How to handle paranoid thoughts

Antonella Trotta

is a clinical psychologist and psychoanalyst. She is a senior lecturer at the University of Essex in the UK, and teaches on mental health and clinical interventions. Her research interests include psychosis, trauma, developmental risk and protective factors in young adulthood.

Edited by Matt Huston

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Need to know

After a stressful morning at work, Jamie enters the canteen for lunch and looks around for colleagues. Across the room, two women begin to whisper. Although Jamie can’t hear what the women are saying, she has a strong feeling that it’s about her.

B and their partner L are invited to celebrate a friend’s birthday. At the party, B feels uncomfortable that L is chatting with other people sitting next to them. Once at home, B sits in silence and looks angry. L asks what is going on, and a verbal conflict ensues.

‘Are you looking at me?’ Sam asks another passenger on the bus. Sam is frightened and thinks the person is spying on him.

In my work as a clinical psychologist and psychoanalyst, I have heard many people describe suspicious thoughts and feelings about strangers, colleagues, friends or family members. These experiences can be deeply alienating. Mr J, whose distrust and suspiciousness led him to cut off meaningful relationships he’d had, recently described to me his feeling of ‘being alone against the world’.

There are certain times and situations in which being wary of the intentions of others can be an adaptive response. And someone can, of course, have legitimate reasons for feeling suspicious and under threat. For example, experiencing discrimination or witnessing violence can shape a person’s beliefs about other people and whether they can feel safe in the world. But when one suspects a threat based on little or no evidence, and when patterns of suspicious thinking become persistent and distressing, or affect a person’s daily functioning (as they did for Mr J), those are signs of a problem with paranoid thinking.

Paranoia has been defined by the psychologist Daniel Freeman and his colleagues as an unfounded fear that other people intend to cause one harm. Typically, a person can distinguish between the sense of threat that comes with facing real danger from what one feels when anticipating potential danger. When someone is struggling with paranoia, that distinction becomes blurred, and the person experiences a recurring state of alert.

There are many ways in which paranoid thinking can manifest. Some common forms include:

fearing that you are being watched critically and judged;
thinking that people are talking about you behind your back; or
feeling at risk of being attacked by others.

Paranoid thoughts exist along a spectrum. The severe end can include persecutory delusions, such as thinking that others are controlling your thoughts or that you are routinely being spied on. These highly distressing forms of paranoia affect a relatively small proportion of people, including those who experience psychosis as part of mental health conditions such as schizophrenia. But people can differ in the level of conviction with which they hold paranoid thoughts and the emotional impact on the person and on others around them.

In its less severe forms, paranoid thinking happens among a much larger portion of the general population – including people who do not suffer from a specific mental health condition. Indeed, it’s been estimated that at least 10 per cent of people regularly experience paranoid thoughts of some kind. It is common to have mild suspicious thoughts, such as thinking People are trying to bother me on purpose, or that you shouldn’t express your opinions to others for fear of being judged. More moderate paranoid thinking could include recurring worries about whether you can trust friends and colleagues, or thinking that, if other people knew more about you, they would use the information against you.

Are you wondering whether you have experienced such thoughts, or how to tell the difference between real threats and paranoid anxiety? In this Guide, I aim to help you understand whether certain thoughts count as ‘being paranoid’ or not – and, if so, how to handle them better. It’s beyond the scope of this Guide to focus on the most severe paranoid experiences (eg, thinking that others are plotting harm or controlling your thoughts); when dealing with such experiences, it is best for the individual or their loved ones to directly consult a healthcare professional (see the Learn More section below). The more common types of paranoid thoughts will be the focus here.

