The Mask of Sanity

by Hervey Cleckley

  We need not assume Head’s interpretation of the aphasias to be entirely and finally correct if it will by analogy help us formulate and clarify a concept of personality disorder, a concept in which the deeper and less obvious levels of function can be compared and contrasted with more superficial aspects of behavior. Let us use the analogy not as evidence for the concept but only as a means of stating it.

  Let us consider several familiar types of psychiatric illness with this aim in mind. The patient with a toxic-delirious psychosis (for example, delirium tremens) shows a maximum of disorder in his superficial aspect. He may not recognize his whereabouts and may scream at nonexistent monsters or belabor the empty air with a broomstick to fight off poison-spitting bugs a yard long which he sees pursuing him. As he leaps over the bed or brandishes a chair, wild-eyed, disheveled, and half-clad, any layman ran recognize him as ill and no doubt admit his disorder is mental (that he is “crazy”). Nothing conceals his psychosis. Delusions, hallucinations, confusion, loss of basic orientations, and irrational conduct are obvious everywhere in his immediate area of contact with the surroundings. Despite the spectacular impressiveness of his manifestations, he is very likely to recover, perhaps in a few days. Although intense, his pathology is in some respects relatively superficial.

  On the other hand, the hebephrenic patient sometimes maintains excellent orientation and calmness. Despite hallucinations and delusions which he often keeps largely to himself, he may carry on clerical work without supervision and do so logically and effectively. It is not difficult for the physician to demonstrate convincing evidence of his grave disorder, but this is usually less obvious, less vivid peripherally, let us say, than in the first example. As a matter of fact, the uninformed layman (especially if a close relative) will sometimes insist for a while that “it can’t be his mind, Doc, it must just be his nerves.” Members of the family may argue that because he has kept his accounts straight at the store where he worked and showed intelligence about other matters, he must have a relatively minor psychiatric disorder. The outer form of normal behavior may be much better preserved in such a patient than in one with delirium tremens despite the fact that beyond this relatively thin functional shell the basic foundations of his personality are in chaotic devastation, and despite the fact that his disorder is maximally malignant, extending deeply into the core of his being.

  A patient with early paranoid schizophrenia is likely to be free of those outer manifestations of mental illness that distinguish the hebephrenic. His reasoning powers may be truly excellent, his emotional reactions appropriate, and his general behavior effective. It might be difficult indeed to find any point at which we can truthfully say his abilities, in the ordinary sense, are impaired by disease. He may be a brilliant and delightful companion at a dinner party and may discuss politics, business, or philosophy with high intelligence and learning. Well concealed beneath all this exterior functional perfection is a serious disorder which may influence him to direct his unblemished talents toward useless or highly undesirable goals or perhaps to carry out, conscientiously and effectively, disastrous antisocial aims. If we consider personality function somewhat as we did the more circumscribed function of speech, we might say that what is pathologic or defective in the paranoid patient must be more centrally situated, more difficult to discern or to demonstrate from the outside. Yet such a disability is not mild. It is as real and often as serious as hebephrenia. Some paranoid patients, particularly those with paranoia vera, show no signs at all of psychiatric impairment that can be demonstrated regularly. If brought to the courts, they may successfully establish their sanity before judge and jury, sometimes excelling their medical and legal examiners in the exercise of reason. Not rarely they attract supporters or disciples in the community who enthusiastically follow their advice. In such patients, despite the impressive outer layers of unimpaired function, psychosis is genuine and severe.

  The delusions of some paranoiacs are circumscribed—confined to conviction about what is indisputably possible or even plausible. A man may, for instance, believe his wife is unfaithful. Sometimes it is difficult to prove objectively that this belief is a delusion rather than a sane mistake, or, indeed, a fact. The pathologic substructure or inner lesion, so to speak, which gives rise to his delusion is not directly accessible to our scrutiny. From that point out, we might say, he behaves rationally. His functions peripheral to this disturbed level may proceed sanely and effectively.

