Pseudo-hallucinations

1. Overview — What are Pseudo-hallucinations?

Pseudo-hallucination (or pseudohallucination) at its core is:

“An experience that resembles hallucinations in every way – vividness, sense of reality, the feeling that it ‘appears on its own’ without intentional thinking –
but the person still knows, or at least somewhat realizes, that it does not come from the external world and is more likely to arise from ‘inside their own head/mind’.”

This differs from the common image of hallucinations usually discussed alongside schizophrenia, which are described as experiences the patient “fully believes” are 100% real.
Pseudo-hallucination, in contrast, seems to stand “in the middle” between ordinary imagination and full-blown hallucinations.
It is not as light as “just daydreaming”, but also not so severe that the person completely believes it is unquestionably real.

In the classical phenomenological tradition of Kandinsky–Jaspers, pseudo-hallucinations are described as experiences that:

Have vividness comparable to normal sensory perception (clear sounds, clear images, a sense of something being “inserted” into one’s mind),

but are placed in “inner space”, or the internal mental space, rather than in “outer space”, the external world.
Patients often describe them as:

“It’s like a voice in my head.”

“It’s like an image popping up in my head, not something I actually see floating in front of me.”

Simple examples include:

Hearing a male voice scolding you inside your head, clearly enough to make out every word, yet the person says:

“I know there’s nobody actually standing there. I know it’s coming from inside my head, but it still feels like a real voice.”

Or during an extremely stressful period, when half-awake and half-asleep, seeing images of blood, dead bodies, or a specific face appearing in one’s mind with sharp clarity, but the person says:

“It’s like an image in my head, not something I actually see in the room.”

What makes pseudo-hallucinations interesting is the degree of insight.

People with pseudo-hallucinations usually can still somewhat distinguish that:

“Okay, it’s strange. It feels real. But it’s probably a symptom / something in my head.”

This is different from true hallucinations, where the person typically believes 100% that:

“The voice is actually there.”

“He’s really standing over there. I saw him with my own eyes. It’s not imagination.”

Another helpful distinguishing point is the localization of perception.

Pseudo-hallucination → often described as “coming from inside”:

“Like a voice in my head / an image in my head / a feeling inside myself.”

True hallucination → placed in the external world:

“The sound comes from the next house / from the TV / from behind the wall.”
“I see someone standing at the foot of the bed / I see a shadowy figure walking in the room.”

In this sense, pseudo-hallucinations are therefore viewed as:

“Hallucinations in which reality testing is not completely broken.”

The person’s system for checking what is real still works to some extent.
They can still question themselves, feel doubtful, and mentally examine their own experience,
instead of believing in it with no room for doubt, as in fully developed delusions plus true hallucinations.

However, in the current era, especially in DSM-5 and ICD-11,

the term pseudo-hallucination is increasingly seen as a term that is “ambiguous” and “inconsistently defined.”
Some authors use it to mean “hallucinations occurring in inner space,” others to mean “hallucinations with preserved insight,” and some use it nearly interchangeably with “vivid imagery.”

Because of this, many groups have proposed that instead of using this term loosely, we should write more explicitly, for example:

“Hallucinations with insight” (hallucinations where insight is still preserved),

“Non-psychotic hallucinations” (hallucinations in individuals without full-blown schizophrenia/psychosis).

In short:

Pseudo-hallucination is an experience that

is as vivid as a hallucination,

is located in the head/mind more than in the external world, and

the person still knows or at least suspects that it may not be “actually real” in the external world.

Thus, it becomes a concept that sits between “mere thought/imagination” and “full-blown psychotic hallucinations”,
and is more often used to describe phenomena such as “voices in the head that the person recognizes as a symptom” or “very vivid flashback-like images linked to trauma but with preserved insight,” rather than being used as the name of a standalone disorder.

2. Core Symptoms — Core Features of Pseudo-hallucinations

When we talk about pseudo-hallucinations, the important point is not only “what is being hallucinated” but also the nature of the experience + the person’s attitude toward that experience.
So we can expand each key aspect in detail like this:

2.1 Having a clearly hallucination-like experience (Percept-like, vivid, intrusive)

Whether it is sound, images, bodily sensations, or a sense of movement, it is typically described as:

“Clear,” “realistic,” “popping up on its own,” “uncontrollable.”

The person is not “sitting and imagining things for fun” or “deliberately thinking it up,” but feels as if it is “inserted into” their mind (passive).

Examples:

Suddenly hearing a voice in the head saying, “You’re worthless,” even though they were not thinking about that topic at all.

Suddenly seeing in their mind the face of a dead person they once saw in the news, popping up with cinematic clarity.

The difference from ordinary imagination (mental imagery) is:

Imagery → is usually somewhat “commandable.”
For example, if you want to stop thinking, you can shift your attention elsewhere.

Pseudo-hallucination → feels like it “forces its way in” rather than being voluntarily generated.

