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In the absence of physical evidence or eyewitness testimony, establishing a criminal charge of child sexual abuse often boils down to a “he said, she said” weighing of credibility of the accuser and accused. As the burden of proof lies on the prosecution to establish the charge beyond a reasonable doubt, witness testimony becomes paramount in determining the outcome of the case. If the alleged victim is suffering from a serious mental illness, such as psychosis, that impairs one’s ability to either accurately recall the alleged abuse or distinguish reality from fantasy, witness credibility will suffer, and the defendant will likely be found not guilty. For both plaintiff and defense counsel, when there is any suspicion of psychotic illness in the accuser, it is critical to assess the following before trial: type and severity of mental illness, genetics, drug use, previous abuse, and neglect.