What is the likely DSM-5 TR diagnosis for an 11-year-old female patient with no notable psychiatric history, who experienced a distressing incident involving an adult individual, resulting in symptoms such as fear, sleep disturbances, and decreased focus?

DSM-5-TR Diagnosis: Acute Stress Disorder

Based on the clinical presentation, the most appropriate DSM-5-TR diagnosis for medicolegal purposes is Acute Stress Disorder (309.81). 1, 2 This 11-year-old patient meets the diagnostic criteria with clear traumatic exposure, symptom onset within the required timeframe, and characteristic symptom clusters that have not yet persisted beyond one month.

Diagnostic Rationale

Traumatic Exposure Criterion Met

• The patient experienced a qualifying traumatic event through direct exposure to threatening behavior when an adult aggressively confronted her at her home, creating fear for her safety and her family's well-being. 1
• The subsequent confrontation at the barangay hall, where she was accused of lying and experienced intimidating behavior, constitutes additional trauma exposure. 1
• Learning about her family's potential legal consequences (fear of incarceration) represents indirect trauma exposure that meets DSM-5-TR criteria. 1

Temporal Requirements Satisfied

• Symptoms began within 3 days of the initial incident (she cried that same night and had distressing dreams). 1, 2
• The evaluation occurred within the 3-day to 1-month window required for Acute Stress Disorder diagnosis. 1, 2
• This temporal distinction is critical for medicolegal documentation—symptoms have not persisted beyond one month, which would change the diagnosis to PTSD. 2, 3

Required Symptom Clusters Present

Intrusion Symptoms (≥1 required): 1, 2

• Recurrent distressing dreams involving the perpetrator shouting and looking for her mother (traumatic nightmares). 2
• Intrusive thoughts when thinking about the problem, causing decreased focus. 2
• Intense psychological distress when reminded of the incident (trembling, palpitations at barangay hall). 1

Avoidance Symptoms (≥1 required): 1, 2

• Apprehension when someone knocks on the door, representing avoidance of external trauma reminders. 1
• Though she attended school, her absences due to headache suggest some avoidance of normal activities. 1

Negative Alterations in Cognition/Mood (≥2 required): 1, 2

• Persistent fear and negative emotional state regarding family's potential incarceration. 1
• Decreased interest in activities (implied by decreased focus and school absences). 1
• Persistent negative beliefs about safety and security in her home environment. 1

Alterations in Arousal/Reactivity (≥2 required): 1, 2

• Sleep disturbances with interrupted sleep following the nightmare. 1, 2
• Difficulty concentrating (decreased focus at school). 1, 2
• Exaggerated startle response (apprehension at door knocking). 1, 2
• Hypervigilance regarding potential return of the perpetrator. 1
• Physical manifestations of hyperarousal (trembling hands, palpitations during barangay hall encounter). 1, 2

Functional Impairment Documented

• The disturbance causes clinically significant impairment in academic functioning (decreased focus, school absences). 1, 2
• Social functioning affected (fear responses, crying episodes). 1
• The symptoms are causing sufficient distress to warrant medicolegal evaluation. 1

Critical Differential Diagnosis Considerations

Why Not Adjustment Disorder

• Adjustment Disorder is ruled out because this patient has specific intrusive re-experiencing symptoms (nightmares, flashbacks), marked hyperarousal (trembling, palpitations), and trauma-specific avoidance behaviors that exceed the emotional/behavioral symptoms seen in Adjustment Disorder. 2
• The presence of dissociative-like features during the barangay hall encounter (difficulty speaking, trembling) further distinguishes this from Adjustment Disorder. 2

Why Not Generalized Anxiety Disorder

• GAD requires excessive worry about multiple events for at least 6 months, not acute trauma-linked symptoms with specific flashbacks and trauma-related fear. 2
• The symptom onset is clearly linked to specific traumatic events, not generalized worry. 2

Why Not PTSD (Yet)

• The primary distinction is temporal: symptoms have not persisted beyond one month post-trauma, which is required for PTSD diagnosis. 1, 2, 3
• For medicolegal purposes, documenting Acute Stress Disorder now is appropriate, with the understanding that if symptoms persist beyond one month, the diagnosis would convert to PTSD. 2, 3

Medicolegal Documentation Recommendations

High-Risk Status Requires Active Monitoring

• This patient is at significant risk for progression to PTSD given the intensity of her fear response during the traumatic events and her belief that harm would come to her family. 3
• The American Academy of Pediatrics identifies patients with intense fear during trauma as high-risk for PTSD development. 3
• Active monitoring should occur at regular intervals rather than passive waiting for the one-month mark. 3

Early Intervention Indicated

• Early trauma-focused therapy during the Acute Stress Disorder phase can prevent progression to chronic PTSD. 2
• The American Academy of Child and Adolescent Psychiatry recommends active treatment, not simple observation. 2
• Referral to mental health services should be documented as medically necessary. 2, 3

Documentation Should Include

• Specific trauma exposures with dates and descriptions. 1
• All symptom clusters with specific examples from the patient's presentation. 1
• Functional impairment in academic and social domains. 1
• Risk assessment for PTSD progression. 3
• Recommendations for trauma-focused psychotherapy. 2

Common Pitfalls to Avoid

• Do not underdiagnose based solely on observable behaviors—most ASD symptoms are internal experiences (nightmares, intrusive thoughts, fear). 1, 3
• Do not wait passively for one month to pass before providing intervention—early treatment is indicated. 2, 3
• Do not confuse the patient's difficulty speaking and trembling during re-exposure as psychotic symptoms—these are dissociative features of ASD, not psychosis. 1
• Do not dismiss symptoms as "normal stress" because she continues attending school—functional impairment is clearly documented through decreased focus and absences. 1