A lot of voice hearing is not schizophrenia: it can be an ordinary inner monologue, cultural, a personality trait, or dissociation in PTSD, and those split-off voices do not respond to dopamine blockade. Take a full history of the voices (OLD CARTS, then keep asking why), and judge them by their effect on functioning. The goal is function, not zero voices, so do not just push the antipsychotic until they disappear.
How we assess them
Use OLD CARTS, even for voice hearing: onset, location, duration, character, aggravating and alleviating factors, radiation, timing.
“Onset, location, duration, character, aggravating and alleviating factors, radiation, timing. So don't forget to apply these wherever possible, even to voice hearing”
21:41Detecting Subtle Signs of Psychosis: Assessment of Voices, Delusions, and PsychosisFeb 2026 Then ask why, again and again: who are the voices, why do they think they have them. Patients rightfully expect to be judged for these experiences.
“Ask why, ask why, ask why, why? Because, again, these are experiences that lots of patients rightfully feel and expect that they're going to be judged negatively for, right”
24:53Detecting Subtle Signs of Psychosis: Assessment of Voices, Delusions, and PsychosisFeb 2026 Whether it was a heard voice or an intrusive thought matters less than how and why it is happening. People with psychotic disorders can experience foreign thoughts, or their own thinking as intrusive and unlike their normal selves.
“It actually doesn't matter if it was a voice or not, because people with psychotic disorders can experience foreign thoughts or they can even experience their own thinking, but in a manner that is quite intrusive and different than their normal selves”
13:24Lindsay Clancy Case: Biggest Misconceptions After the Mistrial Explained by a Forensic PsychiatristSep 2026
What they get confused with
A lot of voice hearing is not the product of a schizophrenia spectrum disorder. It can come from cultural background, a personality trait or syndrome, or PTSD, and many people labeled with an odd psychotic disorder are having dissociative reactions.
“a lot of people who might be identified by some clinicians as having some kind of an odd psychotic disorder are actually experiencing dissociative reactions. A lot of voice hearing is not the product of a schizophrenia spectrum disorder”
44:35Trauma and PTSD: How the DSM Criteria Actually Help Us Understand What’s Going OnOct 2026 Also said in 1 more episode
“A lot of voice hearing is not the product of a schizophrenia spectrum disorder. A lot of voice hearing experience is the product of a cultural background, a personality trait or syndrome, or PTSD. You can experience flashbacks, dissociations as a parent voices, even when it doesn't seem to be directly related to the incident trauma”
42:54Understanding Trauma and PTSD, Diagnosis and Dissociation | Episode 21Apr 2025 Voices can come from many conditions, or from being an ordinary person: some people simply hear an internal monologue.
“Just like psychosis, voices can come from a lot of different mental conditions. It can come from being an ordinary person. Some people simply hear an internal monologue, for example”
41:43Lindsay Clancy Trial: A Forensic Psychiatrist Explains Psychosis, Malingering, & the Insanity DefenseSep 2026 In severe PTSD, hearing apparent voices or noises, or seeing shadows flit past, is often a dissociative process rather than true psychotic features.
“a lot of the time, the experiences of hearing apparent voices, noises, or seeing things, even flits of shadows going past that you see in the severe PTSD is a dissociative process and not properly with psychotic features process”
17:11PTSD Medications: Integrating Pharmacotherapy, Therapy, and the Treatment Frame | Episode 22Apr 2025 Voices from dissociative, trauma or personality syndromes are parts of the self that have been split off. In our experience, and we think in the research, they do not respond to dopamine blockade.
“Those are really just parts of the self that have been split off in terms of an experience, experienced as different or at least separate from the core self. And that does not, in my experience, and I think in the research, actually respond to dopamine blockade”
31:28What is Psychosis? Look at the DSM, Common Mimics, and a Framework for the DifferentialJan 2026
Treatment approach
Do not chase the voice. Getting rid of it often takes an antipsychotic dose high enough to cause intolerable side effects or drug-induced negative symptoms. Aim for function.
“Often you have to go to a high enough dose of antipsychotic that there's intolerable side effects or serious neurolepsis, basically drug-induced negative symptoms. So don't just go, here's the symptom of the voice, I need to get rid of it, right”
30:41What is Psychosis? Look at the DSM, Common Mimics, and a Framework for the DifferentialJan 2026
Pitfalls
In the insanity defense, hearing a voice and following it is not enough. What the person believed at the time has to mean they did not understand the act was wrong.
“it's not enough to hear a voice and follow the voice. What you believe at the time has to justify you following that voice in some sense, in a manner that would mean that you didn't understand it was wrong”
40:03Lindsay Clancy Trial: A Forensic Psychiatrist Explains Psychosis, Malingering, & the Insanity DefenseSep 2026
It also comes up on
- DelusionsPatients with mainly delusions and hallucinations often do not tell you about the hallucinations, or do not see them as hallucinations, so all you are left with is the delusions.
- SchizophreniaPatients with mainly delusions and hallucinations, without negative symptoms or disorganization, often will not tell you about the hallucinations or do not see them as hallucinations, so all you are left with is delusions.
- Negative symptomsWithout negative symptoms or disorganization, diagnosis is harder: many patients with delusions and hallucinations will not report the hallucinations or do not perceive them as hallucinations, so all you are left with is the delusions.
- AntipsychoticsSome people are okay with more hallucinations if they are less sedated, and that does not mean they will be hospitalized. Assess the patient.
- Forensic psychiatryA trauma met through a delusion or hallucination is technically not objectively threatening, but someone who cannot tell it from reality is, in effect, objectively threatened.
- PTSDUnusual routes exist. A delusion or hallucination is not objectively threatening, but most people who could not tell it from reality would be threatened. And in forensics, people can develop PTSD from being the assailant.
- PTSDReserve 'delusions', 'hallucinations', 'negative symptoms' and 'disorganization' for primary psychotic disorders. For trauma and personality syndromes say reported voices, fear or hypervigilance, and overvalued idea or inflexible belief.
- PsychosisIn the DSM, psychosis is more than delusions and hallucinations: it includes disorganized speech, disorganized behavior and negative symptoms. Catatonia sits nearby but is not only seen in psychosis.
From these episodes
- Trauma and PTSD: How the DSM Criteria Actually Help Us Understand What’s Going OnOct 2026 · 1 point
- Lindsay Clancy Case: Biggest Misconceptions After the Mistrial Explained by a Forensic PsychiatristSep 2026 · 1 point
- Lindsay Clancy Trial: A Forensic Psychiatrist Explains Psychosis, Malingering, & the Insanity DefenseSep 2026 · 2 points
- Detecting Subtle Signs of Psychosis: Assessment of Voices, Delusions, and PsychosisFeb 2026 · 2 points
- What is Psychosis? Look at the DSM, Common Mimics, and a Framework for the DifferentialJan 2026 · 2 points
- PTSD Medications: Integrating Pharmacotherapy, Therapy, and the Treatment Frame | Episode 22Apr 2025 · 1 point
- Understanding Trauma and PTSD, Diagnosis and Dissociation | Episode 21Apr 2025 · 1 point
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.