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“Synthetic Psychosis” by Novel Psychoactive Substances: A Psychopathological Understanding of a Clinical Case


This paper intends to examine a new kind of clinical psychiatric syndrome, called by the author “synthetic psychosis”, which can occur in people who abuse novel psychoactive substances (NPS). This syndrome will be considered from both a psychopathological and a phenomenological perspective. The contemporary trend of poly-abuse of NPS in young people can lead to a sort of very intense paraphrenic state characterised by continuous hallucinations and formed by a mental automatism syndrome and by secondary (interpretative) delusions. The clinical case of G., discussed in this paper, is an exemplary case of this synthetic psychosis. The psychopathological understanding of the core symptomatology of the patient examined has been fundamental for the successive therapeutic approach. If this attempt at understanding is ineffective, the frequent consequences include the worsening of the psychopathology and addiction, the patient’s admission into a psychiatric hospital, his/her arrest for crimes related to antisocial behaviour, a diffusion of infective diseases commonly found in addicts, more frequent overdoses, aggressive behaviour, an increase in the costs of public health system and, finally, the suicide of the patient.


  • Synthetic psychosis
  • Schizophrenia
  • Twilight state of consciousness
  • Secondary delusion
  • Induced hallucination
  • Novel psychoactive substances

I moved, and could not feel my limbs:

I was so light—almost

I thought that I had died in sleep,

And was a blessed ghost

S.T. Coleridge

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Fig. 9.1
Fig. 9.2
Fig. 9.3


  1. 1.

    An increasing number of unregulated websites are dedicated to the dissemination of novel psychoactive substances, which include plant-based compounds, synthetic derivatives of well-established drugs, as well as “designer medicines”.

  2. 2.

    See “Le psicosi sperimentali”, Feltrinelli, Milano (1952) which contains the main reference works of Cargnello, Morselli and Callieri.

  3. 3.

    Smoking blend containing synthetic cannabinoids, e.g. JWH-018. It appeared in or around 2004; now some 140 plus different “spice” drugs are available.

  4. 4.

    Aka: Ska Pastora, Shepherdess’ Herb, yerba de Maria, Magik Mint; the active constituent is salvinorin A (k opioid receptor agonist) and an intense and short-acting hallucinogenic plant. Intake: smokable (pipe, bong). Historical use: shamanic inebriant (Mexico).

  5. 5.

    The five members of his mother’s family who died in the accident in 1980.

  6. 6.

    Also known as Ekbom Syndrome; it is characterised by hallucinations containing dermatozoic, zooptic, zoomorphic and zooaptic elements (B. Callieri 2001); even while he is walking, the patient takes off his clothes or shoes or trousers to scratch himself. He also sees animals and insects in general not only on his body but also on other objects. Skin lesions caused by the persistent scratching are present on his limbs and over his torso, while imaginary spots on his face are squeezed (dermatozoic illusions).

  7. 7.

    Evident hallucinations begin at this point in the patient’s recollection of events.

  8. 8.

    Hallucinations of the memory, or retrospective inclusive delusions, which allow for a global reinterpretation of one’s own existence based on a new world of meaning.

  9. 9.

    At this point the patient reveals the interpretative key to his own delusional construction, that is, the connection between the dermatozoic illusion (the animal inside the living body) and the implantations which refer to an external manoeuvring.

  10. 10.

    The patient started using cannabis, cocaine and mescaline during a trip to Mexico when he was 17 years old. Referring to mescaline, which derives from the peyote cactus, Cargnello (1958) wrote “The most important thing to point out and to remember is that the whole hallucinatory state takes place without any serious repercussion on the person’s awareness. In fact the peyotl eater remains almost perfectly aware of all that is happening to him, to the incredible phenomena in which he participates, all of which he is able to describe lucidly—this is possible because of an increased ability to be introspective and communicate. Furthermore, once the effect of the drug has worn off it leaves no unpleasant after-effects and doesn’t lead to dependence. Those people who use peyotl hardly ever become addicts”. The patient had already been suffering from the effects of continuous poly-abuse of NPS for 3 years when what he calls Morgellons syndrome first appeared.

  11. 11.

    Seeing and feeling are the two senses which are very powerfully involved in the synostosis which fundamentally influenced the patient’s delusions.

  12. 12.

    The taking control of his internal space by this increasingly invasive complex reveals itself to be unstoppable.

  13. 13.

    The logical sequence is the following—I discover “objects” that are inside my body; these things are clearly not part of me and are extraneous to my body; therefore they have been implanted into my body by someone, why have they done this? The reasoning follows the pattern—what is happening to me? Who is causing this to happen? And why?

  14. 14.

    Dermatozoic illusion introduces the sense of believing in the presence of numerous extraneous objects present inside one’s own body. Both the boundaries of the self and the physical barrier of skin have been violated. The next stage is the idea that one’s own body is transformed since its very boundaries have been infringed upon. This violation has resulted in the patient no longer recognising his own body as such.

  15. 15.

