The term psychopathic personality was for many years the officially approved designation of the American Psychiatric Association for a great many types of maladjustment in people who were otherwise regarded as free from psychosis, psychoneuro-sis, and mental deficiency. A large number of heterogeneous disorders, many of which have little in common, were included in this category. In 1952 the association officially replaced this term with the general category personality disorders. This category also includes many deviations, maladjustments, and disorders that vary widely in type and in degree. In the present scheme of nomenclature the subclassification sociopathic personality: antisocial reaction includes the type of patient well known to psychiatrists and for many decades referred to by the informal term psychopath.
Definition. The Diagnostic and Statistical Manual, Mental Disorders of the American Psychiatric Association defines antisocial reaction as follows:
This term refers to chronically antisocial individuals who are always in trouble, 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. (1952, p. 38)
Patients classified in this group are distinguished from other sociopaths, a category that includes those suffering from sexual deviation, alcoholism, and drug addiction; this group is also distinct from those exhibiting dyssocial reaction, which the Manual defines as follows:
This term applies to individuals who manifest disregard for the usual social codes, and often come in conflict with them, as the result of having lived all their lives in an abnormal moral environment. They may be capable of strong loyalties. These individuals typically do not show significant personality deviations other than those implied by adherence to the values or code of their own predatory, criminal or other social group. The term includes such diagnoses as “pseudo-social personality” and “psychopathic personality with asocial and amoral trends.” (1952, p. 38)
It should be noted that the patients defined as showing dyssocial reaction are nonetheless capable of loyalties and seem in their rebellion against society to have some standards of their own, even though these may be immoral and condemned by law. This classification apparently covers the ordinary purposive criminal who works consistently toward antisocial but comprehensible goals.
This article will concern itself primarily with patients showing antisocial reaction, to whom we shall refer by the informal but now classic term psychopath. This term is familiar to all psychiatrists, and it clearly designates and distinguishes a well-known clinical entity.
Few modern definitions have surpassed J. C. Prichard’s 1835 description of certain key aspects of the psychopathic personality:
…the moral and active principles of the mind are strongly perverted or depraved; the power of self-government is lost or greatly impaired and the individual is found to be incapable not of talking or reasoning upon any subject proposed to him, but of conducting himself with decency and propriety in the business of life. (Quoted by Cleckley 1959, p. 569)
Prichard is generally credited with formulating the concept moral insanity, which is still used in some parts of the world to designate the abnormality shown by psychopaths. In a recent study McCord and McCord give another definition that is helpful:
The psychopath is an asocial, aggressive, highly impulsive person who feels little or no guilt and is unable to form lasting bonds of affection with other human beings. (1956, p. 2)
The psychopath does not give the impression, even on careful examination, of being mentally ill, handicapped, or emotionally disturbed. Nor does he, typically, show any attitude or outlook that would indicate he lacked conscience or had chosen rebellious or antisocial aims. His reasoning is excellent. What he tells of his allegiances, aims, and understandings indicates that he is normal, reliable, and utterly sincere. Despite this, his past conduct and what will emerge in the future are very likely to bear out the truth of Lindner’s statement that here we encounter “the most expensive and most destructive of all known forms of aberrant behavior.”
The typical psychopath is a person who appears to have at least average, and often unusual, ability and who seems to be clearly aware of the amenities and to affirm the moral code. Frequently he demonstrates superior intelligence and other assets and is likely to succeed brilliantly for a time in work, in studies, and in all his human relations. But inevitably, and repeatedly, he fails, losing his job, alienating his friends, perhaps losing his wife and children. It is difficult to account for these failures. Seldom can one find adequate motivation to explain why a person has, in the midst of success, grossly shirked his immediate responsibilities, and perhaps abandoned his work, at the behest of impulses that seem to the observer no more compelling than a trivial whim. However effective he may show himself to be over a limited period, when given sufficient time, he proves himself inadequate. His failures deprive him of what he tells us are his chief objectives and also bring hardship, shame, and disaster to his wife, children, parents, and all those closely connected with him (Cleckley 1941).
