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Consider the following claim: “Though present-day Russia poses no threat to it whatsoever, 

 is methodically and persistently expanding its military apparatus in the east of Europe and is implementing an encirclement of Russia from the south….All this leaves no doubt that they are preparing a complete encirclement of Russia, which will be followed by the deprivation of her sovereignty.”

You might think this inflammatory accusation was voiced by a certain Russian dictator who has launched a brutal and unprovoked attack on 

. It may surprise you to learn that the statement was made almost 16 years ago, by the renowned Russian novelist and erstwhile dissident, Alexander Solzhenitsyn (1918-2008).

Now consider the 2015 article, “Russian Society Is Increasingly Paranoid,” by Russian journalist Andrei Malgin published in the 

 Writing in the context of the shoot down of Malaysia Airlines Flight 17 on July 17, 2014, Malgin observed,

“Moscow holds that Ukraine is clearly to blame, and yet it cannot allow a tribunal because [Moscow believes] it would deliberately place the guilt with Russia, as always. Everybody—the whole world—is against Russia. They want to investigate the disaster for the sole purpose of humiliating and accusing Russia. It is the typical logic of the paranoid.”

Can whole societies, or their governments, be truly paranoid in the sense that psychiatrists and psychologists ordinarily use that term (ie, as “relating to or exhibiting extreme distrust or suspiciousness”

)? And does psychiatry have a role to play in helping world leaders understand the psychodynamics of what might be called societal 

I think the answers are complex, and we should acknowledge at once that societies are not ideologically or psychologically homogeneous—and even authoritarian governments typically contain some ideological diversity. That said, I was surprised and somewhat amused to find a 2017 article titled, “Paranoid Government Disorder: A New Global Epidemic?” by Peter Sarosi.

 At the time, Sarosi was director of the Drug Policy Program at the Hungarian Civil Liberties Union. His article seemed, at first glance, to be a clever parody of the DSMs’ “one from column A, two from column B” approach to diagnosis. But I concluded that Sarosi was entirely serious in his claim about paranoid government disorder (PGD).

“Governments with this organizational disorder [PGD] may habitually relate to the world by vigilant scanning of civil society for clues or suggestions that may validate their fears or biases,” Sarosi wrote. “Paranoid governments are eager to expand control and surveillance and reduce individual rights. They think they are in danger and look for signs and threats of that danger, potentially not appreciating other evidence….[They demonstrate a] preoccupation with unsubstantiated conspiracy theories about the internal and external enemy.”

Sarosi’s thesis has received some indirect support from studies of “the paranoid style” and “conspiratorial thinking.” A political psychologist, Sander van der Linden, PhD, and colleagues pointed out,

“[R]ight-wing conspiracy theories blaming liberals, Jews, immigrants, foreigners, journalists, academics, and other secret cabals for domestic and international problems—including plans for an alleged “replacement” of the White Christian population with non-White Muslims—have gained political currency throughout Europe....”

The authors noted that this pattern seems particularly evident in countries “where right-wing authoritarianism is in the ascendancy,” such as Hungary and Austria. That said, conspiracy theories also abound in the US, as my colleague Joseph M. Pierre, MD, and I have discussed in detail.

There is, of course, that well-worn quip, “Just because you are paranoid does not mean they are not after you!” And some might argue that 

, for example, has some understandable reasons for fearing complete encirclement by NATO—a geopolitical controversy that would take me far afield.

 Instead, I want to return to the question I raised earlier: Does psychiatry have a constructive role to play in helping world leaders understand the psychodynamics of societal paranoia?

Let us begin by acknowledging that psychiatry already has its hands full, dealing with pressing problems of untreated serious mental illness, a fragmented nonsystem of health care, and limited access to psychiatric services. Should we not focus on these urgent matters before getting tangled up in the ambiguities of PGD? Aren’t such issues best left to fields like sociology and cultural anthropology—and to professional diplomats?

The clinician in me says, “Yes—our first priority is the care and treatment of patients who are suffering with serious psychiatric illnesses.” Indeed, there are serious risks in the unwarranted extension of psychiatry into the political and societal realms, as psychiatrist Robert Cancro, MD, has cautioned

“[P]sychiatry has had increasing difficulty in setting boundaries for itself. Where[as] at one time, it cared for individuals with certain illnesses, it is now attempting to treat societies and to advise on the discomforts inherent in the process of living….There is reason to believe this stance is of greater value to the personal narcissism of the psychiatrist than to the solution of problems. Especially since the end of World War II, psychiatry has been looked to as a source of solutions for problems ranging from alcoholism to prison reforms. Failure was inevitable. No field could possibly fulfill the vast expectations generated by the mental health movement.”

And yet, I think psychiatry does have a constructive role to play in the understanding of societal paranoia and how it may lead to 

Here I turn to the work of the late David A. Hamburg, MD, who died in 2019 at the age of 93. Trained as a psychiatrist, Hamburg and former Secretary of State Cyrus Vance launched the Carnegie Commission on Preventing Deadly Conflict in 1994. In a 2003 interview,

 Hamburg described how conflict resolution and preventive diplomacy can help avert violent conflict between nations. Although he did not specifically mention the role of psychiatry, many of the interventions he discussed fit comfortably in psychiatry’s tool kit. For example, Hamburg cited the need for “ongoing programs of international help—offered by governments, intergovernmental organizations, and also by nongovernmental organizations. These would build the capacity of groups to address grievances effectively without violence and establish permanent mechanisms for sorting out conflicts peacefully before they become explosive.”

