Читать книгу The Mask of Sanity - Hervey M. Cleckley - Страница 10

In raising general questions about personality disorder we have briefly considered (1) persons suffering from illnesses that progress to major mental disability and (2) the numerous citizens of our nation, many of them able and well educated, who hold beliefs generally regarded as unsupported by evidence and considered by many as irrational or even fantastic. Aside from these groups and aside from all types of patients recognized as psychotic, there remains for our consideration a large body of people who are incapable of leading normal lives and whose behavior causes great distress in every community.

This group, plainly marked off from the psychotic by current psychiatric standards, does not find a categorical haven among the psychoneurotic, who are distinguished by many medical characteristics from the people to be discussed in this volume. They are also distinguished practically by their ability to adjust without major difficulties in the social group.

Who, then, are these relatively unclassified people? And what is the nature of their disorder? The pages which follow will be devoted to an attempt to answer these questions. The answers are not easy to formulate. The very name by which such patients are informally referred to in mental hospitals or elsewhere among psychiatrists is in itself confusing. Every physician is familiar with the term psychopath, by which these people are most commonly designated.48 Despite the plain etymological inference of a sick mind or of mental sickness, this term is ordinarily used to indicate those who are considered free from psychosis and even from psychoneurosis. The definitions of psychopath found in medical dictionaries are not consistent nor do they regularly accord with the ordinary psychiatric use of this word.{‡}

These definitions notwithstanding, the word psychopath is, in practice, popularly used for reference to a large group of seriously disabled people, listed with other dissimilar groups under the heading psychopathic personality. This cumbersome and altogether vague diagnostic category officially includes a wide variety of maladjusted people who cannot by the criteria of psychiatry be classed with the psychotic, the psychoneurotic, or the mentally defective, It is by no means uncommon in looking over the reports of a psychiatric examination to find conclusions listed as follows:

(1) No nervous or mental disease.

(2) Psychopathic personality.

The broadness of the familiar diagnostic term and the conflicting attitudes of different psychiatrists toward those so labeled are reflected in the varying concepts it implies and in its plainly diverse referents.{§}

Several decades ago, a large group of abnormalities, mental deficiency, various brain and bodily malformations and developmental defects, sexual perversions, delinquent behavior patterns, chronically mild schizoid disorder, etc., were all classed as constitutional psychopathic inferiority.106 After the ordinary mental defectives and most of the cases with demonstrable brain damage or developmental anomalies were distinguished, a considerable residue of diverse conditions remained under the old classification. Since many of these patients left in the group did not show evidence of congenital pathology and lifelong disorder, another term, constitutional psychopathic state, was devised.

Many psychiatrists still prefer these two terms, which, in their abbreviated form (C.P.I. and C.P.S.), are used most often to designate psychopaths but literally refer to a good many other conditions at the same time.

Talk about the C.P.I. and the C.P.S. still figures prominently in staff room discussion. It is not surprising that confusion flourishes and sharp differences of opinion prevail about what may be one or several subjects simultaneously.

As time passed and psychiatric study continued, an increasing number of observers felt that the term constitutional was scarcely justified for some of the several disorders listed in the categories mentioned above. Eventually these were officially discarded in our country and psychopathic personality adopted, not only for the type of patient to be discussed in this volume, but for a good many others easily distinguished from him in life but only with difficulty in the nomenclature.

In the revised Standard Nomenclature for Diseases of the Psychobiologic Unit, published in 1952, the familiar psychopathic personality has been discarded. In its place we find the category of personality disorders. These, distinguished in the revised nomenclature from psychotic disorders and psychoneurotic disorders, include, sometimes under slightly altered names, all the various pathologic states formerly placed in the category psychopathic personality.62

At present many feel that all the conditions until recently listed under psychopathic personality are hereditary deficiencies, while others see little convincing evidence for this assumption.219 During the last few decades increasing attention has been paid to interpersonal and environmental factors or influences almost entirely ignored before the beginning of Freud’s work, and the tendency to attribute personality disorder wholly and simply to inborn defect has been less prevalent.

