Psychopath

THE MASK OF SANITY

Section 3: Cataloging the Material

Part 2: A comparison with other disorders

31. Deviations recognized as similar to the psychoses but regarded as incomplete or less severe reactions

 

 

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31. Deviations recognized as similar to the psychoses but regarded as incomplete or less severe reactions

As noted earlier, conditions resembling psychoses but appearing incomplete or

less severe are still classified officially under the same general diagnostic term as the

disorder to which this book is devoted. Such an arrangement has been approved by

some as a means of placing together groups assumed to be on the borderline of serious

disorder with a genuine similarity in degree if not in type. There is another argument in

favor of using one term to identify these diverse clinical realities. This arises from

efforts to distinguish as active disease processes the psychoses and psychoneuroses

from other conditions presumed to be circumscribed defect states or relatively static

deviations. It is true that some genuine similarities can be discerned here among many

of the diverse conditions listed under personality disorders. These similarities have, it

seems to me, been given an undue importance.

It is far from proved that pathologic conditions which we call schizoid

personality or paranoid personality begin at birth and remain unchanged throughout life.

There is a vast range of difference in chronicity, reversibility, severity, and prognosis,

throughout the schizoid disorders and, indeed, throughout the paranoid and affective

disorders also. Much would be gained both logically and practically if in out official

nomenclature we could place all essentially schizoid disorders in an appropriate category

and then make what further distinctions are useful as to transiency, chronicity, and

degree.

CATALOGING THE MATERIAL 249

Since schizoid manifestations vary from rapid processes to maladjustments apparently

static, from relatively mild deviations and disabilities to total incapacity and maximum

personality disintegration, let us then reflect these facts in our language. As a matter of

fact, as every psychiatrist well knows, in many patients an initial disorder of slow or

rapid progress (disease process) becomes static or relatively static at widely varying levels

of deviation from the normal. So too, it seems, we should deal with affective and

paranoid disorders. Without minimizing the fact that schizophrenia is an illness, it is

perhaps more profitable to conceive of it as a complicated distortion of the life process

(or, as has been said, a way of life, albeit an extremely pathologic way) than as a

circumscribed external agency that selects and falls upon its victim. Active and

progressive schizophrenic illness probably arises out of tendencies and influences not

unlike those which underlie the milder and more static distortions we label as schizoid

personality.

In many important respects it seems to me that the person who is called a

psychopath or antisocial personality differs greatly from most people showing a

schizoid, paranoid, or cyclothymic disorder or deviation in degree short of psychosis

and in whatever state of chronicity. The psychopath varies not only in type but also in

the severity of his specific disorder, which can range from a mild or borderline degree

that allows him to conduct a relatively normal and acceptable life up through great

degrees of disability. There are also behavior patterns of this sort which prove to be

temporary.

It will perhaps be worthwhile to consider briefly an example from the secondary

group distinguished under various subheadings (schizoid, cyclothymic, and others) and

officially classed with the psychopath in a primary pigeon hole labeled personality disorders.

Well qualified for the diagnosis of schizoid personality is a 19-year-old boy whom

I treated on several occasions. I would prefer to call his reaction one definitely schizoid

in nature, very chronic and relatively static, and lacking most clinical features by which

disorders otherwise similar are recognized as constituting "a psychosis." The first point

that stands out in this patient is how obviously he differs from all psychopaths. On

meeting him, it is immediately seen that he is a lonely person, one recognized as queer

by all who encounter him. In discussing his recent attempt at suicide, he could give no

good reason for his act. No evidence of depression was obtained, As if not knowing

what else to say, he suggested he must have tried to kill himself "just out of curiosity."

He had no positive convictions about a future life or interest in exploring such

possibilities. He had been making good grades at college and he had no worries that he

could express. His attempt at suicide had been authentic. Only by chance had he been

discovered where he hung in a noose made by his belt. No evidence of

250 THE MASK OF SANITY

delusions or hallucinations was ever elicited, A few excerpts fronm a report given by the

college physician, who spent much time with him, are contributory:

Oliver was recognized as a bit odd or eccentric since his coming here during the

summer weeks of 19-. He worked quite willingly with sustained effort and application.

Everyone liked him and although they protested his persistent pipe and untidy personal

appearance (being unshaven, lax about clean garments and combed hair), they were

amused and tolerant. He had the reputation of having superior intellectual capacity and

that gave him the aura of a potential winner. The students included him in everything and

he was a conflicting mixture of pathetic eagerness to be accepted as one of them and to be

the lone wolf. He went through the motions of being one of the group but it all had to be

within the boundaries of his own withdrawal pattern. Though unresponsive in regard to

greetings and small talk, he would talk for hours about himself and his ideas and was eager

for such expression.

