how to communicate to patient with hallucination/delusion?

insatiable · Sep 2, 2008

its been a while since i took psychiatric nursing class. could someone please explain the difference between delusion and hallucination?
i have a patient who says that her baby is dying or her husband is next to her and talking to her or calling for her etc. how do you talk to a patient in this situation? do you set reality by telling them the truth or do you go along and tell them that her baby is fine etc??

i guess my question to you is is this an elderly patient with dementia etc? or are you working on a psych floor with people with schizophrenia etc?...id help me in my explanation :).

Thunderwolf, MSN, RN · Sep 2, 2008

A delusion is a fixed false belief, despite the evidence of being not true.

A hallucination is a sensory perception in absence of external stimuli, involving either of the senses (auditory, visual, somatic, taste, smell).

There are two schools of thought:

1. When a patient reports a delusion or an objective hallucination (sight, smell, or auditory), one could simply state that "I'm not experiencing that (hallucination) right now with you. Since you are, how does this effect you?" or "I thought Jesus died 2000 years ago. How did he come back (delusion)?"....sort of a mild reality check. Also, in this line of approach, it opens the door for the patient to discuss it further with you in order to assess his/her state of mind better.

2. If this is a chronic patient and the delusion/hallucination is not too upsetting to the patient, go along with it during the course of your conversation. "It must be difficult hearing that baby crying (hallucination). That would upset me too." or "It must be hard being Jesus all the time (delusion). I would feel exhausted at the end of the day."....sort of a mild validation regarding the patient's burden (if symptom burden is being experienced by the patient).

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There are always exceptions to the rule, like:

1. The patient says, "The voices are telling me to harm myself today (hallucination)."

Then, as a clinician, a therapeutic, reality based confront may be in order.

"Right now, what you are experiencing may be a very disturbing hallucination, and I am concerned for you. Let's discuss what you and I can do to help you through this."

2. The patient says, "I am Jesus Christ, and I must show the world my power to command the angels. I will throw myself off the highest building in order for them to lift me up from harm...then the world will know that I am who I say I am (delusion)." Delusions, especially of this magnitude, can be difficult to manage. Often, it requires the person hospitalized to protect him/herself until stabilized...because rationality is often greatly impaired. When a patient is delusional to this degree, confronts are often of little use...and should not be attempted. However, redirection of the patient may be helpful, such as:

"Jesus is a great man, always caring for his brothers and sisters, the peacemaker. This is what Jesus is known for. Maybe, instead, you could show the world your power as Christ by showing others how to be good to their fellow man better. Let's see how you can do this, so others may learn from your example. What are some Christian examples that you could practice today?" In this case, you as a clinician are sort of going along with the delusion, but redirecting it....if possible.

You get the idea....but all in all...how a clinician approaches a patient with these psychotic symptoms depends upon:

1. Do the symptoms place the patient or others at harm, immediate or later?

2. Are the symptoms disturbing to the patient....to others?

3. How severe are the symptoms...mentioned on occasion/redirectable vs constantly/unable to redirect?

4. Has the patient acted on them in the past...and how? Level of impulsivity?

5. How do the symptoms impact/impair daily functioning...socialization?

6. How much reality testing has the patient lost as a result?

7. Are they congruent/incongruent with mood?...are they organized/disorganized?

And the last questions, as a clinician, to ask oneself are:

1. Is the patient taking his/her meds as ordered?

2. Has the patient been facing a significant stressor lately?

3. Does the patient abuse substances/alcohol?

A negative response to either of these three questions raises a red flag that may direct you as a clinician to follow up on.

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Also, as a clinical pearl: olfactory/smell hallucinations are rare. If present, especially in an adult and upon first awakening in the A.M., it may signify an organic, neurological cause (ie brain tumor). The patient needs to be seen by his/her physician ASAP to rule out organic etiology.

And lastly, ALL mental/emotional disorders run the risk of psychotic symptoms....the higher the severity, the higher the risk.

Hope this helps.

Thunderwolf, MSN, RN · Sep 2, 2008

As a side note: I am not picking on Jesus as something delusional or being a delusional being.

However, as a previous psych nurse, I cannot count how many times that I have had the pleasure in shaking either Jesus's, Buddha's, Mohammed's, or an angel's hand in person....nurse to patient. Jesus, however, seems to be the favorite....and in many cases, it depends upon the patient's cultural/religious background.

Thunderwolf, MSN, RN · Sep 2, 2008

i have a patient who says that her baby is dying

depends upon the age, diagnosis and context of your patient since we have little knowledge of her. is she young or elderly? did she miscarry at some point in her life? did she even have children? is there a history of child abuse?....the baby may be symbolic of herself.

or her husband is next to her and talking to her or calling for her etc.

again, age comes into play...as well as ethnicity/culture. is her husband deceased? in some cultures, it is acceptable to talk to the dead as a form of grief. presence of dementia (previously mentioned)? if older/elderly/malnourished/eating disorder, presence of any electrolyte imbalances or abnormal labs?

both examples may also be a form of psychotic depression, congruent with mood.
but, we just don't know.

what brought the person in (context & symptoms)?
what is the current diagnostic impression/diagnosis?
any other symptoms?
some brief patient demographics.

need more info to be helpful.

although i gave some examples of general approaches in my other post...

there often is no set cookie cutter approach....because it is often patient driven...unique to that patient within the context that he/she is struggling in.

