Original Paper

Psychopathology 2002;35:272–279
DOI: 10.1159/000067065

Command Hallucinations:
Who Obeys and Who Resists When?
R. Erkwoh a K. Willmes b A. Eming-Erdmann a H.J. Kunert a
a Clinic
of Psychiatry and Psychotherapy and b Clinic of Neurology, Section Neuropsychology,
University of Aachen, Aachen, Germany

Key Words however, appear to be translated into behaviour in a more

Schizophrenia W Command hallucinations W Behaviour W
Prediction
Abstract
The impact of auditory command hallucinations on the
behaviour of schizophrenic patients sometimes appears
to be unpredictable. In order to tackle this problem, the
psychopathological characteristics of command halluci-
nations in 31 schizophrenic patients were assessed using
a 24-item questionnaire. Using binary data and relative
risk analysis methods, predictors were determined for
obeying or resisting command hallucinations. Character-
istics of voices and the attitude toward the voices appear
equally important for prediction. A set of three psycho-
pathological characteristics comprising a voice known to
the patient, emotional involvement during the hallucina-
tions, and seeing the voice as real provides significant
predictivity of behaviour following command hallucina-
tions. These results are interesting for clinical and foren-
sic psychiatrists.
Copyright © 2002 S. Karger AG, Basel
Introduction
Some symptoms of schizophrenia are viewed as behav-
ioural abnormalities, such as catatonic symptoms or posi-
tive formal thought disorders. Command hallucinations,
indirect way. The gap between the symptom and action
should be bridged by a complex including speech, com-
prehension and readiness to act. With respect to clinical
conditions, some of the hallucinated commands are fol-
lowed by consecutive behaviour and others are not. There
is considerable need for the clinician to predict whether or
not hallucinations of the patients have consequences.
In this study, we attempted to answer the following
question: which psychopathological characteristics are of
value in predicting whether a patient will obey or resist
command hallucinations?
Data of predictive value available from forensic stud-
ies [1–3] and from phenomenological surveys [3–6] agree
that several factors together may be important, but the
main emphasis is laid on characteristics of the ‘voices’.
Our hypothesis, however, is that the patients’ attitude
toward these experiences plays an additional if not deci-
sive role.
Patients and Methods
All patients admitted consecutively to the Clinic of Psychiatry
and Psychotherapy in Aachen, Germany, in 1997 and 1998 were
included in the study if they met the criterion of hearing command
hallucinations. An a priori diagnosis of schizophrenia was not
required. Exclusion criteria were severe thought disorders, difficulty
in concentrating and uncooperative behaviour. A total of 31 patients
was included in the study, either due to a beginning psychotic disor-
der with command hallucinations or due to a relapse. All patients
gave informed written consent.

