The Mask of Sanity

by Hervey Cleckley

  In many important respects it seems to me that the person who is called a psychopath or antisocial personality differs greatly from most people showing a schizoid, paranoid, or cyclothymic disorder or deviation in degree short of psychosis and in whatever state of chronicity. The psychopath varies not only in type but also in the severity of his specific disorder, which can range from a mild or borderline degree that allows him to conduct a relatively normal and acceptable life up through great degrees of disability. There are also behavior patterns of this sort which prove to be temporary.

  It will perhaps be worthwhile to consider briefly an example from the secondary group distinguished under various subheadings (schizoid, cyclothymic, and others) and officially classed with the psychopath in a primary pigeon hole labeled personality disorders.

  Well qualified for the diagnosis of schizoid personality is a 19-year-old boy whom I treated on several occasions. I would prefer to call his reaction one definitely schizoid in nature, very chronic and relatively static, and lacking most clinical features by which disorders otherwise similar are recognized as constituting “a psychosis.” The first point that stands out in this patient is how obviously he differs from all psychopaths. On meeting him, it is immediately seen that he is a lonely person, one recognized as queer by all who encounter him. In discussing his recent attempt at suicide, he could give no good reason for his act. No evidence of depression was obtained, As if not knowing what else to say, he suggested he must have tried to kill himself “just out of curiosity.” He had no positive convictions about a future life or interest in exploring such possibilities. He had been making good grades at college and he had no worries that he could express. His attempt at suicide had been authentic. Only by chance had he been discovered where he hung in a noose made by his belt. No evidence of delusions or hallucinations was ever elicited, A few excerpts from a report given by the college physician, who spent much time with him, are contributory:

  Oliver was recognized as a bit odd or eccentric since his coming here during the summer weeks of 19--. He worked quite willingly with sustained effort and application. Everyone liked him and although they protested his persistent pipe and untidy personal appearance (being unshaven, lax about clean garments and combed hair), they were amused and tolerant. He had the reputation of having superior intellectual capacity and that gave him the aura of a potential winner. The students included him in everything and he was a conflicting mixture of pathetic eagerness to be accepted as one of them and to be the lone wolf. He went through the motions of being one of the group but it all had to be within the boundaries of his own withdrawal pattern. Though unresponsive in regard to greetings and small talk, he would talk for hours about himself and his ideas and was eager for such expression.

  Girls interested him less. Actually, though he protested that he had an average interest in the other sex, he had very few dates with them. However, very recently he groomed himself quite adequately and went to Foxbridge to visit a girl whom he used to date during his high school days and who is studying journalism there.

  It was noted and accepted by everyone that Oliver would argue every point, in class and out, but much good-natured teasing caused him to restrain himself somewhat in this respect. However, I have noted in all my contacts with him a persistent negativistic attitude. He prided himself on always taking the opposite point of view and that his philosophy was quite peculiar to himself. He expressed a resentment of everything “expected” of him by way of the simplest courtesies and social amenities of any kind.

  He is sure that there is nothing neurotic about himself and mentioned doctors and nurses other than yourself who have told him that they thought him to be all right. He exhibits an attitude toward his hospitalization quite similar to that toward his attempted suicide. His defense is thick and strong and he reacts with argument or denial to almost anything which is said which seems to imply that all is not quite as it should be with him. He said that you had told him that he would need some help and had better come to see me every few days. He thinks that is not necessary and I think he is right, for I can see no way to approach him even on the outskirts of his problem without stimulating a negative reaction on his part. I noted that same lack of insight as you, and it is so complete as to bar any psychotherapeutic relation. I left the way open for him to come at any time and I will indeed help if I can.

  This fragment from Oliver’s personal notes also brings out something about his state that is difficult to describe in any other way I know:

  Loneliness

  By

  Oliver ______, Jr.

  It is now long after the hour of midnight. I am alone, except for my pipe and my ever-active mind, in one of the front rooms.

  God has created many horrible things, but the greatest of all those monsters is that intolerable loneliness that man calls Love, Sex, Self Pity, Comradeship, und so weiter. I trust that you, as an individual, shall be able to grasp some vague notion of what I, as a purely abstract thinking-apparatus, am trying to convey to you.

  Nothing in a State of Nothingness. Can you imagine a more comforting place? No emotions of fear, love, hate, anger, sympathy, pity. No materiality! No spirituality! No mentality! Nothing! The Hell of the Bible! The Heaven of the Bible! Paradise! Purgatory! and the Inferno! — all One!! All nothing!!!

  Have you ever really delved deeply into why, for what purpose you were born or why anyone was born? To bear children? Yes, but dogs can do that gracefully. To build? To make money? You must leave all behind when you depart. You are unable to carry it with you.

