Paranoia May Not Be What You Think It Is

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Paranoia is a common word that's commonly misunderstood.

"S/he's so paranoid!" can be heard in everyday conversation with the same incomprehension as saying someone is "OCD" because they're organized. Thus, paranoia has been reduced in popular culture to a synonym for cautious or apprehensive. Clinically, it's most popularly associated with schizophrenia, and a patient with baseline suspiciousness might be assumed to have this major mental illness. In fact, researchers have long told us that black males are at particular risk for misdiagnosis as paranoid schizophrenic (e.g., Whaley, 1998; Bolden et al., 2021; Khanolkar, 2022) when they're likely rightfully suspicious of those in authority, including healthcare providers.

The truth is, paranoia is more complicated than its use in popular culture, and can be much more subtle than schizophrenia. It is also not synonymous with conspiracy theorists.

Defining paranoia

Like most psychological phenomena, paranoia exists on a continuum. It is more than fleeting, heightened awareness, and not always of well-formed delusional proportions. The subtlety is such that one colleague quipped, "I can't necessarily describe it, but I know it when I see it."

The word "paranoia" is derived from the Greek para, meaning "beyond" or "outside" and noos, meaning "the mind." Literally translated, we arrive at “outside the mind,” or “a mind distracted.” While various thought processes, like anxious worry, depressive rumination, or intrusive thoughts of OCD are distracting, what differentiates paranoia, as put by psychoanalyst Nancy McWilliams (2013), is, "Paranoia intrinsically involves experiencing what is inside as if it were outside the self [emphasis added]." Hence, the ancient Greeks may well have understood projection, for true paranoia means externalizing an internal conflict; "outside the mind."

It's important to remember that because someone appears paranoid, their isolation, exhibiting suspiciousness, mistrust, and hypervigilance may be 100 percent rooted in reality. Consider those incarcerated for the first time, fleeing an abusive relationship, extricating themselves from cults or organized crime, or refugees taking illegal flight. Symptoms must always be contextualized.

The paranoia spectrum

The following are three examples on the paranoia continuum, from non-pathological, isolated experiences to psychotic episodes, to baseline personality characteristics. Clinical encounters can be anywhere in between. Between the benign, isolated incident and schizophrenia, there are reactive psychoses where, say, someone with no history of psychosis is placed in solitary confinement and develops situational-rooted psychotic delusions (e.g., Toch, 1992). On the other end, paranoid personalities can experience occasional, fleeting, delusional paranoia, especially in response to stressors (APA, 2022).

The isolated incident: To be sure, an isolated, fairly benign paranoid experience is likely not pathological. In fact, it is actually considered common in the general population (e.g., Carlin, 2010; Davies et al., 2021). For example, a patient, Cyrus (name disguised), returned to the gym. He said he was glad to be back, but mentioned seeing a neighborhood man, Gary, whom he held negative sentiment towards. Gary was known to use the main street as a drag strip, and his property was an eyesore to the Main St. community. Despite them never having had a personal exchange, Cyrus felt very defensive seeing Gary at the gym. Cyrus described, "I just know he’s got an attitude! I can feel him looking my way.” Looking closer, Cyrus' negative thoughts about his neighbor included glaring at Gary when he wasn’t looking, and a fantasy of confronting him. Cyrus came to realize he had projected his festering negativity towards Gary onto him, justifying his distaste.

Schizophrenic/psychotic paranoia: On the more pervasive end of the spectrum, there is persistent, well-formed, delusional paranoia. A delusion is a fixed, false belief held with conviction despite objective evidence to the contrary, and most common in schizophrenia-spectrum disorders or affective psychoses. Paranoid delusions tend to be very established and dictate the person's global experience. These paranoid experiences usually endure throughout schizophrenic or affective psychotic episodes, or, in the case of those with delusional disorder, perhaps in perpetuity (e.g. Wustman et al., 2010; Rowland et al., 2019). Delusions, no matter how bizarre, tend not to be some whimsical event, but germinate from internal conflicts. Defensive processes dictate they take on a life of their own, especially if genetic vulnerabilities are present; "nature cocks the hammer and experience pulls the trigger."

Greta (name disguised) sought treatment for anxiety. It quickly became clear that her angst was rooted in paranoia. At age 32, she was living at home since finishing college because of a seizure condition that violated her independence. Greta was convinced her parents were going broke, despite their upper-class status, and would abandon her. This scared her because of her dependence on them. She had frequent arguments with them for "not being honest" with her and would place tape recorders under their bed to spy on private conversations. Further, she harbored elaborate delusions regarding her mother persecuting her. Unfortunately, within a few months, Greta began following the directions of ever-increasing hallucinations, became grossly disorganized, and was hospitalized.

Speaking with her parents upon moving back home, Greta expressed feeling burdensome to the family's financial and emotional well-being. It can be safely surmised that Greta's delusions were a product of defensively projecting her self-persecution regarding her guilt of being burdensome; "I'm not the problem, they are."

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The paranoid personality: On a less-than-delusional/schizophrenic, but much more than incidental level, there is the paranoid personality. These individuals may be summarized as possessing a baseline pattern of suspiciousness regarding the motives and intentions of others. They may have grown up in an environment that encouraged a belief that, "People will invariably, intentionally, betray, take advantage of, or otherwise harm me. It always pays to be wary of others." Thus, people with paranoid personalities can have incredible difficulties in relationships. They may be aloof to keep others at bay, jealous and controlling in romantic partnering, and inordinately confrontational, leading to self-fulfilling prophecies that people do "have it out" for them.

Source: the blowup/Unsplash

Jane (composite identity) recounted her recent breakup with Mason. As their relationship deepened, she noticed Mason was not very revealing, and he sometimes misinterpreted her compliments as insults. She couldn't help but feel that Mason's "attentiveness" seemed to morph into an undercurrent of surveillance and over-protection. The relationship ended when Mason perceived a man at another table to be glancing at them, though he was paying attention to the nearby TV. Projecting his own aggression onto the man, he assumed he "had a problem." When the man walked by to use the bathroom, Mason caught his eye and the man asked if they knew each other. "You're gonna know me if you don't quit looking over here," Mason said. The situation escalated, with the man making threats, and thus Mason had put himself in actual danger.

Collective "paranoia" and conspiracy theorists

It was written in a 1964 Harper's magazine article that "the paranoid style in American politics" was nothing new, and "its targets have ranged from 'the international bankers' to Masons, Jesuits, and munitions makers." Thus, the ostensible paranoia of sociopolitical extremist groups today is only indicative of the ebbing of an old phenomenon. Though sometimes referred to as "collective paranoia" (e.g., Bajt, 2020; Liu, 2021), within groups it is likely more accurately termed "conspiratorial thinking" and not necessarily indicative of mental illness. As summarized by Greenbaugh and Raihaini (2019) paranoia can be differentiated from conspiracy theorists thus:

[Paranoid individuals and conspiracy theorists] also have many phenomenological features in common, including heightened tendency to attribute negative outcomes to malevolent agents and idiosyncratic pattern detection. Nevertheless, paranoia and conspiracy thinking also differ in key respects. Specifically, paranoid thoughts tend to be held in isolation and involve perceptions of harm to the self. Conspiracy beliefs, on the other hand, are shared by others and involve the perception of collective rather than personal harm.

Disclaimer: The material provided in this post is for informational purposes only and is not intended to diagnose, treat, or prevent any illness in readers or people they know. The information should not replace personalized care or intervention from an individual’s provider or formal supervision if you’re a practitioner or student.