Mental Health Issues and the University Student

16. Psychotic Symptoms

Adalet is a 23-year-old Turkish international graduate student in her first year of a comparative literature program. She comes in at the urging of her roommate , an Argentinian international student with whom she was randomly paired. The roommate accompanies Adalet to the session and states, “I think she’s suffering from a broken heart and needs some therapy.” Adalet has fallen in love with Joe, an American student in her program, but according to the roommate, “He doesn’t seem to know that she exists.” Lately Adalet has been eating less, not showering, and not going to classes. She listens quietly to her roommate’s concerns and then asks the roommate to leave. She is casually dressed, but her hair is greasy and disheveled. Her voice is soft and speech is sparse and initially guarded. When asked to describe Joe, she becomes animated, and her affect becomes joyous. She is convinced he loves her and that she will marry him, and she blames herself for inadvertently missing his previous cues that he was interested. For example, she noticed that he changed his Facebook status to indicate where he was going last Friday night, and in retrospect she knows this was a direct invitation to her alone to join him, but she did not. This is how she explains his avoidance of her now in class and his lack of response to her phone calls or texts. She describes several other ideas of reference. She denies depressive symptoms Chapter 16 Psychotic Symptoms Psychotic Symptoms  153 but admits that she has not been sleeping well and is not concentrating in class. However, she expects she will do well in her classes because she can “sense” more information than her peers and sees connections they miss. She shares a literary interpretation that is illogical and demonstrates looseness of associations; she sadly adds that her professor isn’t smart enough to see the brilliance of her work. She has no past psychiatric history, denies any substance use, and is unaware of psychiatric problems in her family, who live in Turkey. Elliot, an 18-year old Caucasian freshman, is brought in urgently by his mother, who came to campus after her son sounded “completely off” in a phone call, “talking nonsense.” She then spoke with one of his fraternity brothers, who said they’d noticed Elliot seemed more anxious lately, saying “weird stuff.” Elliot admits he’d been smoking marijuana a lot recently and had begun to feel anxious and paranoid after intoxication the previous week. However, he denies any use since then. Urine drug screen is positive only for THC. There is no past psychiatric history. He has some awareness that others don’t understand what he’s been saying, and states, “It may be because people think I have a chip in my head. I do have a photographic memory, you know.” He is flushed and appears anxious on exam, easily becoming argumentative, especially with his mother. His mother asks whether this is caused by marijuana and whether her son needs to be taken to rehab. Most students experiencing psychotic symptoms—hallucinations, delusions, paranoia, or grossly disorganized thinking—come to psychiatric attention when others are concerned. Sometimes additional symptoms or flagging school performance bring them in. They may be aware that something is wrong but often lack the insight to consider the psychotic symptoms themselves to be a medical or psychiatric problem. Some may fear that if they reveal their symptoms, they will be labeled crazy. Because major psychotic illnesses, such as schizophrenia, are so disruptive and cognitively disabling, it’s rare for students to arrive at college or graduate school with a poorly controlled psychotic disorder. It’s also rare for the presence of psychotic symptoms to actually signal the start of a major psychotic disorder in this population, but when they do, quick diagnosis and treatment are essential. Prevalence rates of psychotic disorders specifically in college students are hard to come by. The 2012 Healthy Minds Study of more than 20,000 students at 29 institutions found a self-reported incidence of about 0.1% for schizophrenia 154  Clinical Challenges and about 0.2% for other psychotic disorders.1 In 2011–2012 outcome data at the counseling center at Duke University, clinicians reported a “psychotic episode ” diagnosis in 6 of 1607 students seen, or less than 0.4%. However, psychotic symptoms among emerging adults are a different...