In addition to such relatively passive types of failure most fully developed psychopaths also commit aggressive antisocial acts. They forge checks, swindle, steal repeatedly, lightly indulge in bigamy, and show little or no compunction about their sexual behavior, regardless of the consequences. Some psychopaths who have attracted wide public attention committed murder or other shocking felonies, usually with little or no provocation, often without comprehensible motivation (Cleckley 1941). The majority, despite many conflicts with the law, appear to avoid crimes sufficiently grave to result in their removal from society for long prison terms. The psychopath may repeatedly receive punishment that would be likely to cause an ordinary person to mend his ways. But he appears to learn nothing important from experience. He is quite familiar with the correct ethical criteria, claims allegiance to such criteria, and can formulate in words excellent rules and plans for himself to follow. He does not seem to be lying as simply as the ordinary liar, whose motives are usually comprehensible. Sometimes the psychopath does not seem to be aware that he is lying or even to grasp emotionally the essence of falsehood and how falsehood differs from truth. Sometimes such people seem to mean for the moment to do what they promise so convincingly, but the resolution passes almost as the words are spoken.
The psychopath expresses normal reactions (love, loyalty, gratitude, etc.) with a most impressive appearance of sincerity and depth, but the emotional ties and the attitudes he professes fail to deter him from deeds that continually contradict his verbal claims. There appears to be in him a strange lack of insight or, perhaps more accurately, a total lack of one of the dimensions that constitute insight. After innumerable lies that he knows have been detected, he still speaks confidently of giving his word of honor, apparently assured that this will settle the issue immediately and absolutely. Although he may demonstrate, over considerable periods, adequate general abilities, or even extraordinary talent, he always throws away what he has gained, what he insists are his chief objectives. No adequate motivation can be found or even imagined to account for his conduct. Conceivable temptations are often extremely trivial, but they inevitably evoke actions that lead to the loss of fortune and the respect of friends, the destruction of marriage, and imprisonment or confinement in a psychiatric institution. The psychopath seems to be almost totally immune to real remorse or deep feelings of guilt or shame.
At this point it is appropriate to consider the case of a young woman in her early twenties whose appearance of high intelligence is confirmed by psychometric examination and by excellent achievement in her studies and at work during the limited, sporadic periods during which she applied herself. Despite this intelligence she has been a serious problem to her parents since early childhood. She has repeatedly stolen from her family, from strangers, and from stores. Often she has bought unneeded clothes and other articles and has habitually lied with equanimity and effectiveness. At times she has run up such large, unauthorized bills that her father found himself in serious financial difficulties. No punishment or deprivation has influenced her in the slightest degree. As a girl she had been frequently truant from school and violated every agreement made about suitable hours to return from dances or dates. Yet she has almost never been openly or directly defiant and has usually admitted herself in the wrong when her cool and ingenious falsehoods were exposed. She regularly promises, in a convincing and apparently sincere manner, to reform completely but after varying periods of good behavior always returns to her old patterns of irresponsibility and folly.
She has had a number of boy friends but apparently feels less than the average sexual interest. Often she has seemed to be mildly bored but seldom distinctly unhappy. During the year before her admission to the hospital she spent hours each week writing sentimental and rather perfunctory letters, chiefly to boys in military service or at college. Some of these she knew only slightly. When one of the boys, whom she knew much better and actually considered her sweetheart, was killed in an automobile accident, she manifested little sign of grief or concern. She remained a virgin until she was 18 years old. Then one day, without apparent provocation or strong incentive, she left home secretly and was not heard from until two weeks later When police located her in a city approximately a hundred miles away. She showed no remorse about the anxiety her parents had suffered and neither disillusionment nor resentment about the fruitlessness of her venture or the rather brutal treatment she had occasionally experienced.
In explanation of her conduct she said that she had left home with the intention of visiting a boy friend stationed at an army camp in another state. She admitted that she had in mind the possibility of marrying this man, but that no final decision had been made by her, much less by him. She admitted that she had given the matter little thought, and from her attitude one would judge she was moved by little more than a casual whim.
