Edited by: Paola Rocca, University of Turin, Italy
Reviewed by: Maria Gilenko, Ministry of Health, Russia
Massimiliano Aragona, Migration and Poverty (NIHMP), Italy
*Correspondence: Valerio Ricci,
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The relationship between substance use and the onset of psychosis has been a subject of clinical and academic debate for centuries. The potential for cannabis to trigger psychosis was first suggested by Grose in 1772, who documented issues related to cannabis use in India (
This study examines the psychopathological foundations of SIP through the perspectives of Gaëtan de Clérambault and Karl Bonhoeffer. De Clérambault’s theory of “mental automatism” (
Gaëtan Gatian de Clérambault (1872–1934), a leading early 20th-century psychiatrist, is renowned for his theory of mental automatism. Working at the Paris Prefecture of Police’s Special Infirmary for the Insane, he conducted over 13,000 psychiatric evaluations (
Within his framework, Gaëtan de Clérambault identified two subtypes of mental automatism: minor (petit automatisme) and major (grand automatisme). Minor automatism involved subtle, emotionally neutral intrusions that minimally affected functioning. In contrast, major automatism caused significant sensory and motor disruptions, leading to confusion, distress, and cognitive interference. Both minor and major automatisms are subtypes of positive mental automatism, characterized by intrusive mental additions such as unbidden thoughts, sensations, or actions. Progression from minor to major automatism often signaled a deepening detachment from one’s thoughts and actions, culminating in psychotic episodes.
De Clérambault argued that mental automatism, not individual symptoms like hallucinations, was the central mechanism of psychosis. He posited that psychosis arises from disrupted cognitive processes, not specific behaviors. Influenced by earlier French psychiatry, including Jules Baillarger and Jules Séglas, he unified intrusive experiences under a comprehensive framework, redefining psychosis as rooted in automatism rather than symptom clusters (
De Clérambault viewed psychosis as a unified condition with mental automatism as its core process. He argued that automatic phenomena could lead to various delusional beliefs, shaped by how individuals interpreted intrusive experiences. For example, bodily sensations might result in hypochondriacal or persecutory delusions. This approach emphasized psychosis as a singular entity, with delusional content arising from cognitive interpretations of automatism. A firm organicist, de Clérambault believed mental automatism stemmed from biological disruptions, such as infections, intoxication, or brain lesions. He rejected psychological explanations, asserting that the consistent, mechanistic patterns of automatism indicated physical origins rather than unconscious conflicts (
De Clérambault’s work suggested that mental automatism was not only a key component of psychosis but also the primary driver of its symptomatology. He proposed that delusions were secondary responses of the rational mind to subconscious, intrusive phenomena. From his perspective, delusions served as attempts to explain strange sensations or ideas, with the mind attributing these experiences to external sources in order to make sense of the internal disturbance. In his description, a person affected by mental automatism might go through an
De Clérambault’s work identifies a core dissociative mechanism that underpins involuntary phenomena, forming the foundation for delusions and sensory distortions like hallucinations. His insights link dissociation to psychopathological traits and renew interest in “exogenous” psychoses, contrasting them with the “endogenous” model that emphasized genetic inheritance and progressive degeneration. Karl Bonhoeffer (1868–1948) (
Bonhoeffer recognized the complexity of mental health, noting the frequent overlap of exogenous and endogenous causes, making clear distinctions challenging. He stated, “Pure forms of exogenous or endogenous origins are rare in practice … differentiation is challenging.” This perspective highlights the interplay of environmental stress, trauma, genetic predispositions, and neurobiological influences in psychiatric conditions. His approach advocates for moving beyond rigid categories to consider how these factors interact in the development of disorders. Bonhoeffer’s work emphasizes external pathogenic influences, such as substances, as triggers acting on underlying endogenous vulnerabilities. This concept underpins the notion of “lysergic psychoma,” introduced by Cargnello and Callieri (1963) (
Bonhoeffer’s exogenous model, developed alongside Bleuler’s endogenous framework, offers insight into lysergic-induced psychosis as a distinct ego-dystonic experience (
At this point, we can define the significance of mental automatism as the psychopathological foundation of exogenous psychosis, particularly in the context of substance-induced psychotic disorders, from various perspectives.
The initial perspective is that De Clérambault’s research on mental automatism, conducted from 1920 to 1926, focused on the experience of uncontrollable and fragmented mental phenomena, anticipating what Schneider would later term “Gematch” (
The correlation of these two theories could broaden our understanding of the diverse manifestations of substance-induced psychosis, framing them as ego-dystonic experiences characterized by vivid hallucinations and cognitive disturbances. As a clinical example, frequent disturbances in body awareness (cenesthesia) and psychosensory experiences—particularly visual alterations—are key clinical symptoms of substance-induced psychosis, supported by the activation of mental automatism (
In conclusion, the onset of psychiatric symptoms from potent substances is well-documented, often beginning with reversible psychotic episodes. Prolonged, high-dose use increases the risk of persistent disorders. De Clérambault’s theory of mental automatism and Bonhoeffer’s exogenous psychosis model offer critical insights. De Clérambault emphasized uncontrollable, alien phenomena central to psychosis, paralleling lysergic psychoma in substance-induced cases. Bonhoeffer highlighted how external agents interact with neurobiological vulnerabilities to trigger psychosis. Together, these frameworks suggest that prolonged exposure erodes the mind’s resilience, enabling chronic psychosis. Revisiting these theories enhances diagnostic approaches for exogenous psychoses and bridges understanding between endogenous and exogenous psychotic forms (
VR: Conceptualization, Formal analysis, Methodology, Resources, Validation, Writing – original draft. AS: Conceptualization, Formal analysis, Supervision, Visualization, Writing – review & editing. GM: Conceptualization, Formal analysis, Investigation, Resources, Supervision, Writing – review & editing.
The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The handling editor PR declared a shared parent affiliation with the authors AS, GM secondary affiliation at the time of review.
The author(s) declare that no Generative AI was used in the creation of this manuscript.
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