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Visual Hallucinations in the Psychosis Spectrum and Comparative Information From Neurodegenerative Disorders and Eye Disease
Open accessAbstract
Much of the research on visual hallucinations (VHs) has been conducted in the context of eye disease and neurodegenerative conditions, but little is known about these phenomena in psychiatric and nonclinical populations. The purpose of this article is to bring together current knowledge regarding VHs in the psychosis phenotype and contrast this data with the literature drawn from neurodegenerative disorders and eye disease. The evidence challenges the traditional views that VHs are atypical or uncommon in psychosis. The weighted mean for VHs is 27% in schizophrenia, 15% in affective psychosis, and 7.3% in the general community. VHs are linked to a more severe psychopathological profile and less favorable outcome in psychosis and neurodegenerative conditions. VHs typically co-occur with auditory hallucinations, suggesting a common etiological cause. VHs in psychosis are also remarkably complex, negative in content, and are interpreted to have personal relevance. The cognitive mechanisms of VHs in psychosis have rarely been investigated, but existing studies point to source-monitoring deficits and distortions in top-down mechanisms, although evidence for visual processing deficits, which feature strongly in the organic literature, is lacking. Brain imaging studies point to the activation of visual cortex during hallucinations on a background of structural and connectivity changes within wider brain networks. The relationship between VHs in psychosis, eye disease, and neurodegeneration remains unclear, although the pattern of similarities and differences described in this review suggests that comparative studies may have potentially important clinical and theoretical implications.
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“Although the conventional view focuses preferentially on auditory hallucinations in psychosis, epidemiological evidence indicates that hallucinations in the visual domain are very common in, for example, schizophrenia (13).”
From Shift toward prior knowledge confers a perceptual advantage in early psychosis and psychosis-prone healthy individuals (2015) · cites this paper as [13]
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“The authors reported visual hallucinations with a substantial point prevalence of 27% (Waters et al., 2014).”
From What visual illusions teach us about schizophrenia (2014) · cites this paper as Waters et al., 2014
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“…in the auditory modality (Thomas et al., 2007; McCarthy-Jones et al., Submitted), approximately a third will have experienced visual hallucinations (Waters et al., 2014; McCarthy-Jones et al., Submitted), and a smaller minority will have experienced hallucinations in other modalities (Thomas et…”
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Restrepo-Martínez, M., Espínola-Nadurille, M., López‐Hernández, J. C., Martínez, V. M., Téllez‐Martínez, J. A., Bustamante-Gómez, P. A., Bautista‐Gomez, P., Bayliss, L., & Ramírez‐Bermúdez, J. (2021) · Revista Alergia México · doi:10.29262/ram.v68i4.953 · Cited by 8
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“An exception to the mainstream viewpoint is the “hearing voices movement” founded by Romme and Escher (1993) (Corstens et al., 2014; Waters et al., 2014).”
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“T he experience of visual hallucinations, hereafter referred to as visions or seeing visions, is a visual percept(1) experienced when awake, which is not elicited by an external stimulus (Waters et al., 2014).”
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“61 If true, this might suggest that the risk factors for HPPD are distinct from risk factors for psychotic disorders.”
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“Item 18 (‘hearing voices’) is one of the least discriminatory items (15th of 19), which is noteworthy since hearing voices is found to be the most prevalent symptom among schizophrenia patients (WHO, 1973), occurring in around 59% with this diagnosis (Waters et al., 2014).”
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“Despite the documentation of the diversity of hallucinatory experiences, current research on hallucinations in psychiatric populations has mainly focused on auditory verbal hallucinations while hallucinations in other modalities or subtypes of hallucinations are less well understood (Langdon et al., 2011; Waters et al…”
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“…metacognitive performance with other sensory modalities such as audition remains one important question to be examined, as hallucinations among schizophrenia patients are even more prevalent in the auditory domain than the visual domain (59% and 27% prevalence, respectively) (Waters et al., 2014).”
BackgroundVisual hallucinations in psychiatry – what aren’t we seeing?
Ayalde, J., Wearne, D., Hood, S. D., & Waters, F. (2021) · Australasian Psychiatry · doi:10.1177/10398562211038909 · Cited by 7
Self-citationBlackman, G., Dadwal, A. K., Teixeira-Dias, M., & Ffytche, D. H. (2023) · Cognitive Neuropsychiatry · doi:10.1080/13546805.2023.2266872 · Cited by 7
Self-citationDysfunction of Magnocellular/dorsal Processing Stream in Schizophrenia
Chieffi, S. (2019) · Current Psychiatry Research and Reviews · doi:10.2174/1573400515666190119163522 · Cited by 8
Nursing Process Addressing the Nursing Focus “Hallucination”: A Scoping Review
Gonçalves, P., Sampaio, F., Sequeira, C., & Silva, M. A. T. D. C. P. E. (2019) · Clinical Nursing Research · doi:10.1177/1054773819877534 · Cited by 7
“At the level of the diagnoses, if we take into account that 60% to 80% of all patients diagnosed with schizophrenia spectrum disorders experience auditory hallucinations (Waters et al., 2014), and a smaller proportion experience visual or other unimodal hallucination (Lim et al.”