© 2002 S. Karger AG, Basel Prof. Ralf Erkwoh, MD, Senior Physician
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 Ten patients were female, 21 male; female patients had a mean Table 1. Two-component solution for psychopathological symptoms
age of 44.4 years (median 48.5, range 23–57 years), males 36.1 years according to PANSS (varimax-rotated loading matrix)
(median 35.0, range 17–58 years). Sixteen patients were married, 14
lived alone and 1 was widowed. Twenty-five had finished middle Item Factor 1 Factor 2
school, 6 high school. Average duration of illness was 63 months (me-
dian 37, range 7–398 months). According to DSM-III-R [7] criteria, Delusions 0.617 0.581
27 patients had a schizophrenic disorder of the paranoid type Hallucinations 0.028 0.726
(295.3), 3 a schizoaffective disorder (295.7) and 1 an organically Hostility 0.672 0.037
caused hallucinosis (293.82). All patients received neuroleptic thera- Blunted affect –0.865 –0.030
py throughout the study. Emotional withdrawal –0.838 –0.062
Psychopathological symptoms were assessed using PANSS [8] Motor retardation –0.645 0.353
and selected PANSS symptoms were then submitted to principal Formal thought disorders 0.723 –0.448
component analysis (PCA) with varimax rotation and Kaiser nor- Mannerisms 0.472 –0.602
malisation (SPSS, PC version 9.0). An eigenvalue of 1 1 was chosen
as the criterion for the number of principal components to be Explained variance, % 44.1 18.4
extracted. Symptoms for the principal component analyses were cho-
sen according to DSM-III-R criteria: 3 positive symptoms (delusions, Figures in italics are correlating with the corresponding factor.
hallucinations, hostility) corresponding to the psychotic dimension,
3 symptoms corresponding to the negative dimension (blunted
affect, emotional withdrawal, motor retardation), as well as formal
thought disorders and mannerisms, corresponding to a disorganisa-
tion dimension (table 1). N the overall sum of the answers. The 5% limit for the bilateral z test
For a more exact qualification of the auditory hallucinations and is 1.950 [9].
the patients’ readiness to obey, a 24-item questionnaire was devel- (4) In a sample of n individuals, analysed for t binary characteris-
oped and used in a semi-structured interview (Appendix). tics which are independent from each other and each quoted at p =
Item selection was based on the literature [1, 4–6] and on our own 0.5, all of the 2t patterns are equally probable. By the use of the con-
clinical experience. The patients were required to answer either ‘yes’ figuration frequency analysis [9], the value of probability for each of
or ‘no’, but they could add further details or descriptions. Eight the 2t patterns (‘configurations’) is given by the expected value e =
patients answered question No. 24 – whether they obeyed the voices n/2t. ¯2 components are used for testing whether an observed pattern
– with ‘yes’ if they obeyed always (n = 2) or usually (n = 6), i.e. the frequency f is significantly higher than expected, given by (f – e)2/e.
so-called ‘compliers’; 23 patients with ‘no’ if they obeyed rarely (n = In our sample, distinct combinations of predictors were analysed for
12) or never (n = 11), i.e. the so-called ‘non-compliers’. defining demarcated patterns of binary characteristics in order to
Identification of variables for predicting compliance with the hal- compare them in compliers and non-compliers.
lucinated voices was done using a secondary coding procedure [9] as (5) In addition, the presence or absence of certain response pat-
follows. terns for each predictor was determined in order to establish their
(1) Answers to question No. 1–23 (predictors) were coded ‘1’ if accuracy in predicting a patient’s inclination to obey or to resist the
the answers pointed in the same direction as question No. 24; other- voices. To that end, the relative risk Ú+ for compliers and Ú – for non-
wise, they were coded ‘0’. This procedure yielded a binary 0/1 matrix compliers were determined and tested to see if the value was signifi-
with 24 variables and 31 cases. Question No. 7 – whether the voices cantly larger than 1. The relative risk values are estimated from Ú+ =
were located inside the head – was omitted for the evaluation as the 2/1 and Ú – = 1 – 1/1–2 derived from an implementation of the
response profile for this item was inverse to that of question No. 8 – data in the tables of Fisher’s exact test, which is called ‘two binomial
whether the voices were located outside of the body – thus, providing sample’ procedure [10].
no further information. Questions, the wording of which appear to
mirror each other, were nevertheless reserved when the answer pro-
files were not inversely related.
(2) We split all predictor variables into those which describe
Results
properties of the voices (voice variables, questions No. 1–13) and
those which describe individual dispositions of the hallucinating Table 1 shows a two-component solution including all
patients (disposition variables, questions No. 14–23). The coding psychopathological symptoms in the PCA. Principal com-
rules are shown in the Appendix.
ponent 1 is characterised by a high correlation with for-
(3) Thus, the data matrix analysed further includes 22 binary
variables for 31 patients. mal thought disorders, hostility and delusions, as well as
Fisher’s exact test for 2 ! 2 tables was used for comparisons of an absence of blunted affect, emotional withdrawal and
compliers and non-compliers and individual item responses with motor retardation, while component 2 shows a high corre-
positive/negative key answers. lation with hallucinations and a low correlation with
McNemar’s formula for the four-field ¯2 test is
motor retardation.
z = (ad – bc)/sqrt(ABCD/N) Compliers (n = 8) were expected to show relatively
sqrt being the square root and a, b, c, and d being the sum of the cells, more code 1 answers than non-compliers (n = 23), and
A and B the sums of each row, C and D the sums of each column, and non-compliers to show relatively more code 0 answers.