Is this not essentially what we do in our clinical work with dysfunctional couples and families? Hamburg added that nonviolent conflict resolution becomes feasible “when most people in a society feel that they have decent life chances, when they are not oppressed and have their basic needs met for child and adolescent development; and [when they] live in a social environment conducive to attachment, hope, physical security, and reliable standard of living.”

Am I claiming, grandiosely, that psychiatrists can—or should—put an entire society on the couch and try to mitigate its paranoid tendencies? Obviously not. But I believe we can help diplomats and negotiators understand how paranoid and conspiratorial thinking starts—for example, by identifying the risk factors for a society becoming a hotbed of 

 and conspiracy theories. One caveat: Not all conspiracy theories are false, although most prove to be.

Sarosi lists several causes or risk factors for PGD,4 including weak civil society, unstable democratic institutions, significant inequality, and systemic corruption (

). But perhaps psychosocial risk factors can also be identified and remedied. For example, Van der Linden et al noted that conspiratorial thinking is associated with paranoia, narcissism, interpersonal distrust, feelings of powerlessness, lack of agency and control, uncertainty, and low levels of education and intelligence, as well as “magical thinking,” defined as the superstitious tendency to draw false inferences about causal relationships.

In the case of Russia—and perhaps other countries—a pervasive sense of national humiliation may also be driving some conspiratorial thinking within the government. In this regard, Michael Brenner, PhD, professor emeritus of international affairs at the University of Pittsburgh in Pennsylvania, wrote in an email to me on February 28, 2022:

“Russia’s actions in the Ukraine [are] to a great extent…the culmination of the numerous humiliations that the West, under American instigation, has inflicted on Russia’s rulers and the country as a whole over the past 30 years.”

Psychiatrists—who know something about shame and humiliation—could be helpful in identifying societies in which such psychological risk factors are pronounced, with an eye toward heading off conspiracy-inspired conflict.

Yes, I know it all sounds a bit utopian, and maybe even hubristic. Some may argue that psychiatrists have no more to offer in these respects than say, seasoned diplomats. But as medical specialists who understand the risk factors for violence, paranoia, and conspiratorial thinking, I believe psychiatrists are in a unique position to serve as consultants to intergovernmental organizations dedicated to conflict resolution.

is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and editor in chief emeritus of 

Dr Pies is the author of several books. A collection of his works can be found on Amazon.

 April 29, 2006. Accessed March 1, 2022. 

https://www.theamericanconservative.com/larison/good-for-solzhenitsyn/

2. Malgin A. Russian society is increasingly paranoid. 

https://www.themoscowtimes.com/2015/07/29/russian-society-is-increasingly-paranoid-a48629

3. Paranoid. American Psychological Association. Accessed March 1, 2022. 

4. Sarosi P. Paranoid government disorder: a new global epidemic? Civil Liberties Union for Europe. January 23, 2017. Accessed March 1, 2022. 

https://www.liberties.eu/en/stories/paranoid-government-disorder/11272

5. Van der Linden S, Panagopoulos C, Azevedo F, Jost JT. 

The paranoid style in American politics revisited: an ideological asymmetry in conspiratorial thinking.

6. Pies RW, Pierre J. Believing in conspiracy theories is not delusional. 

February 4, 2021. Accessed March 1, 2022. 

https://www.medscape.com/viewarticle/945290

7. Guyer J. How America’s NATO expansion obsession plays into the Ukraine crisis. 

 Updated January 27, 2022. Accessed March 1, 2022. 

https://www.vox.com/22900113/nato-ukraine-russia-crisis-clinton-expansion

8. Cancro R. Some psychiatric considerations on the etiology of war. In: Nettleship MA, Givens D, eds. 

9. Dean JW. Making war unnecessary: an interview with Dr. David Hamburg. FindLaw. December 5, 2003. Accessed March 1, 2022. 

https://supreme.findlaw.com/legal-commentary/making-war-unnecessary.html

Psychiatrists are in a unique position to serve as consultants to intergovernmental organizations dedicated to conflict resolution. Learn more here. 

Does Russia Suffer From "Paranoid Government Disorder”?

Sometimes, on a summer Sunday, I sit outside on my covered porch and contemplate my shade garden. During that time, I also think about my patients, and the lessons that my garden has taught me about them. It may sound strange to compare patients to plants—so let me explain.

Before we became physicians, and even before we started medical school, we were premeds, studying basic biology as well as botany. In Biology 101, we learned about animal habitats and which animals thrive in which habitats, and which would not survive in those same circumstances. Some settings are suitable for some creatures, whereas others are not. Polar bears, for instance, do well in the cold and the snow, whereas tropical birds and butterflies require the opposite conditions. Move those polar bears into the Amazon, and those polar bears will be no more. Many of us learned similar basic biology lessons much sooner, simply from visiting zoos.

