|INTERVIEWING TIP OF THE MONTH
# 64 June 2005
"Uncovering Command Hallucinations"
TISA Description of the Problem: The interviewing tip this month is a bit unusual in format - for I wrote it as opposed to one of our viewers. I was running just a tad late in getting the June Tip up . . . well, more than a tad . . . for I had been on the road providing workshops in a hectic time frame. In any case, because I was late, I received an e-mail from one of our regular tip readers (Richard) asking when I was going to provide the follow-up tip on "command hallucinations" promised in the second tip in TISA's history (Uncovering Auditory Hallucinations) back in April 2000. It was a time when I had not yet received any tips from readers, so I had to write them myself. Well, Richard, here it is!
Tip: Command hallucinations represent auditory commands to perform a specific act. Sometimes they are quite benign directives such as "Stand up." or "Shut the door." At other times such commands may be egging on the patient to harm himself or herself or others. The presence of dangerous commands, in some cases, should strongly influence the evaluator to consider hospitalizing the individual immediately.
Also note that command hallucinations may be comments on the interview process itself such as, "Don't answer his stupid questions." or "Get out of the room now, he wants to hurt you." or "Take this guy out, before he kills you." Obviously, the presence of such commands necessitates great care by the interviewer.
Often knowledge of dangerous command hallucinations is not volunteered by the patient. Consequently, the clinician must actively inquire about their existence. During the inquiry, several phenomenological considerations merit the attention of the clinician.
Command hallucinations are not black or white phenomena in the sense that the patient either has them or does not. In actuality, command hallucinations can vary in numerous fashions. Some of the defining characteristics include the emotional impact on the patient, loudness, frequency, duration, content, degree of hostility, and the degree to which the patient feels driven to follow them.
With these variables in mind, command hallucinations can vary from relatively innocuous phenomena with little frequency and impact on the patient to dangerous phenomena in which the voices incessantly hammer at the patient in an effort to provoke violence. Some people who suffer from chronic schizophrenia have adapted to their voices and pay them little heed. This type of command hallucination is probably of minimal concern.
At the other end of the continuum, command hallucinations can become acutely harassing, loud, and insistent. In such cases, the clinician should always ask to what degree the patient feels in control. Patients may sometimes feel unable to resist even soft yet persistent voices. These types of acutely dystonic command hallucinations generally indicate the need for acute hospitalization. In order to determine the dangerousness of the command hallucination, the clinician must take the time to explore the numerous pertinent variables.
Questions such as the following may be helpful:
1) "What are the voices telling you to do?"
2) "When did your voices first start telling you to do things?"
3) "Are the voices that are telling you to hurt yourself (or others) loud or soft?"
4) "Do you recognize the person who is telling you to harm yourself (others)?"
5) "Do you value this person's advice or feel a need to do what they are telling you to do?"
6) "Do you want to do what the voice is telling you to do?"
7) "What are you doing to make sure you don't do what these voices are telling you to do?"
8) "Do you think you can resist doing what the voices are telling you to do?"
9) "How worried are you that you won't be able to resist?"
TISA Follow-up: Hopefully, the above tips can help you to uncover command hallucinations and help determine their significance with regard to safety. The above discussion also highlights a bias I have that psychopathology and diagnostic interviewing tips should be taught hand in hand. It is through our compassionate understanding of how symptoms present themselves - and how people experience the impact of their symptoms in an individualistic and personalized fashion (e.g. what does it mean to this specific person to have this specific symptom?) - that allows us to understand what questions to ask and why.
In this regard, the above tip is adapted directly from my book on clinical interviewing, "Psychiatric Interviewing: the Art of Understanding, 2nd Edition," pages 446 - 447 (W.B. Saunders, 1998). If you enjoyed this tip, you may enjoy learning more about this book by clicking on the "Book Two" button on our homepage. In any case, good-luck in your interviewing, and thanks, Richard, for the reminder that this tip on command hallucinations was long overdue.
Tip provided by:
Shawn Christopher Shea, M.D.