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Freud formulated the primary process model, describing mental activity that creates the illusion of an actual experience in lieu of reflective thought, at the very start of his career. In this, his initial formulation of unconscious mental activity, he was attempting to account for the nature of dreaming, by inference for the mind of infancy and, more speculatively, for adult psychosis. He never revised the model in light of his later formulations of the structural model and the death instinct, nor did he elaborate on his speculation that it could serve as a model for psychosis, and there has been little subsequent effort to employ the model outside the context of dreaming. A small number of analysts, including Klein, Bion, and Matte-Blanco, have constructed theories of psychosis in idiosyncratic conceptual languages that seem to be describing phenomena similar to those from which Freud constructed his model. Although Klein's model of positions, which has become the most widely accepted theory of psychosis, is generally considered a fundamental departure from Freud, both accounts have remarkable similarity and both tend to confuse primary mental expression with mature thought and normal infancy with psychosis. Contributions by cognitive-developmental psychologists including Werner and Piaget suggest ways to clarify some of the confusion and to supplement and amplify Freud's and Klein's description of some of the salient features of primary mental expression. Findings from neuroimaging studies of dreaming and of schizophrenia support the proposition that primary mental activity is a qualitatively distinctive form of mental expression.