Psychopath

THE MASK OF SANITY

Section 3: Cataloging the Material

Part 1: Orientation

28. Clarifying the approach

 

 

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28. Clarifying the approach

In spite the difficulties that have been discussed, efforts to study the psychopath

have proceeded. No drastic change in the official psychiatric attitude has occurred, and

no step has been taken to make it possible to deal satisfactorily with the disorder by

medical methods. But information has been accumulating that may someday bring this

about.

The studies of Partridge have been valuable in focusing attention on the type of

patient who needs attention as a separate entity rather than in a confused group. In his

writing can be found a discernible and well-presented clinical picture. Partridge's three

general types include only psychopaths, and the relatively modest distinctions among

them impress us as valid rather than imaginary. Here, too, we find a clear rejection of

the time-honored assumption that psychopaths are marked by gross physical defects

and "stigmata of degeneration" and that this disorder has been satisfactorily related to

inborn defects. This valuable contribution, though largely ignored by many authorities,

merits recognition today.233-236

Long ago, when the psychopath was, even more than at present, confusingly

submerged in a nonspecific category (known only by terms applied also to a wide variety

of gross physical defect states), Healy and those who worked with him began to

emphasize the purposive or reactive nature of antisocial behavior.9,124-125 Careful

attention was given to the emotional deprivations and distortions of aim that lay behind

maladapted acts, and evidence of influences essentially psychogenic were noted and

evaluated.

In work with juvenile delinquents, Healy pointed out that under similar

238 THE MASK OF SANITY

conditions of insecurity or emotional deprivation one child might show anxiety and

passive withdrawal and another, aggressive mischief, apparently in response to the

personal stress. These observations have been helpful over the years in efforts to

interpret and to deal with behavior disorder.

Although relatively neglected for a long period by those concerned with

interpretive or causal as contrasted with simply descriptive formulations, the psychopath

received attention from Alexander, who makes an interesting contrast between ordinary

neurosis, in which repressed impulses find a symbolic or substitutive expression in

subjectively unpleasant symptoms, and character neurosis, in which the unconscious

drives are believed to appear in maladapted objective behavior. In both disorders

unconscious conflict is postulated. In orthodox neurosis this conflict may give rise to

conscious anxiety without visible source, or impulses (repressed and ungratified) may be

manifested indirectly by displacement (as in obsessions and compulsions), or otherwise

(as in conversion paralysis and anesthesia). In character neurosis, according to

Alexander, unconscious impulses obtain a degree of fulfillment in another manner, by a

pattern of pathologic behavior in which apparently purposeless and sometimes selfdefeating

and social acts are carried out persistently. This pattern is followed despite

penalties and in the absence of adequate conscious incentive.9,11,12 This formulation has

attracted much popular interest.

Alexander maintained, and many of his followers still maintain, that antisocial

conduct often represents an unconscious but purposive effort to obtain punishment in

order to expiate and gain relief from (unconscious) feelings of guilt. As a hypothesis

this is indeed ingenious and appealing. It has attracted many adherents. I have not been

able, however, to discover such a sense of guilt or remorse (conscious or unconscious)

in any of the psychopaths I have studied. Nor have I seen any convincing evidence of

such unconscious guilt revealed in the work of Alexander or of other observers who

accept his formulation. Such guilt is often assumed but, so far as I know, never

demonstrated. I must therefore remain skeptical of this popular interpretation, however

pleasant it might be to solve the problem of the psychopath by an interpretation so

simple and so graceful.

The more experience I have had with psychopaths, the stranger it has seemed to

me that a theory should insist that they have such deep and influential unconscious

feelings of guilt when they are at the same time so plainly callous and free from remorse

about grievous wrongs and crimes that they clearly recognize as their own. It strikes me

as a quaint fantasy to assume without real evidence that they unconsciously go to such

pains to obtain punishment and win redemption for unknown sins when they plainly

and glibly ignore responsibility for every known misdemeanor and

CATALOGING THE MATERIAL 239

felony and pride themselves in evading penalties and in flouting the basic principles of

justice.

