It is most interesting to note that these earliest observers* not only recorded that serious personality disorder occurred in the absence of “a lesion of the intellect” but also that they were strongly inclined to recognize it as illness, to distinguish it from ordinary crime or depravity.
Despite the fact that they dealt largely with philosophic abstractions and assumed various “faculties” which were treated as separate and established entities, their practical conclusions seem far more realistic than many subsequent concepts and sometimes perhaps more pertinent than those that now determine the medical and legal status of the psychopath.
Dr. Ordronaux, Professor of Medical jurisprudence of Columbia University in 1873, expressed a contrary point of view that soon prevailed and, translated into other terms, represents rather accurately an attitude toward our problem that is still influential today. As quoted in part from Maughs, Ordronaux makes the following statement:205
Our moral nature is, like the mind, a special endowment. It feels, it is conscious … Moral nature knows no alterations in rhythm, craves no rest, never sleeps voluntarily. The only disease to which moral nature is subject is sin.
Though still assuming that “intellect” and “moral nature” are in actuality “things” as separate and independent as the words used to designate them, Ordronaux is quite sure that one, unlike the other, is not subject to any sort of disease.
At this point it might be helpful to ask ourselves a few questions. In psychiatry as in most other fields of human endeavor the belief in faculty psychology has long been abandoned. Primarily and chiefly through the persistent efforts of Adolf Meyer, nearly all medical workers agree today that we do not encounter a “mind” independently of a body, that we had best confine our attention to what we meet in experience, that is to say, a person who may show disorder in various aspects of his functioning. We reject the demand to deal separately with an “intellect,” a “moral faculty,” a “will,” as if they were, apart from the words, things that can be isolated for study or for treatment.174,216,217,218
In view of our generally avowed position in this matter, it is not a little surprising to find how concepts deeply rooted in the long-discarded faculty psychology enter, by the back door, and influence the attitudes and practices of today. A few of the many important points made by Korzybski are extremely pertinent here. Without attempting to go into the deep and general confusion, the ineffective procedures that can arise through the incompatibility of language and concept with fact, it is worth our while to consider for a moment what Korzybski and his co-workers refer to as consciousness of abstracting.121,151,154
It is obvious to us today that what most psychiatrists and psychologists talked and wrote about some decades ago were verbal abstractions and that these were treated as if they referred to what can be met in experience. By juggling these verbal artifacts without realizing (and admitting) that they do not necessarily correspond to real and separate entities, logical and eloquent arguments can be made, but such philosophizing usually has little applicability to the world in which we live. In medical problems this method has been peculiarly unrewarding.*
If we grant that mind and body, thinking and feeling, moral faculty and intellect, and character and personality cannot, except in language, be split apart and dealt with as clear-cut entities, let us keep this fact clearly in mind. This is not to say that such terms must not be used. It is neither practicable nor possible to avoid them. They convey something that is important. When the relative of a patient asks, “It’s not her mind, is it Doc?” and gets the reassuring answer, “No, it’s just her nerves,” he may receive useful and valid information (that she is not psychotic). On the other hand, he may receive a good deal of information that is not only misleading but sometimes distinctly harmful.52 He may find himself automatically instructed to this effect:
His wife’s trouble is confined to the peripheral nerves.
These nerves are weak (in the most literal sense) or perhaps frayed and a bit tangled.
The nerves have actually, as she has often told him, been jumping about in her body and knotting up in painful snarls.
She really has nothing wrong with her but is just putting on.
A little active medicine or a nerve tonic will cure the sickness, which is fortunately localized far from her “mind.”
Since she got run down and developed nervous exhaustion, a lot of rest in bed is plainly the answer.
As psychiatrists it it’s no doubt clear to us that “nervous trouble” is a kind of “mental trouble,” and we are not likely to be confused in such a way as the patient’s husband. Nor are we likely, today, to believe that a neurosis is caused by toxins arising from sexual frustration or that it is something essentially different from a psychoneurosis.84,130 We are not likely to feel we are talking about a patient with ordinary psychosis (“mental illness”) when we refer to a psychopath, despite the fact that our term unequivocally signifies illness of the “mind.” To escape the unjustified implications of faculty psychology, we wisely avoid diagnosing “moral insanities,” but we often turn to “neurotic character” as a term to indicate the same type of disorder.11,79 If we use the current nomenclature, we may classify those usually called psychopaths under the general term personality disorder and the subtype antisocial personality.15 Whatever terms are used, it is important for us to retain full realization that we abstract in a term or concept some aspect of what we meet only as an integrated entity.
The early material cited and discussed by Maughs makes clear the difficulties encountered approximately one hundred or more years ago in trying to solve psychiatric problems on the assumptions of faculty psychology. Some believe that the chief medicolegal decisions today are determined almost entirely on the question of whether or not a “lesion of the intellect” can be demonstrated.
