Some kinds of hallucinations are misdiagnosed due to primary psychotic disorders. Hallucinations can be classified into 3 categories: true hallucinations, pseudo-hallucinations and hallucinosis. True hallucinations are different from the others due to incapacity of insight of the unreal and pathologic character of the phenomenon.

This study reports a case initially diagnosed as psychotic depression that after a rigorous psychopathologic investigation revealed to be an unspecified dissociative disorder.

Twenty-four-year-old female, with a past of psychiatric treatment since 18-years-old, reports brief dysphoric episodes associated with visions of bleeding clowns and skulls that were always connected to a psychosocial stressor. At the interview she asserts that she understands those symptoms as pathological and caused by her mind, and associate them with external stressors. These episodes were brief and remitted spontaneously. The mental state examination did not show any psychopathological disturbance. The reduction and suspension of antipsychotics did not result in worsening of these symptoms.

The psychopathological disturbances reported by the patient did not represent a true hallucination. The presence of insight, the evolution and duration of the symptoms, and the association with psychosocial stressors has shown that the phenomena and symptoms are associated to a dissociative disorder. Therefore, the prescription of antipsychotics involves unnecessary pharmacological and clinical risks for this patient at the moment.

Despite the use of psychopathology is considered by some as outdated, it is still an important semiological instrument for an accurate diagnosis and planning therapeutic conduct.