Reference no: EM133250879

Rick, a 20 year old college sophomore, was referred by his dorm's resident adviser to the school's mental health clinic after appearing "strange and out of it." Rick told the evaluating therapist that he had not been his "usual self" for about 3 months. He said his mind often felt blank, as if thoughts were not his own. He had felt increasingly detached from his physical body, going about his daily activities like a "disconnected robot." At times, he felt uncertain if he were alive or dead, as if existence were a dream. He said he almost felt like he had "no self." These experiences left him in a state of terror for hours on end. His grades declined, and he began to socialize only minimally.

Rick said he had become depressed over the breakup of a girlfriend a few months earlier, describing a sad mood for about a month with mild vegetative symptoms but no impairment in functioning. During this time, he began to notice some feelings of numbness and unreality, but he did not pay much attention at first. As his low mood resolved and he found himself becoming increasingly disconnected, he began to worry more and more until he finally sought help. He told the therapist that his 1 year romantic relationship with his girlfriend had been very meaningful to him and that over the holidays he had planned to introduce her to his mother for the first time.

Rick described a time-limited bout of extreme anxiety in tenth grade. At that time, panic attacks had begun and then escalated in severity and frequency over two months. During those attacks, he had felt very detached, as if everything were unreal. The symptoms sometimes lasted for several hours and were reminiscent of his current complaints. The onset appeared to coincide with his mother's entry into a psychiatric hospital. When she was discharged, all his symptoms cleared fairly rapidly. He did not seek treatment at that time.

Rick also described several days of transient unreality symptoms in elementary school, just after his parents divorced and his father left young Rick living alone with his mother, who had paranoid schizophrenia. His childhood was significant for pervasive loneliness and the sense that he was the only adult in the family. His mother was only marginally functional but generally not actively psychotic. His father rarely returned for visits but did provide enough money for them to continue to live in reasonable comfort. Rick often stayed with his grandparents on weekends, but in general he and his mother lived a very isolated life. He did well in school and had a few close friends, but he largely kept to himself and rarely brought friends home. His girlfriend would have been the first girlfriend to meet his mother.

Rick denied using any drugs, in particular cannabis, hallucinogens, ketamine, or salvia, and his urine toxicology was negative. He denied any history of depression, mania, psychosis. He specifically denied amnesia, blackouts, multiple identities, hallucinations, paranoia, and other unusual thoughts or experiences.

Results of routine laboratory tests, a toxicology screen, and a physical examination were normal, as were a brain magnetic resonance imaging scan and electroencephalogram. Consultations with an otorhinolaryngologist and a neurologist were noncontributory.