Managing Uncontrolled Emotional Outbursts: A Comprehensive Guide

Stress can push the brain to its limits, sometimes distorting perception and creating sensory experiences that feel real but aren’t. While commonly associated with psychotic disorders, hallucinations can also emerge from extreme fatigue, chronic anxiety, or prolonged emotional distress. When stress overwhelms the nervous system, it disrupts normal sensory processing, leading to misinterpretations of reality.

Stress-induced hallucinations can be disorienting, temporarily affecting one’s ability to distinguish between reality and perception. Factors like sleep deprivation, heightened anxiety, and overstimulation can all contribute to these experiences. However, distinguishing between momentary stress-induced distortions and more serious medical concerns is crucial.

This article explores the link between stress and hallucinations, their causes, and when professional intervention is necessary. For those experiencing persistent or distressing hallucinations, seeking professional psychiatric evaluation at Amae Health can provide clarity and evidence-based treatment options.

What Causes Hallucinations?

Hallucinations occur when the brain perceives something that isn’t actually there — whether it’s sights, sounds, smells, or physical sensations. While often linked to psychotic disorders, they can also result from stress, sleep deprivation, and anxiety, which alter brain chemistry and disrupt sensory processing.

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Research suggests that stress-induced hallucinations may stem from dopamine and serotonin imbalances. Chronic stress can overactivate the limbic system, increasing dopamine levels, which is linked to hallucinations in psychotic disorders. The perceptual release theory also explains that when sensory input is reduced — due to exhaustion or stress — the brain “fills in the gaps” with internally generated images or sounds.

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Neuroimaging studies indicate that abnormal activation in the temporal and frontal lobes is associated with stress-related hallucinations. Understanding these mechanisms helps differentiate temporary hallucinations from more serious conditions.

Common Psychological and Medical Causes

Psychotic Disorders

Psychotic disorders, such as schizophrenia and schizoaffective disorder, are among the most well-known causes of hallucinations. These conditions affect the way the brain processes reality, leading to persistent auditory, visual, or tactile hallucinations. Individuals with psychotic disorders often experience delusions alongside hallucinations, making it difficult to differentiate between what is real and what is not.

Anxiety and Panic Disorders

Although less commonly associated with hallucinations, severe anxiety and panic disorders can lead to sensory distortions. During intense episodes, individuals may experience fleeting visual distortions, auditory misperceptions, or even a sense of detachment from reality. Hypervigilance and overstimulation from chronic anxiety can create a state where the brain misinterprets normal stimuli as hallucinations.

Sleep Deprivation and Fatigue

Lack of sleep can have profound effects on brain function, sometimes leading to hallucinations. Individuals suffering from extreme fatigue, insomnia, or conditions like sleep apnea may experience visual or auditory hallucinations, particularly in the form of fleeting images or phantom sounds. Sleep deprivation alters neurotransmitter levels, making it easier for the brain to misinterpret sensory input.

Substance Use or Withdrawal

Psychoactive substances, including alcohol, stimulants, and hallucinogenic drugs, can cause hallucinations both during use and withdrawal. Substances like LSD or psilocybin directly alter perception, while withdrawal from alcohol or benzodiazepines can lead to temporary hallucinations as the nervous system readjusts. Chronic substance abuse may also cause long-term changes in perception.

Chronic Stress (Hyperstimulation)

Prolonged exposure to stress can lead to a state of hyperstimulation, where the nervous system remains in overdrive. This heightened state of alertness can distort sensory processing, making individuals more susceptible to hallucinations. Chronic stress alters cortisol levels, impacting brain areas responsible for perception and memory, potentially leading to transient hallucinatory experiences.

How Can Stress Cause Hallucinations?

Dissociation as a Response to Stress

Dissociation is a defense mechanism triggered by overwhelming stress, leading to a sense of detachment from reality. A study published in Schizophrenia Bulletin Open found that individuals with a history of trauma are significantly more likely to experience hallucinations following acute stressors, reinforcing the link between stress, dissociation, and sensory distortions.

Individuals experiencing dissociation may feel disconnected from their surroundings, themselves, or time. In severe cases, dissociation can manifest as hallucinations, where the brain creates sensory experiences to cope with the overwhelming stress and emotional dysregulation.

