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Hearing voices doesn’t mean you need antipsychotics

SOURCE: Fugitive Psychiatrist
September 1, 2019 January 1, 2020 Antipsychotics, Rants

Words are a funny thing. “Psychosis” is a term used ubiquitously despite having no formal definition.

The DSM describes psychotic disorders as being “defined by abnormalities in one or more of the following five domains: delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms.”

The specifier “with psychotic features” can be applied to non-psychotic disorders if either delusions or hallucinations are present.

But the DSM is not the only act in town.

My friend’s younger brother recently described a Bumble date as “psychotic” but upon further questioning, I discovered he really meant insecure and prone to rage attacks. He wouldn’t give me her number, so I could not confirm his hypothesis, but judging by the degree of body art it seemed promising. Either way, it’s very unlikely this person suffers from a psychotic disorder, but much less unlikely that she uses “psychotic” defenses such as denial, distortion, and projection, especially when fighting with a recently idealized sex partner.

The consistent (or intermittent) use of psychotic ego defenses is another means by which you can be labelled “psychotic” although this is different from the DSM definition, and largely ignored by contemporary psychiatry. These defenses imply an absence of reality-testing (awareness of what is real/true), and this is probably why psychosis is often generally defined as being “out of touch with reality” or having “impaired reality testing” to use some jargon.

Now, contrast the DSM symptom-based diagnosis to notion that psychosis involves a lack of reality testing at some level.

Delusions, by definition, in the DSM, are “fixed false beliefs that are not amenable to change in light of conflicting evidence” and these necessarily imply an absence of reality testing.

Hallucinations, in the DSM, are “perception-like experiences that occur without an external stimulus” and these may or may not involve an absence of reality testing.

Consider these scenarios:

The last time I did mushrooms I was on a boat seeing things that were not real. It would be incorrect to call me psychotic, in the sense of being out of touch with reality, because I knew that what I was seeing was not real and a result of hallucinogenic fungi, but I was still hallucinating nonetheless.

Imagine your next Bumble date tells you she hears voices, since she was 12, telling her to kill herself, but she knows these voices aren’t real, they sound like her hostile mother but she know’s it’s not really her actual mother’s voice, and they have no power or control over her. They are mostly just annoying and remind her that her mom is a relentless bitch.

These are what we call non-psychotic hallucinations because, despite the fact that we are hallucinating, we know we are hallucinating. In other words, our ability to discern real from not real remained intact.

We used to call these pseudohallucinations but we can’t anymore because the people who rely on moral outrage to justify their existence have more or less agreed that it’s stigmatizing to use the prefix pseudo to describe anything (e.g., pseudoseizures, pseudodementia). For the same reason I am supposed to say “an individual with alcohol use disorder” as opposed to “alcoholic” because the latter is offensive, except apparently when used by AA.

The DSM mentions in passing pseudohallucinations in two contexts: PTSD, and grief reactions in other cultures. But pseudohallucinations are a hell of a lot more common than their absence in the DSM, or the average psychiatry residency training program, let’s on.

I am all for treating psychosis, in the sense of impaired reality testing. Most people would become violent to protect themselves or their family. Imagine someone truly believes, without a doubt, that their neighbor is planning to kill them and the police are in on it, or that they have to kill themselves to stop a cult from sacrificing their family instead. You don’t have to be clairvoyant to see how delusions like this can turn tragic.

Schizophrenia today carries a variable prognosis, although the fact that it used to be called dementia praecox, as in premature dementia, should give you an indication that often the prognosis wasn’t great. People tend to equate hearing voices with “psychosis” and specifically schizophrenia, and although it is possible that hearing voices might be indicative of schizophrenia, statistically speaking, it is far more likely that it isn’t.

The lifetime prevalence of schizophrenia is believed to be about .5-.7% of the population (1). The lifetime prevalence of auditory hallucinations, especially hearing voices, has been estimated to be anywhere between 10-20% (1, 2, 3, 4, 5, 6), roughly proportional to the proportion of the population who will be diagnosed with any psychiatric disorder. In some psychiatric patient samples, the prevalence starts to creep up to 30-40% (1, 2, 3).

There is no fucking way that all of these people have schizophrenia, nor will most of them develop it (1, 2, 3, 4). And there is no way that these people are all walking around, floridly psychotic, without the capacity to tell what’s real and what isn’t. Most of these people are experiencing non-psychotic hallucinations, and otherwise living normal lives, or as normal as the typical psychiatric outpatient.

Why do so many people experience pseudohallucinations?

The leading theory is they are like a type of dissociative experience (1, 2, 3), which makes sense since they seem to be more common in disorders where dissociation is also common (e.g., PTSD), and like dissociation, are often triggered by acute stress.

At this point, someone who believes that trauma causes everything will assert that they are caused by trauma, which I’m sure is true to some extent (1). We could also have a discussion about how borderline personality disorder got its name (1, 2).

