Case Study Schizophrenia Paranoid Female

Case Study of Schizophrenia (Paranoid)

Iqbal MZ* and Ejaz M

Hypnotherapist and Psychotherapist, Islamabad, Pakistan

*Corresponding Author:
Iqbal MZ
Hypnotherapist and Psychotherapist
Islamabad, Pakistan
Tel: +92-3349585399
E-mail:[email protected]

Received February 20, 2016; Accepted April 26, 2016; Published April 29, 2016

Citation: Iqbal MZ, Ejaz M (2016) Case Study of Schizophrenia (Paranoid). J Clin Case Rep 6:779. doi:10.4172/2165-7920.1000779

Copyright: © 2016 Iqbal MZ, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Ms. Sk was young lady of 25 year a university student contacted to the therapist through Facebook and got appointment. She was in the company with her close friend when visited the clinic first time and was nervous and perplexed at this occasion, even did not confide therapist for a private sitting. She complained sleeplessness, aggression and strong feelings of dirtiness most of time and feared that CIA would arrest her. On noticing someone staring her she always got startled, and informed in the presence of her friend that she has been under treatment from different psychiatrists for last seven years. She was regularly taking the Cipralex and Lexotanil (anti-depressant). During the treatment as cited above she had been visiting different female clinical psychologists. She was treated by the methods of cognitive behavior therapy (CBT) and counseling but all in vain.

Keywords

Schizophrenia (Paranoid); Hypotheses; Fear stimuli identification therapy (FSIT)

Introduction

Major purpose of this particular case study was to reaffirm and prove the efficacy of fear stimuli identification therapy (FSIT) on empirical grounds [1]. It was also intended to use FSIT in order to eliminate the symptoms of Schizophrenia (Paranoid). Ms. Sk was suffering from. The therapy (FSIT) was already used successfully to remove the symptoms of various disorders in different cases [2,3].

Hypotheses: “It is expected that the FSIT method would effectively cure the Schizophrenia (Paranoid). From which the above referred person Ms. Sk is suffering.”

Fear stimuli identification therapy: FSIT is Base on Missing References. When some fear stuck due to stimulus and became negative association in the unconscious at childhood or teen age. Unconscious state of mind at that time is unable to caught full references of the incident it taken only negative reference. At that time of early childhood capacity of mind to capture some incident with full reference is not possible so, there is the chance due to these missing reference can create a problem that may result in different disorders and FSIT is a technique that can be used to complete these specific missing reference.

Method

Participants: Ms. Sk (client)

Materials: No any specific material used in this case study.

Procedure: In the first three sessions semi-structured interviews were conducted with Ms.Sk. Assessment was made in the light of these interviews and reasons/causes for disorders were dig out. DSM-IV was consulted to decide the nature or type of disorder. In the subsequent ninety sessions Ms. Sk was asked to write on specific topics. Cross questioning was carried out over the ideas mentioned in the writings.

Result and Discussion

Result

After diagnosis of Schizophrenia (Paranoid), treatment was started in the light of FSIT method. Ninety sessions were conducted five sessions per week. In the course of treatment, she and her friend reported about Positive behavioral change in different spheres of Ms. Sk’s life. Clinical observations during treatment also indicated a gradual positive change in his personality. The difference between pre assessment and post- assessment confirmed precision of hypotheses and efficacy of FSIT. Feedback was obtained on weekly basis for a period of three months from Ms. Sk’s about any possible reappearance of symptoms of Schizophrenia (Paranoid). and this was confirmed that there was no reoccurrence of disorder’s symptoms anymore.

Discussion

Before visiting my clinic Ms. Sk have had already consulted different psychiatrists and clinical psychologists and was mostly treated by means of anti-depressants and therapies like CBT etc. This had no significant effects upon client’s disorder. Anyhow these medications helped him in sleep as before he was not able to sleep.

Case history: The client’s profile-family history, social history and medical history was prepared through detailed interviews and incisive questioning pertaining to sensitive issues of his life.

Family history: Her father is retired employee from a low grade position in govt. job while her mother was an illiterate house wife. Client is at ninth (9th) number in the series of nine sisters and brothers.

