What Causes Hallucinations In Alcoholics?

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What Causes Hallucinations in Alcoholics?

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Hallucinations in alcoholics are caused by:

A 2-to-3-fold increase in glutamate activity during alcohol withdrawal [1]
A 15.5% reduction of GABA activity in the brain [2]
Chronic Insomnia in 56.8% [3]
Thiamine deficiencies in up to 80% [4]

whatcauseshallucinationsinalcoholics abbeycare 1

Delirium Tremens Causing Hallucinations In Alcoholics

Delirium Tremens cause hallucinations in alcoholics because of a 2-to-3-fold increase in glutamate activity in the brain during withdrawal, leading to [1]:

Transitory visual, tactile or auditory hallucinations in 42.5% of Delirium Tremens cases during alcohol withdrawal, developing around 48 hours after the cessation of use [5]
An inability to maintain lucidity and recognise altered perceptions, e.g. images and sounds of spiders and rats, peaking in severity around 96 hours after drinking last [6] [7]

One study found that a 49-year-old man with Delirium Tremens experienced microzoopsia and heard voices after sudden cessation following 21 years of alcohol misuse:

The man presented with increased Gamma-glutamyl-transpeptidase levels (GGT) = 149 UI/L, compared to a normal value of 8 – 61 UI/L
Aspartate-aminotransferase (AST) levels of 87 UI/L and Alanine aminotransferase (ALT) levels of 76 UI/L (normal values = 7–45 UI/L) [8]

Hallucinations caused by Delirium Tremens resolve within 5 days or less in 62%, although in some cases may persist for up to 10 days [9].

Alcoholic Psychosis Causing Hallucinations In Alcoholics

Alcohol-induced psychosis (AIP) causes hallucinations in 4.83% of alcoholics due to [10]:

A 62% reduction in dopamine
A 44% reduction in serotonin
A 15.5% reduction in GABA activity in the brain [2]

97% of alcoholics with AIP hallucinate, and 53% experience co-occurring delusions of a paranoid nature with false beliefs about being harmed by another person [10] [11].

One study found that alcoholics with AIP may hallucinate for up to 2 years:

Patients with an average age of 37 developed Alcohol Use Disorder (AUD) at around 20 years old
Positive psychotic symptoms (delusions, distorted thinking) began between 35 – 37 years of age
Patients had greater cognitive impairment compared to alcoholics without psychosis (e.g. delayed recall = 74.5 vs 94.4) [11]

Alcoholic Hallucinosis Causing Hallucinations in Alcoholics

Alcoholic hallucinosis causes hallucinations in alcoholics because glucose metabolism decreases by up to 50% in the frontal, thalamic and cerebellar brain regions, resulting in [12]:

Third-person auditory hallucinations; typically in individuals between 40 – 50 years of age with a 10+ year history of alcohol abuse [13]
Delusions with a derogatory or commanding nature, often including fragments of conversation or music that lead to paranoia and fear [14]

10 – 20% of alcohol hallucinosis cases persist for over 6 months, and 5 – 20% of patients subsequently develop schizophrenia [14].

Wernicke Korsakoff Syndrome Causing Hallucinations in Alcoholics

Wernicke Korsakoff syndrome (WKS) causes alcoholics to hallucinate because of Thiamine (Vitamin B1) deficiencies in up to 80%, resulting from [4]:

Up to 65% of ingested calories being derived from alcohol in alcoholics who consume over 150g of alcohol daily [15]
A 50 – 70% reduction in intestinal absorption; <0.8mg for every 10mg oral thiamine is absorbed in alcoholics, the recommended daily intake is 1 – 1.6mg/day [4][16]

33% of thiamine-deficient alcoholics develop Cerebellar Degeneration, and 44% develop Peripheral Neuropathy; 10 – 12.5% of cases lead to Wernicke’s Korsakoff syndrome [16] [17].

