The descriptive terms included in the third category apply in varying degrees to many of the patients discussed here, but these scarcely seem either broad enough or deep enough to be of value as diagnostic formulations.
Under one term, psychopathic personality, we find grouped many types of disorder. These disorders have very little in common. One thing that has been presumed about some of them, that is, that they are relatively trivial as contrasted with extremely disabling conditions, we grant, so far as schizoid personality, cyclothymic personality, and paranoid personality are concerned. This characteristic of being an incomplete degree of various sorts of disorder we deny as applying to the subject of this volume. Only by a manipulation of verbal abstractions can such disorders be identified with the specific disorder shown by those regularly called psychopaths.
In the 1952 revision of the Diagnostic and Statistical Manual14 we find the general term personality disorders used to designate all the various items formerly listed under psychopathic personality—all these and several more.
Personality disorders
Personality pattern disturbance Inadequate personality
Schizoid personality
Cyclothymic personality
Paranoid personality
Personality trait disturbance Emotionally unstable personality
Passive-aggressive personality
Compulsive personality
Personality trait disturbance, other
Sociopathic personality disturbance Antisocial reaction
Dyssocial reaction
Sexual deviation; specify supplementary term
Addiction Alcoholism
Drug addiction
Special symptom reaction Learning disturbance
Speech disturbance
Enuresis
Somnambulism
Other
Transient situational personality disturbance
Gross stress reaction
Adult situational reaction
Adjustment reaction of infancy
Adjustment reaction of childhood Habit disturbance
Conduct disturbance
Neurotic traits
Adjustment reaction of adolescence
Adjustment reaction of late life [p. 71]
In this long list of items, sociopathic personality disturbance, antisocial reaction, is thus defined:14
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. [p.38]
Here the familiar psychopath could be accurately and officially classified. It seems to me regrettably confusing that under the same general heading of personality disorders there were still listed such astonishingly unallied minor difficulties as learning disturbance, speech disturbance, enuresis, and somnambulism.
Since the 1952 revision of the psychiatric nomenclature just mentioned and since the fourth edition of the Mask of Sanity (1964) another revision of our official terminology was made. The following classifications is given in this latest revision (1968):15
V. PERSONALITY DISORDERS AND CERTAIN OTHER NON-PSYCHOTIC MENTAL DISORDERS (301–304)
301 Personality disorders
.0 Paranoid personality
.1 Cyclothymic personality (Affective personality)
.2 Schizoid personality
.3 Explosive personality
.4 Obsessive compulsive personality (Anankastic personality)
.5 Hysterical personality
.6 Asthenic personality
.7 Antisocial personality
.81 Passive-aggressive personality
.82 Inadequate personality
.89 Other personality disorders of specified types
[.9 Unspecified personality disorder] [pp. 9–10]
In this classification we find a more distinct place for our subject than in the earlier schemes of classification. Here the psychopath is officially designated as personality disorder, antisocial type, a recognizable entity in a fairly large group of different and distinct disorders.
It is perhaps in silent recognition of the absurdities that prevailed for so long in our official categories that psychiatrists in practice will avail themselves of the more or less slang term which is sort of nickname for our subject. When one psychiatrist on the staff of a state hospital, or at a meeting of the American Psychiatric Association, expresses to another some though he has about the psychopath, it is immediately and plainly understood that he is not making reference to schizoid disorder or to sexual deviation per se but to a disorder nearly all psychiatrists recognize and recognize as distinct from the heterogeneous mess of unrelated disorders with which it was for so long officially listed. There is nothing vague about these patients clinically. Their course of conduct can be predicted with much greater accuracy than that of patients with defined psychoses.
Attempts to discuss this type of patient and to use the approved term personality disorder in its official meaning were until recently likely to be neither clear nor accurate. In fact, it was difficult not to talk nonsense if one bore in mind all the things that term was recognized as including.
The currently approved category personality disorder, antisocial type, seems to offer an accurate term and to avoid the great confusion promoted by earlier schemes of classification. It is probable, however, that the older unofficial term psychopath will maintain its currency for a long time. All experienced psychiatrists are used to it, and few, if any, are likely to be misled by it.
Part II: 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.
The contrast with some surrounding types is so obvious that only a few points need be made. In discussing other disorders not so clearly defined and those traditionally confused with the psychopath, more extensive consideration is demanded. When there are important common characteristics between the two groups compared, it may be worthwhile to go into even more detail and bring out all features that can be helpful in delineating our subject. Only a few paragraphs or pages will be given to the discussion of some items that follow. To others which deserve it, a great deal more space will be devoted.