2.2 The person reports that “it comes from inside” / inner space

You often hear phrases like:

“It’s like a thinking voice, but not my own thinking voice.”

“It’s like someone is talking inside my head, not a sound from outside.”

“It’s like an image being projected in my head, not something I actually see with my eyes.”

This is the signature feature of pseudo-hallucinations in the Jaspers tradition:

The experience is placed in “the inner world” (inner subjective space)

It is not described as “coming from the TV, from the window, from the corner of the room,” the way full-blown hallucinations are.

The descriptions usually do not involve pointing to a specific spatial location in real space, for example:

You rarely hear something like, “The sound is coming from the bathroom door.”

It’s more like, “It’s sounding in my head / in my brain.”

2.3 Some degree of insight is preserved (Preserved / partial insight)

The person still has some awareness that something “doesn’t make sense in the real world,” for example:

“I know it doesn’t really make sense to have someone yelling at me inside my head like that, but I can actually hear it.”

“I know other people don’t see this image. Only I see it. It’s probably a symptom.”

This point differentiates pseudo-hallucinations from hallucinations in full psychosis, where people usually firmly believe that:

“This is definitely real.”

“It’s not just a feeling. It’s an event actually happening in the real world.”

Insight may not be 100%, but can exist at levels of “uncertainty” / “half-belief” / “ambivalence”, such as:

One part of them knows it might not be real,

but another part still feels strongly that it is “extremely real.”

→ Cases like this overlap nicely with the topic of hallucinatory experiences with partial insight.

2.4 Still able to distinguish “inner world” vs “outer world” (Reality boundary intact-ish)

People with pseudo-hallucinations can usually still distinguish between:

“What I am experiencing right now,”

vs.

“What other people in the same room are seeing/hearing.”

When asked, “Do you think other people can hear it?”

Many will answer, “Probably not. Only me.”

This indicates that reality testing is still functioning to some degree.

This differs from more severe psychosis, where the person believes:

Other people “must” hear it too,

or is convinced that the voice/image is unquestionably part of the external reality.

2.5 Both highly distressing cases and cases that can coexist with it

Some people feel very distressed:

Fear / irritation / anxiety / insomnia / poor concentration

Severe worry like: “Am I going crazy right now?”

Others, however, are able to coexist with it:

Even though they experience voices/images from time to time, they understand that these are symptoms,

they see them as “noise” in the head or an “echo from the past,” and can still go on with life.

In clinical assessment, clinicians need to look at:

To what extent these experiences disrupt functioning / relationships / sleep / work or study,

rather than just asking, “Is it present or not?”

2.6 Frequency, temporal pattern, and context (Course & pattern)

These can occasionally occur in the general population, for example:

Around sleep onset (hypnagogic) or upon waking (hypnopompic),

During intense stress, extreme fatigue, or sleep deprivation,

When staying in a very quiet, isolated environment for a long time.

They can also occur frequently and be linked to underlying conditions, for example:

PTSD → vivid flashback-like images/voices in the head.

Major depression / bipolar disorder → intrusive self-critical voices in the head.

Borderline / trauma-related → repeated voices of an “internalized abuser” speaking harshly in the head.

Patterns worth noting include:

Occurring only when mood is very low,

Occurring when exposed to specific triggers (smells, places, times),

Occurring only when alone.

→ These aspects are useful for linking pseudo-hallucinations to trauma, mood, or stress.

2.7 The feeling of “Is this really mine?” (Sense of ownership / agency)

Many people say:

“It’s in my head, but it doesn’t feel like something I created myself.”

They feel it is not a thought they deliberately generated (not fully self-generated).

Some feel that the voice/image has its own “personality” distinct from themselves, such as:

A particular tone of voice,

Characteristic mannerisms,

Attitudes or emotional tone different from their usual inner thoughts.

This makes pseudo-hallucinations occupy a middle ground between:

“Inner speech/imagery that clearly belongs to oneself,”

and

“Voices of someone else in reality.”

3. Diagnostic Criteria — How are they “defined” in practice?

To emphasize once again:

There are no official criteria in DSM-5 / ICD-11 with the name “Pseudo-hallucination.”
What is used in practice is a phenomenological description of the symptom, not a separate “disorder” in itself.

But, for practical purposes in articles / notes / slides, we can set up a list of “commonly observed features” as quasi-criteria:

A. Having a perceptual-like experience

There is an experience with qualities similar to perception:

Voices, calling of one’s name, faces, scenes, bodily sensations, etc.

It occurs without any actual external stimulus:

No real person speaking, no real image, no actual touch.

The person does not intentionally “think/draw it up in their mind”:

They report that “it just pops up on its own,” “it just appears in my head.”

In summary:
There must be “something” they can describe, with a quality resembling real perception, not just casual daydreaming.