16% of alcoholics experience all 3 symptoms (The Clinical Triad) of Wernicke Korsakoff syndrome, contributing to the severity of misperceptions [18]:

Mental Confusion: amnesia, apraxia, agitation, memory loss, disorientation
Ocular motility abnormalities: ophthalmoplegia and nystagmus
Ataxia: slurred speech, impaired coordination and balance

Alcohol-Induced Insomnia Causing Alcoholics to Hallucinate

Alcohol-induced insomnia causes alcoholics to hallucinate because of a 15 - 19% reduction in melatonin levels, leading to [19]:

Increased REM sleep (20.4% vs 18.5%) and reduced REM sleep Latency (48.6 vs 79.7 minutes) compared to non-alcoholic controls [20]
Reduced total sleep time (278 vs 357 minutes) and sleep efficiency (72% vs 87%) compared to non-alcoholic controls [20]
Poor quality sleep in 100% of female alcoholics and 88.9% of males (>5 on PSQI), as 2+ drinks for men and 1+ for women decreases sleep quality by 39.2% [21] [3]
Chronic Insomnia (>4 weeks) in 56.8% of alcoholics who are 4 times more likely to hallucinate than those without sleeping difficulties [3] [22]

Hepatic Encephalopathy Causing Alcoholics to Hallucinate

Hepatic Encephalopathy (HE) causes alcoholics with liver disease to hallucinate because of an 83% increase in arterial ammonia concentration due to [23]:

An increased permeability-surface area product of the blood-brain barrier in alcoholics with HE compared to individuals without liver disease or HE (0.22 vs 0.13 ml g -I min –I) [23]
A 66% increase in the regional cerebral metabolic rate for ammonia, resulting from gastrointestinal bleeding in 13 - 34% of alcoholics with Hepatic Encephalopathy [23] [24]

Hallucinations caused by Hepatic Encephalopathy in alcoholics typically include:

Visual: Surrounding objects change in colour, brightness, and contrast e.g. seeing everything darker or with a green tinge
Auditory: Hearing a family member deliver “secret” messages consistently
Gustatory: False perceptions or a change in taste may lead to a delusion of being poisoned

Who Is More Likely To Develop Alcohol Hallucinations?

Groups	Why?
Pre-Existing Brain Damage	1.51% reduction in brain volume within 1 year of TBI and focal lesions in 67.2% increases the risk by 8.5% [25] [26]
Pre-Existing Schizophrenia	1cm reduction in sulcal length in the medial prefrontal cortex increases the likelihood by 19.9% [27]
Polysubstance Abuse	Co-occurring drug and alcohol abuse in up to 90% increases the odds of subsequent psychotic experiences (OR = 1.6, 95% CI = 1.2 - 2.2) [28] [29]
Previous History Of Non-Alcoholic Hallucinations	30 - 33-year-olds with previous hallucinations between 14 - 21 are more likely to: Be diagnosed with a psychotic disorder (OR, 8.84; 95% CI: 1.61–48.43) Develop an SUD (OR, 2.34; 95% CI: 1.36–4.07) [30]

What Conditions Are Mistaken for Alcohol Hallucinations?

	Alcohol-Induced Hallucinations	Pathological Jealousy
Diagnostic Criteria	Hallucinations/delusions >1 month with medical evidence [31]	Partner infidelity delusions >1 month without objective evidence [32]
Triggers	2-to-3-fold increase in glutamate activity during withdrawal [1] 15.5% reduction of GABA activity after chronic use [2]	Fears of abandonment + rejection Poor self-image or self-esteem History of infidelity or betrayal
Patient Presentation	Visual, auditory, tactile, gustatory hallucinations and delusions	Partner infidelity delusions (92.5%) + related hallucinations (72.7%) [32]
Prevalence	Up to 44%, most likely after 10+ years of alcohol abuse [13][31]	Up to 7.59%, mostly in males (68%) and married people (86%) [33]

	Anxiety-Induced Hallucinations
Diagnostic Criteria	Onset of positive symptoms after 6+ months of anxiety symptoms [34] [35]
Triggers	Anxiety or panic attacks Hallucinations last as long as the attack (up to 15 times daily) [36]
Patient Presentation	Auditory hallucinations are most common (55% - 78.4%) [37]
Prevalence	27% with anxiety disorders in the general population [38]

