Section 3: Cataloging the Material

Part 2: A comparison with other disorders

40. The clinical alcoholic



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40. The clinical alcoholic

The term clinical alcoholic is chosen for convenience to signify the large group of

pathologic drinkers who are still making some genuine effort to adjust in normal life but

are using drink to escape reality which they cannot quite face and, by a vicious cycle,

making themselves steadily more inadequate to face this reality. Such drinkers may, in

several respects, be contrasted with the psychopath (antisocial personality) just as the

non-alcoholic neurotic contrasts with the psychotic patient.

Like the psychopath, their drinking is not primarily for pleasure or has at least

ceased to afford much pleasure. They often give a strong impression of drinking to

avoid sober self-appraisal or some other aspect of reality. With alcohol they can remain

a little more comfortably and longer in the


false world of fantasy or in analgesia. They are often introverted people, often tenderminded

and shy. Alcohol enables them to be less self-conscious and to make their way

with greater ease into the social group. They become more and more disabled for real

life, and reverses due directly or indirectly to their alcoholism accumulate, making it ever

more urgent for them to escape into the numbness of drink.273

To a certain point this picture is not unlike that of the psychopath. Perhaps the

psychopath sometimes arrives at his life scheme by way of phases almost identical with

those of some neurotic drinkers, and perhaps the neurotic drinker may regress to levels

at which he can be plainly recognized as a psychopath. Some of the patients described

here as partial psychopaths might be placed by some observers in the class of neurotic


For the purpose of drawing a useful distinction, however, the following points

are offered:

Often the neurotic drinker wants to get well. This may not be obvious, but with

proper psychiatric treatment it may be possible to obtain sincere cooperation. Although

the neurotic drinker lacks insight and often cannot get well by his unaided efforts, he

retains a capability of gaining insight, and good improvement is often possible under

treatment. The psychopath's actual conduct when drinking, and sometimes when sober,

is bizarre, often shameful and shocking, and actively damaging to himself. In the

neurotic drinker such tendencies, if present, are much less pronounced.

The neurotic drinker on his spree is unintentionally destroying his chances for

success and happiness, but this does not appear to be his fundamental aim; his

fundamental aim apparently is to avoid facing his failures. Although this aim may be

present in the established psychopath, it is not easily or regularly discernible. The latter

appears to be driving primarily at evading, or ignoring, or destroying life itself, that is to

say, life in the sense of social attainments and subjective integration.

Drinkers who can be classed as neurotic show better capacity for insight and may

come voluntarily to seek treatment or may be persuaded by relatives to do so. The

psychopath will not come voluntarily, except when he seeks hospitalization to avoid

legal action, and he cannot be persuaded to carry out sincerely any therapeutic program.

To summarize, then, it may be said that the neurotic drinker is capable of insight

and wants to get well. The psychopathologic picture is more readily comprehensible in

terms of cause and effect and, under favorable conditions, is perhaps reversible. The

psychopath, on the other hand, despite his superficial appearance of being a normal

man, shows in his whole behavior pattern deviation and disorder that seem

fundamental. His real


drives, when one tries to surmise them from his reactions, strike the observer as foreign

to ordinary human impulse. The process, if reversible at all, is not ordinarily found to

be so. Apparently there is no latent insight that can be aroused or sincere desire to

become well or, rather, to become like other men. I do not mean to state dogmatically

that the psychopath's illness is irreversible but merely that in my own experience it has,

in typical cases, proved to be so. It may be said that the process of schizophrenia as

compared with hysteria is relatively less reversible, that it ordinarily brings about a

greater and deeper disintegration of the personality. Despite this fact, schizophrenics

often recover. Perhaps the psychopath, too, can recover. Perhaps some generally

satisfactory means of treating him can eventually be devised.

