How to distinguish a genuine auditory hallucination from an 'internal narrarator'?

[tristatenontrad]

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Was shadowing a psychiatrist recently and after hearing so many px answer the question "do you hear voices" in the affirmative and hearing their explanation of what 'the voices' were telling them, I noticed that what a lot of the px stated sounded like an 'internal narrarator' and not necessarily an auditory hallucination. For example I may think to myself, hmm maybe I should order an extra side of buffalo wings and then subsequently order them. This to me would not qualify as 'hearing a voice' but instead would be the 'sound of my thoughts'. Many of the px were so decompensated that they were hardly reliable narrarators and I doubt their answer to this question had much bearing on the subsequent course of action decided upon but was just wondering if any one else here has noticed this in their experience. Not sure how else to ask the question to more accurately determine if the px is indeed experiencing auditory hallucinations but it seemed rather lazy to just check the 'yes' box and not ask any follow up.

 

[splik]

I never ask "do you hear voices" it is a pretty useless question with poor reliability and validity for discerning auditory hallucinations.

Instead I ask questions like:
"do you ever have the experience of hearing people talking to you or about you when no one is around or that others don't hear?"
"do you ever hear someone say your own thoughts out loud, either before you think them, or repeating them?"
"do you ever experience hearing someone giving a running a commentary on your actions?"

Also it can be helpful if you are seeing someone for the first time or someone who is not a career mental patient to explain why you are asking such questions. For example "sometimes when people feel as bad as you do they have experiences they might not normally have..." or "when people are under a great deal of stress like you, it is not uncommon for people to have unusual experiences..." By providing some explanation, validation and normalization you will encourage patients who might be fearful or guarded about talking about this to do so and also not offend patients who aren't psychotic.

In more frank psychotic states it will be quite obvious that the patient is having anomalous experiences (for example they are looking around, or talking to themselves, or laughing at things) and in this case I would try and join the patient with this to understand what is going on. For example "you seem distracted - are you hearing anyone else right now?" or "who were you talking to just then?" or "what was making you laugh?" You must accept the reality of these experiences, maybe joining the patient by trying to listen to. A more advanced technique (that I would not recommend for the unexperienced) is dialoguing where the psychiatrist communicates directly with the voices through the patient. This is a psychotherapy technique that usually can only be achieved when you have a strong rapport with the patient that is somewhat able to overcome the omnipotence of the voices.

 

[notdeadyet]

Good thinking, tristatenontrad. If you keep asking "do you hear voices?" often enough, you'll see a fairly common answer is "I hear yours."

Inner monologue is often mistaken for auditory hallucinations. You see it a lot in abuse victims. You also see it happen with non-native speakers of foreign cultures (I often hear voices in my head as a translate into Spanish when I'm speaking that language).

And you see it happen a lot with individuals who lack the sophistication to recognize an inner monologue/critic. The number of inappropriate descriptions of auditory hallucinations for folks with developmental delays never ceases to chap my hide.

 

[birchswing]

I just watched a black comedy from 2015 called The Voices. It was very good. It had a number of scenes with a psychiatrist asking her patient if he heard voices, and it was fascinating to watch his internal deliberations about whether to admit he did or not. I'm not saying it's accurate at all of what goes through a person's head--in fact I think it's not accurate. Very entertaining movie though. Lead actor was Ryan Reynolds. What made the movie so interesting is that his actions if it were not for the audience's ability to hear the voices would just be incredibly dark. With the voices, his world made sense. Hard to say too much without giving much away, but it's worth watching.

 

[HarryMTieboutMD]

Echo (de la pensee!) what Splik said. Here are some additional thoughts:

In psychiatry, our primary job when encountering a new patient, a patient with an unclear psychiatric history, or even patients with well established psychiatric diagnoses made by good psychiatrist, is to have a diagnostic mindset. And my history taking with concurrent mental status examination (that begins the moment I lay eyes on the patient) guides this process.

