What questions should be asked of a female cruise‑ship patient presenting with persecutory delusions (feeling followed and believing a bartender placed rubber bands in her drink) and recent bloody diarrhea?

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Last updated: November 9, 2026 • View editorial policy

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Assessment Questions for Cruise Ship Patient with Persecutory Delusions and Bloody Diarrhea

You must simultaneously evaluate both psychiatric and gastrointestinal presentations, as the bloody diarrhea represents an alarm feature requiring urgent organic investigation regardless of the psychiatric symptoms. 1

Critical Gastrointestinal History

Alarm Features Assessment

Ask specifically about:

  • Unintentional weight loss (quantify in pounds/kg over what timeframe)
  • Nocturnal diarrhea (waking from sleep to defecate suggests organic disease) 1
  • Duration: When exactly did diarrhea start? (Recent onset <3 months suggests organic pathology) 1
  • Blood characteristics: Is blood mixed throughout stool in the toilet bowl (dysentery/severe disease) or just streaks on toilet paper (possibly hemorrhoids)? 2
  • Fever or chills: Does she feel feverish? (Most travelers lack thermometers, so ask about sweats, rigors, feeling hot) 2
  • Abdominal pain: Severity, location, cramping vs constant
  • Volume and frequency: How many loose stools per 24 hours? Large volume watery vs small frequent bloody stools?

Travelers' Diarrhea Specific Questions

  • Food and water exposure on cruise: What has she eaten in the past week? Raw seafood, buffet foods, ice, tap water, salads?
  • Onset timing: Did symptoms start during or after the alleged incident with the bartender?
  • Other ill passengers: Has she heard of others on the cruise with similar GI symptoms? (Outbreak investigation) 3
  • Functional impact: Is the diarrhea tolerable (mild), distressing/interfering with activities (moderate), or incapacitating (severe)? 2

Medical and Medication History

  • Medications: Specifically ask about antibiotics, NSAIDs, antihypertensives (ACE inhibitors), magnesium supplements, antacids, laxatives 1
  • Previous GI surgery: Any bowel resections, gastric surgery? 1
  • Chronic conditions: Diabetes, thyroid disease, HIV status, immunosuppression 1
  • Alcohol use: Quantity and frequency (can cause diarrhea directly) 1

Psychiatric History

Delusion Characteristics

  • Timeline: When did she first notice being followed? Was it before, during, or after the GI symptoms started?
  • Progression: Are the persecutory beliefs worsening, stable, or improving?
  • Specificity: Who exactly does she believe is following her? The bartender specifically or others? 4
  • Associated psychotic symptoms:
    • Auditory or visual hallucinations?
    • Disorganized speech or behavior?
    • Other delusional themes (grandiosity, reference, control)? 5

Substance Use

  • Caffeine intake: How many energy drinks, coffee, or caffeinated beverages daily? (Excessive caffeine can induce psychosis with persecutory delusions) 6
  • Alcohol: Current use and any recent changes
  • Stimulants: Any amphetamines, cocaine, or other stimulants? 7
  • Medications: Recent changes to any psychiatric medications or dose adjustments?

Psychiatric Background

  • Prior psychiatric history: Any previous psychotic episodes, schizophrenia, bipolar disorder, depression, anxiety? 8
  • Current psychiatric medications: What is she taking and has she been adherent on the cruise?
  • Family psychiatric history: Psychotic disorders in relatives?
  • Trauma history: Using patient-friendly language: "Have you experienced any traumatic events such as physical or sexual abuse, natural disasters, or medical trauma?" 8

Cognitive and Mood Assessment

  • Anxiety level: Severe anxiety can cause both GI symptoms and paranoid thinking 9, 8
  • Depression screening: Sleep changes, appetite changes (beyond diarrhea), anhedonia, suicidal thoughts
  • Insight: Does she recognize any possibility that her beliefs might be influenced by stress or illness?
  • Level of consciousness: Is she alert, oriented to person/place/time? Any confusion or fluctuating awareness? (Rule out delirium) 10

Nutritional and Systemic Assessment

  • Dietary intake: What has she been eating over the past week? Severe dietary restriction due to paranoia? 11
  • Vitamin deficiencies: Any history of malnutrition, B12 deficiency, or restrictive eating? (Can present with psychosis) 11
  • Systemic symptoms: Night sweats, skin changes, joint pains, mouth sores (IBD, systemic disease)

Safety and Functional Assessment

  • Current safety: Does she feel safe right now? Is she avoiding food/water due to poisoning fears?
  • Defense behaviors: What is she doing to protect herself? (Avoiding certain areas, not eating, isolating?) 12
  • Functional impairment: Can she participate in cruise activities? Eating adequately? Sleeping?
  • Suicidal or homicidal ideation: Direct questioning about thoughts of self-harm or harm to the perceived persecutors

Physical Examination Priorities

While you asked about questions, examination findings are critical here:

  • Vital signs: Fever, tachycardia, orthostatic hypotension (dehydration)
  • Abdominal exam: Tenderness, distension, masses, bowel sounds
  • Rectal exam: Confirm blood presence, assess for hemorrhoids vs mucosal bleeding
  • Skin: Excoriations from scratching (delusional infestation), signs of dehydration, nutritional deficiency
  • Mental status: Formal assessment of orientation, attention, thought process, affect

The presence of bloody diarrhea with alarm features mandates stool studies (culture, ova/parasites, C. difficile if antibiotic exposure), blood work (CBC, electrolytes, inflammatory markers), and consideration of endoscopy regardless of psychiatric presentation. 1, 3 The psychiatric symptoms require parallel evaluation but cannot delay investigation of potentially serious infectious or inflammatory bowel disease, especially in the cruise ship setting where outbreaks are common.

References

11
Research

[Delusion and Rose's disease].

Actas espanolas de psiquiatria, 2003

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