Paranoid patients

rn/writer, RN · Mar 9, 2006

Hey just wanted some advice from you guys: I've had paranoid patients before but the guy I have now (I'm his primary nurse) is driving me bonkers! He keeps coming to the nurses station and telling me that someone moved his stuff in his room and people are leaving messages for him (there was a slip of paper that made it into his room). He's taking his meds, Zyprexa 15mg BID but I think it's going to take a while before he gets better. Maybe I wouldn't feel so frustrated but I had a couple of other happy campers (another paranoid and some borderlines) this week. I've been as patient with him but I really thought I was going to lose it earlier today. So any tips for handling this guy? I try not to feed into his delusions and end our conversations when I realize we're going in circles but then he'll come back around with something else to perserverate about. Thanks in advance!

Can he acknowledge that he is paranoid and fixating? How is he in groups? Is there anything in his treatment plan that addresses ways for him to de-escalate his anxiety. The biggest hurdle here is whether or not he can consider the delusional quality of his perceptions. If he is locked into the idea that all of his fears are real, you may just have to wait for the meds to kick in.

If, however, he can open the door even a crack to the concept that his brain is misleading him, you might be able to connect a bit. The paranoia could be the manifestation of other anxieties. You might be able to redirect his attention. When he insists that someone moved his stuff, you can acknowledge his need without picking up the tug of war rope by saying something like, "You want to feel safe."

You might want to suggest he do some journaling--NOT about the litany of assaults on his fragile world but about the events preceding the incidents and the feelings they generated. You might be able to help him see a pattern. Even if it only keeps him occupied, it might be worth the effort.

Print out info on his meds and highlight the time it takes to reach a therapeutic dose that shows results. Keep him grounded in reality by telling him that you understand he is feeling unsafe, but his illness is altering his understanding.

Redirect his activities if you can. Find things for him to do on the unit--recreational or ?? You can give him simple tasks like straightening up games or organizing books (not a violation of patient's rights as long as you are clear that it's voluntary).

As far as the going around in circles, the only way to win is not to play. Cut through the delusion by saying, "I understand what you're telling me." Then write down a reality check that he can carry around with him. "My illness tells me ______. The reality is _______." When he wants to drag you out onto the dance floor, ask him to re-read the message.

One last, but very important, thing. Do keep an eye on the other patients to make sure they're not messing with him. Paranoids can be fun to torment and you really don't want to subject him to that. If you find out there is any of this kind of crud going on, it's important that the offender(s) take responsibility for what they have done.

I wish you both well.

NPAlby · Mar 9, 2006

Thanks for the tips. He does have some insight and I've tried to remind him of why he came (willingly) to the hospital. He does attend groups and participates. He is actually one of the few pts that looks like he has a good shot at a full recovery. It's just working with eight other pts and him coming back and forth with something new to fixate on was driving me bonkers. I've been patient and have tried redirecting him. Today was better, a lot less pts-6 and he was easier to redirect. The tx team met and said he was an exhausting pt so at least I know it's not me (maybe a bit of the paranoia wearing off).

Thanks again!

elkpark · Mar 10, 2006

I second all of rn/writer's good ideas! Another technique that may be helpful, if he has some insight and impulse control, is scheduling an "appointment" once or twice during the shift with him to talk about his concerns (all at once) instead of his coming to the nurses' station repeatedly each time something new occurs to him.

In addition, make a point of conversng with him at other times during the shift about topics other than his paranoid concerns to reward/reinforce more socially acceptable interaction on his part. (If he starts to drift into the paranoid material, remind him that the two of you have arranged a time to talk about that and either shift the topic back to something else or conclude the conversation.)

Best wishes.

chadash · Mar 19, 2006

You work with parnoid patient, so I was wondering if you have ever seen 'shared delusions'? That is, more than a family member that shares the pyschosis at some level?

beochicken · Mar 21, 2006

One patient of mine was very paranoid about beeing spied on by various governement agencies, and believed his room was bugged. Instead of telling him there were no problem, I took the "well, if the room is bugged we need to find the bugs and remove them" approach, and me and the patient went through the whole room from top to bottom to find the bugs. After fifteen minutes of intense searching the patient got boored and told me he wasnt so sure afterall about the governement spying on him, and that we didnt need to search anymore. The topic never came up again after that. Problem solved.

My point is, if you offer the patient to sit watch with him outside his room to avoid "people going through his stuff and slipping him messages", it might be that it wont take very long before he gets boored and realises that that paranoid thought was something he made up to make a booring hospital day go a little faster.

NPAlby · Apr 5, 2006

Just read the last post today (it's been busy few weeks for me) and there is no way I could stay with the pt on a watch. Nor do I think that's a good idea. Isn't that kind of like sharing his delusions?

As I predicted that pt did respond well to meds and was dc'd. He thanked me the day he left for my patience and care. I've come to realize that it's really not the pts that are driving me bonkers but the unit itself. Even on slower days I'm still in a lousy mood. Fortunately it's a travel assignment and I'll be done in May. Anyway just wanted to say thanks.

CharlieRN · Apr 5, 2006

Just read the last post today (it's been busy few weeks for me) and there is no way I could stay with the pt on a watch. Nor do I think that's a good idea. Isn't that kind of like sharing his delusions?
As I predicted that pt did respond well to meds and was dc'd. He thanked me the day he left for my patience and care. I've come to realize that it's really not the pts that are driving me bonkers but the unit itself. Even on slower days I'm still in a lousy mood. Fortunately it's a travel assignment and I'll be done in May. Anyway just wanted to say thanks.

Have to agree that "humoring" any psych pt is a bad idea. In general delusions should be gently confronted. But that is what beochicken was doing. She was confronting the reality of the patients belief. Not denying it, but subjecting it to reality testing. Sharing the delusion would be to have behaved as if the bugs were there, without acting to establish that they were not. She might have done that by whispering or playing a radio while talking to the patient so that they could not be overheard. That would have been a very bad idea. Once the patient cleared he would see that, correctly, as lying. Other clients would observe it and lose trust in the deceitful staff person.