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Daniel Freeman
Cognition and perception, Mental health

‘The book is to help demystify paranoia‘

Our editor Jon Sutton hears from Professor Daniel Freeman (University of Oxford) about his new book ‘Paranoia‘.

26 January 2024

You wrote for us about paranoia 20 years ago… what would you pick out as the main change in the field during that time? 

I had recently finished my training as a clinical psychologist, and the article was describing our use of virtual reality to learn about the causes of paranoia. At that time cognitive-behavioural therapy for psychosis was really emerging. It showed – contrary to long-standing assumptions – that it was possible to talk successfully with patients about psychotic experiences. That was hugely important. It has meant that patients diagnosed with psychosis are now much more likely to be offered psychological therapy.

I saw CBT for psychosis as opening a door for psychological approaches for severe mental health difficulties. For me the key question was: what is the best way to work psychologically with psychotic experiences? My ambition was to develop a much more effective treatment for persecutory delusions. I have principally worked on that over the subsequent two decades. The result – the Feeling Safe programme – is a powerful treatment. Feeling Safe has been shown to bring large benefits for patients, beyond those that come only from a positive therapeutic relationship. Underlying this progress in treatment is a much better understanding of the causes of paranoia.

The application of virtual reality has come a long way too. VR was highly specialist software and hardware when I wrote the article. Now VR is consumer kit. My use of it has increasingly focused on developing automated VR therapies, in order to increase access to psychological treatments for patients. gameChange has become the first VR therapy to be recommended for use in the NHS. 

Do you feel differently about paranoia yourself now? For example, in how you recognise and respond to it in yourself and others?

There is still a lot to learn but my picture of paranoia has become less blurred. Treatment-wise I view the antidote to severe paranoia as the learning of safety. Recovery is finding genuine safety, or at least very low risk, in the person's life so that they can get back to meaningful activity. But there are a number of psychological processes that prevent the person from making that learning even when they are in places of safety, so those need sorting too.

My journey started with clinical paranoia, but it has also led me to see the ubiquity of mistrust in the general population. For instance, my team's work on vaccine hesitancy during the pandemic showed the contribution of conspiracy beliefs and how these have gone mainstream. Levels of trust, mistrust, and social disunion in the population really do matter.

Is paranoia at least in part a sensible response to an increasingly dangerous world? 

Real dangers exist and people do bad things to others. Recognising these facts is not paranoia. Knowing that safety can seldom be guaranteed is not paranoia. Reacting to real risks is not paranoia. Incorrectly, inaccurately, or excessively thinking that other people are trying to harm you is paranoia. 
In certain situations mistrust can be a sensible response. But it's a matter of degree: in the case of mistrust, 'the dose makes the poison'. I really like the old BBC television series Tinker Tailor Soldier Spy. In the book that the series is based on, John le Carré wrote 'Survival is an infinite capacity for suspicion'. But we can't live our lives like characters in a spy novel. And, in any case, it didn't help the character to whom le Carré gave this line, as he is betrayed by his best friend. Calm, measured, and flexible assessments of real risks are needed. As another espionage novelist, Graham Greene, put it: 'It is impossible to go through life without trust; that is to be imprisoned in the worst cell of all, oneself.'

What does paranoia have in common with various other mental health issues? What's the foundational structure? 

Built into diagnostic systems and psychiatric services is a great divide between neurosis and psychosis. Yet severe paranoia, typically seen as a major symptom of psychosis, may have some of its closest links with anxiety, a disorder of neurosis. At the heart of paranoia is a sense of vulnerability from which anxieties spring. Worry escalates the fears. Defensive reactions such as avoidance locks the fears into place. Sleep is worsened which makes everything seem worse. The reality is that there is a lot of shared causation across most mental health conditions. Indeed, it is most likely that in mental health conditions there is a complex interacting network of causes and symptoms at play. 

The chasm opened between psychosis and neurosis has been very limiting. One of the first studies that I carried out was to measure levels of worry in individuals with persecutory delusions and compare these to those in patients with generalised anxiety disorder, a condition in which worry is the defining feature. It is extraordinary that this was the first time that worry had been measured in a study with patients with psychosis; it hadn't been measured before because worry was considered a key problem of neurosis and, by implication, not psychosis. However, I found that the levels of worry in the patients with persecutory delusions was comparable to the patients with generalised anxiety disorder. This then led to treating worry in patients with persecutory delusions, using techniques from generalised anxiety disorder therapies, which led to the delusions reducing significantly too.