Since most of us do not keep polar bears in our backyards, I will not belabor the point and will not pontificate about animals and ecology. Better to talk about gardens, which are more common.

In the popular imagination, gardens need sunshine, as well as good soil, and the right amount of rain, so that roses and so many other beautiful sun-loving flowers can grow. Yet I can look out on my shade garden and see many other lovely flowers which were planted or potted. To my right, are stairsteps covered with caladiums, of many different varieties. I wish I could list each species by name, but I can say with certainty that all their leaves come in a magnificent array of colors, with each leaf shaped like an elongated heart. Some are a dusty red, with green borders, and some are green with red trim. Some have green veins running though reds, whereas others are white, with green stripes, and so on. There are so many permutations to these shade flowers, and so many variations—but they share one thing—they need shade and may wither and die in full sun.

A few feet above those stair steps sits a balcony, surrounded by white fencing, some of which remains in the shade, and some of which continues into the sun. From those railings that rest above the caladiums hang scrolled wire baskets, filled with begonias. Some begonias are off-white, while others are pale pink, and yet more are coral or a deeper red that many might call vermillion. The colors and textures of the begonias play off the translucent shades of the caladiums below, although the shapes and sizes of the begonias are dramatically different from the large, elongated leaves of the caladium. But begonias and caladium have something in common: both prefer shade and cannot tolerate the sun.

While I applaud many advances in our field that help patients lead more productive and more pleasant lives, I sometimes think that we can help some even more by helping them find their own natural habitat.

If you will bear with me just a little bit more, let me mention one more garden, straight ahead of me, in full frontal view, shaded by towering pine trees that drop sticky pinecones each fall. By this time of the summer, the hostas are in full bloom, having grown wider and taller each year. They, too, come in many different hues, and many different varieties, even though each of them is some shade of green. A true horticulturist could name each and every one, but I am content to call each of them beautiful, with no need to know more for now. In the sweltering heat of summer, they sprout long stems with pale lilac flowers. In the early spring, those same rows are occupied by pink daffodils that also thrive in the shade, in contrast to their better-known cousins that demand full sun. I adore those sun-loving narcissi also, with their yellow and orange and gold trumpet-shaped crowns, and which proclaim the start of spring.

I could go on and on about each plant, shrub, and flower in my gardens, but let me explain why I am comparing plants to patients.

Patients Who Found Their Place in the Shade

As humans, we have the hubris to believe that we can change nature and impose our wills on biology (hurricanes, wildfires, and floods notwithstanding). Sometimes we can succeed at altering the course of nature, and often, we should—but not always. For sure, human-made irrigation systems made Israel’s deserts bloom, replacing sand with fruit trees to feed the population. Without surgical interventions, children born with club feet could be left with lifelong limps, unable to ambulate fully. And so on and so forth. Yes, modern medicine has worked miracles for many, often offering longer and healthier lives. But how does psychiatry fit into this picture and how does that impact psychopharmacology in particular?

While I applaud many advances in our field that help patients lead more productive and more pleasant lives, I sometimes think that we can help some even more by helping them find their own natural habitat—even if it is not an environment that is envied by others.

Let me provide 2 patient examples to dramatize this point. Let me call one “Ms A” and the other “Mr B.” Ms A was already an attorney, albeit one who hated reading and writing—and especially arguing. Yet she chose law on the advice of her parents, who dismissed her wish to become a baker, unmoved by the wonderful creations she made for friends and family. Ms A did well in grade school, high school, and college, well enough to be admitted to law school. Yet her concentration dropped as she studied legal details that held little interest for her. A local doctor diagnosed her with attention-deficit/hyperactivity disorder and started her on stimulants, despite the absence of an early history of attention problems, and apparently without inquiring about her interest in the subjects that she studied. With these pharmaceutical aids, she earned her JD, passed the bar, and was hired by a mid-sized law firm in midtown Manhattan. Although her parents were thrilled by her seeming success, (her analogue to a garden’s sunshine), she was unhappy sitting at a desk, staring at a computer screen, when she wanted to be baking.

Because she was so unhappy, she went to each happy hour after work, and soon enough developed an alcohol use disorder. She started coming in late for work when she was not calling in sick. Luckily, the bar association offered help to their members and referred her to treatment, which by this time included antidepressants as well as anti-craving medications. We also added behavioral activation to encourage her to engage in pleasurable activities (and to increase the odds of overcoming depression, as reported in 

Instead of idling away her after-work hours at local watering holes, she signed up for culinary classes. Her mood brightened enough, and her concentration cleared enough, for her to decide on her own to complete a culinary certificate and to change careers. As she put it, she preferred to “knead dough” rather than to make more dough. No longer sitting in a chair for hours on end, she could wander around a commercial kitchen at will. She decided that she no longer needed the stimulants that were prescribed to push her through an education that she disdained. In short, she found her shade garden where she could not just survive, but thrive—even if it was not the sunny rose garden that her parents recommended.

