Sanctuary for the Abused
Sunday, April 08, 2018
Traits of a Psychopath
The psychopath shows a remarkable disregard for truth and is to be trusted no more in his accounts of the past than in his promises for the future or his statement of present intentions. He gives the impression that he is incapable of ever attaining realistic comprehension of an attitude in other people which causes them to value truth and cherish truthfulness in themselves.
Typically he is at ease and unpretentious in making a serious promise or in (falsely) exculpating himself from accusations, whether grave or trivial. His simplest statement in such matters carries special powers of conviction. Overemphasis, obvious glibness, and other traditional signs of the clever liar do not usually show in his words or in his manner. Whether there is reasonable chance for him to get away with the fraud or whether certain and easily foreseen detection is at hand, he is apparently unperturbed and does the same impressive job. Candor and trustworthiness seem implicit in him at such times. During the most solemn perjuries he has no difficulty at all in looking anyone tranquilly in the eyes. Although he will lie about any matter, under any circumstances, and often for no good reason, he may, on the contrary, sometimes own up to his errors (usually when detection is certain) and appear to be facing the consequences with singular honesty, fortitude, and manliness.
It is indeed difficult to express how thoroughly straightforward some typical psychopaths can appear. They are disarming not only to those unfamiliar with such patients but often to people who know well from experience their convincing outer aspect of honesty. A saying current among psychiatric residents, secretaries, medical associates, and others familiar with what goes on in my office may illustrate this point. The saying is in substance that excellent evidence for the diagnosis of psychopathic personality can be found in my own response to newcomers who seek to borrow money or cash checks. It is rather generally believed that only psychopaths are successful and that in typical scams success is inevitable. Although I argue that some exaggeration has perhaps colored this story and overemphasized the infallibility of my reaction as a test, I must admit there is much truth in the matter. Even after so many years of special interest in the subject, I am forced to confess that fairly often observers have had the opportunity to make a snap diagnosis from my response to this sort of appeal and see it gain full confirmation in subsequent events. I might add that no such loan has ever been repaid and that all such checks have bounced.
After being caught in shameful and gross falsehoods, after repeatedly violating his most earnest pledges, he finds it easy, when another occasion arises, to speak of his word of honor, his honor as a gentleman, and he shows surprise and vexation when commitments on such a basis do not immediately settle the issue.
The conception of living up to his word seems, in fact, to be regarded as little more than a phrase sometimes useful to avoid unpleasantness or to gain other ends. How inadequate such ends may be to account for the psychopath's neglect of truth can be shown in a brief example:
In a letter to his wife, at last seeking divorce and in another city, one patient set down dignified, fair appraisals of the situation and referred to sensible plans he had outlined for her security. He then added that specified insurance policies and annuities providing for the three children (including their tuition at college) had been mailed under separate cover and would, if she had not already received them, soon be in her hands. He had not taken even the first step to obtain insurance or to make any other provision, and, once he had made these statements in his letter, he apparently gave the matter no further thought.The psychopath apparently cannot accept substantial blame for the various misfortunes which befall him and which he brings down upon others, usually he denies emphatically all responsibility and directly accuses others as responsible, but often he will go through an idle ritual of saying that much of his trouble is his own fault. When the latter course is adopted, subsequent events indicate that it is empty of sincerity-a hollow and casual form as little felt as the literal implications of "your humble and obedient servant" are actually felt by a person who closes a letter with such a phrase. Although his behavior shows reactions of this sort to be perfunctory, this is seldom apparent in his manner. This is exceedingly deceptive and is very likely to promote confidence and deep trust. More detailed questioning about just what he blames himself for and why may show that a serious attitude is not only absent but altogether inconceivable to him. If this fails, his own actions will soon clarify the issue.
Whether judged in the light of his conduct, of his attitude, or of material elicited in psychiatric examination, he shows almost no sense of shame. His career is always full of exploits, any one of which would wither even the more callous representatives of the ordinary man. Yet he does not, despite his able protestations, show the slightest evidence of major humiliation or regret. This is true of matters pertaining to his personal and selfish pride and to esthetic standards that he avows as well as to moral or humanitarian matters. If Santayana is correct in saying that "perhaps the true dignity of man is his ability to despise himself," the psychopath is without a means to acquire true dignity.
