Psychosis can alter nearly every aspect of how a person sees the world, from full-blown visual hallucinations to subtler distortions in color, motion, depth, and contrast. These visual changes are far more common than most people realize: roughly a quarter to half of people with schizophrenia experience visual hallucinations, and an even larger share report some form of visual distortion. The causes trace back to disruptions in brain chemistry, visual processing circuits, and even measurable changes in the eye itself, painting a picture that is more complex than the popular image of “seeing things that aren’t there.”
How Common Are Visual Problems in Psychosis
Auditory hallucinations tend to dominate conversations about psychosis, and for good reason: hearing voices is the most frequently reported hallucination in conditions like schizophrenia. But visual experiences are surprisingly prevalent. A review pooling data from 29 studies and nearly 6,000 participants found that about 27% of people with schizophrenia report visual hallucinations.1Schizophrenia Bulletin. Visual Hallucinations in the Psychosis Spectrum and Comparative Information From Neurodegenerative Disorders and Eye Disease Other estimates run higher, with one review placing visual hallucinations at 25–50% and visual distortions at around 60%, depending on how broadly the researchers defined the experiences and which populations they sampled.2PubMed Central. The Phenomenology and Neurobiology of Visual Distortions and Hallucinations in Schizophrenia: An Update
The gap between those numbers reflects an important distinction. Visual hallucinations are perceptions of things that genuinely aren’t there: a person standing in an empty room, a creature on the ceiling. Visual distortions, by contrast, involve misperceptions of things that are there: walls that appear to breathe, faces that shift or warp, colors that seem unusually vivid or washed out, objects that look the wrong size. Many people with psychosis experience the distortions without ever seeing a fully formed hallucination. Because distortions are less dramatic than hallucinations, they tend to be underreported and underasked-about in clinical settings.
What People Actually See
The stereotypical image of psychotic hallucinations often involves bizarre or fantastical visions, but research into what people actually report tells a different story. A qualitative study asking people with psychosis to describe their visual hallucinations in detail found three consistent patterns. First, the most common and most distressing visions were of people: familiar faces, strangers, shadowy figures. Second, these figures behaved in coherent, human-like ways. They spoke, moved, made eye contact, even touched the person. Third, and perhaps most unsettling, the visions looked indistinguishable from reality. Participants consistently described their hallucinations as looking “too real,” lacking any obvious marker that would help them identify the experience as false.3PubMed Central. Visual hallucinations in psychosis: What do people actually see?
That sense of realness sets psychotic visual hallucinations apart from many other hallucinatory experiences. A person with Charles Bonnet syndrome (visual hallucinations caused by vision loss) typically recognizes the hallucinations as unreal. Someone experiencing psychotic hallucinations often cannot. The hallucinations tend to be multimodal as well, meaning the figure a person sees may also speak to them or seem to physically touch them, blurring the line between visual and other sensory experiences. This multimodal quality helps explain why visual hallucinations in psychosis can be so distressing and disorienting compared to isolated visual phenomena.
Beyond Hallucinations: The Broader Visual Disruption
Focusing exclusively on hallucinations misses the bigger picture. People with psychosis frequently describe a wide range of visual complaints that don’t involve seeing things that aren’t there. These include difficulty judging distances, trouble recognizing faces, problems with contrast sensitivity (the ability to distinguish an object from its background), and a reduced ability to perceive motion smoothly. These deficits show up on objective testing, not just self-report.
The brain processes visual information through two main pathways. One handles spatial awareness and motion (where things are and how they move), and the other handles object recognition and detail (what things are). Research consistently shows that both pathways are disrupted in schizophrenia. People with the condition show reduced brain activity in regions responsible for fine shape discrimination and object processing.4PubMed Central. Electrophysiological evidence for ventral stream deficits in schizophrenia patients They also have difficulty recognizing fragmented or partially hidden objects, alongside measurable reductions in the brain’s early electrical response to visual input.5JAMA Psychiatry. Impaired Visual Object Recognition and Dorsal/Ventral Stream Interaction in Schizophrenia Brain imaging confirms that the connectivity within and between these visual pathways is structurally altered, with different types of abnormalities showing up in each stream.6PubMed. Ventral and dorsal visual pathways exhibit abnormalities of static and dynamic connectivities, respectively, in patients with schizophrenia
These deficits aren’t just academic findings. A meta-analysis examining the relationship between early visual processing and real-world functioning found a moderate but consistent link: people whose visual processing was more impaired also had worse social cognition and more difficulty with daily roles.7PubMed Central. Systematic review and meta-analysis of early visual processing, social cognition, and functional outcomes in schizophrenia spectrum disorders In other words, the visual changes in psychosis aren’t just strange perceptions in the background; they actively shape how well someone can navigate social interactions and everyday tasks.