References

[1] Ward, R. J., et al. “Biochemical and Neurotransmitter Changes Implicated in Alcohol-Induced Brain Damage in Chronic or ‘Binge Drinking’ Alcohol Abuse.” Alcohol and Alcoholism, vol. 44, no. 2, Jan. 2009, pp. 128–35. Accessed 19 Dec. 2024. “Increases in glutamate release are only observed during the initial stages of withdrawal from chronic alcoholism (∼2- to 3-fold) due to alterations in the sensitivities of the NMDA receptors.”
[2] Kashem, Mohammed Abul, et al. “Metabolomics of Neurotransmitters and Related Metabolites in Post-Mortem Tissue from the Dorsal and Ventral Striatum of Alcoholic Human Brain.” Neurochemical Research, vol. 41, no. 1-2, Jan. 2016, pp. 385–97. Accessed 19 Dec. 2024. “Table 4.”
[3] Escobar-Córdoba, Franklin, et al. “Complaints of Insomnia in Hospitalized Alcoholics.” Revista Brasileira de Psiquiatria, vol. 31, no. 3, Associação Brasileira de Psiquiatria, Sept. 2009, pp. 261–64. Accessed 27 Dec. 2024. “Table 2.”
[4] Government of Western Australia WA Country Health Service. Administration of Thiamine in Chronic Alcohol Abuse Guideline. Aug. 2019. Accessed 23 Dec. 2024. “Approximately 80% of people with chronic alcohol abuse will develop thiamine deficiency.”
[5] Monte, R., et al. “Risk Factors for Delirium Tremens in Patients with Alcohol Withdrawal Syndrome in a Hospital Setting.” European Journal of Internal Medicine, vol. 20, no. 7, Nov. 2009, pp. 690–94. Accessed 19 Dec. 2024. “Table 2.”
[6] Mulkey, Malissa A., and DaiWai M. Olson. “Delirium Tremens in the Older Adult.” Journal of Neuroscience Nursing, vol. 52, no. 6, Dec. 2020, pp. 316–21. Accessed 19 Dec. 2024.“Hallucinations is the ability to maintain lucidity and recognize altered perceptions that are related to alcohol withdrawal.”
[7] NHS Oxford Health. Guidelines for the Management of Alcohol Dependence and Acute Withdrawal on Inpatient Wards. Dec. 2008. Accessed 19 Dec. 2024.“DTs, a condition characterised by delirium, auditory/visual hallucinations, ... often peak later, around 96 hours.”
[8] Addolorato, Giovanni, et al. “Suppression of Alcohol Delirium Tremens by Baclofen Administration: A Case Report.” Clinical Neuropharmacology, vol. 26, no. 5, Sept. 2003, pp. 258–62. Accessed 19 Dec. 2024.“Patient presented with tactile disturbances and hallucination, both visual [microzoopsia] and auditory [far away voices], ... gamma-glutamyl-transpeptidase (GGT) of 149 UI/L 9 (normal value [nv]: 8–61 UI/L).”
[9] DeBellis, Ronald, et al. “Management of Delirium Tremens.” Journal of Intensive Care Medicine, vol. 20, no. 3, May 2005, pp. 164–73, Accessed 19 Dec. 2024. “Symptoms associated with DT will persist for about 5 to 10 days, with 62% resolving in 5 days or less.”
[10] Perälä, Jonna, et al. “Alcohol-Induced Psychotic Disorder and Delirium in the General Population.” British Journal of Psychiatry, vol. 197, no. 3, Sept. 2010, pp. 200–6. Accessed 19 Dec. 2024. “The lifetime prevalence of AIPS among participants who were alcohol-dependent was 4.83, ... 30 (97%) had the subtype ‘with hallucinations.”
[11] Hendricks, Melany L., et al. “Cognitive Changes in Alcohol-Induced Psychotic Disorder.” BMC Research Notes, vol. 10, no. 1, Apr. 2017. Accessed 19 Dec. 2024. “Most commonly, AIPD mostly occurs with auditory hallucinations but also delusions, often of a paranoid nature.”
[12] Valentin Yurievich Skryabin, et al. “Acute Alcoholic Hallucinosis: A Review.” Psychopathology, Karger Publishers, Jan. 2023, pp. 1–8. Accessed 19 Dec. 2024. “Reduced glucose metabolism in frontal (by 28–30%), thalamic (by 50%), and cerebellar (by 36%) regions.”
[13] Psychiatry and Clinical Psychopharmacology. “Alcoholic Hallucinosis.” Volume 24, Issue 1, Jan. 2014. Accessed 19 Dec. 2024. “Vivid hallucinations and can be found in individuals between 40 – 50 years of age, who have been using alcohol for over 10 years.”
[14] Winstock, Adam R., and Kylie D. Reed. “Alcohol Misuse.” Core Psychiatry, 2012, pp. 421–38. Accessed 19 Dec. 2024. “Hallucinations are usually third person auditory hallucinations, often derogatory,... may take the form of fragments of conversation or music.”