    These details indicate the passage from a human body to a post-human body or a “synthetic” body.

  16. 16.

    See Fig. 9.2.

  17. 17.

    The modified body is open to passivity and is easily influenced (Gemachten). Anything is possible inside this body.

  18. 18.

    The dermatozoic illusion is increasingly losing the connotation of being the result of parasites and has become something even more disturbing—extraneous objects have entered the body and are modifying it. It is no longer a parasitic infestation.

  19. 19.

    The symptoms appeared in 2006 and the transformation happened after 3 years of preparation in 2009.

  20. 20.

    The size of the animated extraneous objects changes from microscopic to macroscopic.

  21. 21.

    In patients suffering from Ekbom Syndrome caused by intoxication, the description of small lanceolate corpuscles is quite frequent. They are scales of skin uncovered through continuous scratching.

  22. 22.

    At this point the patient’s interpretation has advanced and the appearance of the extraneous body has changed from zoomorphic to anthropomorphic; the machine-like technology of the object is a clear psychotic indicator.

  23. 23.

    The detailed description is not typical of schizophrenic hallucinations which tend to be filled with atmosphere and contain landscapes (Straus 1930). What we have here is, on the contrary, a very minutely detailed and geographical description of a disperception which now contains all the elements of the successive delusional interpretation. Rather than being a delusional perception, this is a delusional hallucination. The extremely perceptive vividness is maintained by the use of hallucinogenic substances (salvia divinorum, spice, efedrina, ketamine).

  24. 24.

    Here it is evident just how strong the need to interpret is and how over the years the intense evidence felt and perceived by the patient’s senses of the modifications in progress have inevitably led to the necessity of finding a meaning to somehow explain them.

  25. 25.

    Ap 9, 1-6. 9-11 “Then the fifth angel sounded: And I saw a star fallen from heaven to the earth. To him was given the key to the bottomless pit. 2 And he opened the bottomless pit, and smoke arose out of the pit like the smoke of a great furnace. So the sun and the air were darkened because of the smoke of the pit. 3 Then out of the smoke locusts came upon the earth. And to them was given power, as the scorpions of the earth have power. 4 They were commanded not to harm the grass of the earth, or any green thing, or any tree, but only those men who do not have the seal of God on their foreheads.5 And they were not given authority to kill them, but to torment them for 5 months. Their torment was like the torment of a scorpion when it strikes a man. 6 In those days men will seek death and will not find it; they will desire to die, and death will flee from them.9 And they had breastplates like breastplates of iron, and the sound of their wings was like the sound of chariots with many horses running into battle.10 They had tails like scorpions, and there were stings in their tails. Their power was to hurt men 5 months. 11 And they had as king over them the angel of the bottomless pit, whose name in Hebrew is Abaddon, but in Greek he has the name Apollyon”.

  26. 26.

    The transformation of the patient into a completely controlled being is now complete. He is like a programmed robot now that the he feels sure that he is being controlled from inside.

  27. 27.

    The external interference is the cause of the three successive suicide attempts. G. has lost control of himself and is at the mercy of his enemy who can do whatever he wants with him. G. at times identifies himself in this enemy, while at other times, he fights against it. However, he is no longer able to control his own actions. Even when he fights against the system perceived as an enemy, he is only acting in consequence to external forces.

  28. 28.

    The appearance of UFOs underlines the atmospherisation of the hallucinations in which the extraneousness expands from the intrapersonal and intracorporeal space towards an immediately pericorporeal and peripersonal space and ultimately towards an extracorporeal and extrapersonal space.

  29. 29.

    The perceptive-sensorial participation is particularly powerful.

  30. 30.

    Here the sense of corporeal transformation is quite obvious.

  31. 31.

    The transformation from organic to inorganic is part of the patient becoming psychotic.

  32. 32.

    It is well known that this syndrome is frequently encountered in drug-addicted patients (“tactile hallucinations caused by external drugs: alcohol, cocaine, sympathetic-mimetic amines”, Callieri 2001) and, because of this, is considered to be of organic nature. Bruno Callieri in his memorable paper “L’animale nel vissuto corporeo”, published in “Quanto vince l’ombra: problemi di psicopatologia clinica” (1 ed. 1980, La Città Nuova, Roma; 2 ed. 2001, Ediz. Univ. Romane, Roma), examines in great detail Ekbom Syndrome and dermatozoic delirium. Callieri had already written on this subject in 1958 (“Considerazioni su un caso di deliroide dermatozoico”, Il Lavoro Neuropsichiatrico, 22) and later with G. Vella in 1960 (“L’esperienza tattile nel deliroide dermatozoico, Il Lavoro Neuropsichiatrico, 27) considering the delusional formation absolutely “secondary” and at this point explaining the meaning of the term delusion. Callieri was interested in what he called the “plurivoiced perceptiveness”, or the “haptic and optic synaesthesis” (the experience of the I feel-I see).

  33. 33.

    K. Beringer, Der Mascalinrausch, Springer, Berlin, 1927.

  34. 34.

