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
1	58/M; Unemployed day laborer/college graduate, Vietnam Veteran	Handcuffed, paranoid, fearful, agitated, resistant, involuntary	Feared elimination by CIA; feared poison	PSa	Decreased 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 AM	Believed 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
2	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
3	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
4	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
5	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
6	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
7	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
8	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
9	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

Note: ED, emergency department; M, male; F, female; CIA, Central Intelligence Agency; MP, military police; KGB, (Soviet) State Security Committee; NSA, National Security Agency.

^aPS is schizophrenia, paranoid type.

^bBP-I, manic, severe with is bipolar type I, manic, severe with psychotic features.

^cMDD, severe with is major depressive disorder, severe with psychotic features.