Command auditory verbal hallucinations in a culturally diverse early intervention in psychosis service: Prevalence, clinical associations and phenomenology

BACKGROUND: Command auditory verbal hallucinations (CAVH) are a subtype of auditory hallucinations perceived as instructing the hearer to perform specific actions, carrying an elevated risk of harm due to potential compliance with harmful behaviours. Despite the risk, the prevalence, clinical associations and content of CAVH in first episode psychosis (FEP) remain largely underexplored, leaving important gaps in risk assessment and early intervention during this critical illness phase. METHOD: We conducted a retrospective content analysis of medical records from 740 culturally diverse FEP patients with AVH in an early intervention in psychosis service. Prevalence estimates were calculated for phenomenological predictors of CAVH and compliance, and logistic regression analyses were conducted to examine associations with clinical and demographic factors. RESULTS: Over half of patients (51.4%, N = 380) experienced CAVH, of which 75.0% (N = 285) involved harmful and/or life-threatening content, most commonly physical harm directed toward the self, but also others. Nearly one-third (32.1%) complied with commands. Compliance was associated with several phenomenological features, including supernatural or unfamiliar voices and commands directed toward relationally proximal recipients (e.g., family members), and occurred across bodily, psychological, and social domains. Harmful and/or life-threatening commands significantly predicted compliance, particularly when harm targeted the social sphere. Longer illness duration significantly predicted the presence of CAVH. CONCLUSION: Findings suggest that CAVH are prevalent and clinically important in FEP, and that incorporating phenomenological predictors can inform compliance prediction. Detailed assessment of CAVH characteristics, combined with personalized early intervention and safeguarding, may help reduce the risk of harmful outcomes.