How do you differentiate and treat persecutory delusions versus anxiety in an adult patient who presents with symptoms of believing people are out to get them?

Differentiating Persecutory Delusions from Anxiety in Adults Presenting with Beliefs That People Are Out to Get Them

The critical distinction is that persecutory delusions are fixed, false beliefs held with absolute conviction despite contradictory evidence, whereas anxiety-driven paranoid thoughts are recognized by the patient as excessive or potentially unrealistic worries that fluctuate in intensity. 1, 2

Key Diagnostic Features to Distinguish Between the Two

Persecutory Delusions (Psychotic)

• Fixed belief quality: The patient holds the belief with complete certainty and cannot be reasoned out of it, even when presented with clear contradictory evidence 3
• Lack of insight: The patient does not recognize the belief as potentially excessive, disproportionate, or irrational 3
• Pervasive conviction: The belief remains constant regardless of context or reassurance 3
• Associated psychotic features: Look for hallucinations (auditory in 21-56% of cases with genetic FTD variants), disorganized thinking, or other delusions 3
• Functional deterioration: Often accompanied by significant behavioral changes, social withdrawal, or cognitive decline beyond what anxiety alone would cause 3

Anxiety-Driven Paranoid Thoughts (Non-Psychotic)

• Fluctuating intensity: The worries vary in severity and can temporarily improve with reassurance or distraction 1, 2
• Preserved insight: The patient recognizes the thoughts as worries or fears that may be excessive or disproportionate to actual risk 3, 1
• Multiple worry domains: GAD patients worry excessively about multiple life areas beyond just persecution (work, health, family, finances) 3, 1
• Response to context: Anxiety symptoms worsen with stress and improve in safe environments 2
• Duration pattern: GAD requires worry occurring more days than not for at least 6 months, accompanied by at least three physical symptoms (restlessness, fatigue, concentration difficulty, irritability, muscle tension, sleep disturbance) 3

Structured Assessment Approach

Step 1: Screen for Severity and Safety

• Immediate safety assessment: Evaluate for risk of harm to self or others, severe agitation, or confusion/delirium requiring emergency psychiatric evaluation 3, 4
• Use GAD-7 screening: Scores of 10-14 indicate moderate anxiety, 15-21 indicate severe anxiety 1, 2, 4
• Assess functional impairment: Determine impact on home, work, relationships, and daily activities 3

Step 2: Evaluate Belief Characteristics

• Test for fixed vs. fluctuating beliefs: Ask "How certain are you that people are out to get you?" (0-100%). Delusions typically score 90-100% with no variation 5, 6
• Assess insight: Ask "Is it possible you might be worrying too much about this?" Preserved insight suggests anxiety rather than delusion 3, 1
• Examine catastrophizing patterns: In anxiety, patients engage in "what if" thinking and can identify worst-case scenarios; in delusions, the persecution is accepted as current reality 6, 7
• Check for worry processes: Anxiety patients show perseverative thinking, intolerance of uncertainty, and metacognitive beliefs about worry being uncontrollable 6

Step 3: Rule Out Medical and Substance Causes

• Medical causes: Uncontrolled pain, infection, electrolyte imbalances, hypoxia, or delirium can present with paranoid features 3
• Medication-induced: Corticosteroids, stimulants, anticholinergics, or opioids can cause paranoid symptoms 3
• Substance use: Stimulants, cannabis, or alcohol withdrawal can produce paranoid ideation 3, 4
• Neurological screening: In late-onset cases (>40 years), consider frontotemporal dementia, especially with C9orf72 mutations where persecutory delusions can precede classical FTD symptoms by up to a decade 3

Step 4: Assess for Comorbidities

• Screen for depression: Use PHQ-9, as major depressive disorder co-occurs in 75% of GAD cases 3, 1
• Evaluate trauma history: PTSD symptoms include hypervigilance and paranoid-like features but with clear trauma triggers 3
• Family psychiatric history: Increased rates of psychotic disorders in family members suggest genetic vulnerability to psychosis 3

Treatment Algorithm

For Anxiety-Driven Paranoid Thoughts (GAD-7 10-21)

First-line approach: Combined CBT plus SSRI for moderate-to-severe anxiety shows superior outcomes compared to medication alone. 1, 4

Psychological Interventions (Primary)

• Cognitive-behavioral therapy: Target worry processes, catastrophizing, and intolerance of uncertainty with 8-16 sessions 1, 4
• Worry-specific techniques: Teach worry postponement, problem-solving for controllable worries, and acceptance for uncontrollable concerns 5, 6, 8
• Behavioral activation: Address avoidance behaviors that maintain anxiety 1
• Format: Individual face-to-face sessions are preferred by patients and associated with better engagement 3

Pharmacological Management (If Indicated)

• SSRIs as first-line: Start with subtherapeutic "test dose" because initial adverse effects include increased anxiety and agitation 4
• Titrate slowly: Use smallest available increments at appropriate intervals based on half-life 4
• Monitor systematically: Use GAD-7 at regular intervals to track response 2, 4
• Avoid benzodiazepines for long-term use: Risk of dependence, cognitive impairment, and falls; reserve for short-term crisis intervention only 3
• Alternative anxiolytics: Olanzapine, quetiapine, or aripiprazole may offer benefit with lower risk of extrapyramidal symptoms, though sedation is common 3

Reassessment Timeline

• Monthly follow-up: Assess treatment compliance, symptom reduction, and satisfaction until symptoms subside 3
• 8-week decision point: If poor response despite good compliance, alter treatment (add intervention, change medication, or refer to specialist) 3

For Persecutory Delusions (Psychotic)

Immediate referral to psychiatry is mandatory for diagnostic confirmation and antipsychotic medication initiation. 3, 4

Acute Management

• Antipsychotic medication: Required as primary treatment; choice depends on side effect profile, prior response, and patient factors 3
• Avoid standard anxiolytics alone: Benzodiazepines may provide sedation but do not address the underlying psychotic process 3
• Genetic testing consideration: In late-onset cases with family history of neurodegeneration or severe psychotic symptoms, test for C9orf72, GRN, and MAPT mutations 3

Adjunctive Psychological Interventions

• Worry reduction techniques: Even in psychosis, targeting worry processes can reduce delusion distress without directly challenging belief content 5, 8, 9
• Emotional processing interventions: Brief (3-4 sessions) interventions encouraging structured discussion of paranoid experiences can reduce distress 8, 9
• Avoid direct confrontation: Do not argue about the reality of delusions; focus on reducing associated distress and functional impairment 5, 8

Critical Pitfalls to Avoid

• Mistaking anxiety for psychosis: Overdiagnosis leads to unnecessary antipsychotic exposure with significant metabolic and neurological risks 3
• Missing true delusions: Underdiagnosis delays appropriate antipsychotic treatment, allowing functional deterioration and potential safety risks 3
• Premature medication in anxiety: For GAD-7 scores 5-9 (mild anxiety), initiate psychotherapy/CBT first without antidepressants 4
• Ignoring medical causes: Always rule out delirium, substance effects, and metabolic disturbances before attributing symptoms to primary psychiatric disorder 3
• Long-term benzodiazepine use: Associated with dependence, cognitive decline, and falls; time-limit use strictly per psychiatric guidelines 3
• Overlooking neurodegenerative causes: Late-onset persecutory delusions (>40 years) with family history warrant consideration of genetic FTD, particularly C9orf72 mutations 3