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Schizophrenia Research
Published as: Schizophr Res. 2009 March ; 108(1-3): 280284.

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Insomnia and paranoia

Daniel Freeman, Katherine Pugh, Natasha Vorontsova, and Laura Southgate
Department of Psychology, Institute of Psychiatry, King's College London, United Kingdom.

Abstract

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Insomnia is a potential cause of anxiety, depression, and anomalies of experience; separate research
has shown that anxiety, depression and anomalies of experience are predictors of paranoia. Thus
insomnia may contribute to the formation and maintenance of persecutory ideation. The aim was to
examine for the first time the association of insomnia symptoms and paranoia in the general
population and the extent of insomnia in individuals with persecutory delusions attending psychiatric
services. Assessments of insomnia, persecutory ideation, anxiety, and depression were completed
by 300 individuals from the general population and 30 individuals with persecutory delusions and a
diagnosis of non-affective psychosis. Insomnia symptoms were clearly associated with higher levels
of persecutory ideation. Consistent with the theoretical understanding of paranoia, the association
was partly explained by the presence of anxiety and depression. Moderate or severe insomnia was
present in more than 50% of the delusions group. The study provides the first direct evidence that
insomnia is common in individuals with high levels of paranoia. It is plausible that sleep difficulties
contribute to the development of persecutory ideation. The intriguing implication is that insomnia
interventions for this group could have the added benefit of lessening paranoia.

Keywords
Delusions; Persecutory; Paranoia; Insomnia; Psychosis

1Introduction

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Clinical experience indicates that many individuals with persecutory delusions have difficulties
initiating and maintaining sleep. The extent of the problem has never been reported. Often the
insomnia is simply a result of insufficient activity during the day and early retirement to bed.
However the relationship between insomnia and paranoia may hold greater clinical and
theoretical interest. The stressful experience of insomnia may lead to the lowering of mood
and anomalies of experience that drive persecutory ideation. The intriguing clinical implication
is that simple well-established interventions for sleep difficulties could lessen paranoid
experience.
There is evidence consistent with the idea that sleep disturbance has a role in the development
of paranoia. Insomnia is a risk factor for the development of emotional disorder (Ford and

2009 Elsevier B.V.

This document may be redistributed and reused, subject to certain conditions.
Corresponding author. Psychology Department, PO Box 077, Institute of Psychiatry, King's College London, Denmark Hill, London
SE5 8AF, United Kingdom. E-mail: D.Freeman@iop.kcl.ac.uk.
This document was posted here by permission of the publisher. At the time of deposit, it included all changes made during peer review,
copyediting, and publishing. The U.S. National Library of Medicine is responsible for all links within the document and for incorporating
any publisher-supplied amendments or retractions issued subsequently. The published journal article, guaranteed to be such by Elsevier,
is available for free, on ScienceDirect.

Freeman et al.

Page 2

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Kamerow, 1989; Breslau et al., 1996; Morphy et al., 2007) and an association with daytime
mood disturbance has been repeatedly demonstrated (Riedel and Lichstein, 2000; Buysse et
al., 2007). In separate research, paranoia has been strongly linked with negative affect (Freeman
et al., 2008b; Bentall et al., in press), even being considered a type of anxious fear (Freeman
and Freeman, 2008). Therefore insomnia may be one cause of the negative mood that leads to
paranoia. Anomalies of experience such as perceptual distortions and hallucinations are also
considered a key cause of paranoia (Maher, 1988; Freeman et al., 2008a); therefore it is
germane that sleep deprivation has long been noted to produce temporary psychotic-like
experiences (Luby et al., 1960; West et al., 1962). Sleep difficulties are a common prodromal
feature of schizophrenia (Birchwood et al., 1989; Yung and McGorry, 1996) and even in
unmedicated patients with schizophrenia there is evidence of increased sleep latency and
decreased total sleep time (Chouinard et al., 2004). At a neurobiological level it has been
suggested that the overactivity of dopamine D2 receptors in the striatum thought to underlie
the positive symptoms of schizophrenia also enhances wakefulness (Monti and Monti, 2005).

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Recent research demonstrates that paranoid thinking is much more common in the general
population than previously thought (Freeman et al., 2008b). A high prevalence of insomnia
has been recognised for longer. Approximately 30% of the general population experience
symptoms of insomnia, with a third of this group having chronic insomnia (Ohayon, 2002;
Walsh, 2004; Morin et al., 2006). This sleep disturbance is associated with anxiety and
depression (Taylor et al., 2005; Breslau et al., 1996; Buckner et al., 2008); indeed, difficulties
falling or staying asleep are a symptom of the diagnoses of depression, generalised anxiety
disorder, and post-traumatic stress disorder (APA, 2000). In the current study the aim was to
determine whether persecutory ideation and insomnia are associated. A community sample
was used to obtain a range in paranoia severity and avoid the complicating issues of neuroleptic
medication and high levels of inactivity. At the same time the occurrence of insomnia in a
group of patients with persecutory delusions attending psychiatric services for psychosis was
also examined.

