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Psychopath

THE MASK OF SANITY

Section 3: Cataloging the Material

Part 2: A comparison with other disorders

32. The psychoneurotic

 

 

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32. The psychoneurotic

People who suffer from personality disorders which cause them to be anxious,

restless, unhappy, and obsessed with thoughts they themselves recognize as absurd but

who are, in the lay sense, altogether sane have for years been classed as psychoneurotic.

They recognize reason in general, often admit that their symptoms arise from emotional

conflicts, and are free from delusions and hallucinations.

Sometimes their complaints are chiefly physical, of fatigue, of numbness, of

indigestion, even of paralysis. Often they will not admit that this numbness or

indigestion or paralysis could possibly be related to emotional difficulty and indeed they

themselves may be unaware of conflict. They are often resistant to reasoning but more

in the sense of a person with strong prejudices than of one with delusions or with

intellectual dilapidation. Sometimes they feel strong fears that they may carry out acts

which they dread and which would indeed be tragic or criminal, but they recognize the

nature of these acts and do not carry them out. Other acts, all patently senseless but

relatively harmless, they do carry out, recognizing

CATALOGING THE MATERIAL 257

the absurdity of feeling that they must do so but becoming anxious if they resist the

impulse.

In general, psychoneurotic people recognize objective reality and try to adapt

themselves like most others to the ways of society. Patients with traditional

psychoneurosis are not characterized by antisocial activity or by striking inability to

pursue ordinary goals. Their symptoms handicap them often, but in a way we readily

understand. Anxiety, for instance, can make special difficulties for a salesman or

obsessive manifestations can handicap a banker, a scholar, or a housewife. These

patients as a group are sharply characterized by anxiety and by the various symptomatic

schemes that apparently arise from the anxiety and that look as if they were measures

employed in reaction to the anxiety and in efforts to relieve it, it is true that many

patients with conversion symptoms do not show what is ordinarily conveyed by the

word anxiety or by tension, fear, distress, and similar terms. Many psychiatrists believe that

in such instances the paralysis (or the blindness) may be a substitute for conscious

anxiety and probably a defense against it, a means of preventing it or controlling it. The

rather remarkable calmness shown by such patients has often been pointed out. Not a

few psychopathologists maintain that there is an "unconscious anxiety" or what might

be thought of as something embryonic, underlying, or incipient that would be anxiety if

not converted into the physical manifestation.

Certainly it may be said about psychoneurosis, as the term is officially used and

most widely accepted, that patients with this kind of disorder usually find their

symptoms unpleasant, consciously suffer from them, and complain.

On the contrary, those called psychopaths are very sharply characterized by the

lack of anxiety (remorse, uneasy anticipation, apprehensive scrupulousness, the sense of

being under stress or strain) and, less than the average person, show what is widely

regarded as basic in the neurotic. It is very true that Alexander9,11 and others79,209 who

use his terminology and accept his interpretations refer to behavior disorders as

character neuroses. Karpman164 feels that most (but not all) patients who are classed as

psychopaths should be grouped with the neurotic or the psychotic group. So far as its

implication of causal factors is concerned, the term neurotic has undeniably valuable

applications for those who feel that they have discovered such causes; but its tendency

otherwise to identify the psychopath with hysteria, anxiety reactions, or ordinary

obsessive-compulsive disorders is likely to cause confusion and make for practical

difficulties.

If the psychopath really has a neurosis, it is a neurosis that is manifested in a

fundamentally different life-pattern from classic neurosis, manifested,

258 THE MASK OF SANITY

one might say, in a pattern that is not only different but opposite. Alexander and others

have made this quite clear, and the interpretation of the psychopath's behavior as

symptomatic "acting out" against his surroundings, in contrast with the development of

anxiety or headache or obsession is, it seems to me, an interesting formulation. It is of

obvious importance to respect this polar difference between how the psychopath is

going to behave socially and what can be expected of patients with somatization

conversion. I do not believe that psychopaths should be identified with the

psychoneurotic group, for this would imply that they possess full social and legal

competency, that they are capable of handling adequately their own affairs, and that they

are earnestly seeking relief from unpleasant symptoms.