Acute Stress and Hallucinations

Acute stress triggers the body's fight-or-flight response, flooding the system with stress hormones like cortisol and adrenaline. This heightened state of alertness can lead to sensory distortions, causing brief auditory or visual hallucinations. Individuals under extreme stress may misinterpret sounds, see fleeting images, or feel an unexplained presence due to heightened neural activity and hyper-awareness.

Chronic Stress (Hyperstimulation) and Its Impact

Chronic stress results in long-term hyperstimulation of the nervous system, altering brain chemistry and perception. Persistent stress can disrupt neurotransmitter balance, increasing susceptibility to hallucinations. Over time, heightened stress levels can cause hallucinations like auditory whispers, visual flashes, or phantom sensations as the brain struggles to filter sensory input properly.

Sleep Deprivation and Hallucinations

Stress often leads to sleep deprivation, which in turn increases the risk of hallucinations. Sleep deprivation disrupts cognitive processing, causing the brain to enter micro-dream states while awake. This can result in visual distortions, auditory misinterpretations, or a sensation of movement. The longer an individual goes without sleep, the more severe these hallucinations can become.

Types of Stress-Related Hallucinations

Auditory Hallucinations

Auditory hallucinations are among the most common stress-induced hallucinations. Individuals may hear whispers, distant voices, or even music when no external sound is present. These hallucinations can be disorienting, often occurring during periods of extreme anxiety or fatigue or after prolonged exposure to stress. According to research from Yale’s COPE Project, recent social stress directly correlates with both the frequency and distress levels of auditory hallucinations, highlighting the role of everyday stressors in exacerbating these experiences. Managing stress levels and improving sleep quality can help reduce these occurrences.

Visual Hallucinations

Visual hallucinations involve seeing objects, shapes, or figures that are not actually there. They can appear as fleeting shadows, flashes of light, or fully formed images. Stress-induced visual hallucinations often stem from sleep deprivation or severe emotional distress. Practicing relaxation techniques, mindfulness, and ensuring adequate rest can help minimize these experiences.

Tactile and Somatic Hallucinations

Tactile hallucinations create the sensation of physical touch when there is no actual contact. Individuals might feel crawling, tingling, or pressure on their skin. These can occur due to heightened anxiety, sleep deprivation, or intense stress. Grounding exercises and cognitive behavioral therapy (CBT) can be beneficial in managing these symptoms.

Olfactory and Gustatory Hallucinations

Olfactory hallucinations involve detecting smells that are not present, while gustatory hallucinations cause individuals to perceive unusual tastes. These can be triggered by prolonged stress, migraines, or neurological conditions. Identifying and managing stressors, along with medical evaluation, can help determine the cause and reduce their occurrence.

When Should You Be Concerned About Stress-Induced Hallucinations?

Signs You Should Seek Help

If hallucinations become frequent, intense, or start interfering with daily life, seeking professional help is essential. Persistent hallucinations, confusion, or distress warrant medical evaluation. Identifying underlying causes, such as extreme stress, sleep disorders, or mental health conditions, can help in developing an effective treatment plan to restore well-being.

How Are Stress-Related Hallucinations Treated?

Short-Term Coping Strategies

Immediate coping mechanisms include deep breathing, grounding techniques, and mindfulness exercises. Engaging in relaxation activities like meditation or progressive muscle relaxation can help reduce the intensity of hallucinations. Addressing stressors and improving sleep hygiene can also provide quick relief.

Long-Term Treatment Options

Managing stress-induced hallucinations requires a combination of professional and self-care approaches. Amae Health’s specialists offer evidence-based therapies, including cognitive behavioral therapy (CBT) and medication management, to help patients regain stability.

Therapy, such as cognitive behavioral therapy (CBT), can help address underlying stressors. In some cases, medication may be recommended. For individuals with chronic stress-induced hallucinations, psychiatric interventions such as medication targeting neurotransmitter regulation may provide significant relief. Lifestyle changes, including regular exercise, balanced nutrition, and structured routines, can further support mental and emotional well-being.

Regaining Control Over Stress-Induced Hallucinations

Stress-induced hallucinations can be disturbing, but they are often temporary and manageable with the right strategies. While occasional hallucinations caused by stress, sleep deprivation, or anxiety might not indicate a deeper issue, persistent or distressing experiences should not be ignored. 

