Academic Avoidance Behaviors Leading to Self-Harm in a College Student

Case at a Glance

A 19-year-old female college student presenting with a complex pattern of self-harm behaviors, academic avoidance, and suspected malingering, initially diagnosed with major depressive disorder following two suicide attempts within months of each other.

Patient's Story

The patient is a second-year college student who was recently diagnosed with major depressive disorder after two suicide attempts occurring within a few months during her freshman year. She reports that both incidents occurred before major academic examinations. The first attempt involved overdosing on over-the-counter medications (ibuprofen, acetaminophen, antihistamines), after which she contacted emergency services. The second, more serious attempt involved overdosing on prescribed SSRI antidepressants combined with alcohol, resulting in serotonin syndrome requiring hospitalization and subsequent psychiatric inpatient treatment. The patient now reports that these attempts were primarily motivated by academic avoidance rather than genuine suicidal ideation.

Initial Assessment

Following the second suicide attempt, the patient was diagnosed with major depressive disorder during her inpatient psychiatric stay. However, she now reveals significant doubt about this diagnosis, reporting that she deliberately engaged in self-harm behaviors to avoid academic responsibilities and gain accommodations. She describes a recent onset of severe procrastination, loss of academic motivation, and inability to focus on coursework, representing a significant change from her previously high-achieving academic performance.

The Diagnostic Journey

The patient's presentation raises questions about differential diagnoses including malingering disorder, factitious disorder, attention-deficit/hyperactivity disorder, anxiety disorders, or genuine depression with secondary academic avoidance behaviors. Her history reveals excellent academic performance through high school with sudden onset of executive dysfunction and avoidance behaviors in late high school/early college. The patient demonstrates significant insight into her behaviors and expresses genuine distress about her current functioning.

Final Diagnosis

Pending comprehensive psychiatric evaluation to differentiate between: 1) Adjustment disorder with mixed anxiety and depressed mood, 2) Attention-deficit/hyperactivity disorder (adult onset recognition), 3) Anxiety disorder with avoidance behaviors, 4) Factitious disorder vs. malingering behaviors, 5) Executive function disorder related to academic perfectionism and transition stress.

Treatment Plan

1. Honest disclosure to treating psychiatrist about motivations behind previous suicide attempts, 2) Comprehensive psychiatric reassessment including ADHD evaluation, 3) Dialectical Behavior Therapy (DBT) skills training for emotion regulation and distress tolerance, 4) Academic counseling and accommodations assessment, 5) Development of healthy coping mechanisms for academic stress, 6) Regular psychiatric follow-up with focus on underlying executive function and anxiety management.

Outcome and Follow-up

Patient demonstrates excellent insight and motivation for treatment. Prognosis is favorable given her recognition of maladaptive patterns and willingness to seek appropriate help. Close monitoring required to ensure safety while addressing underlying issues contributing to self-harm behaviors and academic dysfunction.