Psychopath Hervey Cleckley THE MASK OF SANITY, Section 4: Some questions still without adequate answers, Part 1: What is wrong with these patients?, 62. The concept of masked personality disorder or defect

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

SOME QUESTIONS STILL WITHOUT ADEQUATE ANSWERS 377

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

378 THE MASK OF SANITY

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

SOME QUESTIONS STILL WITHOUT ADEQUATE ANSWERS 379

speech are readily made but emerge empty, devoid of the content 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 wellconstructed

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.

We need not assume Head's interpretation of the aphasias to be entirely and

finally correct if it will by analogy help us formulate and clarify a concept of personality

disorder, a concept in which the deeper and less obvious levels of function can be

compared and contrasted with more superficial aspects of behavior. Let us use the

analogy not as evidence for the concept but only as a means of stating it.

Let us consider several familiar types of psychiatric illness with this aim in mind.

The patient with a toxic-delirious psychosis (for example, delirium tremens) shows a

maximum of disorder in his superficial aspect. He

380 THE MASK OF SANITY

may not recognize his whereabouts and may scream at nonexistent monsters or belabor

the empty air with a broomstick to fight off poison-spitting bugs a yard long which he

sees pursuing him. As he leaps over the bed or brandishes a chair, wild-eyed,

disheveled, and half-clad, any layman ran recognize him as ill and no doubt admit his

disorder is mental (that he is "crazy"). Nothing conceals his psychosis. Delusions,

hallucinations, confusion, loss of basic orientations, and irrational conduct are obvious

everywhere in his immediate area of contact with the surroundings. Despite the

spectacular impressiveness of his manifestations, he is very likely to recover, perhaps in

a few days. Although intense, his pathology is in some respects relatively superficial.

On the other hand, the hebephrenic patient sometimes maintains excellent

orientation and calmness. Despite hallucinations and delusions which he often keeps

largely to himself, he may carry on clerical work without supervision and do so logically

and effectively. It is not difficult for the physician to demonstrate convincing evidence

of his grave disorder, but this is usually less obvious, less vivid peripherally, let us say,

than in the first example. As a matter of fact, the uninformed layman (especially if a

close relative) will sometimes insist for a while that "it can't be his mind, Doc, it must

just be his nerves." Members of the family may argue that because he has kept his

accounts straight at the store where he worked and showed intelligence about other

matters, he must have a relatively minor psychiatric disorder. The outer form of normal

behavior may be much better preserved in such a patient than in one with delirium

tremens despite the fact that beyond this relatively thin functional shell the basic

foundations of his personality are in chaotic devastation, and despite the fact that his

disorder is maximally malignant, extending deeply into the core of his being.

A patient with early paranoid schizophrenia is likely to be free of those outer

manifestations of mental illness that distinguish the hebephrenic. His reasoning powers

may be truly excellent, his emotional reactions appropriate, and his general behavior

effective. It might be difficult indeed to find any point at which we can truthfully say

his abilities, in the ordinary sense, are impaired by disease. He may be a brilliant and

delightful companion at a dinner party and may discuss politics, business, or philosophy

with high intelligence and learning. Well concealed beneath all this exterior functional

perfection is a serious disorder which may influence him to direct his unblemished

talents toward useless or highly undesirable goals or perhaps to carry out,

conscientiously and effectively, disastrous antisocial aims. If we consider personality

function somewhat as we did the more circumscribed function of speech, we might say

that what is pathologic or defective in the paranoid patient must be more centrally

situated, more difficult to discern

SOME QUESTIONS STILL WITHOUT ADEQUATE ANSWERS 381

or to demonstrate from the outside. Yet such a disability is not mild. It is as real and

often as serious as hebephrenia. Some paranoid patients, particularly those with

paranoia vera, show no signs at all of psychiatric impairment that can be demonstrated

regularly. If brought to the courts, they may successfully establish their sanity before

judge and jury, sometimes excelling their medical and legal examiners in the exercise of

reason. Not rarely they attract supporters or disciples in the community who

enthusiastically follow their advice. In such patients, despite the impressive outer layers

of unimpaired function, psychosis is genuine and severe.

The delusions of some paranoiacs are circumscribed - confined to conviction

about what is indisputably possible or even plausible. A man may, for instance, believe

his wife is unfaithful. Sometimes it is difficult to prove objectively that this belief is a

delusion rather than a sane mistake, or, indeed, a fact. The pathologic substructure or

inner lesion, so to speak, which gives rise to his delusion is not directly accessible to our

scrutiny. From that point out, we might say, he behaves rationally. His functions

peripheral to this disturbed level may proceed sanely and effectively.

