Help navigating Psych patients please.

[IMG69]

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So i'm on Psych now and wow, straight into the deep end, observation rooms etc and i'm at the mental hospital where every patient has a court order to be held there. Can someone with experience please give me any tips for navigating a true history from these types of patients? After today it just seems like I just have to ask symptoms and basically checklists because any open ended questions just get lost in the delusions etc e.g I cut myself then cloned my husband from her own blood etc.

Tips greatly appreciated for my rotation with these extreme patients, i've already done the alcohol/drug rehab part of psych but this is a whole new level.

 

[Rapsidy]

I’m a social worker in a psych hospital who deals with very psychotic delusional patients as well as doing an internship with the criminally insane previously, but will not be starting medical school until fall so take my advice for what it is an different perspective than someone doing rotations.

Grab collateral if you have it/have permission from the patient to talk to collateral. Most delusions have a grain of truth to them which is why they are such deeply held beliefs and having someone to talk to who can give you information is vital.

Never directly challenge a delusion especially if the person is not medicated or isn’t responding to medications. How would you feel if someone said to you everything you believed is wrong and then sat there to explain why everything you think is wrong. It’s a very easy way to agitate someone and then create a dangerous situation. Asking probing questions trying to understand the delusion is fine, but don’t dismiss the person either, they are after all still people who need respect and dignity.

Also realize that medicine is limited when it comes to delusions and often times even on the best medications delusions are still going to be there. That is where long term therapy and treatment helps the most as the person needs someone they can trust to help them understand what is and isn’t real. It’s not something you are going to accomplish or fix in an inpatient setting as inpatient is meant for immediate stabilization.

Finally, be okay with the fact that you are going to have long term chronically sick patients that you will see over and over and over in the hospital and your emergency rooms and right now there isn’t much we can do for those patients as the community resources are not there to handle them. I’m not saying won’t be a fix someday but right now the medicine and treatment approaches we have isn’t enough. There are patients that we see over ten times a year in our hospital have long used up all their Medicare psych days and they are only in their early 30’s and that is just life for them.

I hope some of this information is helpful to you! Please always keep in mine first and foremost that even though they are sick they are still people, many of them who have probably burned most of the family bridges they have in life already. You as the doctor may be the only person who cares for their well being at this point and you have to advocate for them as many of them don’t have a voice of advocacy left.

 

[IMG69]

Thanks a lot for this, I definitely don't challenge anything they say but I also find it extremely challenging to actually pick out what to ask more information on? E.g I almost can't discern what is a delusion and what is real. e.g non bizarre delusions. I just find it extremely difficult to know what to focus on and what actually matters - other than the obvious symptoms (insert anki card checklist).

E.g women believed smoking would make her babies beautiful (believed she was permanently pregnant) and thought the reason she was in was because of smoking, so do I focus on why she believes the smoking is a big issue? Or do I probe more into the pregnancy infatuation.

Collaterals are no issue since it's a normal history basically but just not getting caught on some tangent with the patient themselves seems to be very challenging. I have no issues with the long term patients, we have plenty of TRS patients, murderers etc.

It's just the approach to the patient interview, we're taught 50-50 doctor/patient for all other fields of course but this just feels 99-1 because it gets off tract instantly and the conversation seems to be on a knifes edge as most of them work themselves up into a emotional state/aggressive state. Plus the fact that everyday the patients change - mood fluctuations etc.

What do you do in terms of physical contact etc with patients, e.g one hugs everyone including the staff, so how do you draw the line/handle situations when it quickly gets uncomfortable without causing a scene?

 

[Rapsidy]

I never hug patients, ever. It’s a personal preference for me, but I will continue that practice even when I am a doctor. View it like this, you have something valuable which is your license which in turn will provide for you and your family. Never put yourself in a situation that can be misconstrued as inappropriate and therefore put your license at risk. The most I will do is fist bump with a patient, or a high five, which most patients accept. That will be something you will have to figure out yourself at your comfort level.

Second, your original post suggests that you are in an inpatient psych type of situation correct? You have to always keep the goal of immediate stabilization when trying to parse out delusions. If they are there on petition and certification and are going to mental health court, you need to prove that they need inpatient treatment. Why are they a danger to themselves or others or why if not treated on an inpatient basis, will they decomp to a point that they will not take care of themselves. Your example of the woman with the smoking delusion is irrelevant because it doesn’t matter to the immediate goal of stabilization and if you go to court saying she needs inpatient because she is fixated on being permanently pregnant, your petition and cert is thrown out and she has no treatment now. That is a delusion that should be addressed on an outpatient setting.

