Persecutory Delusions

1. Overview — What Are Persecutory Delusions?

Persecutory Delusions are false beliefs detached from reality whose core theme is:

“Someone / some group / some organization is watching me, trying to harm me, bully me, control me, or destroy my life.”

What makes this a delusion and not just “overthinking” or ordinary “suspiciousness” has several layers:

It is a belief that clearly contradicts the facts — there is no real evidence to support it, or any existing evidence can be reasonably explained in other ways, but the person chooses to believe only the version of reality that says “they’re out to get me.”

It contradicts the view held by most people in the surrounding society — it is not something that everyone in the family/community already believes together (such as a shared religious belief or cultural worldview). It is a belief “held alone,” standing apart from the group.

The person believes it 100% and refuses to shift even in the face of contradicting evidence — when others bring counter-evidence such as CCTV footage, medical reports, lab results, the person still insists:

“No, they faked the evidence / they are all in on it / they’re part of that gang.”

This belief “occupies a large space in life” — it is not just a passing thought in times of stress, but becomes a central theme of daily life. The person ruminates on it repeatedly and plans everything in their life on the assumption that someone is chasing, ambushing, or controlling them.

The core of the content lies in “being deliberately threatened” — it is not fear of natural disasters (floods, earthquakes), but fear of “people” or “groups/organizations” who are perceived as intentionally trying to harm them, such as neighbors, coworkers, a particular gang, a company, a government, a secret organization, an online group, etc.

In ICD-11 there is a separate entry specifically labeled something like “persecutory delusion,” defined as a delusion whose main theme is “being attacked, mocked, bullied, cheated, conspired against, or persecuted.” The target of this harm may be the person themselves or close others, such as a partner, family members, or close friends — it is not limited only to oneself.

On the paranoia spectrum, we can roughly conceptualize a continuum from mild → severe like this:

Mild level: just feeling “I don’t trust people easily” / a bit suspicious.

Intermediate level: having paranoid ideation, e.g., feeling that others are talking about you or making fun of you, but still somewhat able to check reality.

Severe end: Persecutory Delusions — firmly believing that some person/group is truly trying to harm you, being unable to adjust the belief, and interpreting everything around as evidence supporting it.

Persecutory delusions are not a standalone disease, but usually show up as one form of delusion in various conditions, for example:

Schizophrenia / Schizoaffective Disorder — often co-occurring with auditory hallucinations, disorganized thinking/speech, negative symptoms, etc.

Delusional Disorder, Persecutory Type — many areas of life can still look relatively intact, but the person is heavily fixated on the belief of being persecuted or sabotaged.

Bipolar Disorder with Psychotic Features — during severe manic or depressive episodes, persecutory delusions may appear.

Major Depressive Episode with Psychotic Features — the content may be like: “Everyone in the world hates me and wants to get rid of me because I am worthless/sinful.”

Psychosis due to substances / medical conditions — for example psychosis from cannabis, amphetamine, or certain brain diseases, which can manifest with very clear persecutory delusions.

Importantly, the “content” may change shape over time and across contexts, but the core theme remains the same. For example:

In the past, the belief might be that neighbors secretly install cameras or tap the landline.

Today it might become: “My phone is hacked, there’s spyware on my devices, I’m being tracked online, there is AI surveilling me.”

But no matter how modern the content becomes, the structure of the symptom stays the same, namely:

There is a clearly identified “persecutor” (a single person, a group, an unknown individual, or an organization).

There is a “harm plan” which the person believes is either already happening or about to happen.

There is intense fear, anxiety, and constant watchfulness (hypervigilance).

The person’s life, decisions, and behaviors are all adjusted to align with that belief.

Clinically, persecutory delusions are therefore classified as “threat beliefs taken to the extreme.”
Originally, the brain’s job is to detect danger and warn us so we can protect ourselves. But in this case, that system is over-activated, combined with distorted thinking mechanisms, so the person ends up “living as if they are constantly in a persecutory situation,” even when in reality no one is actually doing anything to them.

So the overall picture of this Overview section is:

Persecutory delusions = the belief that “someone is deliberately trying to harm me,” which is false, deviates from the social consensus, is resistant to change, dominates the person’s life, and causes significant distress and functional impairment.

They are not a single disease but a type of delusion that appears across many disorders within the schizophrenia spectrum, mood disorders with psychosis, and psychosis caused by substances or medical conditions.

They represent the severe end of the paranoia spectrum, where brain biology, life experiences, and social factors are all woven together into the form of “a belief that one is being persecuted.”

2. Core Symptoms — The Core of Persecutory Delusions

The big picture is:

“Belief → Emotion → Behavior”

These three levels lock together into a cycle. If we don’t understand all three, then when we write or explain, it will sound like just “being paranoid,” without revealing the true structure of the symptom.

2.1 Belief Content — Detailed Expansion

You outlined 5 core elements; let’s “dissect them one by one” and see how they manifest in real life.

(1) Belief of being harmed — not just “they don’t like me”

In persecutory delusions, the term “being harmed” is very broad. It is not limited to being killed or physically attacked; it encompasses anything that could ruin a person’s life, such as:

Physical harm:

Being assaulted, stabbed, poisoned.
Being made sick, having substances secretly put into one’s food/water/medications.

Damage to status / career:

Someone secretly slanders them to their boss to get them fired.
Someone “lobbies” other companies not to hire them.

Damage to reputation / social standing:

Someone spreads rumors about them at work, in the neighborhood, or online, labeling them as bad, sick, criminal, etc.
Feeling that every whisper or laugh in public is gossip or ridicule about them.

The critical point is: everything in the world is interpreted through the lens of harm.

Neutral messages → interpreted as “threats.”
A neutral look → interpreted as “watching / targeting me.”
Bad things that happen by chance → interpreted as “they intentionally caused it.”

So this is not just “overthinking.” It is an entire meaning-making system that has become distorted.

(2) Belief in a clearly defined “persecutor”

A persecutory delusion is not just a vague fear that “the world is dangerous.”
It usually includes a clearly specified “character or group” identified as the persecutor, such as:

People close by:

Coworkers, boss, neighbors, relatives, family members.
Often individuals with whom there has been some minor conflict in the past, which gets magnified into a long-term persecution plan.

