Our patient simulation today was a women who came in for a blood pressure check. Quickly after the encounter started she mentioned that she stopped taking her meds. The patient eventually revealed that she was diagnosed with schizophrenia at a young age. She sees the things on her medications and believes it will harm her through her pills and food, therefore she has stopped taking her medications and eating. She was told most of this information from another hallucination. Now, I only stated that information so that you could understand these lessons learned.
After this encounter we learned more than a few things about general psych patient interactions:
1. When a patient is hearing voices, go along with what they are saying. You need to gain the patient's trust, and in order to do that, you need to believe what they are saying. If a patient is hearing voices, you cannot tell them that "its all in their head" this creates unnecessary tension between the provider and patient. Most of their friends and family are probably telling them that same thing and another person will not help them get better. The patient is genuinely hearing things, they are not making it up, and as a provider you need to acknowledge that you believe them. One of the providers who interacted with her asked where the voices were coming from and she pointed to a vent on the ceiling. Later he asked for her medication list but the patient stated that the devils did not want him to have it. He said that he would hide it so that they could not see it. She agreed. Reaching in her purse she pulled out a black box wrapped with rubber bands. The provider put his hand over the box so that the devils could not get to it. Once she took the list out she handed it to him and he turned his back to the devils in order to read the list. This may seem silly but to the patient, this was very nice and showed that he believed her. This act helped develop trust with the patient.
2. Once you develop this baseline you need to constantly reassure the patient that they are safe. In this case you can tell the patient "no one is going to hurt you while you are here" "we will protect you" "you can tell me things while you are here in the office, you are safe, I won't let anyone hurt you here." Even as the patient encounter continues, the patient will start to withhold information because they fear something bad will happen if they tell you. Many times voices that the patient hears are telling them not to disclose certain information. In cases where you sense the patient is starting to fear releasing information or start to get anxious, reassure them that they are safe.
3. Do not press for information that the patient really does not want to reveal. For example, we asked about the patient's parents but she stated that the devils did not want her to tell us. When we asked again in another form she seemed to get more upset and state that she could not tell us. In this case, we were not going to get this information today. Maybe after she is medicated and feeling better she will tell us, but until then we do not necessarily need to know this information to treat her and it is not worth destroying trust that we developed during this visit.
4. Sometimes requests by the patient will seem strange, but if possible, these requests can be met. In this case, the patient requested that her meds and food be wrapped in plastic in order to prevent the devil from poisoning her. As a provider we could order that her pills must be from a blister pack that is opened in front of her before administering her meds. We could also request that they wrap her food in plastic at the house she was staying at.
5. Medications never treat these patients 100%. The voices can be muffled but never fully go away. This is part of the problem as to why she stopped taking her medications that were helping her. She started to hear voices that she could understand telling her to stop taking them. In this case maybe she needs a higher or lower dose of her medication to muffle the voices enough so that they are just sounds and not understood. To treat this patient in the best way, she needs to be carefully watched at her home to make sure that we know as soon as she starts to hear the voices again and can treat her sooner rather than later.
There were many other things we learned about psych patients with schizophrenia today that could fill this entire blog, but overall we learned patience, compassion, trust and creativity. We have to listen to these patients, show them care, develop trust and think of new ways to get them to work with us in order to make them feel better.
*the patient actor in this case was unbelievably amazing and so realistic it was very easy to forget that she was an actress.