Hallucinations and Delusional Thoughts (Psychosis)

Definitions

• Psychosis is a serious condition that can affect individuals of all ages. It can occur with and be related to:
  • Substance use.
  • Traumatic brain injury.
  • Severe depression or bipolar disorder.
  • Schizophrenia.
  • Post-traumatic stress disorder (PTSD) or a history of traumatic experiences.
  • Medical conditions.
• The two symptoms of psychosis are hallucinations and delusions.
  • Hallucinations occur when a person has a sensory-based experience that others around her do not. They can be experienced as sights, sounds, feelings, tastes, or smells.
  • Delusions occur when a client expresses bizarre thoughts or beliefs that are inconsistent with her culture and seem unlikely or irrational, such as believing external forces are controlling her thoughts and behaviors, that she has special powers others do not, or that unrelated events are meant to send her a message.
• There are various factors that influence the development of psychosis, including:
  • Heredity/genetics.
  • Brain chemistry.
  • Brain structure.
  • Environmental factors.
  • Physical and chemical changes.
  • Mental health diagnoses.
• Initial symptoms of psychosis usually begin between the ages of 16 and 30. In very rare instances, psychosis has been recognized in children as young as five years old.
  Note: Having “imaginary friends” is a normal part of child development, unless the imaginary friend is provoking dangerous and unsafe behavior or is "telling" the child to self-harm or hurt others.

Some people with psychosis will feel suspicious of mental health providers. It is important that they know their personal information will be kept confidential. See Chapter B-4: Confidentiality and Release of Information.

Clients with psychosis and their caregivers or spouses will likely have questions about their symptoms. Provide clear and concrete information, and connect them with a medical professional or mental health professional for a formal assessment and diagnosis. Work with the caregiver or family to identify any needs they may have related to managing the client’s psychosis, being sure you have a Release of Information if needed.

Find out if the client has been evaluated for or prescribed medications for his psychosis.

Work with the client and his caregivers to gain a clear understanding of:

• How the client is being affected by psychosis.
• How his family is affected by his psychosis.
• The feelings and emotions the client and family have related to his psychosis.

Consider the client, family, and community’s cultural beliefs or traditions.

• Some things that appear to be caused by psychosis may be related to spirituality, such as the belief that their actions are being guided by a greater power.
• Consult with a traditional healer, practitioner, or elder.
• In all situations, ensuring the client's safety and the safety of others is essential.

Some people who have a psychotic experience will recover to their previous level of functioning, while others will have ongoing problems related to the psychosis.

Even with treatment, psychosis can interfere with adolescents' normal social and emotional development and can make new learning difficult.

People who experience psychosis are vulnerable to using substances to cope with their symptoms. Without the appropriate diagnosis and treatment, they are at risk of developing problematic substance use patterns. See Chapter E-2: Co-occurring Disorders.

Individuals who are experiencing psychosis are at high risk for attempting suicide.

Referral information, including reports from medical providers, school staff, clinicians, or other sources regarding the client's wellbeing.

Releases of Information (ROIs)that are current or updated before getting information about the client from other sources.

Client history, related to sensory functioning, development, psychological history, medication, harming the self or others, and onset ofsymptoms.

Treatment Plan, including a history of the presenting problem and recommended course of treatment. Review the DSM-5 for criteria on Schizophrenia.

General Concerns

• Threatens harm to himself or others
• Has thoughts of suicide
  Note: If you suspect the client is at risk for suicide, see Chapter D-6: Suicidal Thoughts and Plans.
• History of mental health problems
• Aggressive or impulsive behaviors
• History of trauma, abuse, neglect, or bullying
• Limited coping skills or skills for regulating emotions
• Speaks in a way that cannot be understood
• Risk of being harmed by people who don't understand his illness

Sensory-based experiences (i.e., hallucinations)

• Hears voices that are degrading or self-deprecating
• Hears voices that tell her what to do
• Hears voices or sounds that others do not
• Sees or experiences differences in light or color or sees spots
• Sees people, animals, or other animate objects that others do not
• Feels things on her body that cannot be seen
• Smells things that are not associated with things in her environment
• Tastes things that have not been ingested

