Can PTSD Cause Hallucinations?

Traumatic events, regardless of their nature, affect people differently. After experiencing a traumatic event, it’s normal to recall it and experience physical, mental, and emotional reactions.

However, if these reactions persist longer than a month and begin to disrupt your life, you may have post-traumatic stress disorder (PTSD).

PTSD¹ is associated with various physical, mental, emotional, and behavioral events. You may:

• Experience flashbacks

• Notice significant changes to your mood

• Have trouble sleeping

• Feel detached from your surroundings

Many people experience hallucinations in addition to other PTSD symptoms.

Although official diagnostic guidelines do not recognize hallucinations as a PTSD symptom, experts suggest hallucinations are becoming increasingly linked to PTSD and should be considered a symptom.

What is PTSD?

Post-traumatic stress disorder (PTSD) is a psychiatric disorder that may develop after experiencing or witnessing a traumatic event.

PTSD may occur from a single event or prolonged exposure to trauma. PTSD affects approximately 6% of the US population, with 12 million people² in the US living with PTSD in any given year.

Not everyone who experiences a traumatic event develops PTSD. While most people eventually recover, people who develop PTSD may continue to relive the event, causing them to feel anxious or fearful for months or years afterward.

PTSD may have long-lasting impacts on your physical and mental well-being, making it difficult for some people to continue living their daily lives.

Symptoms

Symptoms of PTSD vary from person to person as everyone has different triggers and stress responses. According to the Diagnostic and Statistical Manual of Mental Disorders³ (DSM-5), a person can be considered for a PTSD diagnosis if they meet the following criteria:

• Direct or indirect exposure to a traumatic event

• Impaired cognitive function

• Persistent symptoms that last one month or more

• Any disturbances or PTSD-like symptoms not due to medication or other conditions

The DSM-5 has outlined an additional four clusters of symptoms that may appear in PTSD, including one or more symptoms from two groups: intrusion symptoms and avoidance symptoms.

Intrusion symptoms

These symptoms may occur after the traumatic event and remind you of it. This may include:

• Feeling disconnected from reality, as if the event is recurring

• Having recurring intrusive dreams, flashbacks, or memories

• Feeling intense psychological distress when reminded of the trauma

• Having physical reactions to cues that may remind you of the traumatic event (e.g., lightheadedness, nausea, fatigue)

Avoidance symptoms

These symptoms typically lead you to avoid any cues or situations related to the event. Typical avoidance behavior patterns include:

• Avoiding distressing thoughts, memories, or feelings directly/indirectly related to the trauma

• Avoiding any external reminders of the trauma (e.g., people, places, or conversations)

Having two or more symptoms from the following two groups may also indicate PTSD:

Negative changes to cognition and mood

These symptoms may lead to changes that worsen your thought process or feelings over time. Alterations may include:

• Being unable to recall key parts of the traumatic event

• Development or worsening of exaggerated negative thoughts about yourself or others, which may lead to blaming yourself or others for the traumatic event

• Constantly feeling fear, guilt, shame, or anger

• Feeling alienated or detached from others and the surrounding environment

• Being unable to feel positive emotions (e.g., happiness, love, gratitude, satisfaction)

• Having a reduced attention span or little desire to participate in hobbies/activities that you formerly enjoyed

Arousal and reactivity symptoms

These symptoms change how you react to events and may include:

• Sudden irritability or unprovoked outbursts, or extreme responses to minor events

• Reckless or self-destructive behavior

• Hypervigilance (constantly assessing potential threats in your surroundings)

• Problems related to sleeping (e.g., difficulty falling or staying asleep, poor sleep quality)

The timeline of PTSD development is unpredictable and is different for everyone. Although you’re most likely to develop symptoms a few hours or days after the trauma, it may take weeks, months, or even years. Symptoms may also occur randomly.

It’s important to note that the duration and severity of symptoms differ for everyone.

