Psychiatric Assessment and Documentation for an Adolescent: Marissa Case, Differentials, Safety Assessment and Tools

Psychiatric Assessment and Documentation for a Special Population: Adolescent Case (Marissa, 15)

Accurate diagnostic formulation and evidence-based interventions are essential to optimizing client outcomes. Review the case and respond comprehensively with scholarly references and in-text citations.

Case: Marissa, a 15-year-old sophomore, was referred by her school counselor for declining grades, increasing isolation and recent concerning social media posts. Over three months she has withdrawn from friends, stopped attending soccer (which she enjoyed) and stays in her room. Her mother reports irritability, tearfulness and an episode of self-injury two weeks ago after an argument. Marissa feels “overwhelmed and empty,” has occasional trouble sleeping and intense anxiety before school, and denies substance use. She says, “Sometimes I wish I didn’t have to wake up,” but does not elaborate. No history of ASD, ADHD, learning disabilities or psychiatric treatment. Her mother has an anxiety disorder and a maternal uncle has bipolar disorder. No known trauma, though she feels “socially excluded and left behind.”

1. What elements of the presentation require further assessment?
2. What assessment tools and techniques will you use to interview Marissa?
3. Provide three DSM-5-TR differential diagnoses and explain each.
4. What immediate safety assessments are needed?
5. What documentation elements are essential?

Original example for study purposes (about 990 words). This is an educational case analysis, not clinical advice for a real patient.

1. Elements Requiring Further Assessment

• Suicidal ideation and self-injury: the statement “Sometimes I wish I didn’t have to wake up” is passive suicidal ideation and, combined with self-injury two weeks ago, requires immediate, detailed assessment of frequency, intent, plan, method, access to means and prior attempts. The self-injury needs clarification of method, severity, medical treatment, intent (non-suicidal versus suicidal) and function.
• Social media messages: what was posted, whether it signals intent or a goodbye message and whether cyberbullying is involved.
• Mood symptoms: duration and pervasiveness of depressed or irritable mood, anhedonia (loss of interest in soccer), appetite and weight change, energy, concentration, worthlessness and guilt, and psychomotor changes.
• Bipolar screening: given a maternal uncle with bipolar disorder and prominent irritability, ask about any distinct periods of elevated or irritable mood with decreased need for sleep, racing thoughts, risk-taking or grandiosity.
• Anxiety: the nature of pre-school anxiety (fear of social judgment, panic attacks, generalized worry or school avoidance) and somatic symptoms.
• Social context: exclusion, bullying (in person or online), peer conflict, relationships, sexual and gender identity concerns if she chooses to share, family conflict and academic pressure.
• Sleep: pattern, screen use at night and whether she sleeps less without feeling tired (a possible hypomania sign).
• Substances, medical and trauma history: confirm substance denial confidentially, review thyroid function, anemia and medications, and screen sensitively for trauma, as unknown trauma may still be present.
• Strengths and protective factors: supportive adults, prior interests, future plans and willingness to engage.

2. Assessment Tools and Techniques

Interview techniques. Interview Marissa both with her mother and alone, explaining the limits of confidentiality (information about safety will be shared). Use a calm, nonjudgmental, developmentally appropriate approach with open-ended questions, validation and direct questions about suicide; asking about suicide does not increase risk. Gather collateral information from her mother and, with consent, the school counselor.

Standardized tools.

• Ask Suicide-Screening Questions (ASQ): a brief, validated suicide risk screen for youth (Horowitz et al., 2012).
• Columbia-Suicide Severity Rating Scale (C-SSRS): to assess the severity of ideation and suicidal behavior, including non-suicidal self-injury (Posner et al., 2011).
• PHQ-9 Modified for Adolescents (PHQ-A): to measure depressive symptom severity (Johnson et al., 2002), which guidelines recommend for adolescents (Zuckerbrot et al., 2018).
• Screen for Child Anxiety Related Disorders (SCARED): child and parent versions to identify anxiety subtypes (Birmaher et al., 1999).
• Bipolar screening: a parent-report mania screen, such as the Mood Disorder Questionnaire adapted for adolescents, plus a careful history of discrete mood episodes.
• Psychosocial interview: the HEADSS framework (home, education, activities, drugs, sexuality, suicide/depression, plus safety and social media) and the CRAFFT screen for substance use.
• Mental status examination and a medical workup as indicated (thyroid-stimulating hormone, complete blood count).

