Persecutory delusions: a cognitive perspective on understanding and treatment.
Open accessAbstract
A spectrum of severity of paranoia (unfounded thoughts that others are deliberately intending to cause harm) exists within the general population. This is unsurprising: deciding whether to trust or mistrust is a vital aspect of human cognition, but accurate judgment of others' intentions is challenging. The severest form of paranoia is persecutory delusions, when the ideas are held with strong conviction. This paper presents a distillation of a cognitive approach that is being translated into treatment for this major psychiatric problem. Persecutory delusions are viewed as threat beliefs, developed in the context of genetic and environmental risk, and maintained by several psychological processes including excessive worry, low self-confidence, intolerance of anxious affect and other internal anomalous experiences, reasoning biases, and the use of safety-seeking strategies. The clinical implication is that safety has to be relearned, by entering feared situations after reduction of the influence of the maintenance factors. An exciting area of development will be a clinical intervention science of how best to enhance learning of safety to counteract paranoia.
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Psychological processes linked with the problem of distress and dysfunctional behavior are cognitive fusion with internal experiences and maladaptive coping strategies such as experiential avoidance, thought suppression, and worry.
“Psychological processes linked with this problem are cognitive fusion with internal experiences and maladaptive coping strategies such as experiential avoidance, thought suppression and worry (66, 98–100).”
From Developing a mechanism-based therapy for acute psychiatric inpatients with psychotic symptoms: an Intervention Mapping approach (2023) · cites this paper as [66]
The Abstract and “A cognitive model of paranoia” identify worry and safety-seeking behaviours, including avoidance of feared situations, as processes that maintain persecutory delusions. The copy does not identify cognitive fusion, thought suppression, or experiential avoidance of internal experiences as such processes. No page numbers are available in the supplied passages. (LLM, conf=0.85)
Experimental — accuracy not yet measuredParanoia results when decision-making about trust skews excessively to the negative so that judgments are inaccurate.
“Paranoia is what results when that decision-making skews excessively to the negative so that judgments are inaccurate (Freeman, 2016).”
From A counterweight model for understanding and treating persecutory delusions. (2025) · cites this paper as Freeman, 2016
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Transdiagnostic Extension of Delusions: Schizophrenia and Beyond
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Adolescent Paranoia: Prevalence, Structure, and Causal Mechanisms
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Nightmares in the general population: identifying potential causal factors
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Describing the indescribable: A qualitative study of dissociative experiences in psychosis
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The Dunn Worry Questionnaire and the Paranoia Worries Questionnaire: new assessments of worry
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Virtual reality clinical-experimental tests of compassion treatment techniques to reduce paranoia
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Paranoia and conspiracy thinking
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Do depressive symptoms predict paranoia or vice versa?
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A compassionate imagery intervention for patients with persecutory delusions
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Excessive sleepiness in patients with psychosis: An initial investigation
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Belief Updating, Childhood Maltreatment, and Paranoia in Schizophrenia-Spectrum Disorders
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Trauma, Posttraumatic Stress, and Psychosis
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Cognitive appraisals of dissociation in psychosis: a new brief measure
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Body image concerns in patients with persecutory delusions
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Self-citationTheory of mind deficits partly mediate impaired social decision-making in schizophrenia
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A counterweight model for understanding and treating persecutory delusions.
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“…model we describe here was developed to guide both psychological understanding and treatment, and underlies the face-to-face Feeling Safe program (Freeman et al., 2016) and the guided online program Feeling Safer (Freeman et al., in revision), both of which have shown strong treatment effects.”
Ritunnano, R., Littlemore, J., Nelson, B., Humpston, C. S., & Broome, M. R. (2026) · The Lancet Psychiatry · doi:10.1016/s2215-0366(25)00341-4 · Cited by 14 · see citing works
Paranoia: From Passive Social-Threat Perception to Misattunement in Social Interaction
Hajdúk, M., Sasson, N. J., Park, S., & Pinkham, A. E. (2024) · Clinical Psychological Science · doi:10.1177/21677026231218639 · Cited by 14 · see citing works
- Authors
- Freeman, D.
- Affiliations
- Warneford Hospital (GB)
- Corresponding author
- Freeman, Daniel
- ORCID
- Freeman, Daniel
- Venue
- The Lancet Psychiatry
- Publisher
- Elsevier BV
- Published
- 2016-07
- Volume
- 3
- Issue
- 7
- Pages
- 685-692
- ISSN
- 2215-0366 (ISSN-L)
- OpenAlex
- W2460693432
- Cited by
- 356
- References
- 87
- Citations by year
- 2026: 52 · 2025: 44 · 2024: 39 · 2023: 48 · 2022: 37 · 2021: 25 · 2020: 25 · 2019: 36 · 2018: 28 · 2017: 16 · 2016: 6
- FWCI
- 4.09
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The Lancet Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institute for Health and Care Research (RP-2014-05-003)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- persecutory delusions, paranoia, threat beliefs, cognitive approach, delusion maintenance, reasoning biases, excessive worry, low self-confidence, safety learning
- MeSH terms
- Cognition, Delusions, Humans, Randomized Controlled Trials as Topic
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