Discriminating whether AH are psychotic or not

[medstudent234]

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I have a few adolescent and young adult pts in my clinic who have autism spectrum disorder or intellectual disability, and some spontaneously mentioning starting to "hear voices." When I try to clarify whether the voices are their own thoughts or not, the pt can't clearly tease that apart. They report sometimes looking around anticipating someone is there talking to them, but then see no one.

However, they are not responding to internal stimuli in my office and deny most other psychotic symptoms. I was wondering whether anyone has any ways that they determine whether these types of things are new onset psychosis that should be treated or whether these are non-psychotic AH? I always try to talk to families about their observations as well. Thanks!

 

[WisNeuro]

The thing to discriminate from at an early level is actual AHs vs misperceptions. This can be difficult with patients who already have communication differences. But, you need to first figure out if there is an actual sound that they are misconstruing as voices. Family or other caregivers may be the best bet on if they seem to be responding to unheard things in other contexts. Additionally, depending on the ID, as you said, they may have a hard time discriminating inner thoughts. Can they actually make out any words, or is it a vague sense of someone talking? If they can make out words and they are command type prompts, that'd be a big flag for the AH, in many contexts.

 

[Liquid8]

Very difficult in this population, and agree that collateral from caregivers and observation is paramount. Aside from the obvious communication difficulties and limited ability to describing the phenomenology in detail, one also has to take into account the possibility of learned behaviour especially if patients have had exposure to inpatient psychiatric environments or have an extensive family history of mental illness.

Another complicating factor is that behaviours that might indicate psychosis may also be due to other conditions that occur more commonly. One example I recall is that a patient having a migraine aura might appear to be looking around and responding to internal stimuli. It’s been a while since I’ve done anything in that area, but I do remember there being a DSM for ID (DM-ID) that explores the issues.

 

[Linksawakening]

This article ("Faking it: How to detect malingered psychosis" by Phillip Resnick, search for it on Google) is a good place to start for quickly learning how to discriminate auditory hallucinations related to schizophrenia from other conditions.

I take some issue with how the article implies that non-schizophrenic psychotic symptoms are generally due to malingering rather than another diagnosis, but the points it raises are still valid in distinguishing psychotic symptoms related to schizophrenia with those stemming from another condition (such as its emphasis that schizophrenic auditory hallucinations are almost always associated with delusions).