Girls interested him less. Actually, though he protested that he had an average interest

in the other sex, he had very few dates with them. However, very recently he groomed

himself quite adequately and went to Foxbridge to visit a girl whom he used to date during

his high school days and who is studying journalism there.

It was noted and accepted by everyone that Oliver would argue every point, in class

and out, but much good-natured teasing caused him to restrain himself somewhat in this

respect. However, I have noted in all my contacts with him a persistent negativistic

attitude. He prided himself on always taking the opposite point of view and that his

philosophy was quite peculiar to himself. He expressed a resentment of everything

"expected" of him by way of the simplest courtesies and social amenities of any kind.

He is sure that there is nothing neurotic about himself and mentioned doctors and

nurses other than yourself who have told him that they thought him to be all right. He

exhibits an attitude toward his hospitalization quite similar to that toward his attempted

suicide. His defense is thick and strong and he reacts with argument or denial to almost

anything which is said which seems to imply that all is not quite as it should be with him.

He said that you had told him that he would need some help and had better come to see

me every few days. He thinks that is not necessary and I think he is right, for I can see no

way to approach him even on the outskirts of his problem without stimulating a negative

reaction on his part. I noted that same lack of insight as you, and it is so complete as to

bar any psychotherapeutic relation. I left the way open for him to come at any time and I

will indeed help if I can.

This fragment from Oliver's personal notes also brings out something about his

state that is difficult to describe in any other way I know:

CATALOGING THE MATERIAL 251

Loneliness

By

Oliver ______, Jr.

It is now long after the hour of midnight. I am alone, except for my pipe and my

ever-active mind, in one of the front rooms.

God has created many horrible things, but the greatest of all those monsters is that

intolerable loneliness that man calls Love, Sex, Self Pity, Comradeship, und so weiter. I

trust that you, as an individual, shall be able to grasp some vague notion of what I, as a

purely abstract thinking-apparatus, am trying to convey to you.

Nothing in a State of Nothingness. Can you imagine a more comforting place?

No emotions of fear, love, hate, anger, sympathy, pity. No materiality! No spirituality!

No mentality! Nothing! The Hell of the Bible! The Heaven of the Bible! Paradise!

Purgatory! and the Inferno! - all One!! All nothing!!!

Have you ever really delved deeply into why, for what purpose you were born or

why anyone was born? To bear children? Yes, but dogs can do that gracefully. To

build? To make money? You must leave all behind when you depart. You are unable

to carry it with you.

The epicureans had a good idea when they said, "Eat, drink and be merry, for

tomorrow we may die." But why eat, drink, and be merry? Why should one live, or

the animals which are so very close below us? There is no God; there is no Heaven;

there is no Hell; these are the dreams of baby minds. The Church, the Bible, Science,

Spiritualism, and on and on and on can offer not a solitary shred of evidence that there

is a God, Heaven, Hell, Devil, Angels. They are but wistful thinkers - the Church, the

Bible, and Spiritualism. They are the idealists. Scientists are the realists, but they study

nature. Why build machines? What can it matter to you personally one hundred years

from now? You will be nothing. Nothing.

Am I insane? They say I am because I ask, "Why?" and there is no answer to that

by anyone. "What?" can be answered. So can "When?" "Where?" "Who?" "How?"

et cetera, but not "Why?" Healthy minds do not ask, "Why?" Normal people sleep

and love, eat and drink, breathe and excrete, work and, perhaps, think - think, but only

a little and only within the bounds of conventionality.

-Oliver

This boy frequently writes letters to the newspapers commenting on such topics

as politics, art, religion, and history. There is usually a bitterness in his comments and a

kind of wit that seems to leaven his isolation. The brittle strangeness of manner, the

inadequateness and inappropriateness of his affective reactions can only be appreciated

in direct contact. An excerpt from one of his letters to the newspaper follows:

numbers of times before at the cinema. I did not think it dirty. I thought it to be just

what it was--a literally cheap movie.

252 THE MASK OF SANITY

wicked picture, "The Outlaw," to be the funniest screened attraction I'd ever seen (I

saw it on my return trip in Atlanta). It caused more laughs than "Kiss and Tell."

Miss Smith, please find your glasses! My morals are evaporating!

