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Supporting Evidence: New Research
Supporting Jaynes' Bicameral Mind Theory

Command Hallucinations: A Vestige of the Bicameral Mind

Supporting Evidence > Command Hallucinations

In his theory, Julian Jaynes explains how commanding hallucinations directed behavior in an earlier mentality, prior to the development of subjective consciousness. Jaynes's theory would predict that auditory hallucinations would not just consist of random voices, but would in fact comment on or direct behavior. Unknown at the time, hallucinations commanding behavior, referred to as "command hallucinations," have since been documented in dozens of studies. Below is a small sample of research supporting this aspect of Jaynes's theory.

Command Hallucinations

Acting on Command Hallucinations: A Cognitive Approach
Beck-Sander, A., M. Birchwood, & P. Chadwick. British Journal of Clinical Psychology, Feb. 1997, 36(Pt 1): 139-48.
This study explores factors influencing compliance with command hallucinations. The most widely acknowledged factor is the content of the command. Three categories of command content were found to be discrete in terms of compliance: "innocuous' commands, "severe' commands and commands to self-harm. This study takes a cognitive approach and highlights the importance of the beliefs individuals hold about their voices. Beliefs appear to be important in determining whether or not individuals comply with commands and the affect generated. A belief that the voice is benevolent was associated with compliance with both innocuous and severe commands. In addition, participants who believed they retained subjective control over their voices were less likely to comply with all types of command. Furthermore, qualitative evidence suggested that several other beliefs may influence compliance with command hallucinations such as beliefs about the effects of transgression, beliefs about the power and authority of the commander, beliefs about the social acceptability of the action (which may be closely correlated or synonymous with severity) and its effectiveness in achieving a valued goal. Further research is necessary to investigate the importance of these beliefs and their interrelationships more fully.

Command Hallucinations: Who Obeys and Who Resists When?
Erkwoh, R., K. Willmes, A. Eming-Erdmanna and H.J. Kunert. Psychopathology, 2002, 35: 272-279.
The impact of auditory command hallucinations on the behaviour of schizophrenic patients sometimes appears to be unpredictable. In order to tackle this problem, the psychopathological characteristics of command hallucinations in 31 schizophrenic patients were assessed using a 24-item questionnaire. Using binary data and relative risk analysis methods, predictors were determined for obeying or resisting command hallucinations. Characteristics of voices and the attitude toward the voices appear equally important for prediction. A set of three psychopathological characteristics comprising a voice known to the patient, emotional involvement during the hallucinations, and seeing the voice as real provides significant predictivity of behaviour following command hallucinations. These results are interesting for clinical and forensic psychiatrists.

Command Hallucinations Visual Command Hallucinations in a Patient with Pure Alexia
ffytche, D.H., J.M. Lappin, and M. Philpot. Journal of Neurology, Neurosurgery, and Psychiatry, 2004, 75: 80-86.
Around 25% of patients with visual hallucinations secondary to eye disease report hallucinations of text. The hallucinated text conveys little if any meaning, typically consisting of individual letters, words, or nonsense letter strings (orthographic hallucinations). A patient is described with textual visual hallucinations of a very different linguistic content following bilateral occipito-temporal infarcts. The hallucinations consisted of grammatically correct, meaningful written sentences or phrases, often in the second person and with a threatening and command-like nature (syntacto-semantic visual hallucinations). A detailed phenomenological interview and visual psychophysical testing were undertaken. The patient showed a classical ventral occipito-temporal syndrome with achromatopsia, prosopagnosia, and associative visual agnosia. Of particular significance was the presence of pure alexia. Illusions of colour induced by monochromatic gratings and a novel motion–direction illusion were also observed, both consistent with the residual capacities of the patient’s spared visual cortex. The content of orthographic visual hallucinations matches the known specialisations of an area in the left posterior fusiform gyrus — the visual word form area (VWFA) — suggesting the two are related. The VWFA is unlikely to be responsible for the syntacto-semantic hallucinations described here as the patient had a pure alexic syndrome, a known consequence of VWFA lesions. Syntacto-semantic visual hallucinations may represent a separate category of textual hallucinations related to the cortical network implicated in the auditory hallucinations of schizophrenia.