  The epicureans had a good idea when they said, “Eat, drink and be merry, for tomorrow we may die.” But why eat, drink, and be merry? Why should one live, or the animals which are so very close below us? There is no God; there is no Heaven; there is no Hell; these are the dreams of baby minds. The Church, the Bible, Science, Spiritualism, and on and on and on can offer not a solitary shred of evidence that there is a God, Heaven, Hell, Devil, Angels. They are but wistful thinkers—the Church, the Bible, and Spiritualism. They are the idealists. Scientists are the realists, but they study nature. Why build machines? What can it matter to you personally one hundred years from now? You will be nothing. Nothing.

  Am I insane? They say I am because I ask, “Why?” and there is no answer to that by anyone. “What?” can be answered. So can “When?” “Where?” “Who?” “How?”

  et cetera, but not “Why?” Healthy minds do not ask, “Why?” Normal people sleep and love, eat and drink, breathe and excrete, work and, perhaps, think—think, but only a little and only within the bounds of conventionality.

  —Oliver

  This boy frequently writes letters to the newspapers commenting on such topics as politics, art, religion, and history. There is usually a bitterness in his comments and a kind of wit that seems to leaven his isolation. The brittle strangeness of manner, the inadequateness and inappropriateness of his affective reactions can only be appreciated in direct contact. An excerpt from one of his letters to the newspaper follows:

  It was just a fairly good “B” picture. There was nothing in it that I had not seen numbers of times before at the cinema. I did not think it dirty. I thought it to be just what it was—a literally cheap movie.

  Artists only would have banned it. On the other hand, I found the decidedly wicked picture, “The Outlaw,” to be the funniest screened attraction I’d ever seen (I saw it on my return trip in Atlanta). It caused more laughs than “Kiss and Tell.”

  Miss Smith, please find your glasses! My morals are evaporating!

  Oliver _________ Jr.

  At the end of a letter to his father he signs himself,

  With a heart of gold (hard and yellow), I close,

  Your oldest son,

  Oliver _, Jr.

  This is a person who, despite his superior intelligence and his awkward gestures at being sociable, is recognized at once as extremely eccentric, if not indeed bizarre, by his classmates as well as by the exper
t. Evidence of his psychiatric trouble is apparent, and no trained observer would confuse him with the psychopath. A history is not necessary to surmise that he has had difficulties and that further difficulties lie ahead. Although his personality is not outwardly fragmented, it immediately gives clues to the fact that here experience is not what others find it. Such a patient sometimes gives the impression that through him one comes in closer touch with what is most specific and inexplicable in schizophrenia, what is usually blurred or hidden in the chaos of the overt psychosis. Superficially nothing could be more different from what he presents than the socially smooth psychopath who has an explanation for everything, an easy cordiality for everyone. His bitterly authentic seriousness and his capacity for hurt and suffering also contrast with the psychopath.

  In many patients the disturbance classed as schizoid personality might be more accurately regarded as masked schizophrenia or, as has been sometimes said, “ambulatory” schizophrenia. Although the more gross technical signs of psychosis are not evident on the surface, many of these patients have a very serious disorder within. The tendency to call their condition schizoid personality (and therefore label them as definitely “sane”) sometimes results in their being incorrectly treated. Very dangerous tendencies, well concealed, may emerge into tragic acts.

  Some years ago a young woman regarded as seclusive, a bit queer, and withdrawn by her acquaintances called a big-league baseball player to her hotel room on the pretext of grave and urgent business. The business was not what might be expected from such a call by a young woman to a man whom she had never met personally but had seemed to admire, hero-worship, and brood over for a long time in yearning fantasies. According to newspaper accounts, the girl, with no explanation or reason she could explain afterward, shot the ballplayer in a genuine attempt to kill him and one which barely failed to do so.

  I cannot offer a diagnosis on this patient whom I have never seen. Her behavior and her personal characteristics as disclosed in the press are, however, entirely typical of patients with masked but real and serious schizoid disorder. Such patients are perhaps more accurately indicated by the term “masked schizophrenia” than by “schizoid personality,” which may, artificially and unrealistically, ignore the true state of very ill and dangerous persons and classify them with those presumably deviated in mild degree.

  Some patients of this sort eventually show themselves to be psychotic, and it then becomes apparent that a serious inner disorder has, perhaps for many years, been masked by the minor overt peculiarities that constitute what is generally regarded as schizoid personality. Sometimes in patients with masked schizophrenia the serious inner pathology is so well concealed that the patient may be almost indistinguishable from the typical psychopath. It is important to keep in mind that the excellence of the superficial aspect of the patient (whether he be called a masked schizophrenic or a psychopath) gives no reliable indication of how serious the inner, concealed, and at the time undemonstrable pathology may prove to be or how disastrously and unpredictably it may be expressed when it erupts into disastrous antisocial behavior. Like the very dangerous and profoundly ill ambulatory schizophrenic patient whose central disorder is well masked and not yet demonstrable, the psychopath has a concealed but very real and grave pathology. Unlike other types of masked psychosis, the central personality “lesions” of the psychopath are not covered over by peripheral or surface functioning suggestive of some eccentricity or peculiarity of personality but by a perfect mask of genuine sanity, a flawless surface indicative in every respect of robust mental health.