[15] Bunout, D., et al. “Nutritional Status of Alcoholic Patients: It’s Possible Relationship to Alcoholic Liver Damage.” The American Journal of Clinical Nutrition, vol. 38, no. 3, Sept. 1983, pp. 469–73. Accessed 20 Dec. 2024. “A dietary imbalance was observed in the total group; 65% of ingested calories were derived from ethanol.”
[16] Praharaj, SamirKumar, et al. “High-Dose Thiamine Strategy in Wernicke–Korsakoff Syndrome and Related Thiamine Deficiency Conditions Associated with Alcohol Use Disorder.” Indian Journal of Psychiatry, vol. 63, no. 2, 2021, p. 121, Accessed 20 Dec. 2024.“In those consuming alcohol and have poor nutrition, not more than 0.8 mg of thiamine is absorbed, ... daily thiamine requirement is 1–1.6 mg/day.”
[17] NHS. IN-PATIENT ALCOHOL DETOXIFICATION GUIDELINES. Nov. 2021. Accessed 20 Dec. 2024. “Post-mortem analysis has demonstrated that Wernicke’s encephalopathy may occur in as many as 12.5% of chronic alcohol misusers.”
[18] Oudman, Erik, et al. “Wernicke Encephalopathy in Schizophrenia: A Systematic Review.” International Journal of Psychiatry in Clinical Practice, vol. 25, no. 3, Sept. 2020, pp. 233–37. Accessed 20 Dec. 2024. “WE is characterised by a triad of mental status change, ocular signs and ataxia, ... present in 16% of the cases.”
[19] Rupp, Tracy L., et al. “Evening Alcohol Suppresses Salivary Melatonin in Young Adults.” Chronobiology International, vol. 24, no. 3, Jan. 2007, pp. 463–70. Accessed 27 Dec. 2024. “At 140 and 190 min after alcohol administration, melatonin level was reduced by 15% and 19%.”
[20] Brower, K. J., and J. M. Hall. “Effects of Age and Alcoholism on Sleep: A Controlled Study.” Journal of Studies on Alcohol, vol. 62, no. 3, May 2001, pp. 335–43. Accessed 27 Dec. 2024. “Table 2.”
[21] Bryan, Lucy, and Abhinav Singh. Alcohol and Sleep. 4 Sept. 2020. Accessed 27 Dec. 2024. “Figure 1.”
[22] Sheaves, Bryony, et al. “Insomnia and Hallucinations in the General Population: Findings from the 2000 and 2007 British Psychiatric Morbidity Surveys.” Psychiatry Research, vol. 241, July 2016, pp. 141–46. Accessed 27 Dec. 2024. “Mild sleep problems were associated with 2–3 times greater odds of reporting hallucinations, whilst chronic insomnia was associated with four times greater odds.”
[23] Lockwood, Alan H., et al. “Cerebral Ammonia Metabolism in Patients with Severe Liver Disease and Minimal Hepatic Encephalopathy.” Journal of Cerebral Blood Flow & Metabolism, vol. 11, no. 2, Mar. 1991, pp. 337–41. Accessed 20 Dec. 2024. “Arterial ammonia concentration in the patients was 83% higher than in controls (p < 0,01).”
[24] Mumtaz, Khalid, et al. Precipitating Factors and the Outcome of Hepatic Encephalopathy in Liver Cirrhosis. Aug. 2010. Accessed 20 Dec. 2024.“Upper gastrointestinal bleeding in 55 (13.6%) patients were the other precipitating factors identified.”
[25] Lindsey Gurin, MD, and David B. Arciniegas, MD. Psychosis after Traumatic Brain Injury: Conceptual and Clinical Considerations. 19 Apr. 2019. Accessed 30 Dec. 2024. “Incidence of psychosis after TBI to be two to three times that of the general population, and modern estimates suggest rates of 0.9% to 8.5%.”
[26] Cole, James H., et al. “Spatial Patterns of Progressive Brain Volume Loss after Moderate-Severe Traumatic Brain Injury.” Brain, vol. 141, no. 3, Jan. 2018, pp. 822–36. Accessed 30 Dec. 2024. “Patients with traumatic brain injury lost a mean (± standard deviation) of 1.51% ± 1.60 of whole brain volume.”
[27] Garrison, Jane R., et al. “Paracingulate Sulcus Morphology Is Associated with Hallucinations in the Human Brain.” Nature Communications, vol. 6, no. 1, Nov. 2015. Accessed 30 Dec. 2024. “A 1 cm reduction in sulcal length increasing the likelihood of hallucinations by 19.9%.”
