Phenomenological psychopathology, aims to understand and describe experiential alterations that occur in mental illness 1. When applied to addiction, phenomenological psychopathology seeks to understand addiction through the lens of the individuals’ lived experiences and the meaning they attribute to their addictive behaviors.
A phenomenological approach to the understanding the psychopathology of addiction places a strong emphasis on subjective experience, emphasizing the importance of the individual’s existential aspects and emotional experiences 2. Individuals struggling with addiction have unique stories, backgrounds, and contexts that influence their relationship with substances and factors such as childhood trauma, social environment, and cultural background play a significant role in shaping the individual’s experience of addiction 3,4.
The phenomenology of addiction is a subject that has been extensively explored by various authors over the past centuries. The study of these phenomena, however, has over the years often been set aside in favour of the conception of the endogenous nature of psychosis. Authors such as Karl Bonhoeffer, De Clérambault, Moreau de Tours, Giovanni Enrico Morselli and Danilo Cargnello, have deeply analysed these conditions, both through dissertations and studies from a theoretical perspective as well as through self-assumptions in order to study their effects and hypothesise their use also in a therapeutic sense. Famous in this regard is Morselli’s self-administration of lysergic acid diethylamide, which constitutes a very important psychopathological self-description 5.
The problem of differential diagnosis between psychoses of endogenous and exogenous origin is still an open question, not only on a theoretical level, but also on the clinical, therapeutic and management of these patients. In this regard, it appears important to achieve a solid knowledge of phenomenological psychopathology, which can be helpful to distinguish the two different clinical conditions. Although obviously in several cases the two conditions coexist, a careful psychiatric evaluation with a solid phenomenological basis can certainly help to determine which of the two factors assumes more importance in the patient’s psychopathology 6.
The aim of this article is to provide an overview on the main ideas of some of the Authors who have made a relevant contribution in this field. As mentioned earlier, some of them, such as Karl Bonhoeffer, have been gradually forgotten, as the scientific main current of the time valued more the conception of mental illness as an endogenous condition, thus giving more prominence to psychopathologists who emphasised this aspect, such as Karl Jaspers, Eugen Bleuler, Emil Kraepelin and Kurt Schneider.
It is important to consider that the ideas of these Authors are not only of theoretical value, but can also be of great use in the way we approach these patients clinically and therapeutically.
Karl Bonhoeffer and the exogenous psychosis model
Karl Bonhoeffer was born in 1868 in Neresheim, Württemberg (southern Germany) and completed his medical training in Tübingen, Berlin and Munich. In 1904, he was elected director of the Department of Psychiatry at the University of Breslau/Wroclaw Psychiatric Hospital, where he worked together with Carl Wernicke (1848-1905) with patients with alcohol addiction 7,8. In 1912, he moved to Berlin, at the time one of the world’s largest metropolises, where he was elected chairman of the Department of Psychiatry and Neurology at the Charité Hospital 8. Among his models, besides Wernicke, was Theodor Meynert, a Viennese neurophysiologist with whom Sigmund Freud had also worked.
His research contributed significantly to reinforcing the distinction between exogenous and endogenous psychosis. Bonhoeffer argued that in exogenous psychosis there is a different dispersive typology to that present in endogenous (schizophrenic) psychosis, with therefore different semeiological manifestations. In theorising exogenous psychosis, he described a conflict between the psychome, i.e. the psychopathological changes induced by the substance intake, and the critical ego, i.e. the cognitive component that is partially aware of the effect of the substances taken 9. If the intake process is prolonged, the critical ego is unable to cope with the impact of psychoactive substances and an endoreactive psychosis sets in, where the psychopathological manifestations are no longer only related to substance intake, but become chronic and stable 9. Thus, the factors that determine the onset of endoreactive psychosis depend partly on the type and the quantity of substance taken, and partly on intrinsic factors of the critical ego, of a genetic and biological nature.
Bonhoeffer was thus one of the first scientists to perceive and define the exogenous character of psychosis, as opposed to the conception of mental illness as endogenous and thus resulting only from internal and not external or environmental factors. The exogenous component, according to Bonhoeffer, could not only come from substances, but also from infectious, toxic or degenerative processes 7.
