress when separated from attachment figure, excessive worry about losing attachment figure, worry about a bad event that would cause prolonged separation from attachment figure, refusal to go out because of fear of separation, reluctance to be alone, refusal to sleep away from attachment figure, repeated nightmares about losing attachment figure, or repeated physical symptoms when away from attachment figure.
In this vignette, the boy’s symptoms have been present for at least 4 weeks. His behavior has changed from baseline, is persistent, and his behavior is causing distress and impairment in functioning. In childhood, functioning is measured by school performance, ability to make friends and getting along with family.
Answer choice A: Agoraphobia is incorrect.
Answer choice B: Delusional disorder, is incorrect. A delusion is a fixed false belief. While the boy’s belief that he may be kidnapped is irrational, two things need to be considered: 1) it is exceedingly rare for a patient this young to have a psychotic disorder; 2) the constellation of symptoms is better explained by another condition.\
Answer choice C: Dependent personality disorder, is incorrect. The boy in this vignette is too young to have a personality disorder.
Answer choice E: Social anxiety disorder, is incorrect. The patient is more concerned about losing his primary caregiver and not concerned with what peers think about him. He is not meeting new friends because he is having trouble separating from his mother.
Key Learning Point
Separation anxiety disorder is excessive fear when away from home or attachment figure and can be precipitated by a stressful event like loss or moving.
Dr. Ted O'Connell