Asking about psychosis
The questions themselves, why the preface matters, and how to record a negative finding so that nobody later assumes the domain was skipped.
Screening for psychosis is where interviews most often go wrong, in one of two directions. Either the questions are so hedged that nobody understands what is being asked, or they are so leading that the answer was contained in the question.
Both produce unusable findings. This is a guide to asking plainly.
Prefacing the questions
These questions sound strange to someone who has never been asked them. Without a preface, a person may reasonably conclude you have already decided something about them.
"I am going to ask some questions that may sound unusual. I ask everyone these — is that alright?"
Two things are doing work here. Normalising ("I ask everyone") removes the implication that something about this person prompted it. Asking permission gives them a moment to prepare, which matters more than it sounds when the next question is about hearing voices.
Place this section after you have established some rapport, not in the first two minutes. People disclose unusual experiences to someone who has already listened to something ordinary.
Hallucinations, by modality
The commonest omission is assuming auditory. Visual, olfactory, gustatory and tactile hallucinations all occur, and some carry particular significance — prominent visual hallucinations should prompt thought about delirium, substance use or an organic cause rather than being folded into a psychiatric picture.
"Have you ever heard someone speaking when there was no one there?"
"Have you heard noises or voices that other people could not hear?"
"Do you ever see things that other people cannot see?"
"Have you seen anything recently that you were not sure was really there?"
"Any unusual smells that others do not notice?"
"Has your food or drink tasted different lately?"
"Do you ever feel something touching you when nothing is there?"
"Any unusual sensations in your body — anything moving, or crawling?"
Note the phrasing "when there was no one there" rather than "voices that are not real". The first describes the circumstance. The second tells the person what you think, and invites them either to agree with you or to defend the experience.
Getting the detail that matters
A positive answer is the start. What makes the finding usable is the detail, and "auditory hallucinations present" without it tells the next clinician almost nothing.
"Do the voices talk to you, or about you?"
"How many voices are there? Do you recognise them?"
"Do they comment on what you are doing?"
"What do they say?"
"Do they ever tell you to do things?"
"Have you ever felt you had to act on what they said?"
"How distressing is it?"
"When is it worst? Does anything help?"
"Does it happen when you are fully awake, with your eyes open?"
Experiences occurring only while falling asleep or waking (hypnagogic and hypnopompic) are common in the general population and are not psychotic phenomena. Asking whether it happens when fully awake separates them without needing to explain why you are asking.
Command content deserves specific enquiry because it is one of the few perceptual findings that changes what needs recording about safety. Ask what the commands say, whether the person has acted on them, and what has stopped them.
Asking about beliefs
Beliefs are harder to ask about than perceptions, because the question implicitly challenges something the person may hold with complete certainty. Open questions work better than a checklist.
"What has been taking up most of your thinking lately?"
"Do you have any beliefs that other people find hard to accept?"
"Has anything unusual been happening to you?"
"Do you ever feel that people are watching you, or out to harm you?"
"Do you feel safe where you are living?"
"Has anyone been interfering with your food, or your post, or your phone?"
"Do things on television, or online, ever seem to have a special message for you?"
"Do strangers ever seem to be talking about you?"
"Do you ever feel you have abilities or a purpose that others do not recognise?"
"Have you had any plans recently that others thought were unrealistic?"
Then test conviction, gently, because that is what distinguishes a delusion from an overvalued idea: "Has there been any moment when you have wondered whether there might be another explanation?"
Passivity phenomena
Almost nobody volunteers these. If they are not asked about directly they will not appear in the record, and they carry considerable diagnostic weight.
"Do you ever feel thoughts are being put into your head that are not your own?"
"Do you ever feel thoughts are being taken out of your mind?"
"Do you ever feel other people can hear or read your thoughts?"
"Do you ever feel your actions or feelings are being controlled by something outside you?"
Follow a positive answer with "how do you think that happens?" The explanation is often the most informative part, and it is worth quoting.
Why leading questions fail
A leading question produces an answer you cannot rely on, and the record inherits the problem.
"You are not hearing voices, are you?"
"The voices are telling you to hurt yourself, aren't they?"
"You know these thoughts are not real, don't you?"
"Have you heard someone speaking when there was no one there?"
"What do the voices say?"
"What do you make of these experiences?"
The first column shares a feature: each contains the expected answer. A person who wants the interview to end, or who has learned that certain answers lead to admission, will take the offer. So will someone acquiescent through illness or exhaustion.
The last pair matters especially. "You know these are not real, don't you?" both leads and argues. "What do you make of these experiences?" produces the insight finding you were actually looking for.
What to observe while you ask
Half of this domain is observation, and it continues whether or not the person is answering.
- Does the person appear to respond to stimuli you cannot perceive — glancing at an empty part of the room, muttering, pausing as if listening?
- Does their attention break away mid-sentence and return?
- Does the affect fit what is being described? Distress while describing a frightening experience is congruent; laughter is a finding worth recording.
- Do they lower their voice or check the door when certain topics come up?
Someone may deny hallucinations while appearing to respond to them. That is not a contradiction to resolve in the note — it is a finding, and both halves belong in the record, stated plainly.
Recording what you find
Modality, form, content, frequency, distress, and what you observed. Quote where you can.
Auditory hallucinations were described: second person, speaking to him, and a running commentary. He reports two voices, daily and worse at night, which he describes as "commenting on what I am doing". He finds them frightening but says they do not instruct him to act. Hallucinations in other modalities were denied. He was not observed responding to unseen stimuli during the interview.
And the negative case, which matters just as much:
Hallucinations in all modalities were denied on direct questioning, and he was not observed responding to unseen stimuli. He described no unusual beliefs and no passivity phenomena were elicited.
That paragraph takes fifteen seconds to write and establishes that the questions were asked. A blank space establishes nothing, and will be read as though the domain was never covered.
Common questions
How do I ask about hallucinations without leading the patient?
Describe the circumstance rather than judging the experience. 'Have you heard someone speaking when there was no one there?' asks about an event. 'Are you hearing voices that are not real?' tells the person what you think and invites them either to agree or to defend themselves. Open questions produce findings you can rely on.
Which modalities should I ask about?
All of them. Auditory, visual, olfactory, gustatory and tactile. Assuming auditory is the commonest omission. Prominent visual hallucinations in particular should prompt consideration of delirium, substance use or an organic cause rather than being folded into a psychiatric picture.
What are passivity phenomena and how do I ask about them?
The experience that thoughts, feelings, impulses or actions are controlled by an outside agency. Four questions cover it: thoughts being put in, thoughts being taken out, others hearing or reading one's thoughts, and actions being controlled externally. People almost never volunteer these, so they must be asked about directly.
Should I record that hallucinations were denied?
Yes. A blank in the perception domain will be read as the domain never having been covered. One sentence stating that hallucinations in all modalities were denied on direct questioning, and whether the person was observed responding to unseen stimuli, establishes that the enquiry was made.
What if someone denies hallucinations but appears to be responding to them?
Record both. It is a common and clinically important discrepancy rather than a contradiction to resolve on the page. Write what the person said and what you observed, plainly and separately, and let the reader weigh them.