A 23-year-old man comes to the emergency department declaring that police helicopters have followed him for the past year. The patient is convinced that their surveillance lasers are damaging his sperm. He says that the lasers have caused burns on his stomach and a low sperm count. As evidence, the patient points to an area of slight discoloration that looks like a birthmark on his lower abdomen. He has contacted an officer in charge of internal affairs who is investigating his charge of police brutality. The patient has a history of 2 prior psychiatric hospitalizations. His psychosis rapidly improves during hospitalization, but following discharge he stops taking his medication. The patient says, "I used to have schizophrenia, but now I'm cured." He is highly anxious and frequently gets up to pace and look out the window. After describing his fears, he asks if the physician believes him. Which of the following is the best response to the patient?
Effective communication with psychotic patients requires assessment of their level of insight. This patient is acutely psychotic, does not believe he has a psychiatric illness, and has no insight that his fears are delusional. Although a clinician should never lie or make statements affirming a delusion, the outright rebuttal of the patient's beliefs or labeling them as symptoms of an illness is likely to damage the physician-patient relationship and jeopardize adherence to treatment.
The best approach to the psychotic patient with no insight is a nonjudgmental stance that acknowledges the patient's experience and perspective without endorsing specific delusions or hallucinations. After a physician-patient relationship is established and the patient's psychosis begins to improve, it may be appropriate to assist the patient in distinguishing delusional thoughts from reality.
(Choice B) This response suggests that the patient's concerns are reasonable. Physicians should avoid reinforcing psychotic beliefs while working to establish rapport and open communication.
(Choices C, D, E, and F) These statements fail to acknowledge the patient's total lack of insight. Disputing the patient's paranoid delusions or labeling his experiences as symptoms of an illness is unlikely to be effective in his acutely psychotic state and may lead to further agitation. The priority is to acknowledge the patient's distress and establish rapport so he is more likely to be receptive to treatment.
Educational objective:
Acutely psychotic patients with no insight are unable to determine that their psychotic experiences are not real. To build rapport, it is important to acknowledge the patient's experience and distress without endorsing specific delusions or hallucinations.