Some time after the period during which it was generally assumed, by the physician as well as by the clergyman, that abnormal behavior resulted from devil possession or the influence of witches, it became customary to ascribe all or nearly all mental disorder to bad heredity. Even in the early part of the present century this practice was almost universal.181 Before relatively recent developments in psychopathology and before any real attempt had been made to understand the meaning and purpose of symptomatology, the invocation of inborn deficiency or “hereditary taint” was, it would seem, grasped largely for the want of any other hypothesis.

Another factor contributing to the popularity of belief in hereditary causation lies, perhaps, in the fact that families of all patients in state hospitals were investigated and all deviations recorded. Most of these histories revealed aberrant behavior, if not in a parent or grandparent, at least in some great uncle or distant cousin. It is surprising that some investigators gave such little consideration to the fact that few men stopped on the street could account for all relatives and antecedents without also disclosing one or more kinsmen whose behavior would attract psychiatric attention.{**} This is not to say that there is no possibility of genogenic factors playing a part, perhaps a major part, in the development of the psychopath. It is to say that one is not justified in assuming such factors until real evidence of them is produced. If such evidence is produced, these factors must be weighed along with all others for which there may be evidence and not glibly assumed to be a full and final explanation.

In recent years a contrary tendency has become prominent in psychiatry, a tendency to make, on the basis of symbolism and theoretical postulates, sweeping and unverifiable assumptions and insist that these prove the cause of obscure personality disorders to lie in specific infantile, or even intrauterine, experiences.82, 146, 215

After many years of work in psychiatry as a member of the staff in a closed hospital devoted to the treatment of mental disorders, and after many other years in charge of the psychiatric service in a general hospital, I believe that these curious people referred to as C.P.I.’s, C.P.S.’s, or psychopaths, in the vernacular of J the ward and the staff room, offer a field of study in personality disorder more baffling and more fascinating than any other. The present work has been attempted because of an ever-growing conviction that this type of disorder is far less clearly understood than \ either the well-defined psychoses or the neuroses, and that this lack of understanding is, furthermore, not sufficiently recognized and admitted. While the writer does not pretend to achieve a final explanation of so grave and perplexing a problem, it is hoped that a frank and detailed discussion may, at least, draw attention to the magnitude of the problem.42

The chief aim of this study is to bring before psychiatrists a few of these cases, typical of hundreds more, who have proved so interesting to the writer, so difficult to interpret by the customary standards of psychiatry, and all but impossible to deal with or to treat satisfactorily in the face of prevalent medicolegal viewpoints. Many of these cases have been classified consistently as psychopathic personality by not one but a number of expert observers, usually by several staffs of psychiatrists, and nearly always with unanimity. Others are so similar and so typical that few, if any, experts could find grounds to question their status. It is my belief, however, that this diagnosis, as it is authoritatively defined and as it is generally understood, fails to do justice to the kind of patients considered here.

It is hoped that such a presentation may be of interest to physicians in general practice, and, perhaps, to medical students, as well as to those whose work is confined more specifically to personality disorders. It is, indeed, the physician in general practice who will most often be called on by society to interpret the behavior of such patients as these and to advise about their treatment and their disposition.

These people, whom I shall call psychopaths for the want of a better word, are, as a matter of fact, the problem of juries, courts, relatives, the police, and the general public no less than of the psychiatrist. Referring to such cases Henderson says:

“It is often much against his better judgment that the judge sentences a man whose conduct on the face of it indicates the action of an unsound mind to serve a term of imprisonment. But he is almost forced to do so because, according to our present statutes governing commitment, the doctor may not feel that he is justified in certifying the individual as suitable for care and treatment in a mental hospital.”110

It is important that the average physician at least be aware that there is such a problem. According to the present standards of psychiatry, such patients are not eligible for admission to state hospitals for the psychotic or to the numerous hospitals of the same type maintained by the federal government for war veterans. They are classed as sane and competent and, theoretically at least, are held responsible for their conduct. Being so classed, none of the measures used to protect other psychiatric patients (and their families and the community) can be applied to bring them under any sort of treatment or restriction, even when they show themselves dangerously disordered. By many psychiatrists they are, in a technical sense, considered to be without nervous or mental disease. There are many arguments that can be brought forward in support of these beliefs, particularly if one adheres strictly to the traditional and currently accepted definitions of psychiatry and minimizes or evades what is demonstrated by the patient’s behavior.

