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Nursing Management of Delusions and Hallucinations
This page was last updated on September 19, 2013

Outline

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.
   
 
     
     

 
 
 
 
 
             
 

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