Mrs K has a son and a daughter, both in their 60s. The daughter and 3 of her 4 grown children live nearby; the son lives in a distant city. The daughter, who is divorced, does Mrs K's grocery shopping and also drives her to doctors' appointments.
Cognitively, Mrs K is intact—except for this one glitch: She claims to believe that her grandchildren come in the middle of the night, or when she is away during the day, to steal her possessions and that her daughter knows and approves of this. The "stolen" items include sheets, towels, pots and pans, milk, and orange juice. According to Mrs K, her sterling silver and antiques are being sold and replaced with cheaper items by her grandchildren so they can pocket the difference. These accusations have been made time and again over a period of many years. Mrs K also claims that her phone is being tapped. She puts all the blame for this intrusion on her grandchildren and does not feel that either the phone company or the government is involved. According to Mrs K, the grandchildren listen in on her phone calls because they want to know when she is going to sell her house and when they will receive their inheritance.
Mrs K alleges that her grandchildren steal from her and covet her money because things are not going well for them. Being reminded that 3 of the grandchildren have good jobs and that the fourth has a husband who makes a respectable living does not sway Mrs K from this belief. She has been able to convince herself that her grandchildren need the money they steal from her to survive and that she is their savior. Mrs K's extreme hostility toward her family, manifested in many ways over many years, appears to be transformed through this self-deception into an act of their betrayal. The ultimate reason for this harsh criticism is opaque, but there has always been something about her family's success and happiness that has threatened her and tweaked her envy.
Mrs K clearly meets criteria for what DSM-IV designates as delusional disorder, persecutory type.2 Though she has often directed outbursts of anger tinged with paranoia at family members, she has never shown any indication of being clinically depressed or even of having had a sustained period of low mood. No case can be made for psychotic depression. Mrs K has never been manic or hypomanic. Neither she nor any of her blood relatives have ever had a mental disorder diagnosed.
The meaning of paranoia
In Paradise Lost, the English poet John Milton (1608-1674) explicitly acknowledged the mind's role in the creation of human experience: "The mind is its own place, and to itself/Can make a heav'n of hell, or a hell of heav'n."3 Closer to our own time, existential philosophers have argued that, by and large, we are free to create and re-create ourselves and to construct our own world and, in the process, create our own heaven or hell, as circumstances allow. Clinicians who subscribe to this idea see many mental disorders as deriving from self-deceiving, inauthentic modes of what the philosopher Martin Heidegger4 called our being-in-the-world (the hyphens here are meant to emphasize the dialectical interaction and inseparability of person and world).
It seems reasonable to ask whether a willed distortion and deformation of a person's "worlded" being could itself be so significant as to produce psychotic thinking, feeling, and behavior.5 A psychosis originating in this way would be a dimensional phenomenon, having meaning and structure, and would be a primary function of the mind, although one that, like all mental activity, also has a brain neural substrate. Those who create a paranoid psychosis as their (indirectly or subconsciously) chosen mode of being-in-the-world can be seen as making the kind of uncalled-for connections, as well as the inevitable enemies, that those who live in the consensually validated world choose not to make.
The Jungian analyst John Perry, MD,6 understands paranoia as a weakening of the ego's rational controls, whereby the id breaks through to take charge: "Energy goes out of the ego into the subconscious, which then becomes the person's whole world." Mrs K's accusations have a nightmarish, diabolical quality. This part of her world is not controlled by reason, but by primitive processes set loose by what appears to be hatred of her family. The more her children and grandchildren do for her, the more she accuses them. Their attempts to demonstrate the absurdity of her taunts are immediately and vigorously absorbed into her existing delusional belief and are neutralized by it.