It is difficult, however, for society to hold these people to account for their damaging conduct or to apply any control that will prevent its continuing. Those who commit serious crimes have a history that any clever lawyer can exploit in such a way as to make his client appear to the average jury the victim of such madness as would make Bedlam itself tame by comparison. Under such circumstances they escape the legal consequences of their acts, are sent to mental hospitals where they prove to be “sane,” and are released. On the other hand, when their relatives and their neighbors seek relief from them and take action to have “lunacy warrants” drawn against them, not wanting to be restricted, they are able to convince the courts that they are as competent as any man.

It is pertinent here to remind ourselves of the considerable change that has occurred during recent centuries in the legal attitude toward antisocial conduct and punishment. Formerly all who broke the laws were considered fit subjects for trial, and penalties were inflicted without regard to questions of responsibility or competency. As Karl Menninger,181 among others,252, 279 has so effectively pointed out, not only were the irrational considered fully culpable, but also young children and idiots. At an earlier date animals and even articles of furniture, a tree (or a stone) were brought to trial, fantastic as it seems to us now, and sentenced to legal penalties.

Today the murderer who hears what he believes is God’s voice telling him to kill is not, as a rule, hanged. He is committed to a psychiatric hospital for the protection of society and for his own best interests, but not as a punishment. This legal attitude has become so axiomatic, so familiar to the man on the streets, that it is well for us to remember it is relatively new.

We might also bear in mind that once only obvious irrationality was regarded as personality disorder, as disability. Medically we recognize the fact that many less obvious disorders are more serious and incapacitating than those with gross superficial manifestations that can be readily demonstrated. In our attempts to appraise the psychopath and his disorder it will be helpful to bear these facts in mind and not to forget that our present medico-legal criteria are based on knowledge that is far from complete.

These people called psychopaths present a problem which must be better understood by lawyers, social workers, school teachers, and by the general public, if any satisfactory way of dealing with them is to be worked out. Before this understanding can come, the general body of physicians to whom the laity turn for advice must themselves have a clear picture of the situation. Much of the difficulty which mental institutions have in their relations with the psychopath springs from a lack of awareness in the public that he exists. The law in its practical application provides no means whereby the community can protect itself from such people. And no satisfactory facilities can be found for their treatment. It is with these thoughts especially in mind that I seek to present the material of this work in such a manner that the average physician who treats few frankly psychotic patients may see that our subject lies in his own field scarcely less than in the field of psychiatry. After all, psychiatry, though still a specialty, can no longer be regarded as circumscribed within the general scope of medicine.33

In nearly all the standard textbooks of psychiatry the psychopath is mentioned. Several recent textbooks have indeed made definite efforts to stress for the student the challenging and paradoxical features of our subject. Often, however, one finds tucked away at the end of a large volume an obscure chapter containing a few pages or paragraphs devoted to these strange people who take so much attention of the medical staffs in psychiatric hospitals and whose behavior, it is here maintained, probably causes more unhappiness and more perplexity to the public than all other mentally disordered patients combined. From some textbooks the medical student is likely to arrive at a conclusion that the psychopath is an unimportant figure, probably seldom encountered even in a psychiatric practice. Nor will he be led to believe that this type of disorder is particularly interesting. Not only is the chapter on psychopathic personalities often short, and sometimes vague or half-hearted, but even this is nearly always involved with personality types or disorders which bear little or no resemblance to that with which we are now concerned. While it is true that these other conditions are officially placed in the same category with the one discussed here, and which we believe is a clinical entity, it is hard to see how any student unfamiliar with the latter will profit by encountering it vaguely placed in a company of assorted deficiencies and aberrations which are by no means basically similar.

It is my earnest conviction that, classified with a fairly heterogeneous group under a loose and variously understood term, a type of patient exists who could, without exaggeration, be called the forgotten man of psychiatry. If this patient can be presented as he has appeared so clearly during years of observation, if some idea can be given of his ubiquity, and, above all, if interest can be promoted in further study of his peculiar status among other human beings, I shall be abundantly satisfied. It is difficult to contemplate the enigma which he provokes without attempting to find some explanation, speculative though the attempt may be. Present efforts to explain or interpret are, however, tentative, and secondary to the real purpose of this volume, which is to call attention to what may be observed about our subject.