Can Patients with Auditory Verbal Hallucinations Have Good Insight and Judgment?
Yes, patients with auditory verbal hallucinations (AVH) can absolutely have preserved insight and judgment, and this is actually a critical distinguishing feature that helps differentiate between different underlying conditions causing the hallucinations.
Key Clinical Principle: Insight Varies by Etiology
The presence or absence of insight in patients experiencing AVH is diagnostically significant and should guide your clinical approach:
When Insight is Typically Preserved
Charles Bonnet Syndrome patients have true visual hallucinations with preserved insight, recognizing their hallucinations as unreal 1, 2.
Parkinson's disease psychosis characteristically shows preserved insight initially—patients recognize their hallucinations as unreal early in the course, which is uncommon in primary psychotic disorders 3.
Healthy individuals experiencing AVH demonstrate good insight and judgment, as approximately 70% of patients with schizophrenia experience AVH, but a significant minority of healthy individuals from the general population also experience them with preserved insight 4.
When Insight is Typically Impaired
Primary psychotic disorders (schizophrenia, schizoaffective disorder) typically feature impaired insight, with patients believing their hallucinations are real external phenomena 3.
Prominent auditory hallucinations with command voices or running commentary suggest schizophrenia rather than conditions with preserved insight 3.
Practical Assessment Algorithm
Step 1: Determine if insight is present
- Ask directly: "Do you believe these voices are real, or do you recognize them as coming from your own mind?" 1, 2
- Patients with preserved insight will acknowledge the hallucinations are not real external stimuli 1.
Step 2: Evaluate the clinical context
If insight is preserved, prioritize evaluation for:
If insight is impaired, consider:
Step 3: Use validated assessment tools
- The Birchwood Insight Scale (BIS) specifically measures levels of insight in patients with hallucinations 6.
- The Self-assessment of Auditory verbal Hallucinations (SAVH) scale showed no significant correlations between AVH severity and levels of insight, confirming that AVH can occur with preserved insight 6.
Critical Clinical Pitfalls to Avoid
Do not assume impaired insight based solely on the presence of AVH 1, 2. This is a fundamental error that can lead to misdiagnosis and inappropriate treatment.
Do not prematurely diagnose primary psychiatric illness without ruling out ophthalmological and neurological causes, especially when insight is preserved 2.
Recognize that insight can change over time in neurodegenerative conditions—early preserved insight may deteriorate as disease progresses 3.
Consider that communication limitations in patients with intellectual disability may hinder recognition of insight, but this does not mean insight is absent 5.
Judgment Assessment Considerations
Deficits in socialization, comprehension, and executive functioning can make some individuals prone to poor social judgment and decision-making even with preserved insight into their hallucinations 5.
Depression has a complex relationship with cognition and can mimic or worsen cognitive impairment affecting judgment, independent of hallucination-related insight 5.
Cognitive capability to describe or understand medical conditions may be suboptimal in patients with intellectual disability or psychotic illness, requiring collateral information from caregivers 5.
Monitoring Approach
Serial assessments across care transitions are essential, as insight and judgment can fluctuate with disease progression, treatment response, or environmental factors 5.
Use both patient self-report and informant versions of assessment tools, as patients may not be aware of their symptoms or difficulties may not be recognized by family 5, 3.
The SAVH scale enables patient self-assessment, which may enhance symptom awareness and increase insight over time 7, 6.