Causes and risk factors

PTSD may occur following a traumatic or very stressful experience that a person either witnessed or experienced directly. Types of events may include:

• Physical, sexual, or emotional abuse

• Combat experiences

• Health problems

• Natural disasters

• Life-threatening trauma (e.g., car, boating, or plane accidents)

• The death of a loved one

However, not all people who experience these events develop PTSD. While it’s unknown why some people develop PTSD and others don’t, certain factors may influence the risk of developing PTSD, such as:

• History of trauma

• History of substance or alcohol abuse

• History of, or currently dealing with, other mental health disorders

• Family history of mental health disorders

• Lack of social support

• Being in a situation that may increase exposure to traumatic events

The relationship between PTSD and psychosis

Research⁴ has suggested that psychotic symptoms in PTSD are an emerging clinical observation. These symptoms are thought to overlap with intrusive symptoms and can be categorized as positive or negative psychotic symptoms.

Positive psychotic symptoms

Positive psychotic symptoms are changes in thoughts or feelings that add to a person’s experience. These are observed when someone re-experiences or relives the traumatic event and may include symptoms such as:

Hallucinations

Hallucinations⁵ are sensory experiences that occur when you feel or sense the presence of something that isn’t there. Hallucinations can be categorized as:

• Auditory: Hearing sounds (e.g., voices, music, sound effects) without external stimulation

• Visual: Seeing things (e.g., people, lights, objects, patterns) that aren’t there

• Olfactory: Smelling something that isn’t there

• Gustatory: Tasting something without drinking or eating anything

• Tactile: Feeling like something is on or under your skin when nothing is present

Delusions

Delusions⁶ are ideas or beliefs you may think are true despite a lack of evidence or when evidence suggests otherwise. These may be incorrect ideas or beliefs about yourself, others, or the surrounding environment.

One of the most common examples is persecutory delusions when you believe you’re being targeted or mistreated.

Dissociation

Dissociation⁷ is a psychological state that occurs when you feel a disruption or discontinuation of consciousness. With dissociation, you may feel like you’ve lost track or become disconnected from certain things, such as:

• Time

• Memories

• Emotions

• Identity

• Your surroundings

It’s believed to be a protective mechanism to cope with trauma and a hallmark symptom of PTSD.

Negative psychotic symptoms

Negative psychotic symptoms are a group of features that take a person away from their normal function. Examples of such behaviors include:

• Social isolation or withdrawal

• Emotional detachment

• Apathy

• Loss of interest in activities you used to enjoy

PTSD and hallucinations

Evidence increasingly suggests that hallucinations are a common symptom of PTSD. Among the different types of hallucinations, auditory hallucinations are most frequently reported among people with PTSD.

Approximately 30%-40%⁸ of combat veterans with PTSD have reported psychosis-like symptoms without other mental health conditions.

Almost all veterans have reported experiencing auditory hallucinations (e.g., hearing the voice of an enemy/deceased person, people screaming, explosions, and hearing their name being called).

Among civilians living with PTSD, researchers have reported that approximately 67%⁹ experience auditory hallucinations. Similar results¹⁰ were observed in refugees diagnosed with PTSD.

Causes and risk factors

Although PTSD may occur due to traumatic experiences, less is known about why or how hallucinations may appear in people living with PTSD. Researchers believe that trauma may cause hallucinations in different ways:

• Insights from predictive coding¹¹ (a process in which the brain ​​actively predicts incoming information rather than passively registering it) suggest that incorrectly predicting sensory input and favoring trauma-related responses may lead to hallucinations.

• Hallucinations may also arise due to changes in a person’s mindset. As negative changes to cognition and mood (i.e., believing that they have changed for the worse) increase, the body’s stress response shifts into overdrive. The previous, healthier mindset becomes alienated, setting the negative changes as the new normal mindset.

Hallucinations may arise as a result of poorly contextualized intrusive thoughts. Intrusive thoughts are believed to provoke fear through recollection (i.e., remembering the sensation of fear from the time of trauma and fear of the event repeating), which makes the individual aware of the memory.

As they continue to recall the memory, it may undergo memory consolidation (where recent experiences are transformed into long-term memories).

Over time, the process of memory consolidation may alter the memory and the current emotional and mental well-being of the person.

This may initiate a vicious cycle where an intrusive memory invokes more fear, which reinforces the memory and causes more fear, resulting in an increased risk of experiencing hallucinations.

Hallucinations are also at risk of becoming exaggerated or worsened due to risk factors such as:

• Certain traumatic experiences: In addition to a current PTSD diagnosis, people exposed to certain forms of abuse, such as child abuse and war trauma, may have an increased risk of experiencing psychosis-like symptoms in PTSD.