2Method
2.1Participants

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The community sample comprised 300 individuals. There were three entry criteria: aged 18 or
above; able to read and write in English; and no history of treatment for severe mental illness
(e.g. schizophrenia, bipolar disorder). The sample was recruited via the distribution to local
postcodes of leaflets advertising research studies at King's College London. Those who
responded to the leaflet were screened for the entry criteria over the telephone. Questionnaires
were then completed at King's College London, by postal return or an Internet website (only
available to screened individuals). The clinical group was recruited from adult services in the
South London and Maudsley NHS Foundation Trust. The entry criteria were the presence of
a current persecutory delusion, which met the criteria of Freeman and Garety (2000), and a
clinical diagnosis of schizophrenia, schizo-affective disorder, or delusional disorder (i.e.
nonaffective psychosis).
2.2Measures
2.2.1Insomnia Severity Index (ISI) (Bastien et al., 2001)The ISI is a seven-item
self-report questionnaire based upon the insomnia criteria of the Diagnostic and Statistical
Manual of Mental Disorders (APA, 1994). The scale assesses sleep-onset and sleep
maintenance difficulties, associated distress, and interference with daily functioning. Each item
is rated on a 04 scale. The time period is the past fortnight. Higher scores indicate the presence
of symptoms of insomnia. The scale was evaluated in a sample of over two hundred individuals
attending a sleep disorders clinic, and has been repeatedly used in insomnia studies (Buckner

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Page 3

et al., 2008; Savard et al., 2005; Bernert et al., 2007). The questionnaire shows convergent
validity with daily sleep diaries, significant other reports and clinician ratings. In the current
study the scale showed high internal reliability (Cronbach's Alpha = .89). The guidelines for
the interpretation of scores are: no clinically significant insomnia (07), subthreshold insomnia
(814), clinical insomnia of moderate severity (1521) and severe clinical insomnia (2228).

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2.2.2Sleep-50 Questionnaire (Spoormaker et al., 2005)The nine-item insomnia

subscale of the Sleep-50 Questionnaire assesses difficulties falling and staying asleep over the
past month, but not interference with daily functioning. Each item is rated on a scale of 1 to 4.
Higher scores indicate the presence of symptoms of insomnia. The scale was psychometrically
evaluated in a sample of 400 students and 250 sleep clinic patients. In the current study the
internal reliability of the scale was high (Cronbach's Alpha = .88). Clinical insomnia is
indicated by a score of 19 or above.

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2.2.3Green et al. Paranoid Thoughts Scale Part B (Green et al., 2008)The

G-PTS Part B is a self-report measure of the occurrence of persecutory ideation in the past
month. Each of the sixteen items (e.g. I was convinced there was a conspiracy against me,
Certain individuals have had it in for me, I have definitely been persecuted) is rated on a
scale from 1 to 5, and conforms to a clear definition of persecutory ideation (Freeman and
Garety, 2000). The total score can range from 16 to 80. Higher scores indicate greater levels
of persecutory thinking. The questionnaire has been psychometrically evaluated for use in both
clinical and non-clinical populations. The internal consistency of the scale and testretest
reliability are good. Convergent validity with the Paranoia Scale (Fenigstein and Vanable,
1992) has been shown. In the current study the scale had very high internal reliability
(Cronbach's Alpha = .94).
2.2.4Depression Anxiety Stress Scales (Lovibond and Lovibond, 1995)The
DASS is a 42-item instrument with three subscales measuring symptoms of depression,
anxiety, and stress over the past week. Each of the subscales consists of 14 items with a 03
scale (0 = did not apply to me at all, 3 = applied to me very much). Higher scores indicate
higher levels of emotional distress. The scale has been shown to be reliable and valid in large
clinical and non-clinical populations (Brown et al., 1997; Crawford and Henry, 2003; Page et
al., 2007). The anxiety and depression sub-scales were used; each showed very high internal
reliability in the current study (Anxiety Cronbach's Alpha = .91, Depression Cronbach's
Alpha = .96). There are no items on the scales that assess sleep difficulties.
2.3Analysis

