Hallucinatory experiences with partial insight

1) Overview — What are hallucinatory experiences with partial insight?

When we talk about this term, it consists of two main layers:

“Hallucinatory experiences” = hallucinatory experiences
This means the brain “creates sensory experiences by itself” even though, in reality, there is no stimulus present at all.

Hearing people talking / whispering / insulting you while the environment around you is quiet

Seeing people, shadows, lights, or strange shapes even though others don’t see anything

Smelling burning, gas, or corpses even though nothing is found on examination

Feeling as if something is touching you, or as if insects are crawling on you, even though your skin is clear

Sensing strange tastes in your mouth even though you are not eating or drinking anything

“Partial insight” = the person still has “some degree” of awareness that what is happening may not be normal / may not be real
This means they do not 100% rigidly believe that what they are experiencing is “external reality.” Instead, there is another voice in their mind constantly whispering things like:

“This is strange…”

“Could it be because I’m ill?”

“The doctor said it’s a symptom… maybe that’s true.”

What does it mean when we put these together?

So, “hallucinatory experiences with partial insight” means:

Hallucinatory experiences in which the person is still somewhat aware / can still feel / can still question that:

“What is happening might not be entirely real in the external world. It might be a symptom arising from the brain or from some illness.”

In other words, they are aware on two layers at the same time:

Layer 1: The experience feels “very real,” to the point that it seems to be happening right in front of them.

Layer 2: A part of them feels that “this is abnormal,” not like ordinary experiences that most people have.

Examples of how people with partial insight talk about it

Sentences like these often hint at hallucinatory experiences with partial insight:

“I hear people insulting me in my head very often, but it’s strange because other people say they don’t hear anything at all… so I started thinking it might be a symptom of an illness rather than someone actually insulting me.”

“When I’m alone, I often see a shadow of a person walking past, but when I turn on the light and check the cameras, there’s nothing there. So I’ve started to think it’s probably a hallucination.”

“The smell of burning is really strong, like the gas stove is about to explode, but when I call my family to smell it, they don’t notice anything… so I’ve started to doubt myself and wonder if it might be something coming from my brain.”

“It feels like something is touching my shoulder, but when I reach up to touch it and turn to look, there’s nothing there… Sometimes I think maybe I’m just too stressed or I’m having hallucinations.”

All of this carries a tone of “half-believing, half-doubting”, meaning:

They accept that it feels very real,

But they don’t dare to firmly conclude that it’s something supernatural / a spirit / or a real person doing something to them.

They also continually “leave room for medical explanations,” such as brain function, medication, stress, or psychiatric illness, etc.

How is it different from other types of insight?

To make the picture clearer, let’s compare with these three levels:

Good (intact) insight

The person clearly says:

“The voices I hear / the images I see are symptoms of an illness, not something real.”

Their attitude tends to be quite stable, not fluctuating much. When they explain, they often use language like:

“The doctor diagnosed me with psychosis.”

“That was during a period when the illness flared up, so I was having visual hallucinations.”

Partial insight (the focus of this topic)

This sits in the middle between “fully aware” and “no awareness at all.”

There is hesitation, such as:

“It’s probably a symptom… but sometimes I’m scared it might be real.”

“The doctor said it’s a hallucination. I also think that’s probably true, but when it was happening, it felt so real that I couldn’t tell the difference.”

Poor or no insight

They fully believe that:

“What I see/hear = 100% reality.”

They reject all medical explanations and see things as:

The doctor is lying.

The family doesn’t understand.

Everyone is “conspiring together.”

And if we go one step further — when it’s not just hallucinations, but “fixed false beliefs” (delusions) develop on top, for example:

Believing that the headquarters of a secret organization is shooting brain waves at them

Believing that the TV is sending secret messages specifically to them

Believing that the neighbors have hidden listening devices in every corner of their home

At that point, it enters the territory of delusion, meaning it’s not just a perceptual experience, but it has now solidified into a “fact-level belief” in the person’s mind.

Why is this term important in clinical work?

Because it helps clinicians assess how “entangled” a person is with their hallucinatory experiences.

People who still have partial insight tend to:

Cooperate better with treatment

Be more open to talking about their symptoms

But on the other hand, they also “suffer deeply” because they are aware that:

“There is something wrong with me.”

In clinical reports or mental status examinations, clinicians often write something like:

“Auditory hallucinations present; partial insight retained.”

Which roughly means:

“The person has auditory hallucinations, but still retains some awareness that these may be symptoms of an illness.”

In short:

Hallucinatory experiences with partial insight =
When a person has full-blown hallucinatory symptoms while at the same time still “recognizing the possibility” that what is happening may not be external reality, but may be a result of the brain / illness / stress.

