Speaking of Psychology - Understanding paranoia and extreme mistrust, with Daniel Freeman, PhD

Episode Date: March 19, 2025

For years, paranoia was seen a symptom of severe mental illness only. But in recent decades, some psychologists have begun to think about it differently. Daniel Freeman, PhD, author of “Paranoia: A Journey Into Extreme Mistrust and Anxiety,” discusses his research on the links between paranoia and other forms of mistrust and anxiety; why paranoid thoughts are relatively common; and new research on therapeutic treatments for paranoia.  Learn more about your ad choices. Visit megaphone.fm/adchoices

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Google Fi Wireless is not subject to data traffic deprioritization during times of high network usage. Is everyone talking about you behind your back? Is your co-worker trying to undermine you? Why are you always afraid that something bad is going to happen? For years, paranoia was seen as a symptom of severe mental illness, but in recent decades, some psychologists have begun to think about it differently. They've found that paranoid thoughts are relatively common, that there are links between paranoia and other forms of mistrust and anxiety,

and that there are therapeutic treatments that can help. So what are the causes of paranoia? Is paranoia and mistrust more generally becoming more common? Where is the line between a healthy level of skepticism and mistrust and problematic paranoia? What's the link between paranoia and anxiety? Or paranoia and schizophrenia? And what help is available for those suffering from paranoia in its more severe or mild forms? Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association

that examines the links between psychological science and everyday life. I'm Kim Mills. My guest today is Dr. Daniel Freeman, chair of psychology at the University of Oxford and a consultant clinical psychologist in the Oxford Health NHS Foundation Trust. He leads the Oxford Cognitive Approaches to Psychosis Research Group and is one of the world's leading experts on paranoia. His book, Paranoia, A Journey into Extreme Mistrust and Anxiety, was published in the UK in 2024.

The U.S. edition comes out in March. Dr. Freeman, thank you for joining me today. Delighted to be here, Kim. I'd like to start, as we often do on this podcast with a definition. How do you define paranoia in your work? Principally, it's when you think others are trying to harm you in some way. when they're not. So it's inaccurate fear that others are deliberately trying to harm you. So you may fear they're trying to cause you psychological harm to distress you or financial harm or even physical

harm. And there's a whole spectrum of severity of it in the general population and it often builds upon what we call ideas of reference when you think others are talking about you behind your back or spreading messages, and it also builds often upon a sort of sense of yourself being a bit vulnerable to harm from other people. How is it diagnosed? I mean, how do we know when it's reached a clinical level? So at the severe end, the most common form is what's called a persecutory delusion, and that's when we're very sure in our beliefs about what's going on.

So we might be convinced that there are people out there trying to kill us, for example, will take us hostage or try to get us out of the neighborhood. It's where we believe it strongly. Also, when we think about it a lot and it causes us distress. I mean, in essence, it's when it causes disruption to life. And the disruption typically becomes anxiety and depression and when we're responding to a way when we're typically avoiding things that are important meaning for another lives.

Now, we all have a little bit of suspicion, I think, at various times. times in our life. I'm just wondering how common are paranoid thoughts in the general population, and what about a clinical level of paranoia in the general population? We do all have it, and it's perfectly natural because all of us have to make a judgment about whether to trust or mistrust other people, because there are real dangers out there. So there is an element of risk estimation. Paranoia is when it's become overly weighted to mistrust and to such a strong degree, that we're feeling unsafe most of the time. The way I put it is that many people have a few paranoid thoughts,

a few people have many. When it's the level of a persecuted delusion, that's often in presentation of severe mental health problems. This often occurs in people who might receive a diagnosis of psychosis, such as schizophrenia, but there's a large proportion of the population to get paranoid thoughts and a large proportion you want help for it, who feel that it's got too much.

And what I should be very clear is that when there is actual threat out there, when there are real dangers of the person's perceiving, that's not paranoia, that's realistic threat perception. Paranoia is when it's just becoming excessive too much. And do we have any idea the percentage of people with a diagnosable level of paranoia? We're in the small percentages for that. So probably around one or two percent. But in terms of the general population, somewhere at least in our, we did a survey of

UK adults, about 10,000 a representative sample, and around 16% were saying they would like help to be more trusting of other people. So it arises out of a very important psychological process we all have to think about about trust. And it's hard sometimes to know where to set the balance. And when we get it consistently wrong, that's paranoia. But, you know, with all this risk judgment, we need to be flexible. it's going to vary where we live, the neighborhood, time of day, a whole range of factors.