Groups of people:

A group of friends chatting becomes “a gang conspiring to destroy my reputation.”
All the neighbors on the street are believed to be cooperating to install cameras, record audio, and monitor them.

Organizations / systems:

A company, HR department, call-center gang, government, intelligence agency, secret online group, etc.

Once the belief reaches the level of delusion, the person will explain everything in a manner consistent with the existence of a persecutor. For example:

Why does that car keep parking in front of the apartment?
→ “They’re coming to watch my movements.”

Why did the internet cut out?
→ “They are interfering with the signal.”

It becomes a continuous narrative rather than a fleeting thought.

(3) Malicious intent — what makes it “illness” rather than just “not getting along”

In everyday life, people may think “that person doesn’t like me,” but in a persecutory delusion this escalates to:

Not just: “They don’t like me.”
But: “They intend to destroy me and are actively carrying out that plan.”

The differences are:

Intensity – the strength of the belief.
Certainty – the sense that it is 100% true.
Intentionality – the belief that the other party deliberately means harm, not that harm is accidental or incidental.

As a result:

Small actions or words from others are interpreted as “tactics of an enemy.”
There is no room left to consider: “This might be a misunderstanding / they’re just busy / they’re dealing with their own problems.”

(4) Fixed, uncorrectable belief

This is what separates a delusion from:

Overthinking
Paranoid personality traits
A tentative hypothesis

In a delusion:

The more people say “that’s not true,”
→ the more likely the person is to interpret it as: “See? They’re part of it too / they’ve been bought.”

All disconfirming evidence is absorbed into the delusional system as further “proof.” For example:

“The police refused to take my report → that’s because they’re collaborating with this gang.”
“The doctor says there’s nothing wrong → that’s because the doctors are also under their control.”

This is the highest level of confirmation bias + jumping to conclusions.
The thinking system selectively keeps only evidence that fits the existing storyline and “twists” everything else to fit.

(5) Preoccupation — from thought → to entire world

These beliefs are not occasional; they:

Are thought about repetitively throughout the day (preoccupation).

Intrude into all activities: working, using a phone, eating, commuting.

Expand from “one event” to a “whole worldview,” such as:

“The world is unsafe, no one will help me, anyone could be one of them.”

Real-life consequences:

Unable to work (constantly analyzing who might be “one of them”).

Large amounts of time consumed by “checking / investigating / proving” all day.

Relationships deteriorate because the person begins to distrust people around them, including those who genuinely care.

2.2 Affect & Emotion — Why It Is So Distressing

All of the belief content above is loaded with intense emotions, especially:

(1) Anxiety / Panic / Fear — the person is in constant threat mode

Imagine:

The brain truly believes that “someone is going to harm me for sure, but I don’t know when, where, or how.”

That means the body is in fight–flight mode with no off switch. You often see:

Rapid heartbeat, sweating, insomnia.

Startling easily; jumping at small sounds and turning to check them.

Headaches, stomach aches, chronic fatigue due to constant stress.

This is different from an acute panic attack that comes in “waves” and passes.
With persecutory delusions, this is a constant background fear — like a fire alarm in the head that never turns off.

(2) Hypervigilance — an overloaded surveillance system

Hypervigilance = monitoring for threat far more than normal, in a very noticeable way:

Scanning sounds:
Cars stopping in front of the building, footsteps in the hallway, the sound of a text notification.

Scanning visuals:
Strange cars, people standing and looking, CCTV cameras, odd spots on ceilings/walls (interpreted as hidden devices).

Scanning messages:
Ambiguous comments, tweets, statuses, posts that “might be” referring to them.

The problem: the more they scan, the more they inevitably “find something” that can be linked into the delusional story → which strengthens belief → increases suspicion → leads to more scanning.
This becomes a never-ending loop.

(3) GAD-level worry — worry as the engine of the delusion

CBT-for-psychosis research shows clearly:

People with persecutory delusions often have worry at a level similar to generalized anxiety disorder (GAD).

They don’t so much challenge the content of the thought as they circle around the same thought repeatedly, e.g.:

“If they really do this, will I die?”
“If the police don’t believe me, what options will I have left?”

Patterns:

Catastrophizing — mentally simulating the worst possible scenarios.
Trying to imagine many worst-case variations.
Feeling that “I must think through all possibilities” to be prepared.

But in reality:

The more time the mind spends on the belief, the stronger it feels.
Mental images become more detailed and vivid, making them feel “real.”

(4) Depression, low self-esteem, shame — deep layers of self-schema

In many cases, the underlying emotional tone includes:

Feelings of weakness, vulnerability, worthlessness.

Beliefs like: “If the world were to eliminate someone, it would probably be me, because I’m worthless.”

Guilt, shame, a history of being bullied or heavily criticized as a child.

This forms a pattern:

Self-schema: “I am weak / worthless / easily harmed.”

World-schema: “The world is cruel, untrustworthy.”

Persecutory delusions then become a “story” that combines both schemas:

“Because I am weak, the world is now targeting me. They are actually going to act against me.”

Depression often follows:

Feeling there is no escape, that they are cornered.

Feeling trapped by an invisible “enemy” → increasing risk of self-harm / suicide.

(5) Sleep disturbance, exhaustion, irritability, suicidality

Being stuck in chronic fear + worry leads to:

Insomnia — staying awake to “keep watch” or because the thoughts/noises never stop.

Physical and mental exhaustion → poor concentration, impaired decision-making → easier misinterpretation of events.

Irritability, anger (from feeling misunderstood and unsupported).

Some may reach a point where they think:

“If the whole world is conspiring to destroy me, then dying might be easier than staying and fighting.”

At that point, this is a red flag for suicide or possible violence that clinicians must assess seriously.

2.3 Behavior — What You Can Literally See in Real Life

Behavior is the outcome of belief + emotion combined.

(1) Safety behaviors — actions to “keep oneself safe”

Examples:

Avoidance:

Not leaving the house / avoiding places where they feel “the persecutor” might be.
Not using the same route, not walking down certain streets, not taking elevators with others.

Protective behaviors:

Installing many CCTV cameras, changing locks, frequently changing phone numbers.
Keeping curtains closed, avoiding turning on certain lights, placing objects to block suspected hidden cameras.