It is a middle zone between “fully aware” and “fully convinced” on the entire spectrum of insight. 🧠

2) Core Symptoms — Core features

In the group hallucinatory experiences with partial insight, there are three major axes of symptoms that clinicians usually consider together:

The content/form of the hallucinations
The level of insight
The impact on real-life functioning

2.1 Characteristics of the hallucinations themselves

(1) Vividness of the experience

What is “seen / heard / felt / smelled / tasted” is usually extremely vivid, as if real.

The person often says:

“At that moment, it felt completely real.”

“The voice was just like someone standing right by my ear talking.”

Some people, while it is happening, cannot distinguish what is real from what is a symptom.

(2) Common modalities

Auditory hallucinations

Hearing insulting voices, critical voices, commanding voices, or people conversing

It may be a single voice or multiple voices

Some people can clearly specify the gender, age, and tone of the voice

Visual hallucinations

Seeing shadows, unfamiliar people, animals, strange creatures, dark figures, flashes of light, etc.

These may be seen:

On and off, in brief flashes
Or as extended “scenes,” e.g., repeatedly seeing someone walking across a room

Tactile / Somatic

Feeling as if being touched or tapped on the shoulder, feeling insects crawling, or abnormal sensations of heat/cold on the skin without any physical cause

Somatic = sensations inside the body, e.g., as if something is moving in the abdomen or under the skin

Olfactory / Gustatory

Smelling burning, gas, corpses, decay, or tasting strange flavors (metallic, very bitter, abnormally sweet), even though nothing is actually there

(3) Frequency and duration

They may be:

Episodic: Appearing intermittently, a few times a day

Or almost every day, especially when sleeping alone, being in the dark, or under stress

Some people describe that during a “relapse” period, voices or images come in clusters throughout the day, but when medication is effective / they rest well, symptoms become milder.

(4) Common triggers

Sleep deprivation, severe stress

Alcohol use / substance use / missing doses of medication

Being in environments that are:

Very quiet
Dark
Or being alone for long periods

People with partial insight often “identify patterns” to some extent, such as:

“If I’m stressed or haven’t slept enough, the voices come more often.”

2.2 Detailed characteristics of “partial insight”

The key point is that their mind is not completely in the dark. There is still a small light inside constantly saying, “This doesn’t seem normal.”

(1) Acknowledging that “this is different from other people”

The person may say things like:

“Other people don’t hear what I hear.”

“Everyone says they don’t see anything, but I see it very clearly.”

This means they recognize that “their own experience” is genuinely different from that of those around them.

(2) Leaving room for illness/brain-based explanations

They often spontaneously say:

“It might be because of the illness.”

“The doctor said it’s a hallucination. That might be true.”

“I don’t know if I’m just messed up myself or what.”

They do not slam the door shut and decide 100% that:

“It has to be ghosts / magic / enemies using secret technology.”

(3) Two-sided hesitation (ambivalence)

In their mind, two voices are battling:

Voice 1: “This is really happening. It feels absolutely real.”

Voice 2: “But it’s also abnormal. It could be a symptom.”

So they often describe things in a “half-believing, half-doubting” way and do not have a definitive answer for themselves.

(4) Reality-testing

This is a key hallmark of partial insight:

Asking others, “Did you hear that just now?”

Getting up to look around the room, turning on the lights, opening the curtains, checking cameras, videos, etc.

Trying not to follow the voice’s commands and then observing whether anything happens

Some people start keeping a journal to track: “In what situations do these things occur?”

(5) Language/tone

It is not a tone of “certainty,” but a tone of “constantly questioning oneself,” for example:

“It feels so real that I can’t tell, but deep down I know it probably isn’t real.”

“I can’t confidently say whether it’s real or not… but it’s really scary.”

2.3 Fluctuation of symptoms and insight

(1) Fluctuates according to mood and physical state

On days when they rest well, take medication on time, and are less stressed →

The person often says clearly, “It’s probably a hallucination.”

On days of intense stress, poor sleep, or conflicts in life →

The fear becomes larger
They begin to believe the experiences more, e.g., “What if this really is happening…”

(2) Fluctuates according to illness phase

During acute phases (relapse):

Hallucinations are more frequent and intense
Partial insight may temporarily regress, and they may believe more strongly

During remission / when stable on medication:

Episodes become less frequent
Insight improves; they may look back and say:
“At that time, I was really out of it.”

(3) Example patterns in real life

In the daytime, when around other people → they feel it is more likely to be a symptom

At night, alone in a dark room → they begin to feel, “Well, maybe there is something more going on.”

In short, partial insight is not fixed; it “goes up and down” over time, affected by stress, symptom severity, and medication adherence.

2.4 Emotional and functional impact

(1) Anxiety / fear of “going crazy”

Because they know that:

“What I experience is different from other people,”

they worry that they will:

Be seen as bizarre

Be labeled “crazy”

Some avoid telling anyone except their doctor because they feel very ashamed.