So it's a process that we probably don't talk about enough with each other. Often we're just following what others around us are doing. But sometimes the people, it's a process that becomes too unbalanced towards the mistrustful. What's the connection between paranoia and other mental illnesses? I mean, for example, I think that a lot of us have an image of people with schizophrenia also almost always. being paranoid. Is that the case? It's probably the most common sign of psychosis, or what's taken is a sign of psychosis. It's one of the most common. But it's raised in most mental health conditions, people, depression.

In fact, some of the first historical accounts of paranoia talked about in the context of depression and anxiety disorders, but it cuts across. And certainly some of the data we have is that for many mental health conditions, when there is also paranoia in the picture, that is often an indication that things might persist a bit longer. And that's mainly because it often corrods social relationships. And then when they go a little bit wrong, that's not good for psychological health in general. So it's certainly at the severe end most commonly seen in severe mental health conditions, such as schizophrenia, but you can also sit in presentations of PTSD and depression and anxiety.

And a lot of my work actually, when I came to it back in the 1990s, it was only thought really to occur with people with psychosis. and I remember one of the first people I met, it fitted so much with just having a very bad experience as people who treated them very badly. And there were so many overlaps with presentations of anxiety disorders that it really started to make me think, actually, this is much more understandable than it needs to be thought. But also there's so many connections to other mental health conditions. And then my career has gone on, and when you look for it, much more in the general population, it's there at rather high amounts. because it arises out of processes that were all judgments that we already have to make. So once you actually assess for it in the population, it's present. What do we know at this point about the causes of paranoia?

Is it something that is driven by life experiences? Is there a genetic component to it? Is it a combination of those things? We've made huge leaps, I think, in understanding the causes of it. At the broad level you talked about the data we have is about, half of it might be down to the genes, at least across the population, half of the differences down to genes, half down to the environment. But at the psychological level, we know a lot.

There are multiple factors that are tilting the balance towards mistrust. It may be because people have done bad things to you, so it's unsurprising. You're going to be extremely wary of other people. Sometimes actually people are worried about things they've done in the past. Sometimes it's pushed further a lot of mistrust because of people spending a lot of time worrying, rather engage in meaning of activities, self-esteem may be low, people may be having images of their head of what people that are doing to them, there may be discrimination to people that is partly driving this.

For some people, they may be hearing voices that are telling them they're under threat. I could keep on going for quite a while. There's loads of things that can push people along, including some substances like cannabis, for example, there are many different factors. And in essence, the more that you have, have of these, the more likely it's going to push you further along the severity of the paranoia spectrum.

Now, you've developed a treatment for paranoia and extreme mistrust that you call the Feeling safe program. Can you tell our listeners about that program and how it works? Yeah, so when I first trained as a clinical psychologist, my ambition was always to produce a much better psychological treatment for those conditions. And it used to be thought that you shouldn't talk about these experiences, people, and that they well, not really psychologically understandable. And then we had real progress in some early forms of cognitive behavior therapy

showed that it is safe and can help reduce paranoia. And then for me, it's about, well, what are the best psychological techniques to do this? At the broadest level, what you need to do to counter the feelings of mistrust and the people feeling unsafe is to help people learn that actually, at least now, that they are safe. And the best way to do that is to build up direct experience of that. So helping people go back into situations they feel unsafe in and actually learn that they are okay. But it's harder than that because there's a whole range of other things that are pulling the person into paranoia. I've listed some of them.

So even if you go into a situation that is safe, if you're in your mind as catastrophizing and worrying and feeling about how maybe you're inferior to others or vulnerable, you're not going to learn safety. So there's a whole range of other things we need to do to get the person in the right psychological state to experience the world are new and feel safe. So we help people worry less, we help people sleep better, we build up people self-confidence, and then we've got a person to the best psychological state, we then do this direct learning of safety in the world. And that builds up a much more dominant view of the world as safe. And one of the important things to know in this approach is that what we don't really do in our treatment is going, telling the person they're wrong, or challenging their existing position. We're setting out an alternative description of what they be going on.