  The example of schizoid personality or masked schizophrenia just presented under the pseudonym Oliver is obviously distinguishable from the psychopath. His outer aspect contrasts vividly with the smooth and deceptive disguise of the typical psychopath. There are, however, other masked schizophrenics who resemble the typical psychopath much more closely. I have seen a number of patients who were classified by able and experienced psychiatrists as typical psychopaths (antisocial personalities) and by others, equally able, as very well-masked schizophrenics. About these patients the difference of judgment lay in estimates of how effectively the surface function masked the inner disorder and gave an appearance of full health. There was usually no disagreement in the conclusion by all the psychiatrists that an underlying disorder was severe and maximally disabling. The deceptive qualities of the excellent disguise, the perfection of the mask, afford no reliable indication that the true condition is mild or moderate and no assurance that it may not be far more serious than the disability of some patients in whom auditory hallucinations and bizarre delusions can be readily demonstrated.

  It is perhaps pertinent to mention here that there are other disguises behind which other serious personality disorders mislead us. Chamberlain54 was among the first who ably emphasized what he refers to as cryptic depression. Patients so affected may complain only of headache, nausea, a pain in the back, or weakness. On repeated questioning, some will admit depression as a minor element in the situation. Others will deny it convincingly and show no evidence of it. I have seen many such patients in whom the history of previous depressive psychosis, many details of the patient’s personality, and the prompt response to electric shock therapy give indirect but convincing evidence of the invisible illness. Here it might be said that the potentially more serious condition appears only in a substituted reaction that seems to constitute a compromise or a disguise.

  Under the term pseudoneurotic schizophrenia, Hoch and Polatin137 discuss what every psychiatrist has often encountered—the patient who gives one the feeling that he must be a schizophrenic but in whom none of the specifically characteristic features of psychosis can be demonstrated. Often the only complaints are of vague or minor physical discomforts. Sometimes other features that literally indicate a psychoneurosis, and this only, constitute all that can be brought out. Such patients do not express delusions. They deny hallucinations and show no disorder of thinking as this is ordinarily described and no mannerisms or bizarre overt attitudes. They are never grossly irrational in what they express. The history does not show them psychotically deviated in their general behavior until, perhaps, some irreparable psychotic act occurs. Their lack of insight (broader and more profound than in the psychoneurotic patient) and a peculiar emotional deficit and distortion make the examiner realize, without being able to prove it, that he is dealing with schizophrenia. At length the examiner becomes convinced that these patients do not normally experience and evaluate the basic issues of life and that this difference is of the sort and degree not found except in schizophrenia. Some of these people eventually develop delusions and hallucinations, but many go on year after year fully masked by the psychoneurotic facade.

  The patient who is seriously schizophrenic but whose basic disorder is masked by the outer appearance of neurosis or by what seems to be only minor eccentricities or schizoid traits can nearly always be readily distinguished from the true psychopath. As mentioned previously, however, there are sometimes masked schizophrenics whose outer appearance is more like that of the true psychopath.

  Guttmacher discusses these patients in a very interesting paper and designates them by the term pseudopsychopathic schizophrenia.106 The type of patient discussed by Guttmacher may appear for many years to be a typical psychopath and show all the features in his behavior that are characteristic. Some of these patients do not show the outer eccentricities and oddnesses that usually distinguish the masked schizophrenic. Occasionally they may be almost as outgoing, charming in manner, and almost as free from apparent abnormality as the classic psychopath. As pointed out by Guttmacher, sometimes such a patient will eventually develop a full-blown and obvious schizophrenic psychosis.

  It might be argued that the psychosis has developed independently of the psychopathic defect, but I think it much more likely that a serious central disorder was present all the time and that eventually it has become manifest through the disruption of the formerly perfect superfici
al function and outer appearance. Such developments as these lead me to believe not only that the central disorder in the psychopath may perhaps be similar in degree to that in schizophrenia but also that there may be more similarity in quality than is generally recognized.

  An interesting comparison between thoroughly masked schizophrenia and the disorder of the psychopath can be found in the fictional characters Judd Steiner and Artie Straus as they are presented by Meyer Levin in his novel Compulsion.181 Judd Steiner, the fictional representative of Nathan Leopold, gives a strong impression of a deep schizoid disorder masked by generally sane behavior and great intellectual brilliance. Artie Straus, who is modeled on the novelist’s conception of Loeb, emerges in the book as a remarkably well-drawn figure of the classic psychopath. The author admits that his fictional characters are not necessarily true interpretations of the actual characters whose utterly unprovoked sensational murder of a teenaged boy startled and horrified the world in 1924. This long deliberated and ingeniously planned murder for a thrill suggests a callousness and cynicism that are difficult to describe and still astonishing to contemplate. Both the similarities and the differences between Judd and Artie are wonderfully and convincingly conveyed by Levin in his book and should stimulate interest in everyone concerned with the basic problems of psychiatry.