What Causes These Visual Changes
There is no single switch that flips to produce visual disturbances in psychosis. Instead, multiple overlapping mechanisms contribute, and researchers are still sorting out how they interact.
Dopamine sits at the center of most explanations. Excessive dopamine signaling in certain brain regions has long been linked to hallucinations, and this connection holds for visual experiences specifically. Research on both psychotic disorders and Parkinson’s disease (where dopamine-altering medications sometimes trigger visual hallucinations) points to dopamine as a major driver.8PubMed Central. The Pharmacology of Visual Hallucinations in Synucleinopathies A particularly elegant study showed how this works at a perceptual level: when dopamine levels rise (either naturally in hallucination-prone individuals or artificially through amphetamine), people develop a bias toward “seeing” what they expect to see, even when the actual visual signal is ambiguous. That bias correlated directly with dopamine release in a brain region involved in tracking uncertainty.9PubMed Central. A Perceptual Inference Mechanism for Hallucinations Linked to Striatal Dopamine
This connects to a broader theoretical framework. The brain is constantly making predictions about what it expects to see, then comparing those predictions against what the eyes actually report. When there’s a mismatch, the brain updates its model. In psychosis, this prediction system appears to go awry. Some researchers describe it as the brain giving too much weight to its own expectations and not enough to incoming sensory information, so internal predictions override actual visual input. Others have found the opposite in certain experimental conditions, with the brain treating sensory noise as overly meaningful. The picture is not yet settled, but the core idea — that the normal balance between expectation and perception is disrupted — has strong support.10PubMed Central. The Predictive Coding Account of Psychosis
Glutamate and GABA, the brain’s primary excitatory and inhibitory chemical messengers, also play a role. Alterations in both systems have been consistently identified in schizophrenia, and they affect cognition broadly, including visual processing.11PubMed Central. The role of glutamate and GABA in cognitive dysfunction in schizophrenia and mood disorders – A systematic review of magnetic resonance spectroscopy studies The involvement of glutamate is underscored by what happens with drugs that block glutamate receptors (like ketamine or PCP): they produce psychotic-like states that include striking visual distortions, and the brain regions they disrupt overlap substantially with those affected in schizophrenia itself.12PubMed Central. Brain mechanisms of hallucinogens and entactogens
At a circuit level, the thalamus — the brain’s relay station that filters sensory information before it reaches the cortex — shows abnormal connectivity in people with schizophrenia. Visual thalamocortical connections are stronger than normal in the higher-order visual cortex, which may mean that too much unfiltered or distorted visual information is reaching conscious awareness.13PubMed Central. Auditory and Visual Thalamocortical Connectivity Alterations in Unmedicated People With Schizophrenia When the thalamus fails to gate sensory signals properly, the cortex can become overloaded, and the conditions for both hallucinations and distortions become ripe.
