Hearing Voices, Paranoia, and Psychotic Symptoms: Caused by Drugs or a Psychiatric Condition?

Written by the medical team at Day One Rehabilitation Center, Nakhon Nayok, Thailand · Medically reviewed by Dr. Pichayut Kasemphakdeephong (Psychiatrist)

Hearing someone speak when no one is there, believing someone is following or watching to harm them, feeling that the people around them are plotting something, or seeing things others don’t see — these are symptoms that cause great concern for families, especially when they occur in someone using yaba, ice, cannabis, alcohol, or another substance.

The key question families often have is: are these symptoms caused by the substance, or is there a pre-existing psychiatric condition?

The answer isn’t the same for everyone. Some substances can directly trigger hallucinations, paranoia, and psychotic symptoms, while others may have a pre-existing psychiatric condition that substance use aggravates. There are also people who first develop symptoms during substance use, but the symptoms persist even after stopping, requiring further evaluation.

What matters, then, isn’t rushing to conclude “it’s just the drug” or “it’s definitely a psychiatric condition” — it’s looking at the relationship between the type of substance, the timing of use, sleep deprivation, symptoms after stopping, and the person’s symptom history before starting to use the substance, because this information helps the treatment team distinguish the cause and plan appropriate care.

What Are Hearing Voices, Paranoia, and Psychotic Symptoms Like?

Psychotic symptoms are a group of symptoms that change a person’s perception or interpretation of reality. Each person’s symptoms differ, and hearing voices isn’t the only one.

Hallucinations

Hallucinations are perceptions of things others don’t perceive at the same moment — such as hearing sounds, seeing images, or feeling something without a corresponding external stimulus.

Symptoms families may notice include:

• Hearing someone speaking when no one is nearby

• Hearing their name called, criticism, or voices talking about them

• Talking to or responding to voices others don’t hear

• Repeatedly looking at one spot as if seeing something there

• Saying they see a person, a shadow, or something others can’t see

• Feeling something touching or moving on their body with no identifiable cause

Hearing voices doesn’t always mean someone has schizophrenia, because it can occur from many causes, including substance use, withdrawal, certain physical illnesses, and other psychiatric conditions.

Paranoid Thoughts or Beliefs That Don’t Match Reality

Some people may believe very strongly that someone is following, watching, or trying to harm them, even though people around them find no evidence of this.

Behaviors that may be observed include keeping the curtains closed at all times, repeatedly checking doors or cameras, refusing food out of fear of being poisoned, believing their phone is being tapped, or suspecting that someone close to them is conspiring with others to harm them.

For the person experiencing it, these fears can feel very real. Saying “you’re just imagining it” doesn’t make the fear go away, and may make them feel that the family doesn’t understand or has even become part of what they’re suspicious of.

Changes in Thought and Behavior

Psychotic symptoms sometimes don’t begin with clear hearing of voices. Families may notice changes in behavior instead — such as withdrawing, speaking in ways that are hard to understand, connecting ideas in unusual ways, not sleeping for several nights, neglecting self-care, or a sharp decline in performance at school or work.

If these symptoms occur alongside substance use or continuous sleep deprivation, an evaluation by a professional should be sought — don’t wait until symptoms become severe before asking for help.

How Do Yaba, Ice, Cannabis, and Other Substances Cause Psychotic Symptoms?

Many substances can change how the brain functions and cause symptoms resembling psychiatric conditions, but the nature and risk vary by the type of substance, dose, frequency, duration of use, use of multiple substances together, and each person’s physical or mental condition.

Yaba and ice are substances to consider when paranoia occurs alongside substance use. People who use them continuously may become very alert, unable to sleep, irritable, and increasingly paranoid. With heavy use or continuous sleep deprivation, some may hear voices, see images, or believe someone is following and trying to harm them.

Sleep deprivation itself can also make psychotic symptoms more severe, so it’s not enough to look only at the amount of substance used — it’s also important to consider when the person last slept and how long they’ve gone without sleep.

Cannabis can cause anxiety, fear, paranoia, or psychotic symptoms in some people, especially those sensitive to these effects. The fact that some people feel relaxed after using cannabis doesn’t mean it produces the same effect in everyone.

