Mental Health Nursing

open access articles on mental health nursing

Nursing Management of Delusions and Hallucinations

Outline

• Hallucinations
• Delusions
• Treatment
• Understanding levels of intensity
• Steps in Management
• Strategies
• Nurses' responsibility
• Summary
• References

Hallucinations

• Perceptual distortions arising from any of the five senses.
• "A false perception, which is not a sensory distortion or misinterpretations but which occurs as the same time as real perceptions" - (Jaspers)
• Dreams and mental images differ from hallucinations and are often Incomplete, dependent on will, can be recreated.
• Pseudo-hallucinations -  an involuntary sensory experience vivid enough to be regarded as a hallucination, but recognised by the patient not to be the result of external stimuli.

Causes of hallucinations

• Intense emotions.
• Depression
• Words or short phrases-”kill yourself”
• Suggestions
• Hypnosis
• Motivating instructions
• Disorders of sense organs.
• Glaucoma
• Geriatric clients
• Sensory deprivations.
• Repetitive words and phrases.
• Black patch disease.
• Disorders of CNS.
• Lesions on diencephalon and cortex
  • Usually visual.
• Hypnogogic and Hypnopompic
• Organic hallucinations
• Auditory or visual .

Auditory hallucinations

• Elementary or partially or completely organized voices.
• Stimulation of temporal areas.
• Vary in quality ,content.
• Thought echo, second person or third person.
• May be imperative.

Visual hallucinations

• Elementary or partially or completely organized
• Most common in acute organic states
• Extremely rare in schizophrenia.
• sees small animals most often in delirium.
• Often isolated from auditory hallucinations.
• In temporal lobe epilepsy may be experiential.
• Lilliputian hallucinations frequently occur.

Olfactory hallucinations

• Schizophrenics, organic states, temporal lobe epilepsy.
• Uncommon in depressives.

Taste hallucinations

• finds in schizophrenics, organic states.
• can be experienced in Parietal cortex stimulation.

Tactile hallucinations

• finds in Organic states.
• “Cocaine bug.”
• Wind, heat, electrical or sexual sensations.

Special kinds of hallucinations

• Reflex hallucinations
• Extracampine hallucinations
• Autoscopy or phantom mirror image
• Epilepsy ,focal lesions, toxic infective stages
• Parietal lobe disorders
• Negative autoscopy
• Internal autoscopy

Delusions

• False unshakable belief which is out of keeping with the patients social and cultural background.
• Primary delusions.
• Secondary delusions.

Primary delusions

• A new meaning arises not in connection with other psychopathological event and is not understandable.       
• Delusional mood: has knowledge of something going on around him but do not know what it is.
• Delusional perception: attribution of new meaning to a normally perceived object.
• Delusional idea: delusion appears fully formed in the mind.

Secondary delusions

• A delusion which is understandable in terms of persons cultural background or emotional state.

Content of delusions

• Delusions of persecution
  • Persons or groups.
  • About to be killed or being tortured.
  • Being robbed of property or knowledge.
  • Of being poisoned or infected.
• Delusions of reference.
• Delusions of influence.
• Delusions of jealousy.
• Infidelity- seen in brain disease, alcohol addiction, affective psychoses and can be dangerous, may attempt murder.
• Delusions of love.
• Erotomania: may try to follow, contact or persuade.
• Grandiose delusions.
  • Schizophrenia, drug dependence ,organic brain syndromes, mania (jocular and haughty).
  • Regarding worth, talent, knowledge or power.
• Delusions of ill health
  • Depressive illness, schizophrenia.
  • Could be extended to cover persecutory delusions.
• Hypochondriacal delusions.
  • Some physical defect, disorder or incurable diseases.
  • Infestations, ugly or dysfunctional body parts
  • May include spouse or children.
  • Result of somatic hallucinations in schizophrenia.
• Delusions of guilt
  • Unpardonable sin.
  • Can give rise to persecutory delusions.
  • Lead to suicide.
• Nihilistic delusions .
  • Denies the existence of body, mind, loved ones or the whole world.
  • Very agitated depression, delirium, schizophrenia.
• Delusions of poverty- Destitution is facing him and family.
• Delusional misidentification.
• Capgras syndrome.
• Religious delusions- Can be grandiose  in nature.
• Delusions of control.