  The delusional belief in paranoia, although often not intrinsically absurd or irrational, allows the trained observer to realize eventually that such a patient is psychotic despite the unimpaired operation of his exterior functions. This psychosis is extremely well disguised by the covering layers of sanity. The delusion, once it is recognized, gives us a reliable clue to the extremely serious disorder beneath, somewhat as specific notes in the percussion of a chest reveal indirectly to an internist the presence of a lung cavity despite the unmarred exterior of the body.

  In some cases of schizophrenia no delusion or other manifestation technically indicative of psychosis can be elicited. In contrast with paranoia, not even one circumscribed but distinct clue can be offered by the examiner as evidence of a true mental disorder. Under such terms as simple, masked, or ambulatory schizophrenia many of these cases have been described. The psychiatrist who recognizes the psychosis in such a patient is often at a loss to explain his conclusion. He senses a peculiar emotional deficit and distortion and is able to realize that the person does not normally experience and evaluate the basic data of life and that this deviation is of the quality and the degree characteristic of schizophrenia. Let us not deny that the psychiatrist may sometimes erroneously come to such a conclusion. He must rely on a clinical judgment, not on objective scientific evidence. The experienced wine taster may, it is said, detect that his beverage comes from grapes grown on the east rather than the west side of some hill in Touraine. Experts may reliably distinguish in an obscure painting the hand of Benozzo Gozzoli from that of a talented imitator. Perhaps few psychiatrists develop so sure and fine a knack of diagnosing schizophrenia in these cryptic cases. It is true, nevertheless, that experience sometimes enables them to apprehend correctly such a disorder in those who show no objectively demonstrable sign of psychosis. Some of these patients are more dangerous than many who hallucinate, express delusions, and show gross irrationality.

  Most of these masked schizophrenics do not present an outer aspect that appears entirely normal. A brittleness, an indefinable peculiarity of manner, fine details of posture or gesture, and nuances of expression and attitude may cumulatively contribute to the psychiatrist’s impression. Many subliminal or almost subliminal items of perception may be sensed in such a person and correctly identified with similar real but not quite expressible qualities familiar to the observer because he has previously sensed them in hundreds of closely studied schizophrenic patients who also showed gross and indisputable manifestations of psychosis. What is thus sensed may reveal to the psychiatrist that such a patient is emotionally far out of contact in basic human relations and inadequately influenced by sane motives.

  Such patients with schizophrenia suggest in some respects the psychopath in that their major abnormality, their real pathology, is chiefly within and largely concealed by good reasoning and by ability, at least for intervals, to go through the motions of what looks like a sane pattern of life. Occasionally such a patient will attempt to hang himself, address an insulting letter to the President, announce the discovery of perpetual motion, or wander off from home and let no one know whether he is dead or alive for a couple of months, without being able to give any good reason for such acts and apparently without feeling that an explanation is in order. After following for years obviously queer, distorted, and socially restricted, but apparently not psychotic, careers, a few commit without provocation murder or some other tragic misdeed, for which they show little evidence of remorse or other adequate and understandable reactions.

/>   Such patients in some respects, particularly in their central emotional deficit, may seem closer to the psychopath than to the ordinary state hospital schizophrenic. There are, however, important differences. The psychopath’s outer mask of mechanically correct peripheral functioning is immeasurably more deceptive. The masked schizophrenic outwardly shows no obvious or expected signs of traditional psychosis, but he does not achieve the socially appealing presence, the warm, easy manners, or the false promise of strong and superior character and human qualities that are so bewildering in the psychopath. Real peculiarities, cool and strange alterations of emotion, social isolation, and a profound and indefinable queerness emerge in outer aspects of the cryptic schizophrene. Such signs, except to the expert, do not suggest psychosis or adequately warn us that gross and malignant alterations exist beneath such a surface. But the evidence of something schizoid, or something queer and not precisely normal, is usually apparent.

