The Mask of Sanity

by Hervey Cleckley

Forever mummied in their crystal tombs.

  And yet … somehow … as I behold

  These mimic plants, they leave the fancy cold;

  Then, frigid patterns, sleep inviolate

  Within your glassy cells. Unkindly fate

  Denied you death and so denied you life

  I want my plants to feel the tonic strife

  Of all the testing elements; to know

  The flagellation of the rain, the snow,

  The scathing sun, the shrapnel of the hail;

  To bear the hundred lashes of the gale

  And all that soul of man or flower needs

  For flowering—the rivalry of weeds,

  Not clipped or clamped in time’s unyielding vise—

  Eternal molds of sempiternal ice—

  Farewell, stark forms. No more can you beguile,

  You wear the sleety artificial smile

  That freezes as it falls. My earthly flowers

  Can hear the wing-beat of the flying hours

  And, blushing for your deep immortal lie,

  Are unafraid—nay, eager—proud to die.

  So shall they burgeon with a sweeter breath

  Because, like us, they wait the frost of death.

  “Glass Flowers”

  Although to the casual reader these words may suggest more readily the obvious artificiality familiar in the schizophrenic and the schizophrenic’s withdrawal from the pain and pleasure of objective life, a point may be made that the full implication of the poem more properly bears on the state of these personalities we now discuss.

  Such outward perfection as that seen in the glass flowers at Harvard and such complete lack of participation in the essence of life and mortality suggest wonderfully the situation which me mean to portray in the personalities described in this volume. The schizophrenic does not preserve the intact outer form and function of a complete personality, but the psychopath does.

  Without suffering or enjoying in significant degree the integrated emotional consequences of experience, the psychopath will not learn from it to modify and direct his activities as other men whom we call sane modify and direct theirs. He will lack the real driving impulses which sustain and impel others toward their various widely differing but at least subjectively important goals. He will naturally lack insight into how he differs from other men, for of course he does not differ from other men as he sees them. It is entirely impossible for him to see another person from the aspect of major affective experience, since he is blind to this order of things or blind in this mode of awareness.

  It must be granted of course that the psychopath has some affect. Affect is, perhaps, a component in the sum of life reactions even in the unicellular protoplasmic entity. Certainly in all mammals it is obvious. The relatively petty states of pleasure, vexation, and animosity experienced by the psychopath have been mentioned. The opinion here maintained is that he fails to know all those more serious and deeply moving affective states which make up the tragedy and triumph of ordinary life, of life at the level of important human experience. Such capacities vary widely, of course, among normal people and are perhaps proportionate to the general personality development, or, in a far-reaching sense, to true cultural level. The scope or the substantiality of such reactions, if they could be accurately and objectively estimated, would, perhaps more than any other criteria, make it possible to judge how successful and how complete an experiment in nature216 a particular person has proved to be. A Beethoven, a Dante, or an Aeschylus, if his real inner life is faithfully represented in his works, would probably present no less a contrast in this aspect with the illiterate and unimaginative peasant or the successful pickpocket than in objective accomplishments. Nevertheless, no normal person is so unevolved and no ordinary criminal so generally unresponsive and distorted, that he does not seem to experience satisfaction, love, hate, grief, and a general participation in life at human personality levels much more intense and more substantial than the affective reactions of the psychopath. My concept of the psychopath’s functioning postulates a selective defect or elimination which prevents important components of normal experience from being integrated into the whole human reaction, particularly an elimination or attenuation of those strong affective components that ordinarily arise in major personal and social issues.

  However intelligent, he apparently assumes that other persons are moved by and experience only the ghostly facsimiles of emotion or pseudoemotion known to him. However quick and rational a person may be and however subtle and articulate his teacher, he cannot be taught awareness of significance which he fails to feel.* He can learn to use the ordinary words and, if he is very clever, even extraordinarily vivid and eloquent words which signify these matters to other people. He will also learn to reproduce appropriately all the pantomime of feeling; but, as Sherrington said of the decerebrated animal,257 the feeling itself does not come to pass.

  Even his splendid logical faculties will, in real life situations, produce not actual reasoning but that imitation of reasoning known as rationalization, for in the synthesis by which reasoning contributes to sound judgment, the sense of value, that is, the value of truth and feeling, cannot be missing. When this is missing, the process is only rationalization, something which, however technically brilliant, does not satisfactorily guide and shape action. And no difference between the two is more fundamental.58

  When we conceive of the thought, the emotional responses, the general psychic processes, and the behavior of a person in whom is postulated a defect of this sort, we have arrived at something identical or all but identical with the psychopath as he appears in actual life.