Treatment

• Antipsychotics
  • Typical
  • Atypical
  • Sedatives / hypnotics

Understanding levels of intensity Stage 1

• Moderate anxiety.
• Usually pleasant.
• Inappropriate grinning, moving lips, silent and preoccupied.

Stage 2

• Repulsive content.
• Autonomic signs.
• Poor attention span.
• Lose ability to differentiate from reality.

Stage 3

• Severe anxiety.
• Directions will be followed.
• Physical symptoms of severe anxiety.

Stage 4

• Panic stage.
• Terror stricken behaviors.
• Potential for homicide or suicide.
• Physical activity reflects content of hallucination.

Management

Goal of Management

• Help to increase awareness of the symptoms to distinguish the reality.

Steps

• Facilitative communication.
• Observation and listening.
• Can talk about hallucination to know about the level of symptoms.
• Talking about hallucination is reassuring and self validating for the patient.
• If left alone, it will overwhelm coping resources.
• Interactive discussions are very helpful.
• Communicate right at the time of hallucination.
• Modulation of sensory stimulation.

Principles

• Eye contact.
• Speak simply but slightly louder.
• Call by name.
• Use touch.

Strategies

• Establish trusting IPR.
• Calm, patient, acceptance, active listening.
• Asses for symptoms duration, intensity and frequency.
• Observe for behavioral clues.
• Help to record number of hallucinations.
• Focus on symptoms and help to describe the happening.
• Empower by helping to understand.
• Help to control over hallucinations.
• Identify whether drugs or alcohol have been used.
• If asked, point out that you are not experiencing same stimuli.
• Do not argue.
• Suggest and reinforce use of interpersonal relationships as a symptom management technique.
• Encourage to talk.
• Help to mobilize social support.
• Help to describe and compare current and past hallucinations.
• Determine the pattern if any.
• Encourage to remember when it began first.
• Pay attention to the content may helpful in predicting the behavior.
• Alert for commanding hallucinations.
• Determine the impact of the patients symptoms on ADL.
• Provide feedback on coping responses.
• Help to recognize symptom triggers and management strategies.
• Place delusion in a time frame and identify triggers.
• Identify all the components , triggers related to stress or anxiety.
• If related with anxiety, teach anxiety management skills.
• Develop symptom management program.
• Assess intensity frequency and duration
• Fleeting delusions can be worked out in a short time frame.
• Listen quietly until need to discuss.
• Identify emotional components.
• Respond to the underlying feeling.
• Encourage discussions with out assuming right or wrong.
• Observe for evidence of concrete thinking.
  • Is patient and nurse using language in the same way.
  • Is patient takes you literally.
• Observe speech for symptoms of a thought disorder.
  • May not be a time for discrepancy.
• Observe ability to use cause and effect relationship.
  • Is patient making logical predictions based on past experiences.
  • Is patient conceptualizes time.
  • Is patient using recent or remote memory meaning fully.
• Distinguish between description and facts of the situation.
  • Identify false situations.
  • Promote the ability to test reality.
  • Determine hallucinations.
  • Carefully question the facts as they are presented and their meaning.
  • To be done after previous steps.
  • Discuss consequences when the person is ready.
  • Allow to take responsibility of own action.
• Encourage personal responsibility in wellness and recovery.
• Promote distraction as a way to stop focusing on delusions.
• Promote physical activities.
• Recognize and reinforce healthy and positive aspects of personality.

Nurses responsibility

• Don’t argue or reject.
• Try to keep them engaged.
• Encourage to practice some relaxation techniques.
• Use distractions, exercising, hobbies, saying stop.
• Calming by a glass of water or counting.
• Be tactful in approach.
• Do not express approval.
• Acknowledge feelings or fear.
• Reassure and encourage.
• Explain clearly what you are doing and why.
• Maintain consistency.
• Keep communication open and non judgmental.
• Listen understand and respect their feelings.

.References

1. Stuart GW, Lararia MT. Principles and practices of psychiatric nursing (8th edn) Mosby publications; Missouri, 2005.
2. Hamilton M. Fish's clinical psychopathology (2nd edn) Varghese Publications; Bombay ,1994.

This page was last updated on: 18/12/2020

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