Pseudo-Hallucinations: A Diagnostic Conundrum

Background: Pseudohallucinations are vivid, hallucination-like experiences that are internal, recognized as unreal. Distinguishing from true hallucinations remains a diagnostic challenge. Case-report 33-year-old female with family history of psychosis presented with 10-year duration of delusion of infidelity and auditory experiences, with normal Biopsychosocial functioning. She had multiple psychiatric consultations, diagnosed as paranoid schizophrenia, treated with  various antipsychotics, ECT, current prescription of clozapine(350mg) with clozapine induced seizure.  Reported that her husband was emotionally unavailable. She described the voices in her head which were non-threatening, praising her for having qualities of an ideal-wife.  They were constant companions giving her solace and hence refrained from controlling them even if she could (Pseudo hallucinations).  Psychological-assessment corroborated. Inadequate coping was noted. Diagnosis revised to Delusional Disorder. Psych educated, Clozapine tapered and stopped,  Olanzapine(10mg), CBT and Marital therapy administered- improvement noted. Conclusion: Globally few cases are reported with initial diagnosis of psychosis with auditory-hallucinations, later revised as non-psychotic illness with pseudohallucinations. Pseudohallucinations are subjective, with insight and links to psychological stress or coping rather than progressive psychotic deterioration as is our case. Careful phenomenological interview, attention to psychosocial stressors and coping can prevent unwarranted psychotropic exposure and improve long-term outcomes.