She had left with only a few dollars in her purse. Getting off the bus in a town fifty miles from home, she tried to reach the boy by telephone and ask him to telegraph funds to her. She could not reach him and decided to go to the home of another boy, then overseas, whose family lived in the town where she found herself. She asked these people to let her spend the night. They welcomed her. After being there an hour or two, she became suspicious that they might have notified her parents. Without a word to them she slipped out of the house, took a bus in another direction and, late at night, got off in a small, strange town.
For a little while she sat in a hotel lobby, apparently calm and unworried. Soon a man approached her and drew her into conversation. On hearing her story, he offered to pay for a room so she could rest. She realized he meant to spend the night with her, but she made no objection. As far as one could tell by discussing the experience with her, she was neither alarmed, excited, repulsed, nor attracted by a prospect that most carefully raised virgins could not have regarded with indifference. The man apparently handled her in a crude, inconsiderate fashion and showed plain contempt for her and her role, addressing her in unnecessarily derogatory terms. During sexual relations with him she experienced moderate pain and no sexual excitement or response. He gave her a few dollars, which she was pleased to accept.
The next day she telephoned her soldier friend at his camp. She had not discarded her idea of perhaps marrying him, nor had she progressed any further toward a firm decision to do so. He discouraged her strongly against coming, refused to send her money, and emphatically urged her to return home. Apparently she was not upset by this turn of events and, with little consideration of the matter, decided to go to the city where she was eventually discovered. She admits that she had no definite purpose in going there, was prompted by no overmastering thrill of adventure, and was not aware of any strong reason for not returning home or for having left in the first place. In the strange city she got small jobs for a day or two, but these did not pay enough for room and board. She therefore began to spend the nights with various men in search of light sexual adventure. She experienced no real erotic enjoyment from these experiences or any serious qualms of conscience. When detected by police and, later, on meeting her friends at home, she never showed embarrassment or any sign of remorse about what had occurred.
Somewhat similar episodes recurred time after time. On various occasions she expressed the wish to go into training as a student nurse, to do secretarial work, or to get a job in a government agency. At considerable expense and trouble her family enabled her to try all these plans and many others. Each time, she expressed the most confident assurance that she would have no further trouble. In each new venture she made a favorable impression at first and showed herself capable of succeeding and often of excelling. Soon, however, she abandoned each position, sometimes running away to other towns and living more or less as a vagabond. Once she absconded with money obtained from a lending agency operated by the corporation she worked for. She often stole things for which she had no use. Sometimes without any particular reason she simply quit going to the office and in this way lost good positions in which she had expressed great interest and at which she was succeeding with minimal effort.
After dozens of such failures she continued to express the most complete optimism, and her attitude always implied buoyant self-satisfaction.
After coming to the hospital a number of times for psychiatric observation and treatment, she wrote to her physician:
You have given me a new outlook and a new life; shown me things in a different light—and I am happy —and have every hope of making those who, you could even say, have saved me, proud of me. Whether I turn out finally to be a nurse, a business girl or just a wife, I have a new hope for a happy and useful life which I thought would never be mine. If in this new life I ever become discouraged and lose hope I will look at you and have courage and hope again. I now understand myself and my problems, thanks to you. I will go on and succeed and be happy.
After several prompt repetitions of previous failure she continued to give her psychiatrist’s name as a recommendation for positions on the basis of her “good character,” “reliability,” “high moral standards,” etc. She seemed perfectly assured that such recommendations would be in the highest terms and without qualification.
It is not easy to fathom the motivation of such a person. If in hallucinations she had heard God’s voice urging her to leave home or had believed she was being invited to spend the night by a famous motion picture star or a princely lover, her conduct would be easier to understand; it would, in an important sense, be less unreasonable. It would also be easier to account for if she had been tempted by strong and persistent sexual desire or some other major incentive to sacrifice her good name and perhaps her chances of future happiness for a foolish but fascinating or wildly exciting adventure.