So, if a patient previously unknown to me presents to the ED with "hearing voices" I start off my interview with general, open ended questions, looking for formal though disorder, negative symptoms, and delusional statements to consider a schizophrenia spectrum illness. As Splik mentioned many schizophrenics having hallucinatory experiences will adamantly deny having them when asked directly, but if I notice certain characteristic behaviors (hyperkinetic/darting eye movements, vocalizations, extreme distractibility, inappropriate laughing, etc) I will ask the patient about that directly, as Splik said. Through the course of the interview, after some rapport is built, if the patient has still not admitted to having AH, I will ask the patient a question akin to Splik's first question "is there anyone in the room besides me talking right now?" or something along the lines of "have you ever heard a voice of someone not actually present that other people couldn't hear... like someone is talking but there is no person". Keep in mind that on the initial interview whether or not the patient admits to hallucinatory experiences may not be necessary for having a general idea of what is going on. For example, one should keep in mind other symptoms of schizophrenia, subtle signs of mania even if the (prolixity of speech, elevation/irritability/lability, distraction, etc) even if the patient isn't floridly manic or depression (can sometimes be tricky on cross section to delineate from negative symptoms). Again, cross sectionally you are unlikely to come to a definitive diagnosis but at least you should be tracking symptoms to get an idea of what is going on.

As Splik mentioned, I try to gauge the presence of Schneiderian First Rank symptoms, of which the hallucinatory experiences are running commentary, voices arguing, and gedankenlautwerden (a hallucinatory voice speaking someone's thoughts out loud simultaneously with the thought- echo de la pensee occurs when the voice speaks the thought immediately afterwards- most psychiatrists group these together as Thought Echo, but s\Schneider's original term was Gedankenlautwerden). The other First Rank Symptoms are delusions of passivity, thought alientation (insertion, withdrawal, broadcasting), and delusional perception I will ask open ended questions "how many voices"... "do the voices talk to each other"... "what do they say" and then move to direct questions. Often times this is academic but I think important for documentation, clinical skill, and observation purposes.

Sometimes substance intoxication can be difficult to tell, but if the patient is having hallucinations from amphetamines/cocaine/whatever, he or she will often be extremely psychomotor agitated and have some manic type symptoms (or depressive if in a cocaine crash), even without dysautonomia or pupil dilation. Generally, even without a complete history, an astute psychiatrist can deliniate the subtleties. NMDA antagonist intoxication (PCP, Ketamine) is more difficult because you get the negative and thought disordered symptoms as well- they also can appear manic. This is becoming an increasing problem with marijuana (which most of our patients smoke 🙁) as it is not infrequently contaminated with these substances.

Obviously lots of medications and medical conditions can cause hallucinatory experiences, but again, I try to keep a broad ddx in mind and try to rule out the above.

In the absence of signs of SCZ/mania/depression/intoxication/medical issues and unremarkable history, I then think about pseudopsychosis or malingering. Pseudopsychosis is kind of akin to "the sound of my thoughts" but in borderlines they can hear distinct voices when they get really stressed. Some of my co residents like to use directed questions of features classically LESS likely to characterize real psychosis (voice(s) located inside the patient's head and not in a perceptual plane, lateralization of voice, continuity of voice, increasing volume with Valsalva), which I sometimes ask, but I don't find these questions particularly useful, and they are definitely not acceptable when justifying discharging a malingerer or borderline- there are plenty of other ways to do this (Splik correct me if I am wrong). There is a classic paper called The Detection of Malingering Psychosis that is a fun read on this subject. The classic teaching is that true hallucinations occur in an external plane of perception, but plenty of true schizophrenics have hallucinatory experiences inside their heads (Kraepelin described this). Again, sometimes differentiating psychosis from pseudopsychosis can be tough, but if one keeps a diagnostic mindset in mind rather than focusing solely on the complaint of "hearing voices," he or she can usually determine what is going on. Also, sometimes I will deliberately ask a malingering ASPD close ended questions about the voices, and if I get a pan positive "yes" I can document that to build my case (need much more than that to kick out a patient though). Bear in mind that some people with a true psychotic history can fake psychosis and give a textbook description as above (ie, his/her psychosis is controlled with an LAI antipsychotic, yet he or she is homeless yet has enough wherewithal to malinger.

Again, keeping a diagnostic purpose in mind is paramount. The more clinical experiences one has and the more one has read, the better and more useful his or her interview and mental status exam will be.

 

[Ceke2002]

Also it can be helpful if you are seeing someone for the first time or someone who is not a career mental patient to explain why you are asking such questions. For example "sometimes when people feel as bad as you do they have experiences they might not normally have..." or "when people are under a great deal of stress like you, it is not uncommon for people to have unusual experiences..." By providing some explanation, validation and normalization you will encourage patients who might be fearful or guarded about talking about this to do so and also not offend patients who aren't psychotic.