The Eyes Themselves Are Different
One of the more surprising findings in recent years is that psychosis doesn’t just change how the brain handles visual information — the retina itself shows measurable structural and functional differences. Using optical coherence tomography (a high-resolution imaging scan of the back of the eye), researchers have found that people with schizophrenia-spectrum disorders have thinner retinal nerve fiber layers compared to healthy controls. A meta-analysis across 21 studies estimated the thinning at roughly 3 micrometers on average.14PubMed Central. Optical Coherence Tomography in Schizophrenia Spectrum Disorders: A Systematic Review and Meta-analysis Other retinal layers — including the ganglion cell and inner plexiform layers — are also thinner.15PubMed Central. Optical coherence tomography reveals retinal thinning in schizophrenia spectrum disorders
Functional testing of the retina tells a similar story. Electroretinography, which measures the electrical response of retinal cells to light, shows reduced responses from both photoreceptors and the cells that relay their signals, under both bright-light and dim-light conditions.16Molecular Psychiatry. Retina as a potential biomarker in schizophrenia spectrum disorders: a systematic review and meta-analysis of optical coherence tomography and electroretinography These findings have been replicated across multiple studies over several decades.17PubMed Central. Schizophrenia and the Retina: Towards a 2020 Perspective
The retina is part of the central nervous system, developing from the same embryonic tissue as the brain, so these changes likely reflect the same neurodevelopmental processes that affect the brain in psychosis rather than an independent eye disease. Researchers are now investigating whether retinal scans could serve as accessible, non-invasive biomarkers for tracking illness progression or even screening for psychosis risk, though this remains a research tool rather than a clinical one.
Eye movements are also affected. Smooth pursuit eye movements — the ability to track a slowly moving target with your eyes — are consistently impaired across psychotic disorders, including schizophrenia, schizoaffective disorder, and bipolar disorder with psychotic features.18PubMed. Smooth pursuit eye movement deficit as a biomarker for psychotic features in bipolar disorder-Findings from the PARDIP study The impairment shows up as lower tracking accuracy and more frequent involuntary corrective eye jumps.19PubMed. Neurobiology of smooth pursuit eye movement deficits in schizophrenia: an fMRI study These deficits are stable enough that they’ve been proposed as a biomarker for psychosis liability, and they appear even in some unaffected relatives of people with schizophrenia.
Visual Disturbances as Early Warning Signs
Visual problems don’t just accompany psychosis; they may precede it. A large study comparing people in the early stages of psychosis, people considered at clinical high risk for developing psychosis, people with recent-onset depression, and healthy volunteers found that visual disturbances were reported by about 50% of the early-psychosis group and 56% of the high-risk group. By contrast, only about 17% of those with depression and 4% of healthy controls reported similar experiences.20Neuropsychopharmacology. The impact of visual dysfunctions in recent-onset psychosis and clinical high-risk state for psychosis
The fact that visual disturbances were just as common in the high-risk group as in those who had already developed psychosis is noteworthy. It suggests these visual changes aren’t simply a consequence of full-blown illness but may be part of the early unfolding of psychosis. People at elevated genetic risk for psychosis also show visual distortion experiences, even in the absence of hallucinations, and these have been linked to abnormalities in how different brain regions synchronize during visual processing.21PubMed Central. Perceptual Mechanisms of Visual Hallucinations and Illusions in Psychosis In clinical terms, asking about visual changes during risk assessment could help identify people who are moving toward psychosis before the more recognizable symptoms emerge.
When Visual Hallucinations Aren’t Psychosis
Not every visual hallucination signals a psychotic disorder. Several other conditions produce visual experiences that can look similar on the surface but arise from entirely different mechanisms and carry different treatment implications.
Charles Bonnet syndrome occurs in people who have lost significant vision, most commonly from age-related macular degeneration. The brain, deprived of normal visual input, begins generating its own images: patterns, faces, landscapes, sometimes elaborate scenes. The hallucinations are often vivid and detailed, but the person typically knows they aren’t real. It is frequently misdiagnosed as a psychiatric illness, which can lead to inappropriate treatment with antipsychotic medications.
Parkinson’s disease is another common cause of visual hallucinations in older adults, driven by the interplay between dopamine-altering medications and the disease’s own disruption of brain circuits. Research has proposed that some of these hallucinations may actually be dream imagery intruding into waking hours, functioning like a narcolepsy-like REM sleep disturbance.22PubMed. Hallucinations, REM sleep, and Parkinson’s disease: a medical hypothesis The overlap between Parkinson’s-related hallucinations and psychotic hallucinations can become especially challenging when someone carries both diagnoses, as illustrated by case reports of long-standing schizophrenia patients who develop Lewy body dementia and experience a marked shift in their visual symptoms.23PubMed Central. A Challenging Diagnostic Process: A Case of Lewy Body Dementia in Long-Standing Schizophrenia
Drug-induced hallucinations also deserve mention. Serotonergic hallucinogens (like LSD or psilocybin) and dissociative anesthetics (like ketamine) both produce visual experiences, and interestingly, brain imaging studies show that these pharmacologically distinct drug classes activate overlapping brain regions, including prefrontal, temporal, and thalamic areas involved in sensory gating.12PubMed Central. Brain mechanisms of hallucinogens and entactogens This convergence suggests a shared final pathway for sensory overload, regardless of what triggers it.
