Psychosis, Delusions and Paranoia After ABI: Safe Assessment and Support in Community Settings
Psychosis, delusional beliefs and paranoia can develop after acquired brain injury (ABI), either as a direct neurological consequence or alongside trauma, substance misuse or emerging mental illness. These presentations are frequently misunderstood in community settings, with people labelled as “difficult”, “uncooperative” or “resistant to support”. This article sits within mental health and dual diagnosis in ABI and must be delivered through coherent ABI service models and care pathways that integrate mental health expertise, safeguarding and consistent frontline practice.
Good ABI practice does not attempt to argue people out of delusions, nor does it ignore escalating risk. Instead, it focuses on safety, emotional containment, functional impact and defensible decision-making.
Understanding psychosis after ABI
After ABI, psychotic experiences may include paranoia, fixed false beliefs, misinterpretation of others’ intentions, auditory hallucinations or intense suspiciousness. Cognitive impairment can make it harder for individuals to reality-test, reflect or recognise deterioration. Stress, fatigue, pain, isolation and substance use can significantly amplify symptoms.
Critically, ABI-related psychosis often fluctuates. People may appear settled one day and highly distressed the next, which can confuse staff and lead to inconsistent responses unless clear frameworks are in place.
Operational example 1: Paranoia about staff intent
A man with ABI believed support staff were stealing from him and reporting him to authorities. He repeatedly refused visits and threatened complaints.
The provider shifted practice away from reassurance or contradiction. Day-to-day delivery focused on consistency: the same small staff team, transparent routines (showing paperwork, explaining actions step-by-step), and predictable visit structures. Concerns were acknowledged without validating the belief (“I can see this feels frightening”). Incidents and statements were logged carefully, enabling mental health referral. Effectiveness was evidenced through improved engagement, fewer refusals and reduced escalation to complaints over three months.
Operational example 2: Delusional beliefs driving unsafe behaviour
A woman with ABI believed neighbours were poisoning her food and began throwing meals away, leading to weight loss and dehydration.
The service prioritised physical safety and nutrition while awaiting specialist input. Staff supported meal preparation jointly, used sealed food containers, and documented intake daily. A capacity assessment was completed when decisions around nutrition became complex. Multi-agency working included the GP and mental health services. Outcomes were evidenced through stabilised weight, improved hydration and reduced distress recorded in daily notes and review meetings.
Operational example 3: Escalation into safeguarding risk
A man experiencing persecutory delusions began confronting strangers in public, placing himself at risk of assault.
The provider introduced structured community access planning: time-limited outings, staff accompaniment during high-risk periods, and proactive de-escalation strategies. Safeguarding thresholds were clearly defined, and risk management plans were reviewed weekly. Effectiveness was evidenced by a reduction in incidents, no further police involvement and improved confidence in staff decision-making.
Day-to-day practice principles
Effective ABI services supporting psychosis typically embed the following into everyday delivery:
- Do not challenge delusions directly; focus on feelings and safety.
- Use consistent staff, routines and communication styles.
- Monitor functional impact (sleep, eating, engagement), not just beliefs.
- Record patterns and triggers to inform clinical assessment.
- Escalate early when risk increases; do not wait for crisis.
Governance and assurance
Psychosis-related risk must be visible in governance systems. Providers should evidence:
- Regular review of risk assessments and mental health indicators.
- Clear escalation pathways to mental health services.
- Supervision records showing staff confidence and reflective practice.
- Capacity assessments where beliefs materially affect decision-making.
Commissioner expectation
Commissioner expectation: commissioners will expect providers to recognise emerging mental health deterioration early, maintain placement stability, and evidence effective partnership working with mental health services. Clear documentation of risk management and outcomes is essential.
Regulator expectation (CQC)
Regulator / inspector expectation (CQC): CQC will expect risks linked to psychosis and paranoia to be identified, assessed and reviewed. Inspectors will look for personalised care, lawful use of any restrictions, and evidence that staff understand how ABI affects perception, judgement and behaviour.
Impact and outcomes
When ABI services respond to psychosis with consistency, clarity and proportionate safeguards, people experience reduced distress and greater stability. Providers benefit from fewer incidents, stronger defensibility and clearer evidence of safe, person-centred care.