Echoing the importance of this. Even career mental patients can sometimes be reluctant to endorse auditory hallucinations if they've previously had bad experiences with the way medical professionals have reacted. It's important that the patient know they're not going to being judged or dismissed offhand if they admit to experiencing AH.

 

[PistolPete]

Nice post. Any other tips on validating true AH in children vs their own inner thoughts?

 

[splik]

In the absence of signs of SCZ/mania/depression/intoxication/medical issues and unremarkable history, I then think about pseudopsychosis or malingering. Pseudopsychosis is kind of akin to "the sound of my thoughts" but in borderlines they can hear distinct voices when they get really stressed. Some of my co residents like to use directed questions of features classically LESS likely to characterize real psychosis (voice(s) located inside the patient's head and not in a perceptual plane, lateralization of voice, continuity of voice, increasing volume with Valsalva), which I sometimes ask, but I don't find these questions particularly useful, and they are definitely not acceptable when justifying discharging a malingerer or borderline- there are plenty of other ways to do this (Splik correct me if I am wrong). There is a classic paper called The Detection of Malingering Psychosis that is a fun read on this subject. The classic teaching is that true hallucinations occur in an external plane of perception, but plenty of true schizophrenics have hallucinatory experiences inside their heads (Kraepelin described this). Again, sometimes differentiating psychosis from pseudopsychosis can be tough, but if one keeps a diagnostic mindset in mind rather than focusing solely on the complaint of "hearing voices," he or she can usually determine what is going on. Also, sometimes I will deliberately ask a malingering ASPD close ended questions about the voices, and if I get a pan positive "yes" I can document that to build my case (need much more than that to kick out a patient though). Bear in mind that some people with a true psychotic history can fake psychosis and give a textbook description as above (ie, his/her psychosis is controlled with an LAI antipsychotic, yet he or she is homeless yet has enough wherewithal to malinger.

remember in the differential for auditory hallucinations - organic, substance abuse, psychosis, neurosis (including traumatic hallucinosis and the pseudohallucinations of hysteria), personality disorder, and also always think about intellectual disability and neurodevelopmental disorders, as well as factitious disorder, malingering, elaboration of symptoms for psychological gain, and normal reaction (for example it is culturally normative for American Indians to hear to voice of the recently deceased calling them to join them, whereas for a white patient that might be quite concerning).

In terms of malingering: It is usually ill-advised to attempt to discern whether someone is malingering mental illness. Most people who malinger mental illness have a major mental disorder, which is how the learned how to malinger in the first place. Instead, we focus on identifying malingered symptoms. For example, a patient with schizophrenia may claim to hear voices telling him to harm others to gain hospitalization if he is homeless and it is a cold; or he main claim that voices told him to steal if he is trying to evade prosecution. What thus becomes important is the internal consistency - is the reported symptom consistent with the rest of the patient's presentation? is the reported symptom consistent with what the patient had reported in the past? The other aspect of malingering is there must be an obvious external reward. In non-forensic settings (and even then..) patients are none too bright and thus will usually spontaneously reveal the obvious external reward. Patient may give approximate answers to questions and will over endorse symptoms. I will often ask a rapid fire succession of questions that do not give chance for the patient to think if I suspect malingering - for example - I might abruptly ask "are you dead?"

Auditory hallucinations are usually clear whereas malingered voices tend to be vague, or they report not being able to discern them. The malingering patient may not look like they are responding to hallucinations whereas a true psychotic who is hearing voices will be distracted and their attention impaired. Patients with psychosis notice that techniques with distraction and so on help, whereas malingerers may not notice this. If a patient is truly coming in for help with their hallucinations they will likely be distressed (unless their affect is grossly discordant or blunted), whereas malingered symptoms will not cause distress and the patient may be particularly happy to be there. It is not usually very helpful to confront malingerers in these situations and will escalate things. People malinger as an adaptive strategy to cope with what they see as an intolerable situation. Rather than trying to "get to goods on them" (a common failing of junior house staff) and catch them out, you want to see how you can help them. Patients with malingered psychosis will respond much more positively to help (and be pleased that they have "fooled" you) more than someone with true psychosis. Gauging your countertransference is helpful to. The psychotic patient will confuse you or make you feel his terror and despair. The malingerer will frustrate you and make you his tormentor.