Social history: She lived in big joint family system. Three of her brothers were married and lived in the same house with all their children and two youngest sisters. The family has vast social contacts with their other maternal and paternal relatives

Medical history: As stated already, she has been under treatment from various psychiatrists and female psychologists and has been taking different anti-depressant medicines and was using Cipralex and lexotanil for last two years back from the time dating when she visited me but all this did not help her to recover from disorder

Assessment

During the first session for assessment, Therapist asked her to let him meet her parents and elder sister to get some information but she vehemently refused. Even she refused for a conversation by telephone. In this situation the only source of information/history was Ms. Sk herself.

After first three sessions the opinion established that she was a victim of sex abuse in her childhood. For assertion of this opinion it was asked the client to write on the topic of sex. She attempted to write in absence of any one as it was attempt to provide her with isolated environment. After 30 minutes she handed me over her piece of writing. Her writing was absurd and meaningless. There were a lot of cuttings and crosses in her writing. It was asked her how was her experience of writing. She told that during writing she felt aggressive and irritable. She also felt burden over shoulder and at the back of her head. This all was almost a clear confirmation to my initial assessment.

I told the client about my opinion of sex abuse and encouraged her to express clearly of any sort of incident she had gone through. She elaborated hesitatingly about the incident she encountered at the age when she was only nine and half year old. The details of the event are as under:

She used to sleep with the young wife of her elder brother for day sleep in the summer season. One day the wife of her brother put her hands under the client’s shirt and started rubbing over the upper private parts of child’s body. The client was frightened and shocked. According my opinion when a child or even a mature person is encountered to any type of action which is harmful but particularly and specifically becomes a stimulus to fear instinct but the element of terror is also included to fear in such cases.

The client told that this act have been repeated continuously for seven consecutive days. On eighth day, she informed about all this to her mother. Her mother admonished the wife of client’s brother for this shameful act. The client forgot about this incident after few days.

Interestingly, at the age of 15 years i.e. after five and half years later, the client incidentally read an article in a magazine on the topic of sex abuse. She came to know from that article that the child who is subject to sex abuse develops a sense of filthiness in her/his mind. This article also informed her that such child also feels herself/himself a sinful and guilty conscious. After reading that article the client developed the feelings of filthiness guilt and sinful in her mind. It resulted in thought disorder. Sense fear as this was developed in her mind and this sense made her think that she will be arrested by CIA. She felt vulnerably by the staring eyes of people around her which also made her think that the people know about the sin she has committed. This was a terrible state of mind which she was passing through for last 10 years to the day she visited me. After knowing all this history as stated it was established that the client is suffering from Schizophrenia (Paranoid).

Treatment

The treatment prolonged for more than one hundred days consisted of 90 sessions. Five sessions per week were conducted. The method of “Fear Instinct Stimuli Identification” was used for psychoanalysis. I have developed this method through my prolonged clinical experiences and always find this method the most effective as comparison to all other conventional and contemporary methods of treatment.

In the subsequent sessions, I handed her over different topics to write upon. These topics related to her problem and were of different types. The first one was the topic of “Sin”

She wrote on this topic very elaborate but the writing was absurd and contained a lot of crosses and cuttings.

It was inquired her about the how was her feelings during the process of writing. She informed that she felt burden on the back side of her head and over her shoulders as well.

During cross-questioning and on examining her writings it was learnt that she has established a much preformed thought in her mind that she will be answerable and be punished for the sin, she has committed. On the same pattern she was given with the more topics to write upon which included guilt, sense of dirtiness and the last one was “My Fears”.

During the total process of writing she was subjected to the same feelings of burden as cited above.

After conducting a deep analysis of her fears, the positive references were related to the particular incident of sex abuse she had been subjected to. Relationship of positive references was also established to the article which patient had read at the age of 15 years as already referred.

Conclusion

i. The client was suffering from Schizophrenia (Paranoid).

ii. The main reason for disorder was unexpected even of sex abuse which acted as the major stimulus for fear instinct.

iii. The Article on sex abuse made the client recall forcibly about the sex abuse incident she was subjected to at the age of nine and half years

iv. Different feelings like dirtiness, sense of guilt and sense of sin were associated to that particular event by unconscious level of mind and that even without reference to context. These feelings caused thought disorder in the client.

v. After conducting 90 sessions all the symptoms were eliminated and the client became normal. It is worth mentioning that client totally abandoned the use of medicines as a result of my treatment.