Alcohol and certain sedatives raise another important issue: people who use them continuously to the point of dependence may have severe symptoms when stopping suddenly. In some cases, confusion, restlessness, or hallucinations can occur together with withdrawal, which requires medical care.

Therefore, if multiple substances are used together, families should tell the treatment team all the information, because the symptoms may not come from a single substance alone.

How Can You Tell Whether Psychotic Symptoms Are Caused by Drugs or a Psychiatric Condition?

Distinguishing the cause can’t be done by looking at symptoms alone, because people with drug-induced psychotic symptoms and people with a psychiatric condition can present very similarly.

What the treatment team focuses on is the timing of the symptoms.

If symptoms began as substance use increased, after several days of continuous use, or after prolonged sleep deprivation, and gradually decrease after stopping the substance and getting appropriate rest, this points more toward a relationship with the substance.

But if the person had hearing voices, paranoia, or abnormal behavior before starting to use the substance, or if symptoms persist even after the substance’s effects and withdrawal period have passed, a co-occurring psychiatric condition needs to be thoroughly assessed.

Some people may have schizophrenia — a psychiatric condition involving ongoing disturbances in thought, perception, and daily functioning that predates the substance use, with substance use beginning later. Using yaba, ice, cannabis, or other substances can then cause symptoms that had been under control to relapse.

Some people have never had symptoms before, but develop clear psychotic symptoms after using a substance, while others have both a pre-existing psychiatric risk and a substance acting as a trigger that makes the symptoms appear more clearly.

Family history is therefore very useful — for example, whether the person talked to themselves before starting to use the substance, whether they were unusually paranoid before, whether changes at school or work began before or after substance use, and whether symptoms went away or persisted during periods when they were able to stop using the substance for a long time.

Reassessing once the patient has passed through intoxication and withdrawal is therefore important, because an accurate diagnosis may require monitoring symptoms over time.

When Someone Using Substances Has Hearing Voices or Paranoia, What Should the Family Do?

When a family member believes someone is trying to harm them, relatives’ first reaction is often to try to prove that it isn’t true — saying things like “no one is following you at all” or “you’re just imagining it because of the drugs.”

Even though the family wants to help them return to seeing reality clearly, arguing directly while the person is very afraid can increase tension.

There’s no need to confirm that the belief is true, but you can acknowledge their feelings — for example: “We don’t see anyone there, but we can see that you’re very scared right now. We want to help you be somewhere safe.”

Speak in a calm tone, use short and clear sentences, reduce the number of people crowding around to talk, and avoid shouting, threatening, mocking, or trying to force them to admit they’re wrong.

If the person is very suspicious of a particular individual, that person should avoid being the one to confront them or try to persuade them while symptoms are severe.

Another important point is not to allow additional substance use to “calm them down,” because the substance may make symptoms more severe or unpredictable.

If there is extreme confusion, inability to control themselves, severe aggressive behavior, thoughts or behaviors of harming themselves or others, refusal to eat or drink out of paranoia, or hearing voices commanding dangerous acts, safety should be the priority and an urgent medical evaluation should be sought.

How Are Psychotic Symptoms Occurring Alongside Substance Addiction Treated?

Treatment must address safety, psychotic symptoms, and substance use together, because calming the symptoms without addressing substance use may allow the symptoms to return once the person uses the substance again.

Stop Substance Intake and Assess Intoxication or Withdrawal

The first step is assessing which substance is involved, when it was last used, whether multiple substances were used together, when the person last slept, and whether there is any physical condition requiring urgent treatment.

Some substances have withdrawal symptoms that can be dangerous, so stopping or managing symptoms on one’s own without assessment should not be attempted — especially for people who drink heavily or use sedatives continuously in large amounts.

Use Antipsychotic Medication When Indicated

A psychiatrist may consider antipsychotic medication based on the severity and cause of symptoms, to help reduce hallucinations, paranoid thoughts, agitation, or other symptoms that threaten safety and daily life.

If a psychiatric condition requiring ongoing treatment is found, long-term medication may be necessary based on the psychiatrist’s assessment.

Medication shouldn’t be stopped immediately just because hearing voices or paranoia has improved, because the resolution of symptoms doesn’t mean the condition or the risk of relapse has completely gone away.