I would also advise against making a categorical "diagnosis" of malingering and instead document the reasons why you think the patient does not have an acute psychiatric disturbance needing hospitalization, and the reasons why you think malingering of at least one symptom is high on your differential.For example: "The inconsistencies in his narrative, and fact that he reports having delusions (which by definition cannot be self-reported as such), as well as evasiveness when more specific details are solicited strongly suggest malingering. This is further supported by the clear external reward of hospitalization that he seeks, having been kicked out by his father, and his self-reported distaste for shelters. The possibility of a bipolar disorder cannot be excluded, but at the time of evaluation he does not appear to be either depressed or manic."

In patients with borderline or narcissistic personality disorder the "voices" will have an acute onset and content will more often be related to real occurrences (for example the borderline patient may hear the voice of the father who molested her) and core themes of abandoment/failure respective (for example the patient may hear voices telling her that her boyfriend is unfaithful or the nurses do not love her, and the narcissist that he is a failure or reviled by all.) They can usually be understood within the context of the patient's occurrence and do not take much to decode. Whereas the manifest content of psychotic voices may be less clear cut.

Pseudohallucinations of hysteria are typically quite fantastical. For example I had a patient with fibromyalgia who saw a swarm of bees cover her arm.

 

[notdeadyet]

This is great stuff, Splik and Harry...


Sent from my iPhone using Tapatalk

 

[sweetlenovo88]

excellent posts

 

[nitemagi]

Read the book -- Clinical Assessment of Malingering and Deception to start.

 

[tristatenontrad]

Wow. Thanks so much everyone for giving such thoughtful and informative responses, you have all given me much to think about. Thanks again.

 

[smalltownpsych]

Lately it seems I have been getting more and more depressed teens hearing their name called and seeing shadowy figures at the edge of their perceptual field. I have heard this type of report occasionally in the past, but am worried that I am asking question in a way that subtly encourages the report of this or are all these kids really that depressed and how common is that report in the more severely depressed teens? Many are from the Native population so that confounds the diagnosis quite a bit; culturally normative traits like less affective expression, minimal eye contact, and communicating with ancestors.

 

[nitemagi]

Lately it seems I have been getting more and more depressed teens hearing their name called and seeing shadowy figures at the edge of their perceptual field. I have heard this type of report occasionally in the past, but am worried that I am asking question in a way that subtly encourages the report of this or are all these kids really that depressed and how common is that report in the more severely depressed teens? Many are from the Native population so that confounds the diagnosis quite a bit; culturally normative traits like less affective expression, minimal eye contact, and communicating with ancestors.

Hearing your name called up to twice a day is considered WNL according to certain texts. Shadows at the corner of vision can also be, since they're not discrete formed images, and can overlap with many forms of substance use (esp. alcohol).

 

[Ceke2002]

Lately it seems I have been getting more and more depressed teens hearing their name called and seeing shadowy figures at the edge of their perceptual field. I have heard this type of report occasionally in the past, but am worried that I am asking question in a way that subtly encourages the report of this or are all these kids really that depressed and how common is that report in the more severely depressed teens? Many are from the Native population so that confounds the diagnosis quite a bit; culturally normative traits like less affective expression, minimal eye contact, and communicating with ancestors.

I get the exact same thing if my sleep is disrupted, so do a lot of my friends under the same circumstances irrespective of a diagnosis of depression (although obviously depression can disrupt normal sleep patterns, so I'm assuming it's probably more likely to happen during a depressive episode).

It's also the one thing that's almost guaranteed to send one of my friends with untreated BPD into a complete tailspin. At least once a year chances are I'm going to bombarded with a series of increasingly panicked messages (because god forbid the first message doesn't get answered in 10 seconds flat) and it's damn near the same conversation every single time...

Friend - *Gasp!Panic!!!* I think I might have psychotic depression.

Me - (What, again? )...Okay hon, just take a few deep breaths, what makes you think you have psychotic depression?

Friend - I can hear someone calling my name, and I keep seeing these shadow creatures out the corner of my eye, but when I turn to look at them they're gone. It's like they're taunting me.

Me - That sounds like...(the exact same thing you've been telling me for the past how many years now?)...it must feel really scary for you. Are you sleeping okay at the moment? What about stress? Has anything upset you recently?

Friend - Nothing ever goes right for me, everything's gone wrong, let me sing you the song of my people..."Four ill advised relationships hanging on the wall, and if one ill advised relationship should accidentally fall ~ I'll become completely emotionally disregulated and start abusing pills and alcohol and slicing my arms up with a razor blade."

