Carl Jung⁷ wrote that people with delusions are "consumed by a desire to create a new world system . . . that will enable them to assimilate unknown psychic phenomena and so adapt themselves to their own world." Mrs K may wish to perceive and relate to her family on her own delusional terms so as to exert a degree of control over them that she would not otherwise have. Her delusion isolates her from her family, but that may also suit her purpose. It seems that Mrs K is crazy like a fox: she is as crazy as she needs to be, but not crazier.

I have worked with patients whose paranoia, I was certain, was due to anxiety. Mrs K's paranoia has always seemed to peak at times when things were going well for her family, as if what was good for them was bad for her. The diltiazem she takes was started by her physician after a festive get-together of family and friends at her home culminated in an emergency room visit: chest pain, shortness of breath, light-headedness, and tachycardia came on suddenly at the height of the celebration. Her indisposition was most likely her body responding to the anxiety of a perceived threat from her happy family with the somatic symptoms of a panic attack (her first). After that, Mrs K had no more family get-togethers and no more panic attacks.

Paranoid delusions have been challenged with psychotherapy. R. D. Laing⁸ saw schizophrenic patients as "divided selves" who had cracked psychically under the stress of family and social pressures. Taking a page from the existential philosopher Jean-Paul Sartre, Laing⁹ understood psychosis as "a special strategy that a person invents in order to live in an unlivable situation" (original italics). Laing put as much blame for this break from reality—in what, paradoxically, he saw more as a breakthrough than a breakdown—on pressures external to the patient as on the patient's inability to deal authentically with these pressures and overcome them. At his Tavistock Clinic in London, he explored therapeutic techniques to heal what was "divided" in patients who had delusions and hallucinations.

Although several models for treating patients with persecutory delusions have been proposed,¹⁰ there are no published reports to substantiate the effectiveness of these methods. If Mrs K were to be seen now by a psychiatrist, she would in all likelihood be told that she has a chemical imbalance and be encouraged to take antipsychotic medication—in spite of the fact that these drugs have a poor track record in eliminating her type of delusion. To Mrs K, the thought that anything might be wrong with her is unimaginable, and she would bristle at the suggestion that she is at fault in any way. In fact, the only fault anyone has ever heard Mrs K acknowledge is that she has done too much for her family. Even if she would agree to seek help for her "problem," it is unlikely that, in the current therapeutic climate, any clinician would dare to challenge this woman's vital lie—the lie she needs to survive. No doubt, Mrs K will take these paranoid delusions to her grave.

Biologic psychiatrists would argue that Mrs K's paranoia was due to a primary brain disorder, rather than to a functional disorder that is willed and originates in what existential philosophers and clinicians call an intentional act that has meaning and purpose. To justify a biologic provenance for Mrs K's behavior, the following question would have to be answered: How does Mrs K's brain know to select only her family as a target for her paranoia, sparing from accusation almost everyone else in her life? Which neural circuits and neurotransmitters subserve this selection and its behavioral consequences? These questions beg for answers.

Mind and brain: both rule
It has been suggested by Laing and others that psychotic behavior can be part of a strategy to ward off anxiety so overwhelming that it radically threatens one's existence.¹¹ An auditory hallucination could originate as a willed defensive response of a despairing person to an intolerable situation, a last-ditch effort to shore up a crumbling identity. This process, which would be a psychogenic, functional, psychodynamic, and dimensional phenomenon, could be thought of as a pathologic exaggeration of the need many children feel to create imaginary friends and incorporate these fictional characters into their lives.

A cognitive-behavioral model for the treatment of auditory hallucinations has been proposed that includes this explanation for how voices originate: "[H]allucinatory experiences occur when an individual fails to attribute internal, mental events to the self and instead attributes these events to sources that are alien or external to the self."¹² In therapy, patients are taught to "reattribute those voices to themselves" rather than to an external power as they do when they are psychotic.

The American poet Louise Bogan (1897-1970), who experienced her own depressions and mental breakdowns, looked into herself and outward to those she knew and decided that:

All those odd things [people] do, like falling in love with shoes and sewing buttons on themselves and hearing voices, and thinking themselves Napoleon, are natural: have a place. Madness and aberration are not only parts of the whole tremendous setup, but also (I have come to believe) important parts. Life trying new ways out and around and through.¹³

Literary artists have always gone for a larger view of the human enterprise. Bogan's words cut to the heart of what many people in whom a mental illness is diagnosed are trying to accomplish by thinking, feeling, and acting as they do. All behavior has meaning, and pathologic behavior has a different meaning,¹⁴ which serves a purpose. Jean-Paul Sartre, R. D. Laing, Alfred Adler, Gregory Bateson, J. H. van den Berg, and others independently came to this same conclusion.

Dr Muller formerly evaluated psychiatric patients in the emergency room at Union Memorial Hospital in Baltimore. His most recent book, Psych ER: Psychiatric Patients Come to the Emergency Room, was published by The Analytic Press in 2003. The author has no conflicts of interest to report regarding the subject of this article.

Drugs Mentioned in This Article
Clopidogrel(Drug information on clopidogrel) (Plavix)
Diltiazem (Cardizem, others)

References
1. Gerber DJ, Tonegawa S. Psychotomimetic effects of drugs—a common pathway to schizophrenia? N Engl J Med. 2004;350:1047-1048.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994: 296-301.
3. Milton J. Paradise Lost. Book I, verse 1, lines 254-255.
4. Heidegger M. Being and Time. Macquarrie J, Robinson E, trans. New York: Harper & Row Publishers; 1962.
5. Garety PA. Making sense of delusions. Psychiatry. 1992;55:282-291, discussion 292-296. 6. Perry J. Treating first-break psychosis in a non-hospital environment. Department of Psychiatry seminar presented at Johns Hopkins University Medical School; March 26, 1990, Baltimore, Md.
7. Jung CG. The Collected Works of CG Jung: The Psychogenesis of Mental Disease. Vol. 3. Read H, Fordham M, Adler G, eds. Princeton, NJ: Princeton University Press; 1960:189.
8. Laing RD. The Divided Self: An Existential Study in Sanity and Madness. Baltimore: Penguin Books; 1965.
9. Laing RD. The Politics of Experience. New York: Pantheon Books; 1967:115.
10. Blackwood NJ, Howard RJ, Bentall RP, et al. Cognitive neuropsychiatric models of persecutory delusions. Am J Psychiatry. 2001;158:527-539.
11. Breggin PR. Toxic Psychiatry: Why Therapy, Empathy, and Love Must Replace the Drugs, Electroshock, and Biochemical Theories of the 'New Psychiatry.' New York: St Martin's Press; 1991.
12. Bentall RP, Haddock G, Slade PD. Cognitive behavior therapy for persistent auditory hallucinations: from theory to therapy. Behav Therapy. 1994;25:51-66.
13. Jefferson M. I wish I had said that, and I will. The New York Times Book Review. April 11, 2004:23.
14. van den Berg, JH. A Different Existence: Principles of Phenomenological Psychopathology. Pittsburgh: Duquesne University Press; 1972.

Evidence-Based References

• Bentall RP, Haddock G, Slade PD. Cognitive behavior therapy for persistent auditory hallucinations: from theory to therapy. Behav Therapy. 1994;25:51-66.
• Gerber DJ, Tonegawa S. Psychotomimetic effects of drugs—a common pathway to schizophrenia? N Engl J Med. 2004;350:1047-1048.