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The Mask of Sanity The Mask of Sanity

~An Attempt to Clarify Some Issues About the So-Called Psychopathic Personality

Non teneas aururn totum quod splendet ut aururn. ALANUS DE INSULIS

Hervey Cleckley, M.D.

Clinical Professor of Psychiatry, Medical College of Georgia, Augusta, Ga.; author of The Caricature of Love and of The Three Faces of Eve (with Corbett H. Thigpen)

Fifth Edition: private printing for non-profit educational use

Fifth Edition Copyright 1988 Emily S. Cleckley

Previous edition copyrighted 1941, 1950, 1955, 1964, 1976 by the C.V. Mosby Co.

From chaos shaped, the Bios grows
In bone And viscus broods the Id

To L. M. C.

And who can say Whence Eros comes?

Or chart his troubled way?

Nor bearded sage, nor science, yet has shown

How truth or love, when met, is straightly known;

Some phrases singing in our dust today

Have taunted logic through man's Odyssey:

Yet, strangely, man sometimes will find his own.

And even man has felt the arcane flow

Whence brims unchanged the very Attic wine, Where lives that mute and death-eclipsing glow

That held the Lacedaemonian battle line:

And this, I think, may make what man is choose The doom of joy he knows he can but lose.



THE FIRST EDITION of this book was based primarily on experience with adult male psychopaths hospitalized in a closed institution. Though a great many other psychopaths had come to my attention, most of the patients who were observed over years and from whom emerged the basic concepts presented in 1941 were from this group. During the next decade a much more diverse group became available. Female patients, adolescents, people who had never been admitted to a psychiatric hospital, all in large numbers, became available for study and afforded an opportunity to observe the disorder in a very wide range of variety and of degree.

This additional clinical experience, helpful comment in the reviews of the first edition, enlightening discussion with colleagues, and an improved acquaintance with the literature all contributed to modify concepts formulated approximately ten years earlier. In attempting to revise the book for the second edition (1950), I found it was impossible to do justice to the subject by minor additions, deletions, and modifications. It was necessary to write a new and much larger book.

For the third edition, published in 1955, fewer alterations and additions were necessary. But a number of important changes were made. Some reviewers led me to feel that in previous editions I failed to convey accurately or adequately the concept I had formed. It is not easy to convey this concept, that of a biologic organism outwardly intact, showing excellent peripheral function, but centrally deficient or disabled in such a way that abilities, excellent at the only levels where we can formally test them, cannot be utilized consistently for sane purposes or prevented from regularly working toward selfdestructive and other seriously pathologic results. Impressed by its effectiveness as used by Henry Head to distinguish a complex, deep, and obscure type of aphasia, I chose the term semantic to indicate my concept of a personality disorder which appears to have, at least hypothetically, some important similarities. A few readers were misled by my use of the term semantic to believe I claimed that the basic pathology in this disorder, or its cause, is deficiency in the understanding of speech or some other linguistic difficulty. Some comments, on the other hand, gave me the impression that it was assumed I had found fault with the psychopath viii PREFACE TO FIFTH EDITION because he could not achieve a final and absolute understanding of life's meaning at levels more or less eschatological. I restated my concept with the aim of making it more explicit, with the hope of being more articulate.

Since the first edition of this book, revisions of the nomenclature have been made by the American Psychiatric Association. The classification of psychopathic personality was changed to that of sociopathic personality in 1958. In 1968 it was changed again to antisocial personality. Like most psychiatrists I continue to think of the people who are the subject of this book as psychopaths and will most often refer to them by this familiar term. Sociopath or antisocial personality will sometimes appear, used as a synonym to designate patients with this specific pattern of disorder.

Although I spared no effort to make it plain that I did not have an effective therapy to offer, the earlier editions of this book led to contact with psychopaths of every type and from almost every section of the United States and Canada. Interest in the problem was almost never manifested by the patients themselves. The interest was desperate, however, among families, parents, wives, husbands, brothers, who had struggled long and helplessly with a major disaster for which they found not only no cure and no social, medical, or legal facility for handling, but also no full or frank recognition that a reality so obvious existed.