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Table 2. Comparison of compliers and non-compliers with positive (1) and negative (0) answers, divided into voice and disposition
variables

All variables Voice variables Disposition variables

1 0 sum 1 0 sum 1 0 sum

Compliers (n = 8) a = 121 b = 55 A = 176 a = 68 b = 28 A = 96 a = 53 b = 27 A = 80

Non-compliers (n = 23) c = 314 d = 192 B = 506 c = 176 d = 100 B = 276 c = 138 d = 92 B = 230
C = 435 D = 247 N = 682 C = 244 D = 128 N = 372 C = 191 D = 119 N = 310

All variables: z = 1.592 (n.s.); voice variables: z = 1.255 (n.s.); disposition variables: z = 0.990 (n.s.).

Table 3. Comparison of voice and

disposition variables with compliers and Compliers (n = 8) Non-compliers (n = 23)
non-compliers 1 0 sum 1 0 sum

Voice variables a = 68 b = 28 A = 96 a = 176 b = 100 A = 276

Disposition variables c = 53 d = 27 B = 80 c = 138 d = 92 B = 230
C = 121 D = 55 N = 176 C = 314 D = 192 N = 506

Compliers: z = 0.653 (n.s.); non-compliers: z = 0.869 (n.s.).

Surprisingly, the z value of the test was lower than the
limit for the 5% niveau. Moreover, there was no signifi-
cant preference of voice nor of disposition items by com-
pliers or non-compliers (table 2).
According to our hypothesis that the patient’s attitude
towards these experiences plays an important role, apart
from the properties of the hallucinated voices, voice and
disposition variables were tested versus compliance.
There was no significant difference of the frequency of the
answers, neither between both types of variables in the
compliers nor in the non-complier group (table 3), affirm-
ing our hypothesis. Therefore, for the ongoing analysis,
both data sets could be pooled.
In the binary matrix, there was not one item coded 0
for all 23 non-compliers. There were, however, 3 items
coded 1 (prone to agree with voices) for all 8 compliers,
and 1 coded 1 for 7 compliers. The following 4 items were
chosen for further examinations: (1) familiar voice (No.
5); (2) not indifferent following hallucination (No. 16);
(3) being alone (No. 18), and (4) voice is instantly seen as
real (No. 23).
Nineteen patients recognized the voices as attributable
to a person known to them. Indifference following halluci-
nation was coded inversely, i.e., a negative answer was
coded as being positively predictive of compliance. Non-
indifference implies an affective reaction to the hallucina-
tions; here, the additional answers described affects such
as fear, despair, anger or restlessness, sometimes also hap-
piness. Twenty-one patients experienced these reactions.
Most of the patients (29 of 31) were alone when halluci-
nating and a majority (24 of 31) was uncritical toward
their hallucinations.
Table 4 shows a comparison of compliers (n = 8) and
non-compliers (n = 23) regarding the 0/1 coding for the
four characteristics chosen in order to analyse the re-
sponse pattern for frequency and distribution.
The comparison of compliers and non-compliers re-
garding the frequency of patterns reveals that the posthal-
lucinatory affective reaction, being alone, the assumed
reality of the voice and its familiarity occur most often in
compliers. Seven of 8 compliers show a 1-1-1-1 pattern.
This pattern is sufficiently sensitive but not exclusively
specific for compliers, as it is also found in 3 of the 23
non-compliers. Moreover, the pattern of the complier,
0-1-1-1, is identical to that of 6 of the non-compliers. The
possibility arises that two configurations exist with high
frequencies underlying the 2t answer patterns examined
in table 5.