(2) Double burden

Layer 1 = the symptoms themselves (voices / images / smells / sensations) → intrusive, frightening

Layer 2 = awareness that they are “not normal” → leads to:

Shame
Feelings of worthlessness
Self-stigma (“I’m a burden, I’m a strange person.”)

(3) Avoidance

They avoid triggers, such as:

Dark places, quiet rooms, closed-off spaces

Being alone

Some cannot sleep alone and must keep the lights on, TV running, or background sound on at all times.

(4) Impact on work/study/relationships

Decreased concentration; unable to follow conversations because voices/hallucinations keep interrupting

Avoiding social situations, fearing that symptoms will appear in front of others

Family relationships may become strained because people around them “don’t understand what they are fighting with.”

(5) The positive side of still having insight

Overall, people with partial insight tend to:

Be more receptive to treatment than those with no insight

Comply with medication, attend appointments, and are willing to try CBT/psychotherapy techniques

But the trade-off is that “their psychological suffering is often greater,” because they are fully aware that:

“Something is wrong with me.”

3) Diagnostic Criteria — Clinical perspective

To emphasize again → this is not a “disease name,” but a description of a symptom pattern.
So the criteria below are a “framework for thinking” when writing reports/posts, not official DSM/ICD criteria.

A. Clear presence of hallucinatory experiences

(1) Core features of hallucination

It is a “sensory perception” (seeing / hearing / smelling / touching / tasting / bodily sensations).

There is no external stimulus in the real world corresponding to that experience.

It must be distinguished from:

Illusion = there is a real external stimulus but it is misinterpreted (e.g., a coat hanging in the dark is seen as a person).

Imagination = the person clearly knows they are “thinking/imagining it themselves,” not feeling as if they are actually seeing/hearing something right in front of them.

(2) At least one clear modality

For example:

Auditory: critical voices, commanding voices, insulting voices

Visual: seeing people/animals/floating shadows, etc.

Or any other modality where the person “insists” that they genuinely feel it, not just as a fleeting thought.

B. Presence of “partial insight” toward that experience

To be considered “with partial insight,” at least some of the following must be present:

(1) Awareness that the experience is “not like other people’s”

They may say things like:

“Other people don’t hear/see what I do.”

This means they recognize that they are perceiving something that “deviates from the norm of those around them.”

(2) Acceptance of the possibility that it may be a symptom/illness

They use phrases like:

“It might be because of…”

“The doctor said it’s a hallucination. I think there’s some truth in that.”

They are not rigidly convinced that:

“There is only one possible explanation: ghosts / mind control / secret devices shooting waves.”

(3) Presence of uncertainty

They do not conclude 100% that:

“This is definitely real,”

“This is definitely just imagined.”

They speak in forms like:

“I’m not sure myself.”

“Part of me thinks it’s a symptom, but part of me is afraid it’s real.”

(4) Ability to discuss and reason with the doctor

When the clinician asks, for example:

“Is it possible that this is related to sleep deprivation or stress?”

The patient does not shut down the conversation but responds along the lines of:

“It could be, but when it happens, it feels incredibly real.”

C. Reality-testing is still at least partially intact

Reality-testing = the ability to test the reality of one’s own experiences.

For these cases, there should be at least some of the following:

They have tried asking others, “Did you hear that too?”

They have tried turning on the lights / checking the room / looking for the source / checking cameras, etc.

They allow the doctor to conduct tests, such as physical examinations, brain imaging, eye exams, etc.

They accept at least some test results, for example:

“The doctor has checked everything and found nothing abnormal, so I think it’s probably a symptom rather than something actually being there.”

The key point is:

They are not “locked” into their own belief like in delusions.

Their belief can still shift, leaving room for other possibilities.

D. Impact on functioning (distress / impairment)

It is not just “once hearing something while falling asleep” like many people experience, but there must be a clear degree of distress or functional impairment, such as:

Stress/anxiety severe enough to cause insomnia

Avoiding being alone; avoiding social situations

Inability to work; poor concentration due to constant intrusion of voices/images

Damaged relationships with family/friends/partners because others do not understand the symptoms

Feelings of shame, being convinced that they are “crazy,” leading to a serious drop in self-esteem

If there is no distress or impairment at all → it may be considered a transient experience that has not yet reached a “clinical” level.

E. Presence of an underlying “primary disorder” that explains the symptoms

Because “hallucinatory experiences with partial insight” is only:

A pattern of symptom expression,
not the name of a disease.