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Analyses were carried out using Stata Version 10.0 (StataCorp, 2008). Visual inspection
showed that the measures of persecutory ideation, anxiety and depression in the community
sample all showed considerable positive skew; 46.7%, 34.3% and 31.0% had the minimum
scores on the measures of paranoia, depression and anxiety respectively. These variables were
therefore recoded into ordinal categories: Paranoia (16, 1720, 2124, 2528, 29+), Depression
(0, 13, 46, 79, 1012, 13+), Anxiety (0, 13, 46, 79, 10+). The main analyses were ordinal
logistic regressions (using the Stata ologit command) with paranoia as the dependent variable.
In the first stage insomnia was the independent variable (controlling for age, sex, and working
status). In the second stage depression was added as an additional independent variable. In the
final stage anxiety was added to the model. This procedure was carried out separately for each
of the insomnia scales. There were no missing data. The models were repeated adding the data
for ethnicity and education level, which had missing data for three cases, but the results were
unaltered. 95% Confidence Intervals (CI) are reported.

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3Results
3.1Community group

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The community group comprised 140 men and 160 women. The mean age was 37.7
(SD = 12.5). The reported ethnicities were: White (n = 216), Black-Caribbean (n = 16), Black
African (n = 18), Black-Other (n = 6), Indian (n = 6), Pakistani (n = 1), and other (n = 35). One
hundred and six participants were working full-time, seventy were working part-time, thirteen
were retired, sixty-four were unemployed and forty-seven were students. The educational
qualifications were: none (n = 19), GCSE (n = 57), AS/A-level (n = 41), diploma (n = 32),
degree (n = 97), postgraduate degree (n = 53).
Scores on the measures are shown in Table 1. Based on the Insomnia Severity Index, 216 (72%)
participants had no clinically significant insomnia, 62 (20.7%) participants had sub-threshold
insomnia, 17 (5.7%) participants had clinical insomnia of moderate severity and 5 (1.7%)
participants had severe clinical insomnia. Therefore 28% of the community sample had some
degree of sleep difficulty. There was a high correlation between ISI and Sleep-50 Insomnia
scores, r = .83, p < .001. Forty-six individuals (15.3%) scored above the cut-off on the Sleep-50,
indicating potential clinical insomnia.

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Ordinal logistic regressions examining the association of paranoia and insomnia are reported
in Table 2. There is a strong association of the insomnia scales with paranoia. For the
interpretation of the results it should be remembered that the odds ratios for the insomnia scales
refer to one-point changes. A ten-point increase in the Insomnia Severity Index is associated
with an odds ratio of 4.4 for an increase in paranoia category (1.16 raised to the power of 10).
A ten-point increase on the Sleep-50 scale is associated with an odds ratio of 6.2 for an increase
along the paranoia ordinal scale. 70% of those in the highest category of paranoia scores had
at least sub-threshold insomnia difficulties as assessed by the ISI, whereas this was the case
for only 17% of the participants without any paranoid ideation. On the Sleep-50 questionnaire,
59% in the highest paranoia category scored above the cut-off for insomnia, whereas only 8%
in the lowest paranoia category scored similarly. It can be seen that when depression is added
to the regression models that the relationship of insomnia to paranoia is lessened but that there
is a unique contribution of each variable to predicting paranoia scores. When anxiety is added
then the relationship of insomnia to paranoia is lessened substantially further, becoming
statistically non-significant for the ISI.
3.2Clinical group

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The persecutory delusions group comprised 18 men and 12 women. The mean age was 44.2
(SD = 11.7). The reported ethnicities were: White (n = 16), Black-Caribbean (n = 3), Black
African (n = 5), Black-Other (n = 3), Indian (n = 1), and other (n = 2). Twenty-two patients
were unemployed, three were working part-time, three were retired, and one was a student.
The educational qualifications were: none (n = 6), GCSE (n = 10), AS/A-level (n = 5), diploma
(n = 6), degree (n = 1), postgraduate degree (n = 2). The diagnoses were: schizophrenia
(n = 24), schizo-affective disorder (n = 4) and delusional disorder (n = 2). Antipsychotic
medication data were converted into chlorpromazine equivalents grouped into low (0200 mg),
medium (200400 mg) and high ( 400 mg); one person was not taking any medication, eleven
were on a low dose, fourteen were on a medium dose and four were on a high dose. Seven
patients were taking clozapine, seventeen patients were taking other atypical antipsychotics,
and five people were on typical antipsychotic medication. Five patients were being prescribed
two different antipsychotic drugs.
The prevalence of insomnia in the persecutory delusions group as assessed by the ISI was: 27%
(n = 8) severe clinical insomnia, 27% (n = 8) clinical insomnia of moderate severity, and 30%

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(n = 9) subthreshold insomnia. Only 17% (n = 5) had no clinically significant insomnia. There

was a high correlation between ISI and Sleep-50 scores, r = .78, p < .001. Sixty percent
(n = 18) of the persecutory delusions group scored above the Sleep-50 insomnia cut-off. Scores
did not differ by medication level on the ISI, F(2, 26) = .137, p =.872, or the Sleep-50, F
(2,26) = .350, p = .708.

