For a 14-year-old adolescent with a 2–5‑year history of persistent low mood, anhedonia, insomnia, fatigue, weight gain, chronic headaches, recurrent panic attacks, a recent suicide attempt, a history of alleged physical/emotional abuse, remote traumatic brain injury, and ADHD treated with Vyvanse, is major depressive disorder the primary diagnosis or should other primary diagnoses such as post‑traumatic stress disorder/complex PTSD, generalized anxiety disorder, panic disorder, persistent depressive disorder, adjustment disorder, bipolar spectrum disorder, or depressive disorder due to a medical condition also be considered?

This is Not Just MDD—Multiple Primary Diagnoses Must Be Considered

Given this adolescent's history of alleged physical/emotional abuse, recurrent panic attacks, persistent hyperarousal symptoms, and trauma-related triggers causing intense distress and withdrawal, post-traumatic stress disorder (PTSD) or complex PTSD should be strongly considered as a primary diagnosis alongside or instead of MDD. The clinical picture suggests multiple co-occurring primary disorders rather than MDD alone.

Why PTSD/Complex PTSD Deserves Primary Diagnostic Consideration

This patient presents with hallmark trauma-related symptoms that extend beyond typical depression:

• Trauma exposure: Alleged ongoing physical/emotional abuse by relative, witnessed parental divorce, dual grandparent deaths, and remote traumatic brain injury from shaken baby syndrome at 7 months 1
• Re-experiencing phenomena: Recurrent panic attacks "associated with reminders of past distressing experiences" where he "freezes, becomes intensely distressed, experiences physical tension, and curls up or withdraws"
• Avoidance behaviors: Extensive time spent alone walking and reading manga as "ways of coping with interpersonal stress"
• Hyperarousal cluster: Chronic insomnia, persistent irritability, difficulty concentrating, hypervigilance evident in his responses to family conflict

Research demonstrates that PTSD and MDD share substantial symptom overlap, particularly in negative affective symptoms, making differentiation challenging 2. However, the freezing response, physical tension, and withdrawal during triggered episodes are more characteristic of PTSD's re-experiencing and arousal symptoms than pure depression 3.

Additional Primary Diagnoses to Consider

Panic Disorder

The patient reports "recurrent panic attacks" with the most recent 1-2 months ago. While these are "typically associated with reminders of past distressing experiences" (suggesting trauma-related triggers), panic disorder can co-occur independently. The GLAD-PC guidelines emphasize assessing for comorbid anxiety disorders in adolescent depression 1.

Generalized Anxiety Disorder (GAD)

"Chronic anxiety" and persistent worry are described, though the presentation is less clearly GAD-dominant. Research shows GAD factors correlate most strongly with PTSD hyperarousal symptoms 2, making differentiation difficult when trauma history exists.

Persistent Depressive Disorder (Dysthymia)

The 2-5 year duration of "persistent low mood, irritability, emotional dysregulation" beginning in middle school suggests chronicity beyond episodic MDD. However, the recent suicide attempt and severe functional impairment classify this as severe depression regardless 1.

Critical Diagnostic Framework

The GLAD-PC guidelines provide clear direction: An adolescent presenting with a recent suicide attempt should be considered severe category depression, but this does not preclude other primary diagnoses 1. The guidelines explicitly state clinicians must "assess for the existence of comorbid conditions that may affect the diagnosis and treatment of the depressive disorder" 1.

