‘Dear Parent, Your Child Has Had a Psychotic Break’
September 22, 2015 3:30 am September 22, 2015 3:30 am
I sit in my small office at the university counseling center, sighing as I pick up the phone to make the call that I always dread. I have worked as a psychiatrist with college students for 20 years, and this part never gets easier. One, two, three rings, and the mother of a student who had been in my office minutes earlier answers the phone.
I introduce myself and then deliver the news: “I’ve had to hospitalize your son, Jacob.”
“What are you talking about?” she says. “There’s nothing wrong with my son.”
I explain that his roommates brought him in earlier that day. They told me that he hadn’t slept in a week and had barely had anything to eat or drink.
“I know,” she says. “They called me. But he’s just adjusting to school. He arrived a month ago. He’s a freshman, for God’s sake.”
I concede that freshmen can have a tough time adjusting, but emphasize that Jacob is having a psychotic episode. He was afraid to leave my office, I tell her, because he felt he was being followed on campus. He said he had not been able to get any work done because he was confused and distracted by voices in his head. The hospital, I explain, is the safest place for him right now.
“My son was an all-A student in high school,” she maintains. “He won debate competitions.”
I understand her denial. I have college-age children. If one of them became psychotic, I would be in shock. And I would be angry with the messenger.
“So why couldn’t you wait until I got there to see what was going on?” she asks. “I could get a flight in a few days and meet with you and my son.”
Jacob’s mother lives a thousand miles away. There is no father in the picture.
I agree that it would have been better if she and Jacob and I could have met in my office together. But I reiterate that it wouldn’t have been safe to wait until she got here. Jacob was so confused and scared that I wasn’t sure he could have made it back to his dorm.
In an ideal world, there would be somewhere else for Jacob to go until his mother arrived, someplace other than a hospital, where he could get support and be encouraged to eat, sleep and take some medication. But we don’t have anything like that on campus or in our city.
I had spent over two hours with Jacob. I called in another psychiatrist to meet with him and offer her opinion. She agreed that he needed help in a hospital setting right away. If only his mother could have seen him, disheveled, wearing a heavy sweatshirt even though it was 90 degrees out, looking away from us and mumbling at voices only he could hear.
“So what do I do now?” his mother asks.
I suggest that she get on the plane as soon as possible and meet with Jacob and his treatment team at the hospital inpatient unit. I tell her that I don’t know how long he will be in the hospital. It may be a very short period of time.
“And then he will return to school, right?” she asks.
I tell her that I generally recommend that a person who has had a psychotic episode take the semester off, so that he has time to fully recover.
“No, he’ll be back in school,” she insists. And we end the conversation there.
I go to our team nurse to give her an update, in case the hospital or Jacob’s mother calls. But really, I am going to talk about the experience, to share it with a sympathetic listener, because there is always sadness and a sense of loss when a young person has a psychotic break.
I return to my office. Now that I have treated Jacob, I need to do the paperwork. My progress note, which I will fax to the hospital, explains my reason for hospitalizing Jacob. I also call the attending psychiatrist on the unit to discuss the case; I don’t want anything to fall through the cracks.
And then I wait.
A few days pass, and there is no word from the hospital. I hope, for Jacob’s sake, that he will be going home. Some people recover quickly from a psychotic episode, but others can take months. Jacob would be better off under the watchful eye of a parent who could catch signs of a relapse quickly. Perhaps he could transfer to a college near his mother’s house.
Ten days after I hospitalize Jacob, I get a phone call from the hospital. I’m told that Jacob is back at school and wants to see me.
Of course I will meet with him. But I am frustrated. He should be home, or in some sort of housing where daily support is provided, or in an intensive outpatient program. There should be an array of intermediate-level treatment measures after the patient leaves the hospital, for which insurance companies should provide reimbursement. Jacob needs more help than he will get as a college student living on campus. But options are limited.
I see him that afternoon. He is clean-shaven and no longer carries the odor of not having showered for a week. He looks at me, smiles and speaks in a calm voice.
“I’m feeling better now,” he says. “I’m getting caught up in schoolwork. My mother spoke with the case manager in the dean of students office, and the case manager talked with my professors. I may have to drop a class, but I’ll see how it goes.”
“I’m glad you’re feeling better,” I say. “Tell me what it was like being in the hospital?”
“I was only there for four days, and it was strange,” he says. “I do think the medication they gave me is helping, because I’m sleeping and concentrating better.”
“I know you weren’t happy about my sending you to the hospital,” I say. “Are you comfortable working with me?”
“Sure,” he says. “I know I needed to go, because I was very confused.”
I am intrigued by Jacob’s rapid response to medication. I see two possibilities. One is that the stress of moving away from home and starting school overwhelmed him, and he will fully recover as he gets adjusted. The other possibility is that he still has psychotic symptoms, but does not want to open up about them so that he can stay in school. I am hoping it is the former.
I tell Jacob that for the time being he and I should meet every week. I ask him to tell me if he starts feeling confused or having difficulty sleeping, so that we can adjust his medication if needed. If things keep going well, I explain, we should be able to taper his medication eventually.
After a first episode of psychosis, some people will have a full recovery and will not require medication long term. Others may need continuing medication because of an underlying condition such as bipolar disorder or schizophrenia.
I wish I could offer Jacob more, such as a peer mentorship program, where he could obtain additional help from someone who has experienced and recovered from a psychotic episode. In fact, some of my colleagues on campus are working on developing this and other programs to assist students after they have been hospitalized.
In the meantime, I do the best I can with the resources I have. I refer Jacob to a psychotherapist. Jacob also agrees to meet with his case manager in the dean of students office. She will work with him if he needs to adjust his course schedule.
Jacob’s mother was able to come to town for a few days while Jacob was in the hospital, but had to return home to take care of her daughter and go back to work. She speaks with Jacob every day on the phone. He permits me to call his mother for feedback on how he is doing.
I have seen many scenarios play out when young adults have psychotic episodes. The toughest cases stick with you the most.
One of my patients, with bipolar disorder, would periodically decide to stop her medication on her own, and became psychotic and manic each time. She could not be convinced that it was in her best interest to continue the recommended treatment. The last time she stopped her medication, voices told her to drive into traffic. She crashed into several cars, and miraculously, no one was seriously injured.
Her father subsequently became her legal guardian, lived with her and made sure she took her medication. She decided to leave school and focus on her recovery. The patient and her father came in together for her last visit with me, and brought me a plant as thanks for my help. I was touched.
I had another patient, a thoughtful young man, a psychology major, who had bipolar disorder. Before I started working with him, he became psychotic and made a serious suicide attempt. After a week in the intensive care unit, two weeks in a psychiatric hospital and a semester at home, he returned to school on a mood stabilizer and an antipsychotic. He was not having manic or psychotic symptoms when I began to see him, so I met with him every month to do therapy.
We talked about any stressful situation he was experiencing and about ways to cope. I never had to alter his medication. In fact, he felt the medication was so helpful that he never wanted to lower the dose. I was very happy for him when he was accepted into a Ph.D. program in neuroscience.
How will Jacob’s story unfold? I don’t know. But I want Jacob and his mother to know that there is always hope. I see it every day.
Marcia Morris is a psychiatrist at the University of Florida Counseling and Wellness Center.
Details have been altered to protect patient privacy.