References

  1. American Psychiatric Associati on (2000) Diagnostic and statistical manual of mental disorders, (5thedn).
  2. Ejaz M, Iqbal MZ (2016) Case Study of Major Depressive Disorder. J Clin Case Rep 6: 698.
  3. Iqbal MZ, Ejaz M (2016) Case Study of Functional Neurological Disorder (Aphonic). J Psychol Psychother 6: 243.
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Abstract

Delusional paranoia has been associated with severe mental illness for over a century. Kraepelin introduced a disorder called “paranoid depression,” but “paranoid” became linked to schizophrenia, not to mood disorders. Paranoid remains the most common subtype of schizophrenia, but some of these cases, as Kraepelin initially implied, may be unrecognized psychotic mood disorders, so the relationship of paranoid schizophrenia to psychotic bipolar disorder warrants reevaluation. To address whether paranoia associates more with schizophrenia or mood disorders, a selected literature is reviewed and 11 cases are summarized. Comparative clinical and recent molecular genetic data find phenotypic and genotypic commonalities between patients diagnosed with schizophrenia and psychotic bipolar disorder lending support to the idea that paranoid schizophrenia could be the same disorder as psychotic bipolar disorder. A selected clinical literature finds no symptom, course, or characteristic traditionally considered diagnostic of schizophrenia that cannot be accounted for by psychotic bipolar disorder patients. For example, it is hypothesized here that 2 common mood-based symptoms, grandiosity and guilt, may underlie functional paranoia. Mania explains paranoia when there are grandiose delusions that one's possessions are so valuable that others will kill for them. Similarly, depression explains paranoia when delusional guilt convinces patients that they deserve punishment. In both cases, fear becomes the overwhelming emotion but patient and physician focus on the paranoia rather than on underlying mood symptoms can cause misdiagnoses. This study uses a clinical, case-based, hypothesis generation approach that warrants follow-up with a larger representative sample of psychotic patients followed prospectively to determine the degree to which the clinical course observed herein is typical of all such patients. Differential diagnoses, nomenclature, and treatment implications are discussed because bipolar patients misdiagnosed with schizophrenia are severely misserved.

schizophrenia, bipolar, mania, depression, Kraepelinian dichotomy, paranoia, psychosis

Introduction

Modern psychiatry began in the mid- to late 19th century when several syndromes including paranoia were consolidated by Emil Kraepelin and called dementia praecox,1 later renamed “schizophrenia” by Eugene Bleuler in 1911.2 The “Kraepelinian dichotomy” described 2 separate diseases to explain severe mental illness, schizophrenia and manic-depressive insanity or bipolar disorder.1 Bleuler2 and then Schneider3 emphasized that psychosis, to include a paranoid delusional system, was pathognomonic of schizophrenia and discounted the diagnostic implications of mood symptoms. A very different idea was presented in 1905 when Specht4 said that all psychoses were derived from mood abnormalities.5 Kraepelin had also linked paranoia and mood when he used the term “paranoid depression” to describe an illness with a high rate of suicide, severe depression, paranoia, and auditory hallucinations.1,5 The 1933 introduction of schizoaffective disorder6 recognized the diagnostic relevance of mood symptoms in psychotic patients, linked schizophrenia (psychosis) and mood disorders, and eroded the concept of the Kraepelinian dichotomy.7–11 Some now consider schizoaffective disorder to be a psychotic mood disorder and not a subtype of schizophrenia or a separate disorder.7–12 In addition, certain authors in the United Kingdom have associated paranoia with depression and delusional guilt.5 One group in the 1970s implied that about 95% of their sample of patients diagnosed with paranoid schizophrenia actually suffered from mania because “classic bipolar” patients were observed to suffer paranoid delusions.13

Despite these linkages of paranoia and psychosis with mood disorders, the concepts of Bleuler2 and Schneider3 that bound paranoia and all functional psychoses to schizophrenia prevailed, and such cases typically have been diagnosed with paranoid schizophrenia or postschizophrenic depression, not as psychotic mood disorders.5 Paranoia continues to be associated with schizophrenia, rather than with bipolar disorder, both as the most common subtype and as a core diagnostic symptom, as reflected in the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), the International Classification of Diseases, Tenth Edition (ICD-10), and major textbooks of psychiatry.14

