Psychiatric assessment is one of the most nuanced and vital components of clinical medicine. It is not only about diagnosing mental illnesses but also about evaluating safety, functionality, and risk — both to the patient and to others. Whether the assessment is for a patient presenting with hallucinations, suicide risk, substance use, or emotional breakdown, a structured framework is essential.
This article introduces and elaborates on the mnemonic "VOICES HARM ME" — a powerful tool for guiding the initial psychiatric assessment in both emergency and outpatient settings.
Why Structured Psychiatric Assessment Matters
Psychiatric symptoms are often vague, overlapping, and subjective. Unlike physical illnesses, there are no lab markers for schizophrenia or depression. Clinicians rely entirely on:
- Patient interviews
- Collateral history
- Mental state examinations
- Behavioral observation
Using mnemonics like VOICES HARM ME helps ensure that no critical domain is missed — especially in first-contact evaluations or emergency triage.
Mnemonic: VOICES HARM ME – Full Breakdown
| Letter | Assessment Focus | Question Prompt |
|---|---|---|
| V | Visual hallucinations | “Do you ever see things that others don’t?” |
| O | Open/closed eye hallucinations | “Do the visions continue with your eyes closed?” |
| I | In control of voices | “Can you control or talk back to the voices?” |
| C | Changes in vision/vision loss | “Have you noticed any change in your vision?” |
| E | Ear/auditory hallucinations | “Do you hear voices or sounds others can’t?” |
| S | Sleeping problems | “How is your sleep? Any trouble falling or staying asleep?” |
| H | Head trauma/headaches | “Any recent injury to your head or chronic headaches?” |
| A | Attacking self or others | “Have you had thoughts of harming yourself or someone else?” |
| R | Recreational drug use | “Have you used any substances like alcohol, cannabis, etc.?” |
| M | Mental illness in family | “Is there any family history of mental health conditions?” |
| M | Major stress recently | “Have you gone through any stressful life changes lately?” |
| E | Enjoying daily activities | “Do you still enjoy things you used to?” |
Let’s explore each of these questions and their clinical significance.
V – Visual Hallucinations
Visual hallucinations are perceptions of things that are not actually present, involving the visual modality.
Clinical Relevance:
Rare in primary psychiatric illness
Suggestive of organic pathology, such as:
- Delirium
- Lewy body dementia
- Occipital lobe seizures
- Charles Bonnet syndrome
- Substance-induced psychosis
Assessment Tips:
- Ask for clarity, duration, and emotional reaction to the images.
- Are the images formed (people/animals) or unformed (lights/flashes)?
- Are they pleasant or distressing?
O – Open/Closed Eye Context: Is the Vision Internal or External?
Patients should be asked whether hallucinations occur with eyes open, closed, or both. This helps differentiate:
- Hypnagogic hallucinations (as one falls asleep)
- Psychotic hallucinations (projected outward)
- Occipital lobe disturbances (often eyes-open dependent)
Contextual Importance:
- If hallucinations persist with eyes closed, they may originate from the visual cortex.
- Eye-related experiences might signal sensory deprivation, especially in the elderly or blind.
I – In Control of Voices?
This addresses the degree of insight and volitional control over auditory hallucinations, which are most common in schizophrenia spectrum disorders.
Key Questions:
- “Can you talk back to the voices?”
- “Do they tell you to do anything?”
- “Can you ignore them?”
Interpretation:
- Command hallucinations (especially those demanding harmful actions) are high-risk
- Inability to control = increased risk of acting on voices
C – Changes in Vision or Vision Loss
Vision changes may mimic or co-exist with hallucinations. They also point toward organic causes.
Conditions to Rule Out:
- Charles Bonnet syndrome (visual hallucinations in the blind)
- Temporal lobe epilepsy
- Drug toxicity
- Migraine aura
- Multiple sclerosis
Follow-Up: Neurological exam and referral for ophthalmologic and imaging evaluation (e.g., MRI brain)
E – Ear or Auditory Hallucinations
Auditory hallucinations are the hallmark of psychotic illnesses, especially schizophrenia.
Features to Ask:
- Are the voices inside or outside the head?
- Are there one or multiple voices?
- Do they talk to you or about you?
Schneiderian First-Rank Symptoms:
- Third-person running commentary
- Voices discussing the patient
- Thought insertion/broadcast
These are highly specific to schizophrenia.
S – Sleep Disturbance
Sleep disorders are common early signs of psychiatric decompensation. They are seen in:
- Depression (early morning awakening)
- Anxiety (difficulty falling asleep)
- Bipolar disorder (decreased need for sleep)
- PTSD (nightmares and flashbacks)
Ask Specifically:
- “How long does it take to fall asleep?”
- “Do you wake up during the night or early morning?”
- “Do you feel rested in the morning?”
Sleep charts and sleep hygiene education are helpful tools.