BackgroundZhuo, C., Chen, M., Xu, Y. J., Jiang, D., Chen, C., Ma, X., Li, R., Sun, Y., Li, Q., Zhou, C., et al. (2020) · Journal of Clinical Neuroscience · doi:10.1016/j.jocn.2020.07.054 · Cited by 7
“Approximately 25–30% patients with schizophrenia experience VHs [2].”
Chinchani, A. M., Menon, M., Roes, M., Hwang, H., Allen, P., Bell, V., Bless, J. J., Bortolon, C., Cella, M., Fernyhough, C., et al. (2021) · Cortex · doi:10.1016/j.cortex.2021.08.014 · Cited by 6
Self-citationToh, W. L., Richards, S. E., Fernyhough, C., Longden, E., Moseley, P., Ramachandran, P., Thomas, N., & Rossell, S. L. (2025) · Schizophrenia · doi:10.1038/s41537-025-00673-3 · Cited by 8
“Their relative neglect in psychiatry is being remedied by increasing attention of late 43 – 46 ; the presence of visual hallucinations has tentatively been linked to negative imagery, greater illness severity and less favourable outcomes 39,44 .”
Norton, M. J., & McLaughlin, M. (2022) · Psychiatry International · doi:10.3390/psychiatryint3040023 · Cited by 6
Perceptual Mechanisms of Visual Hallucinations and Illusions in Psychosis
Klein, S. D., Olman, C. A., & Sponheim, S. R. (2020) · Journal of Psychiatry and Brain Science · doi:10.20900/jpbs.20200020 · Cited by 6
“In addition, visual hallucinations are associated with more severe psychotic symptoms, and poorer patient prognoses [3,7,8].”
BackgroundIrreversible Primary Visual Cortex Impairment in a Mouse Model of High-Risk Schizophrenia
Chen, X., Chen, C., Ji, F., Xu, Y. J., Wang, W., Lin, X., Jiang, D., Song, X., Gao, X., Tian, H., et al. (2021) · Neuropsychiatric Disease and Treatment · doi:10.2147/ndt.s246163 · Cited by 6
RetractedA single case neuroimaging study of tickertape synesthesia
Hauw, F., Soudany, M. E., Rosso, C., Daunizeau, J., & Cohen, L. (2023) · Scientific Reports · doi:10.1038/s41598-023-39276-2 · Cited by 4
Hallucinations as a presenting complaint in emergency departments: Prevalence, diagnosis, and costs
Waters, F., & Dragović, M. (2018) · Psychiatry Research · doi:10.1016/j.psychres.2017.12.074 · Cited by 6
Self-citationStructural retinal abnormalities as potential markers for psychosis spectrum disorders
Jerotić, S., & Marić, N. (2018) · Medicinski podmladak · doi:10.5937/mp69-18765 · Cited by 6
Psychiatric and Neurological Disorders
Catrambone, V., & Valenza, G. (2021) · Functional Brain-Heart Interplay · doi:10.1007/978-3-030-79934-2_5 · Cited by 4
Vejmola, Č., Šíchová, K., Syrová, K., Janečková, L., Koudelka, V., Tesař, M., Nikolič, M., Viktorinová, M., Tylš, F., Korčák, J., et al. (2025) · Biological Psychiatry Global Open Science · doi:10.1016/j.bpsgos.2025.100524 · Cited by 7
“Given the high prevalence of visual hallucinations in various neurological and psychiatric conditions (84 – 87) and the limited understanding of their underlying mechanisms, establishing reliable preclinical models is essential (88).”
Abrams, K. B., Wilson, A., Hernández, T. D. R., & Choate, A. (2024) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0000000000001772 · Cited by 5
Morin, A., Carle, G., Ponchel, A., Fernández‐Eulate, G., & Nadjar, Y. (2023) · Orphanet Journal of Rare Diseases · doi:10.1186/s13023-023-02851-x · Cited by 5
“Exclusive visual hallucinations are classically highly suggestive of an associated organic disease, since visual hallucinations in schizophrenia are mostly complex and co-occur with auditory hallucinations [35].”
BackgroundVisual hallucinations in psychosis: What do people actually see?
