Section 3: Cataloging the Material

Part 2: A comparison with other disorders

30. The psychotic



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30. The psychotic

For the sake of emphasis let us first contrast very briefly the psychopath with the

general group of psychotic patients to which he is considered not to belong. These, if

their disorder is well advanced, are usually recognized by the law as "insane" and by the

man on the street as irrational, irresponsible, plainly unable to accept the general facts

accepted by humanity at large, and, furthermore, unable to provide for themselves or to

remain safely or conveniently at liberty among their fellows. Such people frequently

have beliefs that are not only false but bizarre, inconsistent, and nearly always

impossible to remove even by convincing demonstrations of their impossibility. Ready

examples are the belief of a soda jerk that he is an emperor dead a thousand years ago, a

belief still maintained although the patient admits he is living in the twentieth century

and realizes that he is in a psychiatric hospital and that he grew up in the local slums,

and the belief of an inconspicuous clerk that a worldwide organization has been formed

to persecute him because of jealousy aroused by the fact that his testicles are pure


Many of these patients hear voices speaking to them and cannot be made to see

that these are imaginary. To the layman they are plainly not people to reason with or to

be relied on but are obviously "demented." It is apparent that they do and say foolish or

fantastic things because their reasoning processes, not to speak of their perceptions, are

gravely disordered or misdirected. Their general personality outlines are often distorted

or sometimes even appear to be destroyed.

Patients in whom a milder psychosis exists usually show some of these specific

peculiarities and always show general personality deviations which enable the

psychiatrist eventually to place them in their proper classification. These patients with a

milder disorder often are able to get along without serious difficulty in the community,

just as a patient with mild influenza may not even go to bed whereas one with a severe

attack may be delirious, unable to sit up, and finally die. These milder degrees of

psychosis, however, show the same type of disorder found in the more severe and

obvious manifestations, just as the mild influenza attack is the same in type but not in

degree as the serious one.


It is perhaps worthwhile to add here that not all those suffering from a typical

psychosis, even when the disorder is serious in degree, give an obvious impression of

derangement. Severe paranoid conditions, particularly those of the most malignant type,

may exist for years in persons who lack all superficial signs that the layman often feels

should be apparent to establish psychosis (insanity).29,210

Sometimes such people appear not only normal but brilliant, and their powers of

reasoning in all areas except those dominated by delusion are intact. The delusions

themselves may even be withheld when the excellent judgment of the subject discerns

that they will not be accepted by others or may interfere with psychotic plans toward

which he is assiduously and ingeniously working. "Why, if I'd let the public in on these

facts, a lot of fools might have thought I was insane," one such patient explained.

Another patient, who had for years been hearing imaginary voices which he accepted as

real, admitted that he denied this to the draft board because, "They might have thought

something was wrong with my mind." He had been doing a satisfactory job and, on the

surface, making a good social adjustment in his community. He was accepted for

service in the army.

Another man with clear-cut paranoid delusions prospered for years by selling

stocks and bonds to opulent widows and to others in whom his enthusiastic optimism

and shrewd reasoning powers worked marvelous conviction. He was indeed persuasive,

To my definite knowledge he induced a friend to believe that serious mental disorder

threatened him, or was perhaps already present. Offering to help the friend, who

naturally became alarmed, the paranoiac made arrangements for his hospitalization and,

accompanying the other, had him voluntarily admitted to a psychiatric institution. After

a period of observation the friend was found to be free of any such trouble. Months

later the real patient's delusional system was elicited and his commitment deemed


Even today one often encounters popular misconceptions of what constitutes

psychosis or seriously disabling "mental disorder" that seem to belong to earlier

centuries. Even when patients are speaking frankly and continually about hearing voices

from the next county (or the next world), relatives occasionally express surprise at the

opinion that anything could be wrong with his mind," insisting that he had been running

the store as well as ever, adding up the accounts without error, and showing his usual

common sense in daily affairs.

