What is the most likely diagnosis for an 11-year-old female with a history of suicidal attempts, depressive symptoms, anxiety, and physical and emotional abuse?

Assessment and Differential Diagnosis

Primary Assessment

This 11-year-old female most likely has Major Depressive Disorder (MDD) with high suicide risk, complicated by significant trauma history and comorbid anxiety disorder. 1 The constellation of persistent suicidal ideation, recent suicide attempt by cutting, prior hospitalization for intentional overdose, pervasive sadness, anxiety, sleep disturbance, and trauma exposure strongly supports this diagnosis. 1

Diagnostic Reasoning

Major Depressive Disorder - Most Likely Diagnosis

MDD is the primary diagnosis based on the following criteria that align with DSM-5 specifications for adolescent depression: 1

• Depressed/irritable mood: Reports being "mostly sad" with persistent low mood following family conflict 1
• Anhedonia: Difficulty enjoying activities, though maintains some interest in friends and hobbies 1
• Sleep disturbance: Sleeping only 4 hours per night, worsening from baseline insomnia since age 7 1
• Fatigue: Consistent with depressive presentation 1
• Concentration difficulties: Struggles with all schoolwork, particularly math, beyond what would be expected from ADHD alone 1
• Recurrent suicidal ideation and behavior: Multiple suicide attempts including recent wrist cutting and prior overdose, with detailed planning (goodbye notes) 1
• Low self-esteem: Feelings related to family rejection and abuse history 1

The presentation includes adolescent-specific manifestations of depression: irritability when people discuss her past, oppositional elements in family dynamics, and somatic complaints that interfere with functioning. 1

High Suicide Risk Factors Present

This patient demonstrates multiple established risk factors for completed suicide: 1

• Recent suicide attempt with method other than superficial cutting: She "cut her veins" with scissors, indicating higher intent than superficial self-injury 1
• Detailed planning: Brought goodbye notes to school, demonstrating premeditation 1
• Persistent suicidal ideation: Thoughts continue despite recent hospitalization 1
• Previous suicide attempt: Recent hospitalization for intentional overdose significantly elevates risk 1, 2
• Stressful life events: Ongoing family conflict regarding mother's custody demands and hearing family criticism 2
• History of physical and emotional abuse: Documented trauma from mother increases suicide risk substantially 1, 3
• First year post-discharge: Currently in highest-risk period following recent psychiatric hospitalization 1

Patients with MDD are 8.62 times more likely to die by suicide compared to the general population, with risk peaking in the first year after discharge. 1

Comorbid Generalized Anxiety Disorder

GAD is highly likely as a comorbid condition: 4, 5

• Constant anxiety without specific triggers: Reports feeling anxious continuously with physical sensation of heaviness 4
• Emotional dysregulation: Crying or screaming episodes due to anxiety 4
• Multiple specific phobias: Claustrophobia, needle phobia, blood phobia 4
• Anxious depression profile: The combination significantly increases suicide risk beyond depression alone 4, 5

Anxious depression is associated with more frequent depressive episodes, higher suicide risk, and poorer treatment outcomes compared to non-anxious depression. 4

Trauma-Related Symptoms (PTSD Features)

Significant trauma history warrants consideration of PTSD: 1, 6

• Physical abuse: Mother "messed her knees up" and hit her repeatedly from age 4 1
• Emotional abuse: Mother's statements about wanting abortion and father not loving her 1
• Sexual boundary violation: Uncle forcing her to undress for shower at age 7, ongoing proximity triggers 1
• Flashbacks: Explicitly mentions wanting flashbacks of abuse to stop 6
• Avoidance: Actively avoids uncle who lives next door 6
• Hyperarousal: Difficulty sleeping since age 7 (timing coincides with shower incident) 6

Eating Disorder - Requires Further Clarification

The patient reports "severe eating disorder" but presentation is atypical: 1

• Purging behavior: Has induced vomiting "a couple times" 1
• Unusual presentation: States her "body doesn't let her eat" without weight/shape concerns 1
• More likely: This may represent somatic manifestation of anxiety/depression rather than primary eating disorder, given absence of body image distortion and ability to eat today with pride 1
• Alternative consideration: Could represent conversion symptoms or psychosomatic response to emotional distress 1