The patient whose history has just been briefly summarized shows many of the characteristics that seem to distinguish the real psychopath from other people, including other psychiatric patients. The following is a list of some of the characteristics that have emerged in the study of many patients of this type: (1) Easy charm and good technical intelligence. (2) A confident and forthright manner that inspires trust. (3) An apparent dignity and seriousness that give the impression of profound sincerity. (4) The absence of delusions, hallucinations, and all other signs of psychotic or irrational thinking. (5) Freedom from abnormal anxiety and other manifestations of psychoneurosis. (6) Ability to formulate excellent life plans that seem to indicate sound judgment and steadfast resolution. (7) Allegiance to moral codes and conventions of society, expressed cogently and with the appearance of deep conviction.
These points are likely to be impressive during psychiatric examination or in any other encounter confined to the patient’s verbal performance as contrasted with his behavior. When we study his behavior over a considerable period of time, other points emerge that are strikingly incompatible with those listed above: (1) Unreliability and irresponsibility in behavior even when very important issues are at stake and personal welfare is involved. (2) Lack of remorse or shame despite eloquent protestations of such feelings. (3) Inadequately motivated antisocial behavior repeated again and again despite interludes of good adjustment. (4) Conduct that demonstrates extremely poor judgment and failure to learn by experience. (5) Inability to love another, and pathologic egocentricity. (6) Shallowness and poverty in the major human emotions. (7) A specific loss of insight despite ability to use words that convincingly give the opposite impression. (8) Unresponsiveness to the important issues that arise in interpersonal relations. (9) Uninviting and outlandish behavior, often with little discernible provocation. (This is particularly prone to emerge when drinking.) (10) Tendency to threaten suicide frequently but rarely to attempt it, despite circumstances that would make strong impulses toward suicide readily understandable. (11) Shallow, impersonal, trivial, and poorly integrated sex life. (12) Failure to follow consistently any life plan. (Although brilliant successes occur, the results of these are often dissipated or destroyed on impulses that appear to be little more than caprice.)
The disorder of the psychopath varies considerably in degree, and some of these patients, despite their technical sanity, prove themselves much less competent, less able to live their lives effectively or without serious damage to themselves and to others than people who show plain manifestations of psychosis. The psychopath, although entirely free of irrationality and often brilliant in all verbal tests, carries on a career that is difficult to account for as a product of sanity.
What is the nature of the disorder or defect in these people? Since the mid-nineteenth century various answers have been offered to this question. It has been said that they suffer from pathologic changes confined to a hypothetical “moral faculty.” It has also been said that they are affected by general constitutional inferiority, subtle hereditary taint, the deprivations of slum life, the influence of evil companions, and parental neglect. Some of these explanations have probably emerged from the observation of patients now distinguished as showing dyssocial reaction and of other types of disorder differing fundamentally from that of the true psychopath but arbitrarily placed in the same category. During recent decades increasing attention has been paid to the influence of environmental or psychogenic factors rather than possible inborn or organic defects. Some observers have expressed the conviction that the psychopath is a product of extreme parental spoiling. Others have seemed as confident that early and subtle rejection by the parents is a major factor in his development (Cleckley 1941).
Franz Alexander’s formulation
Since the 1930s the concepts of Franz Alexander have attracted much attention and have, indeed, been accepted by many psychiatrists as furnishing a scientific explanation of the problem. According to Alexander’s formulation, the psychopath’s maladjustment and antisocial behavior arise from inner conflict similar to that widely believed to underlie psychoneurotic symptoms. Despite the striking lack of ordinary anxiety or self-condemnation in psychopaths, even under circumstances in which these reactions would be normal, Alexander maintains that there is an inner unconscious conflict and sense of guilt (1930).
In reaction to such a conflict the patient with psychoneurosis is thought to develop subjective symptoms and to complain of anxiety, headache, weakness, and other physical disturbances or perhaps to become disturbed by compulsive rituals, obsessive thinking, hysterical paralysis, and temporary blindness. Alexander maintains that the psychopath, instead of passively developing such unpleasant subjective symptoms, reacts to the postulated unconscious conflict by indulging in destructive, self-damaging, antisocial behavior. This process is thought of by Alexander as an “acting out” of the inner problems in relation to society and to the environment (1930). Many of those who accept this hypothesis believe that the psychopath deliberately but unconsciously seeks failure and persistently commits crimes and other acts of aggression to obtain punishment, which he unwittingly desires as an expiation of intense but completely unconscious feelings of guilt and remorse. In this interpretation the psychopath can be thought of as having genuine and adequate reasons for the apparently foolish, antisocial, and uncalled-for acts he commits, damaging himself and others. It is assumed that he knows nothing of these reasons or of their effect upon him. This is in many respects an ingenious formulation. It is widely regarded as offering a “dynamic” explanation of the psychopath. It tends also to make him a dramatic figure and to arouse sympathy for his alleged blind struggle for redemption. [SeeAlexander.]