Not only is the psychopath undependable, but also in more active ways he cheats, deserts, annoys, brawls, fails, and lies without any apparent compunction. He will commit theft, forgery, adultery, fraud, and other deeds for astonishingly small stakes and under much greater risks of being discovered than will the ordinary scoundrel. He will, in fact, commit such deeds in the absence of any apparent goal at all.
Yet we do not find the regularity and specificity in his behavior that is apparent in what is often called compulsive stealing or other socially destructive actions carried out under extraordinary pressures which the subject, in varying degrees, struggles against. Such activities, and all disorder distinguished by some as impulse neurosis,14 as we have mentioned, probably have important features in common with the psychopath's disorder. In contrast, his antisocial and self-defeating deeds are not circumscribed (as, for example, in pyromania and kleptomania), and he shows little or no evidence of the conscious conflict or the subsequent regret that are not regularly absent in these other manifestations. Again the comparison Of a circumscribed dissociation typical of hysteria with the general ego disintegration of schizophrenia may be usefully cited.
Objective stimuli (value of the object, specific conscious need) are, as in compulsive (or impulsive) stealing, inadequate to account for the psychopath's acts. Evidence of any vividly felt urge symbolizing a disguised but specifically channelized, instinctive drive is not readily available in the psychopath's wide range of inappropriate and self-defeating behavior. Two incidents in typical cases are offered:
1. An 18-year-old boy often stole objects for which he had some use, but stealing was not a dominant feature in his almost universally manifested maladjustment. Drifting one day into church, he chose to remain after services and speak personally with the clergyman. As might be expected, he made a profound impression and, spontaneously professing conversion, brought justifiable pride to his counselor. Although disappointed because this new religious attitude did not curtail the boy in his flagrant truancy, his desultory cheating in examinations, and his lying, the clergyman worked hopefully and assiduously with him. On one occasion, after hanging around juke joints and street corners until 3 A.M., he explained his tardiness to his parents in a vivid account of having been injured while wrestling at the school gymnasium. He had, he explained to them, spit up blood and so was taken in an ambulance to the hospital emergency room, where he was treated by the family physician. He gave realistic detail about difficulties in locating the physician, the spirit of emergency prevailing, and techniques of treatment. This story was elaborated despite his knowledge that the next day he was, in the company of his father, going to visit this very physician (for a previously made appointment) and that all he said would be proved untrue.Despite his excellent rational powers, the psychopath continues to show the most execrable judgment about attaining what one might presume to be his ends. He throws away excellent opportunities to make money, to achieve a rapprochement with his wife, to be dismissed from the hospital, or to gain other ends that he has sometimes spent considerable effort toward gaining. It might be said that he cares little about financial success and little about regaining his wife, but it is difficult indeed to say that he is not extremely fain to get out of the psychiatric hospital where he has been locked up for months with other patients whom he regards as "lunatics" and who are, indeed, not desirable associates for the average man or for him. Be it noted again that the psychopath appears as unwilling to remain in a psychiatric hospital and as impatient to regain his freedom as would be the normal man. I have not in these patients ever found reliable evidence that unconsciously they seek and enjoy as punishment such confinement.
Despite repeated and versatile acts inconsistent with the boy's profession of religion, the patient clergyman, naturally impressed with one who seemed so sincere and whose stated attitudes were so admirable, did not lose hope and at times even became quite optimistic. This optimism was particularly shaken after the discovery that his convert had, during communion, succeeded in stealing one of the small glass goblets used in the ceremony.
2. Stealing was a very minor feature of this lady's career, a few details of which were cited in Chapter 12, Anna. While on parole for the afternoon from a private psychiatric institution, she accepted the hospitality of an old friend who had planned tea and sandwiches for several rather demure women whose common interest centered on Sunday school activities. While accompanying her hostess on a preparatory visit to a large grocery store, the patient, as if by whim, slipped into her ample handbag a bottle of vitamin tablets, a package of cream cheese, and a tin of anchovy paste. On arriving at the house (prior to the gathering), she presented all but the vitamin tablets to her hostess as a contribution to the party. She was a woman of considerable wealth and had funds with her. She apparently realized that her theft might be detected and would almost surely be suspected. In carrying out the act she behaved with what can perhaps best be called moderate caution. Apparently she was not strongly influenced by fears of being caught. Nor, on the other hand, did she seem to be seeking purposively but unconsciously any specific thrill, masochistic or otherwise, that might arise in this event. Nothing about her reactions to this and scores of similar acts ever suggested an irresistible force compelling her on against her judgment and will.