In Part II we shall consider the psychopath’s relation to the following subjects:
The psychotic
Patients with deviations recognized as similar to the psychoses but regarded as incomplete or less severe reactions
The psychoneurotic
The mental defective
The ordinary criminal
Other character and behavior disorders, including delinquency
Specific homosexuality and other consistent sexual deviations
The erratic man of genius
The unjudicious hedonist and some other drinkers
The Clinical alcoholic
The malingerer
Fictional characters of psychiatric interest
The psychopath in history
30. The Psychotic
For the sake of emphasis let us first contrast very b
riefly the psychopath with the general group of psychotic patients to which he is considered not to belong. These, if their disorder is well advanced, are usually recognized by the law as “insane” and by the man on the street as irrational, irresponsible, plainly unable to accept the general facts accepted by humanity at large, and, furthermore, unable to provide for themselves or to remain safely or conveniently at liberty among their fellows. Such people frequently have beliefs that are not only false but bizarre, inconsistent, and nearly always impossible to remove even by convincing demonstrations of their impossibility. Ready examples are the belief of a soda jerk that he is an emperor dead a thousand years ago, a belief still maintained although the patient admits he is living in the twentieth century and realizes that he is in a psychiatric hospital and that he grew up in the local slums, and the belief of an inconspicuous clerk that a worldwide organization has been formed to persecute him because of jealousy aroused by the fact that his testicles are pure radium.
Many of these patients hear voices speaking to them and cannot be made to see that these are imaginary. To the layman they are plainly not people to reason with or to be relied on but are obviously “demented.” It is apparent that they do and say foolish or fantastic things because their reasoning processes, not to speak of their perceptions, are gravely disordered or misdirected. Their general personality outlines are often distorted or sometimes even appear to be destroyed.
Patients in whom a milder psychosis exists usually show some of these specific peculiarities and always show general personality deviations which enable the psychiatrist eventually to place them in their proper classification. These patients with a milder disorder often are able to get along without serious difficulty in the community, just as a patient with mild influenza may not even go to bed whereas one with a severe attack may be delirious, unable to sit up, and finally die. These milder degrees of psychosis, however, show the same type of disorder found in the more severe and obvious manifestations, just as the mild influenza attack is the same in type but not in degree as the serious one.
It is perhaps worthwhile to add here that not all those suffering from a typical psychosis, even when the disorder is serious in degree, give an obvious impression of derangement. Severe paranoid conditions, particularly those of the most malignant type, may exist for years in persons who lack all superficial signs that the layman often feels should be apparent to establish psychosis (insanity).29,210
Sometimes such people appear not only normal but brilliant, and their powers of reasoning in all areas except those dominated by delusion are intact. The delusions themselves may even be withheld when the excellent judgment of the subject discerns that they will not be accepted by others or may interfere with psychotic plans toward which he is assiduously and ingeniously working. “Why, if I’d let the public in on these facts, a lot of fools might have thought I was insane,” one such patient explained. Another patient, who had for years been hearing imaginary voices which he accepted as real, admitted that he denied this to the draft board because, “They might have thought something was wrong with my mind.” He had been doing a satisfactory job and, on the surface, making a good social adjustment in his community. He was accepted for service in the army.
Another man with clear-cut paranoid delusions prospered for years by selling stocks and bonds to opulent widows and to others in whom his enthusiastic optimism and shrewd reasoning powers worked marvelous conviction. He was indeed persuasive, To my definite knowledge he induced a friend to believe that serious mental disorder threatened him, or was perhaps already present. Offering to help the friend, who naturally became alarmed, the paranoiac made arrangements for his hospitalization and, accompanying the other, had him voluntarily admitted to a psychiatric institution. After a period of observation the friend was found to be free of any such trouble. Months later the real patient’s delusional system was elicited and his commitment deemed necessary.
Even today one often encounters popular misconceptions of what constitutes psychosis or seriously disabling “mental disorder” that seem to belong to earlier centuries. Even when patients are speaking frankly and continually about hearing voices from the next county (or the next world), relatives occasionally express surprise at the opinion that anything could be wrong with his mind,” insisting that he had been running the store as well as ever, adding up the accounts without error, and showing his usual common sense in daily affairs.
Fanatics and false prophets who show real but not so obvious signs of classic psychosis, as everyone must by now have learned, sometimes attract hundreds or thousands of followers who contribute large funds to projects founded on delusion. If news reports by many observers can be relied upon, even those showing plain evidence of very serious disorder, persons as fully psychotic as many on the wards of the state hospitals, also succeed in appearing to large groups not only as sage leaders or men with supernatural powers but also as God.22,33
The psychopath, on the other hand, is free of all technical signs of this sort. There are no demonstrable defects in theoretical reasoning. At least he is free of them in the same sense that the general run of men and women are free. He carries out his activities in what is regarded as ordinary awareness of the consequences and without the distorting influences of any demonstrable system of delusions. His personality outline is apparently or superficially intact and not obviously distorted.
