Someone bumping into you, the stare of a curious stranger on a train, or a drink being splashed on your foot – all essentially innocuous, if inconvenient, incidents.

But for millions of people in the UK, such everyday occurrences will trigger the kind of paranoid thoughts that at their most extreme are a central component of psychosis and serious mental illness like schizophrenia.

Even at a milder level this kind of intrusive thinking – that might interpret harmless curiosity as threatening behaviour, or an accident as a deliberate calculated act of aggression – can make social interaction difficult.

Effective treatment exists for paranoia – face to face cognitive behavioural therapy (CBT) can help nearly half of sufferers, research has suggested.

But the difficulty is how to get hold of such treatment, even if your paranoia is at the serious end of the spectrum, because of a massive shortage of therapists.

In 2012, a landmark study into schizophrenia found that “only one in 10 of those who could benefit get access to CBT despite it being recommended by NICE (National Institute of Health and Clinical Excellence)”.

And the author, professor Sir Robin Murray, has told i that despite his alarm call, the situation has only “marginally improved” in the last decade.

But now, help could be at hand. NHS trials are under way on a new app that employs CBT techniques to help patients escape a paranoid mindset, using their smart phones.

Known as Stop (Successful treatment of paranoia), the app uses text, graphics, animation and sound, delivered in twelve weekly sessions lasting 40 to 60 minutes, to give patients the tools to tackle paranoia.

It helps people to view incidents such as drink spillages as likely to be accidents rather than a deliberate attacks, and consider more positive explanations.

A user might be encouraged to see the young hairdresser who cut their neck by mistake as an apprentice rather than an adversary, for example. It also deals in serious fears such as the conviction that a random stranger may have a gun or knife and want to kill you.

The idea is not to give scenarios for users to consult as they happen to them but rather to change the way they see things more generally.

Indications from an initial small-scale study involving 60 patients, using desk top computers, are “that there could be a 20 per cent reduction in paranoia symptoms”, according to Jenny Yiend, a professor of cognitive psychopathology at King’s College London, who is leading the NHS trial of the app.

‘Paranoia is a real problem that can be treated’

“I have long suffered from feelings of paranoia. I tried using the Stop app as part of the research study. After just using it twice I felt my world getting a little bit bigger.”

Dr Thomas Kabir is lived experience adviser on the Stop study and was impressed by the app when he tried it for himself.

“The app showed me a sentence describing a scenario. An example might be: ‘You are walking down the street and you notice that someone is watching you’. After reading the scenario, participants are presented with two tasks: to complete a missing letter in a word and to answer a question. Both tasks encourage people to interpret information in a way that promotes helpful beliefs about themselves and others. You work through many of these scenarios in a single treatment session.

“Before using the app, I thought that I might get bored working through so many different scenarios. But I actually found that the interpretations were quite interesting, and gave me new ideas and ways of looking at things that I hadn’t considered before. For example, if I’m in a coffee shop and it’s taking a long time to be served, I can work through different explanations about why that might be, which makes me feel more relaxed.”

“There simply isn’t enough help for people with paranoia in the NHS,” Kabir, deputy director at The McPin Foundation (a mental health research charity involved in this project), said. “If successful, the Stop approach could be used by anyone with a smartphone.
“I hope that studies like Stop will highlight that paranoia is in fact a real mental health problem that can be successfully treated. It’s time to stop paranoia.”

But it is the number of people who could be helped by the technology – developed by London startup Avegen and King’s College – that could be the real game changer as the demand could be huge.

Between 10 to 15 per cent of the UK population regularly have paranoid and suspicious thoughts – so as many as 10 million people – according to a 2018 King’s College paper.

Professor Yiend said she was “really excited” by the potential of the app to widen access to treatment “to help people manage paranoia” and make it more engaging.

“Apps and other digital therapies won’t be right for everyone,” she said. “But those of us working in this area believe that they could be really helpful for many patients, many of whom might otherwise wait a long time to get in-person treatment.

“Digital therapies can feel impersonal, which some people don’t like. But if you’re the kind of person who finds it hard to open up or trust other people – even therapists – then an app can be a great way to receive treatment.”

And for those who want that help now, the NHS trial – being run by the South London and Maudsley NHS Foundation Trust in London and Bath University, as well as Kings College – is still open to adults living in England who are experiencing distressing thoughts.

The paranoia app (Photo: Avegen)

Professor Murray, who is familiar with the app but not involved in the project, said such solutions were “important to help people manage their thoughts and alleviate some of the pressure on stretched mental healthcare services”.

The app could provide an initial round of treatment for many people experiencing paranoid thoughts and may supplement face to face sessions for others, experts say.

Dr Sarah Bateup, CBT therapist and chief clinical officer at Oliva, the employee mental wellbeing service for companies – also not involved in the project – said: “Innovative, tech-led approaches to therapy like Stop are desperately needed – and have the potential to widen access to mental health care for thousands of people.

“From its early testing, Stop looks like a promising and engaging intervention for treating paranoia, which can be debilitating for all who experience it. I look forward to seeing the results of the ongoing clinical trial.”

But Lucy Schonegevel, associate director for policy and practice at Rethink Mental Illness, the charity which published professor Murray’s schizophrenia report, cautioned: “Digital interventions such as apps have the potential to help people recover from severe mental illness, but only as part of a wider package of care.

“When asked for defining moments in recovery, individuals and their carers frequently highlight the kind and humane support they received from a health professional, which offered them hope for the future.”

Professor Murray said: “Digital approaches are not designed to replace [face to face] CBT. Rather, the aim is that they should both be available as part of a wider system that triages people effectively and ensures they have access to the right level of care at the earliest opportunity.”

How the Stop app reduces paranoia

Stop uses videos, activities and assessments, delivered via a smartphone app, to target a psychological process called “biased interpretation of ambiguity”.

Typically, this process means that people with paranoia will automatically interpret emotionally ambiguous situations in a negative way. But the new technology trains individuals to consider alternative ways of seeing situations, which can drive a reduction in distress-inducing paranoia symptoms.

Sessions involve reading text that could be interpreted in a paranoid way (such as the stare of a stranger which could reflect harmful intentions) and encouraging readers to make the alternative interpretation (such as the stare reflecting harmless curiosity) by using word tasks and questions, in which it directs you to put a positive – or realistic – spin on events.

So, for example, one exercise reads: “You start a new job and hope to be friends with your colleagues. At the end of your first day you ask if people would like to go for a drink but they all say they are too busy.”

It then asks you to fill in the missing word: “You sense they are…ap_l_getic.”

So you are guided to spell the word “apologetic”. The next question is: “You ask again on a different day” and you are given yes/no options.

Professor Jenny Yiend, leading the NHS trial of the app, said: “That’s an ambiguous situation. Have you done something wrong, do you smell, have you not done well or are they just too busy and it doesn’t matter?”

“People with paranoia are concerned about these kind of social situations. In our intervention, we’re encouraging people to think of other ways of interpreting that situation than what might first come to their mind. That core is the same basic idea as what’s happening in a face to face therapy but we’re doing it in a completely different way without a therapist”.

“Each of the scenarios is designed to trigger a possible bad interpretation and we encourage people to open their minds to the alternative by presenting them with the alternative. So here the alternative is actually people are apologetic and they will be quite happy to come out with you the next day if you ask again. They just all happened to be busy. We don’t say that directly. We get them to complete the word ‘apologetic’. We encourage you to think of the positive interpretation. We’re not telling people that this is what they think or should think, we’re just presenting a different way of looking at these situations.”

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