Me - You know...(I really should just start calling you Punxsutawney Phil, because goddamn if this doesn't feel like Groundhog day right now)...this does kinda sound like what happened last year as well. Remember when you were dating that guy and it didn't work out so good...(so you just went and completely lost your ****)...and you started having the same experiences you are now, because you were really upset and not sleeping properly? Have you found another therapist to talk to since then?

Friend - Therapy doesn't work for me. I never feel comfortable talking about stuff and then I end up making a fool of myself.

Me - Well, you know...(here's a brilliant idea , therapy might work a lot better if you'd stop falling in love with the therapist and treating your sessions like a date )...sometimes it can take a while to find the right therapist. I really do think you need to talk to someone.

Friend - So you don't think I have psychotic depression? I'm just a failure then.

Me - (Yes, because being diagnosed with MDD with Psychotic Fx is such an achievement

)...I didn't say that, I don't think you're a failure, I just think you're under a lot of stress right now and it might help to see someone who can assess you properly, and who's also trained to be able to talk to people about the sorts of issues you're experiencing.

Friend - Can't I just talk to you?

Me -

 

[smalltownpsych]

Hearing your name called up to twice a day is considered WNL according to certain texts. Shadows at the corner of vision can also be, since they're not discrete formed images, and can overlap with many forms of substance use (esp. alcohol).

Is it safe to say that you wouldn't take these two symptoms as a sign of increased severity of depressed mood then? Also, would you add the qualifier with psychotic features based on these symptoms alone? Usually, I am seeing these kids because they want to die and meet pretty much every criteria for MDD and frequently BPD as well so it's not like it is going to change much other than increasing diagnostic accuracy.

 

[PsyDr]

Resnick, 1997
Harris, 2012

 

[Ceke2002]

Is it safe to say that you wouldn't take these two symptoms as a sign of increased severity of depressed mood then? Also, would you add the qualifier with psychotic features based on these symptoms alone? Usually, I am seeing these kids because they want to die and meet pretty much every criteria for MDD and frequently BPD as well so it's not like it is going to change much other than increasing diagnostic accuracy.

Obviously this is just anecdotal, and based on one person's experience, but (as I'm sure you already know) part of my therapy over the years has involved my learning to be more cognisant of certain experiences, specifically learning to differentiate between the types of things I might experience during the 'psychotic' part of MDD with Psychotic Fx versus the types of things I might experience during periods of high levels of stress or anxiety, emotional disregulation, disrupted sleep, dealing with trauma memories, and so on. For me at least, hearing someone call my name, and seeing shadows out the corner of my eye is definitely not associated with any part of the depressive psychosis spectrum (although it can sometimes indicate a worsening of depressive symptoms alone, just because it typically occurs during an extended period of sleep disruption for me). And if I had been diagnosed with MDD with Psychotic Fx based on those symptoms alone, there'd be a pretty big question mark hanging over that particular diagnosis...(but that's just me though).

 

[Merovinge]

Lately it seems I have been getting more and more depressed teens hearing their name called and seeing shadowy figures at the edge of their perceptual field. I have heard this type of report occasionally in the past, but am worried that I am asking question in a way that subtly encourages the report of this or are all these kids really that depressed and how common is that report in the more severely depressed teens? Many are from the Native population so that confounds the diagnosis quite a bit; culturally normative traits like less affective expression, minimal eye contact, and communicating with ancestors.

I get those symptoms a lot in non-native teens as well. I don't associate it with severity of depression, but it does come up not infrequently in teens hospitalized for suicidality/depression. I think poor sleep may be one of the route causes.

 

[smalltownpsych]

Resnick, 1997
Harris, 2012

I searched these authors and didn't see much that was illuminating. Wondering if there were there some specific research findings that apply that I didn't see?

I get those symptoms a lot in non-native teens as well. I don't associate it with severity of depression, but it does come up not infrequently in teens hospitalized for suicidality/depression. I think poor sleep may be one of the route causes.

Of course, if they are hospitalized then they tend to have more serious depression. I wonder how much sleep is the factor as I see kids with sleep deprviation all the time due to anxiety , worry, or staying up all night playing video games and they don't endorse those symptoms much, if ever.

 

[nitemagi]

Is it safe to say that you wouldn't take these two symptoms as a sign of increased severity of depressed mood then? Also, would you add the qualifier with psychotic features based on these symptoms alone? Usually, I am seeing these kids because they want to die and meet pretty much every criteria for MDD and frequently BPD as well so it's not like it is going to change much other than increasing diagnostic accuracy.

