Verified by 
When my son Bill first exhibited signs of being sick after his freshman year away at college, it was surprisingly difficult to figure out what the problem was, even given my expertise as a psychiatrist with two decades of treating patients.
The onset of psychiatric illness can be insidious. In schizophrenia, for example, there may be a gradual decline from a previous level of functioning, called a prodrome—the person, usually a teenager, no longer functions the same in school and becomes less able to engage socially. Symptoms may include increased anxiety, low mood, sleep disturbance, disorganized thoughts or confusion, feeling suspicious, and difficulties concentrating or focusing. They may verbalize odd statements or assertions that don’t quite make sense.
In depression, there may be a gradual slide into lower moods with no apparent cause—or in some cases, there may be a very abrupt and distinct plunge into depression. Again, often for no apparent reason.
In my son’s case, Bill had not given any indication during his freshman year at Michigan that anything had changed for him, but once he returned home he was clearly different. Where he had previously been outgoing and gregarious, he now kept to himself, intent on not saying too much. He kept reassuring me that everything was okay and that I worried too much.
Was his behavior somewhere on a normal spectrum? Was it drug-induced? Was it psychosis? As a psychiatrist, this is one of the most difficult diagnostic dilemmas, especially in cases where the person is withholding information. But this was my son, so the challenge was made even more difficult by inherent parent-child dynamics.
When Bill returned home from college that first summer, his brothers and I raced to the airport gate, intending to surprise him coming off the plane but we didn’t see him. I had him paged to meet us at baggage claim, and we heard the overhead announcement, “Please meet your family at baggage claim.” Ten minutes later he approached us, looking wary.
“What was that about?” he asked.
“You mean the page?” I said, “We were trying to let you know where to find us.”
He looked uneasy. His brothers punched him on the shoulder like they always did. “Hey man, how was this term?”
Bill didn’t respond, nor did he say much on the way home. He talked about how much harder the second term had been. He warned me that the 3.7 GPA that he had made first semester would be lower this time. But that was about it.
During dinner, he suddenly said, “I’ve been wondering if I’m being followed.”
Alarmed, I asked, “What makes you think that, and why would someone want to follow you?”
“Well, on the plane there were people who seemed to keep an eye on me. And when I was involved in the student paper, I noticed some people watched what I did.”
I asked him “Do you mean other students working on the paper, or other people not connected to the paper?” I was worried that he might be experiencing paranoid psychotic symptoms if the experience was of being watched from the outside and not related to the paper. Paranoid symptoms are not diagnostic of any particular mental state or illness; rather they indicate a break from reality and could be part of drug abuse, schizophrenia, or other illnesses with a psychotic aspect. In contrast, if people on the paper were watching him it could be for a reason related to his performance or other situational factors.
The beginnings of a psychotic disorder
I was concerned about whether he could have the beginnings of a psychotic disorder, given the paranoia, or whether the seeming paranoia could be due to drug use. “Were you doing drugs?” I asked. He wouldn’t discuss what he meant, other than to say he thought he had been noticed by others.
In a later journal entry, Bill described the insidious onset of his illness in the second semester of that freshman year. At first, it was hardly noticeable, but then gradually escalated into a full-blown psychotic state. His mood felt “really good.” And then, “better than good.” He had more energy and more self-confidence, and became more social, engaging in conversations at social occasions and attending parties that he wouldn’t have earlier but now felt energized and exuberant. He began to sleep less and felt like he didn’t need to sleep. Then he experienced auditory hallucinations, one in particular saying, “You’re dead.” Or girls saying, “He’s so hot.”
He described grandiosity, a heightened although uncomfortable sense of being special. He thought of himself as an evolutionary agent like Timothy Leary. He would become a guru and a leader. At the time, he didn’t understand that this was an unfolding of illness; he accepted these experiences at face value as indicating that he was special, with a special role and mission. His experience illustrates how hard it is, for the patient and their loved ones, to recognize mental illness and avoid being in denial.
References
My intention in writing this blog column is to share the experiences that I went through with my son, starting with the first manifestation of his illness and our journey through numerous subsequent episodes. I want to provide commentary as a parent and psychiatrist on issues that these experiences bring up, such as how the diagnostic process works in mental health, and how to work with treatment providers and medications. This may be helpful for people with mental health conditions and also their families and friends.