Therefore, when describing criteria, it must be overlaid on a primary diagnosis, such as:

Schizophrenia / schizoaffective disorder / brief psychotic disorder

Major depressive disorder with psychotic features

Bipolar disorder with psychotic features

Neurocognitive disorders (e.g., Parkinson’s disease, dementia with Lewy bodies, Alzheimer’s disease)

Charles Bonnet syndrome (in patients with severe eye disease)

Substance-induced psychotic disorder

Other brain disorders (epilepsy, stroke, brain tumor, etc.)

Key point:

When writing in clinical notes, doctors will not diagnose:

“Diagnosis: Hallucinatory experiences with partial insight.”

But will instead write something like:

Diagnosis: Schizophrenia, currently with auditory hallucinations; partial insight retained.

4) Subtypes or Specifiers — Subcategories

There is no single “universal standard” for subtypes here, but clinically people often categorize by different perspectives as follows:

4.1 By modality of hallucinations

Auditory hallucinations with partial insight

Hearing insults, criticism, commands, or conversations

Still aware that others do not hear the same things and that it may be part of an illness

Visual hallucinations with partial insight

Seeing shadows, people, animals, or scenes that feel very real

Some patients with eye disease / partial blindness (e.g., Charles Bonnet syndrome) know that these are “illusory images created by the brain,” not ghosts or real people
repository.ubn.ru.nl+3jnnp.bmj.com+3ScienceDirect+3

Somatic / Tactile / Olfactory / Gustatory hallucinations with partial insight

Feeling something moving inside the body / smelling / tasting things in the absence of any stimulus

The person is confused about whether their body is truly abnormal or whether this comes from the brain.

4.2 By level and pattern of insight

Stable partial insight

Overall, they are fairly consistent in saying “this is a symptom,” even though they are still afraid of it.

Fluctuating insight

Sometimes they accept it as a symptom, sometimes they firmly believe it is real.

This is seen in psychosis, dementia, delirium, and some neurological conditions.
jnnp.bmj.com+1

Cognitive insight vs. Clinical insight

Clinical insight = awareness of being ill / needing treatment

Cognitive insight = the ability to question and view one’s own thoughts flexibly (self-reflectiveness, self-certainty)
Cambridge University Press & Assessment+2ResearchGate+2

Some patients admit that “it might be a symptom” (clinical insight is present), but remain highly “attached to the content of their beliefs” (low cognitive insight).

4.3 By context of the primary disorder

Psychotic disorders (schizophrenia spectrum)

Mood disorders with psychotic features (bipolar, depression) ScienceDirect+1

Neurodegenerative disorders (Parkinson’s, DLB, Alzheimer’s) Taylor & Francis Online+1

Neurological / Ophthalmological conditions (e.g., stroke, epilepsy, visual impairment, Charles Bonnet)Lippincott Journals+2ScienceDirect+2

Substance-induced (alcohol, illicit drugs, certain medications)

5) Brain & Neurobiology — How the brain works when hallucinations occur and partial insight is still present

Broadly, when we talk about hallucinatory experiences with partial insight, we are talking about two dimensions that must “overlap” at the same time:

The mechanisms that generate hallucinations

The mechanisms that allow some insight to remain (not completely lost)

Both of these involve multiple interacting brain networks that are constantly communicating.

5.1 The “basic” level: How does the brain generate hallucinations?

Before talking about insight, we need to understand why the brain can generate hallucinations at all.

(1) The brain does not just “receive data” — it is constantly “predicting and filling in.”

Modern neuroscience views the brain through predictive processing / predictive coding:

The brain:

Has an internal “model of the world”

Uses this model to predict what it will see/hear

Then compares that prediction with actual sensory input

When real input is low, noisy, or processing is abnormal:

The brain starts to “trust its own predictions” more than real input

This produces something like “images/voices from within” that are misinterpreted as external stimuli

In simple terms:

When the brain predicts too strongly / sensory input is weak / checking systems fail → hallucinations arise.

(2) Spontaneous firing of the sensory cortex

Imaging studies in people with hallucinations (especially auditory/visual) show that:

When there are voices (auditory hallucinations):

Regions such as the auditory cortex (e.g., superior temporal gyrus) and the auditory-processing network activate just like when real sounds are present.

When there are visual hallucinations:

The visual cortex and associated visual processing networks (occipital, temporal) show increased activity as if the person is actually seeing something.

The key point is:

The brain “fires signals on its own” without any external stimulus,
but the interpretive system mistakenly concludes that these signals come from “the outside world.”

(3) Connections with memory and emotion systems

Hallucinations often have “themes.”

Self-critical voices → linked to self-schema, self-criticism

Strange images of familiar people → linked to past memories and emotions

The memory system (hippocampus, medial temporal lobe) and emotional system (amygdala):

When they interact with sensory cortex out of sync,

Things that were once “thought/feared/remembered” may be “turned into images” or “played as sound” like a movie in the mind.