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Table 4. A comparison of compliers vs. non- Table 5. Frequency analysis of configurations of 4 binary variables
compliers regarding the coding of 4 charac- with 31 patients
teristics of auditory hallucinations
Questions f e (f–e)2/e
Questions
5 16 28 22
5 16 18 22
1 1 1 1 10 1.9375 33.61
Compliers (n = 8) 1 1 1 0 2 1.9375 2.0
0 1 1 1 1 1 0 1 0 1.9375 1.9
1 1 1 1 1 0 1 1 5 1.9375 4.8
1 1 1 1 0 1 1 1 7 1.9375 13.21
1 1 1 1 1 1 0 0 0 1.9375 1.9
1 1 1 1 1 0 0 1 1 1.9375 0.5
1 1 1 1 0 0 1 1 1 1.9375 0.5
1 1 1 1 0 1 1 0 1 1.9375 0.5
1 1 1 1 1 0 1 0 1 1.9375 0.5
0 1 0 1 0 1.9375 1.9
Non-compliers (n = 23)
1 0 0 0 0 1.9375 1.9
0 1 1 0
0 1 0 0 1 1.9375 0.5
1 0 1 1
0 0 1 0 2 1.9375 2.0
1 1 1 1
0 0 0 1 0 1.9375 1.9
0 1 1 1
0 0 0 0 0 1.9375 1.9
1 0 1 1
1 1 1 1
f = Frequency of the configuration in the sample; e = expected
0 1 1 1
value of the configuration to occur.
1 0 1 1 1 1 ¯2 [unilateral; 0.01; (f 1 e); d.f. = 1] = 5.41.
0 0 1 0
1 0 1 1
1 0 1 1
1 0 0 1
0 1 1 1
0 1 1 1 fore, the item which occurred predominantly as code 1
0 0 1 1 among the (‘false’ group of) non-compliers, question No.
1 1 1 0
1 0 1 0
18 (being alone) is eliminated. For the remaining three
1 1 1 0 characteristics, a configural frequency analysis was car-
0 1 1 1 ried out in table 6.
1 1 1 1 As shown in table 6, the configuration of the 1-1-1 pat-
0 1 1 1 tern is unequivocal, with no counterpart that unambi-
0 1 0 0
0 0 1 0
guously samples non-compliers. These three characteris-
tics were also used to estimate the relative risk for com-
Questions: 5 = the patient knows who is pliance (table 7).
speaking; 16 = the patient is not indifferent The relative risk of patients showing all three signs
following hallucinations; 18 = the patient is (voice familiarity, posthallucinatory affective condition
alone when hearing voices; 22 = the patient
and reality check) being compliers compared with non-
immediately accepts the hallucinated voices
as real. compliers is estimated as Ú+ = 6.708. The exact 95% confi-
dence interval was computed using StatXact [10]. Since
the lower confidence interval limit (1.351–95.50) is well
above 1, there is a significantly higher risk of compliers to
have all three signs in common (p = 0.0113). Otherwise,
In fact, there are two significantly frequent configura- the relative risk of patients missing at least one of the
tions; one which comprises compliers (1-1-1-1) and anoth- three signs being non-compliers compared with compliers
er which characterises non-compliers (0-1-1-1). The sec- is Ú – = 6.957 with an exact 95% confidence interval lower
ond configuration, however, is very similar to the first limit of 1.401–85.07), also indicating that non-compliers
sharing three characteristics coded 1. No configuration present with a significantly higher probability of having
can be defined comprising a majority of 0 codes. There- less than all three signs (p = 0.0075).

