The hallucination portrait of psychosis: Probing the voices within

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On recent hospital rounds with residents and medical students, a medical student presented a 20-year-old man with first-episode psychosis. The student mentioned that the patient admitted to hearing voices, and the admission note in the patient’s chart referred simply to “AH+” (auditory hallucinations present)

I was disappointed. This sparse description of a key psychotic symptom ignored rich details that could provide important clinical and safety information about the patient. So I suggested that the students and residents ask this patient many more questions about his AH, including:

• How did the voices start—suddenly or gradually? With or without drug use? Do they speak clearly, or are they muffled and indistinct? Was the patient alarmed when the voices first occurred? Did he hear voices during childhood?
• Does the patient hear 1 voice, 2 voices, or more? Male or female? Recognizable voices of relatives or friends, or voices of strangers? Living or dead people? Are the voices from nonhuman entities such as God, Satan, or a computer?
• Do the voices come from inside or outside the patient’s head? Does he hear them from the left side, right side, or both? Does the patient recognize them as his own thoughts spoken out loud?
• Do the voices speak directly to the patient in the first person or talk about the patient in the third person? If there is more than 1 voice, do they converse about the patient? Do they run a commentary about the patient’s actions, feelings, or thoughts? Does the patient talk back to the voices occasionally, regularly, or not at all?
• Do the voices give orders? Do these orders include harming oneself or others? Can the patient resist those commands, or is he worried that he might carry them out?
• Do the voices insult or praise the patient? Do they upset the patient or make him laugh by cracking jokes? Does the patient laugh to himself because of what the voices say? Do they make the patient cry or scream in frustration?
• Do the voices occur continuously or sporadically throughout the day? What makes them more intense, decrease, or stop? Are they worse at any time during the day? Do they stop when the patient is eating, watching TV, reading a magazine, talking to someone, doing a crossword puzzle, or playing a video game? Do they ever wake the patient at night? Do they sometimes prevent him from falling asleep?
• Have the voices led the patient to become more paranoid or suspicious toward others? Do they make him depressed, anxious, or agitated? Do the voices tell the patient he is guilty of sins or that he will go to hell to be punished?
• Does the patient want the voices to stop, or does he like hearing them, regard them as “friends,” and would miss them if they disappeared? Have the voices stopped in the past in response to medication, and did the patient discontinue the medication just to have the voices return?
• Are the AHs triggers for or sometimes accompanied by other types of hallucinations—such as visual, olfactory, gustatory, or somatic—related to the persons behind the voices?

In my experience, clinicians rarely retrieve and document the wealth of data available about AHs when assessing persons with psychosis. I recommend that clinicians include such details in the initial mental status exam of a patient with psychosis.

Details of AH paint a unique picture of each patient. They provide a useful baseline to monitor the effects of treatment and may warn of potential harm to the patient or others. They help me to empathize with my patients and understand the perceptual chaos that causes their torment and anguish. This empathy can strengthen the therapeutic alliance as we work to restore normalcy to young lives shattered by psychosis.

Comment on this article

On recent hospital rounds with residents and medical students, a medical student presented a 20-year-old man with first-episode psychosis. The student mentioned that the patient admitted to hearing voices, and the admission note in the patient’s chart referred simply to “AH+” (auditory hallucinations present)

I was disappointed. This sparse description of a key psychotic symptom ignored rich details that could provide important clinical and safety information about the patient. So I suggested that the students and residents ask this patient many more questions about his AH, including:

• How did the voices start—suddenly or gradually? With or without drug use? Do they speak clearly, or are they muffled and indistinct? Was the patient alarmed when the voices first occurred? Did he hear voices during childhood?
• Does the patient hear 1 voice, 2 voices, or more? Male or female? Recognizable voices of relatives or friends, or voices of strangers? Living or dead people? Are the voices from nonhuman entities such as God, Satan, or a computer?
• Do the voices come from inside or outside the patient’s head? Does he hear them from the left side, right side, or both? Does the patient recognize them as his own thoughts spoken out loud?
• Do the voices speak directly to the patient in the first person or talk about the patient in the third person? If there is more than 1 voice, do they converse about the patient? Do they run a commentary about the patient’s actions, feelings, or thoughts? Does the patient talk back to the voices occasionally, regularly, or not at all?
• Do the voices give orders? Do these orders include harming oneself or others? Can the patient resist those commands, or is he worried that he might carry them out?
• Do the voices insult or praise the patient? Do they upset the patient or make him laugh by cracking jokes? Does the patient laugh to himself because of what the voices say? Do they make the patient cry or scream in frustration?
• Do the voices occur continuously or sporadically throughout the day? What makes them more intense, decrease, or stop? Are they worse at any time during the day? Do they stop when the patient is eating, watching TV, reading a magazine, talking to someone, doing a crossword puzzle, or playing a video game? Do they ever wake the patient at night? Do they sometimes prevent him from falling asleep?
• Have the voices led the patient to become more paranoid or suspicious toward others? Do they make him depressed, anxious, or agitated? Do the voices tell the patient he is guilty of sins or that he will go to hell to be punished?
• Does the patient want the voices to stop, or does he like hearing them, regard them as “friends,” and would miss them if they disappeared? Have the voices stopped in the past in response to medication, and did the patient discontinue the medication just to have the voices return?
• Are the AHs triggers for or sometimes accompanied by other types of hallucinations—such as visual, olfactory, gustatory, or somatic—related to the persons behind the voices?