  When we say that a disorder at deep levels of personality integration prevents experience from becoming adequately meaningful to the subject, we become vulnerable to the accusation of talking nonsense. It is easy indeed to become unclear, if not to appear actually ridiculous, in attempting to express a point, however tentatively, on these fundamental matters. A reviewer in the New England Journal of Medicine says of the concept here advanced:221

  If that [understanding of the meaning of life] is the disease from which the psychopathic inferior suffers, this term can be applied to most of us and certainly to the reviewer, since, so far as he knows, no one has yet given us an insight into the meaning of life. [p. 349]

  Such a comment is appealing and not without humor, but it scarcely meets the issue in a responsible manner. We need not assume that a normal man understands the ultimate purpose of life or even that he is remotely near final accuracy in his evaluations of his own bits of experience in order to believe that the psychopath is, in comparison, seriously disabled by the specific deficiency we are attempting to formulate.

  Although “meaning” or “the meaning of life” can be applied to a philosophic or religious system that attempts to explain man and the universe, it must be obvious that such an application is not intended here. By saying that a good deal of the affective substance which people find in life experiences is lacking in the psychopath’s responses, we seek only to point out that he is not adequately moved and that he does not find subjective stimuli to make the major issues of life matter sufficiently to promote consistent striving. Furthermore, he cannot achieve true and abiding loyalty to any principle or any person. It is difficult, perhaps, to express anything about such a matter without inviting misunderstanding. Such an affective alteration of fundamental experience is generally granted in the schizophrenic, who shows superficial indications of it. In the psychopath, although it is so strongly indicated by his conduct, this alteration is well masked by his misleading surface. It should not be said that such an estimate can be scientifically proved in either case, or that any subjective state in another can be so established.

  In Brenden Maher’s important work devoted to current problems of psychiatry and psychology published in 1973, thirty-two years after my first effort to formulate these concepts, I find support and encouragement in this comment on subsequent studies of the p
sychopath:194

  Dr. Cleckley’s book, The Mask of Sanity, has been the stimulus for most of the experimental research that has been conducted into the problem of psychopathy. It is one of the best examples available of careful clinical observation leading to hypotheses (not conclusions) which can then be put to controlled test. The wealth of clinical anecdote with which each point is illustrated renders it difficult to find any one sequential extract from the book that might serve to present his hypotheses in a systematic fashion. The extract in this volume consists of several portions of the text selected and assembled to be maximally coherent, while letting Cleckley’s own views be presented in his own words.

  From Cleckley’s hypothesis there has developed naturally a major interest in the psychobiology of the psychopath’s emotional experience—or lack of it. A prima facie credence must be given to the possibility that the psychopath is deficient in those bodily responses that give rise to the emotional experiences of anxiety, pity and the like. Hare, one of the major investigators of the present time, examines this explanation and presents the pertinent data in his paper here. The paper is not previously published elsewhere and it provides a new synthesis of findings from several related lines of research on the topic. [p. 197]

  62. The Concept of Masked Personality Disorder or Defect

  Let us consider further the concept of disorders or defects that are deeply or centrally located. The contrast between such a pathology and one that is peripheral and visible can be demonstrated readily in speech disorders.

  The man whose tongue has been severely mutilated will not be able to pronounce his words clearly. Perhaps he can only mutter unintelligibly. Even a child or a savage can see where the trouble is and understand why function is disrupted. If the hypoglossal nerves are cut, the tongue, although itself unmarred, will not move and words cannot be uttered. An observer may detect the paralysis and in time note that the tongue has shrunk in size. There are, to be sure, some changes discernible at the outer aspect of the organism, but these are less obvious and less gross than the visible swelling, the bruises, and the lacerations that are present when the tongue itself has been directly injured.

  Should localized damage occur much farther away in the motor cortex of the brain or in the pyramidal tract, the tongue itself will maintain its normal size and appearance. Although it cannot be voluntarily used to produce speech, or for other purposes, considerable reflex movement may occur. With none of these three lesions have we encroached upon the understanding of language or upon its use except through one of its peripheral instruments, the tongue. All three of these patients can read and think verbally without impairment. All can write as articulately as before.

  If localized destruction is visited upon neurons in another part of the brain (let us refer to this area roughly and inexactly as the quadrilateral space of Marie), the tongue remains anatomically sound and able to perform all ordinary movements. The entire physiologic apparatus whereby words are sounded remains intact—intact and controlled by conscious volition. The patient can protrude his tongue and move it from side to side as directed. He can speak also, in contrast to our last two examples, and, unlike the one whose tongue was directly injured, his words may be clearly and accurately pronounced. Often, however, the phrase or sentence he utters will not be what he means to say. Perhaps it will carry little or no suggestion of what he wishes to tell us. Perhaps it will amount to a rough approximation or an awkward circumlocution that indirectly gives us a clue. Perhaps some word irrelevant to his actual thought will be repeated over and over.

  Attempting to ask for his pen, he may say, “Ben-Ben-then-then” and, perhaps gesturing with his hand in sign language, at length indicate more to us by the words, “what you write with.” Perhaps in attempting to tell us good morning or to inquire about the health of our aunt, he may, to his embarrassment, shout, “Doggone, doggone, son of a bitch, you bastard.” This is indeed clear but it has nothing to do with what he has tried to express.