Paranoia has a variety of causes and risk factors

Both nature and nurture seem to influence a person’s predisposition to experiencing paranoia. Bullying, trauma and adverse life experiences such as neglect and abuse are all factors associated with paranoia throughout development. According to the stress-vulnerability model, life events such as violence or bullying may, for some, trigger the anticipation of danger and threat beliefs underlying paranoia. This might result in the development of an internal schema about the self, such as I am vulnerable, others are dangerous, and lead to the recurring states of elevated arousal and the search for hidden meaning (eg, hostile intent) that characterise paranoid thoughts. Social isolation, lack of sleep, drinking alcohol, and the use of cannabis or tobacco may also make paranoid thoughts more likely to occur.

Some researchers have suggested that paranoia reflects a person’s emotional concerns, particularly anxieties and worries about relationships. Social anxiety is significantly associated with paranoid thoughts. The stronger the anxiety one experiences in the presence of others, the more likely one is to avoid facing those situations that feel threatening. For example, fear of rejection or of feeling vulnerable might lead some people to think that others are talking negatively about them. If they increasingly avoid social situations, that threat belief goes unchallenged and is more likely to persist.

Through years of clinical practice, I have noticed that when the overall level of anxiety a person feels is heightened – perhaps due to a stressful life event such as a job loss or a relationship breakdown – paranoid thoughts can become more likely. Paranoia can also exacerbate depressive feelings, and vice versa, leading to a negative spiral.

Alongside feelings of anxiety and depression, certain ways of thinking, or cognitive mechanisms, seem to be related to paranoia as well. Research suggests that individuals with a greater vulnerability to paranoia interpret ambiguous information more negatively than those with low vulnerability, a phenomenon called interpretation bias. This is in turn associated with greater levels of distress. For example, interpreting a stranger’s ambiguous stare as malicious is likely to support paranoid beliefs (eg, Most people don’t like me/are out to get me) and increase anxiety about being at risk of mistreatment. Many individuals with paranoid thinking patterns also tend to jump to conclusions based on limited information. These reasoning biases, together with a tendency to blame other people for negative events and/or a lack of flexibility in one’s thinking, can prevent someone from generating or considering alternative explanations for seemingly threatening experiences.

In the rest of this Guide, I will provide a series of steps to help you recognise paranoid thoughts when they appear, deal with those thoughts in a way that can alleviate psychic pain, and reduce the likelihood of paranoid thoughts reappearing. These steps are drawn from my clinical practice and work with people who have experienced paranoia, integrating different psychological models of understanding including cognitive behavioural therapy, acceptance and commitment therapy, and psychoanalytic approaches. With the exercises that follow, I invite you to learn more about your thinking and feelings with the aim of easing the distress that your thoughts might be causing you.

What to do

Notice potential signs of paranoid thinking

Identifying paranoid thoughts might seem like a difficult task to get started on, especially if you feel that there is good reason for feeling suspicious and threatened. However, there are some clues you can use to help you recognise when you might be engaging in paranoid thinking. These can include one or more of the following:

You have recurrent suspicions about others (eg, that they will cause you harm or exploit you, or already have) without having concrete evidence for your suspicions (such as being overtly harassed).
You feel untrusting and angry most of the time.
You often feel hypervigilant. Signs of hypervigilance include overreacting to noises or people around you, and recurrent feelings of being overwhelmed or worried that something negative is going to happen to you.

Developing more awareness of your thinking can help you to identify a paranoid thought when it comes up and to create some distance from it. The next time you are having a thought that involves someone threatening you or potentially causing you harm, simply notice your experience, without trying to change or control the thought – start by just accepting that you are having it. You can put your thought into words in this way: I am having the thought that… This initial step will help you to learn that your thoughts are different from judgments and actions.

Another helpful step for developing more self-awareness is to listen to the sensations coming from your body. How is your body responding in the here-and-now when you are having one of these distressing thoughts? Are there signals that you begin to notice? The fight-or-flight response – a physiological reaction that can include a quickened heartbeat, more rapid breathing, and tension in your jaw, shoulders or muscles – can occur automatically when you face any kind of experience that is stressful or frightening. It can be triggered by paranoid thoughts as well. The signs of a fight-or-flight response may help alert you that you are engaging in paranoid thinking.

