Key Takeaways
- Hallucinations are sensory perceptions without external stimuli; auditory hallucinations are most common in schizophrenia
- Never argue with delusions or reinforce hallucinations; acknowledge the client's experience while presenting reality
- When responding to hallucinations, say "I don't hear the voices, but I can see that you are frightened by them"
- Command hallucinations that tell the client to harm themselves or others require immediate safety intervention
- Positive symptoms (hallucinations, delusions) respond better to antipsychotic medications than negative symptoms (flat affect, social withdrawal)
Schizophrenia: Hallucinations and Delusions
Schizophrenia is a severe mental illness characterized by psychosis (loss of contact with reality). The NCLEX tests your ability to recognize symptoms and respond therapeutically to clients experiencing hallucinations and delusions.
Understanding Schizophrenia
Schizophrenia affects approximately 1% of the global population. Symptoms are categorized as positive (additions to normal experience) or negative (subtractions from normal functioning).
Positive Symptoms
Positive symptoms are excesses or distortions of normal functioning:
| Symptom | Description |
|---|---|
| Hallucinations | Sensory perceptions without external stimuli |
| Delusions | Fixed false beliefs |
| Disorganized thinking | Loose associations, tangential speech |
| Disorganized behavior | Unpredictable agitation, bizarre movements |
Negative Symptoms
Negative symptoms are deficits in normal functioning:
| Symptom | Description |
|---|---|
| Flat affect | Reduced emotional expression |
| Alogia | Poverty of speech |
| Avolition | Lack of motivation |
| Anhedonia | Inability to feel pleasure |
| Social withdrawal | Isolation from others |
Key point: Positive symptoms respond better to antipsychotic medications than negative symptoms.
Hallucinations
Hallucinations are sensory perceptions that occur without external stimuli. The client experiences them as real.
Types of Hallucinations
| Type | Sense | Frequency in Schizophrenia |
|---|---|---|
| Auditory | Hearing | Most common (60-80%) |
| Visual | Seeing | Second most common |
| Tactile | Touching/feeling | Less common |
| Olfactory | Smelling | Less common |
| Gustatory | Tasting | Rare |
Signs a Client May Be Hallucinating
- Eyes moving as if tracking something not visible
- Talking or laughing when alone
- Tilting head as if listening
- Gesturing to empty space
- Inappropriate responses to conversation
- Sudden changes in behavior
Nursing Response to Hallucinations
The therapeutic approach: Acknowledge the experience without reinforcing the hallucination.
Correct response: "I don't hear the voices, but I can see that they are frightening you."
This response:
- Presents reality ("I don't hear the voices")
- Validates the client's distress ("they are frightening you")
- Does not argue or dismiss the experience
- Does not pretend to share the perception
| Do | Don't |
|---|---|
| Acknowledge the client's feelings | Argue about whether it's real |
| Present reality gently | Pretend you also hear/see it |
| Stay calm and reassuring | Act frightened or uncomfortable |
| Focus on the emotion behind the experience | Dismiss or ignore the client |
| Redirect to reality-based activities | Leave the client alone with distressing hallucinations |
Command Hallucinations
Command hallucinations are voices that tell the client to do something. They require immediate safety assessment.
Questions to ask:
- "What are the voices saying?"
- "Are the voices telling you to hurt yourself or anyone else?"
- "Do you feel like you have to obey the voices?"
If the voices command harm:
- Implement suicide/homicide precautions
- Increase observation level
- Remove dangerous objects
- Notify the healthcare provider immediately
- Document the content of the commands
Safety is the priority with command hallucinations.
Delusions
Delusions are fixed, false beliefs that are not based in reality and persist despite evidence to the contrary.
Types of Delusions
| Type | Belief |
|---|---|
| Persecutory | Someone is trying to harm, spy on, or poison them |
| Grandiose | They have special powers, wealth, or importance |
| Referential | Events/media have special meaning directed at them |
| Somatic | Something is physically wrong (e.g., organs rotting) |
| Erotomanic | Someone famous is in love with them |
| Jealous | Partner is unfaithful |
| Religious | They are God or have a divine mission |
| Control | Thoughts or actions are controlled by external forces |
Nursing Response to Delusions
Do NOT argue with delusions. Logic does not work because the belief is fixed.
| Do | Don't |
|---|---|
| Acknowledge without agreeing | Argue or try to reason them out of it |
| Focus on feelings behind the delusion | Say "That's not true" |
| Redirect to reality-based topics | Reinforce or pretend to agree |
| Express doubt gently if appropriate | Make the client feel judged |
Example:
- Client: "The government has implanted a tracking device in my brain."
- Non-therapeutic: "That's impossible. The government doesn't do that."
- Therapeutic: "That must feel very frightening. You're safe here. Let's talk about how you're feeling today."
Communicating with Clients with Schizophrenia
General Principles
- Be concrete and clear - Avoid abstract concepts; clients may interpret literally
- Keep interactions brief - Overstimulation increases symptoms
- Use simple language - Short sentences, one topic at a time
- Maintain consistent routines - Predictability reduces anxiety
- Allow for disorganized thinking - Be patient, don't demand immediate answers
- Build trust slowly - Suspiciousness is common
Therapeutic Responses
| Client Statement | Non-Therapeutic | Therapeutic |
|---|---|---|
| "The voices are telling me I'm worthless." | "Those voices aren't real." | "The voices must be very distressing. I'm here to help you feel safe." |
| "The CIA is watching me through the TV." | "That's paranoid thinking." | "It sounds like you feel watched and unsafe. Tell me more about what you're experiencing." |
| "I am the chosen one with divine powers." | "You're just a regular person." | "You feel you have an important purpose. What would you like to do today?" |
Antipsychotic Medications
First-Generation (Typical) Antipsychotics
| Medication | Key Points |
|---|---|
| Haloperidol (Haldol) | High potency; EPS common |
| Chlorpromazine (Thorazine) | Low potency; more sedation |
| Fluphenazine | Available as long-acting injection |
Major side effects:
- EPS (Extrapyramidal Symptoms): Dystonia, akathisia, parkinsonism, tardive dyskinesia
- Anticholinergic effects (dry mouth, constipation, urinary retention)
- Sedation
Second-Generation (Atypical) Antipsychotics
| Medication | Key Points |
|---|---|
| Risperidone (Risperdal) | EPS at higher doses |
| Olanzapine (Zyprexa) | Weight gain, metabolic syndrome |
| Quetiapine (Seroquel) | Sedating; fewer EPS |
| Aripiprazole (Abilify) | Weight-neutral; partial agonist |
| Clozapine (Clozaril) | Treatment-resistant schizophrenia; requires WBC monitoring (agranulocytosis risk) |
Key nursing consideration for Clozapine: Monitor absolute neutrophil count (ANC) regularly due to risk of fatal agranulocytosis.
On the Exam
NCLEX focus areas:
- Correct response to hallucinations: "I don't hear/see it, but I understand you do."
- Don't argue with delusions
- Command hallucinations = safety priority
- Clozapine = monitor WBC
- Assess for EPS with antipsychotics
A client with schizophrenia says, "The voices are telling me to hurt my roommate." What is the nurse's priority action?
A client states, "The FBI has been following me for years and tapping my phone." Which response by the nurse is most therapeutic?
A client taking clozapine (Clozaril) has a white blood cell count of 2,500/mm3. What is the nurse's priority action?