A 27-year-old Norwegian woman was admitted after a psychotic episode with paranoid features. She was spending the summer holidays in Ibiza with some friends, when she started feeling threatened and scared. She was convinced that someone (probably her ex-boyfriend) had stolen her papers and identity card, preventing her from returning to Norway.

On the day of the admission, she presented with psychomotor agitation, verbal and outwardly directed aggression, emotional lability, and conceptual disorganization. Physical restraint was not necessary; olanzapine, haloperidol, and lorazepam were administered. Any previous access to psychiatric services was denied, as well as any psychiatric history. The patient also denied any substance use. She claimed to be a student, occasionally hired for temporary jobs. However, because of the high levels of hostility and paranoia, the patient was initially not accessible for a full clinical interview. She refused to answer any questions, appeared uncomfortable with the medical staff whom she evidently did not trust; she was concerned about drug therapy and felt that she was being used as a guinea pig by the medical staff, experimenting new substances. She appeared extremely distressed by the situation. On the day of hospital admission, speech was spontaneous, but disorganized; there was evidence of emotional lability and inconsistency between facial expression and speech content, psychomotor arousal, irritability, and a tendency towards verbal aggression. Also, she was seemed disoriented in both space and time, with conceptual disorganization and persecutory delusional ideation towards the medical staff, and she often asked the interviewer to return her documents. No insight nor perception of illness was detected. The next day, a lowered mood and the effects of delayed insomnia, a lack of energy and spatio-temporal disorientation, confusion, and mannerisms were observed. She spoke of a boyfriend, currently in prison, who frightened her and habitually beat her. Her mood changed frequently, showing anger and aggression, suddenly bursting into tears. She often switched between different languages: she spoke mainly in English, but she preferred her mother tongue to discuss emotionally distressing content. By the third day of admission, she seemed more alert and less fatigued. Her mannerisms had diminished. She was reading a book authored by a well-known actor and commenting on it appropriately. Although her mood was still unstable, she was more organized and started to remember and report the events leading to her admission. She reported a large consumption of different drugs (cocaine, ecstasy, and alcohol) throughout her stays on the island, and she mentioned a rave party on the day before she was hospitalized. Notably, she also reported a long-standing tendency to get into trouble or risky situations, underlining it with an ironic attitude. At the last follow-up visit, she was advised to continue her hospitalization due to her unstable condition. The toxicological report was positive for cocaine and amphetamine.

She was discharged 10 days after admission with a diagnosis of a substance-induced psychotic episode in borderline personality disorder.

At around 5 a.m., a young Arab woman was brought by the police to the emergency room at the Can Misses Hospital after displaying aggressive behavior towards others, particularly tourists walking in central Eivissa. The woman was in a state of severe agitation, with poor hygiene, irregular breathing, a rapid heart rate (125 bpm), dilated pupils, and a high fever (38.5 °C). She was highly agitated and yelling incomprehensible words in both Arabic and English. She was administered intravenous diazepam, but this had no clear clinical effect. Several doses of intravenous midazolam, totaling 24 mg, were also given, but her condition did not improve: her agitation and aggressive behavior continued, and she seemed terrified, repeatedly attempting to flee. The medical team struggled to conduct an examination, as she resisted every attempt, and physical restraint was eventually necessary. However, once a female Arabic interpreter arrived, the patient calmed down. She introduced herself in fluent English and asked the men in the room to leave. She appeared hesitant to discuss the events of the previous night and was only partially aware of her surroundings: she knew she was in Europe but could not recall when she had arrived in Ibiza or who had accompanied her. During the interview, she repeatedly sat on the bed, swaying her head and shouting phrases like, “I am the daughter of God… He cast me down… I made a mistake… He no longer wants me”. She also refused to urinate, citing religious concerns about the act.

She was later transferred to the psychiatric ward, where her agitated and aggressive behavior continued, particularly towards the nursing staff. She was given an intramuscular injection of 2 mg/mL haloperidol, which helped stabilize her. A few hours later, a man claiming to be her husband arrived at the ward, requesting her discharge so they could catch a flight to Paris. Through an interpreter, the man explained that they were from Azerbaijan and had come to Ibiza for their honeymoon. They had been married two weeks earlier and were traveling through Europe, having already visited Prague and hoping to visit Paris before returning home. With the help of the interpreter, the husband agreed to postpone their flight, but he refused to provide any details about what had occurred the previous night. The patient did not meet with her husband during his initial visit.

After the haloperidol dose, the patient became more oriented in both time and space, but she remained easily distracted and continued to refuse food and drink. She was highly talkative and echolalic, with evident disturbances in her thinking process, including perseveration. Delusional thoughts with religious overtones, as well as feelings of guilt and shame, were still apparent. She could not remember her marriage and avoided any physical contact with the nursing staff and doctors. In the afternoon, approximately 12 h after her admission, her husband returned for another visit, and this time, the patient quickly threw herself into his arms. The woman, suddenly calm and quiet, was able to recall and explain who she was and why they were in Ibiza. During the rest of her hospitalization, the woman became more submissive and accepted daily talks with psychiatrists and psychologists. Despite pharmacological treatment and its progressive benefits, no recollection of the night before her admission emerged. While she continued to deny the use of psychoactive substances, urine toxicology tests showed the presence of barbiturates (methaqualone).

She was eventually discharged seven days after admission with a diagnosis of substance-induced manic episode with mixed psychotic features.

