What is the likely diagnosis for a 16-year-old female presenting with longstanding anxiety, depressive symptoms, obsessive-compulsive behaviors, self-injurious behavior, and episodic alcohol use?

Primary Diagnosis: Major Depressive Disorder with Comorbid Obsessive-Compulsive Disorder and Emerging Borderline Personality Disorder Features

This 16-year-old female most likely has Major Depressive Disorder (MDD) as her primary diagnosis, with significant comorbid Obsessive-Compulsive Disorder (OCD) and emerging features consistent with Borderline Personality Disorder (BPD), complicated by Alcohol Use Disorder and Panic Disorder.

Rationale for Major Depressive Disorder as Primary Diagnosis

The patient meets full DSM-IV criteria for MDD with daily sadness, hopelessness, guilt, fatigue, indecisiveness, feelings of worthlessness, decreased interest in activities, concentration problems, and recurrent suicidal thoughts 1. These symptoms are pervasive, occur nearly every day, and significantly interfere with her functioning despite maintaining academic performance 1.

• The prominence and persistence of depressive symptoms (occurring daily) distinguish this from mood dysregulation secondary to personality pathology alone 2
• Her depressive episode includes at least 5 of the 9 DSM criteria required for MDD diagnosis, with clear functional impairment 1

Obsessive-Compulsive Disorder as Significant Comorbidity

She clearly meets diagnostic criteria for OCD with intrusive thoughts about food safety, contamination fears regarding bottled water, and time-consuming compulsions including hygiene rituals, jewelry placement rituals, and checking behaviors 2.

• Her obsessions are recurrent, persistent, intrusive, and cause marked anxiety, while her compulsions are repetitive behaviors aimed at reducing distress 2
• The food-related obsessions (believing only specific restaurant food is safe, fears of contamination) and compulsions are clearly excessive and not connected in a realistic way to actual danger 2
• Importantly, these symptoms improved with environmental disruption (summer camps), suggesting they are ego-dystonic and responsive to behavioral intervention 2
• The comorbidity of OCD and depression is common, occurring in approximately one-third of OCD patients, and depression negatively affects OCD treatment outcomes 3

Emerging Borderline Personality Disorder Features

While formal BPD diagnosis requires caution in adolescents, this patient demonstrates multiple concerning features consistent with emerging BPD that significantly impact her clinical presentation and prognosis 4.

Key BPD features present:

• Chronic emotional dysregulation with unpredictable anger outbursts triggered by interpersonal stress 4
• Unstable interpersonal relationships, evidenced by recent relationship ending triggering severe emotional crisis 4
• Recurrent self-injurious behavior (previously every other day) without identifiable triggers or relief—a hallmark of BPD 4
• Difficulty regulating emotions with irritability and anger outbursts 4
• History of trauma (strained paternal relationship with frequent arguments and guilt) contributing to personality development 4

The self-injury pattern is particularly significant: she reports no identifiable triggers and no sense of relief from the behavior, which distinguishes this from excoriation disorder or trichotillomania where the behavior itself provides some gratification 2. This pattern is more consistent with BPD-related self-harm 4.

• BPD shows strong associations with both internalizing disorders (depression, anxiety) and externalizing behaviors (substance use), explaining her complex presentation 5
• The combination of depression, anxiety, OCD symptoms, self-harm, and alcohol use fits the internalizing-externalizing structure where BPD connects to both dimensions 5

Panic Disorder

She meets criteria for Panic Disorder with onset at age 13, experiencing frequent panic attacks with intense fear of dying, rapid heart rate, and other physical symptoms 1.

• Her panic attacks include at least 4 of the required DSM-IV symptoms: palpitations/rapid heart rate, intense fear, fear of dying, and likely additional somatic symptoms 1
• The attacks are recurrent and unexpected, causing significant concern about future attacks 1

Alcohol Use Disorder

Her episodic alcohol use since age 15 with expressed desire for "better control" suggests at minimum problematic use, likely meeting criteria for Alcohol Use Disorder 1.

• Alcohol use co-occurs with OCD at rates significantly greater than the general population 6
• In her case, anxiety sensitivity and social anxiety (evidenced by mistreatment in friend group, fear of flying alone) likely moderate the relationship between OCD symptoms and risky alcohol use 6
• AUD comorbidity in OCD patients is associated with increased suicidality risk, which is particularly concerning given her history of suicidal thoughts and self-harm 7
• The combination of OCD, depression, anxiety, and substance use creates a high-risk clinical picture requiring immediate attention 7

Differential Considerations and What This Is NOT

This is NOT primarily Generalized Anxiety Disorder (GAD): While she has chronic worry about academic and career success, her anxiety is better explained by the combination of panic disorder, OCD-specific obsessions, and BPD-related emotional dysregulation 2.

This is NOT primarily a personality disorder diagnosis at this time: While BPD features are prominent, formal personality disorder diagnosis in a 16-year-old requires careful consideration, and her acute depressive and anxiety symptoms warrant immediate treatment focus 4. However, these features must inform treatment planning.

This is NOT Body Dysmorphic Disorder: Despite some appearance-related concerns (acne treatment), she lacks the characteristic preoccupation with perceived appearance flaws, time-consuming mirror checking for appearance defects, or appearance-driven grooming rituals that would suggest BDD 2.

This is NOT Social Anxiety Disorder alone: While she has social difficulties (mistreatment in friend group, medical procedure anxiety), her social fears are better explained by the combination of panic disorder, OCD contamination fears, and BPD-related interpersonal instability 2.

Critical Clinical Pitfalls to Avoid

Do not dismiss the self-injury as "attention-seeking": The pattern of self-harm without identifiable triggers or relief is a serious symptom requiring immediate safety assessment and intervention, particularly given the high suicide risk in patients with comorbid OCD and AUD 7.

Do not overlook the alcohol use: AUD in OCD patients is associated with increased suicidality, and her anxiety sensitivity and social anxiety significantly increase her risk for problematic drinking 6, 7. This requires specific assessment and intervention.

Do not delay treatment due to her reluctance about medication: Her concerns about long-term medication need to be addressed through psychoeducation, but given the severity of her symptoms, multiple comorbidities, and suicide risk, pharmacotherapy is indicated 1.

Do not ignore the emerging BPD features: While not making a formal personality disorder diagnosis, recognizing these features is essential for treatment planning, as BPD comorbidity affects treatment response and requires specific therapeutic approaches 4, 3.

Treatment Implications

Immediate priorities:

• Safety assessment and monitoring given history of self-harm, suicidal thoughts, and high-risk comorbidity profile 1, 7
• Initiation of SSRI (fluoxetine is FDA-approved for pediatric MDD, OCD, and has evidence for panic disorder) 1
• Intensive outpatient therapy as she requested, with evidence-based approaches including Dialectical Behavior Therapy (DBT) for emotion dysregulation and self-harm, plus Exposure and Response Prevention (ERP) for OCD 4
• Substance use assessment and intervention for alcohol use 7
• Family involvement given her age and strained paternal relationship 4

The complexity of her presentation—with MDD, OCD, panic disorder, emerging BPD features, and AUD—requires integrated treatment addressing all dimensions simultaneously rather than sequential treatment of individual disorders 5, 7.