Command Hallucinations, Compliance, and Risk Assessment
Hersh, K., and R. Borum. Journal of the American Academy of Psychiatry and the Law, 1998, 26: 353-359.
Command hallucinations are auditory hallucinations that instruct a patient to act in specific ways; these commands can range in seriousness from innocuous to life-threatening. This article summarizes two areas of research regarding command hallucinations: rates of compliance with command hallucinations; and factors associated with compliance. Researchers have reported rates of compliance ranging from 39.2 percent to 88.5 percent. Compliance has not been consistently related to dangerousness of commands. Instead, research suggests that individuals are more likely to comply with commands if they recognize the hallucinated voice and if their hallucinations are related to a delusion. Implications for risk assessment are discussed in light of the research.

Command Hallucinations and the Prediction of Dangerousness
Junginger, J. The American Journal of Psychiatry, 1990, 147 (2): 245-247.
Of 44 patients who experienced command hallucinations, those with hallucination-related delusions and hallucinatory voices they could identify were more likely to comply with the commands. The danger of the behaviors specified by the hallucinations did not appear to be a factor in compliance

Command Hallucinations and the Prediction of Dangerousness
Junginger, J. Psychiatric Services, September 1995, 46: 911-914.
OBJECTIVES: Recent studies have supported the belief that command hallucinations can induce dangerous behavior. This study tried to replicate previous findings that compliance with the command was associated with delusions related to hallucinations and the ability to identify the hallucinated voice. This study also assessed the association between compliance and the dangerousness of the command, chronicity of illness, a diagnosis of schizophrenia, and past compliance with hallucinated commands. METHODS: The most recent command hallucination reported by 93 psychiatric inpatients was rated for level of dangerousness and level of compliance with the command. RESULTS: Subjects who experienced less dangerous commands or who could identify the hallucinated voice reported higher levels of compliance, although reported compliance with more dangerous commands was not uncommon. Commands experienced in the hospital were less dangerous than those experienced elsewhere and tended to be specific to the hospital environment. Subjects were less likely to comply with commands experienced in the hospital. CONCLUSIONS: Based on their self-reports, psychiatric patients who experience command hallucinations are at risk for dangerous behavior. Ability to identify the hallucinated voice is a fairly reliable predictor of reported compliance. Level of dangerousness resulting from compliance with command hallucinations may be a function of the patient's environment.

Compulsions Developing into Command Hallucinations
Klemperer, F. Psychopathology, 1996, 29 (4): 249-51.
Intrusive, uncontrollable and bizarre thoughts occur in both obsessive-compulsive disorder (OCD) and psychosis. The origin of these mental phenomena and the relationship between them is unclear. A case is described in which long-standing compulsions and the associated resistance temporarily developed the characteristics of command hallucinations, in the absence of any other psychotic symptoms. The implications for psychopathological theories of hallucinations are discussed.

Command Hallucinations Command Hallucinations Among Asian Patients with Schizophrenia
Lee T.M., S.A. Chong, Y.H. Chan, and G. Sathyadevan. Canadian Journal of Psychiatry, December 2004, 49 (12): 838-42.
OBJECTIVES: The impact of command hallucinations on patients and the determinants of patients' compliance with them are still poorly understood. The extant literature is also divided on their association with violence. This study aimed to establish the prevalence of command hallucinations and to identify the factors that affect compliance with the commands, together with patients' coping methods. METHODS: We recruited 50 consecutive male and 50 consecutive female schizophrenia inpatients who reported hearing voices in the 6 months prior to admission. We interviewed these patients, using a semistructured questionnaire. We collected information on the contents of their auditory hallucinations and their coping methods. RESULTS: Of the patients, 53 (53%) reported command hallucinations. Of these 53 patients, 58% were women and 48% were men; 62% reported complying with the commands. They were also more likely to comply with nonviolent commands. A history of self-harm predicted compliance. Those patients who did not comply with the commands adopted various methods of coping, of which praying was the most common. CONCLUSION: Command hallucinations are common in patients with schizophrenia. Patients with a history of self-harm need closer monitoring because they may be more likely to comply with these hallucinations. Assessment should also include the patient's own coping strategies, which can be incorporated into the treatment.

Command Hallucinations & Violence The Relationship Between Command Hallucinations and Violence
McNiel, Dale E., Jane P. Eisner, and Renée L. Binder. Psychiatric Services, October 2000, 51: 1288-1292.
OBJECTIVE: The purpose of this study was to describe the relationship between command hallucinations and violent behavior. METHODS: One hundred and three psychiatric inpatients completed measures of command hallucinations, other psychotic symptoms, violent behavior, and social desirability response biases. RESULTS: Thirty percent of the patients reported having had command hallucinations to harm others during the last year, and 22 percent of the patients reported they complied with such commands. Logistic regression analyses suggested that patients who experienced command hallucinations to harm others were more than twice as likely to be violent, even when the analysis controlled for demographic variables, history of substance abuse, and social desirability response biases. CONCLUSIONS: The results support the clinical utility of asking about command hallucinations when assessing the risk of violence in patients with major mental disorders.