Environmental arrangement:

Rearranging furniture to “have visual control over all entrances.”
Choosing seats in cafés or restaurants that allow them to see all doors.

The big problem: safety behaviors prolong the delusion.

Because every time “nothing happens,” the brain does not interpret it as “see, no one is really after me,” but as:

“Nothing happened because my precautions worked. If I didn’t do all this, something terrible would have happened.”

So safety behaviors end up feeding and strengthening the belief.

(2) Checking / Monitoring — repeated checking until it becomes life itself

On the surface these may resemble OCD, but the motivation is different:

Repeatedly checking doors/windows/locks/cameras/electricity/gas.

Checking their phone for signs of hacking: reviewing call logs, inspecting suspicious apps.

Monitoring social media: who viewed their profile, who unfollowed, who posted something that “might be” about them.

Walking around the house to search for hidden cameras, microphones, strange wires, etc.

Difference from OCD:

OCD checking = fear of responsibility if something happens (e.g., “If I don’t check the stove, a fire might happen and it’ll be my fault”).

Persecutory checking = fear that “enemies are intentionally targeting me” → the theme is “other people” rather than “my own responsibility.”

(3) Complaints / Legal action — repeated reporting

In many cases:

The person repeatedly goes to the police to report being stalked, poisoned, monitored, etc.
Writes complaints to companies, government agencies, various organizations.
Contacts media or uses social platforms to try to “expose” the persecution plot.

From their perspective:

These are fully reasonable “requests for help,” because they truly believe harm is happening.

When they do not receive the response they expect, this further reinforces the belief:

“See? Everyone is colluding to conceal the truth.”

(4) Potential for aggression / violence — from “victim” → to “the one who acts first”

This is the most dangerous part in terms of risk:

If the belief that “the other party will definitely harm me” is held with high conviction, and the person feels cornered,

They may feel compelled to “strike first” (pre-emptive attack).

Examples:

Assaulting neighbors, a boss, or someone they believe is in the gang.

Sometimes weapons are involved (knives, sticks, household tools).

From their perspective, they do not feel like:

“I’m an aggressive person.”

They feel:

“I’m defending myself from inevitable harm.”

Clinically, this is why:

Risk assessment must be systematic.

Sometimes hospital admission is necessary, for the safety of both the patient and others.

3. Diagnostic Criteria — How Do We Know This Is Truly Persecutory Delusion?

As mentioned earlier, we need to distinguish two levels:

Symptom level — what has to be present to call it a persecutory delusion.

Disorder level — which disorder is it part of? (schizophrenia, delusional disorder, mood disorder with psychosis, etc.)

3.1 “Delusion” Criteria in DSM / ICD — Detailed

Key features of delusion span 4 main axes:

(1) Strongly held false belief — deviates from reality + social context

Both aspects must be present:

Factually false — there is no evidence to support it, or it clearly contradicts verifiable information.

Deviates from common social reality — most people in that culture/community do not share that belief.

Things to be careful about:

Some religious beliefs, cultural beliefs, sect doctrines, etc.

If a belief is widely shared within a group, it is not considered a delusion under DSM/ICD definitions.

We must always consider cultural context, or we risk mislabeling.

(2) High conviction, low amenability to change — not just a passing idea

A delusion differs from an ordinary hypothesis in that:

The person fully believes it is reality (very high conviction).

Even if:

Family, clinicians, the police, objective evidence, video footage, etc., all say otherwise,

The person barely moves, if at all.

Research tools (e.g., PSYRATS – Delusions) often rate:

Conviction
Preoccupation
Distress
Functional impairment

In persecutory delusions, scores for conviction, preoccupation, and distress are usually all high.

(3) Not better explained by religion, culture, or personality

We must rule out:

Religiously or culturally shared beliefs

For example, belief in spirits in some cultures; if the whole community believes similarly, it is not a delusion under DSM/ICD.

Suspiciousness in personality disorders, e.g., Paranoid Personality Disorder (PPD):

PPD = widespread suspiciousness that others are insincere, will betray them, or hide motives.
However, these beliefs usually remain within a broadly shared reality; they may soften when discussed and are not as fixed and bizarre as psychotic delusions.

Persecutory delusions = clearly detached from reality and rigid.

(4) Clinically significant distress or impairment

To count as a delusion at “disorder level,” it must:

Cause clear distress (e.g., severe fear, anxiety, stress, insomnia), and/or

Cause functional impairment (e.g., inability to work or study, ruined relationships, social isolation, legal problems).

If someone has a slightly odd belief but it doesn’t harm their life or cause serious distress, it often does not meet criteria for a psychotic disorder.

3.2 Specific Criteria for Persecutory Delusions (Freeman & Garety) — In Depth

Freeman & Garety proposed more specific criteria for persecutory delusions, widely used in research and CBT for psychosis. Two key components are:

Belief about harm

The person believes that harm will come to them in the present or future.
The harm might be physical, financial, reputational, or status-related.

Belief about a persecutor with intention

The person believes that the harm originates from a persecutor with intentionality.
It is not a natural disaster or random accident.

If either component is missing, it is not considered a “true” persecutory delusion in the strict sense.

Clarifications (useful for writing case vignettes and explanations):

If the harm is only aimed at “others” but not at the person themselves, for example:

Believing that “demons will harm the world but will not touch me,”
Or being concerned purely about a child/close person, without including oneself,
→ this may belong to other delusional themes, not strictly persecutory.

Delusions of reference alone, such as:

Believing a news anchor is talking about them,
Feeling that others laughing are definitely laughing at them,
→ if there is no belief that these people will directly harm them, it may not yet be a full persecutory delusion (though they often occur together).

In summary, in simple terms:

Persecutory delusion = “I will be harmed” + “They are going to / are already doing it.”

It is not just “they are talking about me” or “they don’t like me.”

3.3 Disorder Context — Same Symptom, Different Diagnoses

Persecutory delusion is a “module” that can appear in many disorders. When writing, be careful to specify context:

(1) Delusional Disorder, Persecutory Type

Key features:

A prominent delusion about being persecuted for at least 1 month.

