Case 1, Episode 1: The First Encounter – Sarah, a 22-Year-Old with “Strange Thoughts”
“I don’t feel like myself anymore. I know it sounds crazy, but I think they’re watching me.” These were the first words Sarah said when she sat down in your office.
Sarah is a 22-year-old college senior referred to your outpatient clinic by her professor. The concern? Declining performance, growing isolation, and unusual behavior. In her professor’s words: “She seems lost—like she’s not really there anymore.”
You have 60 minutes.
You have no prior records.
You have a young woman in front of you who is both reaching out—and pulling away.
So how do you begin?
The Art and Science of the First Encounter
The first encounter[1] in psychiatry is both diagnostic and relational. You’re listening for symptoms—but also for meaning, context, and clues to suffering. What she says is important. What she doesn’t say may be even more so.
Let’s slow it down.
Sarah hesitates as she starts. She looks around the room. Her hands fidget. Her gaze occasionally sharpens, as if checking for something—or someone.
“I’ve been feeling weird,” she says. “Like my thoughts aren’t mine. Sometimes I hear whispering, but when I check, there’s no one there. I know it sounds ridiculous. But I swear, people are talking about me.”
The Clinical Puzzle Begins
Immediately, your brain wants to categorize. Is this psychosis? Anxiety? Trauma-related dissociation? Substance use? A mood disorder with psychotic features? But you resist the urge to jump too quickly. Instead, you begin where all good psychiatric assessments start: With the story.
Next Steps: The History of Present Illness (HPI)[2]
Your next questions are not just checklist items. They are windows into the psyche:
When did this start?
Has it happened before?
What changed in your life when this began?
What’s helped—or made it worse?
How is it affecting school, friends, sleep, daily life?
Do you think something is wrong, or do you believe you’re seeing something others aren’t?
Sarah responds with a fragmented timeline. She mentions trouble sleeping. She’s been staying up all night trying to complete assignments she can’t focus on. She talks about feeling like her roommates are spying on her. She drinks a lot of coffee and, occasionally, takes her friend’s Adderall to “concentrate.”
And then she pauses.
“I just don’t know what’s real anymore.”
Why This Matters
At this point, you don’t need a diagnosis—you need a direction. You are not just building a symptom list. You are contextualizing a person.
What happened before the symptoms?
How is she making sense of her experience?
What does she need right now?
This is where the psychiatric HPI becomes both an art and a tool. And this is where we pick up next time.
Reflective Prompt for You
Before we dive into Episode 2, reflect on this:
What’s your default response when a patient presents with paranoia or disorganized thoughts?
Do you move toward symptom control—or toward understanding?
Let us know. Comment below, share your thoughts, or tag a colleague. Let’s raise the standard of psychiatric care—together.
References:
[1] Eppling, Joe. "First encounters: a psychiatric emergency program." Journal of Emergency Nursing 34.3 (2008): 211-217.
[2] Adler, Herhert M. "The history of the present illness as treatment: who's listening, and why does it matter?." The Journal of the American Board of Family Practice 10.1 (1997): 28-35.