However, when mood disorders are explored as a source of paranoia, a different causal relationship presents itself (figure 1). If psychotic mood disorders explain many paranoid presentations, as suspected over 30 years ago,13 questions arise about the distinction between schizophrenia and psychotic mood disorders.7,8,13,15–19Selected reviews of symptoms, course, prognosis, family heritability, and epidemiology conclude that there are no disease-specific characteristics of schizophrenia and that the DSM diagnostic criteria for schizophrenia are common to psychotic bipolar disorder patients.7,8,15–20 Further indications of closure toward one disease derive from recent basic science data, especially molecular genetic and neurocognitive studies, that show considerable overlap and similarities between schizophrenia and psychotic bipolar disorder.18–32 One author states that “ … of the (11) chromosome loci found for the transmission of schizophrenia and bipolar disorder, eight have been found to overlap ....”28 Crow30,31 advances an explanation for the 3 or more loci that do not overlap between schizophrenia and bipolar that is compatible with a single disease to explain all 3 of the functional psychoses: “Epigenetic variation associated with chromosomal rearrangements that occurred in the hominid lineage and that relates to the evolution of language could account for predisposition to schizophrenia and schizoaffective disorder and bipolar disorder and failure to detect such variation by standard linkage approaches.”

Fig. 1.

Psychotic Depression Can Cause Delusions of Exaggerated Severity of Past “Sins” Leading to Delusional Guilt. Such guilt stimulates thoughts that punishment is deserved and imminent. The fear of punishment, torture, and/or execution defines the paranoid psychosis that consumes these patients’ lives. Similarly, psychotic mania can cause delusional grandiosity of ownership of valuable possessions. A logical result is the delusional belief that others want these possessions and are going to kill to get them, leading to paranoid psychosis. Because these patients present with complaints of fear for their lives, the core symptoms of the mood disorder may be overlooked and a misdiagnosis of paranoid schizophrenia made.

Fig. 1.

Psychotic Depression Can Cause Delusions of Exaggerated Severity of Past “Sins” Leading to Delusional Guilt. Such guilt stimulates thoughts that punishment is deserved and imminent. The fear of punishment, torture, and/or execution defines the paranoid psychosis that consumes these patients’ lives. Similarly, psychotic mania can cause delusional grandiosity of ownership of valuable possessions. A logical result is the delusional belief that others want these possessions and are going to kill to get them, leading to paranoid psychosis. Because these patients present with complaints of fear for their lives, the core symptoms of the mood disorder may be overlooked and a misdiagnosis of paranoid schizophrenia made.

There are established differences between psychotic and nonpsychotic bipolar disorders.15–17 Psychotic mood disorders are often phenotypically indistinguishable from schizophrenia, so it is likely that psychotic mood-disordered patients have been misdiagnosed with schizophrenia. Differences considered to exist between “schizophrenia” and “classic” (nonpsychotic) bipolar disorder may be explained by the differences between psychotic and nonpsychotic (classic) bipolar.

The symptom of paranoia, in particular, has been the focus of genetic studies. For example, although preliminary, familial aggregation data reveal that paranoid delusional proneness is an endophenotype common to patients diagnosed with schizophrenia and psychotic bipolar disorder but not nonpsychotic bipolar disorder.16 Schulze et al17 extended this work by linking persecutory delusions (paranoia) to variance at a specific locus, the D-amino acid oxidase activator/G30, located on chromosome 13q34, in patients diagnosed with schizophrenia and with psychotic bipolar disorder. More recent results link this locus primarily to mood disorders “across the traditional bipolar and schizophrenia categories.”29 Such genotypic overlap, when considered with the phenotypic similarities, suggests the hypothesis that the disease called paranoid schizophrenia may be psychotic bipolar disorder and not a separate disorder. Bipolar disorder is more likely than schizophrenia to be the single disease because bipolar is scientifically grounded with unique, disease-specific diagnostic criteria, while schizophrenia has no disease-specific criteria.7,12,15 The following review of 11 patients, each initially diagnosed with schizophrenia but subsequently revealed to suffer from a psychotic mood disorder, serves to illustrate these ideas (table 1). All subjects gave their written informed consent to participate in this Institutional Review Board-approved research.

Table 1.

