A patient’s complaint of “hearing voices” or “seeing things” or of similar perceptual abnormalities leaves the clinician with 2 decisions: (1) Is the patient actually experiencing a hallucination, or does the complaint reflect a different mental experience, ranging from outright fabrication to the misinterpretation or mislabeling of vivid thoughts and emotions? (2) How should the experience reported by the patient, whether determined to be a hallucination or not, be understood in the context of the patient’s entire history and mental state? We report the case of a 16-year-old whose cartoon-like hallucinations had led to the diagnosis of schizophrenia and had directed attention of the patient, her parents, and her clinicians away from critical issues of anxiety, depression, learning difficulties, and traumatic school experiences. This case illustrates how the diagnosis of schizophrenia can be driven by the prominence and vividness of psychotic-like symptoms reported by a patient, the expectation that patients’ chief complaints must be directly and immediately addressed, insufficient attention to collateral information, and the distortions of a “checklist” approach to psychiatric diagnosis driven by the criteria in the Diagnostic and Statistical Manual of Mental Disorders, insurers, and the properties of electronic medical records. Given the consequences of either underdiagnosing or overdiagnosing schizophrenia, and the current lack of validated objective tests to assist with this diagnosis, clinicians are obligated to perform a thorough clinical assessment of such patients, including a probing exploration of the patient’s mental state and a systematic collection of collateral information.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.