This exercise of execrable judgment is not particularly modified by experience, however chastening his experiences may be. Few more impressive examples of this could be offered from the records of humanity than the familiar one of the psychopath who, in full possession of his rational faculties, has gone through the almost indescribably distasteful confinement of many months with delusional and disturbed psychotic patients and, after fretting and counting the days until the time of his release, proceeds at once to get drunk and create disorder which he thoroughly understands will cause him to be returned without delay to the detested wards. It is my opinion that no punishment is likely to make the psychopath change his ways. Punishment is not, of course, regarded as an appropriate measure in medical treatment. It is, however, often considered and administered by legal authorities. And it must be remembered that at present the law deals with these patients more frequently than physicians deal with them.
Despite the extraordinarily poor judgment demonstrated in behavior, in the actual living of his life, the psychopath characteristically demonstrates unimpaired (sometimes excellent) judgment in appraising theoretical situations. In complex matters of judgment involving ethical, emotional, and other evaluational factors, in contrast with matters requiring only (or chiefly) intellectual reasoning ability, he also shows no evidence of a defect. So long as the test is verbal or otherwise abstract, so long as he is not a direct participant, he shows that he knows his way about. He can offer wise decisions not only for others in life situations but also for himself so long as he is asked what he would do (or should do, or is going to do). When the test of action comes to him we soon find ample evidence of his deficiency.
The psychopath is always distinguished by egocentricity. This is usually of a degree not seen in ordinary people and often is little short of astonishing. How obviously this quality will be expressed in vanity or self-esteem will vary with the shrewdness of the subject and with his other complexities. Deeper probing will always reveal a selfcenteredness that is apparently unmodifiable and all but complete. This can perhaps be best expressed by stating that it is an incapacity for object love and that this incapacity (in my experience with well-marked psychopaths) appears to be absolute.
Terms in use for what we experience as "emotion" contain much ambiguity, and their referential accuracy is limited. This contributes to confusion and paradox which are difficult to avoid in attempts to convey concepts about such a matter.
In a sense, it is absurd to maintain that the psychopath's incapacity for object love is absolute, that is, to say he is capable of affection for another ill literally no degree. He is plainly capable of casual fondness, of likes and dislikes, and of reactions that, one might say, cause others to matter to him. These affective reactions are, however, always strictly limited in degree. In durability they also vary greatly from what is normal in mankind. The term absolute is, I believe, appropriate if we apply it to any affective attitude strong and meaningful enough to be called love, that is, anything that prevails in sufficient degree and over sufficient periods to exert a major influence on behavior.
True enough, psychopaths are sometimes skillful in pretending a love for women or simulating parental devotion to their children. What part of this is not pure (and perhaps in an important sense unconscious) simulation has always impressed this observer as that other type of pseudolove sometimes seen in very self-centered people who are not psychopaths, which consists in concern for the other person only (or primarily) insofar as he enhances or seems to enhance the self. Even this latter imitation of adult affectivity has been seldom seen in the full-blown psychopath, although it is seen frequently in those called here partial psychopaths. In nonpsychopaths a familiar example is that of the parent who lavishes money and attention on a child chiefly to bask in the child's success and consciously or unconsciously to feel what an important person he is because of the child's triumphs. Although it is true that with ordinary people such motives are seldom, if ever, unmixed, and usually some object love and some self-love are integrated into such attitudes, in even the partial psychopath anything that could honestly be called object love approaches the imperceptible.
What positive feelings appear during the psychopath's interpersonal relations give a strong impression of being self-love. Some cynical psychologists and philosophers have, of course, challenged the existence of any love which is not on final analysis selfish, saying that the mother who gives up her own life for her child really does so because it would be more painful to her to see the child perish. Without attempting to take up the cudgels in this interesting dispute, it will suffice to say that whatever normal and highly developed and sincere object love may actually be, it is, whether judged behaviorally or intuitively, something that impresses the ordinary observer as definitely unlike anything found in the psychopath.