Telephone calls from Chicago, Denver, Boston, and The West Indies and letters from Miami and Vancouver have convinced me that the psychopath is no rarity in any North American community but that his problem is, by what seems to be an almost universal conspiracy of evasion, ignored by those therapeutic forces in the human group that, reacting to what is biologically or socially morbid, have sensibly provided courts, operating rooms, tuberculosis sanatoriums, prisons, fire departments, psychiatric hospitals, police forces, and homes for the orphaned, the ill, the psychotic, and the infirm. The measures taken by the community to deal with illness, crime, failure, contagion are, one might say, often far from perfect. It cannot, however, be said, except about the problems of the psychopath, that no measure at all is taken, that nothing exists specifically designed to meet a major and obvious pathologic situation. Communications from physicians, sociologists, psychologists, students, and others from Europe, some from countries behind the Iron Curtain, and also from India, Australia, and other distant parts of the world continue to arrive. One interesting, stimulating and deeply appreciated comment came a few years ago from a physician stationed in Antarctica. These communications convince me that the psychopath presents an important and challenging enigma for which no adequate solution has yet been found.

Although still in the unspectacular and perforce modest position of one who can offer neither a cure nor a well-established explanation, I am encouraged by ever increasing evidence that few medical or social problems have ever so richly deserved and urgently demanded a hearing. It is still

PREFACE TO FIFTH EDITION ix my conviction that this particular problem, in a practical sense, has had no hearing.

adequately, or even cogently, with the psychopath

Although I still have no effective treatment to offer for the psychopath (antisocial personality), it has encouraged me to feel that this book has, perhaps, served a useful purpose in making clearer to the families of these patients the grave problems with which they must deal. Apparently many psychiatrists, and many other physicians, have over the years advised relatives of psychopaths to read The Mask of Sanity. The response of these relatives has given me deep satisfaction and has helped me to feel that efforts to pursue this study are not in vain. Although we may still be far from the goal of offering a cure, perhaps something has already been done to focus general interest on the problem and to promote awareness of its tremendous importance. This must be accomplished, I believe, before any organized attempt can be made by society to deal

Even now, thirty-four years after the first edition of this book was published, I often receive several letters a week from wives, parents, brothers, or other kinsmen of psychopaths. Most of these letters help me to feel that this book has at least enabled many people to see more clearly and realistically the nature of the problem with which they have had to deal blindly and in a strange and almost unique confusion. These correspondents often tell me that this book has been of great value in helping them understand better the disorder of a husband, wife, child, or sibling and plan more realistically and effectively to deal with situations heretofore entirely unpredictable and incomprehensible. I am most grateful for these generous and gracious expressions of approval. The many hundreds of letters thanking me for even such a modest achievement encourage me to feel that a fifth edition may be worthwhile and that it deserves my most serious thought and concern.

It is a privilege to thank friends, colleagues, and others who have given me help and encouragement in formulating my concepts and in preparing material for this book.

It could not have been written without the constant assistance of my wife, Louise

Cleckley, who devoted many months of her time over the years not only to the routine of typing and proofreading but to the mutual effort of shaping the essential concepts to be presented into articulate form. Her notable contributions included stimulus, encouragement, and a wisely critical presence during the conative and affective fluctuations apparently inescapable in such a task. They were given in such quality as to be acknowledged as genuine psychotherapy.

Dr. Corbett H. Thigpen, my medical associate of many years, has played a major part in the development and the revision of this work. His observations and his thought, available to me during innumerable pleasant and stimulating hours of discussion, have assisted and profoundly influenced my own conclusions. Without his limitless generosity in relieving me over x PREFACE TO FIFTH EDITION long periods of heavy and urgent responsibilities in teaching and in clinical activity, it would have been impossible for this volume to be written. My debt to him in this, and my gratitude, I can acknowledge but cannot fittingly express.

For similar assistance I am also grateful to my other medical colleagues, Dr. B.

