• Mental health disorders such as schizophrenia, bipolar disorder, or psychosis
• Central nervous system disorders
• Neurological disorders
• Toxic and metabolic disorders and conditions
• Sleep deprivation or disorders
• Physical disorders such as diseases of vision and hearing organs
• Drugs such as some medications, alcohol, and hallucinogens (e.g., plant hallucinogens)
• Stroke
• Post-traumatic stress disorder (PTSD)

More information on the different types of hallucinations and their causes are provided below.

1- How Do You Know If You Hallucinate?

If an individual is hearing, seeing, smelling, tasting, and feeling (touch) things that are not real or do not exist outside their mind, this individual is likely to be experiencing hallucinations.

2- Is It Normal to Hallucinate?

Hallucinations can be a sign of mental health, neurological, and physical disorders. They can also be a sign of drugs consumption such as alcohol and hallucinogens.

3- What Are the 5 Types of Hallucinations?

There are 5 types of hallucinations that are not all due to psychotic disorders. Hallucinations can be caused by psychiatric and physical disorders [1].

3.1. What Are Auditory Hallucinations?

An auditory hallucination is the perception of sounds that are not real or do not exist outside of the mind of an individual [2]. They can be due to the following causes:

• Schizophrenia

Schizophrenia is a complex and severe mental health disorder that is classified as a type of psychosis. It is characterized by significant alterations in thoughts, perception, mood, and behaviors [3].

• Central Nervous System (CNS) Disorders

These are disorders that affect the brain known as encephalopathies or the spinal cord which are known as myelopathies.

• Psychotic Depression

Psychotic depression is a major depression associated with symptoms such as delusions, hallucinations, sleep issues, reduced motivation, and the capacity to experience a pleasure. It is often associated with bipolar disorder and major depression.

• Mania

Mania is a mood disorder characterized by an excessive level of energy, arousal, and enthusiasm.

• Post-Traumatic Stress Disorder (PTSD)

PTSD is an anxiety disorder associated with extremely stressful or distressing situations.

• Peripheral Lesions

Peripheral lesions are lesions that affect sensory or motor neurons of the peripheral nervous system (outside the brain and the spinal cord).

• Middle and Inner Ear Diseases

There are many diseases that affect tissues and organs of the middle and inner ear causing dizziness, inflammation, discharge, or hearing loss.

• Auditory Nerve Disease

This disorder affects the auditory nerve responsible for transmitting sound to the brain.

• Stroke

Stroke is a condition characterized by a very low blood supply to the brain which prevents its proper function.

• Arterio-vascular malformations

These are malformations that affect arteries and vessels responsible for blood supply to organs involved in hearing.

• Delirium

Delirium is a state of mental confusion lasting hours or days with alterations in consciousness, cognition, and attention.

• Dissociative Identity Disorder

Dissociative identity disorder or multiple personality disorder is a mental disorder characterized by the presence of at least two states of personality.

• Pontine Lesions

These are lesions that affect the pons region of the brainstem part of the brain which controls hearing, balance, involuntary actions, taste, and facial sensations.

• Temporal Lobe Epilepsy

Temporal lobe epilepsy is seizures that began in the temporal lobe and spread to other areas of the brain.

• Hallucinogens

Hallucinogens are chemical substances that modify the function of the nervous system causing cognitive, behavioral, perception, and consciousness changes. The most known hallucinogen is LSD (D-Lysergic acid diethylamide).

• Alcohol Hallucinosis

Alcohol Hallucinosis is a chronic state of alcoholic intoxication that affects the auditory system causing hallucinations.

• Syncope

Syncope or fainting is associated with low blood pressure resulting in a loss of consciousness and muscle strength.

3.2. What Are Visual Hallucinations?

A visual hallucination is the perception of images that are not real or do not exist outside of the mind of an individual such as crawling insects or small animals [4]. They can be due to the following causes:

• Neurologic Disorders

Neurologic Disorders are diseases that affect the nervous system including the central nervous system (brain and spinal cord) and the peripheric nervous system.

• Epilepsy

Epilepsy is associated with seizures that are due to abnormal electrical activity in the brain.

• Migraine

A migraine is a severe form of headache that manifests as an excruciating pain on one side of the head accompanied by a feeling of sickness and an increased sensitivity to light and sound.

• Glaucoma

Glaucoma is due to an excessive increase in the intraocular pressure within the eye that leads to damages including vision loss.

• Optic Nerve Disorders

This disorder affects the optic nerves responsible for transmitting visual information to the brain.

