What is the proper way to document auditory hallucinations in a psychiatric mental status examination (MSE) for a patient with a history of schizophrenia and substance abuse?

Documentation of Auditory Hallucinations in Psychiatric Mental Status Examination

Document auditory hallucinations in the MSE by systematically recording their presence, phenomenological characteristics (content, frequency, intensity), associated features (command nature, running commentary, conversing voices), the patient's response and insight, and their impact on functioning. 1

Core MSE Documentation Components

Perceptual Disturbances Section

Record the following essential elements:

• Presence and modality: Explicitly state "auditory hallucinations present" in the perception section of the MSE 1
• Content specificity: Document what the voices say (e.g., derogatory comments, commands, running commentary on behavior) 2
• Number of voices: Note whether single or multiple voices, and if multiple voices are conversing with each other—this is diagnostically significant 3
• Location: Specify if voices are perceived as internal (inside head) versus external (outside head), as externality is a key phenomenological feature 2

Phenomenological Characteristics to Document

Capture these specific dimensions:

• Frequency: How often hallucinations occur (constant, intermittent, episodic) 1, 2
• Intensity/loudness: Rate severity from mild to severe 1, 2
• Command nature: Explicitly note if voices give commands, and whether commands are harmful to self or others 2
• Running commentary: Document if voices provide ongoing narration of patient's actions—this meets lower diagnostic threshold 3
• Conversing voices: Note if two or more voices talk to each other about the patient—diagnostically significant 3

Patient Response and Insight

Document the patient's relationship to the hallucinations:

• Belief about reality: Does patient recognize voices as hallucinations versus believing they are real external stimuli 2
• Emotional response: Document associated distress, fear, or comfort with the voices 2
• Behavioral response: Note if patient responds verbally to voices, follows commands, or uses coping strategies 4
• Degree of control: Document whether patient feels controlled or influenced by the voices 2

Associated Psychotic Features

Always assess and document co-occurring symptoms:

• Delusions: Particularly delusions of control, thought insertion, or thought broadcasting, which strongly associate with auditory hallucinations 5
• Other sensory hallucinations: Visual, tactile, or olfactory hallucinations often co-occur 1, 5
• Disorganized speech or behavior: Required for comprehensive diagnostic assessment 1, 3
• Negative symptoms: Document diminished emotional expression or avolition 1

Critical Diagnostic Distinctions

Rule Out Alternative Etiologies

Document assessment of non-psychotic causes:

• Substance use: Current intoxication or withdrawal states 1, 3
• Medical conditions: Delirium, CNS lesions, metabolic disorders, seizures 1
• Trauma history: PTSD-related hallucinations differ from primary psychotic disorders 6
• Mood episodes: Assess temporal relationship to manic or depressive episodes 3, 5
• Level of consciousness: Unlike delirium, consciousness remains intact in primary psychosis 1, 3

Functional Impact Documentation

Record specific functional consequences:

• Social functioning: Isolation, interpersonal difficulties 1
• Occupational/academic performance: Deterioration from baseline 1, 3
• Self-care: Changes in hygiene or daily living activities 1
• Safety concerns: Risk of harm to self or others based on command hallucinations 2

Common Documentation Pitfalls

Avoid these errors:

• Insufficient detail: Simply writing "auditory hallucinations present" without phenomenological characteristics provides inadequate clinical information 2, 4
• Assuming psychotic disorder: Persistent auditory hallucinations alone do not confirm schizophrenia spectrum disorder without additional A-criteria symptoms 3, 6
• Ignoring temporal pattern: Document duration (must be ≥6 months for schizophrenia diagnosis) and relationship to mood episodes 1, 3
• Missing collateral information: Family/caregiver reports are essential for accurate assessment of course and functional decline 1, 7

Documentation Template Structure

Use this systematic format:

Perception: Auditory hallucinations present. Patient reports [number] voice(s) [internal/external location] occurring [frequency]. Content includes [specific examples]. Voices [do/do not] give commands [specify if harmful]. [Running commentary/conversing voices present/absent]. Patient [believes voices are real/recognizes as hallucinations]. Associated with [moderate/severe] distress. Patient [does/does not] respond behaviorally to voices. 1, 2