Persecutory delusions are a symptom of psychosis that can occur within the context of several mental health conditions. Someone experiencing persecutory delusions will firmly believe that someone or something is intending to cause them harm, which can cause a great deal of anxiety and concern, and sometimes lead to other behaviors such as aggression.

What is a persecutory delusion?

Persecutory delusions are often experienced within the context of a psychotic episode, which can occur due to several mental health disorders, including schizophrenia, bipolar disorder, or a major depressive episode. Research suggests that 70% of people experiencing a first episode of psychosis have one or more persecutory delusions [1].

They are believed to be a symptom of severe paranoia, in which the person experiencing these delusions has a false belief that there is a threat to their safety or well-being [2]. This threat may arise from an internal or external experience, such as an emotion or environmental situation, which is then assigned meaning that confirms the delusion [3][4].

Persecutory delusions are often completely implausible ideas, such as a delusional belief that the mafia are watching and following you, but for the person experiencing these delusions, they feel real and entirely plausible.

Sometimes, people who experience these types of delusions are unable to understand or accept any alternative ideas that could suggest their delusion may be incorrect. They feel with complete certainty that these ideas are real, thereby maintaining their delusion and causing a persistence of persecutory ideas [5].

Because of the perceived threat experienced by people with persecutory delusions, they may sometimes act upon these ideas out of fear or protection. This can cause behaviors such as boarding up windows and doors to the house, avoiding any social interactions, or aggressive behaviors toward the source of the perceived threat [6].

Types of persecutory delusions

Persecutory delusions can occur in the context of several mental health conditions, including [7]:

Examples of persecutory delusions

Persecutory delusions can be based on any theme or idea relating to a perceived threat to personal safety [1][7]. Examples of persecutory delusions may include:

  • The CIA/MI5/mafia are watching me and intend to kill me
  • The birds outside my house are looking in the windows and listening to me, reporting back to the people who want to hurt me
  • People walking past me on the street are listening to my thoughts and laughing at me
  • People have broken into my house while I was sleeping and put poison in my milk

Causes of persecutory delusions

Research suggests that there are many causes of persecutory delusions, related to impaired information processing, emotional dysregulation, environment, and perceived vulnerability [3].

Mental well-being

Persecutory delusions are closely related to feelings of anxiety or depression. These conditions have been found to increase the risk of persecutory delusions occurring and are often exacerbated by these delusions, causing an ongoing cycle of persisting symptoms [8][9].

Self-esteem

Similarly, low self-esteem and negative thoughts about the self are also closely related to the occurrence of persecutory delusions and may arise in the context of a depressive episode [10].

People with low self-esteem may believe that they deserve criticism or rejection, thus expecting hostility from others. This can cause a feeling of vulnerability, which can lead to an increase in paranoid thoughts, such as believing and expecting harm will occur [1].

Worrying

People who are prone to worrying have a higher risk of going on to experience paranoia and persecutory delusions. Similarly, those who experience persecutory delusions have been found to often worry or ruminate on their thoughts. It is also believed that higher levels of worry can cause a longer and more persistent period of persecutory delusions [1][9].

Sleep disturbances

There is a great deal of evidence to show that a lack can sleep can cause an episode of psychosis and other serious mental illnesses [11]. In particular, paranoid thinking is closely related to disturbed sleep, such as insomnia, which is regularly experienced prior to the occurrence of persecutory delusions [12][13].

It is also likely that paranoia then worsens insomnia, by creating feelings of anxiety and depression, in turn exacerbating the persecutory delusions, creating a persistent cycle of symptoms [13].

Information processing

Previous studies show that people who experience delusions are more likely to jump to conclusions and are inflexible in the way they formulate beliefs [5].

Often, there appears to be an inability to demonstrate analytical reasoning by considering any alternatives to the delusion. Without gathering sufficient information or evidence, a strong belief will be formulated with complete certainty, and the persecutory delusion will be accepted as truth [14].

Substance use

Substances alter the way the brain works and can thus cause a change in perception, which may lead to a misinterpretation of internal or external experiences [1]. Many drugs have been found to increase the risk of paranoid ideation, particularly cannabis [15].

