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Understanding paranoia
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What is paranoia?
Are there different kinds?
Who is most vulnerable to these feelings?
What are the causes?
What treatments are available?
What can family and friends do?
Useful organisations
Further reading
"The couple next door are listening in on me, I know it. I saw her in the street yesterday and she looked away."
"The postman is reading my mail. One of my letters last week was not stuck down. He knows all my secrets."
"My son's behaving so strangely; he suspects everyone of plotting against him. The thing is, I daren't talk about it when he's in the house, in case he overhears. I'm getting paranoid about his paranoia."
This booklet is aimed at anyone who wants to know more about paranoia, its causes, and what can be done to help those who experience the problem, their family and friends.
What is paranoia?
Being paranoid means being suspicious without reason, and believing that others are trying to harm you in some way. Everyone can be mistrustful at times, particularly if life hasn't treated him or her well. But people who are prone to paranoia always dread some forthcoming attack or betrayal. They are forever anticipating that something awful will happen, and trying to second-guess what their adversaries might do. They focus on their fears for the future, and take little account of the majority of times when the past has proved them wrong.
In milder forms, the person has some insight into what's going on and realises their suspicions might be groundless. In extreme forms, they can't distinguish reality from fantasy. (Psychiatrists may refer to this as a psychosis, and talk about people having delusions.) It can be a very isolating condition, because people feel they can't depend on anybody. They may feel angry, fearful, guilt-ridden, suspicious, vengeful and excluded, and may become very depressed, as a result. (See How to recognise the early signs of mental distress.)
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Are there different kinds?
The feeling of being threatened or betrayed can take many forms. People may become irrationally jealous, or believe that their thoughts and actions are being controlled or monitored. They may fear that their life is in danger - that their milk or food is being poisoned, for instance.
Some people feel a deep sense of their own badness, while others believe they are being unfairly treated by their imagined persecutors and think they are being unjustly harassed. These two types are known as "bad-me paranoia" and "poor-me paranoia".
Paranoid schizophrenia
Extreme paranoia is one of the symptoms of paranoid schizophrenia. This may also involve people hearing voices, which may comment on their behaviour, echo their thoughts or issue orders.
Paranoid personality disorder
Paranoid personality disorder is another diagnosis, which clinicians consider if the problem has been around for some time, perhaps since adolescence. Commonly, people will have little or no insight into their condition and will never have asked for treatment.
Delusional or paranoid disorder
Sometimes, someone who functions quite well in day-to-day life develops one particular dominating, paranoid idea, of great complexity, that puts them at odds with those around them. This is sometimes called a delusional or paranoid disorder. It doesn't usually involve hearing voices.
Other diagnoses that may include paranoid feelings are manic depression (bipolar disorder), schizoaffective disorder, severe anxiety or depression, and postnatal psychosis. (See Further reading for more information about all these problems.)
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Who is most vulnerable to these feelings?
This is difficult to say, because paranoia can be an element in over eighty different medical conditions. A third of old people in geriatric wards may be affected. People who are getting on in years, or feeling depressed, can easily start feeling they are a burden to friends and relatives. Being partially deaf can also make them think that others are whispering, and hiding something from them.
The problem is more common for elderly women than men, while among the young, men are slightly more often affected. Younger patients also tend to have more spectacular delusions (for example, that "MI5 is controlling my mind"). Some studies of patients diagnosed with mental health problems have found paranoid ideas in as many as ten per cent of people interviewed. Clearly, like depression and drug use, this problem is very much a part of modern life, particularly in towns and cities.
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What are the causes?
Genetic factors
Paranoia is a complex blend of thoughts and feelings, so it's unlikely to have one simple cause. It's possible the genes we inherit from our parents may have some influence, but they alone can't cause it.
Childhood influences
What happens to us in childhood may play a part. If a child is brought up to believe that the world is a very unsafe place and that people are horrible, this may mould their personality in a paranoid direction. Self-esteem, or lack of it, is also important. If children are not brought up to feel that they are basically lovable, they may be suspicious or mistrustful when others show them affection. It's thought that very grandiose behaviour or a highly inflated sense of importance, which paranoid people sometimes show, can be an unconscious compensation for such feelings.
