What are the DSM‑5 diagnoses for this adult female patient who has childhood‑onset inattentive and hyperactive/impulsive symptoms meeting criteria for ADHD combined type, excessive worry and somatic symptoms for >6 months consistent with generalized anxiety disorder, a moderate‑to‑severe alcohol use disorder with two past DUIs, and a past panic disorder now in remission, while currently taking fluoxetine 80 mg and naltrexone?

Diagnostic Formulation for This Patient

This adult female patient meets DSM-5 criteria for three distinct diagnoses: ADHD Combined Presentation, Generalized Anxiety Disorder, and Alcohol Use Disorder—Moderate to Severe, currently in early remission on maintenance therapy. 1

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Primary Diagnoses

1. Attention-Deficit/Hyperactivity Disorder (ADHD), Combined Presentation

The patient clearly meets DSM-5 criteria for ADHD Combined Presentation based on convergent self-report and collateral informant data. 1

Current Symptomatology (Last 6 Months):

• Inattention domain: Self-report shows 6 symptoms rated 3-4 (96-98th percentile, moderately symptomatic); partner corroborates with 6 symptoms rated 3-4 (96-98th percentile) 1
• Hyperactivity-Impulsivity domain: Self-report shows 5 combined symptoms rated 3-4 (1 hyperactivity + 4 impulsivity); partner corroborates with 4 impulsivity symptoms rated 3-4 1
• Total ADHD symptom count: 11 symptoms rated 3-4 on self-report (96-98th percentile), 10 symptoms on partner report (96-98th percentile) 1

Childhood Onset Verification:

• Patient reports symptom onset at age 10, meeting the DSM-5 requirement for manifestations before age 12 1
• Childhood self-report (ages 5-12) shows 7 symptoms rated 3-4 (84-92nd percentile, borderline/somewhat symptomatic) 1
• Critical caveat: Mother's retrospective report shows no elevated symptoms in childhood (all scores <75th percentile, 0 symptoms rated 3-4). This discrepancy is common in adult ADHD diagnosis when parents underreport or fail to recall childhood symptoms, particularly in females who may have presented with less disruptive inattentive symptoms 1

Impairment Across Multiple Settings:

• Home: Impulsivity causing relationship conflict with partner, difficulty with household task completion and prioritization 1
• Work: Excessive phone scrolling (2-3 hours during workday, "all day" when off work), difficulty with task initiation and procrastination 1
• Social: Interrupting friends in conversation, forgetting plans/details, overwhelmed in social settings 1
• Childhood settings: School (talking during class, difficulty focusing), home (parental frustration with listening/applying self) 1

Diagnostic Justification:

The convergence of self-report and partner report at the 96-98th percentile for total ADHD symptoms, combined with documented childhood onset and clear functional impairment across multiple domains, establishes a robust ADHD diagnosis despite the mother's non-corroborating childhood report 1. The Combined Presentation is appropriate given that both inattentive (6 symptoms) and hyperactive-impulsive (5 symptoms) domains exceed the DSM-5 threshold of 5 symptoms in each domain for adults 1.

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2. Generalized Anxiety Disorder (GAD)

The patient meets full DSM-5 criteria for Generalized Anxiety Disorder with prominent somatic manifestations. 1

Core GAD Criteria Met:

• Excessive anxiety and worry for at least 6 months with difficulty controlling the worry 1, 2
• Restlessness and trouble calming down 1
• Mind racing, cannot slow down: Constant thinking about tasks (tomorrow's obligations, household chores), difficulty with task management 1

Somatic/Panic Symptoms:

• Episodes of trembling/shaking, choking sensations, chest discomfort, GI distress, lightheadedness, numbness/tingling, fear of losing control 1
• Important distinction: Patient explicitly denies persistent anxiety about additional panic attacks or maladaptive avoidance behaviors for at least one month, which rules out current Panic Disorder 1, 2

Historical Context:

• Past panic attacks in college before tests, last episode in [YEAR]—this represents Panic Disorder in remission, not an active diagnosis 2

Functional Impairment:

• Difficulty starting tasks, procrastination, mind wandering during conversations 1

Treatment Response:

• Currently on fluoxetine 80 mg for a few weeks, with partial improvement in anxiety symptoms 2, 3

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3. Alcohol Use Disorder, Moderate to Severe, in Early Remission, On Maintenance Therapy

The patient meets DSM-5 criteria for Alcohol Use Disorder with at least 6-7 criteria, placing her in the moderate-to-severe range, currently in early remission on naltrexone maintenance therapy. 1, 4

DSM-5 Criteria Met (Minimum 6-7 of 11):