Adelaide Johnson’s formulation
Another and more recent explanation has been offered by Adelaide Johnson (1959). She also maintains that there are factors operating in the unconscious, not only of the patient but also of his parents. According to this formulation, the parents have criminal impulses of which they remain completely unaware and, without realizing it in the least, work deliberately and persistently to influence their son or daughter to carry out irresponsible, immoral, and destructive antisocial activity in order to obtain for themselves a vicarious satisfaction they do not dare seek more directly. According to this theory, the child, even after he has reached adult life, does not become conscious of this alleged motivation or of the beguiling influence said by Johnson to be exercised unwittingly by the parents. Through this purposive training, the child is said to be inducted by the parent into a career of unrewarding delinquency and self-defeating antisocial behavior.
Evaluation of these formulations
Johnson’s hypothesis, like Alexander’s, seems to offer a “dynamic” explanation in the popular terms of unconscious motivation. Perhaps for this reason both have attracted much attention and have been widely accepted. They are regarded by many as scientific discoveries based on demonstrable evidence.
Let us not forget that both of these intriguing theories rest entirely on arbitrary assumptions about what is in a hypothetical unconscious. None of the patients I have studied have shown anything that could reasonably be regarded as evidence of the hidden sense of guilt and the desperate quest for redemption through punishment attributed to psychopaths by Alexander. Nor have I found anything to indicate that their parents wanted them to indulge in misconduct and, without realizing it, actively influenced them toward it. Such motives and feelings, or any others, may of course be assumed to be present not only in psychopaths but in anybody else if we also assume that they remain unconscious. Care, however, must be taken to distinguish between assumption and proof. Popular methods in psychiatry and psychology generally regarded as dynamic make it easy to ascribe with confidence virtually anything to the unconscious and to obtain pseudoevidence for whatever one might seek to establish, using analogy and the arbitrary interpretation of dreams and symbols. The psychiatric literature abounds in examples of these methods being so used to discover specious explanations of psychiatric disorder in events imagined by the psychiatrist, in accordance with his theory, to have occurred decades earlier, during the first few months of a patient’s life; or, indeed, even during the patient’s intra-uterine existence as an embryo (Cleckley 1957).
Perhaps some people carry out criminal acts repeatedly because of guilt they do not know they experience and do so in order to obtain punishment they do not know they seek. Perhaps there are law-abiding and respected parents who unconsciously want their children to rebel against society and indulge freely in forgery, burglary, bigamy, prostitution, and other forms of misconduct. However, no evidence has emerged in my own experience with psychopaths to indicate that such influences are likely to play a part in their disorder. Until real evidence, as contrasted with mere assumption, can be offered to establish the concepts of Alexander and Johnson, let us regard them with skeptical interest.
For a long time it has been the custom to assume that in unconscious conflict can be found the explanation of psychiatric disorder, of delinquency, and, indeed, of human behavior in general. Jenkins (1960) suggests that it may be worthwhile for us to consider possible effects of the opposite, of a lack of conflict under circumstances that would normally cause anxiety and conflict to develop and that would actually make this imperative. He very pertinently points out that it became known early in the history of medicine that what a person ate could produce illness. Only much later did it become known that what he did not eat might cause a more subtle illness through avitaminosis.
Masked personality disorder
Is there some defect or disorder within the psychopath that causes him to lack the capacity to feel guilt? If so, this hypothetical deficiency seems also to interfere with his reacting to, and pursuing consistently, the normal goals of life. And he seems to lack the ability to participate adequately in the major emotional experiences of life.