The psychopath seldom shows anything that, if the chief facts were known, would pass even in the eyes of lay observers as object love. His absolute indifference to the financial, social, emotional, physical, and other hardships which he brings upon those for whom he professes love confirms the appraisal during psychiatric studies of his true attitude. We must, let it never be forgotten, judge a man by his actions rather than by his words. This old saying is especially significant when it is the man's motivations and real feelings that we are to judge. This lack in the psychopath makes it all but impossible for an adequate emotional rapport to arise in his treatment and may be an important factor in the therapeutic failure that, in my experience, has been universal.
In addition to his incapacity for object love, the psychopath always shows general poverty of affect. Although it is true that be sometimes becomes excited and shouts as if in rage or seems to exult in enthusiasm and again weeps in what appear to be bitter tears or speaks eloquent and mournful words about his misfortunes or his follies, the conviction dawns on those who observe him carefully that here we deal with a readiness of expression rather than a strength of feeling.
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?
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.
Some 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.
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 serve 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.
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.
I cannot say that it is impossible in certain persons for a state of mental disorder identical with that described here as psychopathic personality to be reached eventually in this way. Often, however, these neurotic drinkers, in sharp contrast with the psychopath, worry about their state when sober, are capable of making an earnest effort to get well under psychiatric treatment, and lack most of the deeper personality features of the psychopath. Even in the neurotic drinker it is more often an independent and preexisting personality maladjustment rather than the alcohol which is primarily causal. Many psychiatric observers make this vividly clear and no less convincing.
A major point about the psychopath and his relation to alcohol can be found in the shocking, fantastic, uninviting, or relatively inexplicable behavior which emerges when he drinks - sometimes when he drinks only a little. It is very likely that the effects of alcohol facilitate such acts and other manifestations of the disorder. This does not mean, however, that alcohol is fundamentally causal. Good criteria for differentiation between psychopaths and others who drink, moderately or excessively, can be found in what tendencies emerge after similar amounts have been consumed.
A peculiar sort of vulgarity, domineering rudeness, petty bickering or buffoonish quasi-maulings of wife, mistress, or children, and quick shifts between maudlin and vainglorious moods, although sometimes found in ordinary alcoholics with other serious patterns of disorder, are pathognomonic of the psychopath and in him alone reach full and precocious flower. Even in the first stages of a spree, perhaps after taking only two or three highballs, he may show signs of petty truculence or sullenness but seldom of real gaiety or conviviality. Evidence of any pleasurable reaction is characteristically minimal, as are indications that he is seeking relief from anxiety, despair, worry, responsibility, or tension.
Alcohol, as a sort of catalyst, sometimes contributes a good deal to the long and varied series of outlandish pranks and inanely coarse scenes with which nearly every drinking psychopath's story is starred. Free from alcohol, such a patient would scarcely sit under a house all night idly striking matches, or, concealing himself behind book stacks, urinate from the window of a public library on passersby in the street below. Nor would he, like the psychopathic son of a prominent family, suddenly, as a prank, decide to climb into a tree at a busy street corner, where he deliberately undressed, shouting wildly and puerilely to draw public attention. This man could not be persuaded to withdraw until the local fire department was called to remove him. The alcohol probably does not of itself create such behavior. Alcohol is not likely to bring out any impulse that is not already potential in a personality, nor is it likely to cast behavior into patterns for which there is not already significant subsurface predilection. The alcohol merely facilitates expression by narcotizing inhibitory processes.136 In cases of this sort very little narcotizing may be needed. The oil which lubricates the engine of an automobile neither furnishes the energy for its progress nor directs it.
Psychopaths often indulge in these strange performances after drinking relatively little. They know perfectly well what they have done before when drinking and, with these facts squarely before their altogether clear and rational awareness, decide to drink again. It is difficult indeed for me to see any substantial grounds for placing the responsibility for the drinking psychopath's deeds primarily on alcohol instead of on the disorder which, in ways no less serious even if less spectacular, he shows also when entirely sober.
Although his most theatrical exploits in public are usually carried on when drinking, the psychopath, even after he has been free from all alcohol for months, as for instance, when he is in a psychiatric hospital, retains all the essential personality features which have been mentioned. These show little or no tendency to diminish when he cannot drink. These words translated from Aeschylus, "Bronze is the mirror of the form; wine of the heart," express something pertinent about alcohol and man, whether the man be ill or well.
All the curious conduct reported in patients who drank and who were presented here occurred in the absence of delirium tremens, alcoholic hallucinosis, or any other of the well-known psychoses due directly to intoxication. Of course, such psychotic conditions may occur in psychopaths and in neurotic drinkers. It is important to keep such symptoms separate, since they are clearly due to another type of mental disorder.