B. Localized to an “inner subjective space”

The patient clearly states:

“It is a voice/image in my head,”

“I feel it is inside, not coming from outside.”

When asked follow-up questions such as:

“Where do you think the sound is coming from?”
→ They typically answer “from inside my head,” “from my brain,” rather than pointing to a physical location in the room.

If asked, “If you covered your ears, do you think you’d still hear it?”

Many will answer, “Yes, because it’s not coming through my ears. It’s a voice in my head.”

This criterion is the core of pseudo-hallucinations in the Jaspers tradition:

The experience is not placed in the same physical space as real-world perception.

C. Some level of insight into the unreality (Insight)

The patient accepts, or at least is able to think, that:

What is happening “probably is not something other people can perceive,”

“It conflicts with some aspects of reality.”

Examples of insightful statements:

“This is probably just my symptom, right, doctor?”

“I know no one is actually in the room, but it’s as if someone is yelling at me in my head.”

Insight can vary:

Very good → “This is a symptom of my illness. I know it isn’t real.”

Moderate → “I’m not 100% sure, but I think it’s probably not real.”

Low but still present → “I know it might be impossible, but I still feel it is real.”

If there is no insight at all, with full conviction in its reality plus additional delusional beliefs,

→ it is usually not classified as pseudo-hallucination anymore, but moves into the territory of true hallucinations + delusional belief.

D. Reality testing is not globally broken

Even though the person has unusual experiences, when you:

Ask logical questions,

Invite them to compare with the real world,

they can still “follow the reasoning” to some degree.

A simple test:

Ask, “You just heard a voice insulting you, but the other people in the room didn’t hear anything. What do you think that means?”

If they answer something like, “That suggests it’s probably in my head,” → reality testing is still functioning.

If they answer, “Because they have brainwashing technology that blocks others from hearing it,” and firmly believe that → this moves more toward psychotic delusion.

Good reality testing helps the person:

Dare to talk about the experience (because they know it’s a symptom, not a taboo reality that must be kept secret),

and cooperate better in therapy/treatment.

E. Clinically significant (Distress / impairment / clinical relevance)

Pseudo-hallucination experiences:

Cause distress (fear, anxiety, shame, stress),

Interfere with sleep, work, study, or relationships,

Are considered warning signs (red flags / prodromal signs) of:

Emerging psychosis,
PTSD / trauma-related disorder,
Severe mood disorder, etc.

If these experiences:

Occur only occasionally,

The person clearly understands they are just imagery,

There is no distress and no impact on functioning,

→ they may not be considered “pathological symptoms,” but rather a normal variation of human brain function.

F. What is not pseudo-hallucinations (Exclusion)

To avoid confusion, we should clearly separate pseudo-hallucinations from:

Ordinary mental imagery

We intentionally “picture” something or “think a voice” in our head.

We can control it to some degree – change the scene, change the voice.

It does not feel like it is “invading” us or “not ours.”

Illusions (misinterpretations of real stimuli)

There is an actual stimulus, such as a shadow in the corner, a reflection of light, or the sound of wind.

The brain misinterprets it → sees it as a person, a ghostly shadow, hears it as someone calling.

Pseudo-hallucinations require “no real stimulus” as their base.

Symptomatic hallucinations from intoxication / delirium with no insight

For example, heavy drug/alcohol intoxication, delirium, encephalitis.

The person is often disoriented in time, place, and person → reality testing is globally impaired.

There is usually almost no insight that “this is not real” during the episode.

Obsessions / intrusive thoughts in OCD

These are thoughts rather than “voices/images with perceptual quality.”

The person knows these are their own thoughts (even if unwanted).

They do not feel like someone else’s voice or like peripheral images with perceptual vividness.

G. Using descriptive phrases instead of the term “pseudo-hallucination” in modern medical contexts

When writing clinical reports / notes / academic articles that need to align with current DSM/ICD usage, we can choose descriptions such as:

“Auditory hallucinations with preserved insight, perceived as internal (‘voices in the head’).”

“Vivid intrusive imagery / internal voices, phenomenologically close to hallucinations but experienced as arising within the mind rather than from the external world.”

instead of relying solely on the term “pseudo-hallucinations”, because in contemporary academic literature the term has both supporters and critics, the latter arguing that it is too ambiguous.

4. Subtypes or Specifiers — Subtypes / Specifier Categories

Although there is no formal subtype system, for writing posts/notes we can categorize pseudo-hallucinations from several angles:

4.1 By modality (sensory system)

Auditory pseudo-hallucinations

Hearing “voices in the head” talking to us / commenting / giving commands.

The sound source is usually reported as “inside the head,” not coming from any specific point in the room. Frontiers+1

Visual pseudo-hallucinations

Very vivid images in the mind, e.g., faces, scenes, but the person says, “It’s like an image in my head, not something I actually see with my eyes.”

Somatic / tactile pseudo-hallucinations

Strange bodily sensations with strong vividness, but the person spends a period suspecting and accepting that they may be brain-generated rather than externally real.