This author’s considerations, which now seem taken for granted, were extremely innovative in early 20th century Germany, the home of psychopathology, but at the same time where the dominant ideology favoured the idea that defined the endogenous character of psychosis.
Bonhoeffer was later one of the few who opposed the killing of the mentally ill carried out by the Nazi party and was progressively demoted, forced to emigrate to the United States, and his ideas remained unrecognised for a long time 10. Among the reasons for the devaluation of Bonhoeffer’s ideas were probably the fact that he was of Jewish origins and that the dominant thought in Nazi Germany tended towards the endogenous conception, where mental illness was seen as a biological alteration that made the person suffering from it inferior to others.
The great merit of this Author was therefore that he was among the first to have pointed out that there were psychopathological changes induced by substances, and that psychosis was not necessarily the result of endogenous alterations, but there was an exogenous component, and therefore also social and behavioural.
The concept of the psychoma, of which Bonhoeffer was one of the first proponent, was later recalled by other Authors, such as Danilo Cargnello, Giovanni Enrico Morselli and Bruno Callieri, until more recent times, with the Brazilian psychopathologist Guihllerme Mèssas.
Danilo Cargnello and “experimental psychosis”
Danilo Cargnello (1911-1998) was one of the greatest creators of Italian phenomenological psychopathology, together with, among others, Enrico Morselli, Bruno Callieri and Ferdinando Barison. His work is set in a context where the Italian psychiatric reality was less characterised by the importance of phenomenological ideas than that of other European states and in particular Germany, where there were renowned psychopathologists like Karl Jaspers, Edmund Husserl and Ernst Kretschmer. Cargnello had the merit of writing the first Italian phenomenological articles in 1947-1948, a period in which phenomenological ideas began to spread out in Italy. One of the author’s main credits was to take up and diffuse Binswanger’s concepts in Italy, publishing, among his other works, the book Alienità e Alterità 11.
With regards to the topic of substance abuse, in collaboration with Dr. Niksa Lukinovich, he studied and described a series of subjects with intoxication for experimental purposes by Lysergic Acid Diethylamide (LSD), carefully analysing the effects from a psychopathological perspective. The subjects considered 20 were people undergoing treatment in the Sondrio area (specifically, at the Morelli Sanatorium in Sondalo), a town in northern Italy, where Cargnello was working at the time.
In 1962 Cargnello published the results of this study and brought together the contributions of various psychopathologists, such as Bruno Callieri and Giovanni Enrico Morselli, in a volume entitled Le Psicosi Sperimentali 12. Taking up the concept of psychoma from Bonhoeffer and the German psychologist Hellpach 13, Cargnello described with extreme precision the various visual psychosensory phenomena detected in patients, developing a phenomenological analysis of alterations in the field of consciousness, temporality, corporeality and ideational content. The Author described a wide range of neurological and somatic effects detected in the sample of subjects analysed.
He recognised, like Bonhoeffer, the alteration of consciousness as a possible distinguishing element between endogenous and exogenous phenomena: “the relevant frequency of disorders of lucidity in induced psychoses compared with the rarity of the same in engoden clinical psychoses is a finding that founds and corroborates a rather heavy criticism of the identification between the one and the other” 14, adding that “in pharmacologically induced psychoses by far the hallucinated domain is the visual one, the least of all auditory” 14. Cargnello’s observation regarding the state of consciousness, often defined as crepuscular 14 and altered in substance-induced psychosis, and usually not altered in schizophrenic psychotic phenomena, is therefore interesting. Altered consciousness could therefore be considered as a possible marker of differential diagnosis and a potential prodromal sign of substance abuse-induced psychosis.
Cargnello, therefore, took up the concept of the psychoma and provides a more precise characterisation of this phenomenon from a psychopathological perspective, focusing his studies on the direct observation of the LSD.