[28] Degenhardt, Louisa, et al. “The Associations between Psychotic Experiences and Substance Use and Substance Use Disorders: Findings from the World Health Organization World Mental Health Surveys.” Addiction, vol. 113, no. 5, Feb. 2018, pp. 924–34. Accessed 30 Dec. 2024. “Alcohol abuse and alcohol dependence disorders were associated with increased odds of subsequent PEs (alcohol abuse: OR =1.6, 95% CI= 1.2–2.2.”
[29] Falk, Daniel, et al. “An Epidemiologic Analysis of Co-Occurring Alcohol and Drug Use and Disorders: Findings from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC).” Alcohol Research & Health, vol. 31, no. 2, 2024, p. 100. Accessed 30 Dec. 2024. “Most drug users (approximately 90 percent) used alcohol, whereas only a small minority of alcohol users (less than 9 percent) used drugs.”
[30] Connell, Melissa, et al. “Hallucinations in Adolescents and Risk for Mental Disorders and Suicidal Behaviour in Adulthood: Prospective Evidence from the MUSP Birth Cohort Study.” Schizophrenia Research, vol. 176, no. 2-3, Oct. 2016, pp. 546–51. Accessed 30 Dec. 2024. “Hallucinations reported at both 14 and 21 years were associated with lifetime diagnoses of psychotic disorders (OR, 8.84; 95% CI: 1.61–48.43).”
[31] Cimpean, Delia, et al. Substance-Induced Psychosis in First Episode Programming ISSUE BRIEF. 2017. Accessed 30 Dec. 2024. “Symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication.”
[32] Easton, Judith A., et al. “Delusional Disorder–Jealous Type: How Inclusive Are The DSM–IV Diagnostic Criteria?” Journal of Clinical Psychology, vol. 64, no. 3, 2008, pp. 264–75. Accessed 27 Dec. 2024. “Must be experiencing delusions for at least one month’s duration, ... must focus on the infidelity of the partner.”
[33] Singh, Satyajeet Kumar, et al. “Phenomenology and Predisposing Factors of Morbid Jealousy in a Psychiatric Outdoor: A Cross-Sectional, Descriptive Study.” Open Journal of Psychiatry & Allied Sciences, vol. 8, no. 2, 2017, p. 129. Accessed 30 Dec. 2024. “Frequency of 7.59% in all types of patient irrespective of psychiatric illness.”
[34] NICE. When Should I Suspect Generalized Anxiety Disorder? Feb. 2023. Accessed 30 Dec. 2024. “Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months.”
[35] Reis, Joana, et al. “Case Report: From Anxiety Disorders to Psychosis, a Continuum in Transitional Age Youth?” Frontiers in Psychiatry, vol. 13, Oct. 2022. Accessed 30 Dec. 2024. “Over a 6-month period, a gradual onset of subthreshold psychotic symptoms suggested a prodromal phase of a psychotic disorder, ... particularly persecutory ideas and visual perceptual abnormalities.”
[36] Galynker, I., et al. “Panic Attacks with Psychotic Features.” The Journal of Clinical Psychiatry, vol. 57, no. 9, Sept. 1996, pp. 402–6. Accessed 30 Dec. 2024. “Psychotic symptoms occurred only during panic attacks; however, these could occur up to 10 to 15 times a day.”
[37] Ohayon, Maurice M. “Prevalence of Hallucinations and Their Pathological Associations in the General Population.” Psychiatry Research, vol. 97, no. 2-3, Dec. 2000, pp. 153–64. Accessed 30 Dec. 2024. “Table 4.”
[38] Wigman, J. T. W., et al. “Evidence That Psychotic Symptoms Are Prevalent in Disorders of Anxiety and Depression, Impacting on Illness Onset, Risk, and Severity--Implications for Diagnosis and Ultra-High-Risk Research.” Schizophrenia Bulletin, vol. 38, no. 2, Jan. 2012, pp. 247–57. Accessed 30 Dec. 2024. “Psychotic symptoms were reported in 27% of individuals with a disorder of anxiety/depression in a large sample of adolescents and young adults from the general population.”

About the author

Mischa Ezekpo

Mischa Ezekpo has a Bachelors degree in Psychology from Northumbria
University, and a Masters degree in Childhood Development and
Wellbeing, from Manchester Metropolitan University. Since 2018, Mischa
has written and published work on Addiction, Mental Health, Depression, and Eating Disorders. Content reviewed by Laura Morris (Clinical Lead).

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Last Updated: March 21, 2025