But again, in most of the trauma-psychosis research, there’s that language problem. In the same way that hearing voices shouldn’t be considered synonymous with schizophrenia, or severe/debilitating/progressive symptoms, you can’t use trauma to predict “psychotic-like” experiences, which includes non-psychotic and/or other dissociation-like phenomena, and assume this also applies to hebephrenic schizophrenia.

I don’t know why so many people experience pseudohallucinations, and to be honest I don’t care that much. Someone much smarter than me will make sense of all these studies, with their inconsistent, overlapping definitions.

I’m a simple man. I like simple answers to simple questions:

How many Creed songs can you have on your phone before you cross the line between liking Creed ironically and being an actual Creed fan?


How often does E-40 leave his house without his strap?


Two simple questions, with simple, obvious answers.

Do you always need to treat non-psychotic hallucinations with antipsychotics?

Is there a clear potential for harm and/or deterioration that can only be mitigated with medication?

Two more simple questions, and the answer to both, as far as I can tell, is no.

Two or so times a month I see the exact same patient in the emergency room:

16- to 35-year-old woman presents voluntarily to the hospital with suicidal ideation, although she will insist someone made her come.
Incidentally reports a life-long history of hearing voices that insult her and tell her to kill herself, most days, usually when she is alone, after something stressful happens, or after visiting her family.
She uses the phrase “auditory hallucinations” to describe these voices.
The diagnosis given by her primary provider is usually schizoaffective disorder or psychotic depression, among other things.
She is always on one or more antipsychotics.
She has usually had several admissions for self-harm, but never for psychosis, and possibly an unsuccessful course of ECT.
Her “paranoia” consists of worrying that her boyfriend or husband will leave her, or cheat on her, with intermittent “manic episodes” that consist of losing her shit for a few hours, then crying alone and possibly cutting.
If there is a trauma history, then her “paranoia” also consists of worrying that she will be re-traumatized in the same way she was previously.
She usually has a job, or is in school, but if not it’s because she’s been too depressed to work. If there’s a problem at work, it’s that she keeps quitting jobs, not that she can’t do them.
When speaking to her, she appears to be completely healthy and normal, aside from all the piercings and shit.

I’m not trying to suggest here this is exclusively a female presentation, it’s not. There are an equal number of men like this. I just don’t see them very often because I don’t work in a jail.

When possible, I stop or recommend stopping antipsychotics for these people, and nothing bad ever happens.

Unfortunately there are a lot of people like this, on a bunch of antipsychotics they don’t need, because this is what happens when a patient says “hearing voices” and their doctor’s brain automatically makes an association with schizophrenia, Shutter Island, and olanzapine. They don’t ask themselves “are these just non-psychotic hallucinations that don’t require treatment” because most of the time they have no concept of what non-psychotic hallucinations are. No, they didn’t skip this lecture to cram for the surgery NBME, there was no lecture. It doesn’t help that the DSM has essentially equated psychosis with hallucinations regardless of how severe or impairing the hallucinations may be.

The moral of the story is that you don’t need to panic and prescribe an antipsychotic just because someone tells you they hear voices. You still need to assess the course, severity, and level of insight, other potential symptoms, the degree of functional impairment, and the potential for harm/deterioration, just like with everything else. Then you decide if medication is warranted, not before.

If you do this consistently, I believe you will find that chronic, stable, pseudohallucinations with intact reality testing, in the absence other psychotic symptoms, rarely require antipsychotic medication.

I am not saying pseudohallucinations won’t respond to antipsychotics. They do, and you should certainly consider treating if they are distressing or impairing in some way. But since pseudohallucinations also respond to benzodiazepines, hugs, listening to music, and spending time with other people, I wouldn’t recommend Haldol as a first-line treatment.


  1. Shannon 01/09/2019 at 14:36 - Reply

    I have a very simple question, and I want to know what you think being a psychiatrist and seeing many patients who exibit mental illness, if the Schuman Resonance has any bearing on a person’s state of mind. There are 5 brain wave functions and are all based on presentation, as you so willing expose. What if the Spike’s in our Earth’s atmosphere is causing such imbalances in patients due to these spikes. What if a patient never exibited such prevalent illnesses based on presentation, but merely the high stress of working a 9-5 job put you on the dark side of the theta brain waves, but a sudden Spike in the Schuman Resonance in Gamma brain waves, mimicked some illnesses such as paranoid schizophrenia. Psychiatrist as you claim, are so easy to push antipsychotics, whom never even had or even exibited such behavior in the past. Most psychiatrist are abusing there power these days, and are wrongfully prescribing medications, just based on presentation because it’s easier to label someone psychotic because they are exibiting this behavior. I really believe in such a labeling society it’s easier to pull the pen out and subscribe these medications, rather then finding out if the patient really needs them. I’d like your thoughts on the perscription Risperidone, and if you think it’s necessary to prescribe a patient this medication, if they’ve never exibited such illness in the past. You even said yourself schizophrenia is typically a mental illness that normally shows signs in adolescents. So if this is the case, why are psychiatrists prescribing these medications. It’s infuriating to say the least. Thank you for your time

    • FugitivePsychiatrist 01/09/2019 at 15:04 - Reply

      I think there are times when antipsychotic prescriptions are necessary, yes, and risperidone could be one of them.
      Schizophrenia, by definition, no longer has an early onset with a deteriorating course. That’s one reason why people are so quick to make a diagnosis and write a prescription. The diagnostic criteria became looser over time.