In my experience, clinicians rarely retrieve and document the wealth of data available about AHs when assessing persons with psychosis. I recommend that clinicians include such details in the initial mental status exam of a patient with psychosis.

Details of AH paint a unique picture of each patient. They provide a useful baseline to monitor the effects of treatment and may warn of potential harm to the patient or others. They help me to empathize with my patients and understand the perceptual chaos that causes their torment and anguish. This empathy can strengthen the therapeutic alliance as we work to restore normalcy to young lives shattered by psychosis.

Comment on this article

On recent hospital rounds with residents and medical students, a medical student presented a 20-year-old man with first-episode psychosis. The student mentioned that the patient admitted to hearing voices, and the admission note in the patient’s chart referred simply to “AH+” (auditory hallucinations present)

I was disappointed. This sparse description of a key psychotic symptom ignored rich details that could provide important clinical and safety information about the patient. So I suggested that the students and residents ask this patient many more questions about his AH, including:

• How did the voices start—suddenly or gradually? With or without drug use? Do they speak clearly, or are they muffled and indistinct? Was the patient alarmed when the voices first occurred? Did he hear voices during childhood?
• Does the patient hear 1 voice, 2 voices, or more? Male or female? Recognizable voices of relatives or friends, or voices of strangers? Living or dead people? Are the voices from nonhuman entities such as God, Satan, or a computer?
• Do the voices come from inside or outside the patient’s head? Does he hear them from the left side, right side, or both? Does the patient recognize them as his own thoughts spoken out loud?
• Do the voices speak directly to the patient in the first person or talk about the patient in the third person? If there is more than 1 voice, do they converse about the patient? Do they run a commentary about the patient’s actions, feelings, or thoughts? Does the patient talk back to the voices occasionally, regularly, or not at all?
• Do the voices give orders? Do these orders include harming oneself or others? Can the patient resist those commands, or is he worried that he might carry them out?
• Do the voices insult or praise the patient? Do they upset the patient or make him laugh by cracking jokes? Does the patient laugh to himself because of what the voices say? Do they make the patient cry or scream in frustration?
• Do the voices occur continuously or sporadically throughout the day? What makes them more intense, decrease, or stop? Are they worse at any time during the day? Do they stop when the patient is eating, watching TV, reading a magazine, talking to someone, doing a crossword puzzle, or playing a video game? Do they ever wake the patient at night? Do they sometimes prevent him from falling asleep?
• Have the voices led the patient to become more paranoid or suspicious toward others? Do they make him depressed, anxious, or agitated? Do the voices tell the patient he is guilty of sins or that he will go to hell to be punished?
• Does the patient want the voices to stop, or does he like hearing them, regard them as “friends,” and would miss them if they disappeared? Have the voices stopped in the past in response to medication, and did the patient discontinue the medication just to have the voices return?
• Are the AHs triggers for or sometimes accompanied by other types of hallucinations—such as visual, olfactory, gustatory, or somatic—related to the persons behind the voices?

In my experience, clinicians rarely retrieve and document the wealth of data available about AHs when assessing persons with psychosis. I recommend that clinicians include such details in the initial mental status exam of a patient with psychosis.

Details of AH paint a unique picture of each patient. They provide a useful baseline to monitor the effects of treatment and may warn of potential harm to the patient or others. They help me to empathize with my patients and understand the perceptual chaos that causes their torment and anguish. This empathy can strengthen the therapeutic alliance as we work to restore normalcy to young lives shattered by psychosis.