The Mask of Sanity. Hervey M. Cleckley

entity, it is hard to see how any student unfamiliar with the latter will profit by encountering it vaguely placed in a company of assorted deficiencies and aberrations which are by no means basically similar.

      It is my earnest conviction that, classified with a fairly heterogeneous group under a loose and variously understood term, a type of patient exists who could, without exaggeration, be called the forgotten man of psychiatry. If this patient can be presented as he has appeared so clearly during years of observation, if some idea can be given of his ubiquity, and, above all, if interest can be promoted in further study of his peculiar status among other human beings, I shall be abundantly satisfied. It is difficult to contemplate the enigma which he provokes without attempting to find some explanation, speculative though the attempt may be. Present efforts to explain or interpret are, however, tentative, and secondary to the real purpose of this volume, which is to call attention to what may be observed about our subject.

      CHAPTER 3. NOT AS SINGLE SPIES BUT IN BATTALIONS

      An attempt to determine the incidence of this disorder in the population as a whole is opposed by serious difficulties. The vagueness of officially accepted criteria for diagnosis and the extreme variation of degree in such maladjustment constitute primary obstacles. Statistics from most neuropsychiatric hospitals are necessarily misleading, since the psychopath is not technically eligible for admission and only those who behave in such an extremely abnormal manner as to appear orthodoxly psychotic (that is to say, as suffering from another and very different disorder) appear in the records. If legal and medical rules were regularly followed, statistics from state hospitals and from the federal psychiatric institutions would show no psychopaths at all. Let it also be noted that these institutions contain a vast majority of the patients hospitalized in the United States for mental disorder. Most statistical studies, therefore, cannot be regarded as even remotely suggesting the prevalence of this disability in the population.

      These facts notwithstanding, it is still impressive to note what the records of a typical psychiatric institution reveal.{††} Over a period of twenty-nine months 857 new patients were admitted to one federal hospital, where a staff of ten psychiatrists, including myself, classified them after careful examination and study. Of this group, 102 received the primary diagnosis of psychopathic personality, being considered free of any other mental disorder that could account for the difficulties that led to their admission. This group, comprising nearly one-eighth of all those admitted, indicates that the disorder is far from rare. The records also show 134 other patients classified under alcoholism or drug addiction who, I believe, for reasons brought out in the appendix, were nearly all fundamentally like those diagnosed as psychopaths, the addiction and other complications being secondary. If even one-half of these are considered as psychopaths, we arrive at a figure of 169, or almost one-fifth of the total.

      These statistics from one psychiatric institution cannot, of course, be taken as proof that the disorder is so prevalent everywhere. One must not overlook the fact, however, that each of these patients was accepted despite rules specifically classifying him as ineligible, and often as a result of conduct so abnormal or so difficult to cope with that he was considered a grave emergency. Another factor worth mentioning is the psychopath’s almost uniform unwillingness to apply, like other ill people, for hospitalization or for any other medical service. The survey at least suggests that these patients are common and that they constitute a serious problem in the average community and a major issue in psychiatry.

      I have been forced to the conviction that this particular behavior pattern is found among one’s fellow men far more frequently than might be surmised from reading the literature. If the nature of the disorder in question defines itself throughout the course of this work with sufficient sharpness and clarity to be recognizable as a pathologic entity, little doubt will remain that it presents a sociologic and psychiatric problem second to none.

      The man who develops influenza or who breaks his arm nearly always thinks at once of calling his doctor. The unconscious victim of a head injury is promptly taken by his family, his friends, or, lacking these, by casual bystanders to a hospital where medical attention is given. Persons who develop anxiety, phobia, or psychosomatic manifestations are likely to seek aid from a physician. Even those who demur and delay since they fear they will be called weak or silly because of symptoms commonly classed as psychoneurotic can be, and usually are, persuaded by their families after varying periods of reluctance to ask for help.

      Children, of course, often seek to avoid both the pediatrician and the dentist, despite the advice of parents. But the parent seldom fails, when need of treatment is a serious matter, in getting the child, with or without his willingness, into the hands of the doctor. Many patients ill with the major personality disorders we classify as psychoses do not voluntarily seek treatment. Some do not recognize any such need and may bitterly oppose, sometimes by violent combat, all efforts to send them to psychiatric hospitals. Such patients, however, are well recognized. Medical facilities and legal instrumentalities exist for handling the problem, and institutions are provided to accept such patients and hold them, if necessary against their own volition, so long as it is advisable for the patient’s welfare or for the protection of others.

      When we consider, on the other hand, these so-called psychopathic personalities, we find not one in one hundred who spontaneously goes to his physician to seek help. If relatives, alarmed by his disastrous conduct, recognize that treatment, or at least supervision, is an urgent need, they meet enormous obstacles. The public institutions to which they would turn for the care of a schizophrenic or a manic patient present closed doors. If they are sufficiently wealthy, they often consider a private psychiatric hospital. It should here be noted, also, that such private hospitals are necessarily expensive and that perhaps not more than two or three per cent of our population can afford such care for prolonged periods. No matter how wealthy his family may be, the psychopath, unlike all other serious psychiatric cases, can refuse to go to any hospital or accept any other treatment or restraint. His refusal is regularly upheld by our courts of law, and grounds for this are consistent with the official appraisal of his condition by psychiatry.

      Nearly always he does refuse and successfully oppose the efforts of his relatives to have him cared for. It is seldom that a psychopath accepts hospitalization or even out-patient treatment unless j some strong means of coercion happens to be available. The threat’ of cutting off his financial support, of bringing legal action against him for forgery or theft, or of allowing him to remain in jail, may move him to visit a physician’s office or possibly to enter a hospital. Subsequent events often demonstrate that he is acting, not seriously and with the understanding he professes, but for the purpose of evasion, whether he himself realizes this or not. He usually breaks off treatment as soon as the evasion has been accomplished.

      Since medical institutions refuse to accept the psychopath as a patient, and since he does not voluntarily, except in rare instances, seek medical aid, it might be surmised that prison populations would furnish statistics useful in estimating the prevalence of his disorder. It is true that a considerable proportion of prison inmates show indications of such a disorder.28, 161, 216 It is also true that only a small proportion of typical psychopaths are found in penal institutions, because the typical patient, as will be brought out in subsequent pages, is not likely to commit major crimes that result in long prison terms. He is distinguished by his ability to escape ordinary legal punishments and restraints. Though he regularly makes trouble for society, as well as for himself, and frequently is handled by the police, his characteristic behavior does not include felonies which would bring about permanent or adequate restriction of his activities. He is often arrested, perhaps a hundred times or more. But he nearly always regains his freedom and returns to his old patterns of maladjustment.

      Though the incidence of this disorder is at present impossible to establish statistically or even to estimate accurately, I am willing to express the opinion that it is exceedingly high. Certainly it is hundreds of times more common than poliomyelitis, and its results are usually more disastrous. On the basis of experience in psychiatric out-patient clinics and with psychiatric problems of private patients and in the community (as contrasted with committed patients), it does not seem an exaggeration to estimate the number of people seriously disabled by the disorder still listed under this ambiguous term as greater