The delusional belief in paranoia, although often not intrinsically absurd or

irrational, allows the trained observer to realize eventually that such a patient is

psychotic despite the unimpaired operation of his exterior functions. This psychosis is

extremely well disguised by the covering layers of sanity. The delusion, once it is

recognized, gives us a reliable clue to the extremely serious disorder beneath, somewhat

as specific notes in the percussion of a chest reveal indirectly to an internist the presence

of a lung cavity despite the unmarred exterior of the body.

In some cases of schizophrenia no delusion or other manifestation technically

indicative of psychosis can be elicited. In contrast with paranoia, not even one

circumscribed but distinct clue can be offered by the examiner as evidence of a true

mental disorder. Under such terms as simple, masked, or ambulatory schizophrenia

many of these cases have been described. The psychiatrist who recognizes the

psychosis in such a patient is often at a loss to explain his conclusion. He senses a

peculiar emotional deficit and distortion and is able to realize that the person does not

normally experience and evaluate the basic data of life and that this deviation is of the

quality and the degree characteristic of schizophrenia. Let us not deny that the

psychiatrist may sometimes erroneously come to such a conclusion. He must rely on a

clinical judgment, not on objective scientific evidence. The experienced wine taster

may, it is said, detect that his beverage comes from grapes grown on the east rather than

the west side of some hill in Touraine. Experts may reliably distinguish in an obscure

painting the hand of Benozzo Gozzoli from that of a talented imitator. Perhaps few

psychiatrists develop

382 THE MASK OF SANITY

so sure and fine a knack of diagnosing schizophrenia in these cryptic cases. It is true,

nevertheless, that experience sometimes enables them to apprehend correctly such a

disorder in those who show no objectively demonstrable sign of psychosis. Some of

these patients are more dangerous than many who hallucinate, express delusions, and

show gross irrationality.

Most of these masked schizophrenics do not present an outer aspect that appears

entirely normal. A brittleness, an indefinable peculiarity of manner, fine details of

posture or gesture, and nuances of expression and attitude may cumulatively contribute

to the psychiatrist's impression. Many subliminal or almost subliminal items of

perception may be sensed in such a person and correctly identified with similar real but

not quite expressible qualities familiar to the observer because he has previously sensed

them in hundreds of closely studied schizophrenic patients who also showed gross and

indisputable manifestations of psychosis. What is thus sensed may reveal to the

psychiatrist that such a patient is emotionally far out of contact in basic human relations

and inadequately influenced by sane motives.

Such patients with schizophrenia suggest in some respects the psychopath in that

their major abnormality, their real pathology, is chiefly within and largely concealed by

good reasoning and by ability, at least for intervals, to go through the motions of what

looks like a sane pattern of life. Occasionally such a patient will attempt to hang

himself, address an insulting letter to the President, announce the discovery of perpetual

motion, or wander off from home and let no one know whether he is dead or alive for a

couple of months, without being able to give any good reason for such acts and

apparently without feeling that an explanation is in order. After following for years

obviously queer, distorted, and socially restricted, but apparently not psychotic, careers,

a few commit without provocation murder or some other tragic misdeed, for which they

show little evidence of remorse or other adequate and understandable reactions.

Such patients in some respects, particularly in their central emotional deficit, may

seem closer to the psychopath than to the ordinary state hospital schizophrenic. There

are, however, important differences. The psychopath's outer mask of mechanically

correct peripheral functioning is immeasurably more deceptive. The masked

schizophrenic outwardly shows no obvious or expected signs of traditional psychosis,

but he does not achieve the socially appealing presence, the warm, easy manners, or the

false promise of strong and superior character and human qualities that are so

bewildering in the psychopath. Real peculiarities, cool and strange alterations of

emotion, social isolation, and a profound and indefinable queerness emerge in outer

aspects of the cryptic schizophrene. Such signs, except to the expert, do not suggest

psychosis or adequately warn us that gross and malignant alterations

SOME QUESTIONS STILL WITHOUT ADEQUATE ANSWERS 383

exist beneath such a surface. But the evidence of something schizoid, or something

queer and not precisely normal, is usually apparent.

