Pseudohallucinations in an Adolescent: Considerations for Diagnosis and Treatment in the Case of "Kate"

Abstract

Hallucinations are usually considered a hallmark of severe psychopathology, most commonly psychotic or thought disorders such as schizophrenia or other organic brain syndromes. However, several studies describe '"non-psychotic hallucinations" occurring in children and adolescents who experience hallucinations without other core symptoms of true psychosis, such as the presence of a thought disorder, disorganized behavior, and pervasive dysfunction. Some authors describe the controversial subject of "pseudohallucinations," which appears to be more representative of conversion disorder symptoms rather than psychotic symptoms. We present a case of "Kate," a 16-year-old adolescent female who required psychiatric hospitalization for auditory hallucinations with secondary delusional thinking. She was initially given a diagnosis of psychotic disorder, not otherwise specified (NOS), and treated with an antipsychotic and an antidepressant. At outpatient follow-up, although Kate continued to endorse hallucinations and delusional thinking, her symptoms were not felt to be part of a true psychotic disorder. The hallucinations could be viewed as a product of extreme anxiety; a diagnosis of generalized anxiety disorder (GAD) was made, and Kate was maintained on the antidepressant and antipsychotic medications. However, this did not entirely explain Kate's symptoms. The consideration of "pseudohallucinations" as conversion disorder symptoms in the form of psychiatric symptoms was key to making an accurate diagnosis, predicting prognosis, and tailoring treatment for Kate and her parents. A total of 29 months of a combination of both cognitive-behavioral and psychodynamic treatment by the first author (MAS) included both weekly individual therapy and weekly therapy with her parents for the first 12 months, biweekly individual and parents therapy for the next eight months, and monthly individual sessions for the final nine months, during which Kate was 18 years old. During the initial course of treatment, the antipsychotic was tapered and discontinued without precipitating an exacerbation of symptoms. Symptoms continued to improve throughout treatment with both patient and parents. We discuss the differences between psychosis and “pseudopsychosis” and the reasons for making the distinction in this case. We also discuss the possible explanation for these "pseudohallucinations" in Kate and how treatment was tailored. Finally, we discuss the implications for diagnosis, prognosis, and treatment of this and similar cases of non-psychotic hallucinations.