Case Characteristics

Case No. Age/Sex; Job/School ED Presentation Initial Symptoms Initial Diagnosis Subsequent Symptoms Paranoia Caused by Actual Patient Experience (“Thread of Truth”) Final Diagnosis 
58/M; Unemployed day laborer/college graduate, Vietnam Veteran Handcuffed, paranoid, fearful, agitated, resistant, involuntary Feared elimination by CIA; feared poison PSaDecreased sleep with increased activities; grandiosity; lost 20 pounds due to “no time to eat”; made over 300 phone calls to the CIA often between midnight and 4 AMBelieved that he possessed critical knowledge about the Vietnam war that was embarrassing to the US government who had sent the CIA to eliminate him Had fought in Vietnam BP-I manic, severe withb
46/M; Military officer/college graduate, PhD in engineering Escorted by MP’s, handcuffed, paranoid, fearful, agitated, resistant, involuntary Feared for his life from assassination by KGB and NSA; coded messages from TV PS Decreased sleep with increased activities; grandiosity; called President Reagan multiple times; moved daily from motel to motel to escape assassination Believed that he had a Star Wars missile design that the KGB and NSA wanted for themselves Was a rocket engineer BP-I manic, severe with 
28/M; Microbiology technician/college graduate Delusional paranoia, assaultive, restrained in ED, involuntary Feared his murder by Al Qaeda was imminent; feared poison PS Decreased sleep with increased activities; worked on his computer 24/7 for weeks; grandiosity; marked weight loss due to fear of poison Believed God had named him as a Christian prophet and that Al Qaeda would assassinate him with anthrax because of his Christianity Was a microbiologist and in New York City on November 11, 2001 BP-I manic, severe with 
29/M; Musician Police escort, delusional paranoia, violent, restrained, involuntary Feared execution by Cuban Mafia; messages from TV and radio PS Decreased sleep with increased activities; grandiosity; moved from city to city to escape harm Believed that he had a recording worth millions that the Cuban Mafia wanted Was a Cuban musician who supported the anti-Castro effort BP-I manic, severe with 
24/M; Unemployed/college graduate Delusional paranoia, disorganized, voluntary Feared execution by Cali Cartel PS Decreased sleep with increased activities; fleeing for his life; grandiosity; kept walking and lived on the street to avoid capture Believed that he possessed a formula to make synthetic narcotics so the Cali Cartel wanted it and him dead Was from Columbia, South America and a chemistry major BP-I manic, severe with 
56/M; Unemployed house painter/high school graduate Delusional paranoia, disorganized, suicidal, voluntary Feared death at the hands of the devil and God; feared poison PS, postschizophrenic depression Psychotic, suicidal depression followed by psychotic mania when he ordered 10 000 oysters in the shells for a party for the governor of the state of North Carolina Believed that he had sinned over 40 y before and deserved torture and death by God and the devil; believed that he was friend to the governor Did steal $5 from his boss’ gas station at 15 y of age MDD, severe withc; then BP-I, manic, severe with 
28/M; Fast-food restaurant worker/college graduate Delusional paranoia, handcuffs, catatonia, coprophilia, involuntary Feared his execution by hit men; poison PS Decreased sleep with increased activities; disorganization due to racing thoughts; grandiosity; premeditated corprophilia with a purpose to get transferred to escape hit men Believed that he was to gain ownership of his bank, but hit men were sent to kill him to get the bank for themselves; planned on millions in purchases Did make trips to the bank on a regular basis for his mom BP-I manic, severe with 
40/F; Unemployed lawyer/law school graduate Delusional paranoia, suicidal, voluntary Auditory hallucinations keeping up a running commentary PS Psychotic, suicidal depression; delusional guilt; persecutory delusions; persistent psychosis with downward drift to homelessness; history of hypomanic episodes Believed that she was such a failure that she deserved torture and death; then feared her torture and death Lost several legal positions and then was fired from even menial jobs BP-II, depressed, severe with 
54/F; Artist/master's degree Police escort, delusional paranoia, assaultive, involuntary Feared “rogue CIA and Cuban agents” trying to kill her; messages from TV PS Decreased sleep with increased activities; had flown from New York to Chicago at last minute; extensive grandiosity; angry; violent; loud; intrusive Complex grandiose delusional system incorporating the jewels of the Queen of Spain, Fidel Castro, and the assassination of President Reagan Had visited Spain and Cuba and had a distant relative with a low-level CIA position BP-I, manic, severe with 
10 62/F; Unemployed/college graduate Police escort, delusional paranoia, involuntary Feared her imminent assassination by “anti-Jewish foreign agents” PS Decreased sleep with extensive writing to the US Department of State for 20–24 h a day sustained episodically over decades; fled lodging when TV or radio indicated she had been located; walked all night to escape; slept on the streets Believed that she was an undercover foreign affairs advisor for the US State Department covertly tasked to protect the Jewish people Had held a low-level job in the US government in her 20s BP-I, manic, severe with 
11 36/F; Nurse/college graduate Ambulance, unconscious due to overdose in a serious attempt to die Feared her capture by law enforcement, sentencing to death and execution PS or postschizophrenic depression Psychotic suicidal depression; endorsed full manic episodes in the past with decreased sleep and a marked increase in dangerous activities due to spur of the moment impulses and lack of judgment Believed that she had “murdered” by neglect a terminal, 4-y-old patient under her care in hospice Had lost such a patient under her hospice care BP-I, depressed, severe with 