In more recent decades two tendencies particularly seem to have played a major and persistent role in isolating the psychopath from practical consideration and in concealing him in a strange and gratuitous confusion. One of these tendencies arose from efforts to group these patients with many other types by no means similar. The other seems to have proceeded from ambitious attempts to break down the psychopath’s disorder by fine and largely imaginary distinctions, by all sorts of descriptive nuances and diagnostic legerdemain, into theoretical entities to be differentiated and classified under many subheadings.
These attempts at elaborate differentiation have been applied not to a distinguishable group having in common fundamental features that could be brought into conceptual focus but to an essentially heterogeneous referent. A good analogy would arise if someone set out to establish and list scores of inconsequential differences between Buicks, Oldsmobiles, Plymouths, Cadillacs, and Lincolns by studying assiduously a general material in which automobiles, oxcarts, demolished freight cars, jet planes, rural woodsheds, and the village pump were undistinguished, embraced under a single term, and treated through such concepts as can be formed in such an approach. Would it not be wiser to put all our automobiles together in a field of reference before attempting to take further steps?
It is perhaps worthwhile to say here that the more types our writers enumerate and the more seriously they take these philosophic artifacts, the less likely is any relationship to be found between what is in the book and our direct experience with psychopaths. Before these fine distinctions can be made to any good purpose, there must first appear some recognition of the basic group that is to be further differentiated. This seems notably lacking where wordplay is most extensive and ambitious.
Either of the two practices just mentioned would in itself have introduced more than enough obscurity. Together they have worked to make a confusion unparalleled in the whole field of psychiatry.
As the psychoses were recognized and the psychoneuroses distinguished from these, it became increasingly popular to put virtually anything that failed to fit into these categories with the psychopath in a veritable diagnostic salad of
incompatibles. The term psychopathic personality, of course, invites such practice with its literal applicability to all psychiatric disorders. The new official term Personality Disorder does not totally avoid similar implications of a very broad application.
Early in the present century Meyer called attention to the importance of separating patients now generally called psychoneurotic from the heterogeneous conglomeration of types among which the psychopath was then and is still, to some degree, officially placed.214 Through persistent efforts the mental defective was also distinguished and today is considered apart.
When mentally defective patients, in all their degrees of disability, were not distinguished from the psychopath, while both were listed under the same official term, it is not surprising that many excellent observers found and reported physical abnormalities, stigmata of degeneration, and gross neural pathology in the general group. It is not remarkable to see that such findings became associated with (and regarded as characteristic not only the patients in whom they occurred but also with the psychopath and other unrelated patients, all of whom were considered together as closely related examples of a constitutional defect state.123 It is, however, truly remarkable that such errors persisted through the years and decades. A good example is afforded by material from Sadler’s popular textbook published in 1936.249
In this ponderous volume, totaling 1,231 pages of text, less than five pages were spared for our subject. After several descriptive statements that could apply accurately to the behavior of the real psychopath and that seem to indicate him as the subject under discussion, physical characteristics of “constitutional psychopathic inferiority” are given through an extensive quotation from another authority.131 Some of these physical characteristics, presumably of the psychopath, deserve a moment of consideration:249
The brain may be abnormally large or small or defective either in part or as a whole. The abnormalities may be due to defective development, injury, tumor, infection, or vascular accidents, such as cerebral hemorrhage, or to interference with the circulation of cerebrospinal fluid such as occurs in hydrocephalus. Associated with these abnormalities are weakness and paralyses of various parts of the body as well as varying degrees of intellectual defect. The spinal cord likewise may be affected with resulting weaknesses or paralyses. There may be gross physical defects in the development of the eyes, ears, nose, mouth, arms, hands, legs, feet, rectum, anus, and external urogenital organs. Minor physical defects sometimes referred to as stigmata of defective development include abnormalities of the cranium, malformations of the external ears, nose or mouth (abnormal spacing, position, or defective development of teeth; high-arched palate, harelip or cleft palate), webbing of fingers or toes, distorted or supernumerary digits, excessive amounts or absence of hair, undescended testicles and infantile uterus. [pp. 881–882]
Just what bearing this curious compendium of deformities may have on the question of the psychopath I am scarcely prepared to say. A causal relation, to which Sadler249 does not openly commit himself but seems somewhat evasively to imply, is scarcely to be assumed, even if it is not to be dismissed at once as fantastic. None of the many hundreds of psychopaths whom I have observed showed any such pictures as one gets from reading this quotation in the context that is given. Although such stigmata and such gross brain changes are sometimes associated with mental deficiency, cerebral agenesis, and various organic diseases, they are certainly not regarded as characteristic of psychopathic personality. In fact, if such abnormalities as these were found in a patient, the diagnosis of organic brain disease, mental deficiency, or of some definite heredodegenerative condition would become inescapable and the diagnosis of psychopathic personality (or personality disorder, antisocial type) unlikely if not impossible.*
After other brief descriptions the author under discussion adds a statement which is all but incredible. Following the opinion that prognosis is hopeless for complete recovery, it is asserted that psychopaths are not likely to improve “unless a psychiatrist can take them in hand for six months to a year and teach them how to live.”249 Under these conditions great improvement is considered probable. It is quite clear that more than a few different and extremely unlike things are being considered. Though all these are grouped under one name, they do not thereby gain homogeneity. Nor does it seem helpful for purposes of description, study, or treatment to approach either the psychopath or patients of these other types in such a manner.