  The surface of the psychopath, however, that is, all of him that can be reached by verbal exploration and direct examination, shows up as equal to or better than normal and gives no hint at all of a disorder within. Nothing about him suggests oddness, inadequacy, or moral frailty. His mask is that of robust mental health. Yet he has a disorder that often manifests itself in conduct far more seriously abnormal than that of the schizophrenic. Inwardly, too, there appears to be a significant difference. Deep in the masked schizophrenic we often sense a cold, weird indifference to many of life’s most urgent issues and sometimes also bizarre, inexplicable, and unpredictable but intense emotional reactions to what seems almost irrelevant. Behind the exquisitely deceptive mask of the psychopath the emotional alteration we feel appears to be primarily one of degree, a consistent leveling of response to petty ranges and an incapacity to react with sufficient seriousness to achieve much more than pseudoexperience or quasi-experience. Nowhere within do we find a real cause or a sincere commitment, reasonable or unreasonable. There is nowhere the loyalty to produce real and lasting allegiance even to a negative or fanatic cause.

  Just as meaning and the adequate sense of things as a whole are lost with semantic aphasia in the circumscribed field of speech although the technical mimicry of language remains intact, so in most psychopaths the purposiveness and the significance of all life-striving and of all subjective experience are affected without obvious damage to the outer appearance or superficial reactions of the personality. Nor is there any loss of technical or measurable intelligence.

  With such a biologic change the human being becomes more reflex, more machinelike. It has been said that a monkey endowed with sufficient longevity would, if he continuously pounded the keys of a typewriter, finally strike by pure chance the very succession of keys to reproduce all the plays of Shakespeare. These papers so composed in the complete absence of purpose and human awareness would look just as good to any scholar as the actual works of the Bard. Yet we cannot deny that there is a difference. Meaning and life at a prodigiously high level of human values went into one and merely the rule of permutations and combinations would go into the other. The patient semantically defective by lack of meaningful purpose and realization at deep levels does not, of course, strike sane and normal attitudes merely by chance. His rational power enables him to mimic directly the complex play of human living. Yet what looks like sane realization and normal experience remains, in a sense and to some degree, like the plays of our simian typist.

  Tables 1 and 2 may serve to outline or illustrate some points in this discussion. The various differences between central and peripheral speech disorders cannot of course be pronounced identical with similar differences between masked and obvious psychiatric disorders.

  In Henry Head’s interpretation of semantic aphasia we find, however, concepts of neural function and of its integration and impairment that help to convey a hypothesis of grave personality disorder thoroughly screened by the intact peripheral operation of all ordinary abilities. In relatively abstract or circumscribed situations, such as the psychiatric examination or the trial in court, these abilities do not show impairment but more or less automatically demonstrate an outer sanity unquestionable in all its aspects and at all levels accessible to the observer. That this technical sanity is little more than a mimicry of true sanity cannot be proved at such levels. Only when the subject sets out to conduct his life can we get evidence of how little his good theoretical understanding means to him, of how inadequate and insubstantial are the apparently normal basic emotional reactions and motivations convincingly portrayed and enunciated but existing in little more than two dimensions.

  What we take as evidence of his sanity will not significantly or consistently influence his behavior. Nor does it represent real intention within, the degree of his emotional response, or the quality of his personal experience much more reliably than some grammatically well-formed, clear, and perhaps verbally sensible statement produced vocally by the autonomous neural apparatus of a patient with semantic aphasia can be said to represent such a patient’s thought or carry a meaningful communication of it.

  Let us assume tentatively that the psychopath is, in this sense, semantically disordered. We have said that his outer functional aspect masks or disguises something quite different within, concealing behind a perfect mimicry of normal emotion, fine intelligence, and social responsibility a grossly disabled and irresponsible personality. Must we conclude that this disguise is a mere pretence voluntarily assumed and that the psychopath’s essential dysfunction should be classed as mere hypocrisy instead of psychiatric defect or deformity?