Your book is described as 'practical'. Can you give us a tip from it we might apply to our lives, whether we struggle with paranoid thoughts or not? 

Within the book is an explanation of how the Feeling Safe programme was developed and what would happen if you met myself and team for the treatment. Assessments that we use are included. Part of the point of the book is to help demystify paranoia. It's shown how paranoia shares many causes with many other common mental health problems. Indeed, paranoia shares causes with many things that generally lower our psychological wellbeing. So straight off I can think of six areas from the book to pay attention to improve psychological health: increasing self-confidence, limiting time spent worrying, improving sleep and circadian rhythms, reducing anxious avoidance, enabling distancing from troublesome thoughts, and engaging more in meaningful activity. That is even without mentioning the value of social connection, reflective reasoning processes, physical activity, and so forth!

What's the main lesson you've learned from people with paranoia, as a Psychologist? 

The time spent talking, discussing, and trying things out with patients experiencing paranoia is so valuable. There is still not a single meeting where I don't learn something new. One basic is not to assume without very good reason and to check things out directly. When I started various stages of my research there were so many assumptions in mental health care: that talking about psychotic experiences would typically make them worse; that many delusions were inexplicable; using virtual reality would make the paranoia worse; patients with the severest presentations could not improve with psychological therapy; that sleep problems were just a secondary consequence of psychosis; and so on. None of these held up when directly working with patients. Patients should not be underestimated.
As the book goes on, you pull back and up to consider some pretty wide-ranging societal issues, such as social cohesion. It's as if paranoia can be a lens through which we view our whole discipline of Psychology, the way we live, our future…

Trust and mistrust are central elements of being human that influence so much of our behaviour. I imagine we will see their importance as a number of countries go to the polls this year. Covid-19 was one pivotal moment. I think excessive mistrust, which thrives when social cohesion is frayed, is like an invisible corrosive eating away at individuals and society but this is not easily noticeable. Years before, with Richard Bentall, I had brought together a multi-disciplinary team to study conspiracy beliefs, but I think the funding bodies we went to had considered it too niche to support. But with Covid there would be a defining moment concerning trust: would people take a vaccine when it arrived? I linked up with the vaccine developers in Oxford, who knew vaccine hesitancy was an important issue. We showed how Covid conspiracy beliefs, general vaccine conspiracy beliefs, negative perceptions of healthcare professionals and services, and marginalisation were feeding into mistrust of the new vaccines that were the route out of the crisis. We also showed how messaging based on this understanding may help reduce hesitancy.

If you could go back in time to your Research Assistant days, would you still pick paranoia as your field?

Without hesitation. A number of things came together. I joined an amazing group of researchers who were talented, innovative, and serious (while also being wonderful company). It enabled me to learn so much about how best to approach mental health problems. Then there was the problem of paranoia itself, which is connected to so many other mental health difficulties and fundamental issues in clinical and research practice that it still always sparks challenges and new thinking. Most crucially there was the significant clinical need of the patient group and the obvious need to improve the treatments and services. The original title of the book – following a nickname given to me by a research assistant in my team – was Professor Paranoia, which probably answers the question quickest.

What do you think the future holds, for you and the field?

I feel like I am just getting going! Immediate priorities include testing a new six-month guided online version of Feeling Safe, designed to get this treatment to many more patients. We have been developing the programming for over a year with people with lived experience of paranoia and are very excited. It is called… Feeling Safer. Then there is the development of new automated VR therapies, which is another route to get excellent psychological help to many more people. We are currently testing Phoenix VR Self-Confidence Therapy, which we designed to improve positive self-beliefs and psychological wellbeing of young patients with psychosis. We now leave the VR headsets with patients so that they can work through the programme. There is also the complex work of getting the VR treatments we have already developed into services. In Sleeping Better we are conducting a definitive test of whether improving sleep for people diagnosed with psychosis or at ultra-high risk of psychosis can lead to multiple benefits in their lives. 

There is also the wonderful work of enabling the next generation of clinical researchers to use the methods that have been proving successful for paranoia to other psychotic experiences. Plus the pleasure of collaboration with people developing their own ways of improving outcomes for patients with psychosis. That is just a quick snapshot. There is a lot that needs to be done.

Paranoia book by Daniel Freeman


Paranoia: A Journey Into Extreme Mistrust and Anxiety, by Daniel Freeman, is published by William Collins Books on 1 February 2024 (£25).