5.2 So where is “insight” in the brain?

Insight is not something abstract; it is linked to executive and self-monitoring networks in the brain, especially frontal regions and parts used to “view oneself from a higher vantage point.”

(1) Prefrontal cortex (PFC) — center for reasoning and narrative control

The PFC (especially the dorsolateral PFC) is responsible for:

Planning

Evaluating information

Deciding “how believable something is”

Insight requires capacities like:

Comparing one’s experiences with knowledge/information/what others say

Being able to say:
“This is more unusual than what most people experience. It could be a symptom of an illness.”

In psychosis with very poor insight:

Abnormal activity and connectivity in the PFC are frequently found

The “narrative monitoring system” weakens → anything generated by the brain tends to “automatically become fact in the mind.”

In partial insight:

It is as if the PFC still retains some functional capacity

It can still insert thoughts such as:
“But the doctor said it’s a hallucination.”
“Others can’t see it, but I can see it alone; that’s strange.”

(2) Anterior cingulate cortex (ACC) — conflict/error detection

The ACC functions as an “error/conflict detector” in the brain, for example:

When we see something that does not fit the context

When we break rules we previously set for ourselves

When “what we feel” does not match “the facts”

In people who still have partial insight:

The ACC can still “signal” that:

What they are experiencing (e.g., seeing a person standing in the room)
Does not match objective reality (e.g., cameras see nothing, others see nothing)

This warning helps prevent their “belief in hallucinations” from hardening into 100% conviction.

But if the ACC is dysfunctional / the network is damaged:

The brain will “not sense that something is off.”

Hallucinations then easily merge into delusions because there is no system saying:
“Wait… this doesn’t line up with common sense.”

(3) Parietal regions & sense of agency

The parietal lobe (especially the inferior parietal lobule) is involved in:

Distinguishing “what is me” vs. “what is external”

Knowing whether “this voice/thought was generated by me” or “came from outside”

If this system is disrupted:

Internal thoughts or voices from one’s own thought processes may be misattributed as “coming from outside,”

Leading to “voices” that feel like someone else is speaking.

In partial insight:

The system that recognizes “what is mine” has not completely failed.

So there are moments when the patient can say:

“It’s like a voice in my head, but it’s not like normal thinking.”

This indicates a seed of metacognitive awareness that “something in the internal process is going wrong.”

5.3 Why partial insight instead of full insight or no insight?

Think of Insight = a composite function of several systems:

PFC → reasoning, evaluation

ACC → conflict detection

Parietal + other networks → self-awareness, self vs. non-self distinction

Memory and knowledge about the illness (psychoeducation) → providing a context like “I’ve read/learned that this is a symptom of an illness.”

When an illness or abnormal condition strikes:

For some people, the network is heavily damaged → insight is almost absent.

For others, the network is impaired but not destroyed → a “middle pattern” emerges = partial insight.

And insight does not sit still:

It is modulated by:

Mood (depression / mania / anxiety)
Stress levels
Sleep
Medication

So in the same person:

On one day, they may clearly say, “It’s a symptom.”

On another, when very stressed, they may say, “I don’t know anymore whether it’s real or not.”

5.4 Neurobiology of fluctuation

Hallucinations and insight are not turned on/off by a single switch; they depend on the “balance” of the entire network at any given time.

When antipsychotic medications are working well →

Spontaneous firing in sensory cortex decreases
Frontal networks function better → insight improves

When they forget medication / sleep poorly / experience high stress / use substances →

Abnormal activity in sensory networks increases
The prefrontal cortex is suppressed/disrupted by stress hormones, dopaminergic overload, etc. → the ability to question and evaluate decreases

So we see patterns like:

The higher the stress + psychotic activation → the more prominent the hallucinations / the poorer the insight.
The more the brain returns to a calm state → hallucinations lessen / insight rebounds somewhat.

6) Causes & Risk Factors — Layered causes and risk factors

In this section, when writing clinically or academically, we are not looking for “a single cause” but instead considering multiple layers:

Biological level

Psychological level

Social/environmental level

And most importantly:

Hallucinatory experiences with partial insight are a symptom pattern that “sits on top of an underlying primary disorder,” not something that occurs in isolation.

6.1 Major diagnostic groups where hallucinations + partial insight are common

(1) Schizophrenia spectrum & other psychotic disorders

Schizophrenia

Schizoaffective disorder

Brief psychotic disorder

Schizophreniform disorder, etc.

Common features in this group:

Abnormalities in dopamine / glutamate systems and connectivity across many brain networks

Structural changes in certain brain regions over time in some patients

Hallucinations are core symptoms, especially auditory hallucinations

Partial insight in these disorders often appears like:

During prodromal / early phases of the illness:

The patient begins to feel “something strange is happening to me.”
They do not yet fully believe that it is “supernatural” or “someone doing something” to them.