  Let us remember that his typical behavior defeats what appear to be his own aims. Is it not he himself who is most deeply deceived by his apparent normality? Although he deliberately cheats others and is quite conscious of his lies, he appears unable to distinguish adequately between his own pseudointentions, pseudoremorse, pseudolove, and the genuine responses of a normal person. His monumental lack of insight indicates how little he appreciates the nature of his disorder. When others fail to accept immediately his “word of honor as a gentleman,” his amazement, I believe, is often genuine. The term genuine is used here not to qualify the psychopath’s intentions but to qualify his amazement. His subjective experience is so bleached of deep emotion that he is invincibly ignorant of what life means to others.

  His awareness of hypocrisy’s opposite is so insubstantially theoretical that it becomes questionable if what we chiefly mean by hypocrisy should be attributed to him. Having no major values himself, can he be said to realize adequately the nature and quality of the outrages his conduct inflicts upon others? A young child who has no impressive memory of severe pain may have been told by his mother it is wrong to cut off the dog’s tail. Knowing it is wrong he may proceed with the operation. We need not totally absolve him of responsibility if we say he realized less what he did than an adult who, in full appreciation of physical agony, so uses a knife. Can a person experience the deeper levels of sorrow without considerable knowledge of happiness? Can he achieve evil intention in the full sense without real awareness of evil’s opposite? I have no final answer to these questions.

  Attempts to interpret the psychopath’s disorder do not, of course, furnish evidence that he has a disorder or that it is serious. For reliable evidence of this we must examine his behavior. Only here, not in psychopathologic formulations, can we apply our judgment to what is objective and demonstrable. Functionally and structurally all is intact on the outside. Good function (healthy reactivity) will be demonstrated in all theoretical trials. Sound judgment as well as good reasoning are likely to appear at verbal levels. Ethical as well as practical considerations will be recognized in the abstract. A brilliant mimicry of sound, social reactions will occur in every test except the test of life itself. In the psychopath we confront a personality neither broken nor outwardly distorted but of a substance that lacks ingredients without which normal function in major life issues is impossible.

  Any method that offers the poss
ibility of adding objectivity to our appraisals is indeed stimulating and welcome anywhere in psychiatry but particularly so in this more than ordinarily confusing problem.

  Simon, Holzberg, and Unger, impressed by the paradox of the psychopath’s poor performance despite intact reasoning, devised an objective test specifically to appraise judgment as it would function in real situations, as contrasted with theoretical judgment in abstract situations.260

  These workers are aware that the more complex synthesis of influences constituting what is often called judgment or understanding (as compared to a more theoretical “reasoning”) may be simulated in test situations in which emotional participation is minimal, that rational factors alone by an accurate aping or stereotyping can produce in vitro, so to speak, what they cannot produce in vivo. Items for a multiple choice test were selected with an aim of providing maximal possibilities for emotional factors to influence decision and particularly for relatively trivial immediate gratification impulses to clash with major, long-range objectives. The same items were also utilized in the form of a completion test. The results of this test on a group of psychopaths tend to support the hypothetical interpretation attempted in this book.

  If such a disorder does indeed exist in the so-called psychopath, it is not remarkable that its recognition as a major and disabling impairment has been long delayed. Pathologic changes visible on the surface of the body (laceration, compound fractures) were already being handled regularly by medical men when the exorcism of indwelling demons retained popular favor in many illnesses now treated by the internist. So, too, it has been with personality disorders. Those characterized by gross outward manifestations have been accepted as psychiatric problems long before others in which a superficial appearance of sanity is preserved.

  Despite the psychopath’s lack of academic symptoms characteristic of those disorders traditionally classed as psychosis, he often seems, in some important respects, but not in all, to belong more with that group than with any other. Certainly his problems cannot be dealt with, medically or by any other means, unless similar legal instrumentalities for controlling his situation are set up and regularly applied.