The Mask of Sanity

by Hervey Cleckley

  The seven patients classed as “no nervous or mental disease” had also a history of excessive drinking and maladjustment strongly suggestive of psychopathic personality, or at least of what I mean to define as such, in a milder degree. A few of these, it must be granted, may have been merely cases of neurotic drinking.

  Leaving out all patients who, aside from their major conditions, were probably psychopaths and also those patients in whom a typically psychopathic maladjustment was explained on some other basis (such as psychoneurosis or traumatic condition) but including the alcohol and drug addicts, a formidable proportion of this material qualifies for consideration.

  102 diagnosed as having psychopathic personality

  60 diagnosed as having chronic alcoholism

  41 diagnosed as having chronic alcoholism with deterioration

  14 diagnosed as having acute alcoholic hallucinosis

  8 diagnosed as having psychopathic personality with psychotic episodes*

  3 diagnosed as having acute alcoholism

  8 diagnosed as having drug addiction

  These 236 patients, more than one-fourth of the total, probably represent in varying degree the type of character inadequacy and personality disorder which is the subject of the present discussion. If we count only one-half of the 134 patients not diagnosed primarily as psychopaths, these, with the unquestionably psychopathic patients, give us a total of 169 patients, almost one-fifth of all who were admitted. The question of whether or not the term psychopathic personality is an ideal one and suitable to all these patients I am willing to leave unanswered at present. Since there was considerable disagreement among psychiatrists as to just how much maladjustment is necessary for a patient to deserve this diagnosis, some preferring to apply it only in extreme cases, there is no reason to insist here on its wider application. Standard textbooks did not and still do not make clear to what precise degree the person must be affected to be justifiably placed in this category. With due apologies then to those who would restrict this term, I ask leave to use it for the type of person who is now being considered. Whatever these people may be called, they are not normal.

  If we consider, in addition to these patients (nearly all of whom have records of the utmost folly and misery and idleness over many years and who have had to enter a psychiatric hospital), the vast number of similar people in every community who show the same behavior pattern in milder form but who are sufficiently protected and supported by relatives to remain at large, the prevalence of this disorder is seen to be appalling.

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