The Mask of Sanity

by Hervey Cleckley

  Vexation, spite, quick and labile flashes of quasi-affection, peevish resentment, shallow moods of self-pity, puerile attitudes of vanity, and absurd and showy poses of indignation are all within his emotional scale and are freely sounded as the circumstances of life play upon him. But mature, wholehearted anger, true or consistent indignation, honest, solid grief, sustaining pride, deep joy, and genuine despair are reactions not likely to be found within this scale.

  Craig60 said long ago that patients who suffer from hysteria do not react with awe, reverence, wonder, or pity. Often they do not, it might be said, appear capable of achieving in sincerity the major emotions, although their protestations of such emotions are prominent and their show of feeling is sometimes so vigorous that the observer is often misled to believe that they are in tragic grief or remorse. Although such a diminution of emotional range, especially along the deeper notes, may be seen in the patient with hysteria, in the psychopath it is very much more far-reaching, profound, and final. Even in the situations of squalor and misery into which he repeatedly works himself, when confined in jails and what he regards as lunatic asylums, after throwing away fortunes or catching and transferring gonorrhea to his bride—even under these circumstances he does not show anything that could be called woe or despair or serious sorrow. He becomes vexed and rebellious and frets in lively and constant impatience when confined, but he does not grieve as others grieve.

  Psychopaths are often witty and sometimes give a superficial impression of that far different and very serious thing, humor. Humor, however, in what may be its full, true sense,* they never have.43 I have thought that I caught glimpses of it in psychopaths and, despite a typical history, was inclined to question the diagnosis. Further observation of these patients gave convincing evidence that the apparent humor, like the apparent insight, was really an artifact.

  One might feel a superficial inclination to credit with humor the patient described under “The Psychopath as Scientist” who, after his lamentable marriage to the very unprepossessing streetwalker, laughed and admitted that the joke was on himself. At first glance such a reply might appear to be the valiant humor of a man who can smile in any adversity. And, indeed, it might be correctly judged as this if the speaker showed any evidence of feeling his adversity or accepting his responsibility. But in this instance the only convincing appraisal is that “he jests at scars who never felt a wound.” When the normal man makes a gay or ironic quip on the subject of his own adversity, we may justifiably applaud it as humor. If the quip concerns an adversity which scarcely touches the maker, it is as empty of humor as the empty boldness of a daredevil who wagers his fortune in a dice game where no one is playing for keeps.

  In such a discussion only personal opinions of what is real humor and what is not real humor can be expressed. Everyone’s capacity to appreciate or appraise such a quality varies, no doubt, as widely as one’s sense of what is beautiful.

  The emotional poverty, the complete lack of strong or tragic feeling universally found in all the psychopaths personally observed, has caused me considerable bewilderment in connection with frequent references in the literature to the powerful instinctual drives and passions said to be manifested in such people.79,128,156 Although weak and even infantile drives displaying themselves theatrically in the absence of ordinary inhibitions may impress the layman as mighty forces, it is hardly to be concluded that wise and deeply experienced psychiatrists would be similarly deceived. Perhaps such descriptions apply to other types of personality than that discussed here. And since, as I have already stressed, the present aim is to present a type of personality disorder well known and believed to be a clinical entity rather than to argue about names, efforts will be limited to describing and trying to interpret the material at hand.

  In considering the general shallowness of affect common to all members of this series in connection with their incapacity for object love, there is temptation to wonder about the possible interdependence of these facilities. Is it possible for tragic or transforming emotion to arise in any person without that peculiar and indescribable personal commitment to another? Or, if not to another human being, at least to some abstraction well outside the self?

  55. Specific Loss of Insight

  In a special sense the psychopath lacks insight to a degree seldom, if ever, found in any but the most seriously disturbed psychotic patients. In a superficial sense, in that he can say he is in a psychiatric hospital because of his unacceptable and strange conduct, and by all other such criteria, his insight is intact. His insight is of course not affected at all with the type of impairment seen in the schizophrenic patient, who may not recognize the fact that others regard him as mentally ill but may insist that he is the Grand Lama and now in Tibet. Yet in a very important sense, in the sense of realistic evaluation, the psychopath lacks insight more consistently than some schizophrenic patients. He has absolutely no capacity to see himself as others see him. It is perhaps more accurate to say that he has no ability to know how others feel when they see him or to experience subjectively anything comparable about the situation. All of the values, all of the major affect concerning his status, are unappreciated by him.

  This is almost astonishing in view of the psychopath’s perfect orientation, his ability and willingness to reason or to go through the forms of reasoning, and his perfect freedom from delusions and other signs of an ordinary psychosis.