The diagnostic formulation psychosis with psychopathic personality, listed in the nomenclature that was official until 1952, deserves attention. Such a psychosis was thus defined by the Outlines for Psychiatric Examinations (1943):225
The abnormal reactions which bring psychopathic personalities into the group of psychoses are varied in form but usually of an episodic character. Most prominent are attacks of irritability, excitement, depression, paranoid episodes, transient confused states, etc … True prison psychoses belong in this group.
A psychopathic personality with a manic-depressive attack should be classed in the manic-depressive group and likewise a psychopathic personality with a schizophrenic psychosis should go in the dementia praecox group. Psychopathic personalities without episodic mental attack or psychotic symptoms should be placed in the group “without psychosis.”
In agreement with Cruvant and Yochelson,62 I cannot see that anything was gained through such a classification. If a psychopath develops some other disorder such as schizophrenia or affective psychosis, the additional disorder can be listed properly without recourse to such an appellation as that just mentioned. So, too, if transient confusional states occur, they may be so classified in the psychopath as in others.
Such a category promoted confusion by implying the presence of a specific psychotic illness different from, and in addition to, the psychopath’s essential disorder and that this, even if it is correctly listed as schizophrenia, or paranoid psychosis, needed the further qualification, “with psychopathic personality.” The transient confusional states considered by some as a characteristic reaction of psychopaths to imprisonment are usually trivial (minor) additions to or complications of the very serious, incapacitating disorder that is fundamental. Such manifestations might be compared with those of a schizophrenic patient who by chance also develops temporary delirium.
If the psychopath develops major or minor disorder of a type classed among “the psychoses,” it can be signified by addition of the usual term, just as it he had developed brain tumor or peptic ulcer. There seems to be neither need of nor warrant for a hybridizing concept which does nothing to clarify but a good deal to cloud the issues. I am not sure there was ever much more need for “psychosis with psychopathic personality” than for “psychosis with red hair” or “neurosis with a Ph.D. degree.” The current nomenclature appears better designed to avoid unnecessary confusions of this sort.15 Influences of the older terminologies, concepts, and classifications, however, probably still play a part in serious misunderstandings about the psychopath that have not yet been satisfactorily resolved
.
31. Deviations Recognized as Similar to the Psychoses but Regarded as Incomplete or Less Severe Reactions
As noted earlier, conditions resembling psychoses but appearing incomplete or less severe are still classified officially under the same general diagnostic term as the disorder to which this book is devoted. Such an arrangement has been approved by some as a means of placing together groups assumed to be on the borderline of serious disorder with a genuine similarity in degree if not in type. There is another argument in favor of using one term to identify these diverse clinical realities. This arises from efforts to distinguish as active disease processes the psychoses and psychoneuroses from other conditions presumed to be circumscribed defect states or relatively static deviations. It is true that some genuine similarities can be discerned here among many of the diverse conditions listed under personality disorders. These similarities have, it seems to me, been given an undue importance.
It is far from proved that pathologic conditions which we call schizoid personality or paranoid personality begin at birth and remain unchanged throughout life. There is a vast range of difference in chronicity, reversibility, severity, and prognosis, throughout the schizoid disorders and, indeed, throughout the paranoid and affective disorders also. Much would be gained both logically and practically if in out official nomenclature we could place all essentially schizoid disorders in an appropriate category and then make what further distinctions are useful as to transiency, chronicity, and degree. Since schizoid manifestations vary from rapid processes to maladjustments apparently static, from relatively mild deviations and disabilities to total incapacity and maximum personality disintegration, let us then reflect these facts in our language. As a matter of fact, as every psychiatrist well knows, in many patients an initial disorder of slow or rapid progress (disease process) becomes static or relatively static at widely varying levels of deviation from the normal. So too, it seems, we should deal with affective and paranoid disorders. Without minimizing the fact that schizophrenia is an illness, it is perhaps more profitable to conceive of it as a complicated distortion of the life process (or, as has been said, a way of life, albeit an extremely pathologic way) than as a circumscribed external agency that selects and falls upon its victim. Active and progressive schizophrenic illness probably arises out of tendencies and influences not unlike those which underlie the milder and more static distortions we label as schizoid personality.
The Mask of Sanity Page 35