Seeking professional help, practicing stress management techniques, and maintaining a healthy lifestyle can significantly reduce the risk of experiencing hallucinations. If you or someone you know is struggling with stress-related hallucinations, remember that support is available, and addressing the root cause can lead to long-term relief.

At Amae Health, our specialized team provides comprehensive care for stress-related mental health challenges. Schedule a consultation today to regain clarity and control over your well-being.

FAQ

Can anxiety cause hallucinations? 

Yes, severe anxiety and chronic stress can contribute to hallucinations, particularly auditory or visual ones. Anxiety-induced hallucinations often occur during heightened distress or panic attacks.

Are stress hallucinations dangerous? 

While stress-induced hallucinations can be distressing, they are not inherently dangerous. However, they may indicate underlying mental health concerns that require attention.

Do hallucinations from stress go away on their own? 

In many cases, stress-related hallucinations subside once the underlying stressor is managed. Prioritizing stress reduction, proper sleep, and relaxation techniques can help accelerate recovery. If hallucinations persist, seeking medical guidance is recommended.

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From the outside, you look fine. You show up, you apologize first, you keep your voice level. Inside, a small comment from a friend can set off hours of shame, a spiral of "they're going to leave," and a quiet decision to pull away before anyone can hurt you. That pattern has a name people search for: quiet BPD. It describes borderline personality disorder (BPD) turned inward, where the intense emotions are real but almost nobody sees them.

Quiet BPD isn't a separate diagnosis. It's a way of describing how BPD can look when anger, fear, and despair are directed at yourself instead of at other people. And because it's so easy to miss, people often live with it for years before anyone names it.

Is quiet BPD a real diagnosis?

Not formally. The DSM-5 describes one borderline personality disorder, with no official subtypes. "Quiet BPD," "silent BPD," "internalized BPD," and "hidden BPD" are informal terms that patients and clinicians use for the same inward-facing pattern.

The idea has roots in research, though. Psychologist Theodore Millon described four subtypes of BPD, including a "discouraged" type and a "petulant" type. The discouraged type, marked by avoidant and dependent traits, unexpressed anger, guilt, and shame, is the closest match to what people now call quiet BPD. (We've written separately about the outward-facing petulant type of BPD.)

Newer data points the same way. A 2023 study of 109 patients with BPD in a psychiatric day clinic, published in Personality Disorders: Theory, Research, and Treatment, sorted patients into three groups by symptom pattern. Thirty-five fit an "internalizing" profile, and that group had more co-occurring mood disorders than the others.

So the label is informal. The pattern is not.

Quiet BPD symptoms and signs

The core symptoms of quiet BPD are the same ones the NIMH lists for borderline personality disorder. What changes is the direction they travel.

• Fear of abandonment shows up as hypervigilance and pre-emptive withdrawal. You don't beg someone to stay. You leave first, or go silent, so the rejection can't land.
• Intense, shifting moods happen behind a calm face. An episode can last a few hours to a few days, and the people around you may never know it happened.
• Anger gets swallowed and turned into self-criticism. Instead of an outburst, there's a long internal prosecution of everything you did wrong.
• An unstable sense of self feels like not knowing who you are without someone else's approval, and shape-shifting to fit whoever you're with.
• Chronic emptiness can look like flatness or "I'm just tired" to everyone else.
• Dissociation, feeling cut off from yourself or your surroundings, often under stress.
• Rejection sensitivity: replaying a conversation for days, reading a short text as proof someone is done with you.
• Self-harm or suicidal thoughts, kept hidden.

People with this presentation are often described as perfectionists, people-pleasers, or "the easy one" in the family. That's part of why the condition goes unrecognized.

Quiet BPD vs. "classic" BPD

The difference isn't severity. It's visibility.

In the presentation most people picture, distress spills outward: arguments, accusations, impulsive spending or drinking, visible crises in relationships. In quiet BPD, the same emotional storm happens internally. The person who might shout "you never cared about me" instead thinks "of course they don't care, I'm too much," and quietly stops replying to messages.

Both reflect the same underlying difficulty regulating emotions. Both cause real suffering. One is just far easier to overlook.

