The Mask of Sanity

by Hervey Cleckley

  There is little point in devoting space to detailed accounts of paranoid or cyclothymic personalities. In some degree such characteristics can be seen among anyone’s acquaintances, and to name a quantitative point at which they warrant a diagnosis is not easy. Nor is it possible to lay down specifications that will enable one to delineate confidently where paranoid personality ceases and paranoid state or paranoid psychosis begins. So it is with depressions. Where the depth of negative affect permissible to cyclothymic personality ceases and that of “neurotic depression” begins is perhaps even more difficult to define than where, at greater depths, the disorder should properly be pronounced depressive psychosis. There is about all this much to suggest that traditional concepts have attributed to our terms a good deal more authority than clinical facts uphold.

  I find it helpful to consider all schizoid reactions, of whatever degree or course of development, as qualitatively similar, whether or not they are sufficiently disabling to merit such a term as psychosis. So, too, the affective and paranoid reactions seem to fall naturally each into its primary group rather than into other pigeonholes (on the basis of degree) which may give rise to confusion.

  The characteristic disorder of the psychopath is usually not difficult to distinguish from these other disorders, but like all of them, it, too, is seen in the widest variations of degree, in manifestations ranging from isolated character traits in the successful person, or brief episodes of delinquency in adolescence, to disability far greater than that shown by many of the psychotic patients committed to institutions.

  32. The Psychoneurotic

  People who suffer from personality disorders which cause them to be anxious, restless, unhappy, and obsessed with thoughts they themselves recognize as absurd but who are, in the lay sense, altogether sane have for years been classed as psychoneurotic. They recognize reason in general, often admit that their symptoms arise from emotional conflicts, and are free from delusions and hallucinations.

  Sometimes their complaints are chiefly physical, of fatigue, of numbness, of indigestion, even of paralysis. Often they will not admit that this numbness or indigestion or paralysis could possibly be related to emotional difficulty and indeed they themselves may be unaware of conflict. They are often resistant to reasoning but more in the sense of a person with strong prejudices than of one with delusions or with intellectual dilapidation. Sometimes they feel strong fears that they may carry out acts which they dread and which would indeed be tragic or criminal, but they recognize the nature of these acts and do not carry them out. Other acts, all patently senseless but relatively harmless, they do carry out, recognizing the absurdity of feeling that they must do so but becoming anxious if they resist the impulse.

  In general, psychoneurotic people recognize objective reality and try to adapt themselves like most others to the ways of society. Patients with traditional psychoneurosis are not characterized by antisocial activity or by striking inability to pursue ordinary goals. Their symptoms handicap them often, but in a way we readily understand. Anxiety, for instance, can make special difficulties for a salesman or obsessive manifestations can handicap a banker, a scholar, or a housewife. These patients as a group are sharply characterized by anxiety and by the various symptomatic schemes that apparently arise from the anxiety and that look as if they were measures employed in reaction to the anxiety and in efforts to relieve it, it is true that many patients with conversion symptoms do not show what is ordinarily conveyed by the word anxiety or by tension, fear, distress, and similar terms. Many psychiatrists believe that in such instances the paralysis (or the blindness) may be a substitute for conscious anxiety and probably a defense against it, a means of preventing it or controlling it. The rather remarkable calmness shown by such patients has often been pointed out. Not a few psychopathologists maintain that there is an “unconscious anxiety” or what might be thought of as something embryonic, underlying, or incipient that would be anxiety if not converted into the physical manifestation.

  Certainly it may be said about psychoneurosis, as the term is officially used and most widely accepted, that patients with this kind of disorder usually find their symptoms unpleasant, consciously suffer from them, and complain.

  On the contrary, those called psychopaths are very sharply characterized by the lack of anxiety (remorse, uneasy anticipation, apprehensive scrupulousness, the sense of being under stress or strain) and, less than the average person, show what is widely regarded as basic in the neurotic. It is very true that Alexander9,11 and others79,209 who use his terminology and accept his interpretations refer to behavior disorders as character neuroses. Karpman164 feels that most (but not all) patients who are classed as psychopaths should be grouped with the neurotic or the psychotic group. So far as its implication of causal factors is concerned, the term neurotic has undeniably valuable applications for those who feel that they have discovered such causes; but its tendency otherwise to identify the psychopath with hysteria, anxiety reactions, or ordinary obsessive-compulsive disorders is likely to cause confusion and make for practical difficulties.

  If the psychopath really has a neurosis, it is a neurosis that is manifested in a fundamentally different life-pattern from classic neurosis, manifested, one might say, in a pattern that is not only different but opposite. Alexander and others have made this quite clear, and the interpretation of the psychopath’s behavior as symptomatic “acting out” against his surroundings, in contrast with the development of anxiety or headache or obsession is, it seems to me, an interesting formulation. It is of obvious importance to respect this polar difference between how the psychopath is going to behave socially and what can be expected of patients with somatization conversion. I do not believe that psychopaths should be identified with the psychoneurotic group, for this would imply that they possess full social and legal competency, that they are capable of handling adequately their own affairs, and that they are earnestly seeking relief from unpleasant symptoms.