A twenty-year-old boy who had been working on the island as a waiter for several years, arrived at the ER because of unusual and aggressive behaviors. He had spent the summer season at discos and parties with friends, and he had attended a rave party in Ibiza, taking several substances at the same time, during the weekend before admission. During the first interview in the ER, he appeared conscious, oriented, and cooperative, with some elements of distrust. He showed articulate speech, but the content of his thoughts was disorganized, and he seemed to lack any memory of the days before hospitalization. There was evidence of perceptual alterations, visual hallucinations, and pseudo-hallucinations, although paranoid ideation prevented a full clinical interview during the first few days. During the following days, he extensively talked about his life and family: he had adoptive parents, an adoptive sister, and three brothers. He reported previous psychological contacts during primary school because of some problems with the other children and because the teachers had complained to his parents about his restlessness and lack of attention, but his medical history appeared to be negative for previous psychiatric diagnoses. He reported daily use of cannabis and alcohol during for at least two weeks before admission, and occasional use of methamphetamine, lysergic acid diethylamide (LSD), and ketamine. He also reported recent use of an unknown liquid psychoactive substance. Talking about the latter substance, he perfectly described the hallucinatory symptoms and paranoid thoughts that occurred after taking the drug, which led to the unjustified aggressive behaviors and the subsequent hospitalization. While the visual hallucinations disappeared after a few days, auditory hallucinations, described as “a sort of music in the brain” persisted several days, as well as paranoid symptoms and aggressive behaviors The patient was discharged five days after admission, when a complete remission of symptoms was observed, with a diagnosis of a substance-induced psychotic episode. The toxicological examination was positive for cocaine and amphetamines.

A 43-year-old woman from Slovakia, who had been regularly employed as a realtor in Ibiza since 2012, was accompanied to the psychiatric service of the Can Misses Hospital by her boyfriend because of externally directed aggressiveness and psychomotor excitement, which initially prevented a full clinical interview, although she did not require physical restraint. She denied any drug use or psychiatric history. During the psychological assessment conducted two days after admission, she appeared less nervous and upset with a moderate somatic anxiety, and she referred to some clinical lab results she was waiting for. She claimed to be a translator, able to speak Italian, English, and Spanish simultaneously. Her speech was pressing and unstoppable, with derailed thoughts. Disorganization, an unusual content of thoughts, and poor insight into her conditions, but no delusional symptoms or hallucinations, were observed during this first session. Over the manic excitement, she reported restlessness and insomnia, with no more than 4 h of continuous sleep per night. During the interview, she appeared hostile and suspicious, and she jumped from one topic to the other without meaningful connections between them, describing a recent discussion with her boss, the relationship with her mother, the unbearable sense of responsibility and the urge to demonstrate her moral integrity, and the ability to carry out her projects after her father’s death, but also the desire to have a child, and she reported an increased interest in sexual activities over the last number of weeks.

The day after, although more cooperative, she appeared excited, euphoric, restless, and inattentive. Her thoughts were still disorganized. She reported consumption of cocaine, amphetamines, alcohol, together with an unknown substance that someone else would have put in her drink during a rave party the day before hospitalization. Moreover, she reported increased alcohol consumption during the last 2 weeks (one bottle of wine/a day, i.e., five drinks per night per day), although she denied previous drug use. She referred to herself as a determined and headstrong woman, hiding a man inside herself, and mentioned she was working on the draft of a book about herself and the most important experiences that built her personality. She flipped through the pages while admitting that, while also promising to send me a copy of her book as soon as possible. Mannerisms and hyper-expression were clearly observed. Before the conclusion of the session, she asked to keep in touch with the interviewers. The toxicology report was positive for cocaine and amphetamine, and she was discharged one week after admission with a diagnosis of a substance-induced manic episode.

A 27-year-old male was brought to the psychiatric unit by the police. A few hours earlier, the patient had reported the theft of his identity card as part of a structured and organized project made by an undefined group of persecutors. He had been working as a DJ around the island since the beginning of the summer season, with good performances and success, gaining a discrete level of popularity. His suspicions began a week before admission, during a night at one of the discos where he was used to playing, where he started to feel observed, perceiving a sense of menace and threat, which required him to interrupt his performance and return to his house. However, the same feeling reoccurred once at home, where he felt threatened and persecuted by the people sharing the apartment with him. When he woke up the next morning and he found a girl in his bed, hypothesizing that she had been placed there in order to cause him trouble with his wife, he decided to escape from his own house and hide close to a bus stop at first, and then moving to different hotels on the island, until his referral to the police. In the psychiatric unit, he was admitted in a forced regimen for the first few days. In fact, he was aggressive and extremely suspicious, presenting paranoid ideation and delusions of poisoning, and as such he refused food, medications, and any other supplies, as well as any contact with the staff. After the first two days of antipsychotic treatment with haloperidol, he gradually improved, allowing for more structured interviews and assessments. He reported a frequent use of large amounts of cocaine and other stimulants. The night of the psychotic breakdown, he remembered consuming cocaine, without recognizing its effects. He also reported to be in treatment for alcohol and cocaine use disorders, with a regular intake of topiramate and disulfiram. During the time he spent at the hospital, he showed increasing levels of insight: he started criticizing some memories, feelings, and thoughts, admitting they were difficult to believe, and probably impossible in their nature or at least in some of their elements. He also hypothesized the specific role of the substance he took the night of the psychotic onset as one of the causes of his breakdown. However, his suspiciousness continued to emerge, tapering the possibility of a clear critique of his beliefs. The toxicology report was positive for cocaine. He was eventually discharged with a diagnosis of substance-induced psychotic episode 72 h after hospitalization, when psychotic symptoms disappeared after symptomatic treatment with haloperidol and loxapine.