4.2 By degree of insight

Clearly recognized as unreal (high insight)

The person clearly knows it is a mental symptom / effect of medication / stress.

Ambivalent / half-belief (partial insight)

The person feels it is strange but still leaves some room for “what if it’s real?”

This group is close to what some authors call “hallucinatory experiences with partial insight.”

4.3 By clinical context

In the psychotic spectrum (e.g., schizophrenia, schizoaffective disorder)

Pseudo-hallucinations may represent an early phase before drifting into true hallucinations.

In non-psychotic disorders

PTSD, borderline personality disorder, complex trauma, dissociative disorders, severe depression, etc.,

often show “voices in the head” or hallucination-like experiences with insight. Wiley Online Library+1

In people without clear psychiatric disorders

For example, hypnagogic/hypnopompic hallucinations near sleep onset/offset, sensory deprivation, extreme stress, or low doses of stimulants, etc. Wikipedia+1

5. Brain & Neurobiology — How does the brain work to produce pseudo-hallucinations?

First, we need to be clear that:

At present, there is no definitive evidence that pseudo-hallucinations have a unique, dedicated neural circuit that clearly differs from “regular” hallucinations.

Most research focuses on auditory verbal hallucinations (AVH – “voices in the head”) in:

people with schizophrenia / psychotic disorders, and

people who “hear voices” but do not have psychosis (non-psychotic voice hearers). Nature+2 SpringerLink+2

So when we talk about the brain basis of pseudo-hallucinations, we are essentially borrowing AVH theories and examining how they explain phenomena like “voices/images in the head with preserved insight.”

5.1 The “inner speech & self-monitoring” model — one’s own thoughts mis-tagged by the brain

One of the most prominent theories is the inner speech model.

The basic idea is:

Normally, people have inner speech – the “thinking voice” in their head – constantly present,

such as “I have to finish this task,” “Did I forget something?”

The brain has a self-monitoring / corollary discharge / efference copy mechanism that tags:

“This is a voice/action generated by me.”

If this system fails or becomes inaccurate, then what we ourselves generate (inner speech)
can be misinterpreted by the brain as a voice from “outside the self” → becoming voices in the head as hallucinations. PMC+2 Taylor & Francis Online+2

Neurobiologically:

Studies frequently find that during auditory hallucinations:

Areas involved in speech production (e.g., Broca’s area, supplementary motor area),
and auditory cortex / superior temporal gyrus

are activated similarly to when actual sounds are being heard. PMC+2 Nature+2

Where does pseudo-hallucination fit in this model?

If we see it as a continuum:

On one end: “Normal inner speech” → clearly recognized as self-generated.

In the middle: “Inner speech that is vivid and partially mis-monitored” → the person feels as if there is a voice that “doesn’t fully feel like me,” but they can still guess it is internal → pseudo-hallucination.

On the other end: “Severely impaired self-monitoring” → the voice is interpreted as clearly external (true hallucinations in psychosis).

So in pseudo-hallucinations, the self-monitoring system may be impaired but not collapsed,
and frontal regions related to reasoning and reality testing (e.g., prefrontal areas) can still “pull things back” and conclude:

“Okay, it feels like someone is speaking, but logically it must be coming from inside my head.”

Thus, in neural terms, pseudo-hallucinations can be seen as AVH where self-monitoring is moderately dysregulated,
but not to the point that the brain fully believes the voice is coming from the external world.

5.2 Predictive processing — the brain mispredicts and doesn’t know where to place the experience

Another influential framework is the predictive processing model, which views the brain as a “prediction machine” that works as:

The brain’s predictions (priors) ←→ actual sensory input,
constantly striving to minimize “prediction error.” ore.exeter.ac.uk+1

Under normal function:

If our prediction is strong but sensory input says “nothing is there,”
the brain eventually downgrades the prediction.

But under certain conditions, like dopaminergic dysregulation / high stress / sleep deprivation,
the brain may overweight its predictions relative to sensory input,

leading to “seeing/hearing” things in the absence of actual stimuli.

Some theorists propose:

Hallucinations = situations where prior beliefs/expectations are given too much weight, causing the brain to actually construct percepts.

Pseudo-hallucinations may be a state where:

Predictions are strong enough to generate vivid images/voices,
but parts of the system responsible for reality testing (e.g., prefrontal, parietal regions) can still detect:

“Wait, this doesn’t match the outside world.”

Another important point is the “challenge from pseudohallucinations”:

Lopez-Silva argues that most hallucination theories still struggle to explain why some experiences are placed in inner space (pseudo) while others are placed in outer space (true hallucinations), even though the underlying circuits look similar. PMC+2 ResearchGate+2

From a conceptual angle (the “take-home idea”):

Predictive processing provides a broad explanation of why the brain can generate perceptions without stimuli,

but distinguishing pseudo vs true hallucinations requires additional explanations concerning:

How experiences are mapped onto “inner world” vs “outer world,”
The role of networks that maintain the sense of self, agency, and the self–world boundary.