Social context
It's important to recognise that paranoia is not located "entirely inside the head" but is a response to the world around. A person's thoughts, bizarre though they may be, can often be a reaction to very real stresses in life, and sometimes a sensitive comment on the world. On occasion, paranoid delusions can even be true! It's important to consider this possibility before dismissing them.
Paranoia is a particular attitude to the social world, and will inevitably reflect a person's experience of intimate social relationships. So, a deep fear of dependency in people who experience paranoia could be due to disappointments in the past. Suspicions about "hidden scheming going on" can be the result of experiencing relationships that seem pleasant and charming on the surface, but which carry a hidden layer of anger and aggression underneath. This may have been suppressed and denied, but can still be detected. The feeling of a "double reality" to seemingly innocent situations and events has its roots in real experience, and is quite common.
Thinking errors
In the hope of improving therapy, certain research focused not so much on childhood, family and relationship issues, but on the way someone actually thinks of themselves and of everyday events. It found that people with paranoia have low self-esteem in some aspects of their personality. To protect themselves, they tend to see other people's intentions as negative, rather than risk finding any fault in themselves.
They also have a tendency to jump to conclusions, and to be hasty and overconfident in their thinking. They will seek out information that confirms their beliefs and, at the same time, ignore evidence that contradicts them. Their view of the world tends to be very narrow and to neglect the broader context. So, they very easily get "the wrong end of the stick", and focus on small details rather than the big picture. These thinking errors are known as cognitive biases. They can interfere with social relationships and also lead the person to think in a strange way - causing further social difficulties, and creating a vicious circle.
Lack of empathy
Difficulty in understanding someone else's point of view, or in empathising with their thoughts and feelings, can be partly genetic. (Similar, but more severe problems, occur in autistic spectrum disorders. See Further reading.) It can lead to mistaken assumptions about other people's behaviour, and bring social rejection. This, in turn, may fuel a sense of discontent and of grievance, which generates more paranoia.
The effects of drugs
Chemicals can sometimes be a factor. Drugs such as cocaine, cannabis, alcohol, ecstasy, LSD and amphetamine can all trigger paranoia. So do certain steroids taken by some athletes and weightlifters. Even insecticides, fuel and paint have been associated with symptoms. (See Understanding the psychological effects of street drugs.)
Physical causes
Paranoia, as a symptom, is linked with certain physical illnesses, such as Alzheimer's disease, Huntington's disease, Parkinson's disease, strokes and other forms of dementia. (See Understanding dementia.)
Life events
A sudden increase in stress can be very significant. Losing a job or a relationship break-up can make someone feel very isolated. It can force them to turn inwards, to feel more insecure and under threat. On occasion, this can develop into paranoia. Getting older can also increase a person's loneliness and vulnerability. If they then begin to lose faculties, such as hearing or sight, it can seriously undermine their ability to make accurate judgements about what is going on around them.
Laying blame
It's important that families and partners don't blame themselves. As a rule, paranoia results from a combination of factors, and the most important ones may well have been totally beyond anyone's control. Equally, it's important not to blame the sufferer. The vital thing is to recognise the problem, and do something about it.
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What treatments are available?
Very often, people have little insight into their state of mind, and don't accept that there is anything wrong with them. They may have built up an immensely complex delusional system on the basis of a single incident - perhaps a telephone call, a remark they heard in a shop or an act of coldness from an old friend. But, generally, unless they suspect these beliefs may be wrong, at least in part, they will not accept that they need treatment.
The first point of contact is usually a GP, who may refer the person to a psychiatrist or clinical psychologist. It's also possible to contact practising clinical psychologists directly, and lists are available in major libraries and on the internet. (For more information, see Useful organisations.) However, a psychologist is likely to want a GP's opinion to rule out any physical cause for the condition.
Medication
The main drugs for treating paranoia are called "typical" and "atypical" neuroleptics, also known as antipsychotics. The typical forms are well-established drugs, such as chlorpromazine and haloperidol. Both have a tranquillising effect and tend to make people less aggressive, particularly haloperidol. But they do have some unpleasant side effects.
The newer atypical neuroleptics include clozapine, risperidone and olanzapine. These medicines generally have fewer long-term side effects. Doctors should prescribe atypical drugs for new cases, unless there are good reasons not to, such as a known sensitivity to an ingredient. All antipsychotic medication needs to be prescribed at the lowest effective dose, to minimise side effects. For more information, see Making sense of antipsychotics (major tranquillisers).
