Paranoia and persecution


Most people can think of instances where they have misread the intentions of others. Most obviously, this is particularly likely to be the case immediately after negative events that question our trust in others. For example, for several months after being mugged, people can understandably be very wary, vigilant and suspicious when walking in the street.

Paranoia is the unfounded idea that other people are deliberately trying to harm an individual. Studies reveal paranoia is widespread in the general population. There is a distribution for paranoia just as there is for anxiety and depression.

Evidence shows societies that are more unequal, and have less social cohesion, have higher rates of suspicion and paranoia. It is related to mistrust and is linked to living in cities in higher densities. Insomnia is also now seen as a factor for paranoia.

Extracts: Helping patients with paranoid and suspicious thoughts: a cognitive–behavioural approach. ,

Paranoid and suspicious thoughts are a significant clinical topic. They regularly occur in 10–15% of the general population, and persecutory delusions are a frequent symptom of psychosis. In the past, patients were discouraged from talking about paranoid experiences. In contrast, it is now recommended that patients are given time to talk about them, and cognitive–behavioural techniques are being used to reduce distress.

In this article we present the theoretical understanding of paranoia that underpins this transformation in the treatment of paranoid thoughts and summarise the therapeutic techniques derived. Emphasis is placed on the clinician approaching the problem from a perspective of understanding and making sense of paranoid experiences rather than simply challenging paranoid thoughts. Ways of overcoming difficulties in engaging people with paranoid thoughts are highlighted.

Criteria for a delusion to be classified as persecutory

(Freeman & Garety, 2000)

Criteria A and B must be met:


  • the individual believes that harm is occurring, or is going to occur, to him or her
  • the individual believes that the persecutor has the intention to cause harm


There are a number of points of clarification:

  • harm concerns any action that causes the individual to experience distress
  • harm only to friends or relatives does not count as a persecutory belief, unless the persecutor also intends this to have a negative effect on the individual
  • the individual must believe that the persecutor at present or in the future will attempt to harm him or her
  • delusions of reference do not count within the category of persecutory beliefs

The paranoia hierarchy (Freeman et al, 2005)

How is paranoia understood psychologically?

The prevalence figures are consistent with the idea that paranoid thoughts are an appropriate strategy that can, in particular circumstances, become excessive, just like anxious thoughts. Consideration of the potentially hostile intentions of others can be a highly intelligent and appropriate strategy to adopt. Walking down certain streets can be dangerous. Friends are not always good ones. Whether to trust or mistrust is a judgement that lies at the heart of social interactions, and since it is not always an easy decision to make it can be prone to errors.

Most people can think of instances where they have misread the intentions of others. Most obviously, this is particularly likely to be the case immediately after negative events that question our trust in others. For example, for several months after being mugged, people can understandably be very wary, vigilant and suspicious when walking in the street.

Persecutory delusions are explicable in terms of normal psychological processes. However, there is an important caveat: no single factor is likely to account for paranoia.

Making sense of events

The key opening for the psychological understanding of paranoia is that such thoughts are individuals’ attempts to explain their experiences, that is, to make sense of events (Maher, 1988). The sorts of experiences that are the proximal source of evidence for persecutory delusions are external events and internal feelings.

Clinical experience indicates that ambiguous social information is a particularly important external factor. Such information is likely to be both non-verbal (e.g. facial expressions, people’s eyes, hand gestures, laughter/smiling) and verbal (e.g. snatches of conversation, shouting). Coincidences and negative or irritating events also feature in persecutory ideation.

Unusual or anomalous internal feelings often lead to delusional ideation. For example, the individual might be in a heightened state or aroused; feel that certain events are significant; experience perceptual anomalies (e.g. things may seem vivid or bright or piercing, sounds may feel very intrusive); feel that they are not really ‘there’ (depersonalisation); and might have illusions and hallucinations (e.g. hear voices). Experiences of this sort can also be caused by use of illicit drugs or sleep deprivation.

Typically, individuals who exhibit paranoid thinking are trying to make sense of their internal unusual experiences, often by drawing in negative, discrepant or ambiguous external information (e.g. others’ facial expressions). For example, a person may go outside feeling in an unusual state and rather than thinking ‘I’m feeling a little odd and anxious, probably because I’ve not been sleeping well’, interprets their feelings, together with the facial expressions of strangers in the street, as evidence of a threat (e.g. ‘People don’t like me and may harm me’). But why a persecutory interpretation? We interpret internal and external events in line with our previous experiences, knowledge, emotional state, memories, personality and decision-making processes and therefore the origin of persecutory explanations lies in such psychological processes.


Suspicious thoughts often occur in the context of emotional distress. They are often preceded by stressful events such as difficult interpersonal relationships, bullying and isolation. Further, the stresses may happen against a background of previous experiences that have led to beliefs about the self (e.g. as vulnerable), others (e.g. as potentially dangerous) and the world (e.g. as bad) that make suspicious thoughts more likely (Fowler et al, 2006).

Anxiety may be especially important in the generation of persecutory ideation. This is because anxiety and suspiciousness have the same cognitive theme of the anticipation of danger. In our model we hypothesise that anxiety is central in the interpretation of internal and external events and provides the threat theme of paranoia. Hence, we argue that emotion has a direct role in delusion formation (for a review see Freeman & Garety, 2003); this is in contrast to a popular view that delusions conceal emotional distress or low self-esteem (e.g. Colby, 1975; Bentall et al, 1994). Typically, therefore, in paranoid thinking a person having unusual experiences that they find it hard to identify and correctly label interprets them in line with their emotional state. If they are anxious it is more likely that the interpretation will be of threat.

