What is the likely diagnosis for a 13-year-old female with Attention Deficit Hyperactivity Disorder (ADHD), history of suicidal ideation, insomnia, seizure-like activity, and factitious (made-up) elaborate dreams?

Likely Diagnosis: Conversion Disorder (Functional Neurological Symptom Disorder) with Comorbid ADHD, Major Depressive Disorder, and Insomnia

This 13-year-old female most likely has conversion disorder (functional neurological symptom disorder) manifesting as pseudoseizures, occurring in the context of established ADHD, major depressive disorder with suicidal ideation, and insomnia. The seizure-like activity causing body limpness without true epileptic activity, combined with elaborate dream creation and documentation, suggests dissociative/conversion symptoms rather than a primary psychotic or factitious disorder.

Diagnostic Formulation

Primary Psychiatric Diagnoses

• Conversion Disorder (Functional Neurological Symptom Disorder): The seizure-like episodes with body limpness represent pseudoseizures, which are common manifestations of conversion disorder in adolescent females and often occur in the context of psychological distress 1, 2

• Major Depressive Disorder: The history of suicidal ideation combined with insomnia strongly suggests depression, particularly given that insomnia predicts subsequent suicidal ideation with small-to-medium effect sizes (d = .45) in adolescents 1

• ADHD: Already diagnosed, requiring ongoing management 1, 2

• Insomnia: This is both a symptom and independent risk factor, as insomnia demonstrates longitudinal associations with suicidal ideation throughout adolescence 1, 3

Critical Differential Considerations

• NOT Factitious Disorder: The elaborate dream writing is more consistent with creative coping or dissociative phenomena rather than intentional symptom fabrication for secondary gain 2

• Rule Out Epilepsy: The seizure-like activity requires neurological evaluation with EEG to definitively exclude true seizure disorder before confirming conversion disorder 1

• Trauma History Essential: The American Academy of Pediatrics mandates comprehensive trauma screening, as conversion symptoms frequently emerge following trauma exposure, and this patient's symptom constellation (dissociative-like phenomena, depression, ADHD) suggests possible underlying trauma 1, 2

Comprehensive Assessment Protocol

Mandatory Comorbidity Screening

• Screen for trauma exposure and PTSD symptoms: Conversion disorder and dissociative phenomena often follow traumatic experiences, and the American Academy of Pediatrics requires systematic screening for trauma-related disorders in all children with ADHD and behavioral symptoms 1, 2

• Assess depression severity: Use standardized measures to determine if depression is moderate or severe, as this determines treatment sequencing—severe depression must be treated first before addressing ADHD 2, 4

• Evaluate suicide risk systematically: Given the established link between insomnia and suicidal ideation (median follow-up 10.5 months showing d = .45 effect), and that disturbing dreams in early adolescence predict later suicidal ideation, this patient requires immediate suicide risk assessment 1, 5, 3

• Screen for substance use: Although less common at age 13, the American Academy of Pediatrics mandates baseline substance use screening in all adolescents with ADHD, particularly those with depression and suicidal ideation 1, 2

• Assess for additional comorbidities: Screen for anxiety disorders, oppositional defiant disorder, learning disabilities, and autism spectrum disorder, as these frequently co-occur and worsen functional outcomes 1, 2

Neurological Evaluation Required

• Obtain EEG and neurological consultation: This is mandatory to rule out true seizure disorder before confirming conversion disorder diagnosis 1

• Document seizure characteristics: Frequency, duration, triggers, and whether consciousness is truly lost versus appearing limp while aware 2

Treatment Algorithm

Step 1: Address Immediate Safety Concerns

• Prioritize suicide risk management: The combination of suicidal ideation, insomnia, and disturbing dreams (elaborate dream documentation) places this patient at elevated risk, as disturbing dreams appear 111 days before suicidal crisis and progress to nightmares 87 days before crisis 5, 3

• Treat severe depression first if present: If depression is severe, it becomes the primary treatment target and must be addressed before ADHD, using evidence-based psychotherapy (cognitive-behavioral therapy) and considering SSRI medication 2, 4