Mr B’s situation was somewhat different. Always a shy man, Mr B found solace in his college computer classes that required limited human interaction—and that also promised a bright financial future. It came as no surprise that he landed a good-paying coding job after graduation, but it was an unpleasant surprise when he became paranoid while working in a large open space rather than a confined cubicle. Soon enough, he accused coworkers of plotting against him, and engaged in enough arguments to lose the job. He never had frank auditory hallucinations—only barely audible intermittent whispers—but, in hindsight, his evolving symptoms sounded ominous. It was easy enough to find another job, given his high-level coding skills and the high demand for such skills, and it was surprisingly easy to squash those emerging psychiatric symptoms with a low dose of an atypical antipsychotic.

All might have worked well, had he not developed involuntary facial twitches from his new medication. To avert worse consequences in the future, he reluctantly agreed to stop the medication, even though it had brought him so much relief. We substituted cognitive behavioral therapy techniques instead, and watchful waiting. Then, Mr B was literally saved by the pandemic. Everyone in his office was forced to work from home. Without the untenable proximity to his coworkers, his paranoid symptoms abated, even in the absence of medication. The erratic whispers evaporated. Even his productivity improved, and his supervisor commended him. When the company owners spoke about reopening the office, we opted to request accommodation under the Americans with Disabilities Act, which would allow him to work from his family’s home. Better to work from home than to wind up in a hospital setting, should his rudimentary symptoms return and progress to a full-blown schizophrenic break, which could impair his cognition in the future and interfere with his employability. For Mr B, his home office was his shade garden, where he could survive and thrive.

Is there a moral to this story and a special message to psychiatrists? Yes, there is. These 2 cases of 

 demonstrate the interactions between humans and their environments.

I wish I could claim to have discovered the concept of human ecology, but I cannot. This term was coined many decades earlier. Although we discuss the impact of climate change on human well-being, human ecology is not a concept that we typically discuss in contemporary psychiatry, but perhaps this concept deserves consideration. The concept of human ecology traces back to Carl Linnaeus, MD, whose name we heard in those biology and botany premedical courses taken while we were 

 to becoming physicians. Linnaeus is best remembered as a taxonomist who categorized both animals and plants—but he was much more than that. Linnaeus was both a botanist and a physician who probably would have appreciated how gazing at gardens can add insights into treating patients.

is assistant clinical professor of Psychiatry and Behavioral Sciences at Icahn School of Medicine at Mt Sinai, New York, NY.

1. Park LT, Zarate CA Jr. Depression in the primary care setting. 

Different flowers need different levels of light, water, and shade. What would it mean to treat patients with a similar amount of care? 

Lessons From my Garden About Patient Care

Paranoia, or fear of deliberate harm from others, is among the most common symptoms of schizophrenia-spectrum psychoses, and it also occurs in emotional disorders and other severe mental illnesses, placing 

 on the lives of patients and their families.

 Innovative therapeutic interventions are desperately needed to overcome paranoia and improve outcomes.

Existing therapies, whether pharmacological or psychotherapeutic, have widely recognized limitations in engagement, adherence, and effectiveness. Antipsychotic medication is the mainstay of treatment for most patients. However, distressing symptoms persist in 

 of those who take them, functional outcomes are frequently poor, and many discontinue treatment periodically or permanently, concerned about adverse effects, such as weight gain and metabolic syndrome.

 Psychological therapies, such as cognitive behavioral therapy for psychosis (CBTp), have been shown to improve psychotic symptoms, including paranoia, when added to treatment as usual in large clinical trials.

 But effects need to be improved, and implementation in routine care is poor. Individuals are often not willing or able to access and make use of therapy, particularly those from minoritized groups. There is a scarcity of trained therapists, with estimates suggesting only 0.3% of mental health consumers in the United States have access to CBTp.

A transformation in psychosis care is needed; digital technology has the potential to deliver it by improving the patient experience, therapy effectiveness, and 

 Digital interfaces can be designed to support personalization and accessibility, and they can assist engagement and adherence. Web and mobile technologies are also more readily scaled up than traditional interventions and can be designed to reduce training demands.

A New Frontier: Digital Therapeutics for Paranoia

To the best of our knowledge, metacognitive training (MCT), developed by Steffen Moritz, PhD, MSc, and colleagues, was the first psychological intervention for delusional beliefs that incorporated technology. It used desktop programming and presentation software to provide illustrative games and tasks. Group versions of this training approach were shown to have small to moderate effects on delusions, although it is important to note that patients with severe delusions were excluded and the basic digital materials were not personalized, limiting its ability to address challenges to therapy accessibility and adherence. More recently, individualized delivery of metacognitive therapy (MCT+) has been developed and evidence suggests it may have better effects on delusions, though there are only a few relatively

Building on this pioneering work, recent digital therapeutics for psychosis have sought to harness innovative technology such as virtual reality, social networking, mobile apps, and web-based therapies. Whilst preliminary findings are encouraging, few of these have been tested in large clinical trials, and those 

 In 1 of the largest trials to date, Depp et al (2019)

 investigated the effects of augmenting a single session of CBTp with an app, CBT2Go, compared to a single session of self-monitoring supported by an app or treatment as usual (TAU), in individuals with severe mental illness (N = 255). They found a small effect on general symptomatology favoring the CBT2Go and self-monitoring conditions over TAU. However, the impact on paranoia was not specifically examined, and the authors also note that baseline levels of psychosis symptoms were low. The FOCUS mobile app adopts a similar therapeutic approach, although it was investigated as a standalone app to support self-management in its most rigorous evaluation. Ben-Zeev et al (2019)

 compared FOCUS to a recovery group intervention in 163 patients with severe mental illness. They found no between-group differences on clinical outcomes, nor any within-group changes in psychosis symptoms.