Treat Substance Addiction to Prevent Symptoms From Returning

For people whose symptoms are triggered by a substance, returning to use can cause the psychotic symptoms to come back. Treatment must therefore help the person understand the relationship between their substance use, sleep deprivation, and their own psychotic symptoms.

Psychotherapy, motivational conversations, identifying triggers for substance use, and relapse-prevention planning all play an important role.

For people who have had severe psychotic symptoms, relapse prevention isn’t aimed only at preventing addiction — it also helps reduce factors that could trigger a relapse of psychotic symptoms.

Restore Sleep and Daily Life

Sleep deprivation can worsen mood, thinking, and perception, especially in people who use stimulants.

Recovery must therefore help restore a normal sleep cycle, regular eating, a clear routine, and reduce environments that lead back to substance use.

Once psychotic symptoms begin to stabilize, recovery in school, work, relationships, and returning to social life can gradually be added in an appropriate way.

If the Patient Won’t Accept That They Have Symptoms or a Substance Problem, What Should You Do?

Someone experiencing psychotic symptoms may not recognize that what they’re experiencing differs from reality. For them, the voices they hear or the feeling of being followed may feel very real.

Trying to force them to say “I’m just imagining it” is usually not a good starting point.

Families can start from things both sides can agree on — such as “you haven’t slept for several nights,” “you seem very stressed and scared,” or “lately you’ve had to keep watching the people around you so much that you haven’t been able to rest.”

If the person still doesn’t accept that they have a substance problem, you might start by inviting them to get an evaluation based on the symptoms they’re suffering from — such as being unable to sleep, feeling restless, feeling unsafe, or hearing disturbing voices — rather than starting by arguing that they’re “addicted.”

Once symptoms have calmed down, you can then talk about the relationship between the substance, sleep deprivation, and the symptoms that occurred. Talking during a period when the person can listen and reflect is usually more useful than trying to win an argument while they are severely paranoid.

With Psychotic Symptoms Alongside Substance Use, Where Should You Start Seeking Help?

If the main problem is a psychiatric symptom, and there is only occasional use of alcohol, cannabis, or another substance without a clear pattern of addiction — or if the patient isn’t ready for treatment yet and the family wants guidance first — you can start by consulting at Piti Clinic, our outpatient mental-health clinic in Bangkok (Pradiphat Road, Saphan Khwai), to help with an initial assessment, distinguish the relationship between the psychotic symptoms and substance use, and help the family plan how to talk with the patient to bring them into appropriate treatment.

But if there is repeated substance use that can’t be controlled, repeated relapse after stopping, withdrawal symptoms, or a pattern where every time the person returns to using yaba, ice, cannabis, or another substance, paranoia and psychotic symptoms flare up again, addressing the substance addiction seriously should be the priority.

People with both substance addiction and psychotic symptoms may need an environment that controls access to the substance and can continuously monitor sleep, medication use, and changes in symptoms. Residential treatment is therefore an option worth considering when the problem is complex or the person keeps returning to substance use in the same environment.

Treating Psychotic Symptoms and Substance Addiction at Day One Rehabilitation Center

For people with hearing voices, paranoia, or other psychotic symptoms alongside substance addiction, Day One Rehabilitation Center places importance on assessing both problems together, because psychotic symptoms may be caused by the substance, triggered into relapse by the substance, or be a psychiatric condition occurring alongside the addiction.

Residential treatment helps reduce access to the substance and its triggers, while giving the treatment team the opportunity to monitor how hearing voices, paranoia, and behavior change once the substance is stopped, the person has rested, and sleep begins to return to normal.

A psychiatrist can continuously assess symptoms, consider medication use as indicated, and monitor any co-occurring psychiatric condition, while the treatment team addresses motivation to stop using the substance, understanding of the symptoms, triggers for returning to substance use, and self-care skills.

Once symptoms become more stable, therapy helps the person in treatment look back and see the relationship between substance use, sleep deprivation, stress, and symptom relapse, without blame.

For example, if it’s found that every time the person returns to using ice continuously for several days they begin to lose sleep, become paranoid of the people around them, and hear voices, seeing this pattern themselves can become an important reason to build motivation to avoid returning to substance use.

Before returning home, there should be a clear plan in place — taking medication as prescribed by the doctor, sleep, avoiding the substance and high-risk groups, follow-up treatment, and watching for warning signs such as sleeping less, withdrawing, becoming more paranoid, or starting to seek out the substance again.

