The initial published case has been modified slightly in response to feedback from colleagues.
Juan is a 20 yo young man who is brought to his PCP’s office by his mother for “hearing voices.” You speak with Juan alone first. For 3 months, he has been hearing the voice of a young boy, talking directly to him, sometimes yelling that he needs help, sometimes saying things like “why won’t you help me?” When it first started, he heard the voice occasionally and thought that maybe he wasn’t getting enough sleep. For the last two months, however, he’s been hearing the boy frequently, off and on every day.
When you ask Juan why he thinks he is hearing the boy’s voice, Juan says that he thinks the boy is being held captive by a neighbor. The neighbor created an electric field around his apartment so that other people can’t hear the boy yelling. Juan believes that he can hear the boy because the government implanted a chip in his brain that counteracts the electric field. While the voice has never asked him to do anything specifically, it does cry for help, and Juan finds this very distressing. He has learned that listening to music can sometimes quiet the voice. The voice gets louder at night when no one is around, and he is having a hard time sleeping. He’s always tired during the day. He feels like he can’t think straight anymore. He denies using cannabis or any other drugs.
You ask Juan if you can talk with his mother alone, and he says ok. She tells you that Juan met all of his developmental milestones as a child. He has never had medical or mental health problems. Six months ago, he started to spend more time alone on his computer. For the last two months, she has heard him yelling in his room, telling someone to leave him alone. He stopped going to classes at his college one week ago and won’t talk about why. He has not threatened anyone or talked about not wanting to be alive anymore.
You place an urgent referral to psychiatry but know that Juan is unlikely to be seen for at least 3 months. What do you do now?
This PsychSnap will be released in two parts. In Part 1, we’re going to discuss how to talk with Juan about his experience of hearing voices and screen for other symptoms of psychosis. In Part 2, which will be released in 2 weeks, we’ll discuss the appropriate medical workup for Juan and how to choose and start an antipsychotic medication. Let’s continue with Part 1!
It is not common to see a young person presenting to primary care in their first episode of psychosis, but it is an important opportunity to initiate care. The time from the onset of fully delusional psychotic symptoms, including both hallucinations and delusions, to the first treatment is called the duration of untreated psychosis (DUP). Longer DUPs have been consistently associated with worse long-term functional outcomes in people with schizophrenia (Pentilla 2014).
How should we talk to Juan about his experience of hearing voices and screen for other psychotic symptoms?
It is important to ask your patients what they are experiencing. Once Juan tells me that he is hearing voices, I ask him more about the voices, being sure to address their duration, frequency, intensity, and associated distress. The following table details specific questions that you can ask. Like the experience of having suicidal thoughts, the experience of hearing voices can vary markedly between people.
When asking questions like these, watch the patient’s body language carefully. Some people will feel relieved to be talking with someone about their experience of hearing voices. Other people will find the questions around voices intrusive, particularly if they are feeling paranoid, or if a threatening voice is telling them not to talk about it. If you notice that Juan is looking more tense as you ask more questions, make an empathic comment and redirect the conversation: “These are hard things to talk about. Why don’t we talk about something else?”
|Questions to consider asking about auditory hallucinations (A
|Why this question could be helpful
|Can you tell me more about your experience of hearing voices?
|As with most conversations, start with an open-ended question.
|How many people do you hear? Can you tell if it’s a male or female voice? What kinds of things does the voice say?
|Helps to understand the sensory experience
|How do you feel when you hear the voice? What do you do when you hear the voice?
|Helps to understand the emotional and functional impact
|When did you first hear the voice? Are there certain times or occasions when your voices are more active? (time of day, when doing certain activities, or feeling a certain way)? Are there times when you don’t hear voices? Is there anything you have found that makes the voices go away or seem less intense (talking with someone, talking with the voice, watching TV, drugs, or medications)?
|These questions allow you to explore the patient’s experience further and to help them be curious about their experience. You may be able to partner with the patient in devising coping strategies (for example, listening to music when the voice is bothersome).
|Does the voice ever tell you to do anything? Does it ever threaten to harm you or someone else? Do you do what the voice tells you? Why or why not?
|Risk stratification. A person hearing the voice of God telling them to kill themselves to protect their family from harm is at higher risk than someone hearing the voice of a man constantly commenting on what they are doing.
|Many people I’ve spoken with have thought that their voice might be a friend or family member, or some kind of God or devil. Have you ever wondered something similar? What makes you think the voices is [use the name]? How sure are you?
|Prognosis. Young people who hear voices that are connected with a delusional explanation are more likely to develop the full syndrome of schizophrenia.
|How often do you hear voices? How long do they last when you hear them?
|Treatment planning. Consider starting a medication for frequent, persistent, distressing auditory hallucinations connected to a delusional explanation that are functionally impairing.
|What percentage of the day do you hear the voice?
|Monitoring. If you start an antipsychotic medication for someone who hears voices, this can be a useful number to follow to assess treatment response. A reduction from 75% of the day to 25% would be a robust treatment response.
The experience of hearing voices is not a binary yes/no but a wide spectrum. Auditory hallucinations that are loud, frequent, with distressing negative content, personal threats or commands to harm, or associated with strongly held delusional beliefs are particularly concerning. The questions above can help you understand a patient’s individual experience and devise an appropriate treatment plan.
If someone is hearing voices, it’s important to ask about other associated psychotic symptoms in addition to asking more standard psychiatric screening questions about mood, anxiety, and substance use disorders. These are four questions that make up a brief review of symptoms for psychosis (adapted from headspace.au).
- Visual hallucinations – “Have you ever seen something that other people could not see?”
- Delusions – “Have you thought that unusual things were happening around you, or to you?”
- Paranoia – “Have you been worried that something bad might happen to you?”
- Thought Disorder – “Have you noticed a change in the way that you think – slower, faster, more confused?”
In addition to asking about the patient’s experience of their thinking, pay special attention to the patient’s thought process — how they link words together. Antipsychotic medications can help reduce thought disorganization.
You ask Juan these questions, and you learn that he does not have visual hallucinations. Other than the belief about his neighbor, he has no other unusual thoughts. He says it’s becoming harder to put together thoughts, though on interview, you find his thought process to be linear and goal directed.
Look for Part 2 of this PsychSnap on August 25, covering the medical work-up and initiation of treatment.
- Ask for permission to speak with a patient’s family member or other close contact when patients are experiencing psychotic symptoms.
- The experience of hearing voices is not a binary yes/no but a wide spectrum. Try to understand your patient’s experience with the voices, including the duration, frequency, intensity, and associated distress.
Penttilä, Matti, et al. “Duration of untreated psychosis as predictor of long-term outcome in schizophrenia: systematic review and meta-analysis.” The British Journal of Psychiatry 205.2 (2014): 88-94.
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