Bizarre thoughts or beliefs (i.e., delusions)

• Confused thinking
• Loose associations (the client responds to your questions with unrelated answers)
• Not oriented to reality, e.g., able to tell you her name, where she is, what the full date is, and what the current situation is
• Disorganized thoughts
• Disconnected from surroundings
• Fixed false beliefs
• Believing that someone is out to get her

Emotions/mood

• Sudden, angry outbursts
• Emotional responses that don’t fit what is going on (such as being happy when others would be sad)
• Loss of the ability to experience enjoyment

Behavioral concerns

• Withdrawal from usual social and family activities
• Withdrawal from reality
• Does not attend to personal cleanliness and grooming
• Unusual physical activity, such as rocking back and forth or pacing (aimless walking)
• Major change in sleep patterns
• Talks or laughs to himself

Sensory-based concerns. Do you ever:

• See things that you know are not really there?
• Think that everyday things look abnormal?
• Hear sounds or noises that others do not?
• Smell odors that others do not?
• Feel things on your body that you cannot see?
• Hear voices, even though no one is near you?
  • Do these voices ever talk to you?
  • Do these voices talk about you?
  • Do these voices tell you what to do?

Patterns of psychosis

• What happens when you have these experiences?
• How do you respond to these experiences?
• Do these experiences happen at certain times of the day or during certain activities?
• When was the last time you had an experience like this? How long did it last?
• Is there anything you have found helpful in making these symptoms go away?
• Is it possible that any of these experiences are due to your use of alcohol or other substances (including over-the-counter or prescription medication)?
• Has anyone ever expressed concern about these symptoms?

Routinely review Chapter C-4: BHA/P Services and Common Interventions for how to prepare for and conduct interventions during appointments and for information on the levels of service available throughout Alaska.

As a BHA/P, be aware that clients who are experiencing symptoms of psychosis could act in an unpredictable manner. As such, it is important for you to be aware of your organization's policies and procedures for managing high-risk situations. If the client does not have a documented history of experiencing hallucinations or delusions, contact your clinical supervisor and/or the client's clinician as soon as possible to update them and discuss scheduling an assessment.

Typically, people who experience chronic symptoms of psychosis are prescribed antipsychotic medication to help manage the symptoms. However, people taking these medications might still experience symptoms of psychosis or unpleasant side effects related to the medication. Certain therapy protocols have been shown to be effective in treating these symptoms. One specific approach is called Cognitive Behavioral Therapy for Psychosis (CBTp). Consult with your supervisor on specific strategies that they would like you to use with the client. In addition to specific interventions identified by their clinician, here are some general approaches that can be helpful:

• Because symptoms of psychosis can become worse or more acute if the individual is inactive and isolated, work with the client to increase activity levels by scheduling simple activities. This gives your client something to focus on other than the symptoms.
• For individuals who experience psychosis, social engagement can feel challenging; however, it can be useful as a method of coping. Encouraging social interactions should be done carefully and should include a plan for someone to be present who can help the person respond to overwhelming social situations.
• Help your clients develop coping strategies by:
  • Identifying healthy social supports that they can contact as needed. Consider writing down their names and contact information so this resource is easily accessible.
  • Documenting what has been helpful for them in the past and working with them to develop a safety plan or a plan for getting support when they experience symptoms.
  • Working with them to practice coping strategies regularly.
  • Supporting them via medication management techniques, including checking in with them regularly about whether or not they are taking their medications as prescribed, using motivational interviewing to encourage them to take their medications as prescribed, and making a referral to a medical professional if there are concerns about the client taking their medication as prescribed.
• If the client is referred for an assessment that may result in a civil commitment, take time to explain to them the importance and value of having a higher level of care to help them manage their symptoms. If possible, work with the referring clinicians and referral agency to make sure you are involved in the client's discharge plan and continued care once they've been discharged.

Be sure you are familiar with the information in Mandatory Reporting and Duty to Warn and Documentation and Billing. Report instances of the following, consistent with your organization's policies and procedures:

• Child abuse or neglect.
• Suicidal thoughts or plans.
• Intentions to cause harm or injury to the self or others.
• Referral for an assessment related to involuntary commitment