The Mind Distorted: Hallucinations (Part 4)

Hallucinations: When Perception Breaks from Reality

Hallucinations are among the most widely recognized psychotic symptoms. Like most psychotic symptoms, they are not debilitating simply because they exist—but because of how the individual interprets them.

Hallucinations reflect a breakdown in the reliability of perception, where internal stimuli are experienced as coming from the outside world.

While delusions are distortions in thought and hallucinations are distortions in perception, they are rarely separate. In fact, hallucinations and delusions typically play off of one another.

Take for example a paranoid individual who believes that their neighbors are surveilling them through hidden cameras. Now, they may also hallucinate voices that they interpret as overhearing their neighbors whispering through the vents. One night, after hearing what they believe to be the neighbors discussing an imminent attack, the individual enters the neighbor’s home with a weapon and kills them under the belief that they are defending themselves from an immediate threat.

In this case, the hallucinations and delusions form a self-reinforcing system. The hallucination provides the sensory experience, and the delusion supplies the explanation. This is why psychotic individuals often attribute identity, meaning, and purpose to their hallucinations. This creates a sense of congruence between the person’s thoughts and perceptions. Human beings have a deep psychological need for coherence and to make sense of their experiences—even when psychotic. In fact, one could argue that psychotic thinking reflects a desperate attempt to make sense of what feels internally senseless. Delusions and hallucinations can work together to provide structure and organize internal logic, allowing the person to preserve coherence. Together, they form a coherent—though distorted—internal reality.

It is for this reason that many psychotic individuals believe that the voices they hear come from God, a deceased family member, or even a CIA operative. Analyzing the pattern between belief and perception is common in forensic settings, where psychosis often contributes to criminal acts that appear deliberate but are rooted in disordered thought and perception.

Hallucinations Can Be Meaningful

Hallucinations are often mood-congruent, meaning they fluctuate in tone and content depending on the individual’s emotional state. A person may hear voices criticizing them, warning them, issuing commands, or simply conversing. These experiences often reflect the person’s inner world—fear, guilt, shame, or grandiosity—projected outward.

Like delusions, hallucinations are subjectively real, emotionally charged, and interpreted within a belief system that provides structure and meaning.

The Path to Psychosis: Gradual Disintegration

Hallucinations rarely emerge suddenly or in isolation. In many cases, they are preceded by a prodromal phase—a period of increasing oddness, suspiciousness, and perceptual distortions. A person may begin to feel “off,” as if others are watching them, or as if the world feels subtly changed. They may experience fleeting impressions, whispers, or vague sensations that something is wrong. The early stages of psychosis are often confusing and terrifying.

At this point, insight is often moderately intact, and the person may seek help or express confusion. But over time, these subtle disruptions can coalesce into a fully psychotic episode, with hallucinations that become increasingly believed as external. What begins as a minor perceptual glitch can evolve into an entirely separate reality.

Hallucinations Across Diagnoses

Hallucinations are most commonly associated with schizophrenia, but they appear in many disorders:

• Delusional Disorder: Hallucinations are uncommon, but may appear if thematically consistent with the delusion (e.g., hearing a persecutor’s voice) and are not prominent.

• Schizoaffective Disorder: Hallucinations occur alongside mood symptoms, adding diagnostic complexity.

• Mood Disorders with Psychotic Features: In depression or bipolar disorder, hallucinations are typically mood-congruent—e.g., voices of worthlessness in depression, or grandiose visions during mania.

• Substance-Induced or Medical Causes: Hallucinations may also result from drug use, withdrawal, neurological illness, or sensory deprivation.

Understanding the content, quality, and context of hallucinations is critical, as their meaning and clinical implications vary greatly depending on their source.

Types of Hallucinations

Hallucinations can affect any sensory modality. Common types include:

• Auditory hallucinations: Most common, especially in schizophrenia. Typically involve voices that may comment on, insult, or command the person.

• Visual hallucinations: Seeing things that aren't there—most often full-sized people or human-like figures. Less common in schizophrenia; more often seen in delirium, neurological illness, or substance-induced psychosis.

• Tactile (somatic) hallucinations: Feeling touch or internal bodily sensations (e.g., movement, pressure, sexual abuse). These are rare in schizophrenia and usually occur alongside somatic delusions, such as believing one's organs are rotting.

• Olfactory hallucinations: Smelling odors (often foul, like burning or decay) with no external source. May indicate temporal lobe involvement.

• Gustatory hallucinations: Tasting things that aren’t there, often unpleasant (e.g., metallic or spoiled food). Rare and usually co-occur with other hallucination types.

  
  

Multiple types may co-occur, and how they are interpreted often depends on the individual’s delusional beliefs. For example, visual hallucinations in schizophrenia almost always accompany auditory hallucinations and delusions. Isolated visual hallucinations are far more typical in neurological disorders and are often reported by malingerers.

The Role of Insight

As with delusions, individuals experiencing psychotic hallucinations typically lack insight. It is not merely the presence of a voice that leads to dysfunction, but the belief that the voice is real, external, and powerful—especially if it issues dangerous commands.

Importantly, not all hallucinations are pathological. Some individuals, often referred to as “healthy voice-hearers,” report hearing voices but do not experience significant distress or impairment.

Understanding hallucinations in the context of the broader psychotic process—especially their relationship with delusions—is essential in both clinical and forensic settings. These symptoms are not isolated phenomena, but parts of a larger system that reshapes how the individual sees, hears, and makes sense of the world around them.

Sami Farhat, Ph.D.