F. Moss, Dr. Jere Chambers, and Dr. Seaborn S. McGarity, Jr. Aid in clarifying several important points was given me also by John Creson and by Wayne Thigpen. In the preparation of the fourth edition Cornelia C. Fulghum's generous and effective efforts were indispensable. It is a pleasure also to express appreciation to Marilyn York, Linda Tingle, Patricia Lilly, and Patricia Satcher, secretaries who very kindly and effectively aided me on many occasions, and to my daughter, Mary Cleckley Creson, whose support has been constant and of inestimable value.

The long-delayed appearance of this fifth edition of The Mask of Sanity would not have been possible except for the generous and superb contribution of Louise Thigpen. Her efforts in assisting me to organize scattered items of material, to formulate and present more effectively concepts still unclear in the script, will be held in memory by me, with admiration and with deep gratitude. Her work in typing difficult copy against deadlines and her sagacity in steering me clear of equivocations, and of blunders under pressure, were extraordinary and indeed beyond the call of duty. Her part in this revision of The Mask of Sanity I acknowledge and value as a genuine and gracious collaboration.

THE PRESENT VOLUME grew out of an old conviction which increased during several years while I sat at staff meetings in a large neuropsychiatric hospital. Many hundreds of such cases as those presented here were studied and discussed. The diversity of opinion among different psychiatrists concerning the status of these patients never grew less. Little agreement was found as to what was actually the matter with them. No satisfactory means of dealing with them was presented by any psychiatric authority, and meanwhile their status in the eyes of the law usually made it impossible to treat them at all. They continued, however, to constitute a most grave and a constant problem to the hospital and to the community.

Since assuming full-time teaching duties at the University of Georgia School of

Medicine, I have found these patients similarly prevalent in the wards of the general hospital, in the outpatient neuropsychiatric clinic, and in consultation work with the various practitioners of the community and with the hospital staff. The overwhelming difficulty of finding facilities for their treatment has been no less urgent than the yet unanswered question of what measures to use in treatment. How to inform their relatives, the courts which handle them, the physicians who try to treat them, of the nature of their disorder has been no small problem. No definite or consistent attitude on the part of psychiatric authorities could be adduced in explanation; no useful legal precedent at all could be invoked, and no institutions found in which help might be sought by the community.

I should like here to express my appreciation for their encouragement and guidance about this and about other neuropsychiatric problems to Dr. R. T. O'Neil, Dr. William M. Dobson, Dr. M. K. Amdur, Dr. O. R. Yost, and Dr. M. M. Barship. To all of them as colleagues, and in varying degrees as teachers, during my years with the United States Veterans Administration, I am sincerely grateful.

Dr. John M. Caldwell, of the U.S. Army Medical Corps, Dr. Cecile Mettler, Dr.

Phillip Mulherin, Dr. F. A. Mettler, Dr. Lane Allen, and Dr. Robert Greenblatt, all of the faculty of the University of Georgia School of Medicine, I should like to thank for their interest and helpful criticism in the preparation of this work. Nor can I fail to mention here the kindness and xii PREFACE TO FIRST EDITION active cooperation of other departments in the School of Medicine which, though less directly related to the present study, have been a valuable and constant support to the Department of Neuropsychiatry. Though I name only a few, I should especially like to express appreciation to Dean G. L. Kelly, Dr. J. H. Sherman, Dr. C. G. Henry, Dr. E. E. Murphey, Dr. Perry Volpitto, Dr. R. F. Slaughter, Dr. R. H. Chaney, Dr. W. J. Cranston, Dr. H. T. Harper, Dr. Lansing Lee, and Dr. J. D. Gray. The interest and understanding shown by these and others in the problems of the newly organized full-time Department of Neuropsychiatry have been more helpful than they know.

To Dr. Lawrence Geeslin, Dr. C. M. Templeton, Dr. Joe Weaver, Dr. Alex Kelly, and Dr. DuBose Eggleston, all of the Resident Medical Staff at the University Hospital, I am grateful for their fine and wise efforts to make neuropsychiatry an effective influence on the wards of a general hospital.

It is hard to see how the present manuscript could have reached completion without the understanding and energy contributed to its making by my secretary, Miss Julia Littlejohn.

Mr. Berry Fleming and Mr. Donald Parson, one as a distinguished novelist and one as a poet, but both sharing the psychiatrist's interest in human personality, have kindly made available to me their valuable points of view.

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