Paranoia is not simply synonymous with fear. It is yet another psychiatric term misrepresented/misunderstood by society at large that seeps into clinical work. More than once I’ve had to remind a student or supervisee that someone fearing the worst, like in anxiety, does not qualify as paranoia.

Though I just bashed pop culture for misrepresenting paranoia, there is a popular Vietnam-era song I’ve used to help people understand it.

Paranoia strikes deep goes the Buffalo Springfield song For What Its Worth. The 1966 hit is interesting not only because its a song in which the title doesnt appear in the lyrics, but it gives such an accurate description of the experience of paranoia.

Paranoia, defined:

The word paranoia is derived from the Greek, para, meaning beyond, or outside, and noos, meaning the mind. Translated, we arrive at out of their [right] mind, or a mind distracted. Like most psychological phenomena, paranoia exists on a continuum. It is familiar to most of us, though it was probably fleeting, situational and an appropriate response.

I felt it once, while camped out alone in a remote mountain campground in Oregons Cascades. Few were around and late in the day a couple pulling a camper arrived. The man came over and made small talk, though asked a lot of questions, some seemingly to probe for if I was alone. Becoming extremely wary, I kept my eye on them. No surprise I couldnt sleep; at about 1 in the morning the man exited the camper and muddled about their area. The vibe became stranger to me, and, heart in my throat, I disassembled camp in 5 minutes and fled. Given the circumstance, it was an adaptive psychological experience. I was alone, and their strange actions led me to perceive a threat, initiating the survival mechanism of fleeing. But what about people whose lives consist of regularly feeling something like my experience, even in the absence of obvious threat?

How it develops:

into your life it will creep, continues the tune. People who are pathologically paranoid didnt just have an experience like mine and it stuck. Paranoia is often of an insidious onset, whether it is related to PTSD, someones personality, or in delusional psychotic states. It could be weeks or months of evolution. Learning of the persons background, we often discover that paranoid ideas indeed creep into ones thought process until it fully colors their general view of things.

Paranoia’s three manifestations:


People with Post Traumatic Stress Disorder often suffer from hypervigilance. This means they’re acutely aware of their surroundings to be ready to fight or flee. For some, especially war veterans, hypervigilance can be so severe as to take on a paranoid flavor. Im reminded of Vietnam veterans who were chronically ambushed and how my uncle described, like the song goes, It starts when youre always afraid

Fear, a natural survival mechanism, becomes so honed from being chronically on that it takes on a life of its own, toppling into paranoia over time. Even the rustle of a breeze puts one on edge: Stop!whats that sound? Everything seemed a sign of impending ambush to him. Given the acute survival situation, this again is adaptive, albeit disturbing.

The problem is, for people who have been exposed to chronic, acute survival scenarios, the person cant just shut it off when the situation is over. Their limbic system, the survival piece of our brains, has learned being “on” is now essential to exist. Interestingly, under such chronic stress, the amygdala, an almond-sized and shaped structure (amygdala being Greek for almond) that is the seat of fear in our limbic system, actually expands abnormally. Coming home, the soldier remains stuck with a state of hypervigilance- acutely and distractingly aware of their environment and peoples actions; look whats [maybe about to be] going down. There is emerging evidence that an enlarged amygdala can be reduced, and with it, symptom acuity, especially via mindfulness activity. Whether a shrinking amygdala is wholly responsible for decreased symptoms remains to be seen. Regardless, the good news remains that we know mindfulness practice, grounding and relaxation skills can lower the amperage and the person can be coached into being less on edge.

Paranoid Personality Disorder

Another stage for persistent paranoia is someones personality. Personality has a lot to do with how we interact with others. When a persons interactional style is informed by acute suspiciousness of the motives and intentions of others, you can bet there may be a Paranoid Personality at hand. It is believed that Richard Nixons Paranoid Personality characteristics are what led to Watergate, exemplifying just how pervasive such suspiciousness can be.

Such individuals are prone to global, distorted thinking like the following:

  • Anyone wanting to get close to them is going to try to take advantage
  • Reading compliments as being buttered up for something
  • Perceiving casual comments as slights (e.g.Coworker: Nice tie, Adam! Adam: [inner voice] Whats that supposed to mean?!)

Many with such personality characteristics have an early background of abuse and learned to be mistrustful of anyone so as not to get hurt. Even sincere compliments are shunned; Compliments can be someones way of trying to get close to me. I dont swallow it. Back off! Thus, they retain an aloof aura, in order to keep others at a distance. Given their suspiciousness, people like this are not likely to enter treatment.

Psychotic Disorders

Lastly, we have delusional paranoia as seen in psychotic disorders like Schizophrenia or mood disorders with Psychotic Features. A delusion is a fixed, false belief that is held with conviction. You cant talk someone out of a delusion. It is their reality as much as the rest of us know the sky is blue. Paranoid delusions tend to take on themes of conspiracy, jealousy and persecution. The paranoia expert Ronald Siegel, Ph.D., in his landmark book Whispers: The Voices of Paranoia, succinctly describes an example of a paranoid delusional experience:

You draw the attention of the First Lady. She falls in love with you. Of course, she cannot make a definite avowal of her love, but she shows it in many silent, indirect ways. Her husband learns of her secret desires and lashes out at you. He sends in the FBI, the Secret Service, then the Mafia. You fight back with lawsuits against the government and the phone company

Clearly, this is the kind of out of their mind state the ancient Greeks were describing. Having interacted with people suffering like this, Ive been amazed at how others can become drawn into their reality, they discuss it so convincingly. Amazingly, reducing the neurochemical dopamine can deconstruct such thinking, and is what antipsychotic medications like Haldol, Zyprexa, and Abilify accomplish.

Treatment implications:

  • PTSD patients tend to welcome grounding techniques to learn to quell their amygdalar hypersensitivity.
  • A patient with delusional paranoia, given the excessive dopaminergic activity, will likely require a referral to psychiatry or inpatient care before they can be worked with in psychotherapy.
  • Paranoid Personalities rarely enter treatment given their extreme, global suspiciousness. However, therapists may recognize a patient is struggling with someone with Paranoid Personality characteristics and must help them navigate having such a person in their lives. Psychiatrist Stuart Yudofsky’s book Fatal Flaws has a section on evaluating and managing this condition.

Paranoia is an incredibly pervasive situation. It’s important to not only recognize the condition, but to quickly distinguish amongst its three faces in order to provide the most sound intervention.


Siegel, Ronald K. (1994). Whispers: the voices of paranoia. Simon & Schuster.

Yudofsy, Stuart. (2005). Fatal flaws: Navigating destructive relationships with people with disorders of personality and character. American Psychiatric Publishing, Inc.