During post-treatment / improved clinical state:

Hallucinations may still be present occasionally, but insight improves.
They may say:

“Now I still hear them sometimes, but I know they’re symptoms of the illness.”

(2) Mood disorders with psychotic features

Major depressive disorder with psychotic features

Bipolar disorder (mania/depression) with psychotic features

What is interesting is:

The content of hallucinations often aligns with mood, for example:

Depression → self-deprecating voices, voices urging self-harm, imagery associated with death
Mania → voices praising them, voices telling them they have a grand mission

In these cases, partial insight may sometimes “return” quite clearly after mood stabilization:

During severe episodes: they almost fully believe the hallucinations

After treatment: they look back and say they were “out of touch” at the time

(3) Neurocognitive disorders / neurological disease

Parkinson’s disease
Dementia with Lewy bodies (DLB)
Some cases of Alzheimer’s disease
Other dementias

In this group:

Visual hallucinations are common.

Many patients are “partly aware” that what they see may not be real, for example:

Seeing people/animals in the house, but when family members insist no one is there, they might laugh it off, saying:

“I guess my eyes are playing tricks on me.”

Partial insight may gradually worsen as overall cognitive functioning declines.

(4) Eye diseases and visual loss — Charles Bonnet syndrome

People with severe visual impairment (macular degeneration, glaucoma, partial blindness, etc.)

The brain is “no longer receiving enough input from the eyes” → so it “fills in images by itself” → visual hallucinations

The signature of Charles Bonnet:

Many patients know that “the images they see are probably not real.”

Some explicitly say:
“I know they aren’t really there; my brain is just playing tricks on me.”

This is a clear example of hallucinations where insight remains good or partial insight is high.

6.2 Biological factors

(1) Genetics and family risk

Family history of psychotic disorders / bipolar disorder / schizophrenia

Increases the likelihood that the person’s brain/neuromodulatory systems will be vulnerable.

It does not “transmit a guarantee of hallucinations” but passes on a “vulnerability to psychosis.”

(2) Neurotransmitters

Dopamine

Classical theory: psychosis → abnormal dopamine activity in mesolimbic pathways.

When dopamine rises in the wrong place/wrong time → the brain interprets “ordinary signals as excessively important.”

This may cause self-generated voices/images to be interpreted as “very significant / meaningful / coming from a strange source.”

Glutamate (via NMDA receptors)

Involved in reality processing and learning.

Dysfunction in this system has also been linked with hallucinations and delusions.

Other substances like serotonin and GABA also contribute to the overall balance of neural function.

In partial insight, we might interpret that:

The systems generating hallucinations are disturbed,

But the systems that “govern interpretation and evaluation of credibility” (e.g., frontal regions) have not completely collapsed.

(3) Brain structure and connectivity changes

In some cases of schizophrenia/psychosis, studies have found:

Reduced volume in frontal brain regions

Abnormal connectivity (dysconnectivity) between frontal ↔ temporal / parietal regions

Abnormal connectivity can cause:

Events in the sensory/temporal lobes (voices/images/memories)

Not to be adequately “quality-checked” by frontal regions.

But in people who still have partial insight:

It is as if some “wires” are still functioning.

Insight does not completely go out.

6.3 Psychological factors and coping

(1) Personality and cognitive style

People who have cognitive styles such as:

Jumping to conclusions = drawing conclusions too quickly from very little evidence

Externalizing = quickly attributing causes to external factors

Are more likely to “believe hallucinations are real.”

If their cognitive style is flexible (willing to admit they might be wrong):

It is more conducive to partial insight.

For example, they say:

“I can’t say for sure whether it’s real or not.”

(2) Trauma history and past fears

People with trauma, especially around:

Abuse
Bullying
Severe criticism

Often have hallucination content that reflects trauma, such as self-critical voices or images of aggressors.

Partial insight may reflect that:

They know “this is related to their memories/fears.”

But when symptoms flare, they still shake with fear because the hallucinations are tied to deep wounds.

(3) Metacognition and self-reflection

The ability to:

“Observe one’s own thoughts and feelings from a higher perspective,”

Ask oneself, “How believable is what I’m thinking/feeling?”

People with strong metacognitive skills (not necessarily high IQ, but high metacognitive awareness):

Are more likely to have partial insight,

Because they know how to question their own experiences.

6.4 Social and environmental factors

(1) Chronic stress and harsh life conditions

Prolonged severe stress (work, finances, family, relationships, loneliness)

Overactivates the stress system (HPA axis, cortisol), leading to:

Neurotransmitter imbalance
Poor sleep quality
Weakened frontal control → hallucinations become more likely / insight drops

(2) Stigma around mental illness

If society/family “labels” that:

People who hear voices or see things = crazy = dangerous

Patients with partial insight fully know they are entering a stigmatized zone:

They become more stressed
They hide their symptoms more
They are less likely to seek help

Fear of stigma adds another layer of stress → symptoms fluctuate more severely.

