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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 ( ~ u n ~ i n g e r "to
) 88.5 percent
studies7. have concluded that command (Chadwick and ~ i r c h w o o dI ') . *
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-
~ u n ~ i n ~however,
e r , ~ has noted that com- ies,", l o 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. l 3 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 ~ k e r ~ ~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. l 4 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. l o 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 complied with leagues 1 8 , 19 have also reported that
command hallucinations, none of their voices that were described as "benevo-
sample complied with "severe" (i.e., life- lent" by the patient were associated with
threatening or dangerous) commands. greater "engagement" (a reaction that in-
Similarly, Zisook et a1. l 5 reported that the cludes both compliance and seeking out
rate of suicide attempts did not differ the voices). It is likely that individuals
between patients reporting command hal- experiencing command hallucinations are
lucinations with suicidal content and pa- more likely to trust voices they believe
tients who did not report command hal- they can identify. This trust may enhance
lucinations (although both of the patients compliance, because patients are more
who successfully committed suicide in likely to assume that recognizable, trust-
this study had been experiencing suicidal worthy voices are ordering behaviors that
command hallucinations). The danger- are in the patients' best interests.
ousness issue is further complicated when A patient's beliefs-especially his or
studies have not reported rates of compli- her beliefs about the command hallucina-
ance with command hallucinations but tions themselves-also influence compli-
instead have reported only rates of spe- ance. ~unginger" reported that the pres-
cific contents of the commands. For ex- ence of a delusional belief consistent with
ample, Rogers et al. l 6 reported that 59.0 the command hallucination increases the
percent of their sample experienced com- likelihood of compliance. In fact, the
mand hallucinations with mixed criminal identifiability of hallucinated voices

356 J Am Acad Psychiatry Law, Vol. 26, No. 3, 1998


Command Hallucinations

"may be one aspect of a more system- toms. Similarly, Beck-Sander et a1.I9 re-
atized disorder of reality in which symp- ported that participants who believed that
tom-consistent behavior is likely to fit" they were in control of themselves were
(Junginger, p. 96).20 Other research- less likely to comply with command hal-
ers19. 21 have also noted that a patient's lucinations than participants who be-
interpretation of his or her command hal- lieved that the voices were omnipotent.
lucinations are related to compliance. A These findings support and underscore
logically consistent relationship between the importance of assessing delusions
hallucination and delusion should in- when attempting to estimate the likeli-
crease compliance, because such patients hood of compliance with command hal-
would be more likely to interpret these lucinations, particularly those with vio-
perceptual experiences as congruent with lent content.
their understanding of the world, just as
familiar voices are more likely to be con- Implications for Risk
sistent with patients' experience. Assessment
Whatever the underlying mechanism, it The extant literature clearly shows that
appears that the presence of a delusional not everyone who experiences a com-
belief consistent with the content of the mand hallucination will comply, nor is
hallucination increases the likelihood of everyone who experiences such symp-
compliance. Concerning the implication toms considered dangerous. However,
of this finding for assessing a patient's command hallucinations are certainly
risk of violent behavior, it is worth noting within the appropriate scope of inquiry
that prior research has shown the pres- when conducting a risk assessment.
ence of delusions related to perceived When performing a mental status exami-
threat or an overriding of one's internal nation, a clinician will likely ask about
controls is associated with increased risk psychotic symptom patterns. If there are
for violent b e h a v i ~ r . ~ *These
- ~ ~ symp- indications of psychosis (e.g., hallucina-
toms have been referred to in the litera- tions or delusions) or violent ideation, a
ture as threat/control override or TCO specific inquiry about command halluci-
symptoms. In a large national sample, nations may be indicated ( e g , "Have you
Swanson and c o l ~ e a g u e found
s ~ ~ that per- ever heard voices that talked to you about
sons who reported TCO symptoms were hurting people?"). The necessity of in-
about twice as likely to engage in assaul- quiring specifically about command hal-
tive behavior as those with other psy- lucinations is highlighted by the results of
chotic symptoms and six times more Rogers et ~ 1These . ~authors
~ found that
likely to engage in such behaviors than the clinical staff of an inpatient forensic
those with no mental disorder. Those re- assessment unit overlooked the presence
porting TCO symptoms in combination of command hallucinations in 47.8 per-
with substance abuse were 8 to 10 times cent of their research sample.
more likely to engage in violent behavior If command hallucinations are or have
than persons with no disorder or symp- been present, the clinician may want to

J Am Acad Psychiatry Law, Vol. 26, No. 3, 1998 357


Hersh and Borum

explore this phenomenon in more detail. tion concerning base rates of compliance
First, it may be useful to note which sit- and factors influencing compliance can
uations and which other identifiable pre- be integrated with relevant history and
cipitants are associated with the patient's clinical information to help understand
command hallucinations. Second, it may the salience of these commands in an
be relevant to ask about the content, fre- individual case and to improve the valid-
quency, and recency of these commands ity of risk assessments.
and to inquire about the individual's past
experience with compliance (e.g., "Has
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