And then we challenge that and let's see whether that's right. And we help the person through direct experience. So we try and do less sitting in a room talking much more. Well, let's go to the cafe or walk down the street or give you chances to find out directly how the world is now. And of course, some of the people, you know, the past was difficult. And of course, we don't know what went on then, but we can find out how things are now. So as well, if we do it over six months, it's a sort of face-to-face therapy, but we've recently developed and are currently testing a guided online program that puts all of this an online program and there's also weekly contact with their mental health professional

trained in this approach too. So we're trying to find ways to scale this approach because our outcomes are really good and are what I hoped for when I kind of set up in this journey to develop it. So it's a treatment based upon a really good understanding of paranoia, and that's important because you need to understand the person's position, these thoughts haven't come out of nowhere. The people have thought long and hard to form these beliefs, and we need to understand their perspective, but also set out an alternative counterweight or counterweight that set out a journey they could try to see whether actually that might give a different view of

the world for them now. Is drug therapy generally associated with this kind of treatment? Yeah, so most people I work with are people who are diagnosed with things like schizophrenia, and they all typically be on antipsychotic medication. And my team is normally seeing people who haven't fully responded to standard treatments. So the medication either hasn't worked enough or perhaps hasn't worked for that person. There's certainly evidence that medications can help. But antipsychotics are certainly people of psychosis are really the main line of treatments provided,

but there is good evidence that adding psychological therapy helps, and the former psychological therapy feeling safe that we developed looks to be really good at helping a lot of people. So we often can get recovery in persecuted illusions with our psychological treatment. Having said that, there's still a proportion of people who don't benefit for what we do. So there have been a huge advances in understanding psychologically paranoia, and that's lit a better treatment, but there's still much more to learn about it, and there's still improvements we can do in the treatments.

You've been using virtual reality in your treatment program for quite a few years. How does that work? Why is it such a useful tool for treating paranoia? Yeah, I first used it. It was about 25 years ago, and that's because there's a real issue in paranoia, which really sort of touched upon at the beginning in the sense, is that there are real dangers in the world, and sometimes you don't know whether someone's being paranoid or telling you about genuine threat in the environment, and it's important that we don't close our ears to the fact that some of our patients may be getting also some hostile behaviour from other people. So I use virtuality to, as an assessment talk, first of all, to present people with neutral social situations with computer characters that were programmed to be neutral. And then we knew that people were seeing hostility from these characters.

That was genuine paranoia. So firstly, I use it to assess paranoia and then use it to also work on the understanding that underpins the treatment. But increasingly what we've done is use virtual reality to present a whole range of social situations for the person to learn safety in those situations. And of course, you might say, well, they know it's not a real situation, so doesn't that actually mean they don't learn anything? But that's the beauty of VR. Your body and your mind basically acts if it's real, even if your consciousness is telling

you that actually it's not a real situation. So if actually you learn the virtual character to safe, that learning transfers into the real world and we've certainly got evidence that if you try these sorts of practices in VR, you can get real changes in paranoia in day-to-day life. And in some ways, it's easier for people to tolerate the VR treatment because of this awareness, it's not real. It actually gives you enough psychological safety for the brain to take in new information. So that's been a very intriguing strand of our work. And one thing, we rather like our online program, there's a potential that you automate treatment provision within VR.