Visual Hallucinations in Children
Childhood-onset schizophrenia is rare but tends to be more severe than adult-onset cases, and its visual profile is dramatically different. In a study of 117 children with the condition, a striking 80% reported visual hallucinations, far exceeding the roughly 27% average seen in adult populations.24PubMed Central. Childhood onset schizophrenia: high rate of visual hallucinations Nearly all of these children also had auditory hallucinations, and tactile and olfactory hallucinations occurred almost exclusively in children who already had visual ones.
Children with visual hallucinations in this study also had lower IQ scores, earlier onset of illness, and more severe symptoms overall compared to the minority who did not have visual hallucinations. This pattern raises the possibility that visual hallucinations in childhood psychosis are a marker of broader neurodevelopmental disruption rather than an isolated sensory symptom. For parents and clinicians, the practical takeaway is that visual complaints in children with psychotic symptoms should be taken seriously and probed carefully — they are considerably more common than the adult literature might lead one to expect.
Cultural Variation in What People See
The content and meaning of visual hallucinations are shaped by culture in ways that matter clinically. Cross-cultural research has found that rates of visual hallucinations vary by geographic and ethnic background. One review noted that auditory and visual hallucinations were reported most frequently in African patients compared to Pakistani, Latino, and White-British groups, while the types of delusions that accompanied these hallucinations also differed across groups.25PubMed. The role of culture on the phenomenology of hallucinations and delusions, explanatory models, and help-seeking attitudes: A narrative review
Culture also shapes whether a visual experience is interpreted as a hallucination at all. In some contexts, seeing spirits or ancestors is considered a normal or even valued experience rather than a symptom. This means that what gets labeled as a “visual hallucination” in a clinical assessment reflects not just the underlying neurobiology but also the cultural lens of both the patient and the clinician. The broader literature on hallucinations and culture suggests these differences can affect clinical outcomes: when hallucinations carry benevolent cultural meanings, the distress associated with them tends to be lower, which in turn influences how aggressively clinicians treat them.26PubMed Central. Culture and hallucinations: overview and future directions
Can Visual Processing Be Treated
Antipsychotic medications, which primarily target dopamine, are the frontline treatment for psychosis and can reduce hallucinations. But they don’t always fully resolve visual disturbances, and they do little for the subtler visual processing deficits (like poor contrast sensitivity or impaired object recognition) that affect daily functioning.
Researchers are beginning to develop interventions that directly target visual perception rather than relying solely on medication. A pilot randomized controlled trial tested whether virtual reality-based visual training could improve visual perceptual abilities in people with schizophrenia. Participants who received the VR intervention showed large improvements across all tested visual perceptual measures, outperforming a control group that received conventional rehabilitation.27PubMed Central. Virtual reality intervention for visual perception in schizophrenia-a single blind pilot randomized controlled trial
Earlier work using a computer-based visual training program also showed promise. In a small case series, participants improved in contrast sensitivity and visual acuity after the training, with some showing more generalized gains in perceptual organization.28PubMed Central. Visual Perceptual Remediation for Individuals with Schizophrenia: Rationale, Method, and Three Case Studies A federally funded research program is now working to optimize these visual remediation approaches and determine whether improving low-level visual processing can cascade into improvements in higher-level cognitive abilities and real-world functioning.29PubMed Central. Development and Evaluation of a Visual Remediation Intervention for People with Schizophrenia
These are still early-stage findings, and visual remediation is nowhere close to becoming standard clinical practice. But the logic behind it is compelling: if visual processing deficits are a core feature of psychosis that independently impairs functioning, treating them directly rather than hoping antipsychotics will handle everything represents a gap worth filling. The research so far suggests the visual system in psychosis retains enough flexibility to benefit from targeted training, which is an encouraging sign for a domain that has been overlooked for decades.