The following extract is reproduced with their kind permission.

'I'm going to fall asleep here'

'I used to stay in bed trying to get some sleep for hours, things going through my mind. I used to wake up in the middle of the night and I used to get up very early in the morning as well.'

When I began investigating the relationship between sleep and paranoia back in 2008, it seemed to some a strange move. Indeed, a senior colleague at the Institute of Psychiatry warned that it could be a career-defining step (and not in a good way). 'You don't want to be doing all that non-specific stuff,' I was advised. In other words, focus on a particular disorder, rather than a difficulty that cuts across disorders and defines none. I knew very little about sleep problems. Even today they are given scant attention in clinical training programmes. But so many patients were telling me about their sleep difficulties that this 'non-specific stuff' seemed much more significant than that.

I was in no doubt that poor sleep was causing real distress and exacerbating other psychological problems. Patients reported crushing fatigue: 'I was shattered all the time.' One patient was so exhausted that they warned, right in the middle of a consultation, 'I'm going to fall asleep here.' Insomnia was wreaking havoc with their mood: 'I am more nervous and worried if I don't get sleep'; 'I was stroppy all the time'; 'I'm more agitated if I haven't slept for two or three days'. And it was preventing people from getting on with normal activities: 'It annoyed me, because I was just wasting time really being asleep all day'; 'It wasn't giving me enough time to do what I wanted during the day'; 'it was affecting my social life'. In a nutshell: 'When I'm tired, everything is worse'.

I began by trying to establish whether what I saw in clinic was truly representative. How common were sleep problems in people with persecutory delusions? And what about the general population: was there an association between insomnia and everyday paranoia? To find out, I recruited thirty patients being treated at the Maudsley Hospital, and three hundred local adults without a history of severe mental health disorder. As is often the way with early-stage research, there was no funding. So I tagged it on to other studies, collecting additional data to help decide whether I was on to something or not. It was not a surprise to discover that a large majority of the patient group (83 per cent) were getting insufficient sleep. Over 50 per cent reported clinical levels of insomnia and in more than half of those cases the problem was at the top end of the severity scale.

And the community group? Almost 30 per cent had symptoms of insomnia, with around 10 per cent scoring highly enough to indicate a possible clinical disorder. Moreover, the link between sleep problems and paranoia was unmistakeable. When I looked, for example, at the scores of those with the highest levels of mistrust, 60 per cent were above the threshold for clinical insomnia. In stark contrast, hardly any of those with the lowest paranoia scores reported significant sleep problems (just 8 per cent). Higher levels of insomnia meant higher levels of paranoia – probably because of the negative effect sleep problems have on mood.

A very similar picture emerged when I analysed data from the 2007 British Adult Psychiatric Morbidity Survey. As we saw in Chapter 4, the APMS isn't focused on people with mental health problems but instead covers a representative sample of 8,580 members of the English general public. It turned out that paranoia was at least twice as likely to occur in people with insomnia. And the worse the insomnia, the more severe the paranoia. The 6.6 per cent with chronic insomnia, for instance, were five times more likely to report that there had been times when they believed a group of people was plotting to cause them serious harm. It's the same story internationally. The World Health Organization's mammoth World Health Survey, carried out between 2002 and 2004, included 260,000 adults from seventy countries across the globe from India to Ivory Coast, Denmark to the Dominican Republic. On average, people with sleep problems were twice as likely to report paranoid thoughts.

I was pretty sure that this wasn't a coincidence, although with one-off studies like these one can't be certain. But my hunch that sleep problems might be actually causing mistrust was given a boost when I looked at responses to the first APMS. The initial round of interviews for that survey took place in 2000, with a subset of 2,382 participants assessed again eighteen months later. That allows us to see how things changed, and to infer – on the basis of hard data rather than supposition – what might lie behind those changes. Insomnia proved to be the strongest predictor of subsequent paranoia (alongside worry, which we'll get to in Chapter 11). Indeed, people who reported insomnia at their first assessment had 3.5 times the chance of later developing paranoia compared to those who had not.

My APMS work was the first longitudinal study of paranoia and insomnia – that's to say, the first analysis of their incidence and relationship over time. The results weren't proof of a causal link. But they strengthened my conviction that, if we could help patients with their sleep problems, it would be a lot easier to tackle their paranoia (and indeed other psychological problems they might be experiencing). We had to listen to what patients were telling us about this 'non-specific stuff' – and act upon it.