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Table 6. Cluster analysis of 3 binary vari- Method
ables with 31 patients We used binary data analysis to answer the question
which symptoms accompanying command hallucinations
Questions f e (f–e)2/e
are of risk for the patient to obey or to resist. This method
5 16 22 is favourably applied in studies where responders should
answer in a predefined key direction (Appendix). Binary
1 1 1 10 3.875 9.71
1 1 0 2 3.875 0.9 data have, however, the disadvantage to truncate patient
1 0 1 6 3.875 1.2 answers to ‘yes’ and ‘no’, or to ‘1’ and ‘0’, respectively.
0 1 1 7 3.875 2.5 Configuration frequency analysis [9], developed on the
1 0 0 1 3.875 2.1 basis of binary data analysis, helped to determine the pat-
0 1 0 2 3.875 0.9
tern of symptoms (tables 5, 6) to be selected for the rela-
0 0 1 1 3.875 2.1
0 0 0 2 3.875 0.9 tive risk calculation [10]. Earlier studies of that topic used
correlation analyses [1, 26] which did not divide the
f = Frequency of the configuration in the patient samples into compliers and non-compliers and
sample; e = expected value of the configura- analysed only the interdependence of the variables.
tion to occur.
1 1 ¯2 [unilateral; 0.01; (f 1 e); d.f. = 1] =
PCA was performed to show the structure of the symp-
5.41. toms of our patient sample. We did not consider the psy-
chopathological symptoms found with PANSS since com-
ponent 2, a ‘hallucination factor’ (table 1), was correlated
with delusions and with no other symptom. Nevertheless,
on theoretical grounds, it is possible that formal thought
Table 7. A comparison of compliers vs. non-compliers regarding the disorders or uncooperative behaviour, used as exclusion
presence and the absence of 3 psychopathological characteristics criteria in our study, may provide conditions under which
(questions 5, 16 and 22) of auditory hallucinations in 31 schizo-
compliance with command hallucinations is arguable.
phrenics
Formal thought disorders combined with command hal-
Non- Compliers Total lucinations may prevent establishing an organized pattern
compliers of behaviour and may therefore prevent compliance. On
the other hand, formal thought disorders may be associat-
All 3 characteristics present 3 7 10
At least 1 characteristic missing 20 1 21 ed with increased impulsiveness as a trait of personality
disorders [35], and a lack of control of impulsiveness may
Total 23 8 31
favour behaviour induced by command hallucinations.
Similar considerations apply to uncooperative behav-
iour.

Risk Factors for Compliance with Command

Discussion
Command hallucinations can induce a behaviour
which is hardly predictable and may sometimes be dan-
gerous. Will the patient do what the voices tell him or her
to do? Although this question is of great practical value,
little is known about the connection between command
hallucinations and behavioural consequences. Since the
inception of first-rank symptoms by Kurt Schneider [40],
auditory hallucinations are regarded as being of primary
importance in the diagnosis of schizophrenia, which ac-
cording to DSM-IV [41] can be made solely on the ground
of this one symptom. Competence to predict behaviour
following command hallucinations is relevant for the
treatment of schizophrenia.
Hallucinations
Voice variables and disposition variables which mirror
the attitude of the patients to their hallucinations are of
equivocal importance (tables 2, 3). This result shows that
there is no satisfactory answer given to the question of
prediction unless the psychopathological analysis in-
cludes the nature of the ‘voices’. The triad of voice famil-
iarity, affective condition following hallucinations and
reality testing constitutes a combination which is helpful
when making a prognosis. Based on relative risk calcula-
tion, we found that there is a significantly higher risk of
compliers to have all three signs in common. Otherwise,
non-compliers show a significantly higher probability to
lack at least one of these three signs (table 7). This symp-
tom set appears suitable for clinical bed-side judgments.