The surface of the psychopath, however, that is, all of him that can be reached by

verbal exploration and direct examination, shows up as equal to or better than normal

and gives no hint at all of a disorder within. Nothing about him suggests oddness,

inadequacy, or moral frailty. His mask is that of robust mental health. Yet he has a

disorder that often manifests itself in conduct far more seriously abnormal than that of

the schizophrenic. Inwardly, too, there appears to be a significant difference. Deep in

the masked schizophrenic we often sense a cold, weird indifference to many of life's

most urgent issues and sometimes also bizarre, inexplicable, and unpredictable but

intense emotional reactions to what seems almost irrelevant. Behind the exquisitely

deceptive mask of the psychopath the emotional alteration we feel appears to be

primarily one of degree, a consistent leveling of response to petty ranges and an

incapacity to react with sufficient seriousness to achieve much more than

pseudoexperience or quasi-experience. Nowhere within do we find a real cause or a

sincere commitment, reasonable or unreasonable. There is nowhere the loyalty to

produce real and lasting allegiance even to a negative or fanatic cause.

Just as meaning and the adequate sense of things as a whole are lost with

semantic aphasia in the circumscribed field of speech although the technical mimicry of

language remains intact, so in most psychopaths the purposiveness and the significance

of all life-striving and of all subjective experience are affected without obvious damage

to the outer appearance or superficial reactions of the personality. Nor is there any loss

of technical or measurable intelligence.

With such a biologic change the human being becomes more reflex, more

machinelike. It has been said that a monkey endowed with sufficient longevity would, if

he continuously pounded the keys of a typewriter, finally strike by pure chance the very

succession of keys to reproduce all the plays of Shakespeare. These papers so

composed in the complete absence of purpose and human awareness would look just as

good to any scholar as the actual works of the Bard. Yet we cannot deny that there is a

difference. Meaning and life at a prodigiously high level of human values went into one

and merely the rule of permutations and combinations would go into the other. The

patient semantically defective by lack of meaningful purpose and realization at deep

levels does not, of course, strike sane and normal attitudes merely by chance. His

rational power enables him to mimic directly the complex play of human living. Yet

what looks like sane realization and normal experience remains, in a sense and to some

degree, like the plays of our simian typist.

384 THE MASK OF SANITY

SOME QUESTIONS STILL WITHOUT ADEQUATE ANSWERS 385

Tables 1 and 2 may serve to outline or illustrate some points in this discussion.

The various differences between central and peripheral speech disorders cannot of

course be pronounced identical with similar differences between masked and obvious

psychiatric disorders.

In Henry Head's interpretation of semantic aphasia we find, however, concepts

of neural function and of its integration and impairment that help to convey a

hypothesis of grave personality disorder thoroughly screened by the intact peripheral

operation of all ordinary abilities. In relatively abstract or circumscribed situations, such

as the psychiatric examination or the trial in court, these abilities do not show

impairment but more or less automatically demonstrate an outer sanity unquestionable

in all its aspects and at all levels accessible to the observer. That this technical sanity is

little more than a mimicry of true sanity cannot be proved at such levels. Only when the

subject sets out to conduct his life can we get evidence of how little his good theoretical

understanding means to him, of how inadequate and insubstantial are the apparently

normal basic emotional reactions and motivations convincingly portrayed and

enunciated but existing in little more than two dimensions.

What we take as evidence of his sanity will not significantly or consistently

influence his behavior. Nor does it represent real intention within, the degree of his

emotional response, or the quality of his personal experience much more reliably than

some grammatically well-formed, clear, and perhaps verbally sensible statement

produced vocally by the autonomous neural apparatus of a patient with semantic

aphasia can be said to represent such a patient's thought or carry a meaningful

communication of it.

Let us assume tentatively that the psychopath is, in this sense, semantically

disordered. We have said that his outer functional aspect masks or disguises something

quite different within, concealing behind a perfect mimicry of normal emotion, fine

intelligence, and social responsibility a grossly disabled and irresponsible personality.

Must we conclude that this disguise is a mere pretence voluntarily assumed and that the

psychopath's essential dysfunction should be classed as mere hypocrisy instead of

psychiatric defect or deformity?

Let us remember that his typical behavior defeats what appear to be his own

aims. Is it not he himself who is most deeply deceived by his apparent normality?