  Usually, instead of facing facts that would ordinarily lead to insight, he projects, blaming his troubles on others with the flimsiest of pretext but with elaborate and subtle rationalization. Occasionally, however, he will perfunctorily admit himself to blame for everything and analyze his case from what seems to be almost a psychiatric viewpoint, but we can see that his conclusions have little actual significance for him. Some of these patients mentioned spoke fluently of the psychopathic personality, quoted the literature, and suggested this diagnosis for themselves. Soon this apparent insight was seen to be not merely imperfect but a consistent and thorough artifact. Perhaps it was less a voluntary deception than a simulation in which the simulator himself fails to realize his lack of emotional grasp or that he is simulating or what he is simulating. The patient seems to have little or no ability to feel the significance of his situation, to experience the real emotions of regret or shame or determination to improve, or to realize that this is lacking. His clever statements have been hardly more than verbal reflexes; even his facial expressions are without the underlying content they imply. This is not insight but an excellent mimicry of insight. No sincere intention can spring from his conclusions because no affective conviction is there to move him.

  Such a deficiency of insight is harder to comprehend than the schizophrenic’s deficiency, for it exists in the full presence of what are often assumed to be the qualities by which insight is gained. Yet the psychopath shows not only a deficiency but apparently a total absence of self-appraisal as a real and moving experience. Here is the spectacle of a person who uses all the words that would be used by someone who understands, and who could define all the words but who still is blind to the meaning. Such a clinical picture is more baffling to me than any of the symptoms of schizophrenia, on which attempts have been made to throw some light by psychopathologic theories.79,89,129,269 Here we have a patient who fulfills all the ordinary theoretical criteria of a “sound mind,” and yet with this apparently sound mind is more incomprehensible than the psychotic patient.

  What I regard as the psychopath’s lack of insight shows up frequently and very impressively in his apparent assumption that the legal penalties for a crime he has committed do not, or should not, apply to him. This astonishing defect in realization often seems genuine, as the patient protests in surprise against the idea that prison might be anticipated for him, as for others under similar circumstances. He frequently reacts to such an idea as if to something unexpected and totally inappropriate. This characteristic has already been mentioned in Chapter 18, Gregory.

  S
ome observers believe that what the psychopath expresses about himself and his situation constitutes insight and merits such a term. I cannot agree with this opinion. The chief and most valid connotations of the word disappear in such an application. Profoundly psychotic patients whose gross lack of insight would be admitted by all sometimes express opinions which, if fully meant and appreciated, would indicate an insight that is plainly not there. A few brief examples may help:

  A young man with a very active manic psychosis was interviewed some years ago. He whistled, shouted, winked, expressed the belief that he controlled the movements of the sun by his glance, sang snatches of bawdy songs, announced himself as a “sort of Messiah,” and laid claim to the sexual vigor of seven bulls. Leaping about in a hospital shirt he had torn almost to shreds, he found exposed wires at a place on the wall from which he had torn the electric fixtures.

  Seizing and releasing them and seizing them again, he got good jolts of the city current, which he relished, apparently interpreting the sensation as a manifestation of his own vitality. When asked if he felt anything was wrong with him mentally, he shouted in glee, “Sure, Doc, I’m crazy as a coot! I’m nuts I tell you. Crazier than anybody you ever saw!”

  Another patient on a closed ward, a man badly disabled for years by obvious schizophrenia, often shouted out to the passerby, “Simple case of dementia praecox, Doc, simple case of dementia praecox,” pointing to himself several times. Despite the chance diagnostic accuracy of what he said, this patient, like the one just mentioned, had little grasp of his situation and almost no real appreciation of his disorder and its meaning. Another manic patient not only spoke words that correctly indicated a good deal about his situation but even hammered out with a metal object he had obtained these letters in deep gashes in the wood door: “Bug house nutty.”

  Indications of serious impairment of insight abound in the psychopath’s reactions after his failures have been undeniably demonstrated or his antisocial acts detected. The persistent tendency to ask for recommendations from those they have every reason to know cannot furnish anything but a negative report fatal to their plans has been illustrated. Such decisions in highly intelligent people can hardly mean less than that something crucial is absent from the realization of their status.

  The calm assurance with which they report a successful rehabilitation in the midst of egregious and immediate maladjustment often does not seem so much a real effort to deceive as an indication that the patient himself is greatly deceived. Despite his awareness of major facts, the pivotal significance of these facts seems not to be in his evaluations.

  After a peculiarly overt and spectacular succession of failures, thefts, truancies, falsehoods, and expulsion from school, a young man had to be sent home to a distant state by his aunt and uncle with whom he had been staying. They had taken him in the hope that he might do better in another environment. His parents, after years of struggle, had found no solution.

  All the details of his recent failure and disaster were factually known to him and had been discussed with his aunt and uncle. They made no effort to deceive him about why he had to be sent home. The physician to whom he wrote the letter which follows had also been frank with him. The letter was mailed a couple of days after he returned in what to another person could not have seemed less than total failure and disgrace.

  Dear Doctor:

  Arrived home safe and sound. I really was astonished at the great change in this small, typical, mid-western town when I pulled into it on Sunday … I’m getting on fine here with Mother and Father. I feel like a different fellow. Dr.______ I don’t know how I’ll ever thank you for what you did for me down there. It was my chance to straighten out and I took it. I believe I can say I did a good job of it. I don’t know whether I could have done it alone. But the main thing is it’s done and I want you to know I appreciate your help.

