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Command Hallucinations, Compliance, and Risk Assessment

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Command Hallucinations, Compliance, and Risk Assessment Command Hallucinations, Compliance, and Risk Assessment Keith Hersh, MA, and Randy Borum, PsyD Command hallucinations are auditory hallucinations that instruct a patient to act in specific ways; these commands can range in seriousness from innocuous to life-threatening. This article summarizes two areas of research regarding com- mand hallucinations: rates of compliance with command hallucinations; and fac- tors associated with compliance. Researchers have reported rates of compliance ranging from 39.2 percent to 88.5 percent. Compliance has not been consistently related to dangerousness of commands. Instead, research suggests that individ- uals are more likely to comply with commands if they recognize the hallucinated voice and if their hallucinations are related to a delusion. Implications for risk assessment are discussed in light of the research. Mental health professionals are often actions that command hallucinations or- called upon to assess the risk of violence der the patient to perform range from the posed by people with mental disorders.'-' insignificant, such as making facial gri- In making these assessments, the clini- maces, to those as serious as suicidal or cian must consider and evaluate the rele- homicidal acts. Clinical lore suggests that vant risk factors, including those related people are prone to obey their command to an individual's clinical condition. hallucinations and that "dangerous" com- Command hallucinations are among the mands increase the likelihood that an in- clinical factors that have received in- dividual will engage in violent behavior. creased clinical and empirical attention in Empirical studies have produced more recent years. Command hallucinations are mixed results. auditory hallucinations that instruct the This article examines the empirical ev- patient to act in a certain manner. The idence in two critical areas: (I) the rate of compliance with command hallucina- tions; and (2) the factors associated with Mr. Hersh is affiliated with the Department of Psychol- increased compliance with command hal- ogy, University of North Carolina at Chapel Hill, NC, lucinations. It then discusses the factors and Mr. Borum with the Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, that a clinician should consider when con- Durham, NC. Address correspondence to: Keith R. Hersh, MA, Davie Hall, CB 3270, University of North ducting a risk assessment involving com- Carolina, Chapel Hill, NC 27599-3270. mand hallucinations. J Am Acad Psychiatry Law, Vol. 26, No. 3, 1998 353 Hersh and Borum Rates of Compliance with equally low in a different, less structured Command Hallucinations environment. Studies of single subjects or small sam- Researchers report higher rates of com- ples have often indicated that those who pliance with command hallucinations experience command hallucinations are when they have examined compliance likely to comply with the command^.^-^ with all commands (i.e., both lethal and This topic has only recently been exam- nonlethal) and when they have inquired ined using samples large enough to per- about compliance with commands before mit more generalizable statements about the patient was admitted to the hospital. the rate of compliance. Table 1 summa- Indeed, these studies have demonstrated rizes the results of these studies. A cur- relatively high rates of compliance (see sory examination of these data reveals Table l), with estimates ranging from two. apparently discrepant, trends. Some 39.2 percent (~un~inger")to 88.5 percent studies7. have concluded that command (Chadwick and ~irchwood'I).* hallucinations rarely influence the behav- An important issue regarding compli- ior of those who experience them, includ- ance with command hallucinations is ing the dangerous behavior of forensic whether compliance significantly in- patients. These studies, however, do not creases a patient's degree of dangerous- report actual rates of compliance with ness. The current literature is divided on command hallucinations. Instead, they re- this question. Several studies indicate that port that commands were "generally ig- patients experiencing command halluci- nored'' (Goodwin et al., p. 78)' and note nations with dangerous content are likely that patients experiencing command hal- to comply with these orders and are there- lucinations with violent content did not fore more likely to be dangerous them- display higher rates of violent behavior. selves. Junginger, in two separate stud- ~un~in~er,~however, has noted that com- ies,", lo has reported compliance rates of pliance with hallucinations is mediated by 45.8% and 40.0%, respectively, with dan- gerous command hallucinations. Kasper the hospital environment. Psychiatric in- et n1. l3 reported that 91.7 percent of sub- patients-such as the patients which com- jects experiencing command hallucina- prise the samples for Goodwin et aL7 and tions ordering acts of violence against Hellerstein et a~.