When/If to challenge a delusion?

[winchester1615]

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Hello,

I would really appreciate your input regarding a case I saw today. Pt was seen in the ER and was being held for observation. Pt had a delusion that his family had been murdered by people who were now after him. Pt was very anxious regarding his delusion, crying for his dead wife, etc. We spoke with several family members for collateral regarding the pt.

Is it appropriate or helpful to say to this pt, who is very agitated, that we spoke to the pt's wife/mother/etc and they are fine? It is a challenge to his delusion, but it is also (presumably) reassuring. When (if at all) do you challenge a pt's delusions?

Thank you!

 

[whopper]

I'd say so, as long as its honest. If anything it can help to calm the patient down. You could also offer to arrange for a phone call (if the patient can be trusted not to attack anyone with a phone receiver).

Delusions such be challenged in a diplomatic manner, and you should offer the patient common sense easy to understand information that shows to them that their delusion is not true.

 

[Solideliquid]

Did you admit the patient? I'm not sure I would confront a delusion such as this. Especially if the patient is showing a high level of agitation, I would admit and offer medication.

 

[AF_PedsBoy]

Don't do it - I did two rotations on the lockdown psych ward (for some reason they always put me there...); most times it won't be harmful, per se, but the nature of a delusion is that it's not a logical thought, therefore you can't talk them out of it (i.e. my patient who thought he was an alien with no internal organs and his family are imposters who killed his real family). In fact think of them trying to convince you that what they believe is true -not really working, is it? And then of course there's the rare case where you push them over the edge... Of course that's for medical students and us non-Psychiatry residents - I let them headshrinkers do their thing, God bless 'em!

 

[Therapist4Chnge]

Get them stable first (whatever that entails...meds, etc). Dealing with a person in an agitated state leaves many variables unknown. The last thing you want to do is escalate that person, and often times people who are delusional will escalate if challenged, even if you have the best of intentions. Sometimes a mole hill is just a mole hill, but if it ends up being a mountain, then you will have a larger issue. It is best to address those needs when they aren't in crisis and/or when you have a bit more control over the situation and/or a bit more information.

-t

 

[Anasazi23]

It is rarely useful or indicated to challenge delusions that are in the context of acute psychosis or in a chronic delusional disorder. In an inpatient setting where close observation and daily interviews are conducted, the psychiatrist can foster a better alliance by telling the patient that they can see how they would be distressed by these thoughts or beliefs, and allow medication to take hold.

When the medication is effective, you'll notice less spontaneous mentioning of the delusion, or a "softening" of it. (i.e. Yes, the neighbors are still stealing my mail, but they don't do it as often, or they only take the junk mail out of the mailbox," or a recent example I had after putting a chronic delusional d/o patient on a typical after years of unsuccessful tx: "Well doc, they still break into my apartment when I'm not home, even though I bought that $1000 Israeli lock, but son of a gun...when I leave the apartment, they put all the things they stole from the previous few days back where they belong."

Again, in the context of acute psychosis, one may see a complete resolution of the delusional idea. However, in more chronic states, the delusion is often what they call entrenched, and will likely never resolve completely. The latter cases are notoriously difficult to treat. So-called monosymptomatic delusions were thought at one time to repsond better to low dose typicals, particulary pimozide (Orap). Wizened attendings seem to have different approaches and strategies for treating these types of patients. Get to know them, try them for yourself and add the results to your internal database. 🙂