Aynsworth, C., Waite, F., Sargeant, S., Humpston, C. S., & Dudley, R. E. J. (2024) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12553 · Cited by 5
“Visual hallucinations, also known as visions, are the experience of seeing something in the absence of external stimuli (Waters et al., 2014).”
Self-citationRole play simulation in nurse education: applying the ‘I AM A STAR’ mnemonic
Huggins, R., Mansel, B., & Tait, S. D. (2019) · Mental Health Practice · doi:10.7748/mhp.2019.e1343 · Cited by 5
Brébion, G., Stephan‐Otto, C., Ochoa, S., Cuevas‐Esteban, J., Núñez, A., & Usall, J. (2019) · Consciousness and Cognition · doi:10.1016/j.concog.2019.102823 · Cited by 5
Time varying dynamics of hallucinations in clinical and non-clinical voice-hearers
Marschall, T. M., Koops, S., Brederoo, S., Cabral, J., Ćurĉić‐Blake, B., & Sommer, I. E. (2023) · NeuroImage Clinical · doi:10.1016/j.nicl.2023.103351 · Cited by 4
“Auditory verbal hallucinations (AVH) are often seen as a hallmark of psychosis and occur in approximately 60–80 % of schizophrenia patients (Larøi et al., 2012; Slade and Bentall, 1988; Waters et al., 2014).”
Impaired functional connectivity in patients with psychosis and visual hallucinationsPreprint
van Ommen, M. M., Invernizzi, A., Renken, R. J., Bruggeman, R., Cornelissen, F. W., & van Laar, T. (2022) · medRxiv · doi:10.1101/2022.05.06.22274666 · Cited by 5
Slapø, N. B., Jørgensen, K. N., Elvsåshagen, T., Nerland, S., Roelfs, D., Valstad, M., Timpe, C. M. F., Richard, G., Beck, D., Sæther, L. S., et al. (2023) · Psychiatry Research Neuroimaging · doi:10.1016/j.pscychresns.2023.111633 · Cited by 6
“Furthermore, while hallucinations are most frequently experienced in the auditory domain in SCZspect, it is estimated that 27% of patients experience visual hallucinations (Waters et al., 2014), often co-occurring with hallucinations in other sensory modalities (Lim et al.”
Faster bi-stable visual switching in psychosis
Killebrew, K. W., Moser, H. R., Grant, A., Marjańska, M., Sponheim, S. R., & Schallmo, M. (2024) · Translational Psychiatry · doi:10.1038/s41398-024-02913-z · Cited by 4
“This type of visual dysfunction can be studied using well-established and tested behavioral paradigms that allow the measurement of more subtle behavioral and cognitive disruptions [3].”
BackgroundBrouwer, A., Raison, C. L., & Shults, F. L. (2024) · Religion Brain & Behavior · doi:10.1080/2153599x.2024.2349151 · Cited by 5
“Visions of entities are common in spiritual experience (Brouwer et al., 2023c; Hardy, 1979; Yaden & Newberg, 2022), and visual misperceptions of “shadow figures,” and complex visual hallucinations of people and faces are common in psychosis (Van Ommen et al., 2019; Waters et al., 2014).”
Special Supplement Introduction: Hallucinations
Fernyhough, C., & Waters, F. (2014) · Schizophrenia Bulletin · doi:10.1093/schbul/sbu043 · Cited by 4
“Waters et al 5 then provide a review of visual hallucinations in the psychosis spectrum, examining prevalence, phenomenology, clinical characteristics, and assessment methods alongside studies of cognition, brain imaging, electrophysiology, and treatment.”
BackgroundSelf-citationHuang, J., Song, X., Xu, Y. J., Wang, L., Li, Y., Tian, H., Zhang, Y., Li, G., Zhou, C., & Zhuo, C. (2020) · Psychiatry and Clinical Psychopharmacology · doi:10.5455/pcp.20200302022126 · Cited by 4
Ord, L. M., Henderson, A., & Christiansen, R. M. (2018) · Journal of Visual Impairment & Blindness · doi:10.1177/0145482x1811200506 · Cited by 4
“…of this syndrome are recognized by the sub ject as imaginary, setting this condition apart from others such as dementia and psychosis in which individuals lack in sight and believe the images to be real or to accompany hallucinations in other sen sory modalities (Waters et al., 2014).”
BackgroundA shrunken world – micropsia after a right occipito-parietal ischemic stroke
van den Berg, N. S., Huitema, R. B., Spikman, J. M., van Laar, P. J., & de Haan, E. H. F. (2019) · Neurocase · doi:10.1080/13554794.2019.1656751 · Cited by 4
“Hallucinations are, in contrast to illusions and distortions, not based on an external stimulus (Waters et al., 2014).”
