How Do You Handle Delusions?

[docB]

* I reread the title and can see how that could be ambiguous. Let me clarify by saying I mean your patient's delusions, e.g. that they are the rightful King of Sweden or delusional parasitosis and so on. Not your own delusions that you will achieve career fulfillment, make a positive difference in the system and so on.

When you encounter patient with fixed delusions that are not dangerous how do you handle them? I mean things like non acute drug induced delusional parasitosis, Morgellans (which basically is the former), pseudocyesis and so on. I have been thinking of this since a patient I saw with delusion of retained foreign body.

I have found that challenging the delusion just results in agony for all involved. I use the approach of saying "We have determined that there is nothing dangerous going on right now so I'm discharging you." I have talked to people who feel it is unethical and/or bad medicine to not fully inform the patient of your assessment, i.e. unequivocally challenge the delusion.

Thoughts?

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[deleted547339]

* I reread the title and can see how that could be ambiguous. Let me clarify by saying I mean your patient's delusions, e.g. that they are the rightful King of Sweden or delusional parasitosis and so on. Not your own delusions that you will achieve career fulfillment, make a positive difference in the system and so on.

Way to take the fun out the post......

 

[Tiger26]

When I saw the title, I was going to ask if you meant on the part of patients, staff, or administration .....

 

[TooMuchResearch]

F*ck. App crashed 8 minutes into my response. Will try to recreate later.

Brief version: Started TCAs on itchy, ulcerated, delusional pts in derm but had good follow-up. Could maybe do from ED w/ pcp f/u.

I don't think you need to challenge the delusion if that will create a rift between doc and pt.

 

[Vandalia]

There are a few cases, such as when secondary gain may be involved, that it might be appropriate to challenge a delusion. However, if it is a "true" delusion, then you will have as much success convincing them that their delusion is false, as they will of convincing you that it is real.

In those cases, I simply acknowledge that they believe what they believe and explain the treatment plan (such as it is.) Occasionally, a nurse or an EMT will try to argue with the patient, and I simply tell them they are wasting their breath.

 

[Daiphon]

I use a variation on "the ED is very good at finding out dangerous things that will kill you right away. But, we're not so good at solving long-term issues that aren't immediately life threatening... but we can refer you to those who are."

And then add a psych dx so the chart doesn't get a PG survey. d=)

 

[Birdstrike]

I have been thinking of this since a patient I saw with delusion of retained foreign body.

"I cannot find any radiographic evidence of a foreign body or other vegetables/legumes. I encourage you to see Dr Colonic Hideaway as an outpatient to search for it further, digitally. He is very gentle. Also, I've heard rumors that Dr Crazee Err Thanhispashients, has been lonely and needs a practice boost. Would you mind giving him a ring and helping a brother out? Oh, by the way, repeat after me, 'Five stars is the only answer. Five stars is the only answer.'

Thank you so much"



Sincerely,

Your Doctor Birdstrike M.D.

 

[F0nzie]

As a Psychiatrist at an SMI clinic, I deal with fixed delusions everyday. In the absence of having a therapeutic relationship with the patient, challenging the delusion will often make things worse. My recommendation is state the findings, acknowledge their distress ie. "I know this has been making you to feel very scared and anxious" (while they may disagree with your assessment it may help them feel validated and cared for which may offset their negative feelings), and refer out to a PCP that can begin the groundwork who can then refer them to a Psychiatrist. If you are curious to know what happens longterm (if they engage in treatmemt), antipsychotics and psychotherapy can help them disengage from the fixation so the delusions are not on the forefront of their minds. If a patient has a strong enough relationship with me and a decent level of insight they may come to me for a med adjustment and say "doc I am getting more paranoid can I go up on my Zyprexa?". In other cases the delusions are still present but on the backburner and they are at least able to focus on other things and lead more functional lives.

 

[name?]

Way easier to call someone Your Majesty and roll with it than to convince a Morgellans patient that you just don't see the little hairs/bugs/metal coming out of their skin. Derm referrals don't seem to appease them either. It's the seeking a cure for their delusional disease that leads to conflict. I don't mind the tinfoil hat if they don't mind me ignoring it.