Criterion A for schizophrenia has never been met. That is:

No clear disorganized speech/behavior,
No heavy negative symptoms like classic schizophrenia.

Overall functioning is relatively preserved in many areas.

Impairment mainly revolves around the delusional topic (e.g., conflict with neighbors or coworkers).

Typical picture:

A person who seems relatively functional in many parts of life, but is strongly fixated on “one story” of being persecuted.

Some may engage in prolonged legal battles to “prove” they are being targeted.

(2) Schizophrenia / Schizoaffective Disorder

In the schizophrenia spectrum:

Persecutory delusions are one component among many, such as:

Hallucinations (e.g., voices),
Disorganized speech/thinking,
Negative symptoms (alogia, blunted affect, avolition, etc.).

The overall tone is that “reality as a whole is destabilized,” not just one domain.

In schizoaffective disorder:

There is psychosis (including persecutory delusions) plus mood episodes (mania or depression) that are equally prominent.

Pattern when writing:

During mania: persecutory and grandiose themes may mix.

During depression: persecutory themes may mix with self-blame/guilt.

(3) Bipolar Disorder / Major Depression with Psychotic Features

In mood disorders:

Persecutory delusions often have content that is congruent with the mood, for example:

In depression:

“Everyone despises me and is conspiring to ruin my life because I’m worthless.”

In mania:

“The government fears my power/influence, so they are sending people to take me down.”

Key distinction: Does psychosis persist outside of mood episodes?

If psychosis only occurs during mood episodes → mood disorder with psychotic features.

If psychosis persists beyond mood episodes → think more in terms of schizoaffective/schizophrenia.

(4) Substance-induced / Medical-condition Psychosis

Persecutory delusions also appear in:

Substance-induced psychosis:

From cannabis, amphetamines, cocaine, LSD, etc.
Often presenting with paranoia, visual hallucinations, agitation.

Psychosis due to medical conditions:

Neurodegenerative diseases, epilepsy, autoimmune encephalitis, brain tumors, etc.

From a diagnostic standpoint:

The form of delusion may look similar, but the biological origin differs.

In explanation, it’s important to stress:

The same persecutory content can appear, but diagnosis depends on timeline, substance history, medical conditions, and neurological findings.

4. Subtypes or Specifiers — How Can We Further Classify Persecutory Delusions?

Not every manual lists many official subtypes, but clinically and in research, people often divide them along these axes:

4.1 According to the Disorder Context

Delusional Disorder, Persecutory Type

Schizophrenia with prominent persecutory delusions

Schizoaffective Disorder (persecutory delusions + mood episodes)

Bipolar I with psychotic features, mood-congruent persecutory delusions

Major Depressive Episode with psychotic features (often with mixed self-blame + persecution themes) PMC+1

4.2 Bizarre vs Non-bizarre Content

Non-bizarre: still possible in the real world, e.g.:

Coworkers colluding to sabotage them.
Neighbors secretly installing cameras, state officials wiretapping phones.

Bizarre: content that is impossible under current scientific understanding, e.g.:

Secret agents from another dimension disguised as ordinary humans.
The brain is controlled by cosmic waves or implants that cannot exist in our current era. Rama Mahidol University+1

4.3 Mood-congruent vs Mood-incongruent

Especially in mood disorders with psychotic features:

Mood-congruent: content matches the mood, e.g.:

Depression + belief that “everyone hates me and wants to get rid of me because I’m worthless.”

Mood-incongruent: content conflicts with the mood, e.g.:

A depressed person who believes “the government fears my special powers and wants to eliminate me.”

4.4 Thematic Micro-subtypes (not official codes but useful for writing & formulation)

Common themes include:

Poisoning / contamination: belief that others are poisoning them or putting chemicals in their food/water.

Surveillance / spying: belief that cameras/microphones are hidden everywhere; they are constantly being tracked.

Conspiracy / gang stalking: belief in a secret group that harasses them, drives around their home, etc.

Workplace persecution: belief that colleagues/bosses are conspiring to destroy their position or career.

Digital persecution: belief that hardware, the internet, or platforms are conspiring to attack them.

5. Brain & Neurobiology — Which Brain Systems Are Involved?

The big picture in current research is:

Persecutory delusions = the brain “tagging importance incorrectly” + distorted world prediction systems + dysfunctional threat / social brain circuits.

It is no longer enough to say simply “too much dopamine.” Multiple systems collide.

5.1 Dopamine & Aberrant Salience — Dopamine Tagging the Wrong Things as “Important”

5.1.1 From “mesolimbic dopamine disease” → to “striatal dopamine”

Old models held that psychosis (especially delusions/hallucinations) stemmed from excessive activity in the mesolimbic dopamine pathway — i.e., too much dopamine fired from the midbrain to limbic structures.

Newer reviews (e.g., McCutcheon, 2019) using PET/SPECT imaging show that:

The strongest abnormalities are not only in limbic areas but in the dorsal/associative striatum,

Which is linked with learning, reward, and updating beliefs about the “rules of the world.” diapason-study.eu+1

In simple terms:

Psychosis is not just “emotional over-excitement.”

It is the brain’s learning system (via the striatum) being driven by dopamine in such a way that it learns the wrong rules about the world.

5.1.2 “Aberrant Salience” Theory — The Brain Tags the Wrong Events as “Important”

Kapur proposed the “aberrant salience” theory, now a standard framework for many positive symptoms. ResearchGate+1

Core idea:

Normally: dopamine = a signal of “this is important,” e.g.:

An unusual loud noise,
A new face entering the room,
Discovering a relationship between event A and B.

In psychosis: the dopamine system fires erratically → “tags” ordinary stimuli as important, such as:

The sound of a car passing by.
A brief glance from a stranger.
A particular word spelling that keeps catching their eye.

The brain cannot tolerate these “free-floating feelings of importance,” so it must “invent a story” to explain:

“Why is this important? Why does this sound/person/post stand out so much?”

If the person already has a cognitive tendency to see “others as dangerous” or carries trauma, the narrative that the brain constructs tends to be:

“Someone is targeting me” → persecutory delusion.