5.3 Trauma, dissociation, and “voices from the past”

Another crucial perspective is:

Some voices/images, especially pseudo-hallucinations in people with PTSD or trauma spectrum disorders,
may be “fragments of traumatic memories” resurfacing in a percept-like form. PMC+2 BPS Psych Hub+2

Studies in patients with trauma spectrum disorders (TSD) have found that:

The rate of “hearing voices” in PTSD / dissociative disorders is much higher than previously thought. PMC+2 Taylor & Francis Online+2

The content of the voices often directly or indirectly relates to past traumatic events,
such as:

Abusive phrases identical to those used by the perpetrator,
Threatening voices,
Harsh self-critical voices. OSF+1

Neurobiologically:

Amygdala, anterior insula, medial prefrontal cortex
show hyperactivity in individuals with PTSD / trauma-related hallucinations,
reflecting a hyperactive threat & salience system.

Hippocampus and contextual memory networks
function abnormally, leading to traumatic memories being:

Stored in an “incomplete / poorly contextualized” way (not clearly tied to time and place),
So when they resurface, they appear as raw “images/voices/smells” that feel like they are happening now, rather than clearly belonging to “the past.” Biological Psychiatry CNNI+1

In trauma-linked pseudo-hallucinations:

The person often still knows:

“These voices/images probably relate to past events,” → insight is preserved.

But during strong triggers, these voices/images become so vivid and intrusive that they feel like being re-traumatized.

Many models view pseudo-hallucinations in this context as:

“Replays of trauma memories in the format of perception rather than ‘just thoughts’.”

5.4 Sleep, arousal, sensory gating — the brain too exhausted to filter reality

Another major set of evidence:

Sleep deprivation, poor sleep, and disrupted sleep–wake cycles significantly increase the likelihood of hallucinatory experiences (including those with preserved insight). balancerehabclinic.com+4 PMC+4 ScienceDirect+4

Findings repeatedly show:

Several consecutive nights of sleep deprivation in healthy individuals (with no psychiatric disorder) can lead to:

Mood changes, irritability, anxiety,
Impaired concentration, slowed thinking,
and eventually brief visual phenomena, odd sounds, and even psychosis-like experiences.

Many such individuals know:

“It’s because I haven’t slept for 2–3 days that I’m starting to see/hear strange things,”

→ This fits well into the pseudo-hallucination zone.

Neurologically:

Sleep loss disrupts the functioning of:

Thalamus (sensory gating hub),
Prefrontal cortex (reasoned thinking, reality testing),
and neurotransmitter systems such as dopamine, serotonin, acetylcholine,

reducing the ability to distinguish external sounds vs internal voices or thoughts vs reality. PMC+2 ScienceDirect+2

When sensory gating deteriorates, the brain may:

Detect patterns in noise (pareidolia),
or allow predictive models to construct perceptions on their own.

Pseudo-hallucinations in this context often:

Occur after severe sleep deprivation or chronically poor sleep,

Have random or fragmented content,

And come with insight like, “This is probably because I haven’t slept.”

5.5 Network-level changes — language, salience, default mode

Multiple neuroimaging meta-analyses in people with AVH (both psychotic and non-psychotic) have found key patterns: PMC+3 Nature+3 ResearchGate+3

Language & auditory networks

Superior temporal gyrus, Heschl’s gyrus, planum temporale, Wernicke’s area, etc.,

Show structural (gray matter) and functional (hyper/hypo-activation) changes.

Frontal control & self-monitoring

Inferior frontal gyrus (Broca’s), dorsolateral prefrontal cortex,

Involved in speech generation, control, and reality testing.

Salience network & limbic system

Anterior cingulate cortex, insula, amygdala,

Determine what is “salient/important” – if biased toward threat, they can make hallucinatory content more negatively toned.

Default mode network (DMN)

Medial prefrontal cortex, posterior cingulate, precuneus, etc.,

Related to self-referential thinking, daydreaming, internal narrative.

In non-psychotic voice hearers:

fMRI shows that during voice-hearing episodes:

The activation of language/auditory regions resembles that of patients,
But connectivity with frontal control regions and other networks differs,

→ allowing them to maintain insight and normal functioning. Frontiers+2 SpringerLink+2

This ties in nicely with pseudo-hallucinations:

pseudo-hallucinations = hallucinatory experiences in which the language/auditory network “fires strongly enough,”
but the networks governing thinking and reality testing still keep them framed within the “inner world” rather than the “external world.”

5.6 Content-level summary (as a conceptual structure, not a brief synopsis)

At the brain level, pseudo-hallucinations and hallucinations largely share similar networks — language, auditory, salience, prefrontal.