• Toxic Metabolic Disorders

Toxic metabolic disorders are characterized by the accumulation of products of metabolism (metabolites) in the tissues of the body leading to their damage. When affecting the eyes, it can cause damages that lead to anomalies with vision, such as visual hallucinations.

• Toxic Metabolic Encephalopathy

Toxic metabolic encephalopathy is also associated with the accumulation of metabolites in the brain leading to damages. If damaging parts of the brain involved in vision, it can cause anomalies with the vision such as visual hallucinations

• Schizophrenia

Schizophrenia is a complex and severe mental health disorder that is classified as a type of psychosis. It is characterized by significant alterations in thoughts, perception, mood, and behaviors [3].

• Hallucinogens

Hallucinogens are chemical substances that modify the function of the nervous system causing cognitive, behavioral, perception, and consciousness changes. The most known hallucinogen is LSD (D-Lysergic acid diethylamide).

• Sleep deprivation

Sleep deprivation is associated with insufficient (not enough) sleep that can be acute or chronic leading to reduced alertness, performance, and health issues.

• Drug and Alcohol Withdrawal Syndromes

These withdrawal syndromes are due to the changes in neurotransmission mediated by GABA.

• Retinal Diseases

Retinal diseases are disorders that affect the retina of the eye such as macular degeneration, intraocular tumors, retinal tear, and macular edema [5].

• Affective Disorders

Affective disorders are mental conditions characterized by changes in mood and emotions such as major depressive disorder.

• Conversion Disorders

Conversion disorders are mental conditions that cannot be explained by the presence of a disease or injury and which are characterized by paralysis, blindness, or other symptoms of the nervous system [6].

• Cataract Formation

A cataract is the clouding of the lenses of the eyes that help focus on objects at different distances.

• Enucleation

Surgical removal of the entire eye from its socket.

• Narcolepsy

Narcolepsy is a chronic disorder associated with the reduction in the ability to regulate the sleep-wake cycles.

• Choroidal Disorder

The choroidal disorder is due to damages to blood vessels in the eye known as choroid causing anomalies in vision.

• Sensory Deprivation

Sensory deprivation is an intentional reduction in the perception of one or more senses.

• Intense Emotional Experiences

These are life experiences that had significant emotional effects on the affected individuals such as a loss of a loved one, sexual abuse, or traumatic experiences.

3.3. What Are Olfactory Hallucinations?

An olfactory hallucination is the perception of smell that is not real or does not exist outside of the mind of an individual [7]. They can occur with several mental health disorders such as:

• Schizophrenia

Schizophrenia is a complex and severe mental health disorder that is classified as a type of psychosis. It is characterized by significant alterations in thoughts, perception, mood, and behaviors [3].

• Bipolar Disorder

Bipolar Disorder is a mood disorder characterized by mood swings between periods of depression (depressive episodes), and elevated mood that can be severe known as mania (manic episode) or less severe known as hypomania.

• Substance Abuse

Abusive consumption of drugs

• Eating Disorders

Eating disorders are characterized by unusual habits of excessive eating (e.g., binge eating disorder) or insufficient eating (e.g., anorexia).

3.4. What Are Gustatory Hallucinations?

A gustatory hallucination is the perception of taste (often metallic taste) that is not real or does not exist outside of the mind of an individual [8].

• Temporal Lobe Diseases

Temporal Lobe Disease causes seizures that began in the temporal lobe and spread to other areas of the brain. They can be caused by tumors, injury to the head, stroke, brain infections, or brain lesions

• Parietal Operculum Lesions

These are lesions that affect a part of the cerebral cortex causing the absence of speech.

3.5. What Are Tactile Hallucinations?

A tactile hallucination is the perception of touch that is not real or does not exist outside of the mind of an individual [7]. They can be due to the following causes:

• Substance Abuse

Abusive consumption of drugs

• Drug and Alcohol Withdrawal Syndromes

These withdrawal syndromes are due to the changes in neurotransmission mediated by GABA.

4- Can Stress Cause Hallucinations?

Auditory hallucinations have been associated with Post-Traumatic Stress Disorder (PTSD). PTSD is an anxiety disorder associated with extremely stressful or distressing situations.

6- What Causes Hallucinations in the Elderly?

Most of the hallucinations in the elderly are visual or auditory which can be due to the following causes:

• Side effects of Medications
• Diseases such as brain cancer, kidney, or liver failure.
• Dementia and Alzheimer Disease
• Grieving
• Impairment in hearing and vision
• Delirium

Conclusion

Hallucinations are very complex and their treatment depends on the cause of the hallucination.

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In the US, it was estimated that about 21.4 % of adults would experience a mood disorder in their life [1].

