The clinician's most valuable assessment tool is the mental status examination, addressing mood, affect, appearance, behavior, speech, thought content, thought process, insight, and judgment. The evaluation of paracusias consists of a general psychiatric interview that includes details regarding the evolution of the hallucinations, triggering factors, psychiatric review of systems, past psychiatric diagnosis, history of substance use, family history of psychiatric illness, and history of trauma.Īdditionally, a detailed medical history and medication regimen-including over-the-counter supplements-should be obtained. Neuroimaging studies have demonstrated increased D2 receptor occupancy in the striatal system and 5HT2a receptor occupancy in the caudate nucleus. Īt a neurochemical level, of particular importance are dopamine (D2) and serotonin (5HT2a) receptors. Some data suggest that the thalamus-amygdala pathways are activated, thereby processing an emotional response to the auditory hallucinations, further proved by another study detecting choline and N-acetyl aspirate ratio abnormalities in the thalamus. This mismatch results in the spontaneous firing of sensory neurons in the absence of appropriate inhibitory mechanisms. Ī neurocognitive model called the VOICE model has been offered, which attributes the paracusias to an unbalanced bottom-up limbic hyperexcitation mismatched against a hypoactive prefrontal inhibitory system. įMRI findings have demonstrated spontaneous activation of the auditory network, consisting of the left superior temporal gyrus, transverse temporal gyri (Heschl's gyri), and the left temporal lobe. However, several postulations have been suggested. In Principles and Practice of Forensic Psychiatry, Third Edition (Editors: Rosner R and Scott CL) CRC Press, Taylor & Francis Group, New York, 2017, pp 623-632.The precise mechanism by which paracusias occur remains elusive. Scott CL and Resnick PJ: Clinical assessment of aggression and violence.
Fourth, patients with schizophrenia who experience command hallucinations that generate negative emotions–such as anger, anxiety or sadness–are more likely to act violently than those individuals with voices that generate positive emotions. As an example, a man who hears a voice to kill his neighbor is more likely to act on this command if he believes his neighbor has been invaded by an evil alien who is plotting to kill him. Third, persons are more like to follow harmful command hallucinations when they are associated with a congruent delusion. Second, individuals who believe that following the directive of the command hallucination will benefit them or more likely to comply with the harm-other command hallucination. Clinicians should ask their patient if they experience associated feelings of helplessness or powerlessness associated with the voice and if they believe there would be a bad outcome if the voice command is not followed. First, persons are more likely to act on auditory hallucinations to harm others when they perceive the voice as powerful. Clinicians should be familiar with four factors associated with persons acting on harm-other command hallucinations when conducting a violence risk assessment. Between 30% to 65% of individuals with command hallucinations to harm others (referred to below as “harm-other” command hallucinations) comply with those hallucinations.
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