A 22-year-old college student is brought to the emergency department by his roommates, who say that he has been acting bizarrely for the last 2 months and "is only getting worse." He refuses to leave the house and has put aluminum foil over his windows. The only way his friends could get the patient out of the house today was by threatening to call the police if he did not cooperate. They estimate that it has been 2 weeks since his last shower. He will not eat anything that is not prepackaged. The patient has no known medical or psychiatric history. He does not use alcohol or illicit drugs. Physical examination is unremarkable. On mental status examination, the patient is disheveled and malodorous. He sits quietly on the bed, smiles, and periodically laughs inappropriately. He looks down at the floor and avoids eye contact with the physician. During questioning, he says that his professors are trying to prevent him from graduating. He is unsure why they do not want him to graduate but says that they are sending him "telepathic" messages encouraging him not to attend class. The patient now thinks that his professors have convinced his friends to "join in their plot." He whispers, "The nurse at the front desk is in on it too." Which of the following would be the most effective approach to forming an initial therapeutic alliance with this patient?

Question

A 22-year-old college student is brought to the emergency department by his roommates, who say that he has been acting bizarrely for the last 2 months and "is only getting worse."  He refuses to leave the house and has put aluminum foil over his windows.  The only way his friends could get the patient out of the house today was by threatening to call the police if he did not cooperate.  They estimate that it has been 2 weeks since his last shower.  He will not eat anything that is not prepackaged.  The patient has no known medical or psychiatric history.  He does not use alcohol or illicit drugs.  Physical examination is unremarkable.  On mental status examination, the patient is disheveled and malodorous.  He sits quietly on the bed, smiles, and periodically laughs inappropriately.  He looks down at the floor and avoids eye contact with the physician.  During questioning, he says that his professors are trying to prevent him from graduating.  He is unsure why they do not want him to graduate but says that they are sending him "telepathic" messages encouraging him not to attend class.  The patient now thinks that his professors have convinced his friends to "join in their plot."  He whispers, "The nurse at the front desk is in on it too."  Which of the following would be the most effective approach to forming an initial therapeutic alliance with this patient?

Quizplus · Accepted Answer

Explanation: This patient's paranoid delusions, bizarre behavior and affect, and deteriorating self-care are suggestive of a psychotic disorder. He is acutely psychotic and has no insight into his illness. He is incorporating caregivers into his paranoid delusional system as demonstrated by his belief that the nurse is part of a plot against him. This patient is likely to distrust the physician as well, and initial interactions can be critical to his subsequent cooperation with the evaluation and willingness to accept treatment. The most effective approach to developing a therapeutic alliance with an acutely psychotic patient is to respect the patient's interpersonal distance and to avoid challenging the patient's delusions. Efforts to engage a paranoid patient by being overly warm and friendly are unlikely to be effective. The physician should attempt to understand what this patient is experiencing from his perspective without either endorsing or disputing the irrational beliefs. (Choice A) Unconditional warmth and friendliness at all times are likely to be perceived as suspicious by a paranoid patient and may intensify paranoia and hostility. (Choice B) Confronting a psychotic patient's irrational beliefs is generally not advised, especially during initial interactions. Doing so would likely diminish the patient's willingness to provide additional information and exacerbate his paranoia and could place the physician or others at risk of violence, depending on the patient's condition. (Choice C) Over time and with antipsychotic treatment, it may be possible to gain the patient's trust. However, initially attempting to persuade the patient to be more trusting and open-minded is likely to inhibit a therapeutic alliance. The patient is likely to sense that medical professionals do not believe him and therefore cannot be trusted. (Choice D) Interpretation is a technique used in psychoanalytic psychotherapy with nonpsychotic patients. Patients with acute psychosis are not candidates for this approach, and it would not be appropriate in the emergency setting. Educational objective: The initial approach to the acutely psychotic patient with no insight should involve maintaining interpersonal distance and attempting to understand the patient's experience without challenging the patient's delusions. References: Treatment engagement of individuals experiencing mental illness: review and update. (http://www.ncbi.nlm.nih.gov/pubmed/26833597)

A 22-Year-Old College Student Is Brought to the Emergency Department