  Well, I have to go now…

  He also mentioned in other correspondence that he was helping his brother, who had shown some delinquency, to see the light, explaining that if he himself had been able to do such a thorough job the brother might profit and direct himself by the example, might, indeed, pull himself together, and “be a real man too.” While writing to this effect, he continued the typical behavior without modification.

  Let us consider a man whose wife, after many years of struggle equal to that of others discussed in some detail here, had left him and was seriously considering divorce. It is difficult to imagine a situation in which the necessity of permanent separation could be more clear or imperative. Nor is it likely that any patient described here has given a marital partner more reason to feel this need or has more fully demonstrated that, no matter what he said, he would continue to behave, toward her and in general, just as he had since their marriage. A few excerpts from his letters to the wife are illuminating:

  … You will never be happy either by yourself or with some other man … we have too much in common … I have no reason to lie or to misrepresent things to you now, even though I did try to explain it to you before … There’ll be another day, so I’m told and believe, and even though I don’t expect to get proper judgment here on earth from you and yours I will up there and if I’m wrong I’m willing to suffer for eternity … I do love you. I’ve never loved anyone else since childhood … If I kill myself my blood will be on your hands … it will be heavy on your heart and soul … All wrongs will be righted on Judgment Day … You should have stuck by me—should never have left me … I’ve suffered now really more than I can stand … You think it will bring you happiness to be rid of me … I sincerely hope and pray that it does if you do such a thing. I wish I could feel likewise … and believe everyone is at fault but me.

  There is more in all this than simply false promises and fraudulent efforts to persuade the wife not to get a divorce. There is also indication of inability in his fundamental reactions to size up normally what he has done, what he is, and what he has been.

  56. Unresponsiveness in General Interpersonal Relations

  The psychopath cannot be depended upon to show the ordinary responsiveness to special consideration or kindness or trust. No matter how well he is treated, no matter how long-suffering his family, his friends, the police, hospital attendants, and others may be, he shows no consistent reaction of appreciation except superficial and transparent protestations. Such gestures are exhibited most frequently when he feels they will facilitate some personal aim. The ordinary axiom of human existence that one good turn deserves another, a principle sometimes honored by cannibals and uncommonly callous assassins, has only superficial validity for him although he can cite it with eloquent casuistry when trying to obtain parole, discharge from the hospital, or some other end.

  As in attempting to delineate other aspects of the psychopath, we find ourselves again confronting paradox. Although he can be counted on not to be appreciably swayed in major issues by these basic rules, we often find him attentive in small courtesies and favors, perhaps even habitually generous or quasi-generous when the cost is not decisive. Occasionally his actions may suggest profound generosity in that large sums are involved or something presumably of real value is sacrificed. Usually, however, these appearances are deceiving.

  The psychopath who squanders $1,000 on a lady of the night usually seems not to share very actively in the distressing worry and deprivation that his wife and children (or his parents) may experience quite substantially. The motives of a boy at boarding school who casually sells his new clothes to buy candy bars and Coca-Colas (for the whole dormitory) seem to lack an important dimension of magnanimity. This dimension could be presumed if after his extravagance the boy set to work assiduously in efforts to carry the burden he had created.

  In relatively small matters psychopaths sometimes behave so as to appear very considerate, responsive, and obliging. Acquaintances who meet them on grounds where minor issues prevail may find it difficult to believe that they are not highly endowed with gratitude and eager to s
erve others. Such reactions and intentions, although sometimes ready or even spectacularly facile, do not ever accumulate sufficient force to play a determining part in really important issues. The psychopath who causes his parents hardship and humiliation by repeatedly forging checks and causes his wife anguish by sordid (and perhaps halfhearted) relations with the housemaid, may gain a considerable reputation in the community by occasionally volunteering to cut the grass for the frail old lady across the street, by bringing a bottle of sherry over now and then to bedridden Mr. Blank, or by leaving his work to take a neighbor’s injured cat to the veterinarian.

  Outward social graces come easy to most psychopaths, and many continue, throughout careers disastrous to themselves and for others, to conduct themselves in superficial relations, in handling the trivia of existence, so as to gain admiration and gratitude. In these surface aspects of functioning, the typical psychopath (unlike the classic hypocrite) often seems to act with undesigning spontaneity and to be prompted by motives of excellent quality though of marvelously attenuated substance.

  57. Fantastic and Uninviting Behavior with Drink and Sometimes Without

  Although some psychopaths do not drink at all and others drink rarely, considerable overindulgence in alcohol is very often prominent in the life story. Delirium tremens and other temporary psychoses directly due to alcohol were not commonly found in the hundreds of patients observed by me.

  The view of some professional moralists to the effect that demon rum is the fundamental cause of disaster such as that of the psychopath appears to have little claim to validity. It has been pointed out already that an irreconcilable difference in primary aim appears to exist between the ordinary person who drinks too much and the psychopath. This may be restated briefly as follows: The ordinary drinker gets into trouble by drifting with enthusiasm into the opinion that if two or six or eight drinks have made him feel so good, another (or two more or perhaps five more) will make him feel just so much better. Such rationalizations may assist the normal drinker, especially if he has serious fundamental conflicts, in a progress toward becoming a neurotic drinker or toward an alcoholic breakdown.