Trauma

Various studies suggest that trauma is linked to the development of psychotic symptoms and paranoid beliefs, indicating increased risks of persecutory delusions in patients who have experienced bullying, neglect, or abuse in childhood, trauma or assault in adulthood, or have a diagnosis of post-traumatic stress disorder (PTSD) [16][17][18].

Brain function

Currently, there is not a clear understanding of the specific relationship between neurobiology and persecutory delusions, but research does suggest a link between dopamine levels and the formation of delusions [19].

There is evidence to indicate that altered levels of dopamine can cause schizophrenia and other psychotic symptoms, further indicating that it may play a part in the development of persecutory delusions [20].

Genetics

As is the case in many mental disorders, genetics can increase the risk of developing paranoia and delusional ideation. Research suggests that a family history of psychosis increases the risk of psychotic disorders and symptoms in children, particularly paranoid thinking [21].

Treatment of persecutory delusions

Medication

Depending on the context in which the persecutory delusions are experienced, a doctor may prescribe a medication to help alleviate symptoms [22].

Antipsychotic medications are often used in the treatment of schizophrenia or episodes of psychosis to treat key symptoms such as hallucinations and delusions.

Mood stabilizers are used to treat certain psychiatric disorders such as bipolar disorder. These medications help reduce extreme mood changes, so they can aid in reducing the occurrence of persecutory delusions that occur during manic or depressive episodes.

Antidepressants may be prescribed to treat symptoms of depression, so they can aid in reducing negative feelings that may contribute to the occurrence of persecutory delusions.

Benzodiazepines may be prescribed to help alleviate symptoms of anxiety or to aid in improving sleep quality.

Therapy

Several types of therapy are available to help in managing mental health conditions and the appropriate therapy may differ, depending on the context in which the persecutory delusions are experienced and the occurrence of any other co-existing symptoms.

Cognitive behavioral therapy (CBT) may be extremely useful for someone who has a propensity to worry or experience negative thoughts about themselves [23]. CBT can help to alter negative thoughts and associated behaviors, teach positive coping strategies, and improve sleep, all of which can help to reduce the occurrence of persecutory delusions [24].

Other types of cognitive therapy can be useful in reducing persecutory delusions, such as programs that focus on specific causes of delusions and paranoid thinking, including sleep disturbances, worrying, low self-confidence, feeling unsafe, and impaired reasoning [14][25].

Psychotherapy can help in processing traumatic experiences, reducing anxiety, and gaining a better understanding of the underlying causes of persecutory delusions, which may then aid in reducing persistent symptoms [22].

How to help someone with persecutory delusions

If you are trying to help or support someone who experiences persecutory delusions, you can [22]:

  • Distract: it can be useful to try and distract the person from their thoughts, by engaging with them in something they enjoy, or talking about something else.
  • Help them feel safe: you may be able to do this by simply assuring them that they are safe.
  • Listen and talk: let them express their concerns and fears to you, as this can sometimes help to reduce the intensity of the fear. Ask questions or talk to them about their concerns, to validate their feelings and potentially reassure them.
  • Offer to attend therapy together: if it is appropriate, you could attend therapy with them, to reduce any anxiety they may be feeling about attending, or to help you better understand their experiences.
  • Empathize: show compassion and empathy of their feelings and experiences, as their fear feels very real to them, even if there is no real threat to their safety.
  • Respect their choices: do not try to make decisions for them or go against their wishes; as long as they are safe, try to respect the decisions that they make for themselves.
  • Know who to call: if there is an emergency, someone is in danger of being harmed, or you need professional intervention, know who to contact, such as their doctor or healthcare provider, or the emergency services.

