A visiting attending today told us a true story. Once upon a time, there was a psychiatric emergency room in a busy city hospital. One night in said psych ER, there was no attending on duty. Just a PGY-2 and PGY-3. (At this point, my attending, who was also listening to the story, put his head in his hands and groaned.)
In walked a patient endorsing command auditory hallucinations telling him to kill people with a sword. The PGY-2 and/or PGY-3 saw the patient, decided to discharge him. Maybe he didn’t present a compelling case for admission. Maybe there weren’t enough beds. Maybe they wrote him a recommendation to follow-up with an outpatient psychiatrist. Whatever the reason, the patient was sent away.
And what did he do? He went down the street. Bought a sword. Got on a ferry. Killed two people and injured nine.
The moral of the story was that command auditory hallucinations are scary. Take them seriously, even when the patient — like my patient — says they are not so bad most of the time and she just wants to go home to her mother.
What scares me most about this whole thing is just trying to imagine how terrifying it must be to hear strange voices commenting on your actions, telling you to do things. No wonder the guy snapped. Auditory hallucinations are now up there with Alzheimer’s dementia on the List of Things I Hope I Never Get.