Psychosis as the Sickness Unto Death: Treatment Impasse, Consultation, and Resolution

In this article, I will describe an impasse in the treatment of a 19-year-old male patient and the events leading up to the request for a psychotherapy consultation.

Mr. B's first psychotic episode occurred during his freshman year of college, six months into his first outpatient psychotherapy experience with a female therapist. At the time of his initial hospitalization, Mr. B was delusional, fearing his father wanted to kill him and had sexually abused him as a child. He quickly recompensated but had several other brief psychotic episodes during the summer between his freshman and sophomore years. Most of his acute psychotic symptoms developed just prior to, or in the midst of, his outpatient therapy hours. In his outpatient psychotherapy, Mr. B developed delusions that his therapist was sexually attracted to him and might rape him, that the president of his college was spying on him and reporting on him to the local newspaper, that a male professor had sexually abused him, and that as a physics major he was a divine superpower with the secrets to the “way things really work.” The week after returning for his sophomore year, Mr. B became psychotic in a psychotherapy session and his therapist drove him to a nearby psychiatric hospital for admission. He responded well to medications and was released within a week. Within the next six weeks he was readmitted to the hospital on three separate occasions for psychotic decompensation. Because of the recurring nature of his psychotic disorganization and his inability to manage independently, long-term treatment was sought and the patient was admitted to an open psychiatric hospital and residential treatment center. One noteworthy event was that his admission to the center occurred three days before the tenth anniversary of his mother's death from complications following heart surgery.