Resources:

  1. Freeman, D., & Garety, P. (2014). Advances in understanding and treating persecutory delusions: A review. Social Psychiatry and Psychiatric Epidemiology, 49(8), 1179-1189. https://doi.org/10.1007/s00127-014-0928-7
  2. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Washington, DC: American Psychiatric Association.
  3. Bentall, R.P., Corcoran, R., Howard, R., Blackwood, N., & Kinderman, P. (2001). Persecutory delusions: A Review and Theoretical Integration. Clinical Psychology Review, 21(8), 1143-1192. https://doi.org/10.1016/s0272-7358(01)00106-4
  4. Freeman, D., Garety, P.A., Kuipers, E., Fowler, D., & Bebbington, P.E. (2002). A cognitive model of persecutory delusions. The British Journal of Clinical Psychology, 41(Pt 4), 331-347. https://doi.org/10.1348/014466502760387461
  5. So, S.H., Freeman, D., Dunn, G., Kapur, S., Kuipers, E., Bebbington, P., Fowler, D., & Garety, P.A. (2012). Jumping to conclusions, a lack of belief flexibility and delusional conviction in psychosis. Journal of Abnormal Psychology, 121(1), 129-139. https://doi.org/10.1037/a0025297
  6. Coid, J.W., Ullrich, S., Kallis, C., Keers, R., Barker, D., Cowden, F., & Stamps, R. (2013). The relationship between delusions and violence: Findings from the East London first episode psychosis study. JAMA Psychiatry, 70(5), 465-471. https://doi.org/10.1001/jamapsychiatry.2013.12
  7. Kiran, C., & Chaudhury, S. (2009). Understanding delusions. Industrial Psychiatry Journal, 18(1), 3-18. https://doi.org/10.4103/0972-6748.57851
  8. Freeman, D., Startup, H., Dunn, G., Wingham, G., Černis, E., Evans, N., Lister, R., Pugh, K., Cordwell, J., & Kingdon, D. (2014). Persecutory delusions and psychological well-being. Social Psychiatry and Psychiatric Epidemiology, 49(7), 1045-1050. https://doi.org/10.1007/s00127-013-0803-y
  9. Freeman, D., Stahl, D., McManus, S., Meltzer, H., Brugha, T., Wiles, N., & Bebbington, P. (2012). Insomnia, worry, anxiety and depression as predictors of the occurrence and persistence of paranoid thinking. Social Psychiatry and Psychiatric Epidemiology, 47(8), 1195-1203. https://doi.org/10.1007/s00127-011-0433-1
  10. Smith, B., Fowler, D.G., Freeman, D., Bebbington, P., Bashforth, H., Garety, P., Dunn, G., & Kuipers, E. (2006). Emotion and psychosis: Links between depression, self-esteem, negative schematic beliefs and delusions and hallucinations. Schizophrenia Research, 86(1-3), 181-188. https://doi.org/10.1016/j.schres.2006.06.018
  11. Ford, D.E., & Kamerow, D.B. (1989). Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? JAMA, 262(11), 1479-1484. https://doi.org/10.1001/jama.262.11.1479
  12. Freeman, D., Pugh, K., Vorontsova, N., & Southgate, L. (2009). Insomnia and paranoia. Schizophrenia Research, 108(1-3), 280–284. https://doi.org/10.1016/j.schres.2008.12.001
  13. Freeman, D., Brugha, T., Meltzer, H., Jenkins, R., Stahl, D., & Bebbington, P. (2010). Persecutory ideation and insomnia: Findings from the second British national survey of psychiatric morbidity. Journal of Psychiatric Research, 44(15), 1021–1026. https://doi.org/10.1016/j.jpsychires.2010.03.018
  14. Waller, H., Freeman, D., Jolley, S., Dunn, G., & Garety, P. (2011). Targeting reasoning biases in delusions: A pilot study of the Maudsley review training programme for individuals with persistent, high conviction delusions. Journal of Behavior Therapy and Experimental Psychiatry, 42(3), 414–421. https://doi.org/10.1016/j.jbtep.2011.03.001
