Handling Disruptive Behaviors

Emily Fleischman, PT, DPT, GCS

January 29, 2020

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Question

How do you handle disruptive behaviors of hallucinations and delusions? 

Answer

With hallucinations, you might notice the patient talking to themselves in a conversational or emotional way. They may laugh, smile or frown for no apparent reason and appear to see something that you can't see yourself in the room. In these situations, you want to ask if they saw or heard something. Ask how they feel about the situation because you're trying to find out if they are distressed by it. 

You can also briefly discuss the possibility that the experience is a symptom or hallucination. One way I'll ask this question sometimes is, do you ever hear see things that other people don't hear or see? A lady I was seeing said, "There's something in the room, "but when I look, I can't see it." I asked, "do you think it's possible that you're experiencing that because of the medication you're on and how sick you are in the hospital"? The patient stated, "Yeah, yeah, I know. It's definitely because I'm in the hospital." So that is normalizing it and noting, okay, are we all on the same page. 

You don't want to act shocked or alarmed. It will worsen the situation. You also don't want to tell them it's not real or just casually dismiss it. You don't want to tell them it's not important because this is an expression of their reality at the moment. This is what they're experiencing. So telling them it's not real is not exactly helpful. You don't want to enter a lengthy discussion about the hallucination either. We don't want to dwell on it. A couple of brief questions just to kind of find out what's going on so you can pass this on to the nurse and the medical team is helpful.

For patients that are discussing delusions with you, you should listen neutrally.  Be calm and respectful to them. You should lead the conversation away from the delusional contact. You don't want to dwell on it. For example, I had a patient with a delusion that he founded the hospital I work in. He would bring it up a lot. So he'd always be like, "Well, when I founded this hospital." You should just move the conversation away from it. You don't argue with them about it but talk about something else. If he or she insists on discussing it you should be very clear with, we're going to talk about something else. We're gonna focus on the thing we're working on right now instead. If they really insist on discussing it with you instead of just mentioning it, you can say you don't know. You can explicitly just acknowledge that's the reality and explain that there's a difference in perception between the two of you. But again, after every time you're making a statement, coming back to let's focus on the thing at hand.

You don't want to try to convince or argue someone out of their delusion. Once again, this is a symptom. It's not your role or helpful to have you try to argue with somebody about what's going on. You also don't want to question or discuss the delusion in great detail. For example, back to that patient that was saying, that he founded the hospital you work at. I'm not gonna go state to him that the hospital was founded 100 years ago and that he is thirty-five years old. That's not helpful. We're not getting into a debate about his delusion. It's a symptom of his illness.


emily fleischman

Emily Fleischman, PT, DPT, GCS

Emily Fleischman is a practicing physical therapist at Stanford Health Care in Palo Alto, CA. She has worked with varied populations in the acute care setting including inpatient psychiatry, cardiac, trauma, and neurology. She earned her DPT at Samuel Merritt University in Oakland, CA and became a Geriatric Clinical Specialist in 2018 


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