H – Head Trauma and Headaches
A psychiatric assessment must screen for organic neurological insults that may:
- Precipitate behavioral changes
- Exacerbate existing psychiatric illness
Conditions to Rule Out:
- Post-concussive syndrome
- Frontal lobe damage
- Chronic subdural hematoma
- Personality change after trauma
Investigations:
- CT/MRI Brain
- Neurocognitive testing if symptoms persist
A – Attacking Self or Others: Suicide/Homicide Risk
This is the most critical safety domain in any mental health evaluation. Ask openly:
- “Have you had thoughts of ending your life?”
- “Have you ever made a plan?”
- “Do you feel like hurting someone?”
Suicide Risk Assessment Tools:
- Columbia Suicide Severity Rating Scale (C-SSRS)
- SAD PERSONS scale
Homicidal ideation, especially with psychotic voices, must be taken seriously and reported if the patient poses a risk to specific individuals.
R – Recreational Drug Use
Substance use may be causal, contributory, or comorbid with psychiatric illness.
Substances to Ask About:
- Cannabis (can cause or worsen psychosis)
- Alcohol (depression, withdrawal tremors, hallucinosis)
- Stimulants (cocaine, methamphetamine)
- Hallucinogens (LSD, psilocybin)
Ask non-judgmentally: “Many people use substances to cope. Have you tried any?”
Follow-up: Urine toxicology, referral to de-addiction services
M – Mental Illness in the Family
Psychiatric illnesses often have a strong genetic and epigenetic basis.
Patterns to Ask About:
- Schizophrenia in first-degree relatives
- Bipolar disorder in parents/siblings
- Suicide or substance abuse in family
- Neurodevelopmental delays or autism
This helps in both diagnostic formulation and prognosis estimation.
M – Major Life Stressor Recently
Significant emotional events often precede psychiatric episodes, especially:
- Bereavement
- Divorce
- Academic/career failure
- Interpersonal conflict
- Postpartum period
Ask gently: “Has anything recently happened that was difficult or distressing?”
Stress-related episodes can include:
- Adjustment disorder
- Depressive episodes
- PTSD
- Brief psychotic disorder
E – Enjoying Daily Things? (Anhedonia)
Anhedonia is the loss of interest or pleasure in previously enjoyable activities. It is a core symptom of depression.
Diagnostic Criteria:
- One of two mandatory symptoms (along with low mood) in major depressive disorder (MDD)
Ask Questions Like:
- “Do you still enjoy your hobbies?”
- “When was the last time you truly felt happy or satisfied?”
Anhedonia can also be seen in:
- Schizophrenia (negative symptoms)
- Dysthymia
- Chronic fatigue syndrome
Comprehensive Table: VOICES HARM ME Symptom Checklist
| Mnemonic | Domain | Condition to Rule Out |
|---|---|---|
| V | Visual hallucinations | Delirium, Lewy Body Dementia, substance use |
| O | Open/closed eye context | Occipital lobe epilepsy, Charles Bonnet syndrome |
| I | In control of voices | Schizophrenia, command hallucinations |
| C | Vision loss | Stroke, MS, optic neuritis |
| E | Auditory hallucinations | Schizophrenia, psychotic depression, mania |
| S | Sleep problems | Depression, anxiety, PTSD, mania |
| H | Head trauma/headache | Frontal lobe damage, post-concussion syndrome |
| A | Attacking self/others | Suicide, homicidal ideation |
| R | Recreational drug use | Drug-induced psychosis, withdrawal syndromes |
| M | Mental illness in family | Genetic predisposition to psychiatric conditions |
| M | Major recent stress | Adjustment disorder, brief psychotic episode |
| E | Enjoying daily things | Depression, dysthymia, schizophrenia |
Why This Mnemonic Works in Real Clinical Practice
The “VOICES HARM ME” mnemonic is not just an academic exercise — it is deeply useful in:
- Psychiatric emergency settings
- Primary care and general OPDs
- Inpatient psychiatry
- Post-suicide attempt evaluation
- Students learning mental status examination (MSE)
It helps clinicians:
- Rapidly assess risk
- Build rapport with patients
- Capture hallucinations, delusions, insight, and mood disorders
- Formulate a differential diagnosis
Additional Tips for Psychiatric Assessment
- Always maintain eye contact and observe body language
- Build trust before asking deeply personal questions
- If the patient is disorganized or psychotic, interview should be flexible
- Collateral history from family or friends is invaluable
- Document MSE (Mental State Examination) with key findings
Frequently Asked Questions (FAQs)
Q1. What are the first signs of psychosis?
Auditory hallucinations, paranoia, disorganized speech, and social withdrawal are early indicators.
Q2. Can hallucinations occur in depression?
Yes. Severe major depressive disorder with psychotic features may include mood-congruent hallucinations (e.g., voices telling the person they are worthless).
Q3. Is it normal to see things before sleep?
Hypnagogic hallucinations can be normal, especially in sleep-deprived or stressed individuals.
Q4. When should I hospitalize a psychiatric patient?
If there is a risk of suicide, homicide, poor self-care, or inability to function, immediate hospitalization is indicated.
Q5. Can drugs cause permanent psychiatric disorders?
Some drugs, especially cannabis, LSD, and methamphetamine, can precipitate schizophrenia or bipolar episodes in vulnerable individuals.
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