• Avoidance ​​behaviors: Avoiding or distancing yourself from thinking about the traumatic event may increase the chances of hallucinations as it encourages negative responses to intrusive memories. This is believed to suppress the activation of the fear network¹², which may initiate a vicious cycle that increases the frequency and intensity of intrusive thoughts.

• Emotional dysregulation: People who were upset by re-experiencing or being reminded of their trauma were four times more likely to experience auditory hallucinations.

• Anxiety and depressive symptoms

• Delusional beliefs

• Dissociation

Treatment

Several treatment options are available that may help relieve and minimize the symptoms of PTSD. The main treatment options are behavioral therapies and medication.

Treatments will differ between people and may include a combination of therapies.

Behavioral therapies

Trauma-focused psychotherapies are the first-line treatment recommended for people living with PTSD. This type of psychotherapy, suitable for children and adults, generally involves working with a mental health professional to focus on memories of the traumatic event.

The aim is to provide strategies to emotionally process the trauma and help change current thought processes.

Types of psychotherapies that may help PTSD include:

Cognitive behavior therapy

Cognitive behavior therapy¹³ (CBT) is problem-oriented psychotherapy that uses action-based solutions to challenge thoughts, emotions, and behaviors that may have resulted from PTSD.

A trained mental health professional (e.g., counselor, psychologist, or psychiatrist) uses CBT to encourage patients to identify unhelpful behaviors by using different techniques such as:

• Cognitive restructuring¹⁴: This process identifies and challenges negative thoughts to reduce negative behavioral patterns in exchange for healthy, flexible thinking.

• Cognitive processing: People use this to acknowledge the trauma and understand its impact on thinking processes.

• Education: Learning about PTSD, coping strategies for re-experiences and flashbacks, and emotion-regulation techniques help to relieve stress and manage exaggerated thoughts.

CBT treatments usually occur over 12-16 weeks¹⁵ and can be carried out as individual or group therapy.

It’s considered the gold standard treatment for mental health disorders due to its effectiveness in reducing PTSD symptoms and intrusive thoughts. However, research is ongoing to understand whether CBT effectively reduces the frequency of hallucinations in PTSD.

Eye movement desensitization and reprocessing

Eye movement desensitization and reprocessing¹⁶ (EMDR) is trauma-focused psychotherapy that helps patients process the traumatic event to begin healing.

EMDR therapy generally consists of eight phases:

• Phase I – history taking: This involves establishing a history to obtain background information and thought processes to target.

• Phase II – preparation: The patient is prepared for EMDR by having the treatment explained and resources provided to manage re-experiencing symptoms.

• Phase III – assessment: This phase focuses on the memory of the traumatic event by identifying imagery, current negative beliefs related to the trauma, and current emotional and physical sensations when thinking of the target memory.

• Phase IV to VII – adaptive resolution: These phases are the core component of EMDR and aim to encourage natural healing processes by the brain, which include:

  • Desensitization: The person focuses on the parts of the traumatic memory while performing a specified movement (e.g., eye movements, sounds, rhythmic taps).

  • Installation: This technique aims to replace negative behavioral patterns with positive actions by “installing” the repetitive movements practiced during desensitization.

  • Body scan: By observing physical responses while recalling the trauma and performing the repetitive movement, the counselor identifies any remaining distress that may need to be processed.

  • Closure: During this phase, the patient actively takes in their emotional state and combines the use of guided imagery and relaxation techniques to help relieve any distress.

• Phase VIII – reassessment This phase involves an evaluation of the person's current mental well-being to identify whether treatment effects have been maintained and if any new symptoms or memories have appeared since the previous session.

Although some debate about how EMDR can address hallucinations remains, it is recognized as an effective PTSD treatment by the American Psychiatric Association (APA)¹⁷.

Prolonged exposure therapy

Prolonged Exposure therapy¹⁸ (PE) is an exposure-based treatment for PTSD. This therapy teaches people to confront traumatic memories, feelings, and situations. This can be approached using various methods such as writing or verbally recollecting the memories.

It comprises 8 to 15 sessions during which patients are encouraged to confront their trauma by revisiting and describing the memory for 30–45 minutes.

By recalling these events in a safe environment, PE aims to minimize the fear response associated with memory. Beyond the therapy, individuals are encouraged to approach safe, trauma-related situations that they may have previously avoided due to reminders.