Supporting evidence:

PET shows elevated presynaptic dopamine in the associative striatum in people with psychosis and even in high-risk individuals before onset. PubMed+1

Administration of amphetamine (which increases dopamine) in healthy individuals can induce paranoia/suspiciousness; in vulnerable people it can escalate to persecutory ideas more easily. PMC+1

5.1.3 Why Does the Content Specifically Become “Persecutory”?

Dopamine dysregulation = aberrant salience, but the content (persecutory vs grandiose vs religious, etc.) is shaped by:

Cognitive style: e.g., externalizing interpretations, blaming others.

Self-schema: view of self as weak, easily harmed.

History of trauma / bullying / social defeat.

Howes (2016) suggests that people with a paranoid style interpret odd prediction errors as “threats from others” rather than as random changes in the environment. PMC+1

5.2 Predictive Coding & Hierarchical Bayesian Models — The Brain Mis-predicts the World and Weighs Evidence Wrong

Newer theories (Sterzer, Corlett, Friston, etc.) conceptualize psychosis through predictive coding / Bayesian brain frameworks. jsDelivr+3 PMC+3 PMC+3

5.2.1 Normal Brain: A World-Prediction Machine

Key ideas:

The brain does not passively “receive information.”

It constantly predicts the world and compares predictions with actual input.

Mismatches are called prediction errors (PEs).

The brain updates its model of the world according to how “important” (high precision) it deems each PE.

So the brain has to balance three things:

Priors / existing beliefs

New evidence / input

Precision weight — which side to trust more.

5.2.2 What Goes Wrong in Persecutory Delusions?

Two popular patterns:

Pattern 1 — Over-weighted prediction errors

If dopamine causes PEs to be “amplified” (precision too high),

The brain experiences every minor irregularity as highly important.

It updates beliefs in extreme ways based on very little evidence, e.g.:

A neighbor looks once → jumps to a big belief: “He’s part of a gang monitoring me.”

Corlett and colleagues show that people with psychosis learn odd associations easily because their PE system is abnormal. PMC+2 PMC+2

Pattern 2 — Very strong threat-based priors

If someone has a deeply entrenched prior that “others are dangerous / the world is unsafe” (from trauma, social defeat, bullying, etc.),

The brain downweights evidence that contradicts this prior.

Consequences:

Ambiguous events (people chatting, a brief glance) → are “pulled into” the prior: “They’re talking about how to harm me.”

Disconfirming evidence (like a neighbor smiling) is interpreted as pretend kindness, a cover.

Many cases of persecutory delusions likely involve both:

Dopamine-driven PE abnormalities + strong threat-based priors.

5.3 Threat Processing & Social Brain Networks — Fear Circuits + Mindreading Circuits

Even without predictive coding jargon, we can say:

“The brain circuits for detecting threats and for reading others’ intentions are misfiring.”

5.3.1 Limbic & Threat Circuit — Amygdala, Hippocampus, Insula, ACC, Striatum

Amygdala:

Main “threat sensor.”
In paranoia/psychosis, amygdala often shows stronger responses to angry faces and threat cues than in controls. PMC+1

Hippocampus:

Provides context for experiences (contextual memory).
If hippocampus malfunctions → memories become fragmented; people don’t know where/when certain events occurred, or in what context.
This leads to misapplied threat feelings, e.g., emotional states from past harm get activated whenever something vaguely similar appears.

Insula & Anterior Cingulate (ACC):

Insula = monitors internal bodily states (interoception) and a sense of “something’s wrong / unsafe.”
ACC = detects conflict, error, uncertainty.
In psychosis, connectivity abnormalities in these networks make people feel “uneasy / something is about to happen” without clear reasons. PMC+1

Striatum:

A crossroads for reward learning, habits, and salience.
Distorted dopamine activity in the striatum ties together mislearned fear associations with strange new beliefs.

5.3.2 Prefrontal Cortex — Reality Testing & Belief Updating Break Down

dlPFC (dorsolateral prefrontal cortex):

Involved in working memory, cognitive control, considering multiple pieces of evidence before concluding.

When its function is reduced → people “jump to conclusions,” a key bias in persecutory delusions.

vmPFC / OFC (ventromedial PFC, orbitofrontal cortex):

Evaluate value and safety, integrating evidence with feelings.

Dysfunction leads to “believing feelings of threat more than objective evidence.”

Meaning:

Limbic brain is overactive → strong fear.
Prefrontal “brakes” that should question and review evidence are weak.
So fearful thoughts easily crystallize into rigid beliefs.

5.3.3 Default Mode Network & Social Cognition — Theory of Mind Distortion

The social brain network (medial PFC, TPJ, STS, etc.) supports:

Theory of Mind — inferring what others think and feel.
Self–other distinction — separating our own thoughts from other people’s intentions.

Psychosis research shows: PMC+2 PMC+2

Poor performance on ToM tasks (e.g., reading stories and inferring characters’ mental states).
A tendency to interpret others’ intentions negatively (hostile attribution bias).
Connectivity abnormalities between medial PFC and TPJ → distorted mindreading.

So in persecutory delusions, we see patterns like:

Neutral faces → interpreted as “they hate me.”
Neutral behavior → seen as “they’re hiding something / they have a secret plan.”

5.4 Memory, Learning & Stabilization of Delusions — Why They Become So Fixed

Another often overlooked part is memory and learning mechanisms:

The hippocampus & medial temporal lobe help consolidate stories that the brain spins from aberrant salience into “real memories.”

Each time the person “retells the persecutory story” or “mentally rehearses it,” the neural pathway encoding that belief gets stronger (like training the same muscle repeatedly). ResearchGate+1

In predictive coding terms, some authors use the phrase “doxastic shear pin” — like a broken safety pin where a new belief (delusion) is installed to stabilize a chaotic prediction-error system. ResearchGate+1

In simple language:

Initially, a delusion may arise from “the brain being confused and making an extreme guess.”

Over time, as the story is retold and used to explain everything, it becomes a belief deeply embedded in the memory network, very difficult to dismantle.

5.5 Neurobiology Summary — System-wide Integration

If we tie it all into one sentence:

Persecutory delusions arise from:
– Dopamine–striatal systems mis-tagging trivial events as important (aberrant salience), diapason-study.eu+1
– Predictive coding systems misweighting evidence (distorted prediction errors / priors), PMC+2 PMC+2
– Threat & social brain circuits (amygdala–PFC–TPJ) reading the world and others’ intentions as fundamentally unsafe,
– Memory/learning systems gradually cementing fear-based narratives into delusional-level beliefs.