Giovanni Enrico Morselli and his studies on the effects of mescaline
Giovanni Enrico Morselli was director of the Novara Psychiatric Hospital until 1970. In 1932 he was the protagonist of a self-administration of a massive dose of mescaline, which led him to seek assistance from the on-call doctor at the Novara hospital, where he also worked, due to the psychopathological effects induced by the substance.
Following his recruitment he left a masterful testimony to the lecture he gave at the Second International Neurological Congress, held in London in 1935 5. The full text can be found in the book Le Psicosi Sintetiche, written by Gilberto Di Petta and Danilo Tittarelli and published in 2016 14. His auto-description, in retrospect perfectly lucid about what happened, gives an idea of what Bonhoeffer defines the critical ego, i.e. the insight component that in the moment of taking is opposed to the psychoma.
Morselli described some initially visual phenomena, “the vision of colours begins to alter, everything around seems to oscillate, ... both the figure and the landscape are animated by an incessant uniform vibration, as fine as a fibrillation, and formed by different components, vertical, oblique, horizontal” 14. Subsequently, paranoid phenomena appeared with reference to the paintings he was observing in his studio: “I return to look at the portrait of Titian. His expression has become hostile, provocative and determines in me a real reactive attitude that I voluntarily go along with, thinking above all of the possibility of hearing the figure speak” 14.
Morselli probably went overboard with the dose taken, and therefore had to go to the clinic where he worked and ask to be admitted. Even in his interview with the doctor on call, Morselli said “as I observe my colleague I notice that his features are gradually transformed monstrously” 14.
Although after a few hours the acute phenomena had receded, he recounted that “for at least two months the ‘portrait’ of the unknown in the Pitti Palace was ‘alive’, it had an autonomous existence for me. Although it strongly disturbed and almost repulsed me, it ‘existed’, unbearable as an imposition and my criticism of the ‘given’” 14.
From this self-description we can learn how even at that time it was realised that even a single intake of a substance could have psychopathological consequences lasting several months, even in subjects without previous psychiatric history.
Morselli was not the only author to engage in self-administration for the purpose of psychopathological study. In the late 19th-early 20th century, it had begun to be realised that psychotic manifestations could be induced by substances, and it was therefore common among scientists to experiment on themselves in order to study their effects. Another famous figure in this field was Moreau dei Tours, a Parisian psychiatrist of the late 19th century, who began abusing hashish and cannabis with the aim of reproducing a model that would explain the genesis of psychosis. These rudimentary observations laid the foundations, later on, for the experiments of the first commercially available psychotropic drugs. Another famous example of this is that of Otto Westphal, who tried to study the effects of opiates, with the idea of also using them for therapeutic purposes, with the consequence of later becoming addicted to them and dying of withdrawal in an attempt to detoxify himself 15.
Bruno Callieri and his studies on lysergic acid monoethylamide
Bruno Callieri (1923-2012) graduated in Medicine and Surgery from the University of Rome in 1948, where he then specialised in the Clinic of Nervous and Mental Illnesses, with a thesis on the use of amphetamines in psychotic patients, in 1951. He was able to spend two semesters in the Psychiatric Clinic in Heidelberg, working with Kurt Schneider, at that time a professor of clinical psychopathology in the city.
During his time as an assistant at the Clinic of Nervous and Mental Diseases at the University of Rome, Bruno Callieri published a descriptive study of the effects induced by lysergic acid monoethylamide, comparing his results with the study carried out by Solms, of the Basle Psychiatric Clinic, by direct observation of 21 patients 16. The results he exhaustively described are summarised as “3 acute schizophrenic syndromes, 2 schizophrenias, 1 excitement of a dubious nature, 2 manic-type excitations, 3 epilepsies” 14.
He noted, somewhat as Bonhoeffer had done earlier, that there are primary changes induced by the substance, but also so-called secondary effects, i.e. how the subject feels and perceives the primary effect, as a “stance of the ego in relation to the primary effect, on a purely psychological level”. Indeed, he described how “some patients immediately integrated their lysergic experience into the context of their delusional activity”, while others “incorporated the dysmorphic activity of the drug into their hallucinogenic setting” 14.