(3) Support from family and significant others

If people around them:

Listen without judgment

Believe that they are truly suffering

Are willing to see a doctor together with them

Partial insight has the chance to “grow” into more stable insight.

In contrast, if the family says things like:

“You’re overthinking it.”

“There’s nothing; you’re just rambling.”

“Don’t tell anyone; it’s embarrassing.”

The patient feels lonely + confused → some may turn instead to other belief systems (e.g., superstition / black magic / being cursed / being hypnotized), which reduces medical insight.

6.5 Substances, medications, and other physical factors

(1) Substances / alcohol / certain medications

Amphetamines, methamphetamine, cocaine, LSD, ketamine, cannabis, and alcohol in certain states (e.g., withdrawal)

Can induce hallucinations.

In some cases, substance users say:

“When I was high, I knew I was seeing/hearing weird things, but at that time I also knew I was using drugs.”

This is one form of partial insight (awareness that the substance is involved).

(2) Physical and brain illnesses

High fever, brain infections, delirium, stroke, brain tumors, epilepsy, etc.

At certain points, patients may still have partial awareness:

They know they are “confused/disoriented.”

They may say: “I know I’m acting weird, but I can’t figure out exactly how.”

Partial insight in these contexts often depends on the level of consciousness.

6.6 Why do some people have partial insight while others have none?

A combination of factors push individuals toward the “partial insight” side:

Innate brain structure + genetics

Some people have a stronger frontal network → even with psychosis, they still have room to question their experiences.

Education / knowledge about mental illness / psychoeducation

Those who have read/learned/heard doctors explain → have the language and frameworks to label their experiences as “symptoms.”

Metacognition / less rigid personality

Being open to new perspectives → able to accept, “I might be wrong.”

Past treatment experiences

Having had psychosis, then improving with medication/therapy → they know from “their own experience” that hallucinations can diminish → making it easier to believe “this is an illness symptom.”

Non-stigmatizing social context

If the environment is safe enough for them to say “I hear voices” without being called “crazy” → they have room to practice insight with clinicians/therapists.

Conversely, if:

Frontal/ACC regions are severely damaged

No one provides education about the illness

Society/family is strongly stigmatizin

There is a pre-existing rigid belief system

→ The likelihood that hallucinations will fuse with delusions and nearly extinguish insight becomes much higher.

7) Treatment & Management

7.1 First, clarify the “primary diagnosis”

Take detailed history (onset, substance use, medical conditions, eye disease, family history, etc.)

Conduct a mental status exam — including direct assessment of hallucinations and level of insight Royal Children's Hospital+1

Additional tests such as blood tests, brain imaging (CT/MRI), eye exams, etc., may be necessary depending on the case.

7.2 Biological / pharmacological treatment

Antipsychotic medications

Primarily used to reduce the frequency/severity of hallucinations in psychotic disorders. Lippincott Journals

Antidepressants, mood stabilizers

Used when hallucinations are associated with depression/bipolar disorder.

Treatment of neurological/ophthalmological conditions

In Parkinson’s disease, dementia, Charles Bonnet syndrome, etc., the underlying disorder needs to be treated and medication adjusted accordingly.
jnnp.bmj.com+2ScienceDirect+2

7.3 Psychotherapy and CBT for psychosis (CBTp)

Main goals:

Help the patient understand what hallucinations are and how they relate to brain function.

Train reality-testing skills, such as checking evidence, asking others, distinguishing “feelings” from “facts.”

Reduce tension and fear toward the symptoms (voices/images may still appear, but the patient is less dominated by them).

Change beliefs about the meaning of hallucinations, for example:

From “the insulting voice is a vengeful ghost” → to “it’s a voice produced by my brain when I’m under extreme stress.”

Many studies indicate that improved insight is associated with better treatment response and long-term prognosis.
PMC+2ResearchGate+2

7.4 Psychoeducation — educating patients and families

Explain that having hallucinations does not mean someone is “weak” or “crazy,” but that it is a brain symptom that is treatable in many cases.

Help families understand “partial insight”:

Sometimes they accept it as a symptom.
Sometimes they appear to fully believe it is real → this is not “lying,” but a reflection of the illness and brain function.

7.5 Daily-life coping strategies

Grounding techniques (e.g., counting things around them, focusing on real physical sensations).

Listening to music/podcasts to mask voices (when safe to do so).

Keeping a diary of when hallucinations occur → helps identify patterns and plan ahead.

Practicing relaxation: deep breathing, mindfulness, body scan, etc.