  There are disorders in which the two diverse types of reaction (developing subjectively unpleasant symptoms versus callously carrying out socially destructive acts) seem to exist in the same symptom. The so-called pyromaniac (and kleptomaniac) often seems motivated by forces similar to the classic obsessive-compulsive patient who corrects the alignment of objects on the bureau forty times a day and who is painfully and overscrupulously preoccupied with fears that he may harm his child. Such a patient detests the acts he carries out as a sort of ritual to mitigate his subjective distress and is by no means likely to harm the child. He is, in fact, horrified by these thoughts (fears) and is nearly always conscientious to an excessive degree.

  On the other hand, as Fenichel has pointed out, the patient abnormally impelled to commit arson or theft (or sex murder) is not committing an act in which scrupulous feelings play a direct or major role and (despite possible ambivalence) gains excitement and consciously satisfies strong drives. The distinction emphasized by Fenichel between ego-syntonic and ego-alien motivations (compulsive acts of caution versus so-called “compulsive” antisocial acts) is a fundamental point and brings out a distinction not merely of degree but of quality. Behavior that Fenichel classifies as impulse neurosis seems to lie in an area where the unlike (and, as a rule, mutually exclusive) manifestations of the psychopath and the classic obsessive-compulsive patient both play a part together, the two customary opposites approaching and perhaps merging, paradoxically, in the antisocial act.79,254

  This particular mingling of influences (or merging of pictures) ordinarily quite different (and mutually exclusive) is not unique in psychiatry. Is there any one who has not seen patients manifesting genuine manic and genuine catatonic features? Has any psychiatrist failed to note obsessive relations that are colored with genuine delusion?

  Despite any confusions that arise in arguments about psychopathology (dynamic or descriptive) in regard to the psychopath, all, I believe, will agree that his clinical manifestations are easily distinguished from the syndromes
now classified as psychoneurosis. It is doubtful if in the whole of medicine any other two reactions stand out in clearer contrast.

  The true psychopaths personally observed have usually been free, or as free as the general run of humanity, from real symptoms of psychoneurosis. The psychoneurotic patient, furthermore, is usually anxious to get over his symptoms, while the psychopath does not show sincere evidence of regretting his conduct or of intending to change it.

  Caldwell has effectively set down outstanding differences between these two clinical pictures in a brief tabulation. Our point can be clarified by quoting it:39

  Ego-enhancement (psychopathic): Feeling Hedonistic

  Callous

  Emotionally immature

  Thinking Irresponsible

  Rationalistic

  Acting Antisocial

  Impulsive

  Defiant

  Explosive

  Ego, depreciation (neurotic) Feeling Apprehensive

  Anxious

  Fearful

  Depressed

  Helpless

  Inferior

  Jealous

  Thinking Stereotyped in fantasies

  Preoccupied with moral and religious ideas

  Obsessive

  Acting Antisocial

  Asocial

  Shy, sensitive

  Hesitant

  Indecisive

  Suggestible

  Overly protective

  Sexually conditioned

  Timorous

  Passive

  Some observers believe that the presence of what has long been known as psychoneurosis is sufficient reason for questioning the diagnosis of psychopathic personality. In the study just referred to, Caldwell reports neurotic manifestations in patients whose chief features were plainly those of the psychopath. I believe that the two types of reaction are not characteristically seen together but perhaps there are no two pathologic syndromes in psychiatry, however distinct, that may not sometimes overlap.

  33. The Mental Defective

  The mental defective often behaves foolishly or ineffectively and, if the defectiveness is great, may show prolonged and serious maladjustment in ordinary surroundings. In contrast with the psychopath, however, the mental defective is obviously stupid, and his follies may be understood readily as depending on his lack of intelligence, a handicap that is easily demonstrated. This can be measured with some accuracy in psychometric examinations. Many low-grade defectives show developmental deficiencies or other organic changes in their actual brain structure. The psychopath, on the other hand, is often, if not usually, of superior intelligence when measured scientifically. Some of his accomplishments also indicate he has ability that is average or better when he is using it. He often gives the impression in conversation of excellent intellect and is plainly a very different person from the mental defective. Though in England the psychopathic personality was still until fairly recently sometimes referred to by the expressive term, moral imbecile, the distinction from intellectual imbecility has always been clearly recognized.128

  Serious defects in ordinary intelligence naturally handicap a subject, naturally make it difficult for him to learn complicated relationships between cause and effect, and limit his critical ability in choosing wisely among the many courses of conduct offered every day. The defective is likely to be susceptible to false counsel and prone to overlook the more remote and subtle consequences that may follow the gratification of a petty impulse. Unlike the psychopath, mental defectives show limitations of judgment in theoretical situations. They are often unable to express adequate comprehension of mistakes they have made or wrongs they have done. They do not outline, even verbally, ingenious plans for the future or discuss their total situation in such a way as to give a convincing impression of wisdom and reliability. They cannot simulate successfully deep contrition, purpose, and understanding. The badly handicapped mental defective may repeat time after time acts which result in loss or harm to others and to himself. His limitation in reasoning about facts that play a part in such consequences usually offers a satisfactory explanation of his disability.

