Psychotic symptoms--delusions, hallucinations, paranoia, thought disorder--are mostly attributed now to aberrations in brain structure and function.
Psychotic symptoms-delusions, hallucinations, paranoia, thought disorder-are mostly attributed now to aberrations in brain structure and function. The iconic "chemical imbalance," thought to be a consequence of wrongly wired neural circuits and faulty receptor activity, is seen as an essential component in the distortions of thinking, feeling, and behavior that are different enough from the norm to merit the designation "psychotic."
The physiologic derangement that sometimes occurs in those who use drugs such as amphetamines, lysergic acid diethylamide (LSD), and phencyclidine is a known cause of psychosis. So, too, are certain derangements of electrolyte, endocrine, and metabolic functions. Biologic psychiatry, the dominant paradigm in mental health now, has extrapolated this association between a known, and sometimes measurable, chemical imbalance and psychosis to explain delusions and hallucinations of unknown pathogenesis that are part and parcel of some mental disorders.1 In this model, the mind becomes a somewhat passive theater of the brain's chemical imbalance, ineluctably producing pathologic thought, emotion, and behavior.
Not so fast. The following story about an elderly woman whose behavior would be considered paranoid and delusional by any standard challenges us to reconsider the need to invoke a chemical imbalance to explain all psychotic symptoms.
A willed paranoid delusion?
"Mrs K," who is 95 years old, lives alone in a ranch-style house in a rural suburb. On most days during the spring, summer, and fall when the weather is good, Mrs K works outdoors in the garden. Last fall, she raked 40 bags of leaves. During the winter, when a snowfall is 6 inches or less, Mrs K shovels the driveway out to the road; after heavier accumulations of snow, she calls in someone with a plow. She never complains about having to cope with the long, cold winters.
Mrs K pays her bills and never overdraws her checking account. She prefers to spend most of her time alone and encourages only occasional, short visits from family members. She has no friends and wants none, even though neighbors occasionally make overtures to her. She keeps up with the outside world by watching the news on cable television. In 1986, Mrs K's husband died suddenly of heart failure. She has never shown any sign of mourning and, in fact, seemed rejuvenated by her husband's death. Although Mrs K values life in her advancing years and takes good care of herself, she has made it clear that she is not afraid to die.
Mrs K has a good quality of life and can still do many of the things that were always important to her. Her sense of the world is largely intact. She appears thin and frail, but for a nonagenarian, her health is good. Her close vision has deteriorated and she can no longer sew, but beyond 6 feet she sees well. She takes 81 mg of aspirin every other day and receives monthly subcutaneous injections of vitamin B12 and folic acid. Mrs K has had occasional chest pains since her mid-80s, which her doctor attributes to angina. Sometime after that she was found to have atrial fibrillation. Her only prescription medications are diltiazem and clopidogrel.
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.
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
Diltiazem (Cardizem, others)
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