The Mask of Sanity: An Attempt to Clarify Some Issues About the So-Called Psychopathic Personality is a book written by American psychiatrist Hervey M. Cleckley, first published in 1941, describing Cleckley's clinical interviews with patients in a locked institution. The text is considered a seminal work and the most influential clinical description of psychopathy in the twentieth century. The basic elements of psychopathy outlined by Cleckley have influenced later discussion and diagnosis.
The title refers to the normal "mask" that conceals the mental disorder of the psychopathic person in Cleckley's conceptualization.
Cleckley describes the psychopathic person as outwardly a perfect mimic of a normally functioning person, able to mask or disguise the fundamental lack of internal personality structure, an internal chaos that results in repeatedly purposeful destructive behavior, often more self-destructive than destructive to others. Despite the seemingly sincere, intelligent, even charming external presentation, internally the psychopathic person does not have the ability to experience genuine emotions. Cleckley questions whether this mask of sanity is voluntarily assumed to intentionally hide the lack of internal structure, but concludes it hides a serious, yet imprecisely unidentified, semantic neuropsychiatric defect.Cleckley, p. 238 Six editions of the book were produced in total, the final shortly after his death. An expanded fifth edition of the book had been published in 1976 and was re-released by his heirs in 1988 for non-profit educational use.
History
In the 1800s, Philippe Pinel first used the French term manie sans delire ("mania without delirium") to designate those individuals engaging in deviant behavior but exhibiting no signs of a cognitive disorder such as hallucinations or delusions. Although the meaning of the term has changed through numerous writings on the subject over time, the writing of Cleckley and his use of the label "psychopath" in The Mask of Sanity brought the term into popular usage.
Editions The first edition was published in 1941, with the subtitle then being 'An attempt to re-interpret' rather than as later 'to clarify'. Cleckley says in the preface that the book "grew out of an old conviction which increased during several years while I sat at staff meetings in a large neuropsychiatric hospital". He added that after commencing full-time teaching duties he found similar patients to be as prevalent in a general hospital, outpatient clinic and the community. In later editions he explains that the basic concepts presented in 1941 were based primarily on "adult male psychopaths hospitalized in a closed institution" for several years. Cleckley had worked for a number of years at a United States Veterans (military) Administration hospital, before taking up full-time teaching responsibilities at the University of Georgia School of Medicine.
The second edition published in 1950, Cleckley has described as a "new and much larger book", based on more diverse clinical observations, feedback and literature reviews. The third edition in 1955 he describes as having fewer changes and additions, but important clarifications to key concepts such as the hypothesis of a core semantic deficit. A fourth edition was published in 1964.
A fifth edition was published in 1976 () and is generally considered to be the definitive culmination of Cleckley's work. The preface does not specify the changes made. Unlike the first edition it states: "Dr. Corbett H. Thigpen, my medical associate of many years, has played a major part in the development and the revision of this work." Cleckley also states that it could not have been written without the assistance and contributions of Thigpen's wife and his own (first), both called Louise. A sixth edition was published shortly after Cleckley's death in 1984, but is described by others as having minimal substantive changes.A Critical Analysis of the Historical and Conceptual Evolution of Psychopathy By Andrew R. Stover. ProQuest, 2008. Chapter 4: Hervey Cleckley's The Mask of Sanity Several further years after Cleckley's death, another fifth edition () was released for non-profit educational use by Emily S. Cleckley, his second wife, naming her as well as Hervey M. Cleckley and copyrighted 1988 to her rather than Mosby as for all prior initial releases (which have been repeat published in various different years).
Description The Mask of Sanity, fifth edition, presents clinical theories as well as case studies, written in the form of dramatic, novelistic descriptions of 13 individuals, an amalgamation of those he had observed.
Initial outline The Mask of Sanity begins in Section One, "An Outline of the Problem", by considering the concept of sanity, which Cleckley describes as protean. The first words of the book are a possibly untrue anecdote ending with the line, capitalized and centered in large font, "WHO'S LOONEY NOW?" Cleckley suggests that everyone "behaves at times with something short of complete rationality and good judgment". He notes that many types of people hold beliefs that he and much of society would consider irrational, such as mysticism, pseudoscience, praising of unintelligible or immoral works (e.g. acclaim for the novel Finnegans Wake containing only "erudite gibberish" or for the writing of André Gide on pederasty), and religious faith. He argues, however, that these are personal freedoms and such groups are usually capable of leading useful lives in harmony with others. This he says distinguishes it from psychosis once fully developed and from psychopathy.
