Psychopaths: The Mask of Sanity

Elsewhere I’ve suggested narcissism as perhaps the oldest of recognized personality disorders, as Greek and Roman poets had given us the myth standing behind it, and were musing about it 2000 years ago.

But psychopathy is also one of the more established personality disorders. And though it’s practically disappeared from the DSM, it too can claim some original basis. For in the clinical tradition of American psychology it might be seen as the prototypic personality disorder. For the term “psychopathy,” 100 years ago (in Schneider’s 1923 nomenclature) referred to all forms of personality disorder.

So what happened to psychopaths in the view of American psychology? How did psychopathy become replaced by another diagnostic construct in the American Psychiatric Association’s official manual of mental disorders? The clues lead back to 1941—11 years before the first edition of the Diagnostic and Statistical Manual of Mental Disorders will appear in print.

What appears in 1941 is another book. It’s entitled The Mask of Sanity. Its author, Hervey M. Cleckley, is an American-born psychiatrist. His book is about to make him the seminal modern figure in understanding psychopathy. Cleckley portrays psychopaths as “outwardly a perfect mimic of a normally functioning person, able to mask or disguise the fundamental lack of personality structure, an internal chaos that results in purposeful destructive behavior, often more self-destructive than destructive to others.”

Cleckley derives a checklist of 21 psychopathic features (later reduced to 16). And when DSM-1 appears in 1952, it includes a portion of these features, and links them to other contributors who are all pursuing a “sociopathic personality disturbance,” one variation of which is the “antisocial reaction.” Such persons were said to be “chronically anti-social.”

In retrospect, what we can see already is a psychiatrist with a well-developed vision of psychopathy, and a new manual in search of what was to become an “antisocial personality disorder,” though in hindsight, it wasn’t to throw off its original construct of a sociopathic disorder for another 28 years.

When DSM-2 appeared in 1968, “anti-social” was expanded, but this time, adhering closer to Cleckley’s checklist. In other words, now we had the world’s leading authority on psychopaths being used for an expanded version of a construct starting off as sociopathy, and now veering toward an antisocial personality disorder—using Cleckley’s traits for the expansion. This was a confusing problem. It was going to get worse…

1980 was a significant marker in what I’m reflecting. Prior to DSM-3’s appearance in that year, the diagnosis of mental disorders was notoriously unreliable, and based on clinicians providing a narrative paragraph description of an allegedly prototypic case. No specific or explicit guidelines were provided as to which features were necessary to make the diagnosis, or how many to consider for it to be valid.

The further development of the “Antisocial” disorder had also reached a tipping point, for it finally threw its “sociopathic” construct overboard. And the further development of “Antisocial” was largely shaped and informed by L. Robins’s study of 524 persons who were last seen 30 years earlier, when Robins had worked at a child guidance clinic for juvenile delinquents; which was a study that she closely aligned with Cleckley’s conception of psychopathy.

Despite her intention of being closely allied with Cleckley (which might tell you how highly he was regarded by those toiling in what was ostensibly the same field) there were notable differences in her 19-item list. On the positive side, she eliminated at least one of Cleckley’s more questionable items: “going out of their way to make a failure of life;” while retaining a number of Cleckley’s key traits such as: no guilt and pathological lying. (As key italicized psychopathic traits enter this account, note which that seem to mirror Trump).

However, missing from her list were equally key traits of psychopaths that Cleckley had already captured, notably: no sense of shame, not accepting blame, inability to learn from experience, egocentricity, inadequate depth of feeling, and lacking in insight. Robins also applied an indelicate brush stroke by suggesting that the lack of guilt was among the least of valid criteria.

Forgive the editorializing, but my takeaways here are already several. First, when you have Michelangelo long at work at a definitive project, you don’t send a gal who flicked her brush at the juvee hall 30 years prior, to come brush over the finishing touches on the Sistine Chapel.

Next is my appreciation for Cleckley’s clinical vision; and that if you just read the 8 italicized traits listed in the above 2 paragraphs, it’d give you a clearer portrait of say, Donald Trump for example, than what ASPD provided—and that’s without some of Cleckley’s other psychopathic traits added to the mix.

And with Robins on board now as a member of DSM-3’s personality disorder work group, the group was once more trying to improve the prior group’s stab at an antisocial personality disorder…