When Does Healthy Fear Cross the Line Into Paranoia?

"Paranoia is an interesting concept, both in terms of how it's made its way into the lexicon of current language and the meaning clinically," clinical psychologist Tamara McCintock Greenberg, Psy.D., author of "Treating Complex Trauma: Combined Theories and Methods," writes via email. "And the meaning has changed a lot over time."

Paranoia is generally defined as a thought process characterized by irrational suspicion or mistrust of others. There's a wide range of ways paranoia can show up, but people who experience it may feel like others are out to get them, or they may perceive they're in danger even though there's no clear threat. There are a lot of reasons why people can experience paranoia: dementia, drug abuse, and mental illness can all be characterized by it. But not every case of paranoia is clinical or cause for alarm — many people experience mild paranoia at some point in their lives.

"Freud initially thought of paranoia as a defense in which unwanted thoughts were managed by projection," Greenberg says, pointing out that the concept of "projection" involves having a negative internal thought that is so intolerable, a person attributes it to someone outside of themselves. "The classic example of this is related to aggression — 'I'm not angry or out to get anyone but others are angry and out to get me.' When we describe something as a 'defense,' we typically mean this as something we can all be capable of under certain stressful situations. For example, think of the last time you were really sleep deprived or even sick with a bad cold or flu and then something stressful happens at work. Any of us, under these conditions, could misconstrue and become overly wary about something innocent, like a remark made by a friend or something a boss said."

While just about everyone experiences paranoid thoughts at some point in their lives, paranoia that is problematic typically involves a high amount of stress or anxiety related to beliefs about others, a general mistrust of others, and feeling misunderstood, victimized, and/or persecuted.

"The primary symptom of paranoia that can be part of someone's personality is distrust or excessive interpersonal sensitivity to others," Greenberg says. "But to be clear, they may or may not use projection as a primary defense and this is one way our understanding of paranoia has shifted. Some people just tend to have a more suspicious personality style. And as you can imagine, there are people who function like this everywhere and it may not be an issue for them."

In fact, Greenberg says that people who tend to be more guarded can function just fine with a more cautious attitude, particularly if they're able to find careers and relationships that allow them to be who they are without judgment. "For example, if someone has a more guarded personality style, they probably won't do well in a career in which they have to deal with a lot of people," Greenberg says. "I recall one person I knew who was paranoid (not psychotic, but just a suspicious person) and they worked in sales. This was tough as they were always worried their clients were complaining about them."

When it comes to relationships, Greenberg says more wary people tend to either isolate or gravitate toward people who don't demand too much of them, interpersonally. Isolating isn't necessarily an issue if it doesn't negatively impact a person's quality of life, and being drawn to certain personalities isn't necessarily problematic either — but it can be. "For example a guarded person would not do well with a BFF that needs to talk every day, but they can have gratifying relationships with people as long as they don't feel too put upon or that they need to always be present for others in their lives," Greenberg says.

Social connection is important for everyone to some extent, but that contact can look different for every person. Greenberg says someone with a more suspicious character may choose to have fewer friends and/or choose not to have a partner (she does point out that there are plenty of other reasons people choose to remain single and this in itself should obviously not be pathologized). More cautious people may tend to space out their social interactions to stay comfortable — a once-a-month dinner may be way more preferable than daily check-ins and long, drawn-out chats.

Being careful and guarded is one thing, but when paranoia becomes pervasive and problematic, it's something very different. "People who have a more suspicious personality style are likely aware on some level that they are more guarded than others," Greenberg says. "People who are paranoid and psychotic have much more trouble being aware of the fact that they see things differently than others. The classic example is someone who really believes they are being followed by the FBI. There is no convincing them that this is not the case. To be clear, though it's easy to minimize the distress of people in these situations, they are often very distressed and anxious and endure a great deal of suffering. Paranoia of this kind can occur in schizophrenia and in delusional disorders. Paranoid delusions can also occur in some neurological disorders such as in some dementias. Sadly, paranoid delusions can severely disrupt life and functioning."

Paranoid personality disorder (PPD) is one example of intense paranoia that is no longer just a personality quirk but something serious. Paranoia is the essential characteristic that people with PPD all have in common, but the beliefs they hold aren't just run-of-the-mill cautionary ways of thinking. People with PPD often have unfounded beliefs and tend to blame and distrust others in ways that "interfere with their ability to form close or even workable relationships." The disorder usually begins in childhood or early adolescence and seems to be more common in men than in women. According to the Cleveland Clinic, PPD affects between 2.3 percent and 4.4 percent of the general population.

Unfortunately, clinical paranoia is tough to diagnose until the symptoms progress from mild to severe and because PPD often co-occurs with another mental health problem, like an anxiety disorder, obsessive-compulsive disorder (OCD), and depression, it can often be mistaken for something else.

Treatment can be challenging as well. "If someone is paranoid and severely mentally ill, it can be hard to get help, as the person will tend not to trust doctors, worry that medication may be harmful and they may come across as angry toward others," Greenberg says. "They may not even feel angry, but when someone is really paranoid, there are so many things in the environment they have to keep track of and this makes interactions with others difficult. For example, it's hard to have a conversation if you are wondering what someone might try to do to you, if you are being watched or followed or even what a slight change of expression on someone else's face might mean."