3. Three DSM-5-TR Differential Diagnoses

1. Major depressive disorder, single episode, with anxious distress. Three months of irritability, tearfulness, withdrawal, anhedonia, declining grades, sleep disturbance, emptiness and passive death wishes are consistent with a major depressive episode; in adolescents, irritable mood can replace depressed mood (American Psychiatric Association [APA], 2022). Her anxiety before school may fit the anxious distress specifier. This is the leading working diagnosis.
2. Bipolar spectrum disorder (for example, bipolar II disorder or other specified bipolar disorder). A depressive episode may be the first presentation of bipolar disorder, and a second-degree relative with bipolar disorder raises her risk. Irritability and sleep changes could reflect mixed features or hypomania. Ruling this out matters because antidepressant treatment without mood stabilization could trigger mania in a vulnerable adolescent.
3. Social anxiety disorder. Intense anxiety before school, feeling “socially excluded and left behind” and withdrawal from peers could reflect marked fear of social scrutiny and avoidance lasting six months or more, with depression developing secondarily. Maternal anxiety disorder adds familial risk.

Other considerations include adjustment disorder with mixed anxiety and depressed mood if symptoms follow an identifiable stressor such as exclusion, generalized anxiety disorder and emerging personality-related patterns (emptiness and self-injury after conflict), which should be assessed cautiously and not diagnosed prematurely in a 15-year-old.

4. Immediate Safety Assessments

• Complete a suicide risk screen (ASQ) and, because it will likely be positive, a full suicide risk assessment with the C-SSRS covering ideation, intent, plan, preparatory behavior, prior attempts and the recent self-injury.
• Assess acute risk factors (recent self-injury, social media messages, hopelessness, agitation, insomnia, conflict) and protective factors (family support, connection to school and future goals).
• Ask about access to lethal means, especially firearms and medications at home, and provide lethal means counseling to her mother (lock or remove firearms; lock up medications).
• Check for medical needs from the self-injury (wound care, ingestion).
• Determine the appropriate level of care: imminent risk requires emergency evaluation or hospitalization; lower risk may allow outpatient care with close follow-up.
• Develop a written safety plan with Marissa and her mother covering warning signs, coping strategies, people and places for distraction, trusted adults, crisis contacts (including the 988 Suicide & Crisis Lifeline) and steps to make the environment safe (Stanley & Brown, 2012).
• Assess for bullying or online exploitation and coordinate with the school counselor with appropriate consent.

5. Essential Documentation Elements

• Identifying data, referral source and reason, informants (Marissa, mother, school counselor) and consent and assent, including the confidentiality discussion.
• History of present illness, psychiatric, medical, developmental, family, social, academic and substance use histories.
• Mental status examination findings.
• Screening and rating scale results with scores and dates.
• A structured suicide risk assessment: ideation, intent, plan, means, self-injury details, risk and protective factors and an overall risk formulation (low, moderate or high) with clinical reasoning.
• Lethal means counseling provided and the family’s response.
• The collaborative safety plan, with a copy given to the family.
• Diagnostic impression with differentials and the rationale.
• Treatment plan (for example, evidence-based psychotherapy such as cognitive behavioral therapy or interpersonal therapy for adolescents, medication considerations after ruling out bipolar disorder), level of care decision, referrals, coordination with the school and the follow-up appointment date.
• Any mandated reporting, emergency actions and communication with guardians, written factually and with times.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Birmaher, B., Brent, D. A., Chiappetta, L., Bridge, J., Monga, S., & Baugher, M. (1999). Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): A replication study. Journal of the American Academy of Child & Adolescent Psychiatry, 38(10), 1230–1236. https://doi.org/10.1097/00004583-199910000-00011

Horowitz, L. M., Bridge, J. A., Teach, S. J., Ballard, E., Klima, J., Rosenstein, D. L., Wharff, E. A., Ginnis, K., Cannon, E., Joshi, P., & Pao, M. (2012). Ask Suicide-Screening Questions (ASQ): A brief instrument for the pediatric emergency department. Archives of Pediatrics & Adolescent Medicine, 166(12), 1170–1176. https://doi.org/10.1001/archpediatrics.2012.1276

Johnson, J. G., Harris, E. S., Spitzer, R. L., & Williams, J. B. W. (2002). The Patient Health Questionnaire for Adolescents: Validation of an instrument for the assessment of mental disorders among adolescent primary care patients. Journal of Adolescent Health, 30(3), 196–204. https://doi.org/10.1016/S1054-139X(01)00333-0

Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., Currier, G. W., Melvin, G. A., Greenhill, L., Shen, S., & Mann, J. J. (2011). The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168(12), 1266–1277. https://doi.org/10.1176/appi.ajp.2011.10111704

Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264. https://doi.org/10.1016/j.cbpra.2011.01.001

Zuckerbrot, R. A., Cheung, A., Jensen, P. S., Stein, R. E. K., Laraque, D., & GLAD-PC Steering Group. (2018). Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice preparation, identification, assessment, and initial management. Pediatrics, 141(3), Article e20174081. https://doi.org/10.1542/peds.2017-4081

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