  Various degrees of impairment may be found in those aphasias classified by Henry Head as verbal, nominal, or syntactic.122 Some aphasic patients may utter clear sounds but fail to put syllables together into words. Others may hit upon words but not succeed in making comprehensible sentences or even phrases. Many of those seriously affected by such a disorder understand simple statements made by others. Some can communicate with us far better in writing than by the spoken word. In most, however, along with a serious defect in their own meaningful use of speech, we find some impairment in the understanding of spoken or written language. Even those considerably handicapped in reading, speaking, writing, or grasping the significance of what they are told may retain a relatively good use of “inner speech” and may be able still to make silent use of words for thinking or reasoning. Such people are aware of their difficulty and realize in exasperation that they cannot say what they intend and that language once quite familiar has, for them, somehow lost much of what it formerly conveyed.122

  In discussing these three types of dysarthria we proceeded from the periphery of the functional unit (the injured tongue) inward (the severed hypoglossal nerves) to the relatively central point of the cerebral motor cortex. When we then consider in comparison to dysarthria the aphasias, we find that this entire motor apparatus that produces words is unimpaired and also unimpaired is the sensory system by which language, written or spoken, is accurately perceived. We confront now a deeper disorder. In a sense we may say, roughly and imperfectly, that the instrument itself is unimpaired but the player has lost some of his ability to use it accurately for his purposes. Let us modify this and say that the player (if he is to represent something very inexactly suggested by “mind” or “personality”) is not in immediate contact with the instrument and does not directly use it as, for instance, a pianist who strikes the keys or man at the telephone who puts the receiver to his ear. In our far from adequate analogy let us assume a complicated system of processes between the hand and the keys, between the ear and the receiver.

  To produce speech there must be between the operator and his mechanism for uttering words other instrumentalities of evaluation whereby the words are chosen and used to express his purpose. So too between the correctly received perception (auditory or visual) and its understanding must come processes of recognition and association and integration, the complex shaping of significance that is grasped as a whole, before a real message can be completed. As Suter suggested, speech may be thought of as coming about “as a result of the functioning of a very elaborate kind of reflex arc made up of (1) an afferent, sensory, or receptive part; (2) a central, associative or elaboration part; and (3) an efferent, motor or expressive part.”274

  Speech disorder resulting from damage to the neural mechanisms of (2), on which depend the elaboration of concepts and the association of words with referents in the person’s life experience and designated by Suter as anomia, may be thought of as more central than those chiefly limited to (1) or (3), where the defect is, in a sense, more external.

  Henry Head described under the term semantic aphasia a disorder of language still more central, more (functionally) proximal in the dimension, or area, or direction that (2) serves to indicate. This disorder he believed is related to pathology at, or near, the supramarginal gyrus. Semantic aphasia, according to Head, is “characterized by want of recognition of the ultimate significance and intention of words and phrases … loss of power to appreciate or formulate the general conclusion of a connected train of thought.”122 The person with semantic aphasia “may understand a word or short phrase and can appreciate the various details of a picture but the significance of the whole escapes him.”122

  In semantic aphasia, in which, so to speak, the lesion is more central than in other aphasias, the language function can usually produce more words and better phrases than in verbal or syntactical aphasias, but these have far less meaning or use to the patient. The vehicles or vessels of speech are readily made but emerge empty, devoid of the conten
t they ordinarily define. The patient may enunciate clear, grammatical sentences, but they are irrelevant to any intention of his and do not convey even the distorted hints of valid statement often successfully transmitted by the jargon or the circumlocutions of a patient whose aphasia is more peripheral. In the latter, intentions can be realized inwardly and communicated to some degree by gestures or pantomime, or verbal fragments and approximations. In semantic aphasia, as described by Head, inner speech or verbal thought is seriously crippled, and the patient usually cannot formulate anything very pertinent or meaningful within his own awareness. He cannot by gestures or verbal approximations hint at his message because he lacks the inner experience on which a message might be formulated. If he could do this, the more peripheral difficulties that mar the speech in verbal aphasia would not lie in his way and his thought would proceed to articulate expression. But he has no inner production of thought and feeling to transmit. The instrumentalities for language are apparently adequate. They do in fact still perform smoothly but more or less reflexively and apart from inner purpose, manufacturing phrases and sentences but doing so automatically. But the language does not represent or express anything meaningful.

  It might be said that the very severe inner disorder of language in semantic aphasia is to a considerable degree masked by the mechanical production of a well-constructed but counterfeit speech carried on in some degree of independence by an undirected outer apparatus which has become virtually disconnected from inner purpose. Like real speech, it appears to represent the inner human intention, thought, or feeling, but actually it is an artifact. Behind the superficially good (clear, grammatical) speech there is little or nothing to be symbolized and conveyed. This stands in contrast to the gross superficial disorder of communication in verbal aphasia in which inner purposes can still be intelligently formulated and, however awkwardly and indirectly, are often communicated with some degree of success to another.