Why quiet BPD gets missed

Quiet BPD often arrives in a clinic labeled as something else, usually depression or anxiety. The internal pattern of shame, emptiness, and withdrawal overlaps heavily with both, and BPD frequently co-occurs with them: the NIMH notes that people with BPD may also experience depression, anxiety disorders, PTSD, eating disorders, and substance use disorders. If you're treated for depression alone and keep cycling back, the underlying pattern may not have been named. (For more on that overlap, see how anxiety and depression overlap.)

There's a second reason. People with quiet BPD are skilled at appearing okay, including in a therapist's office. They minimize. They worry about being a burden. A clinician who only sees the composed surface can miss what's underneath.

What causes quiet BPD?

No single cause explains BPD, quiet or otherwise. Genes and environment both contribute.

On the genetic side, a 2021 study of more than 1.8 million people in Swedish national registries estimated the heritability of diagnosed BPD at 46%. Risk was highest among identical twins and fell as relatives became more distant. The remaining variance came from environmental factors unique to each person.

On the environmental side, clinicians often hear about childhoods where feelings were dismissed, punished, or simply never acknowledged. Some people learned early that expressing anger or need made things worse, so they stopped. That's one plausible route from a sensitive temperament to an inward-facing pattern, though research hasn't yet separated what makes one person's BPD quiet and another's outward.

Self-harm and safety

Quiet doesn't mean low-risk. The NIMH notes that people with BPD are more likely to engage in self-harm, and the inward-facing pattern makes it easier to hide. Families sometimes learn about self-harm or suicidal thoughts only after a crisis.

If you or someone you love is having thoughts of suicide, call or text the 988 Suicide & Crisis Lifeline at 988. In an emergency, call 911.

Treatment for quiet BPD

BPD is treatable, and the evidence is strongest for specialized psychotherapy. A 2020 Cochrane review pooled 75 randomized trials with 4,507 participants. Across 22 trials comparing psychotherapy with usual care, therapy reduced BPD symptom severity. The two most-studied approaches were:

• Dialectical behavior therapy (DBT), which was developed specifically for BPD and teaches skills for intense emotions, distress tolerance, and relationships.
• Mentalization-based treatment (MBT), which builds the ability to understand your own and other people's mental states, especially under stress.

For quiet BPD, part of the work is simply making the inner experience visible: learning to notice and name anger, shame, and fear before they turn into silent withdrawal.

Medication plays a supporting role. According to the NIMH, the benefits of medication for BPD are unclear and it isn't a first-line treatment. Clinicians may use it alongside therapy for specific symptoms or co-occurring conditions such as depression.

Can quiet BPD get better?

Yes. There's no long-term research on quiet BPD specifically, but the data on BPD overall is more hopeful than most people expect. In a 10-year study of 290 adults with BPD first assessed during a psychiatric hospital stay, published in the American Journal of Psychiatry in 2010, 93% reached a symptom remission lasting at least two years. Full recovery, meaning remission plus good work and social functioning, was harder: about half got there. That gap is the case for treatment that goes beyond symptoms to rebuild relationships, work, and daily life.

How we treat BPD at Amae Health

Borderline Personality Disorder is one of the conditions our clinics specialize in. Our care teams bring psychiatrists, therapists, primary care physicians, peer mentors, and care coordinators under one roof, working from one treatment plan. For someone with quiet BPD, that matters: the more people who know your history, the harder it is for a composed surface to hide what's going on. Read more about how we approach care.

Frequently asked questions

Is quiet BPD real?

Yes, as a pattern. "Quiet BPD" isn't an official DSM-5 diagnosis, but it describes a recognized way borderline personality disorder can present, close to the "discouraged" subtype Theodore Millon described and the "internalizing" group seen in newer research.

Is there a test for quiet BPD?

There's no validated test for quiet BPD specifically. Online quizzes can prompt reflection, but a BPD diagnosis comes from a clinical evaluation by a mental health professional who looks at your history, patterns over time, and co-occurring conditions.

How is quiet BPD different from depression?

They overlap and often occur together. Depression centers on low mood and loss of interest. Quiet BPD adds intense fear of abandonment, an unstable sense of self, rapid shifts in mood, and relationship patterns driven by rejection sensitivity.

How can I help someone with quiet BPD?

Notice withdrawal instead of reading it as disinterest, and ask directly how they're doing. Avoid pressing for an explanation in the moment. Our guide on how to help someone with mental health issues covers more. If they mention self-harm or suicide, take it seriously and contact 988.