~-would be prevented themselves complied with those orders, from complying with most commands to and 66.7 percent of those experiencing injure themselves or others by the rela- command hallucinations ordering acts of tively high degree of observation, struc- ture, and security inherent in a hospital environment. The fact that suicidal or ho- * Study results reported by Taylor" include the highest micidal command hallucinations are not rate of compliance with command hallucinations (100%).We have not included the results from this study associated with a higher rate of suicidal or when discussing the range of con~plianceobserved by homicidal acts in the hospital does not researchers because only two of the participants reported command hallucinations, and conclusions based upon mean that compliance rates would remain such small sample sizes are unlikely to be robust. 354 J Am Acad Psychiatry Law, Vol. 26, No. 3, 1998 Command Hallucinations Table 1 Compliance with Command Hallucinations (CH) and Dangerousness Associated with CH Reported in Empirical Studies Percentage of Compliance Information Related with to Dangerousness Sample Command in Patients Study Characteristics Hallucinations Experiencing CH Among clinical or offender population: Goodwin et a/.' 117 Psychiatric inpatients 0.0% Compliance in three and outpatients; 42 patients experiencing CH patients with CH with suicidal content Hafner and B~ker~~259 Forensic patients 18.5% Ordered by CH to commit crime 203 Forensic patients; 2 One patient complied with patients with CH order to carry knife Among patients with command hallucinations: Chadwick and 26 Psychiatric inpatients O.OO/oComplied with Birchwood" and outpatients "severe" (i.e., life- threatening) commands Hellerstein et aL8 58 Psychiatric inpatients 51.7% Suicidal content; 5.2% homicidal content; 12.1% lethal injury to self or others contentC Jungingerg 93 Psychiatric inpatients 45.8% Compliance among patients with somewhat dangerous or very dangerous CH Junginger1° 51 Psychiatric inpatients 40.0% Compliance with and outpatients dangerous CH Kasper et aI.l3 25 Psychiatric inpatients; 2 91.7% Compliance with CH patients could not ordering violence toward articulate nature of CH self; 66.7% compliance with CH ordering violence toward others Rogers et 25 Forensic patients 4.5% Criminal content; 59.0% mixed criminal and noncriminal contentc Thompson et a1.14 34 Forensic patients 62.0% Of command (found NGRI) hallucinations related to crime committed Zisook et a/.15 46 Psychiatric outpatients 44% Violent contentc a Rate of compliance not reported. Represents at least occasional or partial compliance. Represents rate of content of commands, not rate of compliance. Represents 'Yull compliance" with command hallucinations; percentage increases to 55.goL when "partial" or "full compliance" is considered. Represents compliance with command hallucinations in recent past; 56.0% of the sample reported at least one instance of unquestioned obedience, and 44.0% reported frequent or very frequent obedience. J Am Acad Psychiatry Law, Vol. 26, No. 3, 1998 Hersh and Borum violence toward others complied with and noncriminal content. They did not, those orders. however, report how many patients com- Not all studies have shown that com- plied with these commands. mand hallucinations are associated with increased dangerousness. In a retrospec- Factors Associated with tive case review of forensic patients Compliance found not guilty by reason of insanity As indicated above, the dangerousness (NGRI). Thompson et al. l4 reported that of the content of commands is not con- command hallucinations contributed to sistently related to compliance. Several the patient's acquittal offense in 62 per- features of command hallucinations ap- cent of subjects reporting command hal- pear to mediate compliance. Jungin- lucinations during the time of their of- ger9. lo reported that patients are more fense. These patients, however, were less likely to comply with familiar voices than likely to have been acquitted of violent with unfamiliar voices. Similarly, Shore offenses than NGRI patients who had et a1." noted three factors that increase been experiencing noncommand auditory the risk that people with schizophrenia hallucinations and NGRI patients who will engage in self-mutilation: (1) the had not been experiencing auditory hal- presence of command hallucinations, (2) lucinations at all. Chadwick and Birch- calm reactions to the voices, and (3) trust- wood" reported that although 88.5 per- ing the voices. Chadwick and col- cent of their sample
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