Three weeks of increasing paranoia — believes classmates are surveilling him, hears a voice commenting on his actions. Sleep disrupted. Grades dropping. Parents brought him in after he barricaded his dorm room. Says (intermittently coherent): 'They're watching everything I do. The voice tells me to be careful.'
History
No prior psychiatric history. Cannabis use (daily for 2 years, recently increased). Maternal uncle diagnosed with schizophrenia. Dean's list student until this semester. Parents describe him as 'always a bit of a loner but very bright.'
Clinical note: Aiden needs psychiatric evaluation for antipsychotic medication before any psychotherapy modality — no therapeutic approach substitutes for medical assessment in acute psychosis. His cannabis use is clinically significant: regular use approximately doubles psychosis risk, especially with early onset and high-potency products (Murray et al., 2017), and the maternal uncle with schizophrenia places Aiden in a high-risk genetic window at age 21. NICE (CG178) recommends CBTp alongside medication, with moderate evidence for positive symptoms (Jauhar et al., 2014: d = 0.36). Open Dialogue, developed in Western Lapland, reported 5-year outcomes with ~80% functional recovery and only ~35% needing antipsychotics (Seikkula et al., 2006) — extraordinary numbers, though from non-randomized studies in a specific cultural context. The debate between medication-first and relationship-first approaches is one of the most consequential in mental health. How Aiden's treatment team navigates this — and whether they can engage him before paranoia forecloses the therapeutic alliance — will shape his long-term trajectory.
Where Approaches Genuinely Disagree
Are hallucinations symptoms to eliminate or experiences to understand?