Mental Automatisms, A conceptual journey into Psychosis

A book by Paul Hriso MD

                                                              PREFACE

       Insanity has been an affliction to humankind from the beginning of time. As society began to view it from a medical perspective, some two hundred years ago, more appropriate attention was conferred to it. However, from a sociologic and scientific standpoint, the understanding and the administrative management of insanity has evolved in parallel with our ability to define it and to describe its inherent characteristics. In that sense, insanity, or psychosis as it was named in the nineteenth century, is intricately linked to the language which defines it, whether this language pertains to the subjective expression of afflicted individuals, or to the language inherent to the observations of clinicians. In retrospect, the greatest difficulty remains, even to this day, in the organization of this language into a coherent and uniform system. Such a system would need to be flexible enough to openly integrate many leading neural concepts and to explain the totality of psychotic symptomatology in an orchestrated and predictable fashion. The lack of such a guiding system often leaves clinicians struggling to identify and evaluate psychotic individuals in a consistent and methodical manner. The multiplicity of presentations inherent to psychotic symptomatology; the subtleness and evasiveness in the great majority of psychotic symptoms; and the ambiguity and uncertainty as to the general concepts pertaining to the mechanisms of psychosis are all elements which contribute to an overall sense of vagueness as to the clinical observation of psychosis. However, if it were possible to develop a global system - a fine detailed and exhaustive descriptive psychopathology of psychosis - our views on this historical ailment would certainly be different, possibly opening up new avenues of treatment and management.  

       Many of the great clinicians who studied psychosis in the last two hundred years became famous for their specific nosologic contribution when they sought to define and uncover specific psychotic entities or illnesses. Other clinicians owed their fame to their description of certain original symptoms of psychosis. However, when possible, few of them were able to avoid the temptation to formulate their own nosology, and subsequently engage in scholastic disputes in defending their findings. Insofar as a clinical approach to psychosis implies a high focus on symptomatology, few researchers and clinicians would attempt to formulate a global system to define and explain psychotic symptomatology and the mechanisms for the production of psychotic symptoms. Many of those who did attempt to do so failed because they were unable to reconcile what seemed to be contradictory concepts, or because they often failed to coherently recognize, define and categorize the disparate symptoms of psychosis. However, one clinician was able to succeed. Gaëtan Gatian de Clérambault was able to formulate an exhaustive and coherent system of psychotic symptom categorization. As a result, in retrospect, Clérambault would most likely emerge as one of the most prominent figures of descriptive psychopathology of psychosis.

       This French alienist of the early part of the twentieth century was a complex man who was recognized to hold a variety of expertises in many areas. Clérambault is most well known in the Anglo-Saxon literature for his work on the ‘psychose passionelle’ (erotomania) otherwise known as Clérambault’s Syndrome. He also excelled in ethnographic anthropology and his lectures at the Beaux Arts and the Sorbonne in Paris were said to be legendary. However, it is his contribution to psychiatric semeology which would prove to be most fundamental. He was able to establish a coherent system whereby the understanding of the basic characteristics of psychotic symptoms would go in pair with the description of their alleged underlying neural processes. These underlying neural processes would be defined in terms of abnormal behaviors of neural connectivity. Rather than simply drafting an arbitrary listing of symptoms, Clérambault would provide an exhaustive taxonomy of psychotic symptoms based on the description of their most subtle features and nuances. Clérambault’s catalogue of psychotic symptoms is original in the sense that each symptom finds its place within a category defined by either a specific characteristic or a specific predominance of one or several characteristics. He would create groups and subgroups for these symptoms when deemed necessary. These groups would be placed into subcategories which were in turn grouped into larger categories. The main categories would include the sensory, the motor and the mental phenomena. However, the great value of Clérambault’s system is that all the groups, subgroups, subcategories and categories, and therefore all the categorized psychotic symptoms, would be defined by one characteristic common to all, their automatic and autonomous nature. The psychotic symptoms would thus become referred to as automatisms.

       Generally speaking, the notion of automatism is a synonymous concept to that of a very basic category of psychotic symptoms. In fact, aside from delusions, automatisms represent all other psychotic symptoms. However, one of the novelties of Clérambault’s concept is that automatisms can occur in the context of normal or subnormal function, that is in the context of the normal thinking process and the so-called subnormal conditions when the nervous system is strongly challenged. As we will see, within the larger concept of automatism, the boundaries of psychosis and normal function are redefined.