  15. Freeman, D., Dunn, G., Murray, R.M., Evans, N., Lister, R., Antley, A., Slater, M., Godlewska, B., Cornish, R., Williams, J., Di Simplicio, M., Igoumenou, A., Brenneisen, R., Tunbridge, E.M., Harrison, P.J., Harmer, C.J., Cowen, P., & Morrison, P.D. (2015). How cannabis causes paranoia: Using the intravenous administration of ∆9-tetrahydrocannabinol (THC) to identify key cognitive mechanisms leading to paranoia. Schizophrenia Bulletin, 41(2), 391–399. https://doi.org/10.1093/schbul/sbu098
  16. Freeman, D., Thompson, C., Vorontsova, N., Dunn, G., Carter, L.A., Garety, P., Kuipers, E., Slater, M., Antley, A., Glucksman, E., & Ehlers, A. (2013). Paranoia and post-traumatic stress disorder in the months after a physical assault: A longitudinal study examining shared and differential predictors. Psychological Medicine, 43(12), 2673–2684. https://doi.org/10.1017/S003329171300038X
  17. Soosay, I., Silove, D., Bateman-Steel, C., Steel, Z., Bebbington, P., Jones, P.B., Chey, T., Ivancic, L., & Marnane, C. (2012). Trauma exposure, PTSD and psychotic-like symptoms in post-conflict timor leste: An epidemiological survey. BMC Psychiatry, 12, 229. https://doi.org/10.1186/1471-244X-12-229
  18. Bentall, R.P., Wickham, S., Shevlin, M., & Varese, F. (2012). Do specific early-life adversities lead to specific symptoms of psychosis? A study from the 2007 adult psychiatric morbidity survey. Schizophrenia Bulletin, 38(4), 734–740. https://doi.org/10.1093/schbul/sbs049
  19. Mishara, A.L., & Fusar-Poli, P. (2013). The Phenomenology and Neurobiology of Delusion Formation During Psychosis Onset: Jaspers, Truman Symptoms, and Aberrant Salience. Schizophrenia Bulletin, 39(2), 278–286. Retrieved from https://doi.org/10.1093/schbul/sbs155
  20. Howes, O.D., & Kapur, S. (2009). The Dopamine Hypothesis of Schizophrenia: Version III - The Final Common Pathway. Schizophrenia Bulletin, 35(3), 549–562. Retrieved from https://doi.org/10.1093/schbul/sbp006
  21. Zavos, H.M., Freeman, D., Haworth, C.M., McGuire, P., Plomin, R., Cardno, A.G., & Ronald, A. (2014). Consistent etiology of severe, frequent psychotic experiences and milder, less frequent manifestations: A twin study of specific psychotic experiences in adolescence. JAMA Psychiatry, 71(9), 1049–1057. https://doi.org/10.1001/jamapsychiatry.2014.994
  22. Paranoia. (2020). Mind. Retrieved from https://www.mind.org.uk/information-support/types-of-mental-health-problems/paranoia/treatment/
  23. Freeman, D., Dunn, G., Startup, H., Pugh, K., Cordwell, J., Mander, H., Černis, E., Wingham, G., Shirvell, K., & Kingdon, D. (2015). Effects of cognitive behaviour therapy for worry on persecutory delusions in patients with psychosis (WIT): A parallel, single-blind, randomised controlled trial with a mediation analysis. The Lancet Psychiatry, 2(4), 305–313. https://doi.org/10.1016/S2215-0366(15)00039-5
  24. Foster, C., Startup, H., Potts, L., & Freeman, D. (2010). A randomised controlled trial of a worry intervention for individuals with persistent persecutory delusions. Journal of Behavior Therapy and Experimental Psychiatry, 41(1), 45–51. https://doi.org/10.1016/j.jbtep.2009.09.001
  25. Freeman, D., Emsley, R., Diamond, R., Collett, N., Bold, E., Chadwick, E., Isham, L., Bird, J.C., Edwards, D., Kingdon, D., Fitzpatrick, R., Kabir, T., Waite, F., & Oxford Cognitive Approaches to Psychosis Trial Study Group. (2021). Comparison of a theoretically driven cognitive therapy (the Feeling Safe Programme) with befriending for the treatment of persistent persecutory delusions: A parallel, single-blind, randomised controlled trial. The Lancet Psychiatry, 8(8), 696–707. https://doi.org/10.1016/S2215-0366(21)00158-9