1. Larger amounts/longer periods: Drinking until blackout, couple "drinks of vodka every 2-3 hours," consuming a fifth per week 1
2. Difficulty cutting down/controlling use: "Always been hard to stop drinking when started" 1
3. Great deal of time spent: Pattern of binge drinking, drinking alone to cope with IVF stress 1
4. Craving: Implied by pattern of use and need for naltrexone 1
5. Failure to fulfill major role obligations: Hiding drinking from partner, relationship conflict 1
6. Continued use despite social/interpersonal problems: Drinking despite partner awareness of problem 1
7. Hazardous use: Two DUIs ([YEAR] and [YEAR]) 1
8. Tolerance: Likely present given escalating pattern and quantity consumed 1
9. Withdrawal: Not explicitly documented but implied by severity of use 1

Severity Determination:

With 6-7+ criteria met, this qualifies as moderate (4-5 criteria) to severe (6+ criteria) Alcohol Use Disorder 1. Given the two DUIs, binge-to-blackout pattern, daily use of a fifth per week, and multiple treatment episodes, severe is most appropriate 1.

Remission Status:

• Early remission (≥3 to <12 months without meeting criteria except craving): Patient had last relapse on [recent date] after argument with mother, currently sober for approximately 2 months on naltrexone 1
• On maintenance therapy: Currently taking naltrexone for 2 months, enrolled in intensive outpatient program, seeing counselor every 2 weeks 1, 4

Treatment History:

• Past recovery program and outpatient treatment after [YEAR] DUI 4
• Vivitrol (injectable naltrexone) for 2 years with good response 4
• Two relapses since starting naltrexone: one on a holiday after 1 month sobriety, one on [recent date] 1

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Diagnostic Hierarchy and Comorbidity Considerations

Why These Are Independent Diagnoses, Not Substance-Induced:

The ADHD and GAD are independent primary disorders, not substance-induced, based on temporal relationships and persistence during abstinence. 1, 4

• ADHD: Childhood onset at age 10, predating problematic alcohol use (which began in college) 1
• GAD: Excessive worry and anxiety symptoms persist currently despite 2 months of sobriety on naltrexone, exceeding the DSM-5 4-week threshold for ruling out substance-induced disorders 1, 4
• Panic Disorder (past): College panic attacks preceded the most severe alcohol use period, suggesting independent etiology; now in remission 1, 2

Comorbidity Patterns:

This triad of ADHD, anxiety disorders, and alcohol use disorder is well-documented and clinically significant. 1, 5, 6

• ADHD commonly co-occurs with anxiety disorders and substance use disorders 1, 5
• The patient's impulsivity (markedly elevated at 99th percentile) likely contributed to both the development of alcohol use disorder and difficulty maintaining abstinence 5
• Anxiety and depression mediate the relationship between ADHD symptoms and substance use behaviors 5
• Comorbid anxiety and alcohol use disorders are associated with poorer outcomes and require integrated treatment 4, 6

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Additional Clinical Observations

Sluggish Cognitive Tempo (SCT):

• Self-report shows elevated SCT symptoms (23 total score, 93-95th percentile, 5 symptoms rated 3-4) 1
• Partner report shows normal range SCT (13 total score, <75th percentile) 1
• SCT is not a formal DSM-5 diagnosis but represents a dimensional construct that may inform treatment planning for attentional difficulties 1

Current Medications:

• Fluoxetine 80 mg: Started recently, on 80 mg for a few weeks, providing partial anxiety relief 2, 3
• Naltrexone: Started 2 months ago, helpful for maintaining sobriety 1, 4

Differential Diagnosis Exclusions:

• Substance-Induced Anxiety Disorder: Ruled out because anxiety symptoms persist beyond 4 weeks of abstinence and predate severe alcohol use 1, 4
• Current Panic Disorder: Ruled out because patient denies persistent anxiety about panic attacks or avoidance behaviors for at least one month 1, 2
• Oppositional Defiant Disorder/Conduct Disorder: Childhood history of "not liking being told what to do" but insufficient criteria for formal diagnosis 1

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Final Diagnostic Summary

DSM-5 Diagnoses (in order of clinical priority):

1. Attention-Deficit/Hyperactivity Disorder, Combined Presentation (childhood onset, currently symptomatic) 1

2. Generalized Anxiety Disorder (current, with somatic features) 1, 2

3. Alcohol Use Disorder, Severe, in Early Remission, On Maintenance Therapy (naltrexone) 1, 4

4. Panic Disorder, in Sustained Remission (last episode [YEAR], no current symptoms) 1, 2

Clinical Implications:

All three active diagnoses require concurrent integrated treatment, as sequential treatment of comorbid conditions yields inferior outcomes. 4, 6 The patient's current regimen of fluoxetine (addressing GAD), naltrexone (addressing AUD), and intensive outpatient programming represents an appropriate integrated approach, though ADHD-specific pharmacotherapy has not yet been initiated and should be considered once alcohol abstinence is more firmly established 1, 4.