The crucial differences lie in:

Self-monitoring still working to some degree,
Reality testing still partially intact,
The mapping of experience into “inner space” rather than the external world.

Main theories explaining these phenomena include:

Inner speech & self-monitoring theories PMC+2 Taylor & Francis Online+2
Predictive processing framework ore.exeter.ac.uk+1
Trauma-related voices models for PTSD/dissociation cases PMC+2 OSF+2
Work on sleep / sensory deprivation, showing that an exhausted, under-stimulated brain can start generating its own perceptions. PMC+2 ScienceDirect+2

No one has found a single “switch point” in the brain that cleanly separates pseudo from true hallucinations;
it is more a matter of degree and balance among multiple neural networks.

6. Causes & Risk Factors — Why do some people develop pseudo-hallucinations more easily than others?

Pseudo-hallucinations are not a standalone disease but a form of hallucinatory experience.
So they need to be viewed as multi-factorial, combining biological, psychological, and social factors (biopsychosocial).

A simple way to think about it:

What makes the brain more likely to generate perceptions on its own?

What allows enough insight to remain so that the outcome is pseudo-hallucinations instead of full-blown psychosis?

6.1 Biological factors

6.1.1 Genetics and family risk

Research on psychosis indicates that there are genetic components that increase the likelihood of hallucinations and psychotic-like experiences in general. ResearchGate

People with first-degree relatives with schizophrenia / schizoaffective disorder / bipolar disorder with psychosis

→ tend to have a higher risk of experiencing psychotic-like phenomena at some point.

For pseudo-hallucinations:

They may represent a “milder expression” of the same vulnerability,

but combined with other factors (e.g., good insight, good support, no substance misuse),
they do not “drift” into full psychosis.

6.1.2 Brain structure and function

As discussed in the neurobiology section:

Changes in auditory/language areas, prefrontal cortex, and salience network are repeatedly observed in people with AVH. PMC+3 Nature+3 ResearchGate+3

In people who have such experiences without psychosis:

A pattern often seen is that language & auditory networks are “fast/sensitive,”

but frontal control networks are still relatively intact → helping preserve insight. Frontiers+1

In simple terms:

Certain brain architectures predispose the brain to “generate extra voices/images,”
but if reasoning/control networks remain strong, the result is more likely pseudo-hallucinations than full psychosis.

6.1.3 Neurotransmitters and sleep–wake regulation

Dopamine, glutamate, and serotonin play key roles in hallucinations generally.

Disturbances in circadian rhythms and sleep architecture are associated with psychotic-like experiences such as hallucinations, paranoia, and cognitive disorganization. ResearchGate+3 PMC+3 ScienceDirect+3

Chronic sleep deprivation or disrupted sleep patterns → increase the likelihood of hallucinations even in otherwise healthy people.

6.1.4 Neurological and medical conditions

Certain neurological conditions, such as:

Epilepsy (especially temporal lobe epilepsy),

Neurodegenerative disorders,

Delirium due to infection/metabolic issues,

can all produce various hallucinatory symptoms.

In individuals who remain sufficiently conscious and retain some insight, parts of these experiences might fit pseudo-hallucination criteria.

6.2 Psychological factors

6.2.1 Childhood and lifetime trauma

The research is now quite robust that:

Traumatic experiences, especially in childhood,
increase the risk of hearing voices / seeing images / psychotic-like experiences, both with and without formal psychotic disorders. Taylor & Francis Online+4 PMC+4 BPS Psych Hub+4

Connections:

Children who are abused, neglected, or sexually assaulted → their stress systems, attachment patterns, and self-concept become distorted.

Later in life, voices/images in their head may:

Represent the perpetrator’s voice,
Or embody deeply negative self-beliefs (“You’re worthless,” “No one loves you”).

Many people have enough insight to recognize that these voices are related to past trauma or realize “nobody is actually there” → pseudo-hallucinations in a trauma context.

6.2.2 Dissociation (internal splitting)

PTSD, complex trauma, and dissociative disorders often come with dissociative symptoms such as:

Feeling detached from oneself,

Feeling the world is unreal,

Having “parts” inside that seem to talk to each other.

Research shows that dissociation can:

Mediate part of the relationship between trauma and hallucinations,

But does not fully explain it. Cambridge University Press & Assessment+1

In trauma-related pseudo-hallucinations:

Voices/images may be described as “a part of myself” that has split off (a self-part).

Insight remains that “it is inside,” even though it feels “not 100% me.”

6.2.3 Inner speech style, vivid imagery, absorption

People who:

Have very vivid imagination (vivid imagery),

Tend to become deeply absorbed in thoughts and imagery (high absorption),

Use dialogic inner speech (arguing with themselves, having inner dialogues),

often report “hearing voices in the head” more frequently than others, even without schizophrenia.