There are disorders in which the two diverse types of reaction (developing

subjectively unpleasant symptoms versus callously carrying out socially destructive acts)

seem to exist in the same symptom. The so-called pyromaniac (and kleptomaniac) often

seems motivated by forces similar to the classic obsessive-compulsive patient who

corrects the alignment of objects on the bureau forty times a day and who is painfully

and overscrupulously preoccupied with fears that he may harm his child. Such a patient

detests the acts he carries out as a sort of ritual to mitigate his subjective distress and is

by no means likely to harm the child. He is, in fact, horrified by these thoughts (fears)

and is nearly always conscientious to an excessive degree.

On the other hand, as Fenichel has pointed out, the patient abnormally impelled

to commit arson or theft (or sex murder) is not committing an act in which scrupulous

feelings play a direct or major role and (despite possible ambivalence) gains excitement

and consciously satisfies strong drives. The distinction emphasized by Fenichel between

ego-syntonic and ego-alien motivations (compulsive acts of caution versus so-called

"compulsive" antisocial acts) is a fundamental point and brings out a distinction not

merely of degree but of quality. Behavior that Fenichel classifies as impulse neurosis

seems to lie in an area where the unlike (and, as a rule, mutually exclusive)

manifestations of the psychopath and the classic obsessive-compulsive patient both play

a part together, the two customary opposites approaching and perhaps merging,

paradoxically, in the antisocial act.79,254

This particular mingling of influences (or merging of pictures) ordinarily quite

different (and mutually exclusive) is not unique in psychiatry. Is there any one who has

not seen patients manifesting genuine manic and genuine catatonic features? Has any

psychiatrist failed to note obsessive relations that are colored with genuine delusion?

Despite any confusions that arise in arguments about psychopathology

CATALOGING THE MATERIAL 259

(dynamic or descriptive) in regard to the psychopath, all, I believe, will agree that his

clinical manifestations are easily distinguished from the syndromes now classified as

psychoneurosis. It is doubtful if in the whole of medicine any other two reactions stand

out in clearer contrast.

The true psychopaths personally observed have usually been free, or as free as the

general run of humanity, from real symptoms of psychoneurosis. The psychoneurotic

patient, furthermore, is usually anxious to get over his symptoms, while the psychopath

does not show sincere evidence of regretting his conduct or of intending to change it.

Caldwell has effectively set down outstanding differences between these two

clinical pictures in a brief tabulation. Our point can be clarified by quoting it:39

Feeling Thinking Acting

1, Ego-enhancement

(psychopathic)

Hedonistic

Callous

Emotionally immature

Irresponsible

Rationalistic

Antisocial

Impulsive

Defiant

Explosive

2. Ego,depreciation

(neurotic)

Apprehensive

Anxious

Fearful

Depressed

Helpless

Inferior

Jealous

Stereotyped in fantasies

Preoccupied with moral

and religious ideas

Obsessive

Antisocial

Asocial

Shy, sensitive

Hesitant

Indecisive

Suggestible

Overly protective

Sexually conditioned

Timorous

Passive

Some observers believe that the presence of what has long been known as

psychoneurosis is sufficient reason for questioning the diagnosis of psychopathic

personality. In the study just referred to, Caldwell reports neurotic manifestations in

patients whose chief features were plainly those of the psychopath. I believe that the

two types of reaction are not characteristically seen together but perhaps there are no

two pathologic syndromes in psychiatry, however distinct, that may not sometimes

overlap.

 

Next: Section 3: Cataloging the material, Part 2: A comparison with other disorders, 33. The mental defective

 

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Section 3, Part 2

 

  • Psychopath Hervey Cleckley THE MASK OF SANITY, Section 3: Cataloging the material , Part 2: A comparison with other disorders, 29. Purpose of this step
    Psychopath Hervey Cleckley THE MASK OF SANITY, Section 3: Cataloging the material , Part 2: A comparison with other disorders, 29. Purpose of this step, Some material has been presented in which manifestations of the disorder occur. It is our task to arrange it in such a way that its features can be seen clearly and compared with the features of other disorders. Such a step should be helpful in our efforts to recognize what we are dealing with and to evaluate it. Let us compare these patients known as psychopaths with others showing clinical illness and deviated reactions or patterns of living. Significant details should emerge, differentiation should become clearer, and distinguishing features of our subject should become more apparent at energyenhancement.org

 

 

 
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