And of course, in VR, you can present stimuli in ways that you can't in the real world that could be therapeutically helpful. So, yeah, that's been both a way to assess but also understand but also treat paranoia. Your summer starts now with Memorial Day deals at the Home Depot. It's time to fire up summer cookouts with the next grill, four-burner gas grill, on special buy for only $199. and entertain all season with the Hampton Bay West Grove

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look like if I were trying to imagine putting on the headset, what would I be seeing? Yeah, so the most obvious things that we would do might put people into getting onto a bus, going into a shop, being a shopping centre, or also practicing walking out the front door, because some of our patients are even getting out of the street is difficult. And there'll be different levels of difficulty. So initially there may be no people in these scenarios, and sometimes we'll introduce a few people, a great number of people, and perhaps in this scenarios the person has to do something where they almost turn their back on people

to make themselves a bit more vulnerable at front of the virtual characters, always set up some games within it where, for example, in a cafe scene, suddenly a child will be blowing sort of bubbles and you have to go and catch them, which means you have to get very near people, and everyone then turns and looks at you, so really the sense of attention. So there are very simple ways to enable people to be in a social setting, to be at the center of the social settings that all eyes are on them,

and to learn that they're okay, they can cope and they're safe. So that's one direct way, but we're also looking at other ways to use to help people build up their self-confidence, so they then feel less vulnerable, for example. So there's a whole range of those other sorts of facts, as I mentioned in paranoia, that potentially you could use VR to help provide all these sort of counterweights to the more mistrustful way of viewing the world. Is there a particular point in the lifespan when paranoia begins to manifest itself? And I'm asking this because I'm thinking about parents who might be listening to this and thinking, wow, I mean, is there something I should be looking for in my kids or does paranoia

really not manifest until adulthood? I think there's an awareness and a decision-making process. I think in the early teens, really, when people are becoming more independent and more aware of threats in the world. And I think that's developmentally appropriate. That's when you're beginning to think about what's safe, what isn't, and you're probably experiencing some bad behaviors from your peers and around you, and there might be bullying and stuff. So actually, there is a normal process of weighing it up. And during that, of course, sometimes people may get a little bit more mistrustful. I mean, you wouldn't want to pathologize it at this point. I think it's a normal process. And it comes out as exactly said at the beginning, it's something that one does have

to bear attention to because there are real threats in the world, and you've got to find the right balance. And those are typically happening from our research when people are reaching a little bit more independence in their world. So it actually arises early. And paranoia actually is highest levels in adolescence and early adulthood. It actually comes down over time. And then perhaps there's a little bit more of an increase later on when people are quite a bit older. And sometimes that may be related. Certainly things like a dementia, there's going to be a little bit more paranoia. And actually sometimes when people have hearing loss, that can raise mistrust as well. Does using marijuana or other drugs put people at higher risk for paranoid thoughts? How does

substance use interact with paranoia? with acute intoxication of some illicit drugs, paranoia goes up and people will tell you that. That's pretty clear. And for a smaller percentage of people, that may continue for a bit longer after the drug has actually left the bloodstream. It is more likely to cause problems, the more you take and the early age of exposure to it. So that increases the risk that actually leads to a severe and more persisting problem outside the acute intoxication of the drug. And of course, it depends what the substance is and how strong it is. So there's a clear link, but also clearly it's not enough for its own because lots of people

take these sorts of substances and don't get these consequences, but it's going to raise the risk. That's clear. It's true for cannabis, certainly, but also I think there's a connection with alcohol use as well, and that's going to raise the risk. But again, of course, lots of people are consuming alcohol without these consequences because of paranoia. There is a multiple things coming together that can vary in individual case, but these things do raise the risk. Did the COVID pandemic have an impact on the prevalence of paranoia?

I mean, for a while there, we were all afraid of everything. Yes, I mean, I don't have good day to this. And it's always hard at the historical level because you don't have the nationally represented samples that are done over time. I mean, I think clearly for a period, anxiety went up. I mean, what was clear, I think, is that conspiracy beliefs are more general and mistrustful view of the world when mainstream at those times for lots of of reasons. Obviously, a lot of time to oneself and on the internet, everyday life had been transformed at that time. So I think at that time is certainly one of the indicators, at least to me, a lot of conspiracy stuff went mainstream. Conspiracy beliefs are different from paranoia.