Research on non-psychotic voice hearers indicates that:

They hear very clear voices, but:

Their insight is generally good,
They function well in life,
Many see the voices as parts of their personality or even as companions. Frontiers+2 SpringerLink+2

In simple terms:

If someone’s mind is naturally “good at staging internal dramas,”
their risk of pseudo-hallucinations is higher than average, without necessarily having psychosis.

6.2.4 Cognitive style: interpretation and beliefs about voices/images

People who hold beliefs like “everything must have hidden meaning”:

Tend to interpret voices/images in their head more intensely than those who see them as “just noise.”

Beliefs such as:

“This voice is a spirit/god/demon,”

Or “This voice proves I’m insane,”

can:

Increase distress,

And raise the chance that pseudo-hallucinations evolve into fully delusional systems.

6.3 Social / Environmental factors

6.3.1 Chronic stress and cumulative pressure

Strong, long-term stress is linked to psychotic-like experiences.

When stress wears down the nervous system and disrupts information filtering,

→ the brain is more likely to misread or “fill in” perceptions by itself. amaehealth.com+1

Many people report that their pseudo-hallucinations:

Became significantly worse during periods of:

Exams,
Heavy workload,
Family conflict,
Breakups and relational crises, etc.

6.3.2 Sleep deprivation, shift work, lifestyle

Working shifts or living in conditions that chronically reduce sleep,
such as:

Night shifts,

Staying up late on the phone every night,

Never taking proper rest,

→ increases the chance of hallucinatory experiences even in the general population. AMFM Mental Health Treatment+3 PMC+3 ScienceDirect+3

In pseudo-hallucinations:

People often link them clearly:

“The times I hear voices the most are when I’m really not sleeping well.”

6.3.3 Sensory deprivation, isolation

Staying in quiet/dark environments for long periods, isolated and under-stimulated,

→ the brain tends to “fill in” perceptions in the form of images or sounds.

Classic historical examples include:

Prisoners in solitary confinement,

Sailors spending long times at sea,

Explorers in extreme environments,

who report hearing voices/seeing people even though they are alone.

Pseudo-hallucinations in this context often come with insight such as:

“I know no one is really here, but it feels like someone is.”

6.3.4 Substances (drugs / alcohol / stimulants)

Alcohol, cannabis, hallucinogens, stimulants (like amphetamines, cocaine)

→ can all produce hallucination-like experiences.

At low–moderate doses, or in people aware that they recently used a substance,

→ insight may still be present:

“I know it’s because I just used.”

Such experiences can sometimes be categorized more as pseudo-hallucinations than full psychotic episodes. PMC+1

6.4 Psychiatric comorbidity

Pseudo-hallucinations often appear within other mental disorders, not just “classic schizophrenia” alone.

6.4.1 Mood disorders (major depression, bipolar disorder)

In severe depression, some people have extremely harsh self-critical voices in their heads.

In bipolar disorder (both mania and depression), hallucinations can occur.

In many cases, the person still recognizes that the voices:

“Come from inside the head” and are related to feelings of worthlessness and guilt → pseudo-hallucinations in the context of mood disorders.

6.4.2 PTSD and trauma spectrum

As noted above, this is one of the contexts in which pseudo-hallucinations are now most frequently seen.

Voices/images are often directly or indirectly tied to trauma. PMC+2 ResearchGate+2

6.4.3 Personality disorders (especially Borderline)

In borderline personality disorder (BPD):

There are reports of “transient psychotic-like symptoms” when under high stress,
such as hearing voices insulting them or feeling constantly watched.

Some individuals still know:

“It happens when I’m extremely stressed, and it probably isn’t real.”

→ These can be placed within the pseudo-hallucination zone.

6.5 Overall picture: pseudo-hallucinations = the intersection of multiple forces

You can think of pseudo-hallucinations as “the point where several lines intersect”:

Biology

Certain brain types, genetic predisposition, sleep, stress systems, neurotransmitters

Psychology

Trauma, dissociation, inner speech style, imagery, belief systems

Social/Environmental

Stress, isolation, lifestyle, substance use

If:

The brain tends to generate voices/images on its own,

The person is exposed to trauma + stress,

Sleep is poor,

but

Insight remains fairly good,

Social/therapeutic support is available,

There are no strong factors pushing toward full psychosis,

→ the outcome can be pseudo-hallucinations:

“Very vivid voices/images in the head that feel real, but the person still knows or at least half-knows that they are not actually real in the external world.”

7. Treatment & Management — Approaches to Care

Because pseudo-hallucinations are a symptom, not a standalone “disease,” treatment focuses on:

Understanding the experience correctly, and

Treating the underlying disorders/conditions.

Main approaches:

7.1 Assessment

First, distinguish whether it is:

True hallucinations?

Pseudo-hallucinations (with insight / inner space)?

Pure mental imagery?

Substance intoxication / delirium / organic causes? PMC+1

Also evaluate:

Mood, anxiety, trauma history, dissociation, substance use, sleep, stress.