Differential Diagnoses to Consider but Less Likely

Borderline Personality Disorder - Premature Diagnosis

BPD should NOT be diagnosed at age 11 despite some overlapping features: 1, 7

• Why it seems to fit: Rapid mood shifts, self-injury, unstable family relationships, fear of abandonment (mother situation), impulsivity 7
• Why it's NOT the primary diagnosis:
  • DSM-5 criteria specify onset in "early adulthood," not childhood 1
  • Personality is still developing at age 11; these symptoms are better explained by MDD with trauma 1
  • The American Academy of Child and Adolescent Psychiatry notes diagnostic complexity when rapid mood shifts present, but emphasizes considering MDD first in children 7
  • Her symptoms are temporally linked to specific stressors (family conflict, abuse) rather than pervasive pattern 1

Bipolar Disorder - Insufficient Evidence

Bipolar disorder is less likely: 1

• Against bipolar: No clear manic or hypomanic episodes described; irritability and mood shifts are better explained by MDD with anxiety and trauma 1
• Euthymic mood on MSE: Current mental status shows euthymic mood with flat affect, not consistent with active mood episode 1
• Tangential speech: More likely reflects anxiety and difficulty organizing thoughts around traumatic content than flight of ideas 1

Psychotic Depression - Possible but Unclear

Visual perceptual disturbances require clarification: 1

• "Seeing faces on objects": Described as "weird faces, not human faces" for "last few days" 1
• Differential considerations:
  • Pareidolia (normal phenomenon of seeing patterns) exacerbated by anxiety/sleep deprivation 1
  • Hypnagogic/hypnopompic hallucinations related to severe insomnia 1
  • True psychotic symptoms suggesting MDD with psychotic features 1
• No other psychotic symptoms: Denies auditory hallucinations, delusions, or paranoia 1
• Clinical significance: If true hallucinations, would indicate more severe depression requiring different treatment approach 1

ADHD - Present but Not Primary

ADHD is documented but not driving current presentation: 1

• Historical diagnosis: Diagnosed when younger, never treated 1
• Current impact: Difficulty focusing in class, but academic struggles more likely related to depression and recent school transition 1
• Not explaining: Suicidal behavior, mood symptoms, or anxiety 1

Critical Clinical Pitfalls to Avoid

Do Not Dismiss Suicidal Statements

"Suicidal thoughts or comments should never be dismissed as unimportant" even when patient currently denies active ideation. 1 She has demonstrated:

• Recent action (cutting "veins" with scissors) 1
• Planning behavior (goodbye notes) 1
• Persistent ideation despite hospitalization 1
• Ambivalence ("sometimes doesn't want to die but doesn't want to feel this way") which is typical and does NOT reduce risk 1

Do Not Overlook Lethality Misjudgment

Children and adolescents systematically overestimate lethality of methods, meaning her intent to cut her "veins" with scissors represents serious suicidal intent regardless of actual medical danger. 1 The attempt was not discovered until she disclosed at school the next day, indicating effort to avoid detection—a high-risk feature. 1

Do Not Minimize Ongoing Stressors

Unresolved custody conflict with abusive mother represents acute, ongoing suicide risk: 2

• Mother's "bribe" with phone contingent on living with her creates impossible situation 2
• Stressful life events are independently associated with suicide attempts (OR 2.32) 2
• Family pressure to "forgive" mother invalidates her trauma experience 2

Do Not Assume Recent Hospitalization Provides Protection

She is in the highest-risk period: first year post-discharge. 1 Despite recent hospitalization helping temporarily, suicidal ideation has returned, and the first year after discharge shows the strongest correlation with completed suicide. 1

Mental Status Examination Interpretation

The MSE reveals important diagnostic clues: 1

• Euthymic mood with flat affect: Dissociation between stated mood and observed affect suggests emotional numbing, common in trauma and depression 1
• Tangential speech: Difficulty organizing thoughts, likely reflecting anxiety and cognitive effects of depression 1
• Withdrawn behavior: Consistent with depressive withdrawal 1
• Good insight and judgment: Paradoxically, she demonstrates awareness of her situation, which can coexist with high suicide risk 1

Summary of Most Likely Diagnosis

Primary Diagnosis: Major Depressive Disorder, Severe, with High Suicide Risk 1

Comorbid Conditions:

• Generalized Anxiety Disorder 4, 5
• Post-Traumatic Stress Disorder (trauma features) 6
• ADHD (historical, untreated) 1
• Rule out: Psychotic features (visual perceptual disturbances require clarification) 1

This diagnostic formulation prioritizes immediate safety concerns while recognizing the complex interplay of depression, anxiety, and trauma that characterizes her presentation. 1 The combination of MDD with anxiety significantly elevates her suicide risk and predicts poorer treatment response, requiring intensive intervention. 4, 5