Key takeaways

• Quiet BPD is an informal name for borderline personality disorder expressed inward: hidden anger, shame, withdrawal, and self-blame.
• It's not a separate DSM-5 diagnosis, but research has identified a similar "internalizing" pattern.
• It's often mistaken for depression or anxiety, and self-harm can stay hidden.
• Specialized psychotherapy such as DBT and MBT has the strongest evidence, and long-term remission is common.

If you recognize yourself here, or you're worried about someone who seems fine but isn't, you can request an intake appointment. Our team will explain how an evaluation works and what to expect from your first visit.

Maybe a genetic report flagged it. Maybe a friend, a forum, or a supplement ad told you it could explain your fatigue, your depression, or why medication never quite worked. Now you're wondering what an MTHFR gene mutation actually means for you.

MTHFR variants are extremely common. Most people who carry them have no health effects at all, and research linking them to mental health conditions shows a real but small association, not a cause. Medical experts don't recommend routine testing for them.

What the MTHFR gene does

The MTHFR gene carries instructions for an enzyme called methylenetetrahydrofolate reductase. That enzyme converts folate, a B vitamin, into the active form your body uses to turn the amino acid homocysteine into methionine. According to MedlinePlus Genetics, the active form, 5-methyltetrahydrofolate, is the main form of folate found in blood.

When the enzyme works less efficiently, homocysteine can build up. That's the mechanism behind most of the interest in MTHFR, including the mental health questions.

C677T, A1298C, heterozygous, and homozygous

Most people searching "MTHFR gene mutation" are really asking about two common variants:

• C677T. The most common and best studied. At position 677 in the gene, the DNA base C is replaced by T. The resulting enzyme is less stable and less active, especially in people with two copies.
• A1298C. The second common variant. The CDC notes there isn't enough evidence that A1298C on its own significantly affects how the body processes folate.

You inherit one copy of the gene from each parent, which is where the lab terms come from:

• Heterozygous means one copy carries the variant (for C677T, written CT).
• Homozygous means both copies carry it (TT).
• Compound heterozygous means one copy of C677T and one copy of A1298C.

These variants are so common they're closer to normal human variation than to a disease. The CDC reports that more people in the U.S. have one or two copies of C677T than don't. Having both copies is less common: MedlinePlus estimates about 25% of Hispanic people and 10% to 15% of North American white people carry two copies of C677T.

MTHFR symptoms: what the variant does and doesn't cause

Most people with common MTHFR variants have no symptoms. Cleveland Clinic puts it plainly: MTHFR gene variants most often don't affect your health or cause symptoms. When they do matter, it's usually through higher homocysteine or lower folate, and mostly in people with two copies of C677T. Even then, how much folate you get from food matters more than your genotype.

That's different from what you'll read on many wellness sites, which attribute everything from fatigue to brain fog to MTHFR. There's no reliable evidence for a list of "MTHFR symptoms" in people with the common variants. If you have symptoms, they deserve an evaluation, not an assumption that a gene variant explains them.

There is one important exception. Rare, severe mutations in the MTHFR gene cause homocystinuria, a serious inherited condition whose symptoms usually appear early in life. Most U.S. newborns are screened for it shortly after birth. That's a different situation from the common C677T and A1298C variants.

MTHFR and mental health: what research shows

Because MTHFR sits in the folate and methylation pathway, researchers have looked hard for links to psychiatric conditions. The findings are consistent in one way: the effect is modest.

• Depression. A 2013 meta-analysis of 26 studies, with 4,992 people with depression and 17,082 controls, found that two copies of C677T were associated with higher odds of depression (odds ratio 1.42). The link was stronger in Asian populations, marginal in white populations, and absent in older adults.
• Schizophrenia, bipolar disorder, and depression combined. A 2011 meta-analysis of case-control studies with 29,502 participants found TT carriers had modestly higher odds of these conditions as a group (odds ratio 1.26). The authors read this as evidence of a shared genetic vulnerability across the three conditions.

An odds ratio of 1.26 to 1.42 is a small increase in relative risk for a very common genotype. Most people with two copies of C677T never develop depression, bipolar disorder, or schizophrenia, and most people with those conditions don't have two copies. Mental health conditions come from many genes and life experiences acting together. MTHFR is, at most, one small piece.