7.2 Psychoeducation

Explain to the person that:

Experiences like this can occur in normal humans, especially around sleep, with alcohol use, or under stress.

Many people “hear voices/see images” but still retain insight and do not have full-blown psychosis.

Understanding this can greatly reduce the fear of “I must be going crazy.” PMC+1

7.3 Psychotherapy

Depending on the underlying condition:

CBT for psychosis / CBT for voices

Helps the person reframe their interpretations of the voices/images.

Teaches coping strategies, such as changing activities, reducing avoidance, and setting boundaries with the voices.

Trauma-focused therapies (if PTSD/trauma is present)

EMDR, trauma-focused CBT, narrative exposure, etc.

Reduce the frequency and intensity of flashbacks / intrusive imagery.

Therapy for personality disorders / emotional dysregulation

DBT, schema therapy, etc., to address emotional regulation and responses to these voices/images.

7.4 Medication

If pseudo-hallucinations occur in the context of:

Clearly diagnosed psychotic disorders / mood disorders,

then antipsychotics / mood stabilizers / antidepressants may be used according to guidelines for the primary disorder. floridabhcenter.org

If the person is a non-psychotic voice hearer with good insight and minimal interference in life:

In some cases, clinicians may opt not to use medication, focusing instead on psychotherapy and coping skills.

7.5 Self-management & Coping

Improve sleep hygiene, stress management, and avoid risky substance use.

Practice grounding techniques when images/voices arise, for example:

Focusing on five things you can see/hear/feel in the real world,
Slow deep breathing,
Journaling when the experience occurs and what emotions are present.

8. Notes — Key Points / Debates

The term “pseudo-hallucination” has been heavily criticized as a “pseudo-concept.”

Berrios and colleagues argued long ago that the term is used so variably that it is unclear whether it refers to:

vivid imagery,
hallucinations with insight,
inner-space hallucinations, etc. Cambridge University Press & Assessment+1

Two important traditions: PMC+1

Kandinsky–Jaspers tradition → emphasizes “inner space.”
The insight-based tradition → if the person knows it is not real, it is called pseudo-hallucination.

DSM/ICD no longer use the term as a formal diagnostic entity. They instead use “hallucinations” as one category and specify the context/disorder/level of insight.

Some guidelines recommend writing:

“auditory hallucinations with preserved insight”

rather than using “pseudo-hallucinations.” NCBI+1

Overlap with “hallucinatory experiences with partial insight”:

In many cases, they overlap 80–90%.
If you emphasize “inner space + vivid imagery” → pseudo-hallucination.
If you emphasize “insight still partially present” → hallucinatory experiences with partial insight.

For content writing (e.g., web articles), it can be useful for SEO and conceptual mapping to separate them into two posts:

Pseudo-hallucinations post → focus on phenomenology / inner vs outer space.
Hallucinatory experiences with partial insight post → focus on the continuum of insight.

Clinically, what matters more than the label is:

Degree of distress,
Real-life functioning,
Underlying conditions and the risk of drifting into full psychosis,

rather than getting stuck on the question, “Is this pseudo or true hallucination?”

Read Schizophrenia

Reference (Brain & Neurobiology + Causes & Risk Factors)

(Focused on pseudo-hallucinations, voice hearing, trauma, and neurobiology.)

Berrios GE. Pseudohallucinations: a conceptual history. Psychological Medicine. 1996. PubMed+1
Dening TR, Berrios GE. The enigma of pseudohallucinations: current meanings and usage. Psychopathology. 1996. Semantic Scholar+1
Telles-Correia D, Moreira AL, Gonçalves JS. Hallucinations and related concepts—their conceptual background. Frontiers in Psychology. 2015;6:991. Frontiers+2 PubMed+2
López-Silva P, Cavieres Á, Humpston C. The phenomenology of auditory verbal hallucinations in schizophrenia and the challenge from pseudohallucinations. Frontiers in Psychiatry. 2022. Semantic Scholar+3 Frontiers+3 ResearchGate+3
Shinn AK et al. Assessing Voice Hearing in Trauma Spectrum Disorders: A Comparison of Two Measures and a Review of the Literature. Frontiers in Psychiatry. 2020. PMC+1
Piesse E, et al. An exploration of the relationship between voices, dissociation and trauma. Clinical Psychology & Psychotherapy. 2023. BPS Psych Hub+1
Quidé Y, et al. Dissociation, trauma and the experience of visual hallucinations in PTSD and schizophrenia. BJPsych Open. 2023. Cambridge University Press & Assessment
Strachan LP, et al. The Trauma-Related Voices Model: An Integration of Trauma, Dissociation and Voice Hearing. (preprint / theoretical model). OSF
Bouso JC. Hallucinations: psychopathology or wisdom? (overview on hallucinations, neurobiology and conceptual issues). 2023. repositorio.uam.es

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