In the UK, it was estimated that 1 in 5 people are affected by mood disorders [2].

2- How Do You Know If You Have a Mood Disorder?

Symptoms depend on the type of the mood disorder and may include the following:

• Persistence state of sadness
• Feeling empty or worthless
• Difficulty focusing or too many thoughts
• Loss of interest in thinks you previously enjoyed doing
• Suicidal thoughts
• Loss of appetite
• Weight loss or gain
• Fatigue or excessive energetic movements
• Sleep disorder or Insomnia
• Irritability
• Risk taking behavior

1- What Are the Causes of Mood Disorders?

• Family history

Higher rates of mood disorders were associated with a family history of affective disorders and instability [3].

• Life changing

Life-changing events such as death, trauma, or divorce can be triggers for depression and mood disorders.

• Physical illness

Chronic diseases such as diabetes, cancer, Parkinson’s diseases, and cardiovascular diseases can result in depression and mood disorders in affected individuals.

•  Medications

Some medications can cause mood disorders such as antiepileptic drugs, interferon (IFN), corticosteroids, and digoxin [4][5].

• Substance Abuse

Alcohol, cocaine, opioids (e.g., heroin) can cause mood disorders [6].

• Brain structure and function

Using MRI (Magnetic Resonance Imaging) technology, mood disorders have been associated with alterations in certain regions of the brain including the frontal lobe, the thalamus, the striatum, the parietal lobe, and the hippocampus that are involved in brain connections that control the frontal‐subcortical circuit, the suicide circuit, and the reward circuit [7].

• Previous Diagnosis with Mood Disorder

Some types of mood disorders can result in a progression into different types of mood disorders.

3- What Are the Types of Mood Disorders?

• Major Depressive Disorder (MDD)

Major Depressive Disorder (MDD) or depression is a debilitating mental disorder characterized by a depressed mood (low mood), low self-esteem, and loss of interest in previously enjoyable activities.

Major depression can be due to genetic factors (family history) or health issues.

It was estimated that around 7.1% of US adults had a least one major depression in their life [8].

Major depression was more prevalent in women (8.7%) than men (5.3%).

• Bipolar Disorder (Manic Depression)

Bipolar Disorder is a mood disorder characterized by mood swings between periods of depression (depressive episodes), and elevated mood that can be severe known as mania (manic episode), or less severe known as hypomania.

Sometimes both depressive and mania episodes happen at the same time.

Bipolar symptoms include symptoms associated with depressive and manic episodes:

Depressive Episodes Symptoms

These include a persistent state of sadness, low self-esteem, fatigue, loss of appetite, loss or gain of weight, lack of focus, feeling empty or worthless, guilt, sleep disorders, and suicidal thoughts [10].

Manic Episode Symptoms

These include irritability, mood swings between delirium and euphoria, impulsivity, excessive energetic movements, lack of restraining, fast thoughts, and risk-taking behavior.

Hypomanic Episode Symptoms

These symptoms are characterized by an unjustifiable elevation in mood, a lack of restraining, and a reduced need for sleep.

There are 2 types of bipolar disorder: a severe bipolar disorder known as bipolar I and a less severe one known as bipolar II.

It is estimated that 2.8% of US adults had bipolar disorder during their lifetime [10].

• Cyclothymic Disorder (Cyclothymia)

Cyclothymia is a mood disorder characterized by depressive episodes, elevated mood, and hypomania but without meeting the criteria of bipolar disorder [11].

Symptoms of cyclothymia include depressed mood, irritability, low self-esteem, helplessness, insomnia, fatigue, inability to feel pleasure (anhedonia), lack of motivation, headaches, and suicidal thoughts. 

• Seasonal Affective Disorder (SAD)

Seasonal affective disorder (SAD) is a type of seasonal depression characterized by major depressive episodes in the fall/winter and remissions in spring/summer.

The symptoms include persistent low mood, lack of interest, irritability, lack of energy, irritability, longer hours of sleep, withdrawal from social situations, and craving for carbohydrates.

• Premenstrual Dysphoric Disorder (PDD)

This mood disorder occurs before menstruation with moderate to severe symptoms that include anxiety, depressed mood, irritability, low self-esteem, decreased interest in activities, difficulty focusing, hypersomnia or insomnia, and anger [12].

• Disruptive Mood Dysregulation Disorder (DMDD)

This mental disorder affects children and adolescents and manifests with persistent irritability, anger, and frequent temper outbursts [13].

• Persistent Depressive Disorder (Dysthymia) 

Dysthymia is a mood disorder that has characteristics of moderate depression but that lasts for a longer period (more than two years).