If for example a person is fixated on their child and thinks they are a demon that needs to be killed, that is something to address because that person is an immediate danger to someone else/themselves. That is the nature of inpatient psych, your goal has to be stabilization that justifies inpatient care and try to help that patient set up continued treatment once discharged.

This of course is under the assumption of a typical psych hospital working with insurance companies. You always have to justify the need for the treatment at the level of care that you are providing it.

 

[IMG69]

I never hug patients, ever. It’s a personal preference for me, but I will continue that practice even when I am a doctor. View it like this, you have something valuable which is your license which in turn will provide for you and your family. Never put yourself in a situation that can be misconstrued as inappropriate and therefore put your license at risk. The most I will do is fist bump with a patient, or a high five, which most patients accept. That will be something you will have to figure out yourself at your comfort level.

Second, your original post suggests that you are in an inpatient psych type of situation correct? You have to always keep the goal of immediate stabilization when trying to parse out delusions. If they are there on petition and certification and are going to mental health court, you need to prove that they need inpatient treatment. Why are they a danger to themselves or others or why if not treated on an inpatient basis, will they decomp to a point that they will not take care of themselves. Your example of the woman with the smoking delusion is irrelevant because it doesn’t matter to the immediate goal of stabilization and if you go to court saying she needs inpatient because she is fixated on being permanently pregnant, your petition and cert is thrown out and she has no treatment now. That is a delusion that should be addressed on an outpatient setting.

If for example a person is fixated on their child and thinks they are a demon that needs to be killed, that is something to address because that person is an immediate danger to someone else/themselves. That is the nature of inpatient psych, your goal has to be stabilization that justifies inpatient care and try to help that patient set up continued treatment once discharged.

This of course is under the assumption of a typical psych hospital working with insurance companies. You always have to justify the need for the treatment at the level of care that you are providing it.

I don't want to hug patients either but that's what i'm asking how are you getting out of it without the patient having a bad reaction etc e.g I started moving away as they got closer but they just followed me and the last thing I want is to say no and have some kind of outburst or something from the patient.

Yes this is acute inpatient and chronic inpatient, the only criteria is that the court/psychiatrist has issued they are not fit for society either currently or indefinitely. My examples were the extremely mild ones where it wasn't obvious to me whether I explore it or move forward, for example she also was extremely violent due to god telling her to punish people for their injustices but obviously that is a gigantic thing and direct a threat to others etc.

Maybe i've overthought this? So it basically seems like I ignore basically anything other than obvious red flags such as self harm from her wrists and the justice in the name of the lord etc. Edit: and typical symptoms anki tells us, mood, energy, sleep etc.

So it really just does seem to come down to a checklist of things I guess then? Which is fine for me lol. We don't have to worry about insurance companies etc, these patients are basically 'done' and can't really function in society ever, e.g like your example of a mother stabbing her son while he sleeps etc.

 

[Rapsidy]

The nature of care and how it’s handled does change things. If it’s short term stabilization yes you focus on the red flags. If it’s long term acute care then yes you can focus on other things. My experience working on a locked forensic unit though has still always been you want to try and either stabilize them enough to stand trial in court or prove to a judge that they are no longer a danger to society and can have conditional releases to places like psychiatric nursing homes. There will be some patients however that will live their lives in a locked psychiatric ward because unfortunately they will always be a danger to society, and it’s just lack of knowledge on our part in how to provide care at lower levels safely. Maybe 50 years from now with better knowledge and medication we can do better for the long term chronically mentally ill.

For your case of a long term patient with no foreseeable outpatient care in their future, you do go back to triage. Try to stabilize immediate safety concerns, then focus on patient comfort. What medications help the most with the most disturbing delusions or psychotic symptoms? What meds do that while also providing the least amount of side effects? Does the pt like art, music, physical activity? What living arrangements can be made to provide an environment they don’t feel threatened by?