These trials suggest that app-based technologies may safely and acceptably augment therapy for paranoia although, but they have yet to demonstrate meaningful clinical outcomes in robust designs. Crucially, there is little evidence that digital therapeutics have been designed to address healthcare inequalities. Indeed, emerging findings indicate digital therapies may actually exacerbate exclusion, with those from privileged demographic groups more likely to access and benefit from them.

In addressing the challenge of transforming psychosis care, we have developed SlowMo, an innovative digitally supported therapy for paranoia. SlowMo is based on the principles of CBTp and leverages technology to address health care inequalities, through enhancing therapy appeal and user friendliness for a 

 SlowMo therapy targets an evidence-based mechanism, or active ingredient, that we and others have shown can fuel paranoia.

 Drawing on the term popularized by Daniel Kahneman, PhD,

, comprising of a jumping to conclusions bias (forming rapid judgements using limited information) and belief inflexibility bias (reduced capacity for reflecting on one’s own beliefs, changing them in the light of new evidence, and considering alternatives). SlowMo is designed to help patients to slow down for a moment, encouraging awareness of a tendency to jump to conclusions and find new ways of feeling safer.

We followed human-centered design principles in the hopes of improving the user experience of therapy and radically enhancing engagement and adherence.

 Our multidisciplinary collaboration of individuals with lived experience, industrial designers, software developers, clinicians, and researchers developed SlowMo over 3 years through 7 cycles of prototyping. To address health care inequalities, we codesigned with stakeholders from diverse demographic backgrounds, who could identify therapy barriers and facilitators, and optimize the inclusivity of the design. SlowMo therapy consists of a web app delivered on a touchscreen laptop to support the delivery of face-to-face individual cognitive-behavioral therapy sessions, which is synchronized with a mobile app for use in daily life (

A Journey of Visualizing Thoughts and Thinking Habits

SlowMo uses new, responsive technologies to support the visualization of thoughts—as bubbles—and their associated thinking habits. This visual concept aims to enhance cognitive therapy by providing an appealing and tangible means of communicating subjective experience. The design minimizes the information processing demands, thereby lowering a significant barrier to engagement with traditional talking therapies. Patients interact with their personalized SlowMo thought bubbles using a touchscreen, altering speed, size, and transparency to reflect related thinking habits, distress, and conviction.

The SlowMo webapp used during sessions presents therapy as a journey, with interactive features including information, animated stories, and games. As well as tailoring worry and positive thought bubbles, patients record key learning points and future plans, with all content synchronized to the mobile phone app for access outside of sessions. The mobile app allows patients to notice their fears and thinking habits as they occur in daily life and helps them to find other ways of managing distressing experiences. It consists of a redesigned CBT thought record for managing paranoia and attempts to overcome the limitations of paper versions, which can be an inaccessible means of support during peak moments of distress. SlowMo uses a native mobile app with opt-in data transfer, addressing patients’ privacy concerns, which was a salient theme during the design research. The mobile app relies on user-initiated interaction and optional push notifications, to accommodate those who wish to have control over their data and find passive monitoring intrusive.

Delivering Evidence-Based Benefits for Recovery in Psychosis

SlowMo therapy has been iteratively developed over the past 10 years, with a number of studies demonstrating the efficacy of previous versions of the 

a large-scale randomized controlled trial

 with N = 362 participants recruited from United Kingdom (UK) clinical psychosis services (

, compared to the minimum 16 sessions recommended by the UK’s National Institute of Health and Care Excellence guidelines for schizophrenia treatment.

Remarkably, despite being half the minimum recommended length, SlowMo had a moderate effect on the measures of delusion severity commonly used in trials (Scales for Assessment of Positive Symptoms, SAPS

 and Psychotic Symptom Rating Scales, PSYRATS

)—for which meta-analyses have found only small effects.

 These positive effects sustained or grew over 6 months, with benefits cascading into other areas, including self-concept, wellbeing, and quality of life. Less consistent improvements were found for referential delusions, meaning that the Green Paranoid Thoughts Scale (GPTS)

 total, which is comprised of ideas of reference and persecution subscales, was not significant at 6 months. However, a psychometrically improved version of this measure, published whilst the trial was being conducted, did reach conventional levels of 

 Importantly, the SlowMo software design appeared to work as intended and was inclusive for a wide range of individuals. Whilst Black people and older patients were found to be less confident and less frequent users of mobile phones prior to doing SlowMo, these differences did not translate to their experience of the therapy, with paranoia outcomes, adherence, and patient experience comparable across groups.

 SlowMo is one of the first digital therapeutics for paranoia to overcome the digital divide associated with age and ethnicity.