7.6 Risk assessment

People with partial insight often know they are “not normal” → this can increase the risk of:

Hopelessness

Shame

Depression

So assessment of suicidal ideation, self-harm, and substance use should always be included.

8) Notes — Important points

“Knowing something is strange” does not mean “they are making it up / attention-seeking.”
Hallucinatory experiences can be so “intensely real” that even the person themselves is confused as to why they feel so real, while at the same time knowing they are abnormal.

Partial insight is a “middle state” on the insight continuum:

It is not a black-and-white between “fully convinced” and “fully aware.”
It can change with mood, stress, medication, and therapy.

It should not be used as a weapon to argue with or pressure patients, e.g.:

“You said you know it’s a symptom, so why are you still scared?”

This kind of statement makes them feel guilty and shut down.

A better approach is:

“We believe it feels very real to you. At the same time, we want to explore whether it might be something the brain is doing, and then work together on how to cope with it.”

Anyone who suspects they might have experiences like these should:

“Collect evidence,” e.g., note timing, situations, stress level, medication/coffee/alcohol use;
Bring this record to a psychiatrist or clinical psychologist.
This helps far more than just saying “I feel strange” without details.

Having insight does not always mean the illness is “lighter.”
Sometimes, people with good or partial insight suffer more because they know they are not normal.

Therefore, emotional support and reducing stigma are extremely important.

Read Schizophrenia

References — Hallucinations + Insight in Psychosis

Selected with a focus on hallucinations + insight, in case you want to use them for Nerdyssey / at the end of the post:

Chaudhury S. Hallucinations: Clinical aspects and management. Industrial Psychiatry Journal. 2010;19(1):5–12. doi:10.4103/0972-6748.77625 PMC+1
Kumar S, et al. Hallucinations: Etiology and clinical implications. Industrial Psychiatry Journal. 2009;18(2):124–131. Lippincott Journals
David AS. Insight and psychosis. British Journal of Psychiatry. 1990;156(6):798–808. doi:10.1192/bjp.156.6.798 PubMed+1
David AS. On insight and psychosis: Discussion paper. Journal of the Royal Society of Medicine. 1990;83(5):325–329. SAGE Journals+1
Reddy MS, Thanvi D. Insight and Psychosis. Indian Journal of Psychological Medicine. 2015;37(3):257–259. PMC+1
Jacob KS. Insight in Psychosis: An Indicator of Severity of Psychosis, an Explanatory Model of Illness, and a Coping Strategy. Indian Journal of Psychological Medicine. 2016;38(3):194–201. PMC+2 Ovid+2
Jacob KS. Insight in psychosis: A critical review of the contemporary literature. Asian Journal of Psychiatry. 2020;51:101867. ScienceDirect+1
Soriano-Barceló J, et al. Insight assessment in psychosis and psychopathological correlates: A systematic review. Actas Españolas de Psiquiatría. 2016;44(1):1–12. SciELO España
Segarra R, et al. Insight in first episode psychosis: Conceptual and clinical aspects. Actas Españolas de Psiquiatría. 2010;38(2):96–105. SciELO España
Lera G, et al. Insight among psychotic patients with auditory hallucinations. Journal of Clinical Psychology. 2011;67(7):701–708. Wiley Online Library+1
Lopez-Morinigo JD, et al. Is too much insight bad for you? British Journal of Psychiatry. 2024;225(1):1–3. Cambridge University Press & Assessment
David AS. Insight and psychosis: The next 30 years. UCL Institute of Mental Health review. 2019. Discovery UCL
Perivoliotis D, et al. Cognitive insight predicts favorable outcome in cognitive behavioral therapy for psychosis. Early Intervention in Psychiatry. 2010;4(3):234–242. Taylor & Francis Online
Johnson S, et al. Insight, psychopathology, explanatory models and outcome of psychosis: A critical review. BMC Psychiatry. 2012;12:159. SpringerLink
Chaudhury S, et al. Clinical aspects and management of patients experiencing hallucinations: A review. (mental health nursing review) Bepls+1

hallucinatory experiences with partial insight / partial insight hallucinations / hallucinations with preserved insight / insight in psychosis / clinical insight / cognitive insight / insight continuum / auditory hallucinations / visual hallucinations / somatic hallucinations / olfactory hallucinations / gustatory hallucinations / schizophrenia spectrum disorders / mood disorders with psychotic features / psychosis and insight / reality testing in psychosis / fluctuating insight / hallucinations vs delusions / Charles Bonnet syndrome / neurobiology of hallucinations / dopamine dysregulation / predictive processing / frontal lobe dysfunction / anterior cingulate cortex / metacognition in psychosis / coping with hallucinations / CBT for psychosis / psychoeducation for psychosis / neurocognitive disorders and hallucinations / Parkinson’s disease hallucinations / dementia with Lewy bodies hallucinations

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