Paranoia and Persecutory Delusions: A Care Staff Guide

Someone tells you the staff are putting something in their food, a neighbour is watching them, or a relative has stolen from them. How you respond in the next few minutes can make the difference between a person who feels listened to and one who feels more threatened. Paranoia is common across mental health, dementia and neurological care, and it is more often a symptom than a diagnosis in its own right.

What is paranoia?

Mind describes paranoia as feeling threatened or suspicious even when there is little or no evidence of a threat. Paranoid thoughts are sometimes called delusions and range from mild, short-lived suspicions to severe, persistent beliefs that other people intend harm. Mind stresses that paranoia is a symptom of some mental health problems, not a diagnosis. Common themes include being talked about, watched or excluded, fear of being harmed, robbed or controlled, believing others use hints or double meanings to threaten or upset, and believing that the government or an organisation is targeting you.

Paranoid thoughts or justified suspicion?

Mind explains that thoughts are more likely to be paranoid if no one else shares them, there is little or no evidence for them, the evidence points against them, or they persist despite reassurance. Justified suspicions are based on real evidence, such as crime in the area or discrimination the person has experienced, and they can help keep people safe. Deciding which is which can be hard. Staff should always check whether there is a real problem before assuming a belief is a symptom, for example whether belongings really have gone missing or whether a safeguarding concern might be behind the worry.

How common is it, and what causes it?

Mind states that up to a third of people may experience mild, non-clinical paranoia at some point, while severe paranoia, also called clinical paranoia or persecutory delusions, is more likely to need treatment. No single cause is known. Mind lists stress, isolation, trauma or bullying, childhood experiences that make a person mistrustful, anxiety, depression, low self-esteem, lack of sleep, recreational drugs and alcohol, and physical illnesses such as dementia, Parkinson's, stroke and hearing loss. Our guides to psychosis and schizophrenia and schizoaffective disorder cover conditions where paranoia is a core symptom.

Why safety behaviours can backfire

Mind notes that avoiding people or staying indoors can feel protective but may reinforce paranoia over time and can lead to isolation, anxiety and low mood. Staff can gently support activity and contact while respecting how frightened the person feels.

How to respond in the moment

• Take the fear seriously. Mind advises taking the person's fear seriously even if you do not share their beliefs.
• Focus on feelings. Acknowledge that the person feels scared or unsafe, and offer reassurance and distraction.
• Do not argue or collude. Avoid insisting the belief is wrong, and avoid agreeing that it is true. Stay calm, curious and respectful.
• Check for real causes. Rule out genuine problems, pain, infection, delirium, hearing or sight loss, and medicine side effects.
• Keep safe. If the person is frightened, aggressive or at risk of harming themselves or others, follow your procedures and call for help.

Treatment

Mind says the first step is to see the GP. Cognitive behavioural therapy is the most common talking therapy for paranoia, helping people examine the evidence for their beliefs and consider other interpretations. Other options include psychodynamic therapy, counselling, family therapy and arts therapies. Antipsychotics are usually offered for paranoid schizophrenia or delusional disorder, and antidepressants or minor tranquillisers may be offered for co-occurring anxiety or depression. Virtual reality combined with CBT is being researched.

Self-help and peer support

Mind suggests keeping a diary of thoughts, triggers, sleep and how strongly the person believes each thought, questioning suspicions by looking at the evidence for and against them, talking to someone trusted, and trying peer support. Mindfulness, relaxation, regular sleep, exercise, time in nature and creative activities may help, and Mind says mindfulness has some evidence for reducing mild paranoia.

Recording and care planning

Record what the person says in their own words, when it happens, what seems to trigger it and what helps. Share the record with the clinical team. Include in the care plan how staff should respond, who the person trusts and what to do if fear escalates. Involve family where the person agrees, and review the plan after any change in health or medicine.

When to seek urgent help

Mind advises seeking help if paranoid thoughts cause distress or interfere with daily life. If someone may be in crisis, encourage them to use their crisis plan and contact emergency services if needed. The Samaritans are available 24 hours a day on 116 123. Our guide to suicide and self-harm awareness explains how to respond if someone talks about harming themselves.

Looking after yourself

Mind notes that supporters should look after their own wellbeing. Share difficult conversations with colleagues, ask for supervision, and use carers' groups or staff support. Learnsignal's CPD library can help teams plan learning on psychosis and mental health.

Frequently asked questions

Is paranoia the same as psychosis? No. Paranoia is a symptom that can occur in psychosis and other conditions, and mild paranoia can occur in many people.

Should we tell someone their belief is wrong? Arguing usually increases fear. Acknowledge the feeling, check for real causes and refer to the clinical team.

What treatment helps? According to Mind, CBT is the most common talking therapy, and antipsychotics are usually offered for paranoid schizophrenia or delusional disorder.