Ms.RN · Sep 2, 2008

i guess my question to you is is this an elderly patient with dementia etc? or are you working on a psych floor with people with schizophrenia etc?...id help me in my explanation :).

okay. patient has diagnoses of dementia with delerium and organic delusional disorder :confused: :thnkg::sstrs:

whenever she experiences this, she either get very upset and screams at staff or she would freeze in one position for hours.

Thunderwolf, MSN, RN · Sep 2, 2008

Well, this clarifies the picture better.

Thank you.

We have several issues here which need addressed individually.

1. Dementia (various types)...which may account for the reference to the baby. Many folks with dementia revert back to earlier, significant stages in life. For women, children or babies are common...it was a significant role that defined that patient most of his/her life. Providing pics of babies (any baby) or providing a baby doll can be a comfort. In dementia, short term memory tends to be impaired to a lesser/greater degree, depending upon the patient. Folks with dementia do best in a structured, low stress environment. Provide cues to orientation within the environment. Also, many folks with dementia may enjoy repetitive tasks. If it is safe, let them do it. It is a coping mechanism which is often grounding for them. Through out the day, encourage low level decision making by the patient in order to foster a sense of independence and accomplishment. What can be very frustrating for some patients is when all decision making is taken away from them. Even with dementia, the patient has choices. Choice should be encouraged.

2. Delirium...what is causing this? Delirium in the elderly often signifies a change within the person or within the environment. Examples: infections, poor oxygen levels, pain, blood sugars, electrolyte imbalances, dehydration, malnutrition, blood pressure issues, heart/lung conditions, physical illness, neuro-syphilis, recent falls, change in staff/personnel, patient room/room mate changes, loud noises, medication changes, et cetera. Trace back before the onset of delirium in order to evaluate probable cause so that it may be possibly addressed. Either way, it is a clouding of consciousness. In delirium, a patient often perceives things in tunnel vision. So, providing info in bite size pieces is often best for the patient. Also, reassurances of safety and of comfort. Minimize change. If having the light on at night brings comfort and reorientation when delirious, leave it on.

3. Organic Delusional disorder...implies a physical cause (like stroke) for the distortion in thought. Debating a person who is delusional is counter productive. Rage and fear are often kissing cousins in delusional folks....so by addressing the fear behind it (from the patient's perspective), you often address the anger in front of you...de-escalating it. Medication may help reduce the symptom severity. Calm reassurances and redirection are best. Catatonia (freezing in one spot for hours, possibly even the screaming) is often a symptom of patient severity and/or of patient overwhelm. If catatonic, evaluate what happened just prior to this (is it the patient, staff, and/or the environment?), discuss the incident with the physician/staff, and provide for patient comfort and ADL's until patient is able to care for oneself again. You can also see catatonia in significant depression too...where the person becomes totally bedridden....requiring caretakers to feed the patient.

Also, in the elderly, a thing to be concerned about is pseudodementia...depression appearing as dementia. This may also account for "her baby dying" ...which is mood congruent in depression, but may also be a part of either the dementia or the delusional disorder. The dying baby may also be symbolic for the patient in how she currently feels about herself...so, allow her to discuss the dying of the baby and what it means for her. You may be surprised. If depressed, encourage socialization. Isolation and depression often feed into the other, a vicious cycle. When depressed, being alone is not the answer.

The husband sitting with her or talking with her (when he is not actually there) may be a part of her delusional disorder which may worsen when delirious, distressed, or depressed. If this is a comfort to her, do not take this away from her. It may be one of her few coping mechanisms left that she has at her disposal. If the husband brings comfort in her mind, what is the harm?...none. However, if the husband is deceased and the delusion/hallucination is encouraging her to suicide in order to be with him....that is an entirely different matter...and you need to monitor her more closely to keep her safe. In this case, delusional talk or reference to the hallucination really needs to be openly discussed with the patient.

"Right now, what you are experiencing may be a very disturbing hallucination, and I am concerned for you. Let's discuss what you and I can do to help you through this."

Some clinicians may tell you to not discuss any delusional material with patients. In this case, it is not the case.

However, in general, with general psychotic material, you may try what I previously mentioned in my other post:

1. When a patient reports a delusion or an objective hallucination (sight, smell, or auditory), one could simply state that "I'm not experiencing that (hallucination) right now with you. Since you are, how does this effect you?"....sort of a mild reality check. Also, in this line of approach, it opens the door for the patient to discuss it further with you in order to assess his/her state of mind better.

Also, if family or a particular family member brings comfort to the patient, encourage more visits...especially around times of care/dining. However, sometimes, family or visitors bring more stress to the patient...yes, an added stressor...so evaluate and/or discuss this with the patient if possible. Sometimes, one visit by one family member or one visitor is less stressful than a whole flock of folks visiting all at once. For some patients, too much stimuli all at once is too much to handle. Each person is different.

Regardless though, with each of the above diagnoses, minimal change or rotation of staff is best for these type of patients. Frequent changes of faces (rotating staff) in and out of the patient's room, during care, et cetera often upsets the applecart for the patient and becomes disorienting/distressing. Structure and routine, allowing personal choices and coping mechanisms, and permitting the expression of one's emotional self go a long way here.

I apologize for my brevity....chuckle.

Now questions for you

What have you/staff tried and/or implemented?

What appears to escalate/de-escalate the patient symptoms?

What are her delusions fixed on?

What typically triggers her catatonia?

What is her general mood?

How functional is she on a good day?....on a bad day?

Hope what I have discussed has helped some.