Almost from the moment he walked into my office, something bothered me about my 18-year-old patient, Mark, sent to see me by his parents after they found marijuana and steroids in his bedroom.
He was tall and muscular, with tousled, dirty-blonde hair, outfitted in a faded T-shirt emblazoned with the words "Sunset Strip," distressed jeans made to look threadbare at midthigh and along the edges of the pockets and a 70's retro leather choker with a few clay beads on it.
A shiny silver bolt pierced his left brow. He shook my hand and introduced himself with a smile, then sat down in the suede armchair opposite me, his legs outstretched, his ankles crossed.
"So tell me what's going on," I said.
"I'm in a serious jam, man," he said. "I think I need rehab to get my life back. You know?"
He didn't sound upset about it.
"What have you lost?" I asked him.
"Got two weeks?" He chuckled.
"I'm listening."
"I don't know if I ought to head to rehab or really go deep into analysis with you or what," he said. "Or maybe we just go the Prozac route."
"You think you're depressed?" I asked.
"Hard to say."
He shrugged. "I'm kind of like the quiet guy who goes to the gym, you know, keeps to himself, maybe hooks up with a girl here and there, but doesn't make a big deal of it. He's, like, sort of on the outside looking in, never letting anything get him too down."
Mark's lapse into the third person - "He's ... on the outside, looking in" - helped me realize what had disturbed me about him from the start.
He seemed fake, as if playing a role. He showed no anxiety or sadness or anger. He spoke in clichés. I'm in a ... jam. I need ... to get my life back. Got two weeks?
His hair looked intentionally messy. Everything about him, down to his carefully chosen, probably pricey, "worn out" clothing felt scripted.
I have treated several other teenagers this year who display a similar kind of profound detachment from self.
It is a kind of identity disorder I believe has its roots in a society that has drifted free from reality and is creating adolescents (and, I would venture, people of many ages) who are at most participant-observers in their own lives, with little genuine emotion - like actors playing themselves.
The signs and symptoms of this identity disorder are everywhere. Teenagers are embracing lies on a wholesale (and retail) scale.
They not only buy clothing made to look old when it is new, but they buy T-shirts emblazoned with logos from bars and bait shops and resorts they have never visited, and that sometimes don't exist at all.
More and more, they use illicit substances and alcohol to keep their genuine feelings at bay. They use steroids (and plastic surgery) to alter their appearances and athletic abilities. Their self-esteem floats ever higher, untethered even when their academic performance and family relationships and prospects for the future sink to new lows.
They pierce themselves and tattoo themselves and have sex more and earlier, in what I see as desperate efforts to anchor themselves to some sort of reality - the reality of the flesh.
If a teenager can feel a steel bolt through her tongue move whenever she speaks, at least she knows she inhabits her own body, even if she doubts her own soul.
If she can use low-cut jeans or a glimpse of thong underwear to attract glances from boys around her, at least she knows she occupies space and time at the center of their attention.
The soil for this detachment from self has been sown for decades, partly by psychiatry itself.
By not opposing vigorously enough the dangerous myth that psychoactive medications are a complete answer to depression and anxiety, we have allowed the idea to take root that we need not heed our emotions as evidence of life crises with real and crucial meaning, that we should turn off our inner voices and "listen to Prozac," instead.
The growth of technology has cleaved us from the reality of self, as well. We say that we are "going" places on the Internet without ever leaving the room.
In elaborate Internet-based games, people pay thousands of dollars to own "real estate" that isn't real at all.
We watch newscasters (who increasingly could double as models or comedians) report on terrible tragedies, then shift gears and joke about the weather or a baseball game. And we learn to mirror them, to respond to our own losses like channels we can change.
We can wage wars that kill tens of thousands of people with "smart" bombs. But we see little, if any, blood. And we can count the dead between episodes of our favorite sitcoms.
We sit still for a cloudy sense of whether our president was elected to his first term. Then the president in the television drama "West Wing" delivers a political statement about the war in Iraq, and people actually pay attention.
A senator appears as himself in the film "Traffic," in which Michael Douglas is the nation's drug czar. Unless Mr. Douglas really is ...
The trouble with all this is that the truth always wins. Reality will not be frustrated forever.
You have to pay back emotional debt, like the national debt, with interest. A crushing major depression lies in wait for Mark, if I fail to help him face whatever demons from the past drove him away from reality, to drugs.
Ever-increasing rates of substance abuse and attention-deficit disorder and depression lie in wait for adolescents emerging into adulthood. And, in not many decades, our nation's sense of itself will, inescapably, depend on theirs.