The term neurotic character adopted by Alexander to designate the psychopath,

although it may be of value in suggesting belief in a psychogenic: etiology, is not

conducive to progress in dealing with our problem. This point has been well

emphasized by Karl Menninger in a discussion of the practical need of a new official

name for the psychopath.208 As pointed out by Menninger, the word character in such a

use offers possibilities of confusion, if one patient has a neurotic character and another

a neurotic personality, then just what is a character? And just what is a personality?

And just how do they differ? There is, we may emphasize again, a considerable

possibility of arousing the ghosts of a faculty psychology in the use of these terms.

Menninger makes another point in speaking of neurotic character that I believe is

of essential importance. "The condition" he writes, "is closer to a psychosis than to a

neurosis and the term neurotic is, therefore, misleading."208

A helpful study of the psychopath by Henderson presented in the Salmon

Lectures (1938) and subsequently published128 called attention to the seriousness of the

problem. From this presentation the reader is able to get clear ideas about actual

patients as they appear clinically and the need for better methods of handling them.

Over a period of several decades Karpman also called attention to the

psychopath, pointing out how little serious effort has been made by psychiatrists to

understand or to deal with the essential problem. He maintained that psychogenic

factors are responsible for the behavior disorder in many instances and believed that

most patients classified as psychopathic personality should be called neurotic. A small

residue of patients for whom he proposed the term anethopath, are, in Karpman's

opinion, essentially unlike the others in that they are disabled by intrinsic defect rather

than by dynamic psychopathologic reactions. 160-164

In these studies the very great egocentricity, the inability to form any important

or binding attachment to another, the failure ever to realize and grasp the very meaning

of responsibility, all features that I believe to be most essential, are emphasized by

Karpman and made clear as seldom done in other literature on the psychopath. It is

doubtful if anyone else has done more to elucidate this psychopathologic picture and

similar antisocial behavior disorders.

In the system of classification that prevailed when the first two editions of this

book were prepared, the diagnosis of psychopathic personality was listed among those

conditions considered as being "without mental disorder."

240 THE MASK OF SANITY

In the New York State Department of Mental Hygiene Outlines for Psychiatric Care the

general term was subdivided as follows:225

· With pathologic sexuality. Indicate symptomatic manifestations, e.g.:

homosexuality, erotomania, sexual perversion, sexual immaturity.

· With pathologic emotionality. Indicate symptomatic manifestations, e.g.:

schizoid personality, cyclothymic personality, paranoid personality, emotional

instability.

· With asocial or amoral trends. Indicate symptomatic manifestations, e.g.:

antisociality, pathologic mendacity, moral deficiency, vagabondage,

misanthropy.

· Mixed types.

The first division, pathologic sexuality, will be discussed in Chapters 37 and 59.

Suffice it to say here that only the last term, sexual immaturity, has been characteristic of

our group.

In the second division, pathologic emotionality, the schizoid, cyclothymic, and

paranoid personalities are regarded as relatively mild and relatively static deviations of

the same types familiar in schizophrenia, manic depressive psychosis, and paranoid

psychosis. Their disorder or disability is very different clinically from that discussed in

this volume. The typical psychopath shows little or no indication of suffering from a

deviation in the direction of such a disorder as schizophrenia, manic-depressive

psychosis, or paranoia but shows a disorder quite different. Characteristic schizoid or

cyclothymic traits are not discernible features of the psychopath. Although psychopaths

tend to blame their troubles on others, they do not, like patients with real paranoid

deviation, organize and persistently follow out highly purposive plans or hold

tenaciously to strong affective attitudes. Emotional instability is, in a shallow sense,

applicable to the psychopath, but this quality scarcely seems an outstanding or

fundamental deviation. Many, as a matter of fact, show less evidence of anxiety,

uneasiness, and other reactions implied by emotional instability than the average person.

The descriptive terms included in the third category apply in varying degrees to

many of the patients discussed here, but these scarcely seem either broad enough or

deep enough to be of value as diagnostic formulations.

Under one term, psychopathic personality, we find grouped many types of disorder.

These disorders have very little in common. One thing that has been presumed about

some of them, that is, that they are relatively trivial as contrasted with extremely

disabling conditions, we grant, so far as schizoid personality, cyclothymic personality,

and paranoid personality are concerned. This characteristic of being an incomplete

degree of various sorts of disorder we deny as applying to the subject of this volume.