    The “Alice in Wonderland Syndrome” was described by Todd, Lippman in migraine and epilepsy, and is characterised by morphological fluctuation, like metamorphopsia, micropsia, macropsia, temporal distortion, temporo-occipital lesion and parieto-occipital lesion.

  35. 35.

    The idea of the Gestalt’s cycle (Gestaltkreis) by Victor Von Weizsacker (1886–1957), instead, is the better model in order to understand NPS psychosis. The cycle “perception-movement” is probably the first and the principal target of NPS. H. Plessner (1892–1985) and M. Merlaeau-Ponty (1908–1961) give a strong contribution to identify and to define this perception/sensation area. Also J. Zutt (1893–1980) wrote about this aesthetic field of lived experience (Das aesthaetisches Erlebnisbereich).

  36. 36.

    These are often sold as something else, e.g. mystical incenses, plant chemicals and bath salts and herbal smoking blend (synthetic cannabinoids, Spice drugs, mephedrone).

  37. 37.

    Illusions, as well as, acoustic, olfactory, gustative and coenesthetic hallucinations, and chronic delusion in particular—where imagination and fantasy lead to bizarre and unrealistic situations—are all fundamental. Another common case is the feeling of being persecuted by strange electronic machines. Other cases include patients who believed they were without vital organs, responsible for “the end of the world”, the son of famous historical figures, protagonists of epic events and in communication with aliens. In differential diagnosis with schizophrenia, the personality cohesion and the affective participation in these cases are not completely damaged and social skills and personal autonomy are well maintained. The patient lives two lives at the same time (one real and another imaginary and delusional), which, however, do not completely compromise his behaviour and his relation with reality.

  38. 38.

    Toxic psychosis, traumatic psychosis, brain disease psychosis, delirium, progressive paralysis and withdrawal psychosis: these are the exogenic psychosis described by Bonhoeffer in 1914.

  39. 39.

    G. de Clerambault was the Director of the Special Infirmary for the Insane (prefecture de police, Paris, 1905). He described a lot of patients intoxicated by absinthe, clorhalius hidratus, ether, hashish and alcohol.

  40. 40.

    The mechanisms generated by psychosis hark back to automatism, or rather the triad of mental, sensitive and motorial automatisms. Among the phenomena that characterise automatism, which when taken together can be considered as being a little mental automatism, are verbal phenomena, word games, nonsense, foolish aspirations and lack of abstract thought. On top of this, we have to add the effects of reactive delirium and the consequences of sensitive automatism which represent the initial tribulations brought on by chronic hallucinatory psychosis. The construction represents an attempt to interpret the sensorial phenomena and is based on (a) the affective form of the patient, which we can sum up as pessimism, optimism or hostility; (b) the intellectual form, for example, an interpretive or imaginary tendency; and (c) on the concordance between the hallucinatory tendency on one hand and the affective-intellectual dispositions on the other. The ideo-verbal type of automatism is characterised by its anideic form (syllable games), ideo-verbal phenomena (thought echo) and negative phenomena (no longer being able to think), all of which have a mechanical origin. This division in which the patient finds himself has been described by De Clerambault with the metaphor of the two personalities where the second one receives sensorial data and the first one elaborates the data coherently with its own intellect and its own character: every psychosis is like a kind of double or two-piece delirium in which the psychisms are united in the same brain and where one dominates the other because it is more inventive and persistent, dominating it with mechanically derived laws. He goes as far to say that it isn’t the persecutory idea that creates the hallucinations, but, on the contrary, the hallucinations that create the very idea of persecution.

  41. 41.

    Five years previously, in 1930, the Rivista Sperimentale di Freniatria published Morelli’s “Sulla dissociazione mentale” better known as “Il Caso Elena” where he affirms that even if nothing specific can be argued about the nature of the dysfunction, we can venture to say that any suspicion that Elena’s sensorial motility, apart from being damaged indirectly by dissociation and by intrapsychic reactions, represents very real disorder caused by an unknown organic “process”. See the article in Rivista Sperimentale di Freniatria, vol. CXXXV, N. 3, 2011, Franco Angeli Editore, Milano.

  42. 42.

    Empathising means “feeling the other from within” (Stein 2012). The “pathicity” of existence is the background of this phenomenological approach (Binswanger 1942, 1957, 1963; Binswanger et al. 1958; Minkowski 1971, 1973, 1980, Von Weizsaecker (1886–1957), Straus (1891–1975)). Every feeling is a feeling-of-something: hate, disgust, love, desire, joy and sadness (H. Plessner (1892–1985), Scheler (1875–1928). Our feelings are not senseless state of consciousness or psychic facts, but concrete modes of existence in situations with others (F. J. J. Bujtendijk (1887–1974).


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Di Petta, G. (2016). “Synthetic Psychosis” by Novel Psychoactive Substances: A Psychopathological Understanding of a Clinical Case. In: Stanghellini, G., Aragona, M. (eds) An Experiential Approach to Psychopathology. Springer, Cham.

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