    • Shannon 02/09/2019 at 12:21 - Reply

      Schizophrenia also doesn’t just come out of the blue either. High stress also cause the same symptoms! So maybe psychiatrists need to do more research to, instead of presecrbing these pills just to prescribe. Try Risperidone please because I want you to grow a set of breasts like my friend. That would make for a great study.

  2. Sandra 01/09/2019 at 17:10 - Reply

    Hey there, I find your blog realistic in context, deeply comedic in nature and an interesting school of thought. Thank you for your service as a psychiatric provider…and for the insight and entertainment equally so.
    What advice would you offer psychiatric residents to help shape the future of psychiatric providers?

    • FugitivePsychiatrist 02/09/2019 at 11:48 - Reply

      Just because your attendings, textbooks, or treatment guidelines say something doesn’t mean it’s true – practice reading primary sources and thinking for yourself.

  3. Phoebe Wagner 02/09/2019 at 08:59 - Reply

    Haldol is only a “first line treatment” from those prescribers who want to punish or torture patients, I reiterate that if you want to see what antipsychotics feel like, why not try 10mg of this? (Why not? Because it will be agonizing….)

    • FugitivePsychiatrist 02/09/2019 at 10:28 - Reply

      Because I don’t have any spare Haldol at the moment, Phoebe.

    • Shannon 02/09/2019 at 12:15 - Reply

      It’s the worst Haldol, I agree! My best friend killed herself while on it. She had tremors, and she could barely speak or walk. They then took her kids away, because she wouldn’t take it.

  4. bootsyhina 02/09/2019 at 16:53 - Reply

    Very well wrtitten as always !

    I have just one query that have been into my mind for the last few years. This is that Schizophrenia is usually diagoned in adolescence and it is unlikely that a person passed 30 years of age and develop for the first time full blown typical Schizophrenia or Something on these lines ? There was a case in December 2015 happened in Toronto when a 39 year old women MBA passed looking constantly for a reasonable employment but she couldn’t and ended up with nothing, no place to live , no friends & unsupportive family , in huge debt and one day she killed a complete stranger another woman stabbed in her chest in a shopping store. Trial went on, upon investigation it revealed she was hearing voices of her previous boss who bullied her once she was in a job which she left. She had afterwards few times history of psychiatry admission and given Olenzapine which she took and admitted she got better but left, that because she made her sleepy all day and she couldn’t start again searching for a job…. long story short the court jury reached a verdict that she has been very sick mentally having schizophrenia diagnosed by psychiatrists involved in the trial, and decision was to admit her in psychiatric facility instead of jail.

    What I want to ask here that is it possible to get schizo at that age of her late 30s ?… I remember that in all that never mentioned that she had any kind of signs and symptoms in her younger life.
    Thank you !

    • FugitivePsychiatrist 02/09/2019 at 17:32 - Reply

      Yes it is possible. “Schizophrenia” is no longer defined by an age of onset in adolescence. In women the peak is later than men, and doesn’t decline until about 35. There is also a later rise near the end of middle age that possible means the onset of dementia. There is also delusional disorder and paraphrenia that have a later age of onset. It’s all a messy business. But the bottom line is psychosis can start at any time in the life span. We don’t rule out a diagnosis based on age, although a non-typical age does make us worry about other causes.

    • bootsyhina 02/09/2019 at 19:58 - Reply

      I really appreciate your reply.
      The facts you mentioned are terrifying though ,but it also warns that underestimating this all nasty illnesses could end up in tragedies.

    • Shannon 03/09/2019 at 11:49 - Reply

      Well in my opinion based on all facts given, you claim there isn’t a early onset of schizophrenia. It’s a messy topic, because it all sounds trauma based. Genetics I thought were the only cause for schizophrenia. As psychosis is more caused by environmental factors.

    • FugitivePsychiatrist 03/09/2019 at 16:46 - Reply

      What I meant was that schizophrenia, the way it’s defined today, does not necessarily have an early onset. You’re right, messy topic indeed.

  5. Emi 18/09/2019 at 07:44 - Reply

    Do people like the case you described, who have absolutely obvious BPD, really get diagnosed as bipolar/schizoaffective instead? What’s the reason for that? How does that fit in with the inverse phenomenon, where people seem to get diagnosed with BPD on the basis of self harming, being irritable, and being a young woman?

    • FugitivePsychiatrist 18/09/2019 at 13:29 - Reply

      It happens all the time, at least where I work. I think the answer is simple: hearing voices is automatically equated with psychosis, so therefore the person must have a psychotic disorder or a mood disorder with psychotic features. The notion that hearing voices could be a relatively common, benign experience (maybe more common in people with a certain personality organization) doesn’t enter into thought. Therefore, even though the person may appear kinda borderline (or antisocial, or whatever) they need another diagnosis to account for the voices.

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