There's obviously an overlap of general form of mistrust. In paranoia, you believe you're targeted and pretty much you're the only one. Conspiracy beliefs, that's not the case. It's a belief about some effect to a large number of people. So they share some causes, but there's also differences in those two. So at an individual level for the patients, say with psychosis I met, I think the pandemic at the time had different effects of different people. For some people, actually, when they're outside, there was more space from other people because you had to distance and the world became a little easier to navigate. For some people, that probably did ramp up fears a bit. What is the relationship between paranoia and physical illness? There's some overlap,

And certainly for patients, I see you with psychosis, if the withdrawal and the isolation is bad for your physical health. And also there's some conditions and pain, for example, it's going to affect your sleep, which is going to affect your mood, which is going to link to mistrust. So again, it can contribute to make things worse. And then, of course, there are, as I mentioned before, things like dementia later that also is likely to bring on mistrust too. What got you interested in studying this aspect of mental illness? I mean, I think you alluded earlier to the fact that it was really seen as something that wasn't treatable years ago. And now it is partly through the work that you're doing.

But what was so intriguing to you about this particular issue? Yeah, so I remember at university, being talked about psychosis and these sorts of problems and the traditional view that actually wasn't much psychology to it is ununderstandable. That was the dominant view and their psychological treatments, weren't, well, they weren't recommended at that point. And for me, I remember very vividly just meeting the first patient diagnosed with psychosis. And it had to be a home visit because they wouldn't come up at their house because they were worried about governments of various agencies who are going to kidnap them and torture them. And to be a home visit. And also,

I was told, don't knock on the door. They went answer. I had to go through to side window, tap on that three times. And Robert let me in. And we talked for an hour. And, you know, was so clear on the basis of things that happened to him in his past, why he would be so wary of other people. He'd become basically agoraphobic, had left the house. So in fact, you know, although he was fearing all these bad things, he was never really being outside to find out that actually he was going to be okay. And I could see so many connections with anxiety that for me, the routine was, at least initially, to view this as having a very large contribution of anxiety. He was very fearful of the world. He had a very strong, what we call a threat belief, which is typical of anxiety disorders.

He was worrying. He was anticipating harm. And he was putting up the defenses so that actually he was protecting his fears. So for me, it was the root in the first research I did. Actually, the first research I did was, I measured levels of worry, people with severe paranoia and found they were very high. And that sounds unsurprising. But actually, that was the first time anyone had measured levels of worry in people with psychosis, because it was thought that worry was a problem of anxiety depression, psychosis, something completely different. So people didn't even measure levels of worry in our patient. But of course, if you do have worry and you have some fears, this is going to make everything worse. It elaborates the content, it bringing images to mind, mix it, you

play on your mind all the time. So worry was one. Another one I've done a lot of research on her out, which I didn't even mention yet, is that poor sleep. And again, it was ignored in our clients. Everyone was kind of aware our patients didn't sleep very well. It was just thought, well, that's the consequence of it all. But actually, and again, it's not really surprising. if you sleep badly, it makes you anxious, it makes you more miserable and affects your judgments of the world. So do a lot of work now treating sleep problems in people with psychosis. We can definitely treat the sleep problems and that brings down the heat of the situation is lessens the paranoia to a degree. It's not the only thing, just like worry isn't the only thing,

but you could do a whole range of things to calm the temperature down a little bit and enable the person to then think and you and then find out and you how the world is now. For people who might be on the border line where they're anxious and they worry a lot and maybe they're in danger of falling into a level of early paranoia, what can they do to prevent it? Are there any sort of mental exercises, things that you would recommend that people could do to ward off and maybe to stop the rumination that makes everything worse? Yeah. I think there's some, I mean, these cut across most mental health conditions, really. I think it's pay attention to sleep. It is about reducing worry and it probably is building up self-confidence.

Those are three big ones. The worry stuff really, I mean, it's a very understand people worry when they feel frightened because they feel worry protects people, keeps them safe. And really actually worry just skews the worldview. And it's much better to limit the amount of time worry, perhaps using problem solving. But most importantly, and again, this is crucial, just making sure you're doing meaningful activity that you have less time on your own ruminating because that's not good for any of us.

So if you can try and share your ideas with someone you trust so you're able to speak them aloud rather than having to turn them in your head all the time, we just write them down just to get them stopping for them and sort of rolling around in your mind and spending too much time on them, get engaged in factivity, try and get good sleep. Also just try and actually go back to all the good qualities we have and make sure we're putting them in action.

