12 February 2006

A basic hypothesis of Psychopathy

From: The Mask of Sanity, by Hervey Cleckley, 5th edition

Now that we have proceeded with our task through the stages of (1) presenting observations of the gross material and (2) sifting and tabulating as conveniently and intelligibly as we were able the pertinent residue of our data, let us attempt the next step. This will consist in searching for some concept or formulating some theory that might satisfactorily account for the facts observed. Much of the material appears contradictory, not only in the ordinary world of average or normal living but even in the world of mental disorder commonly granted to be less readily comprehensible in terms of ordinary reason. Even the accepted postulates which help us come to some understanding of the patient with hysteria or the delusional schizophrenic seem at first to fail when applied to the psychopathic, or antisocial, personality.

A patient whose fragmented personality prevents him from becoming aware of significant facts and puts him at the mercy of fantasies indistinguishable from what is real may conduct himself in a fashion that strikes us as altogether absurd and irrational if we fail to take into consideration this fragmentation. A man who is sane by the standards of psychiatry, aware of all the facts which we ourselves recognize, and free from delusions but who conducts himself in a way quite as absurd as many of the psychotic becomes another problem altogether. The observer is confronted with a paradox within the already baffling domain of mental disorder.

In the attempt to arrive at an applicable conception, one consistent with the facts of our observation, I find it necessary first of all to postulate that the psychopath has a genuine and very serious disability, disorder, defect, or deviation. To say that he is merely queer or perverse or in some borderline state between health and illness does little or nothing to account for the sort of behavior he demonstrates objectively and obviously. The practice, quite popular until recent years, of classifying the disorder of these patients, no matter how plain their incapacity to lead normal lives, as (1) no nervous or mental disease and (2) psychopathic personality, whatever the sanctions afforded by tradition, emerges not only as a misleading practice but also as sometimes promoting absurdity when we honestly examine the material to which such terms are applied.

Let us for a moment consider the essential evidence brought out in staff meetings on which experienced psychiatrists establish in an obvious case the diagnosis of schizophrenia and on which legal action is taken to declare the patient psychotic and incompetent (insane) and commit him for treatment. In the brief summarizing statement to support such opinions we often find such words as these:

The history shows that he has failed repeatedly to make a satisfactory adjustment in the social group. His actions indicate serious impairment of judgment and show that he cannot be relied upon to conduct himself with ordinary regard for the safety of himself or of others. His irrational and unacceptable behavior has, furthermore, occurred without normal or adequate motivation. He shows no real insight into his condition and tends often to project the sources of his troubles to the environment. His emotional reactions are grossly impaired and he has repeatedly shown inappropriate or inadequate affect. We may say, then, that he is psychotic, incompetent, incapable of carrying on the usual activities of life, and in need of close supervision.

Such facts have often over many decades constituted more convincing evidence for the diagnosis of schizophrenia than the delusions and hallucinations also frequently present but sometimes not demonstrable in that psychosis. All of these statements just recorded (excepting only the one word "psychotic") may be applied with full validity to the psychopath. This, of course, does not make him a patient with schizophrenia but it does, I maintain, afford grounds for saying he has a grave psychiatric deficit, and grounds that cannot be dismissed lightly. Although I insist on the gravity of his abnormality, I frankly admit that it is a different kind of abnormality from all those now recognized as seriously impairing competency. It is an abnormality that differs more widely in its general features from any of those than they differ from one another.

The first and most striking difference is this: In all the orthodox psychoses, in addition to the criteria just mentioned, or to some of these criteria, there is a more or less obvious alteration of reasoning processes or of some other demonstrable personality feature. In the psychopath this is not seen.

The observer is confronted with a convincing mask of sanity.

All the outward features of this mask are intact; it cannot be displaced or penetrated by questions directed toward deeper personality levels. The examiner never hits upon the chaos sometimes found on searching beneath the outer surface of a paranoid schizophrenic. The thought processes retain their normal aspect under psychiatric investigations and in technical tests designed to bring out obscure evidence of derangement.

Examination reveals not merely an ordinary two-dimensional mask but what seems to be a solid and substantial structural image of the sane and rational personality. He might then be thought of, in the full literal sense, as an example of what Trélat meant to designate by his expressive term, la folie lucide.

Furthermore, this personality structure in all theoretical situations functions in a manner apparently identical with that of normal, sane functioning. Logical thought processes may be seen in perfect operation no matter how they are stimulated or treated under experimental conditions. Furthermore, the observer finds verbal and facial expressions, tones of voice, and all the other signs we have come to regard as implying conviction and emotion and the normal experiencing of life as we know it ourselves and as we assume it to be in others. All judgments of value and emotional appraisals are sane and appropriate when the Psychopath is tested in verbal examinations.