The typical psychopath’s excellent intellectual abilities and his freedom from the manifestations of ordinary psychiatric disorder make it difficult to believe that deep within him may be concealed a deficiency that leads not to conflict or unconscious guilt but, instead, makes him incapable of feeling normal remorse and of appreciating adequately the major emotional experiences of human life (Cleckley 1941).
The outer characteristics of the psychopath strongly indicate warmth of feeling, kindness, sincerity, pride, courage, a deep sense of honor, and genuine capacities for love and loyalty. Such an outer appearance could be the result of excellent peripheral function in the organism, which gives strong and convincing promise of robust health within and makes it difficult to suspect that there may be a central and very serious inner defect. The psychopath’s conduct, however, is consistent with a serious defect in the very qualities for which his superficial aspect and verbal performance give such rich promise. The peripheral mechanisms, one might say, of his functional entity are undamaged and operate well. They demonstrate technical intelligence and convincingly mimic the expression of normal inner experience. But the implied inner experience, the glowingly promised emotional participation in life, is not there.
If we compare speech disorders with personality disorders, an analogy emerges that may be helpful in conveying this concept. When the outer physiologic apparatus involved in the production of speech is damaged, the disability is overt, and its cause is usually easy to understand. When the tongue is mutilated or its motor nerve damaged, there is likely to be gross difficulty in enunciating words and perhaps even in moving the tongue itself. Efforts to speak may give rise only to inarticulate sounds that communicate nothing. The inner use of language, however, and its meaning to the person who has suffered the injury, is preserved intact. In contrast with dysarthria, in which the peripheral apparatus of speech is affected, let us consider the aphasias which are caused by lesions more centrally located in the brain. In these the outer mechanisms of speech are preserved.
Let us consider particularly semantic aphasia as described by Henry Head (1926). In this very deep-seated disorder of speech, words are clearly and accurately enunciated, and often complete and grammatical sentences are fluently spoken. These utterances, however, have little or no meaning. They are not related, within the person, to ideas or feelings that they seem to indicate and seem intended to convey. The words of this ostensible communication are, in a very important sense, not really words but only a mimicry of words, produced mechanically by the peripheral mechanisms of speech that have become isolated from the inner source that gives rise to thought, feeling, and intention. Despite this more or less reflex simulation of real speech, a deep loss has occurred that prevents the person from using language inwardly to think. [SeeLanguage, article onSpeech Pathology.]
If the psychopath has a profound and centrally located defect that prevents him from participating significantly in man’s deepest fulfillments and joys, is it not possible that this inability to participate might contribute to restlessness and boredom? And might this not in turn prompt him to indulge in unprofitable or damaging indiscretions and destructive behavior that would not be particularly tempting to others who are devoting their attention to major goals and responding to major fulfillments? This hypothesis—of an extremely serious central pathology or a biological deficit concealed by misleading peripheral functions, by what one might call an impressive “mask of sanity”—cannot be established by objective evidence at present but is, in many important respects, consistent with the psychopath’s behavior (Cleckley 1941).
It may be helpful to consider the case of patients who are affected by what has often been called “masked schizophrenia.” Though these patients do not have delusions or hallucinations and are often rational in their verbal expression of thought, the psychosis may be as genuine and its degree as great as in the hebephrenic patient, whose extremely disabling disorder is obvious. The patient with masked schizophrenia, unlike the psychopath, nearly always shows on examination a brittleness, some undefinable peculiarity of manner, an emotional coolness, or, perhaps, certain subtleties of posture, gesture, expression, or attitude that indicate he is by no means normal. It might be said that his psychosis is concealed but that it is concealed by the appearance of lesser abnormality, by the outer disguise of a very eccentric and peculiar person. In contrast to this, the mask of the psychopath is that of complete and robust health.
