What is the DSM-5 diagnosis for a female adolescent patient with a history of emotional dysregulation, previous self-injury, and recent symptoms of persistent sadness, decreased appetite, sleep disturbances, and recurrent thoughts of self-harm following alleged sexual abuse and a traumatic event?

DSM-5 Diagnosis: Major Depressive Disorder, Moderate to Severe

This adolescent patient meets DSM-5 criteria for Major Depressive Disorder (MDD), with severity classified as moderate to severe given the presence of suicidal ideation, prior self-harm, and functional impairment. 1

Diagnostic Rationale

Core Depressive Symptoms Present

The patient exhibits the following DSM-5 criteria for MDD, requiring at least 5 symptoms present for at least 2 weeks, with at least one being depressed mood or anhedonia 1:

• Depressed mood: Persistent sadness since the triggering event 1
• Anhedonia: Decreased interest in activities (though partially compensated at school) 1
• Appetite disturbance: Decreased appetite 1
• Sleep disturbance: Sleep disturbances 1
• Psychomotor changes: Emotional dysregulation and distress 1
• Fatigue: Implied by overall presentation 1
• Feelings of worthlessness/guilt: Expressed distress about the situation and fear of consequences 1
• Suicidal ideation: Recurrent thoughts of self-harm with prior suicide attempt (wrist cutting last year) 1

Severity Classification: Moderate to Severe

The presence of recurrent suicidal ideation with a history of prior self-harm (cutting wrists last year) and recent thoughts of self-harm (one week ago) automatically elevates this to at least moderate-to-severe depression, regardless of symptom count. 1

According to GLAD-PC guidelines, an adolescent should be considered in the severe category if presenting with suicidal ideation, recent self-harm history, or severe impairment in functioning, even if not all 9 DSM-5 symptoms are present 1. This patient meets multiple high-risk criteria:

• History of prior suicide attempt (cutting) 1
• Recent suicidal thoughts (one week ago) 1
• Ongoing emotional distress and functional decline (academic performance decreased) 1
• Current protective factor (concern for boyfriend) is external and unstable 1

High-Risk Features Requiring Immediate Attention

This patient is at elevated risk for suicide completion based on multiple risk factors 1:

• Prior suicide attempt: History of self-injury (wrist cutting) is a strong predictor of future attempts 1
• Recent suicidal ideation: Thoughts of self-harm within the past week 1
• Ongoing stressors: Forced separation from boyfriend, family conflict, legal involvement 1
• Emotional dysregulation: Long-standing pattern since early adolescence 2, 3
• Unstable protective factors: Only refraining from self-harm due to concern for boyfriend's legal situation, not internal motivation 1

Differential Considerations and Exclusions

Why Not Adjustment Disorder?

While the depressive symptoms were triggered by a specific stressor (discovery of sexual activity and family conflict), the severity and duration of symptoms, combined with prior depressive episodes and self-harm history, indicate MDD rather than adjustment disorder 4. The patient describes depressed mood "since early adolescence" with "intermittent self-harm thoughts," suggesting a chronic or recurrent pattern beyond situational adjustment 1, 4.

Why Not Complex PTSD?

Although the patient experienced a traumatic event (family discovery, forced separation, police involvement) and exhibits emotional dysregulation, she does not describe the core PTSD symptoms of re-experiencing, avoidance of trauma reminders, or persistent perceptions of heightened threat 1, 3. The emotional dysregulation appears to be a longstanding trait rather than trauma-specific 2. Complex PTSD requires exposure to "threatening or horrific events" with specific disturbances in self-organization beyond what is described here 1.

Why Not Disruptive Mood Dysregulation Disorder (DMDD)?

DMDD requires severe recurrent temper outbursts and persistently irritable/angry mood between outbursts, with onset before age 10 5. This patient's presentation is characterized by sadness and self-directed harm rather than outwardly directed irritability or aggression 5.

Borderline Personality Disorder Considerations

The pattern of emotional dysregulation, self-harm, unstable relationships, and fear of abandonment raises consideration of emerging borderline personality disorder 1. However, personality disorder diagnoses in adolescents should be made cautiously, and the current acute depressive episode with suicidal risk takes diagnostic and treatment priority 1. The emotional dysregulation described may be part of the depressive presentation or a separate trait requiring longitudinal assessment 2.

Critical Clinical Actions Required

Immediate Safety Assessment

This patient requires urgent evaluation for hospitalization given the combination of active suicidal ideation, prior attempt, and unstable protective factors 1:

• The only stated reason for not acting on self-harm thoughts is concern for boyfriend's legal consequences—an external, unstable protective factor 1
• Adolescents at highest risk include those with prior attempts, current suicidal ideation, and depressed mood 1
• Hospitalization should be strongly considered until mental state and suicidality stabilize 1

Environmental Safety Measures

Parents must be explicitly instructed to remove all potentially lethal means from the home 1:

• Secure or dispose of all medications, including over-the-counter preparations 1
• Remove any sharp objects that could be used for cutting 1
• Remove firearms if present in the home (most common method of adolescent suicide completion in many regions) 1
• Warn about the dangerous disinhibiting effects of alcohol and other substances 1

Family Involvement and Support

Information must be gathered from multiple sources including parents, and the family must understand the severity of the situation 1. The current family conflict and maternal anger are significant stressors that require intervention 1. Discharge (if hospitalization is not pursued) can only be considered if adequate supervision and support will be available continuously 1.

Treatment Implications

Psychotherapy as First-Line

Psychotherapy should be the primary treatment modality for this adolescent 1. The 2014 literature indicates no data supporting drug treatment as superior to therapy for adjustment-related depression, and several authors have demonstrated ineffectiveness of drug therapy alone in similar presentations 4.

Medication Considerations if Needed

If pharmacotherapy is considered as an adjunct (not as monotherapy), SSRIs such as sertraline or fluoxetine are FDA-approved for adolescent depression 6. However, medication should never replace comprehensive psychotherapy and safety planning in an actively suicidal adolescent 1.

Ongoing Monitoring

This patient requires close, frequent follow-up with continuous reassessment of suicidal risk 1. The protective factor (concern for boyfriend) could disappear if legal proceedings conclude or if contact is permanently severed, potentially precipitating acute crisis 1.

Common Pitfalls to Avoid

• Do not dismiss suicidal thoughts as "attention-seeking" or minimize prior self-harm: Any history of self-injury significantly increases risk of future attempts and completion 1
• Do not rely on "no-suicide contracts": These have no proven efficacy and may provide false reassurance to clinicians and families 1
• Do not discharge without ensuring environmental safety: Explicit removal of lethal means is mandatory 1
• Do not overlook the unstable nature of the current protective factor: External motivations (boyfriend's welfare) are unreliable compared to internal protective factors 1
• Do not diagnose personality disorder prematurely: While traits suggest possible borderline features, focus on the acute depressive episode and suicide risk first 1