Folate, folic acid, and methylfolate

A common online claim is that people with MTHFR variants can't use folic acid and need "methylated" supplements instead. The CDC says that isn't true: people with an MTHFR variant can process all types of folate, including folic acid. People with the TT genotype have blood folate levels only about 16% lower on average than people with CC at the same intake, and folic acid intake matters more than genotype in determining blood folate.

L-methylfolate, the active form, has been studied as an add-on to antidepressants. In two randomized trials published in the American Journal of Psychiatry in 2012, adults with depression that hadn't responded fully to an SSRI received L-methylfolate or placebo alongside their medication. The first trial, with 148 patients starting at 7.5 mg a day, found no difference. The second, with 75 patients at 15 mg a day, found a significant benefit over placebo. Both enrolled people based on their depression, not on a genetic test. Whether any add-on makes sense for a specific person is a clinical decision that depends on their full history.

For more on how folate and other nutrients relate to mood, see our article on nutrient deficiencies and anxiety.

Should you get tested for MTHFR?

For most people, no. MedlinePlus states that medical experts don't recommend testing for common MTHFR gene changes in most cases. A provider may order it in specific situations, such as high homocysteine on a blood test combined with a family history.

The American College of Medical Genetics and Genomics went further in a 2013 practice guideline: MTHFR polymorphism testing has minimal clinical utility and shouldn't be part of a routine evaluation for blood clotting disorders. Recent meta-analyses had disproven the links that originally motivated the testing.

If you already have a result, it's still useful context to share with your care team. It just isn't a diagnosis, and it isn't a treatment plan.

When depression or mood symptoms don't improve

People often look up MTHFR because something isn't working: depression that keeps coming back, medication that only half helps, or mood swings no one has explained. Those problems are real, even if MTHFR is unlikely to be the answer. They usually call for a fuller psychiatric evaluation: a closer look at the diagnosis, past medication trials, co-occurring conditions, sleep, substance use, and physical health.

That's the kind of care we provide at Amae Health. Our clinics specialize in conditions including Major Depressive Disorder, bipolar disorder, and schizophrenia. Our care teams bring psychiatrists, therapists, primary care physicians, and dietitians under one roof, so lab results, nutrition, and medication history are reviewed together, by people who share one treatment plan. See how our integrated outpatient clinics work.

Frequently asked questions

How common is the MTHFR gene mutation?

Very common. According to the CDC, more people in the U.S. have one or two copies of the C677T variant than don't. Two copies are less common, estimated at about 25% of Hispanic people and 10% to 15% of North American white people.

What are the symptoms of being MTHFR C677T heterozygous?

Usually none. According to MedlinePlus, raised homocysteine is seen mainly in people with two copies of C677T. If you have symptoms, they need an evaluation of their own rather than being attributed to one copy of a common variant.

Does MTHFR cause depression?

No single gene causes depression. Two copies of C677T are associated with modestly higher odds of depression in meta-analyses, with an odds ratio around 1.4, but most people who carry them never develop depression.

Do people with MTHFR need methylfolate instead of folic acid?

According to the CDC, no. People with MTHFR variants can process folic acid, and folic acid intake matters more than genotype for blood folate levels. L-methylfolate has been studied as an add-on treatment for depression, regardless of MTHFR status, and decisions about it belong with a clinician.

Is MTHFR testing worth it?

For most people, it isn't recommended. Medical genetics experts say the common variants have minimal clinical utility. A provider may order testing in specific cases, such as unexplained high homocysteine with a family history.

Key takeaways

• An MTHFR gene mutation usually means one or two copies of the common C677T or A1298C variants, which most people carry without health effects.
• Two copies of C677T can raise homocysteine and are linked to modestly higher odds of depression, bipolar disorder, and schizophrenia, but the effect is small.
• People with MTHFR variants can process folic acid, and routine MTHFR testing isn't recommended.
• If depression or mood symptoms aren't improving, a full psychiatric evaluation is more useful than a gene result.

If you or someone you love is living with depression, bipolar disorder, or schizophrenia that hasn't responded to treatment, request an intake appointment. Our team will walk you through how an evaluation works and what to bring, including any lab or genetic results you already have.