The trial also had limitations. First, despite clear improvements in more severe persecutory delusions, consistent improvements were not found in milder referential delusions. One explanation is that SlowMo helped patients manage ideas of reference and their experiential components (eg, being watched by others), which prevented their elaboration into persecutory delusions (eg, being hunted by the mafia) but had less of an effect on directly modifying these underlying ideas of reference. This suggests that digital therapeutics for paranoia need to consider the broader phenomenological context fueling worries.

Accordingly, future versions of SlowMo will incorporate content on how to notice, understand, and manage the sensory-perceptual experiences (including altered salience and anomalous experiences) that are common obstacles to therapeutic change. The trial also did not control for effects of time with a therapist. TAU was chosen as the comparator condition because there is a low penetration of evidence-based psychological treatment in mental health care, thus the key question is whether SlowMo therapy confers benefits over and above standard care. Further, we had previously established the superiority of an earlier brief version of the intervention against an active control intervention, suggesting SlowMo’s positive effects are 

To illustrate SlowMo, Alex (name changed to protect their identity) has kindly agreed to us sharing their experience of therapy. Alex (a Black British Caribbean man in his late 20s) came to therapy reporting a strongly held distressing belief that he was being followed by a past acquaintance who intended to harm him and his family. In early sessions, he used the webapp to visualize these fears as personalized worry bubbles, and to build a picture of his fast thinking, including triggers and the impact on his life (

Alex could view and modify his personalized worry bubbles on the mobile app, which helped him develop an awareness of times when he thought fast. The SlowMo sessions then supported Alex to find ways to slow down for a moment and feel safer.

Alex connected with interactive stories of others discussing their own worries and tendency to jump to conclusions in everyday life. Reflecting on how these stories related to his own experiences, Alex audio-recorded messages to remind him how to slow down his worries. Using SlowMo tips, he created colorful, safer thought bubbles as he progressed through the therapy. Crucially, the synchronization of the web app with the mobile app meant that he could access this personalized helpful content (SlowMo strategies, messages and safer thoughts) when he needed them most. This helped him to consider alternative explanations when fast thoughts were triggered in daily life, for example recognizing that screams and laughter on the street could just be “people having fun” and not specifically related to him (see 

). Alex described how the principle of slowing down his thinking became “almost automatic” through early and regular use of the mobile app. By the end of therapy, Alex reported reduced fast thinking, distress, and conviction related to the fear of harm from others. He described how SlowMo therapy had helped him to “slow down…think different, act different, and feel different.”

As discussed in this article and exemplified by the SlowMo approach, therapy is likely to be most effective when it targets evidence-based processes that maintain distress (eg, fast thinking) whilst also being tailored to individual needs. Close attention to the patient experience of therapy is critical to deliver interventions that are accessible, engaging, and memorable.

A guiding principle of SlowMo is that assessment and intervention should include working with the patient in real-life environments, where fears of others are triggered (eg, public transport or crowded markets). This allows therapeutic targets to be understood in the broader context of the individual’s life, including relevant social factors such as experiences of poverty and discrimination.

It is crucial to promote and consolidate helpful learning and embed this into daily life, and digital tools represent a powerful method of achieving this. While SlowMo utilizes carefully designed digital tools, aspects reported by people as helpful (eg, recording and accessing helpful messages) may be replicated in simplified form using functions typically available on mobile devices.

Having found evidence for SlowMo’s efficacy and user friendliness, we are developing a new version for rollout in mental health services, which will build on its strengths while also addressing some of its limitations. We are encouraged by our findings to date, but the reality is that most digital therapeutics fail to be implemented outside of clinical contexts, due to organizational, provider, and consumer barriers.

 Further development is therefore required to deliver the benefits of SlowMo in routine care. Some challenges are beyond the direct control of developers and require governmental and provider intervention, such as access to hardware and data, and opportunities to acquire digital literacy skills. In line with these concerns, the next version of SlowMo will provide training on how to use the software, focus on a broader range of worries, and include additional tools to support therapists in providing evidence-based strategies to their patients. Implementation research is now required to establish whether efficacious digital therapeutics for paranoia can deliver on their promise of being a solution for transforming psychosis care.

is a professor of clinical psychology at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. She is one of the pioneers of cognitive-behavioural therapy for psychosis and has led evaluations of innovative digital therapeutics for psychosis, including AVATAR and SlowMo therapy. 

 is a clinical psychologist lecturer at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. She led on the development of SlowMo therapy and investigates the user experience of digital therapeutics. 

 is a research clinical psychologist at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. He is the therapy lead for the AVATAR and SlowMo therapy teams.

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7. Aref-Adib G, McCloud T, Ross J, et al. Factors affecting implementation of digital health interventions for people with psychosis or bipolar disorder, and their family and friends: a systematic review. 

8. Depp CA, Perivoliotis D, Holden J, et al. Single-session mobile-augmented intervention in serious mental illness: a three-arm randomized controlled trial.

9. Ben-Zeev D, Brian RM, Jonathan G, et al. Mobile health (mHealth) versus clinic-based group intervention for people with serious mental illness: A randomized controlled trial. 

10. Hardy A, Wojdecka A, West J, et al. How inclusive, user-centered design research can improve psychological therapies for psychosis: development of SlowMo. 