Fear and persecutory delusions may lead people to refuse or sabotage their drug treatment, for example, by holding the drug in their mouth until they are alone, and spitting it out.
Talking treatments
Cognitive behaviour therapy (CBT) is a very effective psychological therapy. It involves carefully examining a person's thinking patterns and the evidence they have for their beliefs. It goes on to help them find alternative interpretations to the ones that are distressing them. It teaches them to monitor and control their thoughts, and is therefore a really useful means of self-help. CBT also helps people who hear voices to control them, change what they say, and cope better. (See Mind's booklet, Making sense of cognitive behaviour therapy (CBT).)
Many others forms of psychotherapy are available, including psychoanalytical psychotherapy, transactional analysis and gestalt therapy. Although they have different underlying ideas, they generally involve talking over personal experiences, in detail, and exploring feelings.
Psychotherapy for paranoia is not commonly available on the NHS. There have been some positive reports from people who have been helped by it. However, if the client is highly suspicious of the therapist's motives, it can be difficult to establish a good enough rapport between them, and therapy is likely to come to an early end. (See Further reading.)
Community services
People often benefit by getting away from their current circumstances, whatever they are, either temporarily or permanently. This can involve visiting day centres or day hospitals on a regular basis. Or it could mean a bigger move into a group home or some kind of sheltered housing, such as a psychiatric aftercare hostel. Daycare provides an opportunity to mix with different people, some with similar problems, and the chance to join in shared activities. Inpatient facilities should, ideally, enable people to live in a supportive environment and develop the skills to live independently, eventually.
Hospital
It may be necessary to admit someone to hospital if he or she is very disturbed and a threat to themselves or others. Because they may have little insight into how unreasonable their beliefs are, they may be admitted involuntarily, under the Mental Health Act 1983. (See the series of Mind's rights guides.)
The usual treatment in hospital is medication, but under the Care Programme Approach (CPA), people are entitled to an assessment and care plan, for support and treatment, once they leave hospital. (See factsheets about community care.)
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What can family and friends do?
Living with a paranoid person is exceedingly distressing, made worse by the person's own lack of insight into their condition, and occasional aggressive outbreaks. Families, friends and carers should not suffer in silence. They should ask friends and relatives to help out, and try to get some time away. If the delusions have a religious content, it may be worth contacting an appropriate person at the local church, mosque, temple or synagogue. The following strategies may be helpful.
Establishing control
It's necessary to help the person separate out what he or she can or can't control. For example, someone may not be able to stop hearing voices, but may have more control over how they interpret and react to what the voices say. This is particularly important if voices are very self-destructive, urging people to hurt themselves or attack someone else. There is a growing body of literature on coping with hearing voices, and this is an area where CBT has been beneficial.
Supporting good judgement
It's important to sort out those things that could have some basis in reality ("the bus driver is unfriendly") from those that couldn't ("the milkman is poisoning the milk"). It can be very damaging to the paranoid person's self-esteem if it's always assumed that everything they say is wrong. Recognising when he or she is showing good judgement is helpful and therapeutic.
Foreseeing difficulties
It's best to anticipate problems, rather than waiting for them to happen. For example, when moving to a new area, or a new job, it's a good idea to talk over the kind of difficulties that might arise, such as the threat of mixing with new people. Any visitors also need to be aware of the problem.
Distinguish facts from assumptions
It's much better to regard thoughts as assumptions based on evidence, rather than as solid facts. Assumptions and evidence can be questioned and discussed, and can therefore be revised. This is the approach used by cognitive behaviour therapists. Acquiring information about paranoia can make the disorder seem less mysterious and threatening, and can give everyone additional hints on coping.
Communicating honestly
When someone with paranoia believes something that is almost certainly incorrect, it's always necessary to stand firm. Say that you accept that they have their beliefs, but that you don't share them.
Avoiding confrontation
To tell someone they are stupid or talking rubbish is disrespectful, dismissive and unhelpful. It damages self-esteem, gives the impression that you do not care about the person, and is liable to make things worse.
Encouraging independence
It's a mistake to be over-protective, over-involved or critical. Everybody needs space to live their life, as well as respect and love. It's also helpful to encourage general conversation about things other than the person's delusions.
