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An episode of The Simpsons provided my first introduction to paranoia. The episode featured Bart going through what we would clinically call a substance-induced psychotic break. The not-so-clinical description would involve a comedy of a kid imagining all kinds of conspiracies linked to Major League Baseball leading him to steal a tank. I laughed.

Years later, when I faced my own experiences with paranoia I did not find things so funny. I found myself in a state of what could almost be described as terror. I am thankful to have recovered.

Among the work I have done as a psychotherapist, little has been more meaningful to me than that with people experiencing paranoia. Paranoia enters a person’s life as a cloud isolating them from others and hiding aspirations. Moving through that cloud in psychotherapy and watching a person reconnect to life is incredible.

Paranoia is a common, often disorienting, human experience. For most, thankfully, paranoia is transient. Yet, for some, paranoia takes deeper roots.

Chronic Paranoia

Those I have met experiencing chronic paranoia often express feeling lonely, afraid, and disconnected. It’s hard to know who to trust when you feel in danger. As well, relaxation and sleep require a sense of safety, which often evades the paranoid. It is a distinct kind of pain.

In terms of diagnosis, paranoia is most often seen in two classifications of mental disorders: Paranoid Personality Disorder and those disorders that involve an element of psychosis, such as Schizophrenia, Schizoaffective Disorder, and mood disorders with psychotic features. Of these, paranoia is most closely associated with Schizophrenia.

Paranoia in paranoid personality disorder tends to involve one’s relationships. There is a sense of distrust, rumination over past grievances, hypervigilance, and sometimes revenge-seeking behavior. At times it can be a precursor to a psychotic disorder, but for most the paranoia never reaches a level that would be aberrant enough to justify a diagnosis of such.

In the second cluster, psychosis, paranoia takes on a more unique, sometimes bizarre quality. In psychosis, paranoia could involve themes of conspiracy by government officials, law enforcement, or spiritual figures. The fixation breaks with consensus reality and into the world of delusion. For example, someone might believe that law enforcement is looking for them due to thought crimes or that the FBI is poisoning their food.

People will also sometimes do things in response that make little sense to those around them, such as hiding or throwing away all their food. It’s important to know that while these beliefs seem unreal to those around them, the perils are very real in the mind of someone experiencing psychosis and these behaviors make sense within their thought system. As paranoia drives a person to vigilantly protect what’s theirs, there is often an ironic pulling away, resulting in loss of opportunities, relationships, and joy.

Two Paranoias

Beyond diagnostic clusters, psychologists have identified two classifications of persecutory beliefs. Colloquially, these have been labeled "poor me" paranoia and "bad me" paranoia (Melo et al, 2006), based on whether or not the person feels deserving of the attack. Another way to understand these is as grandiose (poor me) and depressive (bad me) paranoia.

Grandiose Paranoia (Poor Me). A person experiencing grandiose paranoia feels undeserving of their plight and so their anger is a natural response. There is sometimes a link between this type of paranoia and grandiose delusions, like a belief of being on a special mission that someone is trying to sabotage. Grandiose paranoia tends to involve a single individual or a smaller group of individuals but is less likely to be global. For example, a person experiencing grandiose paranoia might believe that their neighbor is conspiring against them, but is less likely to feel that the entire town is in on it. The person might confront the individual(s) they see as threatening or take other steps toward revenge. In grandiose paranoia, the mood may be neutral or even manic. This is the most common type of delusion seen in individuals with bipolar disorder who are in a manic episode (Carlson et al, 2000). It is also common among individuals with schizophrenia spectrum conditions.

Depressive Paranoia (Bad Me). Similarly, in depressive paranoia, a person is more likely to hold a negative self-view and see themself as deserving of their circumstances. Fear, guilt, embarrassment, and sadness are natural responses. Depressive paranoia can manifest with beliefs that an entire group is engaged in a conspiracy, like a workplace or government, leaving few others on one's side. Deep guilt for a crime they believe has caused their struggle is sometimes part of the experience. The "crime" may be unrelated to the focus of their paranoia, such as having walked on sacred ground many years ago. With such guilt, social withdrawal is a common response. A depressed mood is typical. This is among the most common delusions in psychotic depression.

Treatment Options

For those experiencing clinical levels of paranoia, effective treatment is available. Recognition of the pattern of beliefs and those underlying one’s paranoia is important because that determines what course of treatment has the best chance of success.

With psychosis, a biological component is often relevant, so evaluation by and treatment with a psychiatrist is typically necessary. Psychotherapy can also play a key role in treating paranoia. Several approaches exist for these conditions, such as cognitive behavioral therapy, acceptance and commitment therapy, and radically-open DBT. These therapies can assist with reconnecting with the community, and a strengthened sense of self-efficacy. Many are able to overcome the holds of paranoia and achieve a full recovery.

Closing Thoughts

The thing about paranoia is that it tells you everyone else is out to get you, but what follows you closest is paranoia itself. By convincing you to isolate yourself it puts you in danger. It blocks your dreams and preoccupies your senses. Everything fades into anxiety, depression, and confusion.

I hope that someday we can create a world where people do not feel foolish to trust. We need to not laugh at the people with the tinfoil hats or feel sorry for them. Maybe we can realize that every one of us is in a way paranoid and striking a balance between autonomy, trust, and connection is at once the most difficult, and meaningful, task we have in life.