When a teen sees, hears, or feels things that aren’t real, they are hallucinating.

“When we say reality, we mean ‘consensus reality,’ because everyone’s reality is different, of course,” clarifies Lauren Cona, LCSW, Program Director at Evolve Residential Treatment Center in Los Angeles’ San Fernando Valley. Cona has years of experience working with adolescents struggling with hallucinations and delusions, which are beliefs that aren’t rooted in reality.

Hallucinations and delusions are the two primary markers of psychosis.

Seeing Things

If your teen is hallucinating, he or she may be seeing things that aren’t there.

For many, it starts at night. Teens can start having perceptual changes, seeing what looks like strange visions or shadows. Or they can “see” glimpses of people who aren’t really there. At first, they may not be sure if they’re actually seeing something or if it’s their mind playing tricks on them. This is particularly the case if your teen is still in the early stages of psychosis (called prodromal symptoms). If your teen is in the later stages of psychosis, they are fully convinced that what they’re seeing is real. This is also true for everything else related to psychosis: the prodromal symptoms are weaker versions of the full-blown hallucinations and delusions.

Qualitative data shows that teens who have schizophrenia often hallucinate “family members, religious figures, and animals” (Teeple, 2009). A common hallucination tends to be spiders.

Hearing Voices

Another type of hallucination is auditory—hearing voices. This is probably the most common. In fact, in a study of teens who experienced trauma, most of them experienced auditory hallucinations.

Based on reports, these voices can sound different for every person. For Eleanor Longden, who shared her experience with schizophrenia on a famous TED Talk, the voices in her head started out as neutral commentary. She was in college when she had her first psychotic episode:

“I was leaving a seminar when it started, humming to myself, fumbling with my bag just as I’d done a hundred times before, when suddenly I heard a voice calmly observe, “She is leaving the room.” I looked around, and there was no one there, but the clarity and decisiveness of the comment was unmistakable. Shaken, I left my books on the stairs and hurried home, and there it was again. “She is opening the door.” This was the beginning. The voice had arrived. And the voice persisted, days and then weeks of it, on and on, narrating everything I did in the third person. “She is going to the library.” “She is going to a lecture.” It was neutral, impassive and even, after a while, strangely companionate and reassuring.

Command Hallucinations

However, voices are not always so neutral. At times, they can be downright hostile. Lauren, a social worker and blogger at “Living Well with Schizophrenia,” says that sometimes the voices she hears are just “idle chatter”: They talk about the weather, plans for the day, and so on. Other times, the voices can get dark and negative. The voice will start harping on her weaknesses and stating them “aloud,” at times even issuing commands to harm herself. These hallucinations are called command hallucinations.

Likewise, Longden’s command hallucinations not only told her to self-harm, but also to bring harm to others.  Eventually, she grew so frustrated with these voices that she even once attempted to “drill a hole inside my head” to get them out.

Voices vs. Internal Dialogue

Everyone has an internal dialogue inside their head. However, it’s important to realize that one’s own thoughts are not the same as “hearing voices.” Of course, many teens with mental health issues can be compelled to hurt themselves or hurt others. A teen with depression can be tempted to cut himself or herself. An adolescent with disruptive mood dysregulation disorder (DMDD) can feel so much anger that they cannot help but throw a chair at their teacher. But these urges do not necessarily come from external voices. They are often part of one’s internal thoughts.

On the other hand, teens with schizophrenia or severe psychosis actually hear voices that are different than their own internal dialogue. For example, in efforts to distinguish her external voice from her own internal thoughts, Lauren from “Living Well With Schizophrenia” describes how she named one specific voice “Jennifer”.

Other Types of Hallucinations

The majority of psychotic hallucinations are auditory or visual, but there are also other types. Olfactory hallucinations involve smelling a strong odor that isn’t there (usually an unpleasant one). Tactile hallucination is having a sensation of being touched when you’re really not. One common tactile hallucination is feeling lots of bugs crawling on your skin. Gustatory hallucinations are when you feel like you’re tasting something that isn’t there.

What To Do If You Think Your Teen is Hallucinating

While hallucinations are often a symptom of psychosis—like schizophrenia—it’s not always. If your teen is hallucinating, it can also just be a one-time experience. Lack of sleep, drugs, stress and other external issues can all cause a teen to hallucinate. To know whether your teen’s hallucinations – auditory, visual or otherwise – is connected to a mental health issue, seek out a mental health professional right away. In case the hallucinations are due to schizophrenia, bipolar disorder, or another issue, early intervention is crucial and has the best chances of treatment.