Case No. Age/Sex; Job/School ED Presentation Initial Symptoms Initial Diagnosis Subsequent Symptoms Paranoia Caused by Actual Patient Experience (“Thread of Truth”) Final Diagnosis 
58/M; Unemployed day laborer/college graduate, Vietnam Veteran Handcuffed, paranoid, fearful, agitated, resistant, involuntary Feared elimination by CIA; feared poison PSaDecreased sleep with increased activities; grandiosity; lost 20 pounds due to “no time to eat”; made over 300 phone calls to the CIA often between midnight and 4 AMBelieved that he possessed critical knowledge about the Vietnam war that was embarrassing to the US government who had sent the CIA to eliminate him Had fought in Vietnam BP-I manic, severe withb
46/M; Military officer/college graduate, PhD in engineering Escorted by MP’s, handcuffed, paranoid, fearful, agitated, resistant, involuntary Feared for his life from assassination by KGB and NSA; coded messages from TV PS Decreased sleep with increased activities; grandiosity; called President Reagan multiple times; moved daily from motel to motel to escape assassination Believed that he had a Star Wars missile design that the KGB and NSA wanted for themselves Was a rocket engineer BP-I manic, severe with 
28/M; Microbiology technician/college graduate Delusional paranoia, assaultive, restrained in ED, involuntary Feared his murder by Al Qaeda was imminent; feared poison PS Decreased sleep with increased activities; worked on his computer 24/7 for weeks; grandiosity; marked weight loss due to fear of poison Believed God had named him as a Christian prophet and that Al Qaeda would assassinate him with anthrax because of his Christianity Was a microbiologist and in New York City on November 11, 2001 BP-I manic, severe with 
29/M; Musician Police escort, delusional paranoia, violent, restrained, involuntary Feared execution by Cuban Mafia; messages from TV and radio PS Decreased sleep with increased activities; grandiosity; moved from city to city to escape harm Believed that he had a recording worth millions that the Cuban Mafia wanted Was a Cuban musician who supported the anti-Castro effort BP-I manic, severe with 
24/M; Unemployed/college graduate Delusional paranoia, disorganized, voluntary Feared execution by Cali Cartel PS Decreased sleep with increased activities; fleeing for his life; grandiosity; kept walking and lived on the street to avoid capture Believed that he possessed a formula to make synthetic narcotics so the Cali Cartel wanted it and him dead Was from Columbia, South America and a chemistry major BP-I manic, severe with 
56/M; Unemployed house painter/high school graduate Delusional paranoia, disorganized, suicidal, voluntary Feared death at the hands of the devil and God; feared poison PS, postschizophrenic depression Psychotic, suicidal depression followed by psychotic mania when he ordered 10 000 oysters in the shells for a party for the governor of the state of North Carolina Believed that he had sinned over 40 y before and deserved torture and death by God and the devil; believed that he was friend to the governor Did steal $5 from his boss’ gas station at 15 y of age MDD, severe withc; then BP-I, manic, severe with 
28/M; Fast-food restaurant worker/college graduate Delusional paranoia, handcuffs, catatonia, coprophilia, involuntary Feared his execution by hit men; poison PS Decreased sleep with increased activities; disorganization due to racing thoughts; grandiosity; premeditated corprophilia with a purpose to get transferred to escape hit men Believed that he was to gain ownership of his bank, but hit men were sent to kill him to get the bank for themselves; planned on millions in purchases Did make trips to the bank on a regular basis for his mom BP-I manic, severe with 
40/F; Unemployed lawyer/law school graduate Delusional paranoia, suicidal, voluntary Auditory hallucinations keeping up a running commentary PS Psychotic, suicidal depression; delusional guilt; persecutory delusions; persistent psychosis with downward drift to homelessness; history of hypomanic episodes Believed that she was such a failure that she deserved torture and death; then feared her torture and death Lost several legal positions and then was fired from even menial jobs BP-II, depressed, severe with 
54/F; Artist/master's degree Police escort, delusional paranoia, assaultive, involuntary Feared “rogue CIA and Cuban agents” trying to kill her; messages from TV PS Decreased sleep with increased activities; had flown from New York to Chicago at last minute; extensive grandiosity; angry; violent; loud; intrusive Complex grandiose delusional system incorporating the jewels of the Queen of Spain, Fidel Castro, and the assassination of President Reagan Had visited Spain and Cuba and had a distant relative with a low-level CIA position BP-I, manic, severe with 
10 62/F; Unemployed/college graduate Police escort, delusional paranoia, involuntary Feared her imminent assassination by “anti-Jewish foreign agents” PS Decreased sleep with extensive writing to the US Department of State for 20–24 h a day sustained episodically over decades; fled lodging when TV or radio indicated she had been located; walked all night to escape; slept on the streets Believed that she was an undercover foreign affairs advisor for the US State Department covertly tasked to protect the Jewish people Had held a low-level job in the US government in her 20s BP-I, manic, severe with 
11 36/F; Nurse/college graduate Ambulance, unconscious due to overdose in a serious attempt to die Feared her capture by law enforcement, sentencing to death and execution PS or postschizophrenic depression Psychotic suicidal depression; endorsed full manic episodes in the past with decreased sleep and a marked increase in dangerous activities due to spur of the moment impulses and lack of judgment Believed that she had “murdered” by neglect a terminal, 4-y-old patient under her care in hospice Had lost such a patient under her hospice care BP-I, depressed, severe with 