The patients also listen to recordings of the therapy sessions, which may help ease the severity of PTSD symptoms.

Medication

Medications such as selective serotonin reuptake inhibitors (SSRIs) and antipsychotic medication can also be used in PTSD treatment to help relieve symptoms.

SSRIs

SSRIs¹⁹ are a type of medication typically used to treat depression and anxiety. However, certain SSRIs have also been found to relieve PTSD symptoms. Currently, only sertraline (Zoloft) and paroxetine (Paxil) are approved by the US Food and Drug Administration²⁰ for treating PTSD. However, your doctor may prescribe other SSRIs based on your symptoms.

These medications may relieve PTSD symptoms by blocking the reabsorption of serotonin in the brain.

As a result, this helps regulate mood functions in the brain and may be responsible for reducing PTSD symptoms of re-experiencing, avoidance, numbing, and hyperarousal. Research is ongoing to understand if SSRIs help with psychotic symptoms arising from PTSD.

Antipsychotic medication

Antipsychotic medicines²¹ are typically used to treat psychosis symptoms in schizophrenia. However, they have also been used for PTSD symptoms.

Although no FDA-approved antipsychotic medicines are available for PTSD treatment, 41.8%²² of off-label (FDA-approved drugs for one condition are used for a different condition) antipsychotic medication prescriptions were written for people with PTSD.

The most commonly prescribed antipsychotic medicines for PTSD are quetiapine (Seroquel) and risperidone (Risperdal). Both medications affect chemical messengers (e.g., dopamine and serotonin) in the brain.

While research is ongoing, some reviews²³ have shown promising results of using risperidone or quetiapine for PTSD treatment. Subjects in clinical trials reported outcomes such as improved PTSD symptoms and reduced scores across PTSD diagnostic tests.

However, such medications are often reserved for patients with treatment-resistant PTSD, as antipsychotic medicines are not guaranteed to be effective for psychotic symptoms in PTSD.

When to see a doctor

Following a traumatic event, it’s normal to be upset, shocked, and to feel anxious. You may also experience other symptoms such as flashbacks, difficulty concentrating, or trouble sleeping. However, with time, these symptoms should fade.

If these symptoms persist after a month, preventing you from carrying out everyday activities, or if you’re experiencing psychosis-like symptoms, it's best to see your doctor. They’ll be able to diagnose your PTSD, provide management options, or refer you to a qualified mental health professional for psychotherapy and further assessment.

The lowdown

PTSD is a chronic, debilitating mental illness that can happen to anyone who has experienced trauma. It’s associated with various reactions, with positive and negative psychosis symptoms such as hallucinations becoming increasingly recognized in new PTSD diagnoses.

Hallucinations can be intimidating, especially when experienced alongside other symptoms of PTSD. However, you aren’t alone. Seeking treatment from your doctor or a qualified mental health professional may help you manage PTSD symptoms, allowing you to eventually resume everyday activities.

Frequently asked questions

Can PTSD cause other mental health conditions?

People living with PTSD may experience other mental health conditions due to the overlap in symptoms. However, it’s unclear whether PTSD is a definitive risk factor for developing other mental health issues.

Symptoms of PTSD can overlap with conditions such as major depressive disorder, anxiety disorders, and alcohol and drug abuse without necessarily being the cause of those conditions.

What’s the difference between hallucinations and delusions?

Hallucinations and delusions are often grouped together, but they’re different from each other. Hallucinations occur when a person experiences sensations that aren’t real. A person may see, hear, feel, smell, or taste something without any real stimulus. Delusions are false thoughts or beliefs that one might have despite reality suggesting otherwise.

Who can have hallucinations or delusions?

Numerous conditions can cause hallucinations or delusions. These symptoms are more likely in people with substance abuse disorders or certain mental health conditions such as schizophrenia.

What’s the difference between PTSD and schizophrenia?

Although there are similarities between PTSD and schizophrenia symptoms, they are different conditions. PTSD is a mental health condition that can occur following a traumatic event. People living with PTSD may experience a range of symptoms, including psychosis.

However, not everyone with PTSD presents with psychosis symptoms. Schizophrenia is also a mental health condition, but it’s characterized by disruptions in thinking processes, social interaction, and emotional responsiveness. Schizophrenia is believed to have genetic and environmental links, whereas PTSD is normally linked to a triggering traumatic event.