The goal, then, isn’t only to make hearing voices go away for a while — it’s to help reduce the chance that the substance and psychotic symptoms will trigger each other again, while helping the person in treatment return to living life more steadily.

Frequently Asked Questions About Hearing Voices, Paranoia, and Drug Use

Does hearing voices always mean someone has schizophrenia?

Not always. Hearing voices can have many causes, including substance use, withdrawal, certain physical illnesses, and various psychiatric conditions. It must be assessed together with the person’s history and other symptoms.

Can yaba or ice cause hearing voices and paranoia?

Yes. Yaba and ice can cause anxiety, insomnia, and paranoia, and in some people, hallucinations or other psychotic symptoms — especially with continuous use or accompanying sleep deprivation.

Can cannabis cause psychotic symptoms?

Yes, in some people. Cannabis can trigger anxiety, paranoia, and psychotic symptoms, with sensitivity to its effects varying from person to person. Anyone who has previously had psychotic symptoms should tell their doctor about their history of cannabis use.

If someone stops using drugs, will hearing voices go away on their own?

For some people, symptoms may lessen after stopping the substance and resting, but it shouldn’t be assumed that this will happen for everyone. If symptoms are severe, threaten safety, or continue after stopping the substance, an evaluation by a psychiatrist is needed.

The patient says someone is following them — should I tell them they’re imagining it?

You shouldn’t argue with or mock them while they’re very afraid. There’s no need to confirm that the belief is true, but you can say that you yourself don’t see the same thing, while acknowledging that they are afraid, and help get them to a safe situation.

What should I do if the patient hears voices telling them to do something dangerous?

Safety should be the priority, and an urgent evaluation should be sought — especially if the person seems likely to act on the voices, has thoughts or behaviors of harming themselves or others, or can’t control their behavior.

Can psychotic symptoms caused by drug use be treated?

Yes, they can be treated. Treatment depends on the type of substance, the severity of symptoms, and whether a co-occurring psychiatric condition is present. Some people improve significantly after stopping the substance, resting, and receiving treatment, while others need ongoing treatment and monitoring.

If someone already has schizophrenia, is it okay to still use cannabis or other substances occasionally?

Occasional use shouldn’t be seen as risk-free, because some substances can trigger a relapse of psychotic symptoms and disrupt treatment. Anyone with a history of psychotic symptoms should talk openly with their psychiatrist about their substance use.

With psychotic symptoms and substance addiction together, which should be treated first?

They should be treated in a connected way, starting with safety, intoxication, withdrawal, and severe psychotic symptoms first. Once symptoms are stable, the substance use problem must continue to be treated — treatment shouldn’t stop just because hearing voices or paranoia has improved.

Do psychotic symptoms occurring alongside substance use always require going to a treatment center?

Not for everyone. If the psychiatric problem is the main issue and substance use is only occasional, without a clear pattern of addiction, a mental health assessment can be a starting point. But if there is repeated substance use that can’t be controlled, relapse after stopping, withdrawal symptoms, or a clear link between returning to substance use and a relapse of psychotic symptoms, residential addiction treatment at Day One Rehabilitation Center is an option that should be seriously considered.

Psychotic Symptoms and Substance Addiction Need to Be Understood Through Both Their Causes and Their Triggers

Hearing voices, paranoia, and psychotic symptoms don’t mean the person is dangerous or that there’s no way for them to return to a normal life. Nor should these symptoms be concluded to come from drug use alone without proper assessment.

Some people have symptoms caused by the effects of a substance, some have a pre-existing psychiatric condition that the substance aggravates, while others have both substance addiction and a psychiatric condition that need to be treated together.

For families, what matters most during a period of severe symptoms is safety — not arguing with the beliefs or perceptions the patient is experiencing — and bringing them into an appropriate evaluation. Once symptoms are stable, you can then help them see the relationship between the substance, sleep, stress, and the symptoms that occurred.

If it turns out that returning to substance use causes hearing voices or paranoia to come back repeatedly, treating the addiction is an important part of preventing relapse of the psychotic symptoms. Continuous care for both sides helps ensure the goal isn’t only to calm the symptoms, but includes returning to a stable life, work, and relationships with family.