Taking the group of chronic alcoholics as a whole, we are likely to find here

people in whom the excessive drinking is a common symptom of underlying disorders

that vary widely in type and in degree somewhat as we might say that fever may arise

from a bad cold, measles, pneumonia, tuberculosis, meningitis, and other differing

illnesses too numerous to list.

Alcoholics Anonymous,7 whose excellent work it is appropriate to mention here,

has, in my experience with this group as a whole, appeared to be one of the most

valuable therapeutic agencies available. Many gravely maladjusted patients in whom

alcoholism was at the same time a disabling symptom and a secondary but major causal

agent in disastrous life patterns have, through this agency and its program, made

changes and progress that with no exaggeration can be called remarkable. Some

patients whose behavior and emotional attitudes definitely suggested the psychopath's

disorder have to my knowledge not only avoided for years the disabling effects of their

former drunkenness but also other unrewarding and antisocial activities. Whether or

not these were psychopaths in the full and deepest sense is not a question that can be

answered confidently.

It is my belief that this type of disorder, like all other psychiatric disorders, may

be seen in almost limitless variations of degree and severity. We see the utterly

disorganized schizophrenic who has for twenty years been on the worst ward of a state

hospital, and we also see schizoid reactions and limitations that persist for decades in

people who continue to be self-supporting and to a considerable degree socially

competent. I recall one patient who has expressed to me delusions typical of full-blown

schizophrenia over some years and who is still an able worker with many pleasant social

relations and recreational activities. Many more come to mind whose delusions are less

extreme but who for decades have manifested autistic withdrawal, oddities, emotional

distortions, and impairments consistent only with a schizoid reaction.


We also see manifestations identical with those of full-blown schizophrenia in

every respect except their transiency. A 30-year-old man who, after taking a small dose

of testosterone, experienced not only hallucinatory sexual and spiritual sensations within

himself but also in others will serve as an excellent example. Vivid delusions were very

prominent for approximately a week. These included an absolute conviction that all

virtuous women at the mere sight of him caught the impact of magic, glowed with a fire

both erotic and holy, and were visibly transformed. It was also his belief that this

caused harlots who might sense his powers a block off to run up alleyways in shame.

For several days, through false perceptions, he specifically "felt" men and women some

miles away responding viscerally, intellectually, and spiritually, and in diverse ways, to

what had miraculously become incarnate in his person. After being psychotic for a

week and without specific treatment, he regained insight, lost his schizophrenic

symptoms, and has for a number of years remained entirely free of them.

In the other disorder, that of the psychopath, I believe there also occur similar

variations in chronicity, in severity, in completeness, in depth, and in every other

respect. Although malignancy and irreversibility seem typical of the psychopathology as

we meet it clinically in its advanced or long fixed forms, outwardly similar behavioral

and characterologic patterns sometimes prove reversible. Few, if any, features of the

full psychopath are more impressive than his inability to respond with consistent acts or

in other ways that would indicate deep or genuine desire to change his situation. In

therapeutic programs it is characteristic of him not to make valid or persistent efforts to

cooperate. In their relations with Alcoholics Anonymous, psychopaths sometimes show

at first what seems extraordinary zeal, sincerity, and promise, only to reveal after varying

intervals that the whole matter was only a sort of prank or lightly taken adventure in

versatile careers of self-ruin.

Fundamental points in the Alcoholics Anonymous system of group therapy and

self-reorganization are the following:

1. The need for a most profound intention (an authentic and major desire) to

overcome one's disability

2. The necessity for extensive and basic changes in attitude and orientation at the

core of the personality

At both of these points we find in the full psychopath an almost uniquely

unfavorable situation. Although I know of nothing available today that can be counted

on to succeed regularly, the evidence has suggested that Alcoholics Anonymous may in

some cases affect favorably latent resources very difficult to reach by most methods in

patients showing reactions that may have something in common with those of the

typical psychopath.


Next: Section 3: Cataloging the material, Part 2: A comparison with other disorders, 41. The malingerer


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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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