Most of this asocial, unacceptable, and self-defeating behavior associated with the psychopath's drinking seems to occur without the benefit of extreme inebriation. If actual confusion from alcohol prevailed or states of genuine amnesia were induced before the grotesque shenanigans began, intoxication could more plausibly be suspected of playing a larger causal role. The psychopath often reacts in this typical way while in perfect orientation, with unclouded awareness and in anything but the deeply drugged state thought by some to be a prerequisite.
For whatever reason the psychopath may drink, it is true that, in contrast with others who use alcohol to excess, he hits upon conduct and creates situations so bizarre, so untimely, and so preposterous that their motivation appears inscrutable. Many of his exploits seem directly calculated to place him in a disgraceful or ignominious position. He often chooses pranks and seeks out situations that would have no appeal for the ordinary person, whether the ordinary person be drunk or sober. The observer sometimes wonders if a truly astonishing ingenuity, or an actively perverse inventiveness is directing him, so consistently does he bring off scenes not only uncongenial but even unimaginable to the average man.
Furthermore, these exploits seem to such little purpose, almost as hard to understand on the assumption that they are for amusement or play as on the grounds of utility. One patient with numerous other outstanding incidents in his career, while sitting at a formal dinner party given by friends in honor of his birthday, turned coolly and spat with deliberation on the cake as it was brought to his side for him to cut.
One patient who developed typical symptoms early in life showed, long before he had ever touched anything alcoholic, prankish tendencies worth noting here. When taken into a store by his parents to be fitted with new clothes, he often allowed intestinal gas to pass quietly but with vivid olfactory manifestations. Considerable embarrassment and vexation were experienced by the clerks and by his parents, but he was never ruffled and apparently took mild or moderate pleasure in the situation. He occasionally resorted to these tactics while riding with his parents and dignified company in a car when the windows were tightly closed because of cold weather. A few times he discomfited his family considerably by the same means in church. At first the parents accepted his apologies after reprimands and they were inclined to believe his innocent-faced explanation that an involuntary lapse of control had occurred. The timing of events and the predilection for close places and special surroundings, as well as the emergence of other behavior, convinced them in time that these acts were deliberate.
Another young psychopath who had never encountered liquor of any sort did many things that would not attract the ordinary mischievous teenager. Finding time a little heavy on his hands (and his parents out of the house for a few hours), he took tools from the cellar and, working with no little skill and dispatch, got the connections of the bathroom toilet apart, put into the outlet pipe a small electric motor, and then carefully reconnected the fixture. The subsequent flooding, mess, trouble, and expense did not seem to give him hilarious mirth or vindictive satisfaction. Certainly he showed no evidence of such feeling in a degree to warrant his risking the punishment he received.
The pranks or buffoonery of the sober adult psychopath naturally differ somewhat from those typical of adolescence or earlier. With a few drinks the similarity of the adult's behavior often increases.
Despite the deep behavioral pattern of throwing away or destroying the opportunities of life that underlies the psychopath's superficial self-content, ease, charm, and often brilliance, we do not find him prone to take a final determining step of this sort in literal suicide. Suicidal tendencies have been stressed by some observers as prevalent. This opinion, in all likelihood, must have come from the observation of patients fundamentally different from our group, but who, as we have mentioned, were traditionally classified under the same term. It was only after a good many years of experience with actual psychopaths that I encountered my first authentic instance of suicide in a patient who could be called typical.
Instead of a predilection for ending their own lives, psychopaths, on the contrary, show much more evidence of a specific and characteristic immunity from such an act. This immunity, it must be granted, is, like most other immunities, relative.
Although suicide, then, cannot be named an impossibility among this group, its unlikelihood still merits strong emphasis. Since most psychopaths do not remain hospitalized or under other protective supervision, the rarity of this act becomes more significant. Also worth noting is the fact that most real psychopaths, not once or a few times but habitually, work themselves into situations that might strongly prompt the normal man to end his own life. Since suicidal threats, like promises and well-formulated plans to adopt a new course, are so frequently offered by these patients, there is good reason to keep in mind the fact that they are nearly always empty. Many bogus attempts are made, sometimes with remarkable cleverness, premeditation, and histrionics.