Only very slowly and by a complex estimation or judgment based on multitudinous small impressions does the conviction come upon us that, despite these intact rational processes, these normal emotional affirmations, and their consistent application in all directions, we are dealing here not with a complete man at all but with something that suggests a subtly constructed reflex machine which can mimic the human personality perfectly.

This smoothly operating psychic apparatus reproduces consistently not only specimens of good human reasoning but also appropriate simulations of normal human emotion in response to nearly all the varied stimuli of life. So perfect is this reproduction of a whole and normal man that no one who examines him in a clinical setting can point out in scientific or objective terms why, or how, he is not real. And yet we eventually come to know or feel we know that reality, in the sense of full, healthy experiencing of life, is not here.

Fortunately for the purpose of this discussion, but unfortunately indeed in any other light, an objective demonstration is available which coincides perfectly with our slowly emerging impression.

The psychopath, however perfectly he mimics man theoretically, that is to say, when he speaks for himself in words, fails altogether when he is put into the practice of actual living. His failure is so complete and so dramatic that it is difficult to see how such a failure could be achieved by anyone less defective than a downright madman* or by a person totally or almost totally unable to grasp emotionally the major components of meaning or feeling implicit in the thoughts that he expresses or the experiences he appears to go through. In the actions of his living, then, he confirms our subjective impression, or it might be said that our surmise coincides with the objective and demonstrable facts.

During my early observation of psychopaths that preceded publication of the first edition of this book in 1941, I was so much impressed with the degree of maladjustment in these patients that I felt at the time, and said, they should be called psychotic. Subsequent consideration led me long ago to change this opinion and to find myself in complete accord with Richard L. Jenkins who in 1960 wrote:

Hervey Cleckley, in The Mask of Sanity, expresses the belief that the psychopathic personality is a psychosis not technically demonstrable, maximally concealed by an outer surface of intact function and manifested only in behavior. The disagreement I would express with this intriguing definition is that, to me, it strains the concept of psychosis past the breaking point. A psychosis is a major mental disorder. A psychopathic personality shows not a disorder of personality but rather a defect of personality, together with a set of defenses evolved around that defect. The defect relates to the most central element of the human personality: its social nature. The psychopath is simply a basically asocial or antisocial individual who has never achieved the developed nature of homo domesticus.

There is another important point against classifying the psychopath's grave defect with the psychoses. Though I believe he is in degree as maladjusted for leading an acceptable life as the psychotic patient, I do not believe there are similar reasons to consider him legally irresponsible or morally blameless for the frauds he perpetrates and the crimes he may commit.

Let us then assume, as a hypothesis, that the psychopath's disorder, or defect, or his difference from the whole or normal or integrated personality consists of an unawareness and a persistent lack of ability to become aware of what the most important experiences of life mean to others.

By this is not meant an acceptance of the arbitrarily postulated values of any particular theology, ethics, esthetics, or philosophic system, or any special set of mores or ideologies, but rather the common substance of emotion or purpose, or whatever else one chooses to call it, from which the various loyalties, goals, fidelities, commitments, and concepts of honor and responsibility of various groups and various people are formed.

Let us assume that this dimension of experience which gives to all experience its substance or reality is one into which the psychopath does not enter. Or, to be more accurate, let us say that he enters, but only so superficially that his reality is thin or unsubstantial to the point of being insignificant.

Let us say that, despite his otherwise perfect functioning, the major emotional accompaniments are absent or so attenuated as to count for little. Of course he is unaware of this, just as everyone is bound, except theoretically, to be unaware of that which is out of his scale or order or mode of experience.

If we grant the existence of a far-reaching and persistent blocking, absence, deficit, or dissociation of this sort, we have all that is needed, at the present level of our inquiry, to account for the psychopath.

The effort to express what is meant by experiencing life in a full sense, or by awareness of a solid emotional contact, runs through the psychoanalytic literature, which so often stresses the difference between an actual, or emotionally participating, understanding of some important situation and a mere verbal or academic understanding, however complete in that dimension. This point is also implicit in the concepts of Adolf Meyer's psychobiology, which, by its very definition of terms, shows that it is striving to emphasize the wholeness of experience or the full meaning of reactions.

Among lay observers of human problems and human values is sometimes found a sharp awareness of the very point I mean to stress in trying to describe the so-called psychopath.

A poet of our century, Donald Parson, chilled by the dead perfection of the celebrated glass flowers at Harvard, seems to see and translate into metaphor and allegory something closely related to the problem of the personalities discussed here and whose outer state I am trying to describe as a mask of sanity:

I stand in wonder. What amazing art!

No counterfeit is this, but counterpart
Itself, carved with the infinite detail
That makes the plodding step of patience fail.
From life's authentic prompt-book is this leaf.
To cup the rain and captivate the sun:
The poignant lilac whose sharp sword of scent
Can make the memory bleed - that sacrament
We call a rose - a thousand other blooms,
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 nature 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,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.

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:

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 psychopath:

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]

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