  This disability is considered by courts before which the defective may be tried for misdemeanors or felonies and which may be called upon in efforts to hospitalize him or in other ways to safeguard and help him. It is not only admitted that intellectual defect diminishes judgment and legal responsibility, but varying degrees of defect are recognized and, for practical purposes, accepted as implying degrees of competency.

  If a high-grade moron commits murder, his relatively slight defect will be regarded as slight by the jury. The idiot or the imbecile will, however, be properly considered as one with a disability that may have played a major part in such an act. So, too, there has usually not been much difficulty in having the idiot committed (if necessary, against his own will and judgment) to a medical institution where he can be protected and cared for. No jury, however, not even a jury of morons, would deprive of his legal freedom a man showing no more defect than what is customary with an I.Q. of 70.

  It is important for us to note that particularly in the question of commitment for a mental defective, varying degrees of disability are recognized and are regarded as affecting competency in varying degrees. In determining the presence of disability and its degree, the record of the defective’s actual behavior is not ignored. Psychometric tests furnish evidence which helps the psychiatrist to classify patients properly as idiots, imbeciles, or morons, and this evidence contributes to medicolegal decisions concerning competency. The need for institutionalization in a defective is, however, demonstrated more effectively by his acts than by his I.Q. In contrast, we find that no matter how much evidence of incompetency emerges in the psychopath’s record, this classification alone is (officially) regarded as establishing complete sanity, absolute competency.

  34. The Ordinary Criminal

  Though efforts have been made to interpret criminalism as a form of mental disorder and many criminal careers have been expounded as reactions to emotional conflict,11,12 the sort of person described here shows the following important points of distinction from the typical criminal:

  The criminal usually works consistently and with what abilities are at his command toward obtaining his own ends. He sometimes succeeds in amassing a large fortune and may manage successfully and to his own profit a racket as complicated as a big business. The psychopath very seldom takes much advantage of what he gains and almost never works consistently in crime or in anything else to achieve a permanent position of power or wealth or security. Mercier long ago made the following statement quoted by Henderson:128 There are persons who indulge in vice with such persistence, at a cost of punishment so heavy, so certain, and so prompt, who incur their punishment for the sake of pleasure so trifling and so transient, that they are by common consent considered insane although they exhibit no other indication of insanity.

  The man who is essentially criminal may then be regarded as consistently purposive, whereas the psychopath seems hardly purposive at all in comparison. To say the least, the pattern of his actions over any fairly long range of time indicates little that the observer can understand as what a human being would consciously choose. The patient himself sometimes convincingly denies any particular temptation driving him toward the situations to which his behavior repeatedly leads.

  The criminal ends, though condemned, can usually be understood by the average man. The impulse to take money, even unlawfully, in order to have luxuries or power otherwise unobtainable, is not hard to grasp. The criminal, in short, is usually trying to get something we all want, although he uses methods we shun. On the other hand, the psychopath, if he steals or defrauds, seems to do so for a much more obscure purpose. He will repeatedly jeopardize and sometimes even deliberately throw away so much in order to seek what is very trivial (by his own evaluation as well as by ours) and very ephemeral. He does not utilize his gains as the criminal does. Sometimes his antisocial acts are quite incomprehensi
ble and are not done for any material gain at all.51

  The criminal usually spares himself as much as possible and harms others. The psychopath, though he heedlessly causes sorrow and trouble for others, usually puts himself also in a position that would be shameful and most uncomfortable for the ordinary man or for the typical criminal. In fact, his most serious damage to others is often largely through their concern for him and their efforts to help him.

  The typical psychopath, as I have seen him, usually does not commit murder or other offenses that promptly lead to major prison sentences. This is true of the disorder as I present it in what I consider a pure culture. A large part of his antisocial activity might be interpreted as purposively designed to harm himself if one notices the painful results that so quickly overtake him. Of course I am aware of the fact that many persons showing the characteristics of those here described do commit major crimes and sometimes crimes of maximal violence. There are so many, however, who do not, that such tendencies should be regarded as the exception rather than as the rule, perhaps, as a pathologic trait independent, to a considerable degree, of the other manifestations which we regard as fundamental. It is, of course, granted that when serious criminal tendencies do emerge in the psychopath, they gain ready expression, and that no punishment can discourage them. Psychopaths who commit physically brutal acts upon others often seem to ignore the consequences. Unlike the ordinary shrewd criminal, they carry out an antisocial act and even repeat it many times, although it may be plainly apparent that they will be discovered and that they must suffer the consequences.