Over the years most observers have been impressed by the failure of psychopaths to respond to any treatment or be changed fundamentally by any other influence (Cleckley 1941). A few psychiatrists have expressed encouragement about psychoanalytic treatment of patients they regarded as psychopaths (Johnson 1959; Karpman 1955; Schmideberg 1949). Lindner enthusiastically reported success with the use of hypnoanalysis (1944). Others have occasionally reported improvement through the use of drugs, through the effects of simple counseling, through milieu therapy, through the methods of general semantics, and through various other types of psychotherapy (Lip-ton 1961; Lynn 1938; McCord & McCord 1956; Thompson 1953). Occasionally psychiatrists have been favorably impressed by reports of the use of electric shocks (Darling 1945) and lobotomy operations (Banay & Davidoff 1942). Perhaps some of these optimistic reports, which conflict so sharply with the experience of most observers, can be accounted for by the psychopath’s tendency to use his excellent abilities temporarily—and perhaps one might also say, capriciously—to succeed for a while in whatever he undertakes. These spontaneous remissions, like those long familiar in multiple sclerosis, may lead the therapist to an erroneous belief that they are the result of his treatment. Most psychiatrists share the opinion that there is no effective treatment available today for genuine and typical psychopaths [SeeMental Disorders, Treatment Of; see alsoCleckley 1941; Greenacre 1947].
It would seem that important steps can be taken toward working out a better means of dealing with the many problems posed by the psychopath. First, a more general recognition is needed that his disorder is a genuine incompetency or psychiatric abnormality, a specific pattern of malfunctioning that, in severe cases, causes maximal disability and makes it impossible for him to maintain his role as a responsible member of the community. At present most psychopaths elude restriction. Neither penal institutions nor psychiatric hospitals possess the legal means of holding them long enough to afford the community protection or to give an adequate trial to any therapeutic measures that may be attempted.
Although the psychopath’s record of extreme incompetency may facilitate his efforts to obtain exoneration or leniency in the courts when faced with imprisonment, it does not, as matters now stand, enable society to keep him under psychiatric supervision through commitment. Scores of times patients repeat apparently purposeless thefts, forgeries, embezzlements, bigamies, swindlings, distasteful or indecent acts in public, and yet, because the official medical category in which they are placed makes them sane and competent according to the books and tradition, they cannot be committed to psychiatric institutions for medical care or for the protection of themselves and others. If by chance they are committed, which is exceptional, their “sanity” is soon re-established by a staff of able psychiatrists at the institution to which they are sent, who correctly diagnose them as cases of psychopathic personality. However genuine their real disorder, this frees them (as legally competent persons) from control or supervision.
On the other hand, these patients frequently, and in most courts usually, are able to evade prison sentences for their antisocial acts. Their lawyers are able to point out the obviously incompetent features in their careers, and the jury, despite expert psychiatric testimony to the contrary, is often unwilling to punish persons whose conduct shows such plain evidence of mental abnormality. The Durham Rule—that the accused is absolved from criminal responsibility if his act was a product of mental disease—lias apparently not resulted in any improvement in this confused situation [SeePsychiatry, article onForensic Psychiatry].
If a means could be made available of obtaining adequate control over psychopaths who plainly show themselves not fitted for unrestricted freedom in the social group, it would then be possible to set up facilities specifically designed to deal with their problems. Large state and federal psychiatric institutions in the United States, organized for the treatment of patients psychotic in the traditional sense, are not at present well adapted to handle the psychopath. Numerous private hospitals, whether primarily designed for the needs of the psychoneurotic patient or for the psychotic, lack the means of restraining the psychopath and are unable to deal adequately with the problems he creates. There would be no use in establishing institutions primarily for psychopaths unless legal means of controlling them were made available. The expense of building and operating specialized institutions of this sort would be great. There is good reason to believe, however, that even this would cost less than what the psychopath is costing the public today. And even if no effective treatment should ever be discovered, systems of parole and probation specifically set up for the psychopath and carefully designed in the light of his needs and his proclivities could give each patient as much freedom from restraint as he showed himself capable of utilizing safely. In a properly and persistently controlled situation it might be possible for many psychopaths to use their excellent abilities constructively and eventually achieve a much better adjustment than is possible for them today. If laymen were to become more acquainted with this enigmatic figure behind his misleading mask of sanity, and with the ever-accumulating sorrow, damage, despair, confusion, farce, and disaster that each psychopath leaves in his wake, organized effort might be mobilized to devise adequate medicolegal means of restraining him in his now virtually unhindered career of folly and purposeless destruction.