Classification schemes Cleckley also addresses the confusing traditions of classification in the area of psychopathy, a term he admits is itself confusing and not being used in line with its etymological meaning ('mental sickness'), though adopts it as the most familiar and apparently durable. He considers the terms sociopathic personality and antisocial personality, as adopted by the Diagnostic and Statistical Manual of Mental Disorders; the relationship to the overall category of personality disorder; and the earlier widespread concept of "constitutional psychopathic inferiority", disputing its hereditary assumptions. He states that the main purpose of the book is to bring a few cases before other psychiatrists, and also to raise the profile among the public, to enable better management of psychopaths. He criticizes the 'doctrine of permissiveness', and refers with regret to the lack of prominence of psychopathy in psychiatric textbooks.
Prevalence Cleckley argues under a subsection titled "Not as single spies but in battalions" (a phrase appearing in Hamlet), that although reliable statistics are hard to come by, there are various reasons to suspect both psychiatric and prison admission rates are an underestimate, and the incidence of the condition is in his opinion "exceedingly high". He does present some statistics from a survey whereby he and nine other psychiatrists diagnosed 1/8th of patients as having psychopathic personality without any other mental disorder that might explain the condition, and considers that quite a few others classified as alcoholic or drug addicted would actually have qualified too. Their survey is further detailed in the book's appendix, where Cleckley clarifies it took place between 1937 and 1939 at a federal Veterans Administration hospital, located on the Southeastern seaboard, for the care of ex-service men, mainly from World War I. He critiques the 'benign policy' of the VA of not diagnosing more psychopathic personality due to giving the benefit of the doubt to issues such as neurasthenia, hysteria, psychasthenia, posttraumatic neuroses, or cerebral trauma from skull injuries and concussions. He concludes they have "records of the utmost folly and misery and idleness over many years" and if considering the number in every community who are protected by relatives, "the prevalence of this disorder is seen to be appalling."
Method Finally, Cleckley asserts that the account provided in his book will accord with the scientific method, as pointed out by Karl Pearson in The Grammar of Science, which he loosely summarizes as: to record observed facts; group them together by correlation as distinguished from other facts; to try to summarize or explain in a way that indicates the significance. He also says his method takes inspiration from that used in an earlier work, The Psychology of Insanity, by English physician Bernard Hart (first edition published in 1912 and now open access).
Characteristics In Section Two, "The Material", Cleckley presents a typical "full" psychopath's behavior in a series of vignettes: originally nine in the first edition, and all male, but later editions expanded to 15 and included women.
For example, the psychopath can typically tell vivid, lifelike, plausible stories that are completely fraudulent, without evincing any element of delusion. When confronted with a lie, the psychopath is unflappable and can often effortlessly pass it off as a joke. In another typical case history, the psychopath is hospitalized for psychiatric treatment but because of his constant trouble-making, leaving wards in an uproar, the hospital is finally forced to turn him over to the police. Eventually, the police become so sick of his repeated antics that they try to hospitalize him again.
Also included are six vignettes of "Incomplete manifestations or suggestions of the disorder" in non-patients, such as "The businessman", "The gentleman" or "The physician".
Differentiation In Section Three, 'Cataloging the material', Cleckley continues the conceptual outline started in Section One, now termed 'Orientation'. He criticises the tenets of faculty psychology (now known as modularity of mind), arguing that such things as intelligence, morality and emotions are not separate parts in the brain but separate concepts we apply. He believes psychopaths would have been included in the 19th century concepts of 'mania without insanity' by Philippe Pinel and Prichard's moral insanity, but rejects their faculty basis. He notes the confusingly broad literal meaning and practical usage of the terms psychopathic personality or personality disorder, giving the example of the most authoritative textbook of the second quarter of the century, Psychopathic Personalities, by German psychiatrist Eugen Kahn.
He rails against the counterculture antihero and gives as an example the novelist Alan Harrington for suggesting a socially necessary role for psychopathy in modern times, calling the idea "perverse and degenerate". He also criticizes Freudian-inspired ideas about antisocial acts being caused by unconscious guilt. He also disagrees with theories of neurotic, emotional or paranoid problems in subtypes of psychopathy, as in his concept there is always a relative or complete lack of this. He says the new DSM "personality disorder, antisocial type" offers an accurate term equivalent to psychopathy which he thinks will also continue as a term for a long time.The Mask of Sanity, Fifth edition, pp 225 - 243
Psychosis Cleckley then considers how schizophrenia is different from psychopathy, having a defect in theoretical reasoning. He notes that schizoid disorders may appear more similar, and might be more accurately called "masked schizophrenia", which he notes can sometimes be difficult to differentiate from psychopathy. He also notes other 'disguises' of severe personality disorder, such as "cryptic depression" or "pseudoneurotic schizophrenia" or "pseudopsychopathic schizophrenia". He finds the diagnosis of "psychosis with psychopathic personality" unnecessarily confusing. He declares, "There is little point in devoting space to detailed accounts of paranoid or cyclothymic personalities."