The symptoms include fatigue, insomnia, hypersomnia, eating disorders, and low self-esteem.

It is estimated that 2.5% of US adults had dysthymia during their lifetime [14].

• Depression Induced by Substance Use or Medication

This type of mood disorder is associated with the induction of changes in certain parts of the brain and alterations in the activity of neurotransmitters such as dopamine, serotonin, neuropeptide Y, and corticotropin-releasing factor (CRF).

Symptoms include depressive mood, fatigue, irritability, low self-esteem, insomnia, psychomotor retardation, and suicidal thoughts which can progress to manic symptoms [15].

• Depression Related to Medical Illness

Chronic diseases such as diabetes, cancer, Parkinson’s diseases, and cardiovascular diseases affect the individual purpose and meaning of life which can result in depression [16].

• Atypical Depression

Individuals that are affected by this type of depression have similar symptoms as dysthymia or major depression but have higher reactions to their environment such as positive events or rejection [17].

• Psychotic Major Depression (Psychotic Depression, Depressive Psychosis)

Psychotic Major Depression is characterized by a combination of symptoms of major depression, hallucinations, and dilutions [18].

• Melancholic Depression

This type of depression is mostly biologically caused and is characterized by depressed mood, low self-esteem, fatigue, anorexia, excessive guilt, slow movement, absence of reactions to the environment, and lack of motivation [19].

• Postpartum Depression (Postnatal Depression)

Postpartum Depression is a mood disorder that manifests after childbirth and is characterized by symptoms such as anxiety, sadness, fatigue, sleep disorder, irritability, and the tendency to often cry [20].

3- How Do You Deal with Mood Disorders?

Anti-depressants

For the treatment of depression selective serotonin reuptake inhibitors (SSRI) are used.

Mood Stabilizers

These medications are used to modulate mood swings particularly in individuals with bipolar disorder.

Antipsychotics

These medications are used for the treatment of manic or depressive and manic episodes.

Light Therapy

Light therapy is used for the treatment of seasonal affective disorder (SAD).

Psychotherapy (Talk Therapy)

This involves counseling sessions and cognitive behavioral therapy.

Brain Stimulation Therapy

When treatments with medications are not successful for bipolar disorder patients, electroconvulsive therapy (ECT) may be used, which consists in applying current impulses on the patient scalp or forehead to inhibit or activate the brain [21].

Other brain stimulation therapies are also used such as stimulation Repetitive transcranial magnetic stimulation (rTMS) uses electromagnetic pulses to stimulate specific nerve cells in the brain.

Conclusion

Mood disorders are very common and affect millions of people; however, only half of the people affected with mental diseases receive treatment. Therefore, it is essential to increase awareness, improve detection methods, and make treatment available to all affected individuals to prevent cases of extreme desperation associated with suicidal thoughts.

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The prevalence of BPD is estimated to be 1.6% in the general population and 20% in the inpatient psychiatric population [1]. It is estimated that 10% of BPD patients commit suicide, which is 50% higher than that of the total population [2].

What causes borderline personality disorder?

The causes of BPD are complex and involve genetic factors and adverse childhood experiences that alter emotions and cause impulsivity leading to behavioral alterations and psychosocial struggles and deficits.

Studies using neuroimaging technologies identified differences in certain parts of the brain of BPD patients, including the amygdala, hippocampus, and medial temporal lobes. Neurobiological studies suggested the potential implication of serotonin in the pathogenesis of BPD [1].

1- Genetic Factors

Evidence of the involvement of genetics in BPD was provided by the study of identical and non-identical twins. A study showed that the rate of BPD in Identical twins is 70%, while it was only 7% for non-identical twins [3]. These results were confirmed by other twin studies that reported a genetic heritability of 50% [4].

2- Adverse Childhood Experiences

Many patients with BPD reported experiences of traumatic neglect and abuse during their childhood, including childhood sexual abuse that represented 40-70% of the reported cases of BPD and difficulties reaching stable attachments or losing attachments figures (e.g., parents) [5][6].

Borderline Personality Disorder Symptoms

The symptoms of BPD are complex and involve affective, cognitive, behavioral, and interpersonal symptoms [7]:

1- Affective Symptoms

These symptoms include intense and frequent episodes of uncontrolled and constant anger with repeated fights, chronic feelings of emptiness, and affective instability associated with anxiety and irritability.

1- Cognitive Symptoms

These symptoms are characterized by temporary stress-related feelings of being persecuted or harassed, or the presence of severe dissociative symptoms such as the feeling as if one is outside, one’s body, and loss of memory.