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4Discussion
The rates of sleep difficulties in the community sample were consistent with the
epidemiological literature; almost 30% had symptoms of insomnia and approximately 10%
were in the clinical range. But the unique focus of the study was on a potential association
between sleep difficulties and paranoid thinking. The results were clear: higher levels of
insomnia were associated with higher levels of persecutory thinking. Confirmation was
provided by the high prevalence of insomnia in the individuals with clinical paranoia. Insomnia
is most likely an overlooked problem in psychiatric services for individuals with persecutory
delusions.

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Sleep disturbance is already incorporated into a theoretical account of persecutory delusions

(Freeman et al., 2006), but its role had not been directly tested. In this study the relationship
between sleep and paranoia was largely accounted for by levels of anxiety and depression. This
is unsurprising; both paranoia and sleep difficulties are closely linked with negative affect.
Nevertheless the mediating routes between insomnia and paranoia require closer (and more
rigorous) examination. A second plausible route is via the occurrence of perceptual anomalies.
A lack of sleep may cause a puzzling internal state for the individual that, in the context of
anxiety, is incorrectly attributed to external threat. Study of the mechanisms underlying
insomnia in patients with persecutory delusions is also needed; sleep disturbance may be partly
maintained by established insomnia-related processes such as rumination, attention to sleeprelated threat, and dysfunctional beliefs about sleep (Harvey et al., 2005).

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The representativeness of the samples in the current study is questionable; the community
group was only a minority of the many people leafleted in the local postcodes, while the clinical
group was of a small size. There was also a reliance on self-report assessments. The study
focussed on a specific experience (paranoid ideation), but it could be argued that completion
of a full diagnostic screening interview by the non-clinical population would have provided
information of interest. However the key limitation of the study is the cross-sectional design.
The causal direction of the relationship between insomnia and paranoia is unknown. It is
plausible that the insomnia assessed is simply a consequence of living with paranoid fears,
although a circular relationship between insomnia, anxiety and paranoia is more probable.
Longitudinal studies of the relationships are clearly warranted. A priority is the evaluation of
well-established insomnia interventions (e.g. Espie, 2006; Harvey et al., 2007) for individuals
with delusions. These interventions will provide a stronger test of the causal relationship
between insomnia and paranoia and hold the promise of enhancing the efficacy of treatments
for delusional beliefs.

Role of funding source

Funding for this study was provided by a Fellowship awarded by the Wellcome Trust to Dr.
Daniel Freeman. The Wellcome Trust had no further role in study design; in the collection,
analysis and interpretation of data; in the writing of the report; and in the decision to submit
the paper for publication.

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Contributors
Daniel Freeman designed the study, analysed the data and wrote the paper. Katherine Pugh,
Natasha Vorontsova, and Laura Southgate collected the data and commented upon the
manuscript.

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Conflict of interest
There were no conflicts of interest.

Acknowledgement
The research was funded by a Wellcome Trust Fellowship awarded to Dr. Daniel Freeman.

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Table 1

Questionnaire scores
Community group (N = 300)

Persecutory delusions group (N = 30)

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Mean

SD

Min.Max.

Mean

SD

Min.Max.

Insomnia Severity Index

5.90

5.17

028

15.07

7.34

027

Sleep-50 Insomnia

13.89

4.95

935

23.07

8.44

1136

GPTS-Part B (persecutory
ideation)

19.94

7.85

1673

65.27

13.49

3980

DASS Depression

4.42

6.99

042

26.63

11.17

241

DASS Anxiety

3.32

5.56

038

21.93

10.90

441

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Table 2

Ordinal logistic regressions for the community sample (N = 300) with paranoia as the dependent variable and controlling
for age, sex and work status

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Odds ratio

p-value

95% CI

1. Insomnia Severity Index

1.16

< .001

1.11, 1.22

2. Insomnia Severity Index

1.09

< .001

1.04, 1.15

Depression

1.73

< .001

1.46, 2.03

3. Insomnia Severity Index

1.04

.180

.98, 1.09

Depression

1.33

.002

1.11, 1.60

Anxiety

2.22

< .001

1.67, 2.96

1. Sleep-50 Insomnia

1.20

< .001

1.14, 1.26

2. Sleep-50 Insomnia

1.13

< .001

1.07, 1.19

Depression

1.67

< .001

1.41, 1.97

3. Sleep-50 Insomnia

1.07

.024

1.01, 1.13

Depression

1.31

.004

1.09, 1.58

Anxiety

2.12

< .001

1.59, 2.82

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