Hierarchical Assessment Approach:

1. PTSD/Complex PTSD evaluation takes priority given:

   • Clear trauma history with ongoing exposure
   • Trauma-specific symptom patterns (freezing, triggered episodes)
   • High comorbidity rates: 96% of PTSD patients meet criteria for at least one other disorder 4
   • Depression commonly develops secondary to PTSD 5, 6

2. Panic disorder assessment for the recurrent panic attacks, noting whether they occur exclusively in trauma-related contexts or independently

3. MDD severity classification is already established (severe due to recent suicide attempt per GLAD-PC criteria) 1

4. Rule out bipolar spectrum given:

   • Irritability and emotional dysregulation
   • GLAD-PC specifically warns to consider severe if "family history of first-degree relatives with bipolar disorder" 1
   • Family history notes "mental health concerns on paternal side" (unspecified)

Critical Comorbidity Patterns

Research demonstrates that comorbid PTSD in predominant MDD is associated with increased suicide risk (OR = 3.58) 6. This patient's presentation may represent:

• Primary PTSD with secondary MDD: Most likely given trauma history and symptom patterns 5, 4
• Co-primary PTSD and MDD: Both developing from shared traumatic exposures 2
• MDD with trauma-related features: Less likely given the specific re-experiencing symptoms

The somatic symptoms (chronic headaches, GI symptoms, weight gain, fatigue) align with both depression and PTSD, as somatic anhedonia shows independent associations with self-harm behaviors 7.

Medication Considerations

The current Vyvanse (stimulant) treatment for ADHD requires immediate scrutiny. The FDA label warns that stimulants can cause or exacerbate:

• Anxiety, psychosis, hostility, aggression
• Suicidal or homicidal ideation
• Insomnia and decreased appetite 8

This patient exhibits ALL of these concerning features. While he's been on Vyvanse since third grade, the temporal relationship between dose escalations and worsening psychiatric symptoms must be evaluated. Stimulant-induced anxiety and insomnia could be significantly contributing to the clinical picture.

The recently initiated Prozac (3 weeks) has shown "minimal perceived improvement"—insufficient duration for full antidepressant effect, but also raises questions about whether SSRI monotherapy addresses the primary pathology if PTSD is driving the presentation.

Developmental and Neurological Factors

The remote traumatic brain injury from shaken baby syndrome with seizures at 7 months cannot be dismissed. Neurology recommended "periodic developmental reassessment due to concerns about potential impact on development," but family never followed up. This raises the possibility of:

• Depressive disorder due to another medical condition (TBI sequelae)
• Organic contributions to emotional dysregulation
• Cognitive processing difficulties (he reports words "blur together" unless in larger print, struggles with reading comprehension)

The learning difficulties and need for 504 accommodations (which he doesn't consistently use) suggest unaddressed neurocognitive deficits that compound psychiatric symptoms.

What This Is NOT

This is not adjustment disorder. The 2-5 year duration, multiple suicide attempts, severe functional impairment, and chronic course far exceed adjustment disorder criteria, which requires symptom resolution within 6 months of stressor cessation.

Common Diagnostic Pitfalls to Avoid

1. Anchoring on the suicide attempt as solely depression: The GLAD-PC correctly classifies this as severe depression, but severe depression can be comorbid with or secondary to PTSD 1, 6

2. Overlooking PTSD when trauma history isn't volunteered: This patient's trauma history emerged through evaluation—many adolescents don't spontaneously report abuse 1

3. Attributing all symptoms to "adolescent angst" or family conflict: The specific symptom patterns (freezing, triggered episodes, hyperarousal) indicate pathological responses beyond normal stress

4. Ignoring the stimulant contribution: Vyvanse can directly cause anxiety, insomnia, and mood symptoms that mimic or worsen primary psychiatric disorders 8

5. Missing the TBI history: Remote brain injury can have lasting neuropsychiatric sequelae affecting mood regulation and cognitive function

Immediate Clinical Actions Required

• Comprehensive trauma-focused assessment using structured PTSD diagnostic tools
• Evaluate stimulant necessity and contribution to anxiety/insomnia/mood symptoms
• Neuropsychological testing to assess TBI sequelae and learning disabilities
• Safety planning addressing ongoing alleged abuse and suicide risk
• Collateral information from school, other caregivers to clarify symptom timeline and triggers

The answer is definitively: This is not just MDD. Primary PTSD/complex PTSD with comorbid severe MDD and panic disorder represents the most parsimonious explanation for this clinical presentation, with critical consideration of stimulant medication effects and remote TBI contributions.