Hervey M. Cleckley
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For both forensic psychiatry and legal purposes, the correct diagnosis of psychiatric disorders in criminal offenders is crucial to establish legal and criminal responsibility. Psychopathic personality disorder (PPD) is a psychiatric disorder. The majority of patients with a psychiatric disorder do not commit crimes. For that matter, although psychopathic personality disorder shows a high prevalence among criminals, it does not imply that all carriers of the disorder will necessarily become involved with criminal activity. Conversely, all criminals do not have a psychiatric disorder. An estimated 1–4% of individuals among the general population present some degree of the symptoms described for psychopathic personality disorder.
Psychopathic personality disorder is a chronic psychiatric condition with specific manipulative and exploitive behaviors that persist for many years. The cause of PPD is unknown, although genetic factors and a history of child abuse are thought to play a role. The condition affects more men than women, and often, persons with psychopathic personality do not seek treatment unless ordered to do so by a court. The diagnosis of psychopathic personality is most often made by a forensic psychiatrist.
Perhaps the main characteristic of PPD is the inability to feel remorse. The American psychiatrist and neuroscientist Bruce Perry defines remorse as a painful emotional reaction that results from the realization of how much suffering the individual has caused to another person. Remorse, therefore, implies the capacity to empathize with the pain one has caused another person. People with psychopathic personality disorder have no such capacity. They can repent or intellectually recognize they were wrong, when they are caught, especially if such recognition brings some advantage to his or her situation. However, repenting is a rational exercise, and not an emotional event, according to Perry. People with PPD are often highly intelligent and have able manipulative skills, but often have poor emotional intelligence and are unable to understand or consider other people's feelings. In essence, they are predators, often presenting a cunning intuitive perception of other's psychological fears and weaknesses, which they exploit for self-benefit. Persons with PPD are not solely found among criminal ranks; often they are present at the workplace, in social circles, and in the political scenery. Swiss psychiatrist Karl Jung (1875–1961) made an interesting psychological assessment of Hitler in the late 1930s, describing characteristics belonging to Hitler which resemble the main criteria for PPD: superficial charm, grandiose sense of self worth, keen manipulative skills, lack of realistic longterm goals, irresponsibility, lack of remorse or guilt, callous lack of empathy, poor behavioral control, self-centered and self-important feelings, blaming others for his failures, predatory attitudes, easily-frustrated, impatient, and ambitious.
People with psychopathic personality disorder who do not commit crimes are likely to have troubled relationships at home and in the workplace, due to their destructive personality characteristics and need to manipulate and control others. They have the ability to undermine self-esteem and self-confidence in others. They feel superior to others and consider themselves above the rules that regulate society. Their main aim is self-gratification, even when they pretend to be caring and concerned with the well being of others. Self-image and self-interest are a high priority for people with these characteristics. They often lie, abuse, steal, cheat, and are unscrupulous in business partnerships and commercial transactions. Appearing fearless, they may put at their lives and the lives of others at risk during thrill-seeking activities. Many white-collar criminals share characteristics with this personality group, and often elude authorities.
Violent psychopaths who end up in prisons are usually less intelligent or have little education, and began criminal activities as juveniles. Violent psychopaths may have a childhood history of torturing small animals and/or of repeated acts of vandalism, systematic lying, thefts, violent behavior towards smaller children, and defiant attitude with parents, teachers, and other authority figures.
In contrast with other psychiatric offenders, criminals with psychopathic personality disorders have a clear understanding that they are breaking the rules. They are convinced, however, that rules exist only for those who are inferior to themselves. Breaking the rules without being caught is a means of proving their superiority. Rehabilitation programs usually provide little benefit to criminals with psychopathic personality disorder, as they do not view incarceration as deserved punishment, and they have no remorse for their actions or wish to alter their behavior.
see also Criminal profiling; Criminology; Hitler Diaries; Psychiatry; Psychology.