       One can only speculate as to the reasons for which the notion of automatism has not gotten a more extensive audience in American and English psychiatry. Perhaps simply because of the language barrier, knowing how difficult it is to provide an exact translation of the reputed fine detailed clinical descriptions of such a great clinician as Clérambault whom Jacques Lacan regarded as his “only master in the observation of patients.” Another reason may be the natural filiation of the German influence on the Anglo-Saxon schools by way of the Kraepelinian thinking which has somewhat displaced the French contributions. In retrospect, we can also appreciate the manner in which Kraepelin’s concepts have influenced an overwhelming attention and orientation of clinicians toward nosology rather than discriminative symptomatology. Historically speaking, we can safely venture to say that symptomatology has unfortunately been subordinate to nosology. It may be that this phenomenon is an indirect result of a frantic need of psychiatry to belong to medicine. Like in medicine, psychiatric researchers engaged in an obsessional search for a true scientific nosology modeled on medical nosology.

       Despite this historical drift in favor of nosology, the psychotic nosologic or diagnostic entities that have been brought forth so far have mostly proven to be fleeting. They have either failed or will fail the test of time. The appearance, the success and life span of the various theoretical nosologic systems of psychosis have been more the result of arbitrary sociologic factors than based on true scientific merit. They were mostly the result of conceptual trends that were prominent at the time they became accepted. As a result, the survival of a nosologic concept would depend on the manner in which its author and supporters were able to impose it, and also the way by which it was accepted by the public. The simple fact that a particular nosology is determined by such sociologic influences almost guaranties its limited life span. In retrospect, we may wonder today if this is not the inexorable fate of any nosologic system in psychiatry.

       On the other hand, the psychotic symptomatology has historically proven to be interestingly stable. If we move away from any abusive interpretation of the content of a particular psychotic symptom to focus on the formal characteristics of the symptom, we realize that the formal aspects of a symptom do not change while it may carry a wide variety of themes or content. Clérambault’s work on automatisms essentially pertains to the formal study of psychotic symptomatology. The degree of clinical objectivity inherent to the study of formal characteristics of symptoms is such that a work, like that of Clérambault, would still be as valid today as it was at the time it was written. Clérambault’s work is a unique endeavor that still remains modern simply because psychotic individuals mostly present with the same formal symptoms regardless of the times, and regardless of their culture. The times and the culture of an individual are two variables that would only tag a content to a symptom which should be considered as a process abnormality in the first place. Aside from the notion of automatism, Clérambault introduced a variety of very interesting concepts. He discovered, for instance, several psychotic symptoms.

       One such symptom, the pseudo-awareness will prove to be determinant in the understanding of the pathogeny and the formation of delusions. In addition, while studying the intricate mechanisms of psychotic symptoms, Clérambault formulated an explanation for the presence of psychotic symptoms based on basic notions of neural connectivity and behaviors of connectivity. One example is the way in which the threshold concept, a well established neural concept, allowed Clérambault to develop the idea of hallucinability and establish the factors which would influence this threshold phenomenon. In extrapolating neural processes to explain the psychiatric processes of psychosis, Clérambault’s work was a precursor in the application of neural network theories to psychotic semeology and determine reproducible models for psychotic symptoms.

       However, aside from the theoretical implications brought forth by the concept of automatism, Clérambault’s clinical descriptive prowess alone is extraordinary. The fine descriptions of this author for every differentiating characteristic nuance of the most subtle psychotic symptoms continue to this day to astonish readers. His ability to recognize and isolate those core symptoms in the all too often confusing and complex clinical presentations of psychosis demonstrates to us the presence of a certain order in the way psychosis is structured. Bringing such clarity in what is still traditionally construed as a nebulous ailment makes each case history presented by Clérambault a lesson from a clinician who has reached a rare degree of clinical maturity and who continues to inspire awe and admiration.

       As a result, Clérambault’s work on automatism becomes an essential reference manual for students, clinicians and researchers, or anyone who seeks to understand the most fundamental aspects of psychotic symptomatology and psychosis.

ISBN: 0-9718923-4-2
Pages: 485
Size: 9 5/8 x 6 5/8 inches
Paperback
Publication date: 11/2002