Help! I’m Not a Mental Health Nurse! Part II: My Patient is Hearing Voices

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

Melinda is conducting nursing sick call in a local jail. Her next patient submitted a slip indicating right ankle pain. She interviews the patient; asking about the initiation, duration, and quality of the pain while examining the patient’s ankle. The patient explains that he hears voices at night talking about the tracking device implanted in his ankle. When it is turned on he gets a sharp pain that lasts for about 20 minutes. He knows that his movements are being tracked by the government. This patient has been in the jail for 5 days. The initial screening form only indicates that the patient is not suicidal and has no history of medical or mental health treatment.

Auditory hallucinations are one of the most common types of psychiatric symptoms. Most often these false perceptions manifest as voices but they can also be clicks, music, or other sounds. Like this patient’s presentation, psychotic disorders can include both hallucinations and delusions. A delusion involves a false personal belief that the patient continues to believe even after proof to the contrary. Here is a short list of common delusion types:

• Control: Belief that objects or persons have control over him. This patient has a control delusion.
• Grandeur: An exaggerated sense of importance or power. This delusion can be combined with religiosity. (“I am Jesus Christ”).
• Persecution: Belief that others intend the patient harm. This patient also expresses a persecution-type delusion.
• 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 Dr. says I am not.”

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

An earlier post discussed ruling out medical conditions that might cause psychiatric symptoms – particularly delirium. Melinda plans to discuss this with the on-call physician once she has gathered all the data. She knows this patient will likely need a referral to a mental health professional. The mental health nurse practitioner sees patients two afternoons a week. She won’t be in until tomorrow afternoon, though, so what should Melinda do to help this patient right now?

Subjective and Objective Findings

Melinda still needs to perform a physical assessment and document subjective and objective findings. Although it is unlikely that the patient has a tracking device implanted in his ankle, he may actually be feeling pain and may have an injury.  Always fully evaluate a patient concern.

In addition, exposure to medications or drugs and medical conditions such as hepatic disease or electrolyte imbalance can cause psychotic symptoms. There is little known about this patient’s history. Melinda may be able to obtain helpful background information from the patient or, if available, the patient’s family.

Determine Harm to Self or Others

When a patient reports hearing voices, the underlying cause can be variable: auditory hallucinations, thoughts characterized erroneously as “voices,” or an indicator of malingering. 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, perform a full suicide evaluation. If the voices instruct the patient to harm others the patient needs to be isolated from other inmates until there is a full mental health evaluation and therapy is active.

General Tips for Working with Psychotic Patients

It can be challenging to handle a patient interaction with someone who is not in touch with reality. There are a few things that Melinda was keeping in mind when communicating with this patient.

• Avoid touching the patient without warning. Although we avoid touching anyway in corrections, touch happens during assessment and vital sign readings.
• 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’ rather than ‘they’.
• If appropriate, as when a patient is hearing the hallucination in your presence, respond truthfully in an affirming tone. Such as “Even though the voices are real to you, I do not hear them.”
• 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

Once Melinda fully evaluated the patient she contacted his mother who was indicated on the intake form as an emergency contact. With the patient’s permission, she asked his mother about his prior medical history and discovered that the patient had, indeed, been under psychiatric care in the past and had been taking Risperdal (risperidone). The patient had left home several months ago and his mother was no longer able to encourage compliance.

Armed with this information, the on-call provider was contacted and an order was obtained for this medication. Risperidone is an atypical antipsychotic agent (also called second generation) often prescribed for schizophrenia. Other drugs in this class include Clozapine (Clozaril), Olanzapine (Zyprexa, and Quetiapine (Seraquel).

Medication is not the total answer for a psychotic condition and this patient will likely need some type of therapy such as behavioral therapy, group therapy, or individual psychotherapy. Unfortunately, many settings like Melinda’s have limited resources for these mental health services.

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

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