This explains both why they emerge and why they are so hard to change.

6.Causes & Risk Factors — Why Do Some People Go All the Way to Persecutory Delusions?

The clearest view comes from a biopsychosocial lens:

Genes + brain + experience + environment colliding.

6.1 Biological / Genetic — Brain Vulnerabilities That Make “Breaks from Reality” Easier

6.1.1 Genetics and Psychosis Risk

In the schizophrenia-spectrum:

Heritability is about 70–80% from twin/family studies (for psychosis overall). ScienceDirect+1

There is no single gene; it is polygenic risk — many small-effect genes increase risk bit by bit, including genes related to dopamine (DRD2), glutamate, synaptic pruning, etc. ScienceDirect+1

Meaning:

With genetic vulnerability, dopamine/glutamate/GABA circuits in the fronto-temporal–striatal network are fragile.

Under stress, trauma, or substance exposure, the chance of slipping into delusional psychosis is higher than in people without such vulnerabilities. jsDelivr+1

6.1.2 Neurodevelopment & Brain Structure

Neuroimaging in psychosis shows:

Slight gray matter volume reductions in prefrontal, temporal, hippocampal, thalamic regions (a group pattern, not something you diagnose from a regular MRI). diapason-study.eu+1

White matter connectivity changes in networks such as default mode, salience, fronto-parietal, etc. (network dysconnectivity). PubMed

Together with dopamine abnormalities, this produces:

A brain that “sends the wrong signals and is wired in atypical patterns,”
biasing perception and interpretation of the world toward threat and persecution.

6.1.3 Secondary Psychosis — Medical/Neurological Causes of Persecutory Delusions

Persecutory delusions are not exclusive to schizophrenia. They occur in:

Epilepsy (especially temporal lobe epilepsy),

Autoimmune encephalitis, e.g., anti-NMDA receptor encephalitis,

Neurodegenerative diseases, e.g., Parkinson’s disease psychosis, Lewy body dementia,

Certain metabolic states or types of brain hypoxia, etc. PMC+1

Common features:

Involvement of limbic, temporal, or frontal brain regions.

Patients may retain some reasoning capacity but have content skewed toward “someone is targeting me.”

ICD-11 even has a separate category for Secondary Psychotic Syndromes to emphasize that sometimes the true root cause of psychosis (including persecutory delusions) is a medical condition, not a primary psychiatric disorder. jsDelivr

6.2 Psychological Mechanisms — How Does the Mind End Up at a Persecutory Delusion?

This is the core of Freeman, Bentall, and others’ cognitive models: persecutory delusions are “threat beliefs” maintained by specific psychological processes. medweb1.unige.ch+2 PubMed+2

6.2.1 Worry & Rumination — The Engine That Solidifies the Belief

Startup, Freeman & Garety’s work shows:

People with persecutory delusions often have catastrophic worry at levels similar to GAD.

They don’t so much challenge the thought content; instead they walk in circles around the same thought, e.g.:

“If they really do this, will I die?”
“If the police don’t believe me, what will I do?”

Results:

The more the belief is thought, rehearsed, and elaborated in detail, the more “real” it feels.

CBT trials show that targeting worry directly (instead of arguing about content) can reduce persecutory delusions, suggesting worry is a key maintaining factor. Nature+1 ORA+1

6.2.2 Negative Self-schema & Self-esteem — “I’m Weak, Others Are Dangerous”

Freeman & Bentall show persecutory delusions are often associated with:

Low implicit and explicit self-esteem,

Self-schemas like “I am bad / not competent / have no value / cannot protect myself.” uol.de+2 ScienceDirect+2

When something strange happens:

If someone sees themselves as strong → they might interpret it as “just a normal problem; I’ll handle it.”

If their self-schema is “I’m fragile” → they interpret it as “this is a big threat I can’t deal with, and others will take advantage of it to harm me.”

MacKinnon (2011) found that persecutory and referential delusions are “self-diminishing” — they worsen self-image, rather than being defensive grandiosity. ScienceDirect+1

6.2.3 Attributional Style — External–Personal Blame

Cognitive models highlight:

People with persecutory delusions often show an attributional bias:

Negative events → blamed on “others intentionally doing this” (external–personal),
Rather than “situations/systems/chance” (external–situational).

Example:

A coworker doesn’t say hello.

General interpretation: “They might be busy / stressed about something.”
Persecutory style: “They intentionally ignored me because they’re part of a conspiracy.”

Howes and multiple meta-analyses show that this attributional style is strongly tied to paranoia and may link to dopamine-driven enhancement of threat-related prediction errors. PMC+2 jsDelivr+2

6.2.4 Anomalous Experiences — Strange Experiences Seeking an Explanation

Freeman suggests persecutory delusions often arise as attempts to explain very unusual experiences, such as: PubMed+1

Depersonalization / derealization,
Odd bodily sensations,
Voices in one’s head, fleeting images, clusters of coincidences.

The brain asks:

“Why do I feel like this? Why does the world look strange? Why are people looking at me more than usual?”

If the person’s internal psychology + life history = “the world is unsafe,” then the most fitting answer becomes:

“Because someone is out to get me.”

6.2.5 Social Cognition Deficits — Misreading Others’ Intentions

There may be:

Problems with theory of mind,
Jumping-to-conclusions bias (rapid judgments with minimal data),
Hostile attribution bias (overinterpreting others’ intentions as hostile).

These factors make:

Normal social events appear as “evidence” of persecution.
Example: a group laughing together → taken as clear proof “they must be laughing at me.”