Oliver _________ Jr.

With a heart of gold (hard and yellow), I close,

Your oldest son,

Oliver -, Jr.

This is a person who, despite his superior intelligence and his awkward gestures at

being sociable, is recognized at once as extremely eccentric, if not indeed bizarre, by his

classmates as well as by the expert. Evidence of his psychiatric trouble is apparent, and

no trained observer would confuse him with the psychopath. A history is not necessary

to surmise that he has had difficulties and that further difficulties lie ahead. Although

his personality is not outwardly fragmented, it immediately gives clues to the fact that

here experience is not what others find it. Such a patient sometimes gives the

impression that through him one comes in closer touch with what is most specific and

inexplicable in schizophrenia, what is usually blurred or hidden in the chaos of the overt

psychosis. Superficially nothing could be more different from what he presents than the

socially smooth psychopath who has an explanation for everything, an easy cordiality for

everyone. His bitterly authentic seriousness and his capacity for hurt and suffering also

contrast with the psychopath.

In many patients the disturbance classed as schizoid personality might be more

accurately regarded as masked schizophrenia or, as has been sometimes said,

"ambulatory" schizophrenia. Although the more gross technical signs of psychosis are

not evident on the surface, many of these patients have a very serious disorder within.

The tendency to call their condition schizoid personality (and therefore label them as

definitely "sane") sometimes results in their being incorrectly treated. Very dangerous

tendencies, well concealed, may emerge into tragic acts.

Some years ago a young woman regarded as seclusive, a bit queer, and withdrawn

by her acquaintances called a big-league baseball player to her hotel room on the pretext

of grave and urgent business. The business was not what might be expected from such

a call by a young woman to a man whom she had never met personally but had seemed

to admire, hero-worship, and brood over for a long time in yearning fantasies.

According to newspaper accounts, the girl, with no explanation or reason she could exCATALOGING

THE MATERIAL 253

plain afterward, shot the ballplayer in a genuine attempt to kill him and one which barely

failed to do so.

I cannot offer a diagnosis on this patient whom I have never seen. Her behavior

and her personal characteristics as disclosed in the press are, however, entirely typical of

patients with masked but real and serious schizoid disorder. Such patients are perhaps

more accurately indicated by the term "masked schizophrenia" than by "schizoid

personality," which may, artificially and unrealistically, ignore the true state of very ill

and dangerous persons and classify them with those presumably deviated in mild degree.

Some patients of this sort eventually show themselves to be psychotic, and it then

becomes apparent that a serious inner disorder has, perhaps for many years, been

masked by the minor overt peculiarities that constitute what is generally regarded as

schizoid personality. Sometimes in patients with masked schizophrenia the serious

inner pathology is so well concealed that the patient may be almost indistinguishable

from the typical psychopath. It is important to keep in mind that the excellence of the

superficial aspect of the patient (whether he be called a masked schizophrenic or a

psychopath) gives no reliable indication of how serious the inner, concealed, and at the

time undemonstrable pathology may prove to be or how disastrously and unpredictably

it may be expressed when it erupts into disastrous antisocial behavior. Like the very

dangerous and profoundly ill ambulatory schizophrenic patient whose central disorder is

well masked and not yet demonstrable, the psychopath has a concealed but very real and

grave pathology. Unlike other types of masked psychosis, the central personality

"lesions" of the psychopath are not covered over by peripheral or surface functioning

suggestive of some eccentricity or peculiarity of personality but by a perfect mask of

genuine sanity, a flawless surface indicative in every respect of robust mental health.

The example of schizoid personality or masked schizophrenia just presented

under the pseudonym Oliver is obviously distinguishable from the psychopath. His

outer aspect contrasts vividly with the smooth and deceptive disguise of the typical

psychopath. There are, however, other masked schizophrenics who resemble the typical

psychopath much more closely. I have seen a number of patients who were classified

by able and experienced psychiatrists as typical psychopaths (antisocial personalities) and

by others, equally able, as very well-masked schizophrenics. About these patients the

difference of judgment lay in estimates of how effectively the surface function masked

the inner disorder and gave an appearance of full health. There was usually no

disagreement in the conclusion by all the psychiatrists that an underlying disorder was

severe and maximally disabling. The deceptive

254 THE MASK OF SANITY

qualities of the excellent disguise, the perfection of the mask, afford no reliable

indication that the true condition is mild or moderate and no assurance that it may not

be far more serious than the disability of some patients in whom auditory hallucinations

and bizarre delusions can be readily demonstrated.