Compliance with Command Hallucinations: The Role of Power in Relation to the Voice, and Social Rank in Relation to the Voice and Others
Reynolds, Nicky and Peter Scragg. Journal of Forensic Psychiatry & Psychology, 2010, 21: 1.
This study examined three factors hypothesised which influence compliance to harm-others command hallucinations. The factors investigated were the perceived power of the commanding voice, participants' perceived social rank in relation to the commanding voice and to the others. Thirty-two male participants were recruited from forensic services. Participants were identified as belonging to one of the two groups: compliers or resisters. Semi-structured interviews and questionnaires were administered to participants. Beliefs, that the commanding voice was more powerful than the self and of a higher social rank than the self, were associated with compliance. There were no significant differences between the two groups on perceptions of social rank in relation to others. The significant findings of this study can be understood in terms of the relationship an individual has with the commanding voice and which are congruent with cognitive models of hallucinations.

The Clinical Presentation of Command Hallucinations in a Forensic Population
Rogers, R., J.R. Gillis, R.E. Turner, and T. Frise-Smith. American Journal of Psychiatry, 1990, 147: 1304-1307.
In a forensic population, patients with command hallucinations (N = 25) were compared to two groups of psychotic patients: those with noncommand hallucinations (N = 24) and those without hallucinations (N = 16). The three groups did not differ in overall impairment as measured by the Global Assessment Scale and the Social Behavior Rating Schedule. However, the group with command hallucinations differed in the content of their hallucinations (more aggression, dependency, and self-punishment themes), and nearly one-half did not report or denied their command hallucinations to the assessment team. Many patients (N = 11, 44%) reported that they frequently responded to hallucinatory commands with unquestioning obedience.

Relation Between Command Hallucinations and Dangerous Behavior
Rudnick, A. Journal of the American Academy of Psychiatry and the Law, 1999, 27: 252-257.
This article presents an updated review of studies on the relation between command hallucinations and dangerous behavior. The author reviewed all studies published between 1966 and 1997 according to MEDLINE and between 1974 and 1997 according to PSYCLIT. Forty-one studies were found, of which 82.9 percent dealt with the relation between command hallucinations and dangerous behavior. Of these studies, 32.3 percent were controlled, and they were grouped into three partially overlapping classes: those concerned with violent behavior, those concerned with suicidal behavior, and those concerned with mediating variables. Most of these studies agreed on the non-existence of an immediate relation between command hallucinations and dangerous (violent or suicidal) behavior. Even though the studies were divided about the existence of a relation between severity/dangerousness of command content and compliance with the commands, there was agreement about the existence of a direct relation between compliance with commands and both benevolence and familiarity of commanding voice. It seems that the research and knowledge available to date on this subject is both scant and methodologically weak. Future study should probably concentrate on mediating factors, such as appraisal and coping attitudes and behaviors.

Command Hallucinations in Outpatients with Schizophrenia
Zisook, S., D. Byrd, J. Kuck, D.V. Jeste. Journal of Clinical Psychiatry, Oct. 1995, 56 (10): 462-5.
BACKGROUND: The presence of command hallucinations in individuals with schizophrenia may result in an increase in clinical monitoring to reduce the perceived risk of violent behavior. However, the issue of whether command hallucinations hold any clinical relevance in relatively stable outpatient samples has not been established. METHOD: The clinical and research records of individuals with schizophrenia who participated in outpatient research protocols at the University of California, San Diego were reviewed for the presence of command hallucinations. Information on clinical characteristics was collected in a detailed chart review from 106 patient records. RESULTS: Command hallucinations were reported by one half of all patients with auditory hallucinations, and these hallucinations often were violent in content. Yet, in over a third of the patients, these hallucinations had not been documented in their clinical charts, but instead were uncovered during a secondary source review. Patients with command hallucinations generally did not differ on prognostic or clinical course variables. However, the 2 patients who committed suicide during the study were patients with command hallucinations. CONCLUSION: Although command hallucinations may be more frequent than clinicians generally note, in most cases they have minimal influence on the outcome of schizophrenia. However, in outpatients with schizophrenia who have a history of suicide attempts, suicidal command hallucinations should be taken seriously.