6.3 Trauma & Early Environment — From “Being Harmed” → to “Everyone Will Harm Me”

Over the last decade, research has drawn fairly straight lines:

Childhood trauma and experiences of intentional harm are significantly associated with psychosis, especially paranoid/persecutory phenomena. Wiley Online Library+3 PMC+3 Frontiers+3

6.3.1 Childhood Maltreatment & Emotional Abuse

Multiple meta-analyses find that childhood sexual, physical, emotional abuse and neglect significantly increase the risk of psychotic experiences and delusions in both adolescents and adults. PMC+2 OUP Academic+2

Van Nierop (2014) notes that “intention-to-harm” experiences are more strongly associated with psychosis than traumas without clear malevolent intent (e.g., natural disasters). Maastricht University+1

This maps almost directly onto persecutory delusions:

Persecutory delusion = belief that “others are intentionally harming me.”
Childhood trauma with intention-to-harm = real experiences of “others intentionally harming me.”

Same theme, shifted from past → generalized into present and future.

6.3.2 Harsh / Critical / Invalidating Parenting

Family environments where:

Criticism is intense,
The child’s value is repeatedly devalued,
Emotions are invalidated or rejected, leaving the child feeling unsupported,

Gradually build:

Negative beliefs about self: “I have no value / I don’t deserve protection.”
Negative beliefs about others: “Others are ready to attack, crush, exploit me.”

Calvert et al. (2008) & Bloomfield (2021) suggest that trauma-related negative cognitions about self and world mediate the relationship between trauma and delusions/paranoia. Cambridge University Press & Assessment+1

6.3.3 Dissociation & Affect Dysregulation

Heriot-Maitland (2022) and others propose: Frontiers+2 Ovid+2

Trauma leads to dissociation (feeling detached from self or reality).
Memories become fragmented and incomplete.
This co-occurs with problems in affect regulation — intense fear/anger/shame that are hard to control.

A mind built on this foundation, when then exposed to stress + dopamine abnormalities, is primed to move into psychotic states with threat/persecution themes.

6.4 Social / Environmental Risk — A World That Repeatedly Says “You’re an Outsider / You’re Crushed”

Social factors are not mere irritants; major models explicitly address them, such as Selten’s social defeat hypothesis. PMC+2 OUP Academic+2

6.4.1 Social Defeat & Exclusion — Being Pushed Out of the Group

Social defeat = chronic experience of being an outsider/loser/excluded member in a social system.

Selten suggests:

Repeated exclusion, discrimination, and defeat sensitizes mesolimbic dopamine systems.

This may link factors such as:

Being a migrant or ethnic minority,
Being bullied,
Growing up or living in large cities (urbanicity),
Unemployment, living alone, low social status, etc. PubMed+2 PMC+2

In current terms:

Being repeatedly told by society “you’re not one of us,”
having a dopamine-vulnerable brain = a setup for seeing the world as hostile and eventually developing persecutory delusions.

6.4.2 Social Isolation & Loneliness

Longitudinal studies show:

People who are socially isolated, lacking support, and chronically lonely have higher risk of paranoid ideation.

Social adversity (poor relationships, rejection) exerts effects via cognitive vulnerabilities (negative schemas, worry, low self-esteem) leading to paranoia, as in Jaya et al. (2017). OUP Academic+1

This maps very naturally onto real life:

The fewer trusted people one has, the more one’s own thoughts and fears are left unchallenged.

Without feedback like “hey, you might be overthinking this,” strange beliefs go unchecked.

6.4.3 Substance Use — Cannabis, Stimulants, Alcohol

Cannabis (especially high-THC used from adolescence) is a major psychosis risk factor.

Stimulants like amphetamine and cocaine are textbook inducers of paranoia.

Heavy alcohol use + withdrawal also raises the risk of psychotic episodes.

Mechanism:

They stimulate/disrupt dopamine and glutamate systems → pushing the brain into an aberrant salience mode.

In someone with trauma + cognitive biases, the content is more likely to gravitate toward persecutory themes. PMC+2 Nature+2

6.4.4 Urbanicity, Inequality, and Structural Stress

Growing up or living in large urban centers is associated with significantly increased psychosis risk across epidemiological studies.

Inequality, structural discrimination, policing, housing insecurity, etc., provide a background of chronic stress + social defeat + mistrust that supports long-term paranoia. PubMed+2 PMC+2

6.5 Big Picture: The Biopsychosocial Loop of Persecutory Delusions

Putting it all together:

Biology / Genes

Genes + brain development → fragile dopamine–striatal, glutamate, GABA systems.

Subtle structural/connectivity differences in threat/social/cognitive-control networks.

Psychological Processes

Worry, rumination, jumping to conclusions.

Negative self-schema, low self-esteem.

Hostile attribution, external–personal blaming.

Unusual fear-laden experiences.

Trauma & Early Experience

Childhood abuse/neglect, bullying, invalidation.

Deeply embedded beliefs: “I have no value / others are dangerous / the world is unsafe.”

Social Environment

Social defeat, migration, minority status, discrimination.

Isolation, loneliness, chronic stress.

Substance use superimposed on this.

Neurobiology in Action

Dopamine generating aberrant salience.

Distorted predictive coding: strong threat priors + abnormal prediction errors.

Threat/social brain networks locking the entire world into a place filled with “persecutors.”

All of this converges into:

Persecutory delusions = threat beliefs
grounded in
“A brain that mislearns and mispredicts the world + life experiences that reinforce the idea that the world (and others) are dangerous.”

7. Treatment & Management — How Do We Manage This?

The goal is not only “make the delusion disappear,” but to reduce distress and risk, and improve quality of life and functioning.

7.1 Pharmacological — Medication

Antipsychotics (D2 / D3 blockade)

First- and second-generation antipsychotics are the mainstay.

In Delusional Disorder, systematic reviews show they can work, but there may be treatment resistance, requiring regimen adjustments and careful case-by-case tolerability assessment. MDPI+1

Choice of medication depends on:

Side-effect profiles (metabolic, EPS, prolactin, etc.).

Comorbidities (diabetes, obesity, heart disease, etc.). MDPI+1

Adjunctive meds

Antidepressants or mood stabilizers if there is a comorbid mood disorder.

Short-term anxiolytics in crisis (with caution about dependence).

7.2 Psychological Interventions

Cognitive Behavioral Therapy for psychosis (CBTp) is the backbone, especially for persecutory delusions. Cureus+3 PMC+3 mirecc.va.gov+3

Main foci:

Detailed assessment & formulation specifically for persecutory delusion:

Who is the persecutor?
What are they supposedly doing, when, and how?
What evidence supports / contradicts this?
What maintains the belief (worry, sleep loss, isolation, substance use, etc.)?