Step 2: Address Conversion Symptoms

• Initiate psychotherapy for conversion disorder: Evidence-based approaches include cognitive-behavioral therapy focused on symptom management and addressing underlying psychological stressors 2

• If trauma is identified, implement trauma-focused therapy: The International Society for the Study of Trauma and Dissociation recommends beginning trauma-focused therapy (prolonged exposure, EMDR, cognitive restructuring) without requiring prior stabilization 2

Step 3: Optimize ADHD Management

• If depression is moderate (not severe), initiate stimulant medication for ADHD first: Stimulants have rapid onset and often improve depressive symptoms, allowing quick assessment of whether ADHD symptom reduction improves the overall clinical picture 2, 4

• Combine medication with behavioral interventions: The American Academy of Pediatrics recommends parent training in behavior management (PTBM) and behavioral classroom interventions as essential components 1, 2

• Prescribe FDA-approved stimulant medications: Titrate to achieve maximum benefit with minimum adverse effects, with approximately 70% response rates expected 2, 4

Step 4: Address Insomnia Aggressively

• Treat insomnia as both symptom and risk factor: Given that insomnia predicts suicidal ideation with d = .30 to .45 effect sizes over extended follow-up periods, and that 80% of patients in suicidal crisis have altered dreams, insomnia treatment is critical for suicide prevention 1, 5

• Implement sleep hygiene and cognitive-behavioral therapy for insomnia: These are first-line interventions before considering pharmacological sleep aids 1, 2

• Monitor dream content as prodromal indicator: The progression from bad dreams to nightmares to suicidal dream content can help identify escalating suicide risk, with bad dreams appearing 4 months before crisis, nightmares 3 months before, and suicidal scenarios 1.5 months before 5

Educational and Chronic Care Management

School-Based Interventions

• Implement Individualized Education Program (IEP) or 504 plan: Educational interventions are necessary components of treatment, including school environment modifications, appropriate class placement, and individualized instructional supports 1, 2

• Establish behavioral classroom interventions: These are essential for managing ADHD symptoms and addressing trauma responses in the educational setting 1, 2

• Coordinate communication between school and healthcare providers: Follow chronic care model principles with bidirectional communication to monitor functioning across settings 2, 4

Ongoing Monitoring Requirements

• Monitor for emergence of new comorbidities: Particularly substance use as the patient approaches mid-adolescence, as untreated ADHD increases risk for substance use disorders 1, 2, 6

• Reassess suicide risk regularly: Given the longitudinal associations between disturbing dreams, insomnia, and suicidal ideation throughout adolescence, ongoing monitoring is essential 1, 5, 3

• Track conversion symptom frequency: Document seizure-like episodes to assess treatment response and identify triggers 2

• Manage as chronic condition: Follow medical home principles with periodic re-evaluation of treatment effectiveness, as untreated ADHD increases risk for early death, suicide, psychiatric comorbidity, lower educational achievement, and incarceration 1, 2, 6

Critical Pitfalls to Avoid

• Do not dismiss the seizure-like activity as "attention-seeking": Conversion disorder represents genuine neurological dysfunction with psychological etiology and requires appropriate psychiatric treatment, not dismissal 2

• Do not treat ADHD in isolation: The high comorbidity burden (depression, insomnia, conversion symptoms, suicidal ideation) means untreated comorbidities will significantly worsen outcomes 1, 2

• Do not overlook trauma history: Failure to assess and address underlying trauma will result in persistent conversion symptoms and poor treatment response 2

• Do not underestimate suicide risk: The combination of ADHD, depression, insomnia, and disturbing dreams (elaborate dream documentation) places this patient at substantially elevated risk, with ADHD occurring more frequently in suicidal groups than controls across multiple studies 1, 5, 3, 7, 8

• Do not prescribe medication without concurrent behavioral interventions: Combined treatment is superior to either medication or behavioral therapy alone 1, 2