Fanatics and false prophets who show real but not so obvious signs of classic

psychosis, as everyone must by now have learned, sometimes attract hundreds or

thousands of followers who contribute large funds to projects founded on delusion. If

news reports by many observers can be relied upon,


even those showing plain evidence of very serious disorder, persons as fully psychotic as

many on the wards of the state hospitals, also succeed in appearing to large groups not

only as sage leaders or men with supernatural powers but also as God.22,33

The psychopath, on the other hand, is free of all technical signs of this sort.

There are no demonstrable defects in theoretical reasoning. At least he is free of them

in the same sense that the general run of men and women are free. He carries out his

activities in what is regarded as ordinary awareness of the consequences and without the

distorting influences of any demonstrable system of delusions. His personality outline is

apparently or superficially intact and not obviously distorted.

The diagnostic formulation psychosis with psychopathic personality, listed in the

nomenclature that was official until 1952, deserves attention. Such a psychosis was thus

defined by the Outlines for Psychiatric Examinations (1943):225

The abnormal reactions which bring psychopathic personalities into the group of

psychoses are varied in form but usually of an episodic character. Most prominent are

attacks of irritability, excitement, depression, paranoid episodes, transient confused states,

etc... True prison psychoses belong in this group.

A psychopathic personality with a manic-depressive attack should be classed in the manicdepressive

group and likewise a psychopathic personality with a schizophrenic psychosis

should go in the dementia praecox group. Psychopathic personalities without episodic mental

attack or psychotic symptoms should be placed in the group "without psychosis."

In agreement with Cruvant and Yochelson,62 I cannot see that anything was

gained through such a classification. If a psychopath develops some other disorder such

as schizophrenia or affective psychosis, the additional disorder can be listed properly

without recourse to such an appellation as that just mentioned. So, too, if transient

confusional states occur, they may be so classified in the psychopath as in others.

Such a category promoted confusion by implying the presence of a specific

psychotic illness different from, and in addition to, the psychopath's essential disorder

and that this, even if it is correctly listed as schizophrenia, or paranoid psychosis, needed

the further qualification, "with psychopathic personality." The transient confusional

states considered by some as a characteristic reaction of psychopaths to imprisonment

are usually trivial (minor) additions to or complications of the very serious,

incapacitating disorder that is fundamental. Such manifestations might be compared

with those of a schizophrenic patient who by chance also develops temporary delirium.


If the psychopath develops major or minor disorder of a type classed among "the

psychoses," it can be signified by addition of the usual term, just as it he had developed

brain tumor or peptic ulcer. There seems to be neither need of nor warrant for a

hybridizing concept which does nothing to clarify but a good deal to cloud the issues. I

am not sure there was ever much more need for "psychosis with psychopathic

personality" than for "psychosis with red hair" or "neurosis with a Ph.D. degree." The

current nomenclature appears better designed to avoid unnecessary confusions of this

sort.15 Influences of the older terminologies, concepts, and classifications, however,

probably still play a part in serious misunderstandings about the psychopath that have

not yet been satisfactorily resolved


Next: 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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Section 3, Part 2


  • Psychopath Hervey Cleckley THE MASK OF SANITY, Section 3: Cataloging the material , Part 2: A comparison with other disorders, 29. Purpose of this step
    Psychopath Hervey Cleckley THE MASK OF SANITY, Section 3: Cataloging the material , Part 2: A comparison with other disorders, 29. Purpose of this step, Some material has been presented in which manifestations of the disorder occur. It is our task to arrange it in such a way that its features can be seen clearly and compared with the features of other disorders. Such a step should be helpful in our efforts to recognize what we are dealing with and to evaluate it. Let us compare these patients known as psychopaths with others showing clinical illness and deviated reactions or patterns of living. Significant details should emerge, differentiation should become clearer, and distinguishing features of our subject should become more apparent at





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