What psychiatric assessment questions should be completed for a patient presenting with hallucinations, considering their demographic information, medical history, and potential underlying conditions?

Psychiatric Assessment Questions for Hallucinations

A comprehensive mental status examination should assess the patient's appearance, behavior, thought process, thought content (including presence or absence of hallucinations or delusions), mood and affect, and insight and judgment, with specific focus on characterizing the hallucination modality, frequency, severity, and associated symptoms. 1

Core Assessment Components

Hallucination Characteristics

• Modality identification: Determine whether hallucinations are visual, auditory, tactile, gustatory, or olfactory, as this provides critical diagnostic clues 1, 2
• Visual hallucinations are the dominant presentation in conditions like Parkinson's disease psychosis (up to 80% of cases) and dementia with Lewy bodies, whereas auditory hallucinations with command voices or running commentary suggest primary psychotic disorders like schizophrenia 3
• Frequency and severity: Document both how often hallucinations occur and their intensity, as severity-based scoring has greater clinical relevance than frequency alone 1
• Complexity: Assess whether hallucinations are simple (flashes of light, sounds) or complex (formed images, voices with content), as complex visual hallucinations occurring acutely suggest organic causes 2
• Insight preservation: Determine if the patient recognizes hallucinations as unreal—preserved insight initially is characteristic of Parkinson's disease psychosis and Charles Bonnet syndrome, not primary psychotic disorders 4, 3, 5

Associated Psychiatric Symptoms

• Delusions: Screen for presence of delusions, as their combination with hallucinations helps differentiate primary versus secondary psychosis 1
• Disorganized speech or thought: Document presence of thought disorder, which is more common in primary psychotic disorders 1
• Negative symptoms: Assess for diminished emotional expression, avolition, and alogia, as these suggest schizophrenia spectrum disorders when present with hallucinations 1, 2
• Mood symptoms: Evaluate for depression or mania, as psychotic symptoms can occur in mood disorders with psychotic features 1
• Agitation and behavioral changes: Document associated agitation (present in 41% of pediatric cases with hallucinations) 2

Temporal Pattern and Context

• Onset timing: New-onset hallucinations in older adults (≥65 years) have higher likelihood of medical causes, while onset after age 10 in children suggests psychiatric etiology 1, 2
• Duration: Acute onset (77% in pediatric series) favors organic causes, while chronic duration suggests primary psychiatric disorder 2
• Fluctuation pattern: Assess whether symptoms fluctuate throughout the day with lucid intervals, which is characteristic of delirium 1
• Previous episodes: Document history of identical episodes, as recurrence suggests underlying psychiatric disorder 2

Medical and Substance History

Critical Screening Questions

• Current medications: Review all medications, as 41% of drugs associated with hallucinations have known hallucinogenic adverse effects 2
• Substance use: Obtain detailed substance use history including alcohol, illicit drugs, and recent withdrawal, as these are common secondary causes 1
• Medical conditions: Screen for infections (especially urinary tract infections and pneumonia), endocrine disorders, autoimmune diseases, neurological disorders, and nutritional deficiencies 1
• Fever and vital signs: Document presence of hyperthermia (present in 21% of pediatric cases) and other vital sign abnormalities, as these suggest organic etiology 2
• Headaches: Ask about headaches (present in 28% of pediatric cases with hallucinations), which may indicate neurological causes 2

Neurological Assessment

• Level of consciousness: Distinguish between intact awareness (typical in primary psychosis) versus altered consciousness (suggests delirium or other organic causes) 1
• Focal neurological signs: Assess for focal deficits that would indicate structural lesions along the visual pathway 1
• Delirium screening: Use validated tools like the Confusion Assessment Method (CAM) when delirium is suspected, as inattention is a cardinal feature 1

Family and Developmental History

• Psychiatric family history: Document parental psychiatric history, as this correlates with psychiatric causes of hallucinations (p=0.036 in pediatric study) 2
• Personal psychiatric history: Previous psychiatric diagnoses and prior hallucinatory episodes (93% of children with psychiatric history had experienced hallucinations before) 2
• Developmental factors: In children and adolescents, consider whether symptoms could represent psychotic-like phenomena due to developmental delays, trauma exposure, or overactive imagination rather than true psychosis 4
• Cultural context: Cultural factors may influence how patients describe their experiences and should be considered when differentiating pseudohallucinations from true hallucinations 4

Safety Assessment

• Suicidal ideation: For patients with hallucinations and any psychiatric symptoms, assess current and recent suicidal ideation, as this determines level of care 1
• Command hallucinations: Specifically ask about voices commanding self-harm or harm to others 3
• Risk to others: Evaluate concerns about harm to others, which may require breaking confidentiality 1
• Behavioral response: Assess whether patient acts on hallucinations or has insight to resist them 4

Collateral Information

• Interview caregivers separately: Obtain information from family members or caregivers, as patients frequently minimize symptom severity 1
• Functional impact: Document how hallucinations affect daily functioning and caregiver burden 1
• Precipitating factors: Identify any triggers or circumstances surrounding hallucination onset 2

Common Pitfalls to Avoid

• Do not assume visual hallucinations always indicate organic pathology—they can occur in primary psychiatric disorders, though auditory hallucinations are more common in schizophrenia 1, 3
• Do not overlook Charles Bonnet syndrome in patients with visual impairment who have visual hallucinations with preserved insight 4, 5
• Do not miss delirium by failing to screen for inattention and fluctuating consciousness, as mortality doubles when delirium is missed 1
• Do not order routine brain imaging without clinical indication based on history and physical examination, as routine CT scanning in psychiatric patients has low yield and exposes children to unnecessary radiation 1
• Do not ignore seasonal patterns—hallucinations in children show bimodal seasonal distribution with peaks in spring and fall 2