What is the likely diagnosis for a 14-year-old senior high school student with a history of chronic bullying, presenting with recurrent panic attacks, anxiety, depressive symptoms, social withdrawal, and sleep disturbances?

DSM-5-TR Diagnostic Formulation

This patient meets diagnostic criteria for Panic Disorder with comorbid Major Depressive Disorder and likely Post-Traumatic Stress Disorder (PTSD), all precipitated by chronic bullying victimization. 1

Primary Diagnosis: Panic Disorder

The recurrent, unexpected panic attacks with characteristic symptoms (palpitations, trembling, shortness of breath, body stiffness, numbness, fear of collapse) that began in Grade 9 and recurred throughout Grades 10-11 clearly establish Panic Disorder as the primary diagnosis. 1, 2

• The panic attacks were recurrent and unexpected, occurring near-daily at peak severity during Grade 9 1
• Attacks included at least four characteristic symptoms: palpitations, trembling, shortness of breath, paresthesias (numbness), feelings of choking, and fear of losing control ("ayoko na") 1, 2
• The attacks led to persistent concern about additional attacks and maladaptive behavioral changes (school avoidance, social withdrawal, requiring assistance to be carried) 1, 2
• Significant functional impairment occurred, including frequent school absences and academic decline 1

Secondary Diagnosis: Major Depressive Disorder

The patient developed a full major depressive episode characterized by persistent sadness, social withdrawal, sleep disturbance, passive and active suicidal ideation, and statements of wanting to die ("ayoko nang mabuhay"). 1

• Depressed mood was present most of the day, nearly every day (persistent sadness, crying) 1
• Marked social withdrawal and isolation (locking herself in her room) 1
• Sleep disturbance (initial insomnia, reduced total sleep time from 9 to 6 hours) 1
• Suicidal ideation, both passive and active, with specific plans (cutting herself) and verbal expressions of death wish 1
• Significant functional impairment requiring intervention from local authorities and social services 1
• Females who experience bullying victimization are at risk for depression regardless of frequency, and the psychopathology is significantly worsened by the victimization 1

Tertiary Diagnosis: Post-Traumatic Stress Disorder (PTSD)

The patient exhibits PTSD symptoms related to the traumatic bullying experiences, including intrusive memories, avoidance behaviors, negative alterations in cognition and mood, and hyperarousal. 1, 3, 4

PTSD Criterion A: Exposure to Trauma

• Direct experience of physical assault (being pushed, resulting in leg wound; being pushed near sink) 1
• Repeated verbal assaults and public humiliation ("mataba," "baboy," "oink oink oink") 1

PTSD Criterion B: Intrusion Symptoms

• Intrusive visual memories (seeing the bully's face when closing eyes) 1
• Psychological distress at exposure to trauma cues (hearing "baboy" chants triggered immediate panic symptoms) 1
• Physiological reactions to trauma reminders (palpitations, trembling when hearing insults) 1

PTSD Criterion C: Avoidance

• Avoidance of places associated with trauma (stopped going to market, stopped attending school) 1
• Efforts to avoid trauma-related thoughts and feelings 1

PTSD Criterion D: Negative Alterations in Cognition and Mood

• Persistent negative emotional state (fear, shame toward classmates) 1
• Social detachment and isolation 1
• Research demonstrates that past bullying experiences are associated with PTSD symptoms that persist into young adulthood, with negative appraisals related to bullying influencing social interactions and mental health 5, 3, 4

PTSD Criterion E: Alterations in Arousal and Reactivity

• Hypervigilance (awareness of hostile stares and comments) 1
• Exaggerated startle response (immediate panic when hearing insults) 1
• Sleep disturbance 1

Duration and Functional Impairment

• Symptoms persisted for more than one month (from Grade 9 through Grade 11) 1
• Caused clinically significant distress and functional impairment (school avoidance, academic decline, social withdrawal) 1
• Being bullied in childhood increases PTSD risk and affects progression after subsequent stressors, with PTSD symptoms decreasing over time among those not bullied but persisting among victims 4

Additional Clinical Considerations

Bullying as a Trauma and Suicide Risk Factor

This patient represents a high-risk profile: female adolescent with chronic bullying victimization, panic attacks, depression, and active suicidal ideation. 1

• Bullying victimization in females is associated with later suicide attempts and completions even after controlling for conduct and depressive symptoms 1
• The patient experienced all four categories of bullying: direct-physical (pushing, assault), direct-verbal (insults, name-calling), indirect-relational (public humiliation), creating substantial distress 1
• Personal mental health problems that predispose to suicide include sleep disturbances, depression, panic attacks, and posttraumatic stress disorder—all present in this patient 1
• The patient exhibited both passive and active suicidal ideation with specific plans, requiring immediate safety assessment and intervention 1

Perceptual Experiences Requiring Clarification

The report of hearing "oink, oink, oink" from multiple individuals requires careful assessment to distinguish between hypervigilance/trauma-related misperceptions versus possible psychotic symptoms. 1

• Given the context of severe PTSD and panic disorder, these experiences may represent trauma-related hypervigilance and misinterpretation of ambiguous stimuli rather than true auditory hallucinations 1
• The experiences were consistently related to the trauma theme (animal sounds matching the bullying content) 1
• No other psychotic symptoms (delusions, disorganized thinking, negative symptoms) were reported 1
• However, if true auditory hallucinations are present, this would require consideration of a psychotic disorder or severe PTSD with dissociative features 1

Prognostic Indicators and Treatment Response

The patient demonstrated periods of symptom improvement during summer breaks and following psychosocial interventions, suggesting good treatment responsiveness. 1, 6, 7

• Symptoms improved with removal from triggering environment (summer breaks, family bonding) 1
• Significant improvement occurred following structured intervention: inclusion in youth council, family counseling, psychoeducation, and weekly counselor visits 1, 6
• By the most recent assessment, the patient reported normalized sleep and appetite, absence of sadness, no panic attacks, and non-distressing residual thoughts 1, 6
• This pattern suggests that combined psychosocial support and trauma-focused interventions are effective for this patient 6, 7

Critical Clinical Pitfalls to Avoid

• Do not dismiss the severity of bullying-related trauma—bullying victimization is associated with severe baseline psychopathology that is significantly worsened by the victimization, with long-lasting psychological impact 1, 8
• Do not overlook suicide risk—this patient had active suicidal ideation with plans and requires ongoing safety monitoring despite current improvement 1
• Do not misdiagnose perceptual disturbances as primary psychosis without ruling out trauma-related hypervigilance and PTSD-related dissociative symptoms 1
• Do not underestimate ongoing vulnerability—research shows PTSD symptoms from childhood bullying can persist and affect response to future stressors 5, 3, 4