BackgroundPezzoli, S., & Venneri, A. (2020) · Springer eBooks · doi:10.1007/978-3-030-57231-0_17 · Cited by 4
Distressing Visual Hallucinations after Treatment with Trazodone
Santos, G., & Moreira, A. M. (2017) · Case Reports in Psychiatry · doi:10.1155/2017/6136914 · Cited by 4
“However, the patient’s insight into the fictional nature of his hallucinations and the fact that the visual hallucinations of schizophrenia are rare without auditory hallucinations makes this diagnosis highly unlikely [17].”
BackgroundMontagnese, M., Leptourgos, P., Fernyhough, C., Waters, F., Larøi, F., Jardri, R., McCarthy‐Jones, S., Thomas, N., Dudley, R. E. J., Taylor, J., et al. (2020) · doi:10.31219/osf.io/zebxv · Cited by 4
Self-citationPainting psychosis: an empirical investigation of the self-portraits of Edvard Munch
Bettelheim, E. C., Liu, J., Dazzan, P., & Turkheimer, F. (2026) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1643264 · Cited by 5
Visual Hallucinations in Serotonergic Psychedelics and Lewy Body Diseases
Heller, N. H., Barrett, F. S., Buchborn, T., Collerton, D., Dupuis, D., Halberstadt, A. L., Jardri, R., Noorani, T. N., Preller, K. H., Taylor, J., et al. (2025) · Schizophrenia Bulletin · doi:10.1093/schbul/sbaf068 · Cited by 3
“These findings align with theories suggesting that sensory deficits and associative hyper-activity contribute to hallucinations across contexts, including neurodegeneration 35, 110 , sensory deprivation 111 and meditation 112 .”
Self-citationMultidimensionalidad del Habla Interna y su relación con las percepciones anómalas
Tamayo-Agudelo, W., Vélez-Urrego, J. D., Castaño, G. G., & Garcelán, S. P. (2016) · Revista Colombiana de Psiquiatría · doi:10.1016/j.rcp.2016.02.001 · Cited by 3
Metadata
- Authors
- Waters, F., Collerton, D., ffytche, D. H., Jardri, R., Pins, D., Dudley, R., Blom, J. D., Mosimann, U. P., Eperjesi, F., Ford, S., & Larøi, F.
- Affiliations
- The University of Western Australia (AU)
- Cumbria Northumberland Tyne and Wear NHS Foundation Trust (GB)
- King's College London (GB)
- Centre Hospitalier Universitaire de Lille (FR)
- University of Groningen (NL)
- University of Bern (CH)
- Aston University (GB)
- Sir Charles Gairdner Hospital (AU)
- University of Liège (BE)
- Corresponding author
- Waters, Flavie
- ORCID
- Venue
- Schizophrenia Bulletin
- Publisher
- Oxford University Press (OUP)
- Published
- 2014-06-13
- Volume
- 40
- Issue
- Suppl_4
- Pages
- S233-S245
- ISSN
- 0586-7614 (ISSN-L)
- 1745-1701
- PMC
- PMC4141306
- OpenAlex
- W2146834289
- Cited by
- 325
- References
- 123
- Citations by year
- 2026: 21 · 2025: 33 · 2024: 23 · 2023: 33 · 2022: 33 · 2021: 31 · 2020: 37 · 2019: 29 · 2018: 19 · 2017: 20 · 2016: 26 · 2015: 12 · 2014: 8
- FWCI
- 12.27
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- cc-by
- Locations
- Schizophrenia Bulletin (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- UWA Profiles and Research Repository (UWA) (publishedVersion, other-oa)
- PubMed (publishedVersion)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (publishedVersion)
- HAL (submittedVersion, other-oa)
- Aston Publications Explorer (Aston University) (submittedVersion)
- Bern Open Repository and Information System (University of Bern) (submittedVersion, cc-by)
- Research Portal (King's College London) (submittedVersion, other-oa)
- ORBi (University of Liège) (submittedVersion)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion)
- Newcastle University ePrints (Newcastle Univesity)
- Open Access CRIS of the University of Bern
- Funders
- Coordenação de Aperfeiçoamento de Pessoal de Nível Superior
- Topics
- Life Sciences › Neuroscience › Cognitive Neuroscience › Hallucinations in medical conditions
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Life Sciences › Neuroscience › Cognitive Neuroscience › Visual perception and processing mechanisms
- Keywords
- visual hallucinations, psychosis spectrum
- MeSH terms
- Affective Disorders, Psychotic, Brain, Eye Diseases, Hallucinations, Humans, Schizophrenia, Schizophrenic Psychology, Severity of Illness Index, Visual Cortex, Neurodegenerative Diseases
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