Worry-focused CBT

RCTs show targeting worry itself can reduce persecutory delusions. The Lancet+1

Belief modification & alternative explanations

Using guided discovery and behavioral experiments (e.g., testing stalking beliefs under controlled conditions).
Helping patients gradually shift conviction from 100% → 80% → 60%, and so on.

Feeling Safe Programme (Oxford group)

A CBT program specifically designed for persecutory delusions.
RCT in Lancet Psychiatry: about half of participants “recovered” from persecutory delusions at a clinical level after completing the program. psy.ox.ac.uk+1

Work on self-esteem & trauma

CBT, schema therapy, compassion-focused therapy to address negative self-schemas that uphold persecutory beliefs. ScienceDirect+1

7.3 Psychosocial & Environmental Management

Family psychoeducation & communication training

Helping families understand that bluntly saying “It’s not real!” usually makes beliefs more rigid.

Reducing social isolation

Connecting the person with peers, community, vocational rehab, etc., to reduce paranoia and improve social cognition. cci.health.wa.gov.au+1

Substance use treatment

Behavioral and pharmacological approaches to reduce cannabis, stimulant, and other substance use.

7.4 Risk Management

Always assess risk of harm to self/others, because persecutory delusions are relatively likely to be acted on, either via extreme self-isolation or violence. Wikipedia+1

Hospitalization (including involuntary admission, depending on local law) is indicated when:

There is significant suicide or violence risk.
Self-care is severely compromised.
The delusion leads to absolute refusal of treatment that endangers safety.

8. Notes — Common Confusions & Practical Distinctions

8.1 How It Differs from “Ordinary Suspiciousness / Paranoid Personality”

Paranoid Personality Disorder (PPD):

Broad suspiciousness, hypersensitivity, scanning for signs of insincerity.

But beliefs remain broadly within shared reality and can soften with discussion; they are not as fixed or bizarre as psychotic delusions. Wikipedia+1

Persecutory delusions:

Beliefs are clearly detached from reality and strongly fixed.

Resistant to challenge even in the face of overwhelming evidence.

Often accompanied by other psychotic symptoms (e.g., hallucinations in schizophrenia).

8.2 How It Differs from PTSD + Hypervigilance

PTSD:

Threat is linked to an actual trauma; vigilance makes sense in that context.

Threat interpretation is anchored in real events that did occur.

Persecutory delusions:

New threats not supported by real evidence, woven into complex stories like “a secret organization is targeting me.”

8.3 Cultural Context

Shared cultural/religious beliefs are not delusions.

Diagnosis must be made with careful consideration of context, culture, and social norms, following DSM-5-TR / ICD-11 frameworks. Drugs and Alcohol+1

8.4 For Readers / General Public

All of the above is for academic understanding and for writing/research.

Having some suspicious thoughts does not automatically mean someone has a psychotic disorder.

Diagnosis must be made by a psychiatrist or clinical psychologist via full clinical assessment.

Read Schizophrenia

References

ICD-11 – Persecutory delusion (MB26.07)
World Health Organization. ICD-11 for Mortality and Morbidity Statistics: MB26.07 Persecutory delusion.
Definition: a delusion whose main theme is “being attacked, mocked, bullied, cheated, conspired against, or persecuted” toward oneself or close others. Find-A-Code+1

ICD-11 – Delusional disorder (6A24)
World Health Organization. 6A24 Delusional disorder. Clinical descriptions and diagnostic requirements for ICD-11 mental, behavioural and neurodevelopmental disorders. Geneva: WHO; 2024. Find-A-Code+1

Freeman & Garety — Cognitive model of persecutory delusions
Freeman D, Garety PA. A cognitive model of persecutory delusions. Behaviour Research and Therapy. 2002;40(11):1143–1168.
Proposes persecutory delusions as “threat beliefs” arising from anomalous experiences + cognitive biases + emotional processes + environment. PubMed+2 MedWeb+2

Freeman D. — Persecutory delusions: cognitive perspective
Freeman D. Persecutory delusions: a cognitive perspective on understanding and treatment. (Oxford group review). Summarizes work on worry, self-esteem, trauma, and social factors maintaining persecutory delusions. ORA

Kapur — Aberrant salience & psychosis
Kapur S. Psychosis as a state of aberrant salience: a framework linking biology, phenomenology, and pharmacology in schizophrenia. American Journal of Psychiatry. 2003;160(1):13–23.
Proposes that abnormal dopamine firing turns ordinary events into “inappropriately important” ones, requiring delusional explanations. PhilPapers+3 PubMed+3 Psychiatry Online+3

McCutcheon et al. — Schizophrenia, Dopamine and the Striatum
McCutcheon RA, Abi-Dargham A, Howes OD. Schizophrenia, dopamine and the striatum: from biology to symptoms. Trends in Neurosciences. 2019;42(3):205–220.
McCutcheon RA et al. Dopamine and glutamate in schizophrenia. World Psychiatry. 2020;19:15–33.
Summarize evidence on presynaptic striatal dopamine dysregulation and positive symptoms (including delusions). ScienceDirect+2 ResearchGate+2

ICD-11 – Delusion vs Paranoid ideation
WHO. MB26.0 Delusion and MB26.7 Paranoid ideation. Explain distinctions between fully delusional beliefs and “ideation” that has not reached delusional intensity. Find-A-Code+1

Wikipedia – Persecutory delusion (for general readers / cross-check)
Persecutory delusion. Wikipedia, the free encyclopedia.
Summarizes symptoms, causes, associated disorders, and Freeman & Garety’s criteria in an accessible way. Wikipedia

persecutory delusions, persecutory delusion, paranoid delusions, threat beliefs, delusional disorder persecutory type, schizophrenia persecutory delusions, paranoia and psychosis, aberrant salience, dopamine dysregulation, predictive coding in psychosis, threat processing, theory of mind deficits, catastrophic worry, negative self-schema, childhood trauma and psychosis, social defeat, social isolation and paranoia, CBT for psychosis, Feeling Safe Programme, antipsychotic treatment

banner

ads-d