11. Kendler KS, Campbell J. Interventionist causal models in psychiatry: repositioning the mind-body problem. 

12. Ward T, Garety PA. Fast and slow thinking in distressing delusions: a review of the literature and implications for targeted therapy. 

14. Garety P, Ward T, Emsley R, et al. Effects of SlowMo, a blended digital therapy targeting reasoning, on paranoia among people with psychosis: a randomized clinical trial. 

15. Garety P, Ward T, Emsley R, , et al

 Digitally supported CBT to reduce paranoia and improve reasoning for people with schizophrenia-spectrum psychosis: the SlowMo RCT. 

16. Haddock G, McCarron J, Tarrier N, Faragher EB. Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales (PSYRATS). 

17. Andreasen NC. The scale for the assessment of positive symptoms (SAPS). The University of Iowa; 1984.

18. Green CE, Freeman D, Kuipers E, et al. Measuring ideas of persecution and social reference: the Green et al. Paranoid Thought Scales (GPTS). 

19. Freeman D, Loe BS, Kingdon D, et al. The revised Green 

, Paranoid Thoughts Scale (R-GPTS): psychometric properties, severity ranges, and clinical cut-offs. 

20. Garety P, Waller H, Emsley R, et al. Cognitive mechanisms of change in delusions: an experimental investigation targeting reasoning to effect change in paranoia. 

21. Hardy A, Ward T, Emsley R, et al. Bridging the ‘digital divide’ in psychological therapies for paranoia in psychosis: The user experience of the SlowMo mobile app. 

22. Greenhalgh T, Wherton J, Papoutsi C, et al. Beyond adoption: a new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies. 

A new digital therapeutic helps patients with psychosis to slow down and manage their fears.

Psychiatry’s Problem With Paranoia—Is Digital Part of the Solution? 

1. Kane JM, Smith JM. Tardive Dyskinesia Prevalence and Risk Factors, 1959 to 1979. 

2. Carbon M, Hsieh CH, Kane JM, Correll CU. Tardive Dyskinesia Prevalence in the Period of Second-Generation Antipsychotic Use: A Meta-Analysis.

3 Solmi M, Pigato G, Kane JM, et al. Clinical risk factors for the development of tardive dyskinesia. 

4 Tenback DE, van Harten PN, van Os J. Non-therapeutic risk factors for onset of tardive dyskinesia in schizophrenia: a meta-analysis. 

5 Zai CC, Maes MS, Tiwari AK, et al. Genetics of tardive dyskinesia: Promising leads and ways forward.

6 Zai CC, Lee FH, Tiwari AK, et al. Investigation of the HSPG2 Gene in Tardive Dyskinesia – New Data and Meta-Analysis.

7. Bakker PR, van Harten PN, van Os J. Antipsychotic-induced tardive dyskinesia and polymorphic variations in COMT, DRD2, CYP1A2, and MnSOD genes: a meta-analysis of pharmacogenetic interactions. 

8. Patsopoulos NA, Ntzani EE, Zintzaras E, et al. CYP2D6 polymorphisms and the risk of tardive dyskinesia in schizophrenia: a meta-analysis. 

9. The American Psychiatric Association Practice Guideline for The Treatment of Patients With Schizophrenia, Third Edition. 2021. https://doi.org/10.1176/appi.books.9780890424841

10. Bergman H, Bhoopathi PS, Soares-Weiser K. Anticholinergic medication for antipsychotic-induced tardive dyskinesia. 

11. El-Sayeh HG, Rathbone J, Soares-Weiser K, Bergman H. 

Non-antipsychotic catecholaminergic drugs for antipsychotic-induced tardive dyskinesia.

12. Soares-Weiser K, Maayan N, Bergman H. 

Vitamin E for antipsychotic-induced tardive dyskinesia.

13. Soares-Weiser K, Rathbone J, Ogawa Y, et al. Miscellaneous treatments for antipsychotic-induced tardive dyskinesia. 

14. Ad1elufosi AO, Abayomi O, Ojo TM. Pyridoxal 5 phosphate for neuroleptic-induced tardive dyskinesia. 

15. Kane JM, Smith JM. Tardive dyskinesia prevalence and risk factors, 1959 to 1979. 

16. Caroff SN, Leong SH, Roberts C, et al. Cumulative Burden of Illness in Veterans With Tardive Dyskinesia and Serious Mental Disorders. 

17. Carroll B, Irwin DE. Health Care Resource Utilization and Costs for Patients with Tardive Dyskinesia. 

18. Guy W. ECDEU assessment manual for psychopharmacology: revised. DHEW Publication No. ADM 76-338. Rockville, MD: US Department of Health, Education, and Welfare, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, NIMH Psychopharmacology Research Branch, Division of Extramural Research Programs; 1976: 534-537.

19. Chouinard G, Ross-Chouinard A, Annable L, Jones B. The extrapyramidal symptom rating scale. 

20. Kalachnik JE, Sprague RL. The dyskinesia Identification System Condensed User Scale (DISCUS): reliability, validity, and a total score cut-off for mentally ill and mentally retarded populations.

21. Casey DE. Tardive dyskinesia: pathophysiology and animal models. 

22. Margolese HC, Chouinard G, Kolivakis TT, et al. Tardive dyskinesia in the era of typical and atypical antipsychotics. Part 1: pathophysiology and mechanisms of induction. 