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To our knowledge, our cohort of patients exhibiting the
psychopathological symptom of command hallucinations
is comparatively large. Nevertheless, cross-validation
with a new patient group is needed.
Identification of the Voice. In analyses of auditory hal-
lucination, it is well established to emphasize the proper-
ties of the voices. Cognitive models of the pathogenesis of
auditory hallucinations stress the hypothesis of dysfunc-
tional monitoring of inner speech [11–17]. Imaging tech-
niques have underlined the importance of linguistic neu-
ronal networks [18–22], but have also given ambiguous
findings [23]. Our results suggest that patients tend to
obey command hallucinations if the voice is familiar. Lis-
tening to a voice that is known to the listener seems to
increase the credibility of the voice. Junginger [24] also
considered voice familiarity a risk factor for compliance.
Possibly, in these cases, a stored voice memory is acti-
vated and via activation of the primary auditory cortex
(Heschl’s gyrus) reaches the hearing in form of a halluci-
nation [21]. As suggested by the findings of Frank et al.
[25] and Oulis et al. [26], however, the linguistic charac-
teristics of the hallucinations or their form of address
hardly allow a conclusion regarding compliance.
Reality Decision. Accepting hallucinations as real is an
important factor in obeying command hallucinations. All
compliers saw them as real, i.e., they were uncritical; but
not all uncritical patients obeyed their commands. There-
fore, accepting hallucinations as real does not provide suf-
ficient reason for compliance. Reality testing theories [27,
28] assume that schizophrenics see their hallucinations as
real when their source is externalised (given that real
acoustic signals usually originate from outside of the
body) [29]. In our sample, there were 5 of 8 compliers who
externalised versus only 6 of 23 non-compliers. Drawing
on Jasper’s [30] definition that ‘genuine’ hallucinations
are real, objective and occur outside of the body, the
voices inside the head described by our patients could
thus be considered pseudohallucinations.
Being alone played a minor role as a predictor of com-
pliance. It implies the absence of competing external stim-
uli to the cortex, which processes acoustic signals or, in the
case of hallucinations, generates them. When asked to lis-
ten to music or the news [31] or to read a short story out
loud, schizophrenics undergoing controlled hallucination
report a suppression of their hallucinations [32, 33]. Fal-
loon and Talbot [34] reported that a number of patients
they interviewed increased social contact in an attempt to
cope with the voices.
Affective Alterations. From a scientific point of view, it
is noteworthy that with posthallucinatory affective reac-
Command Hallucinations
tion, a new aspect, an emotional response, is emphasized
as the third element bridging symptom and compliance.
All compliers showed posthallucinatory affect (non-indif-
ferent), in contrast to their condition prior to hearing
voices. These patients gave additional descriptions when
reporting non-indifference following hallucinations,
which were mainly negative emotions such as fear, de-
spair, anger or restlessness, rarely happiness. These nega-
tive emotions could be a link between the semantic con-
tent of the hallucinations and the patient’s behaviour.
They evidently favour a connection between illusion and
action, or of compliance in Junginger’s [2] sense, i.e., a
heightened readiness to obey.
Forensic Consequences
Predictors of behaviour following command hallucina-
tions have been dealt with before, especially in the foren-
sic literature. However, the cases described included
chronic schizophrenia [36], a history of violent crimes
[37], delusional interpretations of hallucinations or, as
in our study, familiarity with the voice [24]. Patients
with such abnormal experiences cannot be distinguished
clinically or prognostically from paranoid-hallucinatory
schizophrenics [3].
The forensic literature deals particularly with the dan-
ger of acts resulting from command hallucinations. Exam-
ining a small cohort of convicted criminals showing these
symptoms, Rogers et al. [38] pointed out the singular
aggressivity of the voices heard and the fact that they
often talked of self-punishment. On the other hand, Hel-
lerstein et al. [39], examining a psychiatric in-patient
cohort, found no differences in the danger of harming
oneself or others between patients with command halluci-
nations and those with other types, such as commenting
or dialoguing hallucinations. According to Junginger [2],
command hallucinations show a distinct possibility of
influencing the patient’s behaviour precisely when they
do not give dangerous instructions, whereas the reverse
would facilitate the patient’s compliance with other in-
structions. This would lend particular weight to the corre-
lations between command hallucinations and compliance