Although he deliberately cheats others and is quite conscious of his lies, he appears

unable to distinguish adequately between his own pseudointentions, pseudoremorse,

pseudolove, and the genuine responses of a normal person. His monumental lack of

insight indicates how little he appreciates the nature of his disorder. When others fail to

386 THE MASK OF SANITY

immediately his "word of honor as a gentleman," his amazement, I believe, is often

genuine. The term genuine is used here not to qualify the psychopath's intentions but

to qualify his amazement. His subjective experience is so bleached of deep emotion that

he is invincibly ignorant of what life means to others.

His awareness of hypocrisy's opposite is so insubstantially theoretical that it

becomes questionable if what we chiefly mean by hypocrisy should be attributed to him.

Having no major values himself, can he be said to realize adequately the nature and

quality of the outrages his conduct inflicts upon others? A young child who has no

impressive memory of severe pain may have been told by his mother it is wrong to cut

off the dog's tail. Knowing it is wrong he may proceed with the operation. We need

not totally absolve him of responsibility if we say he realized less what he did than an

adult who, in full appreciation of physical agony, so uses a knife. Can a person

experience the deeper levels of sorrow without considerable knowledge of happiness?

Can he achieve evil intention in the full sense without real awareness of evil's opposite?

I have no final answer to these questions.

Attempts to interpret the psychopath's disorder do not, of course, furnish

evidence that he has a disorder or that it is serious. For reliable evidence of this we

must examine his behavior. Only here, not in psychopathologic formulations, can we

apply our judgment to what is objective and demonstrable. Functionally and structurally

all is intact on the outside. Good function (healthy reactivity) will be demonstrated in all

theoretical trials. Sound judgment as well as good reasoning are likely to appear at

verbal levels. Ethical as well as practical considerations will be recognized in the

abstract. A brilliant mimicry of sound, social reactions will occur in every test except

the test of life itself. In the psychopath we confront a personality neither broken nor

outwardly distorted but of a substance that lacks ingredients without which normal

function in major life issues is impossible.

Any method that offers the possibility of adding objectvity to our appraisals is

indeed stimulating and welcome anywhere in psychiatry but particularly so in this more

than ordinarily confusing problem.

Simon, Holzberg, and Unger, impressed by the paradox of the psychopath's poor

performance despite intact reasoning, devised an objective test specifically to appraise

judgment as it would function in real situations, as contrasted with theoretical judgment

in abstract situations.260

These workers are aware that the more complex synthesis of influences

constituting what is often called judgment or understanding (as compared to a more

theoretical "reasoning") may be simulated in test situations in which emotional

participation is minimal, that rational factors alone by an

SOME QUESTIONS STILL WITHOVT ADEQUATE ANSWERS 387

accurate aping or stereotyping can produce in vitro, so to speak, what they cannot

produce in vivo. Items for a multiple choice test were selected with an aim of providing

maximal possibilities for emotional factors to influence decision and particularly for

relatively trivial immediate gratification impulses to clash with major, long-range

objectives. The same items were also utilized in the form of a completion test. The

results of this test on a group of psychopaths tend to support the hypothetical

interpretation attempted in this book.

If such a disorder does indeed exist in the so-called psychopath, it is not

remarkable that its recognition as a major and disabling impairment has been long

delayed. Pathologic changes visible on the surface of the body (laceration, compound

fractures) were already being handled regularly by medical men when the exorcism of

indwelling demons retained popular favor in many illnesses now treated by the internist.

So, too, it has been with personality disorders. Those characterized by gross outward

manifestations have been accepted as psychiatric problems long before others in which

a superficial appearance of sanity is preserved.

Despite the psychopath's lack of academic symptoms characteristic of those

disorders traditionally classed as psychosis, he often seems, in some important respects,

but not in all, to belong more with that group than with any other. Certainly his

problems cannot be dealt with, medically or by any other means, unless similar legal

instrumentalities for controlling his situation are set up and regularly applied.

I believe that if such a patient shows himself grossly incompetent in his behavior,

he should be so appraised. It is necessary to change some of our legal criteria to make

attempts at treatment or urgently needed supervision possible for him, the most serious

objections are primarily theoretical. Perhaps our traditional definitions of psychiatric

disability can stand alteration better than these grossly defective patients and those

about them can stand the present farcical and sometimes tragic methods of handling

their problems.

This is not to say that all people showing features of this type should be regarded

as totally disabled. It is here maintained that this defect, like other psychiatric disorders,

appears in every degree of severity and may constitute anything from a personality trait

through handicaps of varying magnitude, including maximum disability and maximum

threat to the peace and safety of the community.