23. Blanchet PJ, Parent M-T, Rompre PH, Levesque D. Relevance of animal models to human tardive dyskinesia. 

What do we know about TD? What is on the horizon? Take the quiz to learn more.

Tardive Dyskinesia: 8-Question Quiz on What We Know

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

 is the Dr Frances S. Arkin professor and chairman of the department of psychiatry, professor of psychiatry and medicine at Tufts University School of Medicine, and psychiatrist-in-chief at Tufts Medical Center. Dr Summergrad served as the 141st president of the American Psychiatric Association from 2014 to 2015. He is also a past president of the American Association of Chairs of Departments of Psychiatry and is Secretary for Finances of the World Psychiatric Association and a member of the WPA executive committee. Dr Summergrad’s research focuses on mood disorders, medical-psychiatric comorbidity, and health system design. He received the Distinguished Faculty Award from Tufts University School of Medicine in 2015 and the Leadership award of the American Association of Chairs of Departments of Psychiatry in 2018. He was elected to the Honorary Fellowship of the Royal College of Psychiatrists, their highest honor, in 2020. He is the lead editor of the 

 (2020, American Psychiatric Association Publishing).

In many ways, Dr Summergrad exemplifies the best of psychiatric leadership. He has a charismatic and warm persona, an in-depth knowledge of psychiatry’s history, an appreciation of its pluralistic roots in medicine as well as psychoanalysis, and a preference for taking the long view of psychiatry’s development as a field. I was pleased to be able to speak to Dr Summergrad about his intellectual development, his views on psychiatry’s identity, and the challenges facing the medical model and psychiatric classification.

 Perhaps we can begin with the trajectory of your intellectual and philosophical understanding of psychiatry, particularly how you have navigated the psychoanalytic as well as neuroscientific aspects of psychiatry over the course of your career?

 I have been thinking a lot about this, and I do not know that I can separate any of this from certain cardinal experiences of my life. So, I think we will have to take a little detour into my life story and how I entered medicine and psychiatry.

I am a child of the 60s in the sense that I was in college during the 60s. That was an extremely disruptive time in American history for a variety of reasons, and it became a disruptive time in my own life as well. I had been interested in psychiatry well before that, probably since I was 14 or 15 years old. For some reason, I was just pulled towards psychiatry. Maybe it was because I read 

in high school, or because I had also worked at a camp run by a Jewish social welfare organization. There was a cohort of kids at the camp who had emotional and social difficulties. As part of that experience, we learned a bit about how to work with kids who had emotional difficulties, and that also reinforced my interest in psychiatry.

I started college in 1967. Looking back on it, I doubt that I was clinically depressed, but it was definitely an emotionally turbulent period of my life. I was significantly thrown off both by where I was living as well as by my living circumstances. I hated Buffalo and its winters. Going outside in the winter there seemed like crossing Siberia to a New York City native. I was not really prepared for it. And I was a freshmen male living in gender segregated rental housing off campus. During that year, I took a course on the 

, which as you know is one of the foundational texts of Buddhism. I was very much drawn to that course, as well as to another course on Chinese history, but otherwise I felt very disconnected from school. Like probably a lot of other college students at that time, I started smoking cannabis. In the spring of that year, I took LSD—I am certainly not advocating for the casual use of psychedelics or cannabis here—and I had a profoundly religious experience. It was as if I had been dropped into Nirvana, perfection, holiness, oneness. It was a deeply mystical experience, and it also changed my thinking about the 

. It made me think a lot about neurobiology and consciousness, because if a tiny dose of a drug like this could change one’s perception so profoundly, what did that mean regarding how we understand the mind-brain relationship, and relevant to psychiatry, the etiology of mental illness?

Partly as a result of that, I then went on to study Zen Buddhism and considered training as a Buddhist monk. I ended up spending a couple of years doing very intensive Zen Buddhist meditation at a training center in Rochester, New York. There was no drug use of any kind and a fairly ascetic lifestyle. Towards the end of that period, I spent a year in a self-imposed isolation, in a liminal state, because I really felt that I needed to cut out the external messages of the dominant culture to discover what I really wanted to be and do. At the end of this period, I had a couple of important dreams and one of the dreams was extraordinarily powerful, a great dream in the Jungian sense, which basically resolved my dilemma. I woke up and my crisis was over. I knew exactly what I wanted to do and how to integrate the various strands of my life. I knew I wanted to go to medical school and to likely become a psychiatrist.

In this conversation, a former APA president discusses mystical and meditative experiences, reconciling psychoanalysis and neuroscience, and tensions surrounding the medical model. 

Paranoid Schizophrenia

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Psychiatry’s Problem With Paranoia—Is Digital Part of the Solution?

Tardive Dyskinesia: 8-Question Quiz on What We Know

Psychiatry and the Long View: Paul Summergrad, MD

Digital Therapeutics Improves Paranoia

A Potential Schizophrenia Treatment Trial Falls Short

Eliciting the Phenomenon of Schizophrenia From an Autobiographical Narrative

Condemning Torture and Abuse: A Call to Action

The Link Between Immune System Dysregulation and Schizophrenia