The psychopath's sex life invariably shows peculiarities. The opinion has already been expressed that homosexuality and the other specific deviations, though of course occurring in psychopaths, are not sufficiently common to be regarded as characteristic. Evidence of consistent, well-formulated deviation was extremely rare in a large group of male psychopaths personally observed in a closed psychiatric institution. Among male and female subjects seen as outpatients and in general hospitals, such complications, though more frequent, do not seem to be a distinguishing feature. If we take another viewpoint and consider the group who come or are sent to the physician primarily for sexual deviation, we find again some patients with behavior patterns resembling in various degrees that of the real psychopath. These patients are probably not typical of the deviate group as a whole, whose members much more frequently show different fundamental patterns of adjustment and maladjustment.
Unmistakable psychopaths who do not show evidence of strong or consistent deviated impulses but who nevertheless occasionally carry out abnormal sexual acts have been seen much more often than those in whom the two fundamental patterns seem to overlap. This is not surprising in view of the psychopath's notable tendencies to hit upon unsatisfactory conduct in all fields and his apparent inability to take seriously what would to others be repugnant and regrettable. The real homosexual seeking an outlet for his own impulses often finds it possible to engage the psychopath in deviated activities, sometimes for petty rewards, sometimes for what might best be called just the hell of it.
It has been said that some people whose sexual activities are normal under ordinary circumstances may, in the absence of normal opportunities, resort to immature or abnormal practices as a substitutive measure. It is not hard to believe that a man of orthodox sexuality, if stranded and alone for years on an uninhabited island, might develop impulses toward masturbation. Some studies of prisoners give the impression that mutual masturbation and far more abnormal relations occur in persons who, when not confined, sought only heterosexual intercourse.184,296 Surely every psychiatrist has seen people whose sexual aims are usually directed toward the other sex but whose orientation is so confused, and whose evaluation of sexual experience is so trivial, that they sometimes also engage in homosexual and other types of abnormal relations.
In psychopaths and in many other people who cannot be correctly placed with the well-defined homosexual group, there are varying degrees of susceptibility or inclination to immature or deviated sex practices. In contrast with others, the psychopath requires impulses of scarcely more than whimlike intensity to bring about unacceptable behavior in the sexual field or in any other. Even the faintest or most fleeting notion or inclination to forge a check, to steal his uncle's watch, to see if he can seduce his best friend's wife, or to have a little fling at fellatio, is by no means unlikely to emerge as the deed. The sort of repugnance or other inhibiting force that would prevent any or all such impulses from being followed (or perhaps from even becoming conscious impulses) in another person is not a factor that can be counted on to play much part in the psychopath's decisions.
The activities of a typical patient of this sort whom I once studied are highly illustrative. This 27-year-old man, honor graduate of a college despite great irregularity in his studies, had for a number of years followed a career so similar to those of the other patients cited that there is no point in going into detail. He showed no indications of ordinary homosexuality in manner, dress, physique, or in personality features. He had been rather active in heterosexual relations since about fifteen, his partners being professionals, girls of respectable family, and married women.
All of these relations had apparently been to him more or less equivalent and entirely without personal significance. He admitted having once or twice, and more or less experimentally, submitted to the wishes of a homosexual and also to a couple of blundering ventures into deviated activity while drinking with others apparently more like himself. These did not seem to give him any particular satisfaction, and there is reason to believe that he distinctly preferred what he did with women. To the patient, any idea that he might be a homosexual seemed absurd.
In the absence of any persistent or powerful urge in this specific direction, the patient, apparently without much previous thought, hit upon the notion of picking up four Negro men who worked in the fields not far from his residence. In a locality where the Ku Klux Klan (and its well-known attitudes) at the time enjoyed a good deal of popularity, this intelligent and in some respects distinguished young man showed no compunction about taking from the field these unwashed laborers, whom he concealed in the back of a pickup truck, with him into a well-known place of amorous rendezvous. At the place he chose, "tourists' cabins" were discreetly set up in such a way that women brought by men to them for familiar purposes could enter without the possible embarrassment of being identified by the management. Despite these facilities suspicion arose, and the patient was surprised by the man in charge of the resort while in the process of carrying out fellatio on his four companions. He had chosen to take the oral role.
He had often evaded penalties for antisocial acts in the past, and he had a good deal of easy confidence. Although he expressed regret and said his prank was quite a mistake, he seemed totally devoid of deep embarrassment.