The Bureau of Justice reports that 15% of persons in prison and 24% of persons in jail reported having thought disturbances. Psychotic patients have lost touch with reality and have unusual thought disturbances such as hallucinations and delusions. Thus, correctional nurses are likely to provide nursing care to psychotic patients during their career.  The most common psychotic disorder is schizophrenia, but patients can manifest any variety of psychotic symptoms without having this diagnosis.

Psychotic disorders can include both delusions and hallucinations. A delusion involves a false personal belief that the patient continues to believe even after proof to the contrary is provided. Here is a short list of common delusion types:

• Control: Belief that objects or persons have control over him. For example, the patient believes that the EKG machine in the closet is making his heart skip beats.
• Grandeur: An exaggerated sense of importance or power. This delusion can be combined with religiosity. For example, the patient believes that he is Jesus Christ.
• Persecution: Belief that others intend the patient harm. For example, the patient says he cannot be transferred to D Unit because every person there has tried to “take him out.”
• Reference: Irrational belief that all objects and actions refer to the patient. “All the articles in this magazine are talking about me in code.”
• Somatic: Delusions based on body function. A 65 year old woman saying “I know I am pregnant even though the physician says I am not.”

Labeling the delusion, however, is not as important as accurately describing what the patient is hearing and experiencing.

Hallucinations may be visual, auditory, or tactile. Visual hallucinations occur when the patient sees things that aren’t there. The hallucinations may be of objects, visual patterns, people, or lights. Auditory hallucinations most often involve hearing voices, but may also include hearing clicks, noises and music that is not there. Tactile hallucinations involve the physical feeling of something that is not there, like bugs crawling on the skin.

An earlier post discussed ruling out medical conditions that might cause psychiatric symptoms – particularly delirium, and the nurse should discuss this with a provider once the full patient evaluation is completed.  The nurse should anticipate that a referral to a mental health professional will be needed. Until the patient is seen by Mental Health, it is vitally important to keep the patient and others safe.

Determine Potential Harm to Self or Others

When a patient reports hearing voices, there may be multiple underlying causes, including auditory hallucinations and thoughts characterized erroneously as “voices.” Regardless, if a patient reports hearing voices, it is important to fully evaluate how this might affect the patient’s safety and the safety of those around him. Ask the patient what the voices are saying and attempt to get a full range of the content. If there is any indication that the voices instruct the patient to harm himself/herself/themselves, perform a full suicide evaluation and contact the provider or mental health clinician, if you have one at your facility. If the voices instruct the patient to harm others, the patient needs to be isolated from other incarcerated persons until there is a full mental health evaluation, the provider is informed and a treatment plan is in effect.

General suggestions for Working with Psychotic Patients

It can be challenging to handle a patient interaction with someone who is not in touch with reality. Here are a few things to consider when communicating with a patient exhibiting signs of psychosis:

• Avoid touching the patient without warning. Although we avoid touching anyway in corrections, touch does happen during physical assessment and the measuring of vital signs.
• Maintain an attitude of acceptance to encourage the patient to fully share the delusion or hallucination.
• Do not reinforce the hallucination. For example, refer to an auditory hallucination as “the voices you are hearing” rather than “they.”
• If a patient is hearing the hallucination in your presence, respond truthfully in an affirming tone, like “Even though the music is real to you, I don’t hear it.”
• Do not argue or deny a false belief. Instead, present a “reasonable doubt” position such as “I understand that you believe this, but I am personally having a hard time accepting it.”
• Avoid laughing, whispering, or talking quietly to other staff around the patient.
• Maintain an assertive, matter-of-fact, and genuine approach.

Therapy Options

Medication is usually not the only treatment for a psychotic condition, and more often the treatment plan will include some type of therapy such as behavioral therapy, group therapy, or individual psychotherapy in conjunction with medication.. 

Have you had a sick call episode with a patient hearing voices? Share your experience in the comments section of this post.