 

[TooMuchResearch]

As a Psychiatrist at an SMI clinic, I deal with fixed delusions everyday. In the absence of having a therapeutic relationship with the patient, challenging the delusion will often make things worse. My recommendation is state the findings, acknowledge their distress ie. "I know this has been making you to feel very scared and anxious" (while they may disagree with your assessment it may help them feel validated and cared for which may offset their negative feelings), and refer out to a PCP that can begin the groundwork who can then refer them to a Psychiatrist. If you are curious to know what happens longterm (if they engage in treatmemt), antipsychotics and psychotherapy can help them disengage from the fixation so the delusions are not on the forefront of their minds. If a patient has a strong enough relationship with me and a decent level of insight they may come to me for a med adjustment and say "doc I am getting more paranoid can I go up on my Zyprexa?". In other cases the delusions are still present but on the backburner and they are at least able to focus on other things and lead more functional lives.

Thanks.

 

[WilcoWorld]

I do not try to disillusion my delusional patients. I hear them out, remain politely agnostic regarding their delusion, and do the ED-appropriate workup.

Usually they leave dissatisfied (or get admitted to Psych), but occasionally I actually figure something out.

A little over a week ago I had a patient with rash, chronic itching & weakness who had been seen many times for these complaints. He & his wife launched into a tirade about how the medical profession, and Dermatologists especially, were far too dismissive of Morgellon's. They actually used the term Morgellon's. I explained that I was neither a Dermatologist nor a Parasitologist, but that I was pretty good at diagnosing emergencies. When they pointed out his actinic keratoses and showed me pictures of his parasites I looked at them. But I then pointed out his yellow sclera and spider telangiectasias (they were really impressed by the blanching, or was it the word "spider" in the name?). When his bilirubin came back at 5.8 I explained that liver failure causes itching and fatigue and telangiectasias (the actinic keratoses were a red herring). I recommended he stop drinking and referred him to a hepatologist. That encounter turned out much better than I expected it to after reading the triage note.

 

[styphon]

The patients have usually been to tons of specialists, all who tell the pt they don't have bugs in their eyes/skin/ears. Then they end up in emergency care out of desperation. I just state I can't currently see the bugs in their eyes/ears/skin and to f/u with PMD as arguing is a waste of both of our time. If I try to mention therapy/seeing a counseling the interaction usually starts going downhill.

I had a patient convinced they had African River blindess, which he saw on some medical TV show, and he brought a stack of WebMD papers with him. But he had never been to africa (or anywhere outside of the state), or been in contact with someone from africa. He had seen multiple optho doctors - who he claimed were all "quacks". He also brought a bag of scabs to show me, which he claimed were "bugs". I took a look at his skin, and did a fundoscopic exam - he left unsatisfied and claimed that I was also a "quack".

 

[Birdstrike]

The patients have usually been to tons of specialists, all who tell the pt they don't have bugs in their eyes/skin/ears. Then they end up in emergency care out of desperation. I just state I can't currently see the bugs in their eyes/ears/skin and to f/u with PMD as arguing is a waste of both of our time. If I try to mention therapy/seeing a counseling the interaction usually starts going downhill.

I had a patient convinced they had African River blindess, which he saw on some medical TV show, and he brought a stack of WebMD papers with him. But he had never been to africa (or anywhere outside of the state), or been in contact with someone from africa. He had seen multiple optho doctors - who he claimed were all "quacks". He also brought a bag of scabs to show me, which he claimed were "bugs". I took a look at his skin, and did a fundoscopic exam - he left unsatisfied and claimed that I was also a "quack".

Press Ganey = fail.

If you had lied to him, acted co-dependent in the delusion, and prescribed some worthless drug so he could think you were working hard to "fix him" you would have had a "satisfied customer," and rocked the Press-Ganey score.

 

[styphon]

Press Ganey = fail.

If you had lied to him, acted co-dependent in the delusion, and prescribed some worthless drug so he could think you were working hard to "fix him" you would have had a "satisfied customer," and rocked the Press-Ganey score.

My archenemy, patient surveys..Feels like I work for McDonalds, "customer is always right!"

 

[gman33]

Press Ganey = fail.

If you had lied to him, acted co-dependent in the delusion, and prescribed some worthless drug so he could think you were working hard to "fix him" you would have had a "satisfied customer," and rocked the Press-Ganey score.

If you give them a psych diagnosis, does this result in no Press Ganey being sent?

 

[WilcoWorld]

If you give them a psych diagnosis, does this result in no Press Ganey being sent?

That is institution-dependent. My Psych patients still get surveyed.

 

[Apollyon]

That is institution-dependent. My Psych patients still get surveyed.

Haha, sucker! See, this is where I give the useless answer of "move somewhere else (like Texas)!" <-- because "pick up and move" is a completely viable, simply executed maneuver!