Write down your thoughts and possible triggers

Start to keep a daily log in which you describe potential paranoid thoughts and related feelings. Focus on thoughts that involve a sense of threat or harm from others and that cause you distress.

For each description of one of your thoughts, you can also write down answers to these questions:

When did the thought appear?
How much did you believe the thought?
How worrying did you find it?
What are possible causes or triggers for the thought?
Are there other explanations or possible outcomes?

When you consider possible triggers, they might include things that affect your wellbeing or state of mind, such as not getting much sleep, or stressful events that happened during the day.

Here’s an example of what this might look like:

The thought: I had the thought that people were staring at my outfit and were making derogatory comments about me because they thought I looked stupid.
When it happened: when I was at my friend’s party.
How much I believed it: I believed it pretty strongly.
How I felt: it made me very anxious. It was like being on my own against everybody else in the room. I also felt angry. I felt like hiding so they wouldn’t notice me. It made me not want to go to parties any more.
Possible triggers: I noticed someone looking at me, with a smile. Also, I haven’t been sleeping well, and I had some glasses of wine.
Other explanations: the person might have liked my outfit; they might have wanted to approach me to have a chat.

Ask yourself about the evidence

If you’re not sure whether a distressing thought you’ve noted in the daily log is indeed a paranoid thought, it could be helpful to ask yourself some more questions about it. You could also begin these reflections in the moment, when the thoughts first come to mind. You might ask:

Is there any concrete evidence that supports the thought?
Is there any evidence against the thought?
Do I still have the thought despite reassurance from others?
What would I tell a good friend who was in the same situation?

For example, you might suspect that a stranger’s glance during a social gathering suggests that people there are negatively judging and talking about you – but upon reflection you realise that there is no clear evidence of any negative attitude in this ambiguous behaviour. And the fact that most people at the event have interacted kindly with you could be evidence against the thought that you were being judged. Perhaps your best friend has also told you that she hasn’t seen signs that anyone is judging or criticising you. If your friend was in a similar situation, having a similar thought, you might have even interpreted the situation in a more positive light than you have in your own case, reassuring your friend that the last time they went out, they managed well with meeting new people and had a good time. For the above reasons, you might reframe this thought so that the situation is not as threatening as you initially thought it to be.

As you consider the questions above and your answers, you can also write them down. You might want to carry the questions and answers with you so that you can look at them in the future when similar thoughts arise.

Slow down your thinking

I have described some of the thought processes involved in paranoia, including jumping to conclusions and interpreting ambiguous information in an overly negative way. A shared characteristic of these processes is fast thinking – a rapid succession of thoughts that can be difficult to hold in your mind and examine carefully. Racing thoughts that seem beyond your control can be distressing, especially if they include worries about your physical or psychological safety.

Slowing down one’s thinking has been found to reduce paranoia and help improve the quality of life for those who struggle with paranoid thoughts. When you notice your thoughts becoming faster and faster, like racing cars on a highway, you can try the following mindful breathing exercise (adapted from the NHS website) to help slow down your thinking:

Sit or lie down comfortably, relaxing your head and neck.
Place one hand on your upper chest and the other on your abdomen, just below your rib cage.
Breathe in slowly through your nose, counting for four seconds, letting the air in deeply.
Exhale through pursed lips to a count of four seconds. Repeat the breathing steps for a few minutes, or until you start to feel yourself becoming calmer.

After anchoring your awareness with your breathing, take a moment to concentrate on the present, the here and now. Focus your attention on the chair you are sitting on, the room you are in, the time of day. If you notice that your attention drifts away from the present moment, gently return again to being aware of your breathing.

Mindful breathing reduces the body’s stress response and promotes a feeling of calm, helping to quiet down or stop racing thoughts.

These exercises can also become part of a daily self-care routine. For example, you might decide to practise them for 10 minutes at the beginning and/or at the end of the day, or several times a day. Most people tend to have higher amounts of racing thoughts and worries when they wake up or when they go to bed. Starting the day by anchoring yourself in the present can help you to feel more grounded as the day unfolds.