It is perhaps pertinent to mention here that there are other disguises behind

which other serious personality disorders mislead us. Chamberlain54 was among the first

who ably emphasized what he refers to as cryptic depression. Patients so affected may

complain only of headache, nausea, a pain in the back, or weakness. On repeated

questioning, some will admit depression as a minor element in the situation. Others will

deny it convincingly and show no evidence of it. I have seen many such patients in

whom the history of previous depressive psychosis, many details of the patient's

personality, and the prompt response to electric shock therapy give indirect but

convincing evidence of the invisible illness. Here it might be said that the potentially

more serious condition appears only in a substituted reaction that seems to constitute a

compromise or a disguise.

Under the term pseudoneurotic schizophrenia, Hoch and Polatin137 discuss what every

psychiatrist has often encountered - the patient who gives one the feeling that he must

be a schizophrenic but in whom none of the specifically characteristic features of

psychosis can be demonstrated. Often the only complaints are of vague or minor

physical discomforts. Sometimes other features that literally indicate a psychoneurosis,

and this only, constitute all that can be brought out. Such patients do not express

delusions. They deny hallucinations and show no disorder of thinking as this is

ordinarily described and no mannerisms or bizarre overt attitudes. They are never

grossly irrational in what they express. The history does not show them psychotically

deviated in their general behavior until, perhaps, some irreparable psychotic act occurs.

Their lack of insight (broader and more profound than in the psychoneurotic patient)

and a peculiar emotional deficit and distortion make the examiner realize, without being

able to prove it, that he is dealing with schizophrenia. At length the examiner becomes

convinced that these patients do not normally experience and evaluate the basic issues

of life and that this difference is of the sort and degree not found except in

schizophrenia. Some of these people eventually develop delusions and hallucinations,

but many go on year after year fully masked by the psychoneurotic facade.

The patient who is seriously schizophrenic but whose basic disorder is masked by

the outer appearance of neurosis or by what seems to be only minor eccentricities or

schizoid traits can nearly always be readily distinguished from the true psychopath. As

mentioned previously, however,

CATALOGING THE MATERIAL 255

there are sometimes masked schizophrenics whose outer appearance is more like that of

the true psychopath.

Guttmacher discusses these patients in a very interesting paper and designates

them by the term pseudopsychopathic schizophrenia.106 The type of patient discussed by

Guttmacher may appear for many years to be a typical psychopath and show all the

features in his behavior that are characteristic. Some of these patients do not show the

outer eccentricities and oddnesses that usually distinguish the masked schizophrenic.

Occasional) they may be almost as outgoing, charming in manner, and almost as free

from apparent abnormality as the classic psychopath. As pointed out by Guttmacher,

sometimes such a patient will eventually develop a full-blown and obvious

schizophrenic psychosis.

It might be argued that the psychosis has developed independently of the

psychopathic defect, but I think it much more likely that a serious central disorder was

present all the time and that eventually it has become manifest through the disruption of

the formerly perfect superficial function and outer appearance. Such developments as

these lead me to believe not only that the central disorder in the psychopath may

perhaps be similar in degree to that in schizophrenia but also that there may be more

similarity in quality than is generally recognized.

An interesting comparison between thoroughly masked schizophrenia and the

disorder of the psychopath can be found in the fictional characters Judd Steiner and

Artie Straus as they are presented by Meyer Levin in his novel Compulsion.181 Judd

Steiner, the fictional representative of Nathan Leopold, gives a strong impression of a

deep schizoid disorder masked by generally sane behavior and great intellectual

brilliance. Artie Straus, who is modeled on the novelist's conception of Loeb, emerges

in the book as a remarkably well-drawn figure of the classic psychopath. The author

admits that his fictional characters are not necessarily true interpretations of the actual

characters whose utterly unprovoked sensational murder of a teenaged boy startled and

horrified the world in 1924. This long deliberated and ingeniously planned murder for a

thrill suggests a callousness and cynicism that are difficult to describe and still

astonishing to contemplate. Both the similarities and the differences between Judd and

Artie are wonderfully and convincingly conveyed by Levin in his book and should

stimulate interest in everyone concerned with the basic problems of psychiatry.

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

256 THE MASK OF SANITY

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.

 

Next: Section 3: Cataloging the material, Part 2: A comparison with other disorders, 32. The psychoneurotic

 

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Section 3, Part 2

 

 

 

 

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