Only by a manipulation

CATALOGING THE MATERIAL 241

of verbal abstractions can such disorders be identified with the specific disorder shown

by those regularly called psychopaths.

In the 1952 revision of the Diagnostic and Statistical Manual14 we find the general

term personality disorders used to designate all the various items formerly listed under

psychopathic personality-all these and several more.

Personality pattern disturbance

Inadequate personality

Schizoid personality

Cyclothymic personality

Paranoid personality

Personality trait disturbance

Emotionally unstable personality

Passive-aggressive personality

Compulsive personality

Personality trait disturbance, other

Sociopathic personality disturbance

Antisocial reaction

Dyssocial reaction

Sexual deviation; specify supplementary term

Addiction

Alcoholism

Drug addiction

Special symptom reaction

Learning disturbance

Speech disturbance

Enuresis

Somnambulism

Other

Gross stress reaction

Adult situational reaction

Adjustment reaction of infancy

Adjustment reaction of childhood

Habit disturbance

Conduct disturbance

Neurotic traits

Adjustment reaction of adolescence

Adjustment reaction of late life [p. 71]

defined:14

profiting neither from experience nor punishment, and maintaining no real loyalties to any

person, group, or code. They are frequently callous and hedonistic, showing marked

emotional immaturity, with lack of sense of responsibility, lack of judgment, and an ability

to rationalize their behavior so that it appears warranted, reasonable, and justified.

The term includes cases previously classified as "constitutional psychopathic state" and

"psychopathic personality." As defined here the term is more limited, as well as more

specific in its application. [p. 38]

242 THE MASK OF SANITY

Here the familiar psychopath could be accurately and officially classified. It

seems to me regrettably confusing that under the same general heading of personality

disorders there were still listed such astonishingly unallied minor difficulties as learning

disturbance, speech disturbance, enuresis, and somnambulism.

Since the 1952 revision of the psychiatric nomenclature just mentioned and

since the fourth edition of the Mask of Sanity (1964) another revision of our official

terminology was made. The following classifications is given in this latest revision

(1968):15

V. PERSONALITY DISORDERS AND CERTAIN OTHER NON-PSYCHOTIC

MENTAL DISORDERS (301-304)

.0 Paranoid personality

.1 Cyclothymic personality (Affective personality

.2 Schizoid personality

.3 Explosive personality

.4 Obsessive compulsive personality (Anankastic personality)

.5 Hysterical personality

.6 Asthenic personality

.7 Antisocial personality

.81 Passive-aggressive personality

.82 Inadequate personality

.89 Other personality disorders of specified types

[.9 Unspecified personality disorder] [pp. 9-10]

In this classification we find a more distinct place for our subject than in the

earlier schemes of classification. Here the psychopath is officially designated as

personality disorder, antisocial type, a recognizable entity in a fairly large group of

different and distinct disorders.

It is perhaps in silent recognition of the absurdities that prevailed for so long

in our official categories that psychiatrists in practice wtill avail themselves of th

emore or less slang term which is sort of nickname for our subject. When one

psychiatrist on the staff of a state hospital, or at a meeting of the American

Psychiatric Association, expresses to another some though he has about the

psychopath, it is immediately and plainly understood that he is not making reference to

schizoid disorder or to sexual deviation per se but to a disorder nearly all

psychiatrists recognize and recognize as distinct from the heterogeneous mess of

unrelated disorders with which it was for so long officially listed. There is nothing

vague about these patients clinically. Their course of conduct can be predicted with

much greater accuracy than that of patients with defined psychoses.

Attempts to discuss this type of patient and to use the approved term

CATALOGING THE MATERIAL 243

personality disorder in its official meaning were until recently likely to be neither clear

nor accurate. In fact, it was difficult not to talk nonsense if one bore in mind all the

things that term was recognized as including.

The currently approved category personality disorder, antisocial type, seems to offer

an accurate term and to avoid the great confusion promoted by earlier schemes of

classification. It is probable, however, that the older unofficial term psychopath will

maintain its currency for a long time. All experienced psychiatrists are used to it, and

few, if any, are likely to be misled by it.

 

Next: Section 3: Cataloging the material , Part 2: A comparison with other disorders, 29. Purpose of this step

 

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Section 3, Part 1

 

 

 

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