Delusional Behavior

No, I’m not talking about bloggers who think their party has the corner on brains and answers, I’m talking about those few patients who arrive to the ED with a Chief Complaint that’s not real.  Oh, it’s real to them, just not in reality.

Every EM doc has had these patients, and they can be imminently frustrating to deal with, which is why I now don’t.  Allow me to explain with a few heavily-sanitized for-their-protection encounters I’ve had:

  • Patient comes in wanting me to remove the device planted in their head by the CIA.  Normal exam, not a danger to self or others, but has fixed belief there’s an implanted device (fixed delusion).  After a thorough exam, I offered an X-ray of the skull to demonstrate that there wasn’t anything foreign in there.  “Oh, they don’t show up on X-ray” was the response, and this is the crux of the problem trying to deal with these patients: they don’t want to be told the truth, they want their belief to be validated, real or not, sensible or not.
  • Patient presents with CC ‘all my organs have been removed’.  When queried as to how they’d be alive with no organs, answers ‘they put someone else’s’ in’.  After exam showing no signs of drug or alcohol abuse, and notable for none but trivial scars of living, I pointed out that I’ve seen lots of patients with organ transplants, and they have rather remarkable scars, but you don’t. ‘They replaced my skin after’ was the response.  There’s always an answer that refutes rationality.
  • Patient presents with complaint of a foreign body in their nose, for 5 weeks, and there’s nothing there.  ‘No, it’s right there’, pushes on completely normal area of nose.  Examined 3 times for patient’s benefit, and no amount of reassurance can convince them it’s not there. 
  • Delusional parasitosis is probably the most common of them, but it’s harder to determine there’s not an actual cause initially, especially as they’ve usually scratched themselves into cellulitis by the time they’re seen.

These patients aren’t dangerous, not suicidal, and no amount of ED intervention will fix their problem.  I have finally learned not to spend a ton of time with attempts at reason, as the human brain has a remarkable ability to explain away rationality to believe whatever they want.  Though tempting, I won’t try a “got it out” ploy as a) it’s unethical and b) they’re delusional, not stupid, and lying will just make the problem worse.  They lack the insight to question their self-diagnosis, so psych referral is not just dismissed but is a really good way to get them to go from disappointed to angry in about two seconds.

After two thorough attempts to explain the absence of actual physical confirmation of their complaint, I then refer them to their PCP for further evaluation, and that’s it.  It’s disappointing for the patient, and for me, but there’s a limit to what I can fix in the ED. 


  1. When I was an ED clerk, there was an older woman who called every other week or so complaining about worms in her arms. Each time, I gave her the usual spiel about how there was nothing I could do for her over the phone and that if she felt she needed medical attention, she could come to the ED. Not wanting to be rude, I’d let her talk for five or ten minutes, and then hang up. She never actually came in, as far as I know. Now I know she had delusional parasitosis.

  2. We have a schizophrenic guy who always claims to have something stuck in his throat and is obsessed with the fact that one’s Adam’s Apple moves a bit with the usual swallowing motion. One time I counted and he’d had 8 soft tissue Xrays of his neck. One time he had 3 in 1 week.

    I haven’t seen him around lately though; maybe he’s moved on to the hospital down the street since we couldn’t help him.

  3. I have a regular “delusions of parasitosis” patient.

    These types are a living nightmare for every Infectious Disease doc and Dermatologist. My “regular” delusional patient is a former nurse with a strong narcissism streak, has seen every ID specialist and Dermatologist in town, and they’re all incompetent. She’s been to multiple academic tertiary centers, and they’re idiots too.

    Whenever I see her, I simply plead ignorance (“I’m jes’ a poor ole’ ER doc”), and advise her that if some of the sharpest specialists in the country can’t help her, then I don’t even know where to start.

    She usually looks at me with a mixture of anger and disgust, and goes home.

    Whenver she comes in, I’m always reminded of the famous soliloquy from “Cool Hand Luke”

    What we’ve got here is… failure to communicate. Some men, you just can’t reach. So you get what we had here last week, which is they way he wants it. Well, he gets it. And I don’t like it, any more than you men”

  4. We have had a girl come in for a few months now that comes in convinced that she is pregnant. Last time she came in she had a car seat and baby clothes because she was in ‘labor’. This girl weighed about 120 and had a flat tummy, she just was a little delusional about this one subject. No matter the number of ultrasounds and negative HCG’s she got she was convinced it just wasn’t showing on her tests. She would grab my hand and hold it to her flat tummy and tell me the baby was kicking. She admitted having her periods, but had heard about people who can have periods while being pregnant.

    I haven’t seen her in a few weeks, but I worry that she is the type of girl that abducts an infant when it finally hits her that she isn’t having a baby. Have you guys have had this type of patient? What do you do with someone like that?

  5. wow. haven’t seen one in a while who was not schizophrenic. saw a guy once who was convinced that someone at his place of employment was, intermittently, letting small drops of water or mist particles of water fall onto his left shoulder. he was not sure what this meant but was concerned and convinced. seems to me i would prefer a more dangerous delusion.

  6. No Acute Distress says:

    1) Isn’t it sad that you can’t make the appropriate referral, in this case to a psychiatrist, without genreating a formal complaint which you’ll have to spend too much time responding to?

    2)”they don’t want to be told the truth, they want their belief to be validated, real or not, sensible or not.”

    In that respect, this holds true for a lot of patients who you couldn’t properly classify as delusional. Some common examples include those patients who come in complaining of yet another “ear infection” i.e. ear PAIN, another “sinus infection” i.e. headache/face pain, another “throat infection” i.e. pharyngeal discomfort, or a “lump in the throat” i.e. GERD. The first three demand antibiotics (and often, opiates). The latter want a CT scan.

  7. Gruntdoc, i like the way you explain how you treat these patients. It is nice to see how your verbal approach has evolved with experience. appreciate your comments

  8. Great. Send them back to the PCP. You EM guys are worthless! Can’t even remove devices secretly implanted in a person’s head. You are the ones with the secret detection and removal equipment. We can’t afford to have that sort of thing in our office. I always send my delusional patients to the ED. I explain to them that you are the only ones with that “special” equipment.

  9. Dr. Rob: heh.

  10. When I finally surrender to my delusions, I have promised to indulge myself in a little FUGUE STATE. That has got to be the best psychiatric/medical diagnosis EVER…I think I feel it coming on now…unfortunately, I will need to postpone it until my child is fully grown. JC

  11. I am reminded of an interesting patient we managed. He had multiple medical conditions besides borderline dementia, underwent an incision and drainage of an abscess and was on multiple drugs while recuperating. On rounds next morning when asked how he felt he said he said he felt as if ants were crawling up his penis.The attending and residents thought he was getting delirious and the medicines were pushing him over.But I checked the Foley’s insertion site, and sure enough there were ants making a trail from the Uribag he brought with him from the nursing home. His random sugar was 512!!

  12. On my urology rotation, I saw a patient who was convinced he had a hole in his scrotum through which he leaked urine. Oddly enough, even with a negative retrograde urethrogram and a negative exam (no hole, no fluid), he was still convinced. “But it bothers me so much! I get a quarter-sized spot of fluid on my underwear, and then it’s all wet and uncomfortable! I want surgery!”

    My attending gave him pyridium, told him to put a bandage over the “hole”, and if anything orange came out to come back. It was the only way to get him to leave.

  13. Scott Sullivan says:

    Hi Doc,

    What’s your opinion on Prurigo nodularis?

    Semp Fi, Sully

    [GD: Never heard of it. Here’s an article. Not an ER problem.]


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