Also you can always try redirection with your pt who likes to hug. When they started to follow you did you try something like putting your hand up and saying hi five. Or sitting the patient down and try to explain to them hey I’m uncomfortable with hugs can we do a high five instead? Don’t assume someone will get aggressive automatically if they don’t get what they want, and you can always try these approaches in range of another staff member so you feel safer trying to address the issue. Never feel the need to justify your boundaries for safety and patient care and as always psych is a team effort. Have you tried asking colleagues what they do? I can’t imagine every single person on the unit who has ever worked with this person has been okay with hugs from this person.

 

[IMG69]

The nature of care and how it’s handled does change things. If it’s short term stabilization yes you focus on the red flags. If it’s long term acute care then yes you can focus on other things. My experience working on a locked forensic unit though has still always been you want to try and either stabilize them enough to stand trial in court or prove to a judge that they are no longer a danger to society and can have conditional releases to places like psychiatric nursing homes. There will be some patients however that will live their lives in a locked psychiatric ward because unfortunately they will always be a danger to society, and it’s just lack of knowledge on our part in how to provide care at lower levels safely. Maybe 50 years from now with better knowledge and medication we can do better for the long term chronically mentally ill.

For your case of a long term patient with no foreseeable outpatient care in their future, you do go back to triage. Try to stabilize immediate safety concerns, then focus on patient comfort. What medications help the most with the most disturbing delusions or psychotic symptoms? What meds do that while also providing the least amount of side effects? Does the pt like art, music, physical activity? What living arrangements can be made to provide an environment they don’t feel threatened by?

Also you can always try redirection with your pt who likes to hug. When they started to follow you did you try something like putting your hand up and saying hi five. Or sitting the patient down and try to explain to them hey I’m uncomfortable with hugs can we do a high five instead? Don’t assume someone will get aggressive automatically if they don’t get what they want, and you can always try these approaches in range of another staff member so you feel safer trying to address the issue. Never feel the need to justify your boundaries for safety and patient care and as always psych is a team effort. Have you tried asking colleagues what they do? I can’t imagine every single person on the unit who has ever worked with this person has been okay with hugs from this person.

Thanks a lot! Yeah this is a locked psych hospital. Haha I did high five the patient as well but then one of the nurses told me some disgusting stories about the patients and their hygiene 🤮. I haven't seen anyone not hug her so guess i'll wait till I do and see how they avoid it.

Thanks again, i'm sure this info also helped a lot of others, we're not really taught how to actually deal with these types of psych patients, so thanks a lot for your insight. I'm kind of grateful our school gives us exposure to these types of patients because 95% of us will probably never see patients of this magnitude again.

 

[Rapsidy]

Yeah hygiene can be a huge issue with these patients. But it’s better to do a high five or fist bump and wash your hands afterwards especially if your concern is hygiene and they want a hug!

Don’t feel bad about your abilities if you are out of your element, inpatient/acute psych, especially treatment resistant psych is not for everyone and has a high burnout rate. There is no shame in being uncomfortable and being apprehensive about how to do a good job. It boils down to we do the best we can and hope the future provides better alternatives. Use this time as a learning experience like you said and be okay with the idea that this population may not be your cup of tea.

 

[IMG69]

Lol I just want to survive the rotation tbh 😆 No but i'm just asking here because our psych is basically AWOL so I can't really ask anyone else about this stuff atm. Thanks again.

 

[Mad Jack]

Thanks a lot! Yeah this is a locked psych hospital. Haha I did high five the patient as well but then one of the nurses told me some disgusting stories about the patients and their hygiene 🤮. I haven't seen anyone not hug her so guess i'll wait till I do and see how they avoid it.

Thanks again, i'm sure this info also helped a lot of others, we're not really taught how to actually deal with these types of psych patients, so thanks a lot for your insight. I'm kind of grateful our school gives us exposure to these types of patients because 95% of us will probably never see patients of this magnitude again.

We've had patients that specificly would try to get people to touch their hands right after they had been masturbating in a manner that appeared to be for sexual gratification or some other weirdness. In psych, don't touch your patients unless you absolutely have to.

 

[IMG69]

We've had patients that specificly would try to get people to touch their hands right after they had been masturbating in a manner that appeared to be for sexual gratification or some other weirdness. In psych, don't touch your patients unless you absolutely have to.

Oh yes at the end of the day I was told basically this exact story except it was with objects and a student once picked up something thinking somebody had dropped it and they quickly rushed the student to wash her hands. Don't worry i've invested in 3 bottles of hand sanitizer 😆 but yes i'm trying for as minimal contact as possible. Was just the hugger which was a semi awkward situation.