What diagnosis would you give to a 32-year-old male with a history of Major Depressive Disorder (MDD), Obsessive-Compulsive Disorder (OCD), and Antisocial Personality Disorder, who presents with symptoms of depression, anxiety, and impulsivity following a romantic breakup?

Primary Diagnosis: Adjustment Disorder with Mixed Disturbance of Emotions and Conduct (Resolved)

Based on the clinical presentation, I agree with the provisional diagnosis of Adjustment Disorder with mixed disturbance of emotions and conduct (resolved), rather than the previously assigned diagnoses of MDD, OCD, or Antisocial Personality Disorder. The patient's symptoms were clearly time-limited, directly linked to a specific stressor (romantic breakup), and have resolved without medication, which is inconsistent with chronic psychiatric disorders 1.

Rationale for Adjustment Disorder Diagnosis

The clinical picture strongly supports Adjustment Disorder rather than major psychiatric illness:

• Temporal relationship to stressor: All symptoms emerged immediately following the December 2024 breakup and resolved within months, which is characteristic of Adjustment Disorder 1, 2
• Symptom resolution without treatment: The patient is currently euthymic, stable, and functioning well despite no medication since May 2025, which would be highly unusual for true MDD or OCD 1
• Stressor-specific behavioral escalation: The maladaptive behaviors (stalking, repeated contact attempts) were entirely focused on obtaining closure from the ex-partner, not generalized patterns 3
• Current functioning: Patient maintains structured routine with volunteering, chess clubs, piano, choreography, and gym—inconsistent with active major psychiatric illness 2

Why Previous Diagnoses Are Questionable

Major Depressive Disorder - Not Supported

The MDD diagnosis does not fit the clinical course:

• Current BDI-II score of 18 indicates only mild depression, and patient rates mood 6-7/10 4
• No vegetative symptoms: appetite only "slightly decreased," energy normal, able to enjoy hobbies and experience pleasure 5
• Intentionally sleeping 5-6 hours (not insomnia), concentration "somewhat poor" but functioning well 5
• True MDD would not resolve spontaneously after 6 months without treatment 6

Obsessive-Compulsive Disorder - Does Not Meet Criteria

The OCD diagnosis is not supported by current or past presentation:

• YBOCS score of 4 is far below diagnostic threshold (severe OCD requires ≥28, or ≥14 for obsessions/compulsions only) 5, 4
• No time-consuming rituals: OCD requires obsessions/compulsions taking >1 hour per day 5
• Rumination about breakup is reality-based worry, not irrational obsessions—this is characteristic of adjustment reactions or depression, not OCD 5
• No compulsive behaviors: Repeated contact attempts were goal-directed (seeking closure), not ritualistic neutralizing behaviors driven by obsessions 5
• Patient's preoccupation was about a real-life concern (relationship ending) rather than the intrusive, ego-dystonic thoughts characteristic of OCD 5

Antisocial Personality Disorder - Incorrect Diagnosis

The forensic psychologist's ASPD diagnosis appears to be a fundamental misdiagnosis:

• No childhood conduct disorder: ASPD requires evidence of conduct disorder before age 15—patient has no such history 7
• No pattern of antisocial behavior: Single episode of boundary violations during acute distress does not constitute pervasive pattern 7
• Good premorbid functioning: Completed MD and Master's degree, successful residency training until this episode—inconsistent with ASPD 7
• Remorse and insight: Patient demonstrates genuine remorse, shame, and insight about his actions—rare in true ASPD 7
• Situational impulsivity: Impulsive behaviors were limited to one relationship crisis, not lifelong pattern 7

The forensic evaluation likely conflated acute behavioral dyscontrol during Adjustment Disorder with personality pathology 7.

Consideration of Borderline Personality Traits

While full Borderline Personality Disorder criteria are not met, some traits warrant monitoring:

• Rejection sensitivity and emotional reactivity during the breakup episode suggest borderline traits 7
• Fear of abandonment manifested in desperate attempts to prevent relationship loss 7
• Impulsivity under stress: Two aborted suicide attempts and escalating contact attempts 7
• However, no evidence of these patterns outside this single relationship crisis—patient reports making friends easily, no prior relationship difficulties, stable family relationships 7
• Borderline traits as vulnerability factors rather than personality disorder diagnosis is appropriate 7

Rule Out Generalized Anxiety Disorder

GAD-7 score of 8 indicates mild anxiety symptoms that warrant monitoring:

• Score of 8 falls in mild range (5-9), not moderate (10-14) or severe (≥15) 4
• Current anxiety symptoms (restlessness, concentration difficulty, worry) are likely reactive to ongoing psychosocial stressors (legal involvement, career interruption) rather than generalized anxiety disorder 5
• No evidence of excessive worry about multiple domains prior to the breakup episode 5
• Symptoms may resolve as legal situation resolves and career path clarifies 1

Risk Assessment

Current suicide risk is LOW, but chronic risk is ELEVATED:

• Protective factors: Euthymic mood, good insight, remorse, hopeful about future, family support, structured routine, no current ideation/intent/plan 4
• Risk factors: History of two aborted attempts in May 2024, impulsivity under stress, rejection sensitivity, ongoing stressors (legal, career) 4
• Pattern suggests crisis-driven suicidality rather than chronic suicidal ideation—risk escalates with acute stressors, particularly interpersonal rejection 8

Treatment Recommendations

Psychotherapy is the primary indicated treatment; medication is NOT currently warranted:

Weekly Psychotherapy (Essential)

• Combination approach: CBT for cognitive distortions and rumination patterns, psychodynamic for attachment issues and relationship patterns, DBT skills for emotional regulation and distress tolerance 7, 4
• Focus areas: Rejection sensitivity, emotional reactivity to interpersonal stress, distress tolerance skills, healthy relationship boundaries 7
• Relapse prevention: Identify early warning signs of emotional dysregulation, develop coping strategies for future stressors 1

Medication - NOT Indicated Currently

No psychotropic medication is warranted at this time because:

• No active psychiatric disorder: Adjustment Disorder has resolved, current symptoms are mild and reactive 1
• Previous Lexapro trial: Patient stopped in May 2025 and has remained stable without it for months—demonstrates medication is not necessary 5
• Risk of unnecessary treatment: Medicating resolved or mild symptoms can lead to prolonged unnecessary exposure and side effects 5
• Monitor for symptom worsening: Reassess need for SSRI only if depressive symptoms worsen (BDI-II >20) or anxiety significantly increases (GAD-7 >10) 4

Monitoring Plan

• Close outpatient follow-up every 2-4 weeks initially to monitor for symptom reemergence 4
• Repeat BDI-II and GAD-7 at each visit to track symptom trajectory 4
• Assess for suicidal ideation at every contact given history 4
• Consider SSRI initiation only if: BDI-II rises above 20, GAD-7 exceeds 10, functional impairment increases, or suicidal ideation emerges 4, 6

Common Pitfalls to Avoid

Do not over-diagnose chronic psychiatric illness based on a single crisis episode:

• Adjustment Disorder can present with severe symptoms including suicidality, but temporal relationship to stressor and resolution pattern distinguish it from major psychiatric disorders 1, 3
• Forensic evaluations during acute crisis (while incarcerated) may overestimate personality pathology 7

Do not continue unnecessary medication:

• Patient has demonstrated stability without medication—continuing Lexapro would be treating resolved symptoms 1

Do not underestimate chronic suicide risk:

• Despite current stability, pattern of impulsive suicidality under interpersonal stress requires ongoing monitoring and development of safety planning 4