So, I mean, and I think those things are good across mental health conditions, really. Try not to spend too much time in your thoughts, certainly not in the nighttime in the early hours, which often we all do, but that's just not a good way to solve things. If you really want to worry, fine, but just keep it to a much smaller portion of your day. Problem solving is better, and what's even better is actually really being engaged in stuff that is meaningful and purposeful for you. For people who have a clinical level of paranoia, is there any self-awareness that maybe what they're thinking is unrealistic? I mean, is there some way of getting people to

understand that, no, everybody is not looking at you, the world is not out to get you? Yes. I mean, I think clinically it varies. So for some people, what we call the degree of convection in the beliefs, how strongly they believe it? We might say, how strong you do believe it to not 100%. Not a percent I don't believe at 100%. I believe it absolutely. Some of our patients, it might be around 50 or 60 percent, but go up in particular moment. But some patients who will sell, they'll say, I believe a thousand percent. And we can certainly get really good outcomes of the treatment, even if people have no awareness. But plenty of people do have an awareness, even at the high extent that it's dominating their lives too much,

that this is taking up too much headspace. And the way in for our treatment is really sometimes just recognizing this is tough. It's taking up all your headspace. You're not thinking about all those other things you'd like to be doing in life. And it's making you anxious and you're not sleeping so well. So maybe we can work on that a little bit. And then as we work with people, we might then do exercise. is, you know, is it better to stay in your room while we're in, let's try that for a few hours,

or go out for a walk. So we test that out and see which is better. And while we're not making a big song and dance about that stage, the person while they're out on a walk might go, that was quite nice that walk. And I saw some people, and it was okay. So you're allowing the person to have some experiences a bit more positive. And later on, we'll, we do make that very clear. We're looking at the signs of safety and we're trying to work out where the safety is in the world now. but there's lots of lots of things we could do. But clearly for some people, there are difficulties engaging with help, and that's half for the person, but also half for the people around them

who would like them to talk to someone and get help, and that really can be difficult. But for us, generally, it would be less saying going get help for your paranoia, because that may not go down so well as a label. And often the words we're using and worries about other people, but we might be saying, well, these are having effects on the things you do, on your mood, relationships,

so maybe that's worth checking in with someone about. So what are you working on now? What are the big questions you're still trying to answer? Oh, lots of things. Lots of things. We're doing a very large study

treating sleep problems in patients with severe mental problems, this idea that we can improve sleep a lot, that's great in the cell, but also that will less problems like paranoia. We're doing another large clinical trial testing,

feeling safer, which is our guided online program, which is basically putting our really good face-to-face therapy into guided form online. So that's about accessibility. We're doing some VR work, treating low self-esteem in people with psychosis. Basically, my team does a lot of work. We do a lot of work trying to develop the understanding of problems like paranoia, using that knowledge to develop better treatments and then trialing it. And then also work around getting it out there into services,

someone that is in training or some of it is in models of delivery that actually perhaps rely, less on a therapist but more on the person having more control. What is always learning, you know, we're evolving people with who've had or have severe paranoia in our research and they contribute a lot to working out what's important to research and how to do it. So we have a lot of lived experience advisors. It improves the quality of our work and the purpose of it. So we're focused really and trying to develop really good psychological therapies and get them out there. And there's lots of work to be done on that.

Dr. Freeman, I want to thank you for joining me today. This has been really interesting. You can find previous episodes of Speaking of Psychology on our website at speakingofpsychology.org or on Apple, Spotify, YouTube, or wherever you get your podcasts. And if you like what you've heard, please subscribe and leave us a review. For those of you who want to know more about psychology and the work of the American Psychological Association, you can join us as a supporter. You don't have to be a psychologist. The benefits include a subscription to our award-winning magazine, monitor on psychology, as well as discounts on books and other publications. So psychology is your passion, or if you just want to know more about the science,

you can become a supporter by visiting at.ap.a.org slash speaking. That's at.a.a.org slash speaking. If you have comments or ideas for future podcasts, you can email us at speaking of psychology at APA.org. Speaking of psychology is produced by Lee Winerman. Thank you for listening. The American Psychological Association, I'm Kim Mills. Relax and let Ralph's delivery handle your grocery shopping this week.

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