Explaining paranoia: cognitive and social processes in the occurrence of extreme mistrust
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Background: Paranoia—incorrectly thinking that others are deliberating trying to harm you—causes distress, undermines social interactions and leads to withdrawal. It presents across multiple psychiatric diagnoses. Objective: The primary aim was to determine the extent that cognitive and social processes may explain paranoia. The secondary aim was to identify explanatory factors that distinguished paranoia and social anxiety. Methods: 10 382 UK adults, quota sampled to match the population for age, gender, ethnicity, income and region, participated in a non-probability survey. All participants completed a paranoia measure and assessments of cognitive and social processes. Structural equation modelling was conducted. Findings: 2586 (24.9%) participants described being mistrustful of other people. 1756 (16.9%) participants wanted help to trust more. 66.7% of variance in paranoia was explained by a model comprising (in descending order of importance): within-situation defence behaviours, negative images, negative self-beliefs, discrimination, dissociation, aberrant salience, anxiety sensitivity, agoraphobic distress, worry, less social support, agoraphobic avoidance, less analytical reasoning and alcohol use. All explanatory factors were associated with paranoia and social anxiety. Ten factors were more closely associated with paranoia than social anxiety, including discrimination, hallucinations, negative images, aberrant salience and alcohol use. Nine factors were more closely associated with social anxiety, including less positive self-belief, an external locus of control, worry and less analytical reasoning. Conclusions: Multiple causes are likely to be involved in paranoia. Cognitive and social processes may explain a high degree of paranoia. Clinical implications: Multiple clear targets for intervention to reduce paranoia are identified.
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In a study of 22 cognitive and social causes of paranoia, all 22 causes were individually associated with paranoia.
“We found that all 22 causes were individually associated with paranoia, and in a combined model, 13 factors explained two thirds of the variance in paranoia.”
From A counterweight model for understanding and treating persecutory delusions. (2025) · cites this paper as Freeman & Loe, 2023
The 13 factors were: within-situation defense behaviors, negative images, negative self-beliefs, discrimination, dissociation, aberrant salience, anxiety sensitivity, agoraphobic distress, worry, less social support, agoraphobic avoidance, less analytical reasoning, and alcohol use.
“The 13 factors were: within-situation defense behaviors, negative images, negative self-beliefs, discrimination, dissociation, aberrant salience, anxiety sensitivity, agoraphobic distress, worry, less social support, agoraphobic avoidance, less analytical reasoning, and alcohol use.”
From A counterweight model for understanding and treating persecutory delusions. (2025) · cites this paper as Freeman & Loe, 2023
In a combined model, 13 factors explained two thirds of the variance in paranoia.
“We found that all 22 causes were individually associated with paranoia, and in a combined model, 13 factors explained two thirds of the variance in paranoia.”
From A counterweight model for understanding and treating persecutory delusions. (2025) · cites this paper as Freeman & Loe, 2023
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The Social Determinants and Focus of Clinical Delusions
Williams, D. R., Wilkinson, S., & Miyazono, K. (2026) · Oxford University Press eBooks · doi:10.1093/9780191976360.003.0009
Greenway, F. T., Weal, M. J., & Palmer-Cooper, E. C. (2026) · BMJ Open · doi:10.1136/bmjopen-2025-115399
Jeppesen, U. N., Vernal, D. L., Christensen, M. J., Pinkham, A. E., Veling, W., Hidding, M., Jensen, S. N., Austin, S. F., Nordentoft, M., & Glenthøj, L. B. (2026) · Schizophrenia Bulletin Open · doi:10.1093/schizbullopen/sgag028
Barak, A., Aktürk, B. E., Koç, A. E., & Kurt, A. (2026) · Psychological Reports · doi:10.1177/00332941261484076
Aslam, F., Saleem, S., & Zahra, S. T. (2026) · The Family Journal · doi:10.1177/10664807261483725
Widyasari, D. C., Kingston, J., Schlier, B., Clark, T., & Bentall, R. (2026) · Clinical Child Psychology and Psychiatry · doi:10.1177/13591045261494383
António, H., Gamito, P., Bouchard, S., & Pinto, R. (2026) · Social Sciences & Humanities Open · doi:10.1016/j.ssaho.2026.103901
- Authors
- Freeman, D., & Loe, B. S.
- Affiliations
- Oxford Health NHS Foundation Trust (GB)
- University of Cambridge (GB)
- Corresponding author
- Freeman, Daniel
- Venue
- BMJ Mental Health
- Publisher
- BMJ
- Published
- 2023-11
- Volume
- 26
- Issue
- 1
- Pages
- e300880
- ISSN
- 2755-9734 (ISSN-L)
- PMC
- PMC10649488
- OpenAlex
- W4388540215
- Cited by
- 55
- References
- 48
- Citations by year
- 2026: 28 · 2025: 21 · 2024: 6
- FWCI
- 11.20
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Licence
- Locations
- BMJ Mental Health (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- Apollo (University of Cambridge) (submittedVersion, cc-by-nc)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- HighWire Press Open Archive (submittedVersion)
- Funders
- NIHR
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
- Keywords
- paranoia, social anxiety, cognitive processes, social processes, discrimination, aberrant salience, negative self-beliefs, anxiety sensitivity, alcohol consumption, dissociation, locus of control, worry, social support, agoraphobic avoidance, hallucinations
- MeSH terms
- Adult, Anxiety, Anxiety Disorders, Cognition, Fear, Humans, Paranoid Disorders
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