Like Cargnello, he also focused on substance-induced somatic changes, such as miosis, observed in almost all subjects, and changes in coenesthesia.
The interesting and innovative aspect for the time highlighted by Callieri was that he observed how psychopathological changes depend not only on the type and quantity of substance taken, but also on the way the person subjectively and psychically integrates the delusional and hallucinatory experience induced by the substance.
Guilherme Messas and studies on temporality in addictions
Guilherme Messas is a Brazilian psychiatrist, founding member of the Brazilian Society for Phenomeno-Structural Psychopathology and author of many peer-reviewed articles in the field of psychopathology. His book entitled The Existential Structure of Substance Misuse is an important and comprehensive phenomenological analysis of psychoactive substance abuse behaviour 17.
Messas takes up the ideas of temporality and spatiality analysed in depth, among others, first by Husserl and later also by Japanese psychopathologist Kimura Bin.
Husserl defined the concepts of retentio (what once was and is no longer, but still influences what is) protentio (what is not yet, but attracts the intentionality of what is) and presentatio (what is around us, influenced by the past and stretching into the future) 18. Usually, these three concepts are interspersed in a single, coherent human experience, independent of each other. Kimura Bin, a Japanese phenomenologist, instead described three fundamental entities: ante-festum, intra-festum and post-festum. The ante-festum, according to Kimura, represents the moment of expectation, where “everything is travelled joyfully anticipating the event of the feast, or, conversely, dramatically when it is its desolating failure that is anticipated by anguish” 19,20.
The post-festum, on the other hand, is a moment of taking stock after the fact, linked to the situation that comes (literally) after the feast, or the regret of an irreparable mistake 19. The third moment is the intra-festum, literally in the course of the feast, which refers to the possibility of grasping the present as such, in its pure duration characteristic of immediacy.
These three features can be altered in different ways in various psychiatric disorders: in melancholia, for example, the post-festum or retentio prevails, as the subject lives in the past, whereas schizophrenia is characterised by continuous waiting typical of the ante-festum or protentio 18. On the contrary, mania and substance abuse, as well as borderlinepsychopatology, exalt the intra-festum with a chaotic immediacy and the search for a momentary and morbidly illusory ecstasy.
Messas adopts these concepts by focusing his analysis on addiction, speaking in this regard of a continuous present, where presentatio prevails over the other two temporal aspects. As in other conditions, such as mania and borderline personality disorder, substance abuse is characterised by a hyper-presentification of time, temporality becomes punctiform and fragmented. During addictive behaviour the abuser remains in the present, forgetting what has happened and losing the horizon of what is to come: retentio and protentio are subordinated to the present. In the same way, the delusion developed after taking substances often runs around present, is crystallised, does not have a prospective character, encompassing and projected into the future like that typical of schizophrenic patients, whose delusional symptoms more often have an apocalyptic character, of continuous waiting and projected towards something that will happen.
The result of chronic substance use is therefore what Messas calls biographical undifferentiation, which is realised in the difficulty of existential maturation of many abusers, who are unable to maintain stable relationships, to take responsibility in life and to set themselves future objectives. Thus, there is no longer a life perspective, an ability to wait and be patient.
From a recovery-oriented approach, according to Messas’ perspective, it is therefore crucial to implement interventions that reconcile these altered relations of temporality.
In this sense, Messas proposes three strategies to support the recovery of temporality: the Author mentions “reducing the intensity of the experience of the present, replacing the intensity caused by intoxication with other immediate experiences, or attempting to increase the emphasis on retentio and protentio, reducing hyper-presentification” 17.
To reduce the intensity of the present, according to Messas, psychopharmacology is the most frequently used instrument. Its use is aimed at preventing psychoactive substances from taking control of the patient’s consciousness. The author provides the example of Naltrexone, a drug used in opiate addiction, but also in alcohol and behavioural addictions. Even neurobiologically, this drug does not have the effect of adversely affecting addiction behaviour, but of making the pleasurable experience less intense, and in a phenomenological sense, reducing the intensity of the present.
