The Mask of Sanity. Hervey M. Cleckley

convictions and the sort of people who hold them, the more impressive becomes the old saying attributed280 to Artemus Ward and indicating that our troubles arise not so much from ignorance as from knowing so much that is not so. Hundreds of other examples like those above are available to demonstrate that many persons of high ability and superior education sincerely cherish beliefs which seem to have little more real support from fact or reason than the ordinary textbook delusion. Such beliefs are held as persistently by respected persons and influential groups, despite evidence to the contrary, as by psychotic patients who are segregated in hospitals.

      Let it be understood that X am not advancing an opinion that those who are persuaded by prophets that the world will end next Thursday or that those who appeal to faith healers to protect a child from the effects of meningitis, should be pronounced as clinically psychotic and forcibly committed to hospitals. Despite the similarity between the way such beliefs are adopted and the way a schizoid or paranoid patient arrives at his delusions, and despite the similar lack of evidence for considering either true, people such as those now under discussion are usually capable of leading useful lives in harmony with the community and sometimes of benefit to society. Nothing, in my opinion, is more basic than the necessity for men to allow each other freedom to believe or not to believe; however sacred, or however false, different creeds may be held by different groups.

      Convictions that the world is flat, that one must not begin a job on Friday, or that Mr. Arthur Bell of Mankind United168 is omnipotent, are apparently held by some in reverent identity with the deepest religious attitudes of which they are capable. In this basic sense, each man’s religion, as contrasted with the dogma or illusion in which he may frame it, his basic attitude and emotional response to whatever meaning and purpose he has been able to find in his living, deserves respect and consideration. The Methodist, the Mormon, and the Catholic, as well as the man who cannot accept any literal creed as a final statement of these issues, can honor and value, in a fundamentally religious sense, the valid reverence and the ultimate subjective aims of a good Mohammedan. This is possible without the ability to share his pleasant convictions about the likelihood of houris in paradise

      CHAPTER 2. TRADITIONS THAT OBSCURE OUR SUBJECT

      In raising general questions about personality disorder we have briefly considered (1) persons suffering from illnesses that progress to major mental disability and (2) the numerous citizens of our nation, many of them able and well educated, who hold beliefs generally regarded as unsupported by evidence and considered by many as irrational or even fantastic. Aside from these groups and aside from all types of patients recognized as psychotic, there remains for our consideration a large body of people who are incapable of leading normal lives and whose behavior causes great distress in every community.

      This group, plainly marked off from the psychotic by current psychiatric standards, does not find a categorical haven among the psychoneurotic, who are distinguished by many medical characteristics from the people to be discussed in this volume. They are also distinguished practically by their ability to adjust without major difficulties in the social group.

      Who, then, are these relatively unclassified people? And what is the nature of their disorder? The pages which follow will be devoted to an attempt to answer these questions. The answers are not easy to formulate. The very name by which such patients are informally referred to in mental hospitals or elsewhere among psychiatrists is in itself confusing. Every physician is familiar with the term psychopath, by which these people are most commonly designated.48 Despite the plain etymological inference of a sick mind or of mental sickness, this term is ordinarily used to indicate those who are considered free from psychosis and even from psychoneurosis. The definitions of psychopath found in medical dictionaries are not consistent nor do they regularly accord with the ordinary psychiatric use of this word.{‡}

      These definitions notwithstanding, the word psychopath is, in practice, popularly used for reference to a large group of seriously disabled people, listed with other dissimilar groups under the heading psychopathic personality. This cumbersome and altogether vague diagnostic category officially includes a wide variety of maladjusted people who cannot by the criteria of psychiatry be classed with the psychotic, the psychoneurotic, or the mentally defective, It is by no means uncommon in looking over the reports of a psychiatric examination to find conclusions listed as follows:

      (1) No nervous or mental disease.

      (2) Psychopathic personality.

      The broadness of the familiar diagnostic term and the conflicting attitudes of different psychiatrists toward those so labeled are reflected in the varying concepts it implies and in its plainly diverse referents.{§}

      Several decades ago, a large group of abnormalities, mental deficiency, various brain and bodily malformations and developmental defects, sexual perversions, delinquent behavior patterns, chronically mild schizoid disorder, etc., were all classed as constitutional psychopathic inferiority.106 After the ordinary mental defectives and most of the cases with demonstrable brain damage or developmental anomalies were distinguished, a considerable residue of diverse conditions remained under the old classification. Since many of these patients left in the group did not show evidence of congenital pathology and lifelong disorder, another term, constitutional psychopathic state, was devised.

      Many psychiatrists still prefer these two terms, which, in their abbreviated form (C.P.I. and C.P.S.), are used most often to designate psychopaths but literally refer to a good many other conditions at the same time.

      Talk about the C.P.I. and the C.P.S. still figures prominently in staff room discussion. It is not surprising that confusion flourishes and sharp differences of opinion prevail about what may be one or several subjects simultaneously.

      As time passed and psychiatric study continued, an increasing number of observers felt that the term constitutional was scarcely justified for some of the several disorders listed in the categories mentioned above. Eventually these were officially discarded in our country and psychopathic personality adopted, not only for the type of patient to be discussed in this volume, but for a good many others easily distinguished from him in life but only with difficulty in the nomenclature.

      In the revised Standard Nomenclature for Diseases of the Psychobiologic Unit, published in 1952, the familiar psychopathic personality has been discarded. In its place we find the category of personality disorders. These, distinguished in the revised nomenclature from psychotic disorders and psychoneurotic disorders, include, sometimes under slightly altered names, all the various pathologic states formerly placed in the category psychopathic personality.62

      At present many feel that all the conditions until recently listed under psychopathic personality are hereditary deficiencies, while others see little convincing evidence for this assumption.219 During the last few decades increasing attention has been paid to interpersonal and environmental factors or influences almost entirely ignored before the beginning of Freud’s work, and the tendency to attribute personality disorder wholly and simply to inborn defect has been less prevalent.

      Some time after the period during which it was generally assumed, by the physician as well as by the clergyman, that abnormal behavior resulted from devil possession or the influence of witches, it became customary to ascribe all or nearly all mental disorder to bad heredity. Even in the early part of the present century this practice was almost universal.181 Before relatively recent developments in psychopathology and before any real attempt had been made to understand the meaning and purpose of symptomatology, the invocation of inborn deficiency or “hereditary taint” was, it would seem, grasped largely for the want of any other hypothesis.

      Another factor contributing to the popularity of belief in hereditary causation lies, perhaps, in the fact that families of all patients in state hospitals were investigated and all deviations recorded. Most of these histories revealed aberrant behavior, if not in a parent or grandparent, at least in some great uncle or distant cousin. It is surprising that some investigators gave such little consideration to the fact that few men stopped on the street could account for all relatives and antecedents without also disclosing one or more kinsmen whose behavior would attract psychiatric attention.{**} This is not to say that there is no possibility