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Case 1

A 58-year-old Vietnam veteran living in a suburban neighborhood was presented to the emergency department (ED) in handcuffs accompanied by police. He reported to the interviewing psychiatrist that he had nailed shut his doors and windows except for small slits through which he “planned to fire on attacking Central Intelligence Agency (CIA) operatives.” Having amassed numerous small arms weapons including an illegal, fully automatic machine gun, he brought attention to himself by spraying automatic gunfire through his attic because he thought that “they had gotten into the attic.”

The patient's behavior and resistance in the ED necessitated involuntary commitment. On the unit, he was agitated and fearful, avoiding eye contact, any communication, and taking anything by mouth because he feared he would be poisoned. A thorough medical work-up for organic causes, including a urine drug screen, blood work, and imaging studies, was negative. He was diagnosed with schizophrenia, paranoid type. After 3 days of intramuscular (IM) haloperidol (Haldol) 10 mg twice a day, he began to eat and drink as well as to reluctantly cooperate with the staff, providing further history.

This individual said that he had led illegal US government operations in Cambodia and had become convinced that the CIA intended to eliminate him for fear he would “publish his memoirs.” He said that during the past 2 weeks, he had called the CIA over 300 times, frequently between midnight and 4 AM. Further, he said that he had not slept or eaten for fear of “getting overrun” and had lost over 15 pounds. He admitted that his thoughts had been racing. The patient said that a war buddy he had called had told him to slow down and had finally hung up on him. He had stopped using his telephone for calls other than the CIA for “fear of wiretaps.”

Although he endorsed prior episodes of major depression, he had not sought treatment. His diagnosis was changed to bipolar disorder, type I (BP-I), manic, severe with psychotic features. Lithium was rapidly titrated to a therapeutic blood level and effectively stabilized his mood. In subsequent outpatient follow-up, the patient revealed that he had a paternal uncle who had previously been diagnosed with BP-I and was also taking lithium.

Case 2

Prior to the fall of the Soviet Union, a 46-year-old divorced senior military aerospace engineer presented to military police (MP) afraid for his life and with his briefcase chained to his wrist. His chief complaint was that the (Soviet) State Security Committee (KGB) and the National Security Agency (NSA) were following him and planned to “erase him.” He tried to leave the ED when he became suspicious of the interviewing physician. He was restrained by the MP’s and forcibly admitted to the locked unit. With affect of agitation and paranoia, he was prescribed an antipsychotic combined with a benzodiazepine. The patient's absent without leave status for over 2 months, his rank as an officer, and his high-level security clearance were confirmed. After 2 days on the unit, he admitted that he had “gone underground,” had moved every 2–3 days, and had not reported for duty in order to escape assassination. He claimed to have received coded messages from the TV over the previous 3–4 weeks, telling him that he was in danger of attack by the KGB “who had conspired with the NSA to eliminate him.” He was diagnosed with schizophrenia, paranoid type.

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