A few paragraphs beyond the account of physical defects and gross neurologic abnormalities just quoted we find the description of a subtype, “the feebly inhibited,” which includes these interesting statements:249
On the functional side these individuals are notoriously subject to general nervousness. Specifically, we find tremors, facial or other tics (habit spasms), abnormal movements of the eyes, headaches, little attacks of dizziness, enuresis, prolonged throughout childhood, and so on. The organs of the special senses are particularly apt to show signs of inferiority; defective vision is very common. [p. 883]
Any person familiar with the psychopath as he is met in clinical experience will need no prompting to realize what confusion is likely to ensue if the medical student tries to reconcile books and facts at this point.
Let us give a little more attention to these statements. The book from which they are taken was published in 1936. The last quotation is to be found, repeated precisely to the last comma, in another volume by Sadler published in 1945.250 It is of interest to note that the entire passage also appears in The Individual Delinquent (William Healy, 1915),123 a work which expresses concepts widely accepted and congruent with the terminology at that time but at confusing variance with official standards in 1936* and long ago discarded by Healy. Though no longer representing the thoughts of the original author or the criteria of the American Psychiatric Association, we find this archaic concept carried verbatim in a text book published twenty-one years later and in another published thirty years later.
And with all this we find other statements, some applicable to the real psychopath and apparently so directed but plainly incongruous, if not indeed fantastic, if we attempt to correlate them with the material just quoted from the same volume. For instance, it is said of these people that “they suffer from no physical or mental disease that would account for their deficiency.” (What about those brains abnormally large or small and defective in part or as a whole? What about tumor, infection, cerebral hemorrhage? What about paralyses and “gross physical defects of the … nose … legs … anus”?)249
The confusion about our subject as it has been so often presented in psychiatric textbooks should not be peremptorily attributed to carelessness or ignorance on the part of the authors. It is worthwhile for us to remember that these authors are attempting to treat many disparate and not a few distinctly incongruous matters under a single heading. Even today our officially approved standards demand that a good many different disorders be so treated.15 Often we find much broader and more heterogeneous areas embraced, and such a motley conglomeration of diverse subjects appears under a single label that even the most sagacious author can say little without falling at once into paradox, error, and soon into absurdity. His statements may be sound, accurate, and entirely pertinent to the various subjects he, perchance, has in mind and at the same time ring loud with nonsense as they strike willy-nilly upon other and alien subjects all forced under a single identifying term that applies to nothing except in language.
The second tendency, already mentioned, is illustrated in the brief space (five pages) of the textbook we have been discussing.249 Not only do we find many dissimilar subjects treated under one term, but also a record of ambitious attempts to devise subtypes on a superficially descriptive basis unrelated to the real and obvious differences (such as, for instance, between a patient with cerebral agenesis and a typical psychopath). We are given the various “types” as listed by Kraepelin, Schneider, and Partridge:
Kraepelin Schneider255 Partridge236
The excitable
The unstable
The eccentric
The liars and swindlers
The emotionally unstable
The quarrelsome
The hyperthymic
The depressive
The insecure
The fanatic
The self-seeking
The anti-social
The explosive
The affectless
The weak-willed
The asthenic
The delinquent
The inadequate
Those with general incompatibility
To these Sadler219 adds his own list of types:
Kleptomania
Pathologic liars
Eccentrics
Sex abnormalities
The feebly inhibited
Is it an exaggeration if we say that the difficulties confronting the psychiatrist who has had to approach the psychopath through such a tangle of concepts (and it has been our traditional method) are comparable with those that would be faced by a general practitioner discussing leukemia if this term meant also a broken leg, hemorrhoids, pregnancy, brain tumor, and the common cold? And if there were no other term available?
Throughout the second quarter of this century Kahn’s treatise entitled Psychopathic Personalities156 was, judging by references in textbooks and in the psychiatric journals, generally regarded as the authoritative and the most useful source of information about our present subject. This I believe to be scarcely less unfortunate than paradoxical. Here we have a valuable and scholarly work by a distinguished psychiatrist, a large volume embodying the author’s fundamental concepts of personality structure and psychopathology in general. But we find little or nothing in all this material that has any pertinent relation to our group of patients. We find, in fact, all the psychoneuroses treated under the heading “psychopathic personality” and a list of sixteen categories that seem occasionally to touch but never to clarify our subject. Kahn’s use of the term psychopathic personality is, in my opinion, not only justifiable but more in accordance with its obvious literal meaning than our customary use. Such questions are, however, not particularly germane. The point that demands emphasis is that our chief scientific work generally regarded for a couple of decades as authoritative in the field turns out not to be a book about the psychopath but a careful and valuable study of other subjects. Among these subjects it is difficult to find material related to our problem.
The Mask of Sanity Page 33