Review habits and routines with potential triggers in mind

Since a lack of sleep and using alcohol or drugs can intensify paranoia, consider whether these factors might be playing a role in your thinking. For instance, after observing and taking note of recent situations in which you had what seem like paranoid thoughts (as in the previous example of the party), perhaps you notice a trend – eg, that distressing thoughts about being judged or threatened tend to happen more frequently when you have been drinking or using a drug. If that is the case, you could focus on managing the potential trigger by reducing or stopping your use.

Similarly, if paranoid thinking seems to follow a bad night’s sleep, you might want to find ways to work on that trigger by improving your sleep hygiene. This can include developing a consistent sleep routine, in which you aim to go to sleep and wake up around the same time every day. You could also avoid screen use before bed, and relax by taking a bath or reading a book prior to bedtime.

More generally, engaging in routine physical activity, eating and sleeping well on a regular basis, and immersing yourself in nature through walks or other outdoor activities can all help foster wellbeing and reduce stress over time, which could in turn reduce the risk of paranoid thoughts.

Stay connected and consider sharing your thoughts

Central in paranoia is the idea of an imminent threat, whether it is physical or psychological. One of the ways that people sometimes try to defend themselves from the perceived threat is to retreat, limiting or avoiding contact with others. However, this ultimately leads to isolation and loneliness, which in turn are known risk factors (and maintaining factors) for paranoia.

A sense of trust and safety with others is a fundamental factor in overcoming paranoid thinking. Though you might feel vulnerable or ashamed about your thoughts, or fear what the reaction will be if someone learns about them, sharing your thoughts with someone you can trust – such as a family member, close friend, or a psychologist or other healthcare professional – can help you increase your sense of being heard and understood. You might want to think about what you would like to share, as well as what feels, for you, like a confidential space and a safe way to communicate with a trusted person (whether that is face to face in a quiet room, by phone, or in writing).

If you decide to share with a trusted listener, try to be as honest and open as possible about your feelings and thoughts, as well as what your difficulties and needs are. You may also share what they could do to help you, including practical things such as going for a walk together, accompanying you to social situations that you find difficult to go to alone, or offering regular check-ins to ask how you are feeling. Sharing resources about paranoid thoughts with them, such as this Guide (or those in the Links and Books section below), might help them to better understand what you’ve been dealing with. It is also important to respect the other person’s boundaries, and to recognise that they may need some space at times, and that this is not the same as a rejection or negative judgment.

Being part of a group of people you regularly connect and communicate with (whether in person or online) can also help support your sense of belonging. You might explore the possibility of joining a group that meets to engage in a specific activity that you find interesting, such as a book club or exercise class. Self-help and support groups organised by local charities (see the Links & Books section below) can also provide an environment in which you receive encouragement and feel listened to – and hear about other people’s experiences and challenges, which you may find are both different and similar to yours.

Key points – How to handle paranoid thoughts

Paranoia is an unjustified fear that other people intend harm. It includes distressing, suspicious thoughts and feelings that can vary in severity.
Paranoia has a variety of causes and risk factors. Adverse life experiences may increase the risk of paranoia. Anxiety and certain cognitive tendencies (such as a bias toward negative interpretations) could also play a role, along with other factors.
Notice potential signs of paranoid thinking. These may include recurrent suspicions without concrete evidence to support them and frequently feeling untrusting or hypervigilant.
Write down your thoughts and possible triggers. Take note of when a suspicious thought appeared, how you responded, what might have contributed to it, and whether there were other ways of explaining the situation.
Ask yourself about the evidence. If you’re unsure if a thought is a paranoid one, consider whether there is clear evidence to back it up – and if there is evidence against it.
Slow down your thinking. Racing thoughts can feed into paranoia, but mindful breathing and a deliberate focus on the present can help calm them.
Review habits and routines with potential triggers in mind. Managing paranoia can include improving your sleep hygiene, reducing substance use, or other behaviour changes that promote wellbeing.
Stay connected and consider sharing your thoughts. Avoiding others could reinforce paranoia; being with and sharing with trusted people can help overcome it.