or non-compliance found for this symptom in the present
psychopathological analysis.
Acknowledgement
The authors thank A. Rodón for translation and editing.
Psychopathology 2002;35:272–279 277
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 Appendix
Questionnaire, trait coding 0/1, hypothetical basis of rules for coding of compliance/non-compliance
1 How many voices do you hear? (If one voice, it is coded 1, as it is
easy to obey one voice; if more than one, it is coded 0, as it is
difficult to obey several different voices)
2 Do the voices address you directly? (If the patient is addressed
personally, it is coded 1, as being addressed directly makes obey-
ing easier; if not addressed personally, it is coded 0)
3 Do the voices command using address in the third person (he or
she)? (If not, it is coded 1; if yes, it is coded 0, as being addressed
in the third person makes obeying more difficult)
4 Is it a human voice? (If yes, it is coded 1, as it is familiar to obey a
human voice; if the sound is unsimilar to a human voice, it is
coded 0)
5 Do you know who is talking to you or about you? (If the voice is
attributed to known persons, it is coded 1, as it is easier to obey a
familiar voice; in case of an alien voice, it is coded 0)
6 Do you hear the voices very often or constantly? (If often, it is
coded 1, as it is more likely to obey an intrusive command; if the
voices are rarely heard, it is coded 0)
7 Are the voices located inside your head? (If not, it is coded 1; if
yes, it is coded 0, as within-head localisation is unusual)
8 Are the voices located outside of your body? (If yes, it is coded 1,
as out-of-body localisation is normal in hearing; if not, it is
coded 0)
9 Do the voices speak in regular conversation volume? (If yes, it is
coded 1, as loudness of conversation corresponds to normal con-
ditions; in deviating cases, it is coded 0)
10 Do the voices whisper? (If not, it is coded 1, as the voices should
otherwise be understandable; if yes, it is coded 0, as whispering is
unusual)
11 Do the voices speak in full sentences? (Speaking in full sentences
is coded 1, as commands tend to be obeyed more readily when
given in full sentences, any different version is coded 0)
12 Do the voices speak in single words? (If not, the voice is sup-
posed to be well designed and is coded 1; single-word commands
are harder to obey being coded 0)
13 Do the voices talk all at the same time? (For a single voice, the
risk to obey is deemed high and coded 1; if yes, it is coded 0, as it
is hard to obey when the voices are all talking at the same time)
14 Were you calm before you started hearing the voices? (For not
being calm, there is a variety of irritable or nervous conditions to
note; they are all coded 1; calmness is coded 0, as a relaxed
patient is stabler and less likely to obey)
278 Psychopathology 2002;35:272–279
15 Were you nervous before you started hearing the voices? (A sim-
ple ‘yes’ is coded 1, as nervousness is associated with a higher
predisposition to obey; if not, it is coded 0)
16 Were you emotionally indifferent after hearing the voices? (For
not being indifferent, there is a variety of irritable or nervous
posthallucinatory conditions to note; they are all coded 1; for
indifference, it is coded 0, as indifference is associated with sta-
bility and a lower predisposition to obey)
17 Were you nervous after hearing the voices? (A simple ‘yes’ is
coded 1, as posthallucinatory nervousness is associated with a
higher predisposition to obey; if not, it is coded 0)
18 Were you alone when you heard the voices? (When alone, it is
coded 1, as there are fewer distractions when one is alone; when
not alone, it is coded 0)
19 Were you doing something when the voices started? (When not
engaged in activity, it is coded 1, as there would not be any dis-
tractor; otherwise, it is coded 0, as a patient who is currently
engaged in an activity tends to be distracted from hallucina-
tions)
20 Were you talking to someone when the voices started? (When
silent, it is coded 1, as hallucinations can be suppressed by con-
versation; when in conversation, it is coded 0)
21 Can you suppress or stop the voices? (When there is no interrup-
tion, it is coded 1, as hallucinations are experienced as indepen-
dent of the will; otherwise, it is coded 0, as suppression of halluci-
nations implies control)
22 When you hear the voices, do you think that the commands you
hear were actually said? (If the hallucination is instantly taken as
real, it is coded 1, as commands believed to be real are followed
more readily; if not, it is coded 0)
23 After hearing the voices, do you ever think about whether these
perceptions are actually possible? (If a belated consideration
comes to the judgment of the hallucination to be real, it is coded
1, as critical thinking constitutes an additional reality check; in
the negative case, it is coded 0)
24 Did you ever do what the voices told you to do? (A complier is
coded 1; a non-complier is coded 0)
Erkwoh/Willmes/Eming-Erdmann/Kunert
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