The Mask of Sanity. Hervey M. Cleckley

mockery for some of their behavior. Many psychiatrists still regard such patients, unlike those suffering from ordinary psychoses, as “totally responsible” for their misconduct and their difficulties. As this volume will subsequently show, I do not share such an attitude. The faulty reactions in living which these patients show are, however, difficult to describe without sometimes using terms that come more readily to moralists or sociologists or laymen than to psychiatrists. The customary psychiatric terminology does not, I believe, offer a range of concepts into which we can fit these people successfully.

      With other patients whose disorder is frankly recognized we can, by our impersonal and specifically medical language, communicate fairly well to each other what we have observed. Some aspects of the psychopath which elude such language may be reflected, however imperfectly, in the simplest accounts of direct impression by those who have been closest to him and felt the impact of his anomalous reactions. For these reasons, then, and with apology, reference may be made to some actions as outlandish, foolish, fantastic, buffoonish, etc.

      The chief aim of the present work is to help, in however small a way, to bring patients of this sort into clearer focus so that psychiatric efforts to deal with their problems can eventually be implemented. It has, of course, been necessary and in every way desirable to eliminate all details that might lead to the personal identification of any patient whose disorder has been studied and recorded. AH patients referred to have been carefully shielded from recognition. It is nevertheless true that the psychopath engages in behavior so unlike that of others and so typical of his disorder that no act can be reported of a patient from Oregon seen ten years ago without strongly suggesting similar acts by hundreds of psychopaths carried out in dozens of communities last Saturday night. I can only express regret to the scores of people whose sons, brothers, husbands, or daughters, I have never seen or heard of, but who have, no doubt, reproduced many or perhaps all of the symptoms discussed in this volume. This disorder is so common that no one need feel that any specific act of a psychopath is likely to be distinguishable from acts carried out by hundreds of others.

      In discussing the possible influence of environment on the development of this disability, I hope I will not promote unjustified regret or remorse in any parent. Hundreds of times fathers and mothers have discussed their fear that some error or inadequacy on their part caused a child to become a psychopath. Most parents of such patients personally studied impress me as having been conscientious and often very kind and discerning people. As will be brought out later, I do not believe obvious mistreatment or any simple egregious parental errors can justifiably be held as the regular cause of a child’s developing this complex disorder. All parents, no doubt, make great as well as small mistakes in their role as parents. It has seemed at times that the very points about which some mothers and fathers feel most uneasiness are the opposite of those so regretted by others and assumed to be the crucial mistakes that have contributed to the maladjustment of a child. Less than in most other kinds of psychiatric disorder has it seemed to me that one could find and point out as causal influences gross failures on the part of the parents which people of ordinary wisdom and good will might have readily avoided.

      Cruvant and Yochelson56 have expressed the opinion that strong and inappropriate negative attitudes toward psychopaths are commonly aroused in psychiatrists who attempt to deal with them as patients. This is an important point. Such reactions, there is reason to suspect, have tended to distort psychiatric appraisals of the disorder. I am not so rash as to claim total immunity from the subtle bias these patients seem to promote in so many physicians. It is hoped that the earnest wish to avoid this distorting influence will minimize effects of what can be more readily detected in the estimates of others than of one’s self. A strong personal conviction that in the psychopath we are dealing with genuine illness should be of some remedial value, to whatever degree of this prejudice I am, unwittingly, a victim.

      When one has the opportunity to follow the career of a typical psychopath, his pattern of behavior appears specific—something not to be confused with the life of an ordinary purposeful criminal or of a cold opportunist who, in pursuit of selfish ends, merely disregards ethical considerations and the rights of others.

      This pattern, I believe, differs no less distinctly than the specific and idiomatic thought and verbal expressions of schizophrenia differ from those of the mentally defective and from other psychiatric conditions. Never in faults of logical reasoning, or in verbal confusion or technical delusion, but rather in the sharper reality of behavior, the psychopath seems often to produce something as strange and as obviously pathologic as the following statement taken from the letter of a patient with schizophrenia:

      “Financial service senses worries of 35 whirlpools below sound 1846, 45, 44, A.D. Augusta City treasur, Richmond County treasur, United States Treasur of Mississippi River flood area. Gentlemen will you come to… and idenafy none minastrative body that receives the life generated by fourth patented generative below sound. Further arrange financial credit for same. Would like two bedrooms at uptown Hotel and convenient to roof garden. Further what my occupation is you may as well announce me as comforting 35 whirlpools below sound. May you gentlemen have gray eyes and thick bones as the flat sense minastrated are very valuable in idenafying me.”

      Even such a relatively simple bit of word-salad stands out at once as indicative of profound and specific disorder within the writer. As in the words of the schizophrenic, so in the behavior of the psychopath there seems to work a positive knack for producing situations which can be accounted for only in terms of psychiatric illness which is unique.

      SECTION 2. THE MATERIAL

      Part 1. The Disorder in Full Clinical Manifestation

      CHAPTER 5. MAX

      This patient first came to my attention years ago while I was serving my turn as Officer of the Day in a Veterans Administration psychiatric institution. His wife telephoned to the hospital for assistance, stating that Max had slipped away from her and begun to make trouble again. With considerable urgency and apparent distress she explained that she was bringing him to be admitted as a patient and begged that a car with attendants be sent at once to her aid.

      He was found in the custody of the police, against whom he had made some resistance but much more vocal uproar. The resistance actually was only a show of resistance consisting for the most part of dramatically aggressive gestures while he was too securely held to fight and extravagant boasts of his physical prowess and savage temper. His general demeanor in this episode suggested the familiar picture of small boys, held fast by peacemakers, who wax ever more eloquently militant as the possibilities of actual conflict diminish.

      He came quietly with the attendants and on arriving at the admission ward was alert, self-assured, and boastful. Extolling his own mettle as a prizefighter, as a salesman, and as general good fellow, he was, nevertheless, friendly and even flattering toward the examining physician and the hospital.

      He was far from what could be called drunk. It would, in fact, be stretching a point to say he was “under the influence.” He had been drinking, it is true, but he knew well what he was doing and only by an impracticable flight of fancy could one attribute his behavior primarily to liquor.

      At the admitting ward of the hospital accompanying papers promptly revealed that the patient’s desire for treatment arose in consequence of some checks which he had forged in Spartanburg, S. C. He had been arrested and convicted but instead of being sent to jail an agreement was reached whereby he might come to the hospital for psychiatric treatment.

      His wife, his attorney, and representatives of a veterans’ organization pointed out that he had frequently been in hospitals for the treatment of mental disorder and maintained that he was not responsible for his misconduct.

      He seemed pleased to be at the hospital, was expansive and cordial, a little haughty despite his well-maintained air of camaraderie. Though a small man, only five feet six, he made a rather striking impression. His glance was fresh and arresting. His movements were quick, and he had an air of liveliness vaguely suggestive of a chipmunk. Though preposterously boastful, he did not show any indications of a psychosis.

      The hospital records showed that he had been a patient eight years