Learn more

If thoughts about being threatened or harmed are significantly disrupting your life – for example, if you are feeling a sense of severe persecution, or have repeated thoughts that people are trying to cause you significant harm or control you – this can be very distressing and isolating, and it is important to receive the right support. Speaking with a GP/primary care physician could be the first step to accessing appropriate help. They can conduct an initial consultation and refer you to a mental health specialist, such a psychotherapist and/or a psychiatrist. They might also recommend local support options that you can access if needed.

Therapy can be a valuable resource for exploring and working through experiences of paranoia. There are many therapeutic approaches out there. Cognitive behavioural therapy (CBT), metacognitive training, and cognitive remediation therapy (CRT) have each shown effectiveness in helping individuals who struggle with paranoid thinking. These approaches are designed to work on underlying beliefs, so that you can process information in a way that better promotes wellbeing. In CBT, for example, the therapist and the patient work together to try to make sense of, and review, the internal processes that lead to paranoid thoughts. Similarly, metacognitive training is a short-term treatment that focuses on ‘thinking about thinking’ and aims to increase awareness of the cognitive biases that are involved in the formation of paranoia. Cognitive remediation is a behavioural training intervention to improve attention, memory, executive function and social cognition.

Family or systemic therapies understand individual difficulties, including paranoid thinking, as part of a system of interpersonal relationships. They help explore individual strengths as well as social resources to create new perspectives on the challenge for both the individual and their family.

Longer-term approaches such as psychoanalytic or psychodynamic therapies can help you to take a deeper look into your thoughts and worries. In this type of therapy, the present moment of the therapeutic relationship (between the patient and therapist) becomes a vehicle for increasing awareness about the personal and interpersonal patterns that influence one’s daily life.

The choice to engage in therapy usually involves an initial consultation and assessment with a therapist, which can help orient you toward the type of work that is fit for you at that particular moment. If one of the above approaches sounds especially appealing, and you would like to contact a therapist directly for a consultation, you might want to check local therapists’ websites or online profiles to see whether they mention offering these types of therapy.

If you are interested in seeing a therapist privately in the UK and Ireland, the British Association for Counselling and Psychotherapy (BACP), the British Association for Behavioural and Cognitive Psychotherapies (BABCP) and the British Psychoanalytic Council (BPC) websites have lists of accredited therapists. In the US, the American Psychological Association offers a ‘Psychologist Locator’ for finding licensed clinicians. And Psychology Today’s directory includes information about local therapists in these and a number of other countries.

Links & books

In the UK, the charity Mind provides advice and support via its website to empower anyone experiencing a mental health problem. Some of the suggestions in this Guide are partly inspired by resources from Mind.

Rethink Mental Illness is another UK organisation that helps individuals to meet their mental health needs. Its website provides information on conditions and treatments, as well as guidance on accessing mental health services and support groups in England.

Clic is a free online community that supports adults in the UK with their mental health.

In the US, the National Alliance on Mental Illness (NAMI) offers free support groups for ‘any adult who has experienced symptoms of a mental health condition’. The organisation advises contacting the nearest NAMI affiliate, which can be found through its website.

The book Overcoming Paranoid and Suspicious Thoughts (2nd ed, 2016) by the longtime paranoia researchers Daniel Freeman and Philippa Garety, and the writer and editor Jason Freeman, offers an extended self-help guide on how to use techniques from cognitive behavioural therapy to deal with the experience of paranoia.

The website Paranoid Thoughts from the psychiatry department at the University of Oxford features personal accounts of paranoid thinking as well as useful tips and resources for coping with these thoughts.

For a visual walk-through of a mindful breathing exercise, see this animated video from Every Mind Matters, a campaign run by NHS England.