Replacing the intensity of the present with other immediate experiences underlies the common association between substance abuse and novelty-seeking, as is especially the case in the youth population 21. The aim is thus to maintain a highly stimulated present, while filling it with healthy experiences such as sport or the arts, which give a similar experience of temporal intensity, rather than with harmful ones 22,23.
In enhancing the dimensions of retentio (past) and protentio (future), the role of the family is crucial. Indeed, the involvement of the family unit often plays a key role in treatment 24,25. Messas writes: “normally, the family is the most stable aspect of people’s lives; family relationships have the strongest roots in existence, making them ipso facto the representatives of maintenance” 17. Another alternative aimed at reducing over-involvement in the present consists in introducing people into the rehabilitation process who have no connection with the patient’s personal history. In this sense, self-help groups or a therapeutic community are very useful, as they provide the patient with a new collective identity on which he or she depends while developing a new life plan 26. The group relationship can provide this orientation, since it is often difficult to build a life project alone. This is why it is crucial in the rehabilitation process to have a continuity of care team: the clinician has the responsibility of being the depository of the patient’s biographical memory, giving the patient a temporal and identity continuity that the subject is unable to develop, having lost the possibility of integrating these aspects into his or her existence.
It is therefore necessary to create an interpersonal connection, provided by the proximity of a therapeutic figure capable of overseeing the patient’s daily life. The role of the therapist in this sense is crucial in providing clarity, differentiation and stability. Messas mentions the concept of authority: the clinician has personal and moral authority over the patient, he is the Auctor, that is, the leader, the master, whose influence “derives from his moral stature and not from his coercive power” 17.
New perspectives on phenomenological reflections on addiction
Phenomenological reflections on addiction have long been neglected, despite the fact that many authors have shown interest in this field. One of the reasons for this devaluation surely lies in the fact that for decades the dominant idea has been the conception of psychosis as an endogenous illness, with the valorisation of the thoughts of authors such as Emil Kraepelin, Eugen Bleuler and Kurt Schneider among others.
The Authors mentioned were among the first to understand, study and describe the psychopathological changes induced by the psychoactive substances, focusing on both the biological and the psychic and subjective components. Their reflections made the premises of the subsequent research on psychotropic drugs, and also to the current studies about the use of psychedelics in major psychiatric disorders 27,28.
Messas is credited with having taken up the concepts of temporality in the study of addiction, providing an interesting and useful perspective.
It would be very important to enhance these concepts in order to carry out clinical studies that consider temporality as a crucial aspect of psychopathological evaluation, as well as to implement interventions that consider temporal continuity as an important aspect. Substance use patterns are constantly changing, both in terms of the types of legal and illegal drugs on the market, and in terms of the way they are used, which is somehow increasingly aimed at maintaining contact with society and certain levels of standards and performance, and less to escape from society.
A possible horizon for the development of these concepts could focus on the so-called behavioural addictions, e.g. gambling, gaming disorder and internet addiction. For instance, gambling disorder could be seen in some way as the search for the immediacy of the present, for a prevalence of presentatio over retentio and protentio. Furthermore, in regards to social media addiction, or video game addiction, where the gamer spends most of his/her day playing videogames and neglecting school, family and friends relationships, the concept of biographical undifferentiation described by Messas can be suited. Also in this condition, common among children and adolescents, the continuous absorption in the illusory present causes one to lose the horizons of the future and the past, in a period of life of existential development.
Since addiction manifests differently across cultures, it would be crucial to maintain a cross-cultural and integrative approach, combining phenomenological research with other disciplines like sociology or anthropology to provide a more holistic view of addiction 1,29. Furthermore, it would be essential to implement research protocols that integrate neuroscientific knowledge and the principles of phenomenological psychopathology, going towards a neuro-phenomenological and individually-tailored approach 30.
The phenomenological approach can offer a valuable framework for understanding the complex, subjective nature of addiction, and further research in this area can contribute significantly to both theoretical knowledge and therapeutic intervention.
Conflict of interest statement
The Author declares no conflict of interest.
All the direct quotations of the book are taken from the Italian edition of the books cited and are made by the present Author.