Taking a positive approach
People suffering from paranoia are often intelligent, imaginative and talented people. Their paranoia is really an unfortunate misuse of their imagination. It's well worth looking through it towards the positive qualities that underlie it. Many people have turned their irrational thinking around and eventually made it work for them, not against them.
Self-help groups
There may be other families in the neighbourhood who have similar difficulties, and you may be able to find this out, perhaps via the hospital or local health centre. There's no need to leave the therapy entirely to the professionals. Families can help each other.
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Useful organisations
Alzheimer's Society
helpline: 0845 300 0336 tel. 020 7306 0606
web: www.alzheimers.org.uk
Advice, information and support for people with dementia, their carers and professionals
British Association for Behavioural and Cognitive Psychotherapies (BABCP)
tel. 0161 797 4484
web: www.babcp.com
Full directory of psychotherapists available online
British Association for Counselling and Psychotherapy (BACP)
tel. 0870 443 5252 minicom: 0870 443 5162
web: www.bacp.co.uk
Provides details of local practitioners
The British Psychological Society
tel. 0116 254 9568
web: www.bps.org.uk
Publishes a directory of chartered psychologists across the UK. Available on the web and in public libraries
Carers UK
tel. 020 7490 8818 (England) tel. 029 2081 1370 (Wales)
helpline: 0808 808 7777
web: www.carersuk.org
Information and advice on all aspects of caring
Huntington's Disease Association
tel. 020 7022 1950
web: www.hda.org.uk
Advice and support – local support groups available in England and Wales
Parkinson's Disease Society
helpline: 0808 800 0303 tel. 020 7931 8080
web: www.parkinsons.org.uk
Information, advice and support
Rethink Severe Mental Illness (formerly the National Schizophrenia Fellowship)
advice line: 020 8974 6814
web: www.rethink.org
Help for everyone affected by severe mental illness
The Stroke Association
helpline: 0845 303 3100 tel. 020 7566 0300
web: www.stroke.org.uk
Information for people affected by strokes, and their carers
Turning Point
tel. 020 7481 7600
web: www.turning-point.co.uk
Services for people with alcohol, drug or mental health problems across England and Wales
Useful Websites
www.hearing-voices.org
www.personalitydisorder.org.uk
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Further reading
Accepting voices eds. Prof M. Romme, S. Escher (Mind 1993)
Conquering a sense of inferiority (Mind 2004)
Going mad? Understanding mental illness M. Corry, A. Tubridy (Newleaf 2001)
How to cope as a carer (Mind 2006)
How to cope with hospital admission (Mind 2006)
How to look after yourself (Mind 2006)
How to rebuild your life after breakdown (Mind 2004)
How to recognise the early signs of mental distress (Mind 2004)
Making sense of antipsychotics (major tranquillisers) (Mind 2007)
Making sense of cognitive behaviour therapy (CBT) (Mind 2007)
Making sense of counselling (Mind 2004)
Making sense of psychotherapy and psychoanalysis (Mind 2004)
The Mental Health Act 1983: an outline guide (Mind 2006)
The Mind guide to advocacy (Mind 2006)
The Mind guide to managing stress (Mind 2006)
Mind rights guide 1: civil admission to hospital (Mind 2004)
Mind rights guide 2: mental health and the police (Mind 2004)
Mind rights guide 3: consent to medical treatment (Mind 2004)
Mind rights guide 6: community care and aftercare (Mind 2005)
Overcoming low self-esteem: a self-help guide using cognitive behavioural techniques M. Fennell (Robinson 1999)
Overcoming paranoid and suspicious thoughts: a self-help guide using CBT D. Freeman, J. Freeman, P. Garety (Robinson 2006)
Understanding anxiety (Mind 2006)
Understanding autistic spectrum disorder (ASD) (Mind 2004)
Understanding dementia (Mind 2004)
Understanding depression (Mind 2007)
Understanding personality disorders (Mind 2007)
Understanding postnatal depression (Mind 2006)
Understanding the psychological effects of street drugs (Mind 2007)
Understanding schizoaffective disorder (Mind 2003)
Understanding schizophrenia (Mind 2005)
Understanding talking treatments (Mind 2005)
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This booklet was written by Peter Chadwick
First published by Mind 1989. Revised edition © Mind 2007
ISBN 9781874690849
No reproduction without permission
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