Table 3.

Case Examples of Patients Arriving to Clinic with Presenting Concerns, Preliminary Clinical Impressions, and Potential Referrals

Presenting Concerns	Preliminary Clinical Diagnostic Impression	Example Treatment Or Assessment Referral
Janelle is a Black adolescent with occasional feelings of being unsafe and mistrust toward others. She attributes these feelings to living in a high-crime neighborhood and experiences of discrimination. She says that these feelings make her initially wary of establishing close relationships but overall keep her safe and do not interfere with her life. She also has persistent fears of forgetting to lock her apartment door and turn off the stove, which she knows are excessive. These fears lead her to spend hours each day checking the door and the stove and have led her to miss class.	Janelle might be experiencing obsessive-compulsive disorder (OCD). Janelle’s occasional feelings of being unsafe and mistrust toward others due to environmental factors and personal history of discrimination are currently more consistent with adaptive cultural paranoia than psychosis or psychosis risk.	Referral to evidence-based treatment for OCD (e.g., cognitive behavioral therapy [CBT] with exposure and response prevention). Continue monitoring worries about safety and mistrust for increases in distress, generalization to other areas without clear environmental explanation, and functional impairment. As clinically indicated, consider re-assessing for psychosis risk.
Trevor is a White adolescent who occasionally sees a monster in his bedroom for 20-minute periods two times per month. During these periods, he fully believes the monster is real and hides in his closet out of fear. This occurs while he is fully awake and resolves without medication. Outside of these periods he knows the monster is not real.	Trevor may be exhibiting symptoms of a psychosis-risk syndrome (BIPS/BLIPS subtype). His clinical presentation is currently not consistent with a full-threshold psychotic disorder given that his psychotic symptoms are brief, spontaneously resolve, and are not seriously disorganizing or dangerous.	Referral for psychosis-risk assessment (e.g., SIPS, CAARMS), followed by referral to psychosis-risk specialty care clinic (e.g., step-based care or other appropriate services within the local community) as clinically indicated.
Rowan is a White child who endorses hearing voices and exhibits affective flattening. When prompted to elaborate, he explains that by “hearing voices”, he is referring to his own internal thought monologue. He makes minimal eye contact with others, struggles to understand social interactions, has hypersensitivities to textures of food and clothing, and has difficulty deviating from his rigid daily schedules.	Rowan’s clinical presentation might be more consistent with autism spectrum disorder than psychosis or psychosis risk. Rowan’s endorsement of hearing voices may be better accounted for by idiosyncratic thought and interpretation of the assessment question rather than overt psychotic hallucinations.	Referral for autism spectrum disorder assessment (e.g., Autism Diagnostic Observation Schedule) and multicomponent autism treatment program tailored to the individual’s needs. Continue monitoring for potential psychotic symptoms and consider re-assessing for psychosis risk as clinically indicated.
Alex is a Black young adult who quit his job last week due to becoming certain that his boss was plotting against him and poisoning his coffee at work. When asked for further information, Alex says that a voice that he has heard daily for hours at a time over the past two months which his co-workers do not hear told him about his boss’s plans.	Alex might be experiencing first-episode psychosis (i.e., indicative of a psychotic disorder) given the frequency, severity, functional impact, and recent onset of his symptoms.	Referral to Coordinated Specialty Care for First-Episode Psychosis or other appropriate services within the local community.
Casey is a Korean American nonbinary young adult who endured a serious physical assault one year ago. Since the event, they have experienced flashbacks, persistent feelings of guilt, sleep troubles, detachment from others, an exaggerated startle response, hearing the voice of the attacker in their head, and they avoid thinking about the assault. Starting three months ago, they began hearing voices unrelated to the attacker in the absence of anyone else being in the room. They have also become fully convinced that the government is monitoring them via cameras outside of their house, which has led them to keep all the lights off and not leave home for days at a time.	Casey might be experiencing comorbid post-traumatic stress disorder (PTSD) and first-episode psychosis given their history of a traumatic assault and symptoms of both overt psychosis and PTSD which are not fully accounted for by one another.	Referral to evidence-based trauma-focused treatment (e.g., cognitive processing therapy, prolonged exposure), Coordinated Specialty Care for First-Episode Psychosis incorporating trauma-focused treatment, and/or other appropriate services within the local community. Initial treatment targets may depend on concerns that are considered primary, concerns that result in the most distress and/or impairment, and the patient’s recovery goals.
Madison is a White adolescent who endorses a special connection with God and feels as though she can personally communicate with God. When asked what others in her religious community think of this connection, she shares that her priest and other church members say that this is a common experience for them as well. She additionally reports month-long periods of sadness and low interest, difficulties falling asleep, low appetite, and thoughts of suicide that are distressing and interfere with her schoolwork.	Madison might be experiencing major depressive disorder. Madison’s religious beliefs are currently more consistent with the cultural norms of her church community than indications of psychosis or psychosis risk.	Suicide risk assessment and collaborative safety planning as clinically indicated, followed by referral to evidence-based depression-focused treatment (e.g., CBT, interpersonal therapy). Continue monitoring for development of beliefs inconsistent with the norms of her church community, increases in distress, and functional impairment. As clinically indicated, consider re-assessing for psychosis risk.
Marcos is a Venezuelan American adult with a seven-year history of major depressive and manic episodes. Exclusively during manic episodes, he hears voices that others do not hear complimenting him on his behavior and appearance, and he holds strong false beliefs that he is a famous athlete and that strangers are in love with him.	Marcos might be experiencing bipolar disorder with mood-congruent psychotic features. The duration of Marcos’ symptom presentation is more consistent with longstanding psychosis than first-episode psychosis.	Referral to evidence-based services for treatment of serious mental illness.
Charlie is a White adolescent transgender woman who is starting to wonder if spirits are communicating with her. She is seeing shapes of animals out of the corner of her eye multiple times per week and is experiencing time as moving unnaturally quickly. These experiences began within the past year. She finds them unsettling, but she is still able to distinguish them from reality.	Charlie may be exhibiting symptoms of a psychosis-risk syndrome (APSS/attenuated psychosis subtype, current progression). Her clinical presentation is currently not consistent with a full-threshold psychotic disorder given the presence of attenuated psychotic symptoms which are not seriously disorganizing or dangerous and lack full delusional conviction.	Referral for psychosis-risk assessment (e.g., SIPS, CAARMS), followed by referral to psychosis-risk specialty care clinic (e.g., step-based care or other appropriate services within the local community) as clinically indicated.

Notes: These are fictitious case examples that are not based on actual individuals. Thorough clinical assessment by qualified individuals and relevant trainings and certifications are warranted to make formal clinical diagnoses and treatment decisions.