Interim discussion

To our knowledge, previous studies have not explored the presentation of individuals

reporting varying content of command hallucination. Whilst this would seem to be a

clinically useful exercise, it proves very difficult from a methodological point of view

because very few individuals report experiencing just one type of command. Despite this

complexity, previous research has not really drawn (or perhaps paid) attention to the

presence of multiple commands and has suggested that the profiles that are described (for

instance, beliefs about malevolence and beliefs about self) are related to just one content.

When clinicians are faced with making decisions regarding risk, this literature may

misguide them.

It is clear when we adopted the methodology that has been used by previous researchers,

that is when we focussed on predominant content only, very few differences existed

between the three main groups (harm-other, suicide and self-harm). Indeed, the only

significant difference between the groups was the degree of retardation as measured by

the BPRS composite. On this variable, those with commands to harm others reported

experiencing the most severe degree of retardation. It may well be that this difference is

underpinned by differences in the treatment that is received by the three groups. If, as the

existing literature suggests, those who experience dangerous commands are more likely

to be prescribed significantly higher doses of antipsychotic medication it may be that the

retardation that is reported is a result of the side effects of their treatment regime. Such

treatment regimes may also minimise the likelihood of detecting any differences on the

There are some methodological difficulties that are inherent to trying to explore the

differences between the three main types of command hallucinations, namely that it was

impossible to separate the groups as such a large proportion of those with command

hallucinations reported multiple content. What the group comparisons therefore tell us is

perhaps what the added burden is of each type of content. It is clear from the comparison

of those with multiple commands versus one type of command only, that experiencing

multiple content command hallucinations is associated with significantly greater levels of

distress generally, and greater levels of distress that is directly related to the voices.

Although the results from these analyses are methodologically limited, there are some

interesting findings that could serve to inform future research and guide the design of

clinical interventions.

Interestingly, there were very few significant differences between those that did and did

not report experiencing suicide commands and between those that did and did not report

experiencing commands to harm themselves. It may be that there is very little exclusivity

amongst these groups in that the majority of those reporting command hallucinations

reported commands to harm or kill themselves (65% and 55% of the total sample of

command hallucinators respectively) compared to those reporting commands to harm

someone else (39% of the total sample). If individuals are therefore represented in both

categories it decreases any difference between the groups.

The findings with regard to harm-other commands are perhaps easier to interpret. Whilst

generally experiencing a greater degree of symptom severity, those that reported hearing

psychotic symptoms than those without command hallucinations to harm others. They

did, however, experience significantly more severe affective symptoms, a difference

which appears to be underpinned by differences between the groups on how much guilt

they experience on a day-to-day basis.

Guilt is an important factor, it would appear from these results that individuals with

commands to harm others experience more feelings of guilt than those without

commands to harm others. The nature of this analysis precludes any opportunity to

hypothesise about the direction of causality. It may be, of course, that those who hear

commands telling them, for instance, to kill another person feel guilty because of what

they are hearing. However, an analysis of the individuals’ original responses to the

BPRS suggests that the guilt is not necessarily related to the content of the commands per

se rather it is related to past life events or to the pain or distress caused to others as a

result of hospital admission. Whilst this analysis was not concerned with the factors that

drive or contribute to compliance, guilt is an important variable in understanding why

individuals comply. The theories outlined briefly in chapter two suggest that guilt

enhances the likelihood of compliance but this is when the guilt is specifically associated

with non-compliance. What remains to be seen is whether any form of guilt increasing

the risk of compliance or whether, in fact, guilt associated with extraneous variables or

situations, or guilt associated with hearing a dangerous command actually serves as a

protective factor against complying with the command.

Those with harm-other commands also showed a significantly greater belief that the

voices they heard originated from an external source. Again, this is an important finding.

has also been previously found that those voices that are perceived to be of external

origin are more likely to be appraised as ‘real’ and are more likely to be obeyed (see

Junginger, 1996). Individuals with harm-other commands also reported significantly

stronger beliefs that the voices they heard were malevolent in nature and that as a group

they had significantly more resistant coping strategies. When between-group

comparisons were made according to predominant content, those with predominantly

self-harm commands reported the strongest beliefs about malevolence.

Previous studies have highlighted the importance of beliefs about self in the development

and maintenance of voices and associated distress (Birchwood and Gilbert, 2004).

Significant differences have also been found in the self belief of those that comply with

command hallucinations. We were interested to discover whether there were any

differences between individuals with varying content of commands in the perception of

social rank. In this analysis, none of the between group comparisons returned significant

differences when the social comparison scale was used. Furthermore, the effect sizes for

all of the variables resulting from the social comparison scale were small. Examining the

descriptive data for social rank, it would appear that the mean scores for all groups were

on the low side.