2- Behavioral Symptoms

These symptoms are associated with impulsivity and frequent suicidal behavior, gestures, or threats, or self-mutilating behavior.

3- Interpersonal Symptoms

These symptoms are associated with hysterical efforts to prevent real or imaginary abandonment but also the existence of unstable and intense interpersonal relationships that are characterized by a switch between extreme acts of devaluation and overestimation of an admired aspect of another person.

Diagnosis of Borderline Personality Disorder

Before performing a comprehensive psychiatric assessment, a careful history and physical examination are performed. Diagnostic screening tools for BPD are also used such as the Zanarini Rating Scale for borderline personality disorder [1]. It has also been shown that patients with BPD have high rates of comorbid disorders:

• Mood disorders 80% to 96%
• Anxiety disorders 88%
• Substance abuse disorders 64%
• Eating disorders 53%
• Attention deficit hyperactivity disorder (ADHD) 10%-30%
• Bipolar disorder 15%
• Somatoform disorders 10%

Borderline personality disorder treatment

1- Psychosocial Interventions

These interventions involve mentalizing-based therapy (MBT) to help the emotional aspect of the patients, dialectical behavior therapy (DBT) that combines mindfulness practices with tangible interpersonal and emotion regulation skills, and transference-focused psychotherapy (TFP) to help make the patients aware of problems associated with interpersonal interactions.

2- Pharmacotherapy

So far, there are no medications that are approved to specifically treat BPD; however, medications such as SSRIs, mood stabilizers, and antipsychotics are used for the control of anxiety, depression, sleep disturbance, or psychotic symptoms [7].

Prognosis of Borderline Personality Disorder

Compared to other mental disorders such as bipolar disorder, BPD seems to have a better prognosis. A study has reported a remission of 75% of hospitalized patients who were included at the start of the study followed up was for 6 years.

The study also reported that only 6% of those who achieved remission had a later recurrence and only 4% of the patients committed suicide within the 6-year study period [8]. Another study that included 290 patients with BPD, reported a remission of 35% after 2 years, 91% after 10 years, and 99% after 16 years.

Conclusion

Although borderline personality disorder is a severe mental disorder characterized by high rates of suicide, psychosocial interventions combined with pharmacotherapy to relieve symptoms such as anxiety, depression, and psychosis, have led to high rates of remission. However, while waiting for better and more cost-effective treatments, early intervention and prevention strategies during childhood or adolescence can certainly help the development of this disorder.

References

[1] Chapman J, Jamil RT, Fleisher C. Borderline Personality Disorder. [Updated 2021 Aug 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.

[2] Swartz, M., Blazer, D., George, L. and Winfield, I., 1990. Estimating the prevalence of borderline personality disorder in the community. Journal of personality disorders, 4(3), pp.257-272.

[3] Torgersen, S., Lygren, S., Øien, P.A., Skre, I., Onstad, S., Edvardsen, J., Tambs, K. and Kringlen, E., 2000. A twin study of personality disorders. Comprehensive psychiatry, 41(6), pp.416-425.

[4] Amad, A., Ramoz, N., Thomas, P., Jardri, R. and Gorwood, P., 2014. Genetics of borderline personality disorder: systematic review and proposal of an integrative model. Neuroscience & Biobehavioral Reviews, 40, pp.6-19.

[5] Zanarini, M.C., Yong, L., Frankenburg, F.R., Hennen, J., Reich, D.B., Marino, M.F. and Vujanovic, A.A., 2002. Severity of reported childhood sexual abuse and its relationship to severity of borderline psychopathology and psychosocial impairment among borderline inpatients. The Journal of nervous and mental disease, 190(6), pp.381-387.

[6] West, M., Keller, A., Links, P.S. and Patrick, J., 1993. Borderline disorder and attachment pathology. The Canadian Journal of Psychiatry/La Revue canadienne de psychiatrie.

[7] Lieb, K., Zanarini, M.C., Schmahl, C., Linehan, M.M. and Bohus, M., 2004. Borderline personality disorder. The Lancet, 364(9432), pp.453-461.

[8] Zanarini, M.C., Frankenburg, F.R., Hennen, J. and Silk, K.R., 2003. The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. American Journal of Psychiatry, 160(2), pp.274-283.

[9] Gunderson, J.G., Stout, R.L., McGlashan, T.H., Shea, M.T., Morey, L.C., Grilo, C.M., Zanarini, M.C., Yen, S., Markowitz, J.C., Sanislow, C. and Ansell, E., 2011. Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study. Archives of general psychiatry, 68(8), pp.827-837.

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