A 33-year-old man is hospitalized after he was found by his mother rocking back and forth on the floor of his room, repeatedly saying, "I deserve to die." The patient has a history of schizophrenia since his early twenties and lives with his parents. His antipsychotic medication was recently switched to aripiprazole due to poor response to quetiapine. The patient has no other medical history. He does not use alcohol or illicit drugs. Physical examination is unremarkable. On mental status examination, the patient is fearful and agitated. He appears to be responding to internal stimuli and says the devil's voice is saying, "Why don't you kill yourself." The patient asks the physician, "Don't you hear the devil?" Which of the following is the most appropriate response to this patient?

Question

A 33-year-old man is hospitalized after he was found by his mother rocking back and forth on the floor of his room, repeatedly saying, "I deserve to die."  The patient has a history of schizophrenia since his early twenties and lives with his parents.  His antipsychotic medication was recently switched to aripiprazole due to poor response to quetiapine.  The patient has no other medical history.  He does not use alcohol or illicit drugs.  Physical examination is unremarkable.  On mental status examination, the patient is fearful and agitated.  He appears to be responding to internal stimuli and says the devil's voice is saying, "Why don't you kill yourself."  The patient asks the physician, "Don't you hear the devil?"  Which of the following is the most appropriate response to this patient?

Quizplus · Accepted Answer

This patient is acutely psychotic and actively responding to auditory hallucinations. He has no insight that what he is experiencing is due to his psychiatric illness and believes that the devil's voice is audible to others. From the patient's perspective, the voices are very real and extremely frightening. The most effective approach to developing a therapeutic alliance with an acutely psychotic patient is to empathize with how the patient is feeling without reinforcing or challenging the patient's psychotic beliefs. In this situation, it would be appropriate to acknowledge that although the physician does not hear the voice, the patient's experiences are real and frightening for him. It is counterproductive to tell the patient that the voices are not real or due to a psychiatric illness when he has no insight. Challenging patients' psychotic beliefs prematurely can have the detrimental effect of creating distrust and possibly interfering with their willingness to cooperate and accept treatment. (Choices A and B) Challenging the reality of the patient's experience by attributing symptoms to an illness that can be helped only with medication is likely to cause the physician-patient relationship to deteriorate. Initial interactions can be especially critical for a patient's subsequent cooperation with the evaluation and willingness to accept and adhere to antipsychotic treatment. (Choice D) Although it is important to perform a safety assessment, asking an acutely psychotic patient with impaired judgment to make a commitment to safety is both inadequate and potentially dangerous. If the patient is at high risk for self-harm, one-to-one observation may be necessary. (Choice E) The suggestion to ignore the voices is likely to be ineffective as the patient has no insight at this point. Practical behavioral strategies (eg, engaging in a distracting activity) can be beneficial once patients have developed some insight into their condition and have some ability to recognize the voices as a symptom of their illness. Educational objective: The initial approach to acutely psychotic patients is to acknowledge their experience without reinforcing or disputing their beliefs. Challenging psychotic beliefs prematurely can create distrust and interfere with patients' willingness to accept treatment. References: Treatment engagement of individuals experiencing mental illness: review and update. (http://www.ncbi.nlm.nih.gov/pubmed/26833597)

A 33-Year-Old Man Is Hospitalized After He Was Found by His