Anxious thoughts are truly persecutory when they contain the idea that harm is actually intended by the perpetrator. The cause of this idea of intent is underresearched. We think that most often ideas of threat contain an implicit attribution of intent. Irritation, resentment or anger – often not expressed because of fears of others’ reactions (‘timidity’) – may perhaps contribute to this idea of hostile intent, since judgements of blame and attributions of intent are central to anger. A lack of trust in others, an unwillingness to discuss emotions, or social isolation mean that the feelings of threat and intent are not shared with others but are ruminated on alone, preventing disconfirmation of their persecutory nature.


The final piece of the puzzle is reasoning. It needs to be remembered that persecutory delusions are inherently a judgement and therefore reasoning processes are of central importance. Persecutory ideas are more likely to reach a delusional intensity if there are accompanying biases in reasoning such as reduced data gathering (jumping to conclusions) (Garety & Freeman, 1999), failure to consider alternative explanations (Freeman et al, 2004) and a strong belief confirmation bias (Wason, 1960). When reasoning biases are present, suspicions become near certainties; ideas of threat are held with a conviction unwarranted by the evidence and may then be considered delusional.

Our model contains further hypotheses concerning the maintenance and emotional reaction associated with persecutory delusions. For example, since the explanations contain threat beliefs, the fears will be maintained by processes similar to those outlined in the anxiety disorders literature, such as the use of safety behaviours (e.g. avoiding other people) which prevent the processing of disconfirmatory evidence (Clark, 1999). Furthermore, the individual’s relationship with the persecutor may be important in determining emotional reactions; the belief that the persecutor is powerful has been associated with higher levels of depression (Birchwood et al, 2000b; Freeman et al, 2001). Thus, we conceptualise paranoia as resulting from individuals’ attempts to understand their experiences, particularly unusual internal states, while under the influence of emotional states such as anxiety and biases of reasoning. Careful assessment is needed to determine the relevant factors in each individual case.

The techniques of cognitive–behavioural therapy for paranoia

The general strategy of trying to understand, in the context of an empathic and collaborative approach, are key whatever treatment is adopted. But for a cognitive–behavioural intervention there are many additional elements, and these are outlined here. There have been repeated demonstrations of the efficacy of cognitive–behavioural therapy (CBT) for delusions and hallucinations (e.g. see review byZimmermann et al, 2005). The evidence base is strongest concerning CBT for persistent positive symptoms such as delusions. About 20% of patients with persistent symptoms do very well in treatment and another 40% show important improvements (e.g. Kuipers et al, 1997). Tarrier et al(1998) report that, in a comparison with routine care alone, CBT resulted in almost eight times greater odds of a reduction in psychotic symptoms of 50% or more.

In acute psychosis, there is evidence that CBT can speed time to recovery (Druryet al, 1996; Lewis et al, 2002). Furthermore, there is a small amount of evidence that some forms of CBT may reduce relapse rates (Gumley et al, 2003). The intervention is certainly popular with patients. However, not all respond to this approach. It is recommended for people with distressing delusions, since it enables individuals to engage with the collaborative goal of reducing distress. It is much less likely to be of use for individuals who are not distressed by their paranoid experiences. Cognitive deficits are not a contraindication for treatment, nor is the absence of insight into having an illness.

It is important to note that at this stage of development CBT for delusions is not a brief treatment; typically, it needs to be provided weekly for at least 6 months. Although similar to CBT for other disorders, clinicians should be aware that modifications to the approach are needed for delusions. Therapists using CBT for psychosis are often working with people who have complex disorders and need a good understanding of the psychology of psychosis, cognitive therapy skills, and regular supervision and support. It is also important to be aware that CBT is provided as part of a multi-modal treatment that includes antipsychotic medication and, for example, assertive community treatment, rehabilitation, supported employment and family intervention.

Six key self-help steps in overcoming paranoid thoughts

  1. Become a detached observer of your fears. Readers are shown how to monitor and learn about their paranoid thoughts using diaries and writing exercises
  2. Develop a detailed understanding of the causes of suspicious thoughts. Substantial information is provided on the causes of paranoid thoughts, and readers are shown in a structured way how to formulate their own experiences
  3. Review paranoid interpretations rather than just accepting them. The rules of good decision-making are introduced and readers are shown how to review their paranoid thoughts and alternative explanations for their experiences
  4. Test out suspicious thoughts. It is explained how to test out paranoid fears in behavioural experiments. Hierarchies of tests are constructed, predictions made and the results of tests considered
  5. Let go of a suspicious thought when it comes. Readers are encouraged not to fight suspicious thoughts when they occur but instead to let them go and focus on what they are doing, not what they are thinking
  6. Spend less time worrying about paranoid thoughts. Reduction in worry is attempted by showing how worrying makes things worse, introducing ‘worry periods’ and substituting problems

(Freeman et al, 2006)


Cognitive–behavioural therapy for paranoid and suspicious thoughts draws on a range of techniques that are applied on the basis of an individualised formulation of the patient’s difficulties.

However, importantly, what unites the techniques is the assumption that the patient’s subjective experiences should be taken seriously and that patients can be helped to make paranoid experiences less threatening, less interfering and more controllable. This parallels the psychological approaches taken to treat emotional disorders such as anxiety and depression and reflects a substantial advancement in the treatment of paranoid thoughts.



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