What is the likely diagnosis for a 15-year-old boy presenting with anger, irritability, mood swings, pain attacks, anxiety, social issues, talking back, restlessness, and a history of bullying?

Differential Diagnosis for a 15-Year-Old Boy with Anger, Irritability, Mood Swings, Pain Attacks, Anxiety, Social Issues, Talking Back, Restlessness, and History of Bullying

This adolescent requires immediate screening for depression, anxiety disorders, and suicide risk, as the combination of irritability, mood swings, anxiety, and bullying history places him at significantly elevated risk for suicidal ideation and behavior. 1

Primary Diagnostic Considerations

Most Likely: Anxiety Disorder with Comorbid Depression

The constellation of anxiety, social issues, irritability, restlessness, and mood swings most strongly suggests an anxiety disorder (likely Generalized Anxiety Disorder or Social Anxiety Disorder) with comorbid depressive features. 1, 2, 3

• Excessive, uncontrollable worry about everyday situations combined with irritability and restlessness are hallmark features of Generalized Anxiety Disorder in adolescents 2, 3
• Social anxiety presenting with fear of negative peer evaluation and social withdrawal is common at this developmental stage 3
• The history of bullying victimization is strongly associated with concurrent anxiety and depression, and significantly worsens baseline psychopathology 1
• Male adolescents with bullying victimization history are at particular risk for anxiety disorders 1
• "Pain attacks" may represent panic attacks with somatic manifestations (abrupt surge of intense fear with physical symptoms) 2, 3

Critical to Rule Out: Bipolar Disorder

Bipolar disorder must be carefully evaluated given the mood swings, irritability, and restlessness, though the presentation lacks classic manic features. 1, 4

• True bipolar disorder requires distinct periods of abnormally elevated, expansive, or irritable mood with increased energy lasting at least one week, accompanied by decreased need for sleep, racing thoughts, and marked psychomotor activation 1, 4
• Irritability alone is insufficient for bipolar diagnosis—it must represent a marked change from baseline functioning and be evident across multiple settings, not just reactive anger 1, 4
• The pattern described (anger, talking back, irritability) is more consistent with anxiety-related irritability or disruptive behavior rather than true mania unless there are distinct episodes with decreased sleep need and racing thoughts 1
• Manic grandiosity and irritability present as marked changes in mental state rather than temperamental traits or anger outbursts 1

Alternative Consideration: Disruptive Mood Dysregulation Disorder (DMDD)

If the irritability and anger outbursts are chronic and severe (occurring most days for at least 12 months), DMDD should be considered, though this typically presents earlier in childhood 5

Critical Risk Assessment Required

Immediate suicide risk screening is mandatory—this patient has multiple high-risk factors. 1

High-Risk Factors Present:

• Male gender 1
• History of bullying victimization (strongly associated with suicidal ideation and behavior in males) 1
• Anxiety symptoms 1
• Irritability and severe anger (predispose to suicide) 1
• Possible panic attacks ("pain attacks") 1
• Social difficulties 1

Bullying victimization in males is associated with substantially increased suicidal ideation and behavior even after controlling for depression, and the risk is highest in bully-victims (those who are both bullied and bully others). 1

Specific Assessment Steps

Psychiatric Symptom Evaluation:

Screen systematically using validated instruments: 1, 2

• PHQ-9 or PHQ-2 for depression 1
• GAD-7 or SCARED for anxiety 3
• Direct questioning about suicidal ideation, plan, and intent 1

Characterize the "mood swings" precisely: 1, 4

• Are these distinct episodes lasting days/weeks with clear onset and offset, or continuous irritability?
• Is there decreased need for sleep (not just insomnia from worry)?
• Are there racing thoughts, pressured speech, or marked increase in goal-directed activity?
• Is there grandiosity or reckless behavior beyond typical adolescent risk-taking?

Clarify the "pain attacks": 2, 3

• Do these represent panic attacks (abrupt surge of fear with palpitations, sweating, trembling, shortness of breath, chest pain)?
• Or are they somatic manifestations of anxiety (muscle tension, headaches)?

Bullying Assessment:

Determine the nature and extent of bullying involvement: 1, 6, 7

• Is he a victim only, or also engaging in bullying behavior (bully-victim status carries highest psychiatric risk)?
• What types: physical, verbal, relational, or cyberbullying?
• Current or past? Frequency and duration?
• Associated school avoidance or safety concerns?

Medical Rule-Outs:

Obtain thyroid function tests and fasting glucose to exclude hyperthyroidism and hypoglycemia as anxiety mimics. 2

Family and Environmental Factors:

• Family history of mood disorders, anxiety, or suicide 1
• Substance use (including caffeine excess, which can mimic anxiety) 1, 2
• Pathologic internet use (associated with depression and suicidality) 1
• Sleep patterns (distinguish insomnia from decreased need for sleep) 1

Treatment Approach Based on Most Likely Diagnosis

For anxiety disorder with depressive features (most likely diagnosis):

First-Line Treatment:

Initiate combination therapy with an SSRI (sertraline or paroxetine) plus cognitive-behavioral therapy (CBT), as this combination is superior to either alone. 2

• SSRIs are first-line pharmacological treatment for both generalized anxiety and panic disorder 2
• CBT provides durable skills that may prevent relapse after medication discontinuation 2
• CBT for anger and irritability targets emotion regulation deficits and social problem-solving 8, 5

Monitoring Protocol:

Schedule follow-up at 2 weeks, then monthly for the first 3 months to monitor for worsening anxiety, suicidal ideation, and medication adherence. 2

• Close monitoring for suicidality is essential, especially in the first months of SSRI treatment (boxed warning for suicidal thinking through age 24) 4
• Distinguish behavioral activation (motor restlessness, insomnia occurring early in treatment, improving with dose reduction) from true mania (appearing later, persisting despite medication changes) 4

Common Pitfalls to Avoid

• Dismissing symptoms as "just teenage drama" or normal adolescent behavior 3
• Missing the suicide risk associated with bullying victimization in males 1
• Overdiagnosing bipolar disorder based on irritability alone without distinct manic episodes 1
• Failing to assess for bully-victim status (both perpetrator and victim), which carries the highest psychiatric risk 1
• Not screening for substance use as self-medication 1, 3
• Overlooking medical causes of anxiety (hyperthyroidism, hypoglycemia) 2, 3
• Treating in isolation without addressing the bullying situation and school environment 6, 7