I would not take these are markers of severity of mood, and would definitely NOT qualify these as psychotic symptoms. They're at best very "soft" symptoms. My antennae also go up a little more for malingering and exaggeration of symptoms, as well as for those who have an incentive to exaggerate (identity in their dx, etc). Most often, especially in teens, the problem I've seen is they just don't understand what real hallucinations are, yet feel they're struggling, so try to find a "yes" to every question so you'll take them seriously. It's more exaggeration or attempting to accommodate to the interviewer than outright lying. Usually.

 

[smalltownpsych]

I would not take these are markers of severity of mood, and would definitely NOT qualify these as psychotic symptoms. They're at best very "soft" symptoms. My antennae also go up a little more for malingering and exaggeration of symptoms, as well as for those who have an incentive to exaggerate (identity in their dx, etc). Most often, especially in teens, the problem I've seen is they just don't understand what real hallucinations are, yet feel they're struggling, so try to find a "yes" to every question so you'll take them seriously. It's more exaggeration or attempting to accommodate to the interviewer than outright lying. Usually.

You hit the nail on the head, with that. Thanks for the help. My intuition was sensing that I was missing something and this clarified things. These kids I'm thinking of are in extreme distress and desperately crying out for help and thus wanting to answer the "yes" to take them seriously. That explains the difference from what I have seen in the past. This community is so fractured that it often won't attend to anything, but the most severe of cases. For example, frequently these kids still get no follow-up treatment even after a suicide attempt so of course they are trying to make sure I know how serious it is.

 

[DD214_DOC]

I never ask "do you hear voices" it is a pretty useless question with poor reliability and validity for discerning auditory hallucinations.

Instead I ask questions like:
"do you ever have the experience of hearing people talking to you or about you when no one is around or that others don't hear?"
"do you ever hear someone say your own thoughts out loud, either before you think them, or repeating them?"
"do you ever experience hearing someone giving a running a commentary on your actions?"

Also it can be helpful if you are seeing someone for the first time or someone who is not a career mental patient to explain why you are asking such questions. For example "sometimes when people feel as bad as you do they have experiences they might not normally have..." or "when people are under a great deal of stress like you, it is not uncommon for people to have unusual experiences..." By providing some explanation, validation and normalization you will encourage patients who might be fearful or guarded about talking about this to do so and also not offend patients who aren't psychotic.

In more frank psychotic states it will be quite obvious that the patient is having anomalous experiences (for example they are looking around, or talking to themselves, or laughing at things) and in this case I would try and join the patient with this to understand what is going on. For example "you seem distracted - are you hearing anyone else right now?" or "who were you talking to just then?" or "what was making you laugh?" You must accept the reality of these experiences, maybe joining the patient by trying to listen to. A more advanced technique (that I would not recommend for the unexperienced) is dialoguing where the psychiatrist communicates directly with the voices through the patient. This is a psychotherapy technique that usually can only be achieved when you have a strong rapport with the patient that is somewhat able to overcome the omnipotence of the voices.

Yes, be more specific. "Do you hear voices?" is about like asking, "Do you ever have abrupt fluctuations in mood?" to evaluated for bipolar.

Another caveat is that patients with psychosis that may not be severe, or who may be more functional at the time of diagnosis, can sometimes, "keep it together" for a bit. If you suspect active psychosis, continuing to press them can unravel whatever is holding them together and reveal what's actually going on. I've done this a few times recently, and other providers who didn't bother to press on completely missed the delusions.

 

[Ceke2002]

Yes, be more specific. "Do you hear voices?" is about like asking, "Do you ever have abrupt fluctuations in mood?" to evaluated for bipolar.

Another caveat is that patients with psychosis that may not be severe, or who may be more functional at the time of diagnosis, can sometimes, "keep it together" for a bit. If you suspect active psychosis, continuing to press them can unravel whatever is holding them together and reveal what's actually going on. I've done this a few times recently, and other providers who didn't bother to press on completely missed the delusions.

Seconding the importance of this from a patient's point of view. Some of us are very good at appearing 'normal', so if you notice any subtle signs that might indicate AH and we're telling you 'no, nothing like that is happening', then find a way to press the issue that will hopefully encourage us to open up more...(I know I'm open about my symptoms on this forum, but in real life not only do I struggle to verbalise what's happening during active episodes of psychotic type features, I also just don't like talking about my symptoms in general and try my best to hide them as much as I can).