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.), 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.
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." In the first edition Cleckley described his psychopathic patients as "frankly and unquestionably psychotic", but modified this in later editions. In the fifth edition he describes long ago changing his opinion and now agreeing with the psychiatrist
Richard L. Jenkins that this would stretch the definition of psychosis too far. However at various other points it is still suggested that, despite "traditional" classification, the extent of the inner abnormality and associated dysfunction in psychopathy is such that it might be considered a psychosis in many respects.
Criminality Cleckley draws important distinctions between the psychopath and non-psychopathic criminal. He states that the psychopath very seldom takes much advantage of any gain, has an obscure or inconsistent purpose, usually puts himself unnecessarily in a shameful position as much as causing trouble for others; and usually does not commit the most serious or violent crimes, but usually does end up harming himself. However, despite the general picture of weak-willed and inconsistent antisocial behavior, he also states, at least in later editions, that some may develop drives towards the most serious or sadistic crimes. He suggests this is a somewhat separate additional pathology but does not explain why or how. Cleckely considers that the concept of
delinquency has much in common with his concept of psychopathy, and argues that it could be considered a mild version of psychopathy if it continues for a long time and is generalized. He notes that many respectable mature productive citizens can look back on short periods of unprovoked social misconduct, including such things as property damage,
racism,
bestiality,
voyeurism, rebellion, and
promiscuity. On the other hand, he notes prolonged but prescribed behavioral disorder in the case of a woman who remained for some time "irrationally promiscuous and
bisexual", but who had plausible psychological reasons for her behavior and was otherwise functional in her work and life. He also notes he no longer considers that
homosexuality should be classed as sexual psychopathy, on the grounds that many homosexuals seem to be able to live productive lives in society. He considers that sexual
fetishes are not particularly consistent with psychopaths, as the latter tend to have weak drives. He then states that psychopathy can be associated with particular
sadistic drives and often be responsible for the most serious
sex crimes.
Other conditions He distinguishes psychopaths from non-psychopathic
alcoholics, who by contrast have a purpose for drinking such as to avoid reality, and may want and try to change, whereas the psychopath appears to drink simply to behave outrageously and get into trouble. He also separates
psychoneurotics (though accepts there may sometimes be overlap) and "
mental defectives" (who unlike the psychopath will test poorly on theoretical intelligence tests as well as in behavior in life). The psychopath does not suffer from any obvious mental disorder but in the end seems to deliberately court failure and disaster for no obvious reason and despite intelligence, in what Cleckley calls a social and spiritual suicide. Cleckley then considers whether psychopathy may be erratic
genius. In surveying some noted literary works embodying what he describes as "malignantly perverse attitudes", such as by
Paul Verlaine,
Dostoevski,
Marquis de Sade,
Baudelaire and
Swinburne (some associated with the
Decadent movement), he suggests that it might be a form of psychopathy, and might appeal to similarly disordered people or to "new cults of intellectual defeatists and deviates" such as certain
avant garde groups. However he concludes that such artworks and sexual deviations are more likely due to
schizoid disorder with
misanthropy and life perversion, whereas the "true psychopath" would not labor to produce art extolling pathologic or perverse attitudes; on the contrary, they would tend to superficially proclaim belief in a normal, moral life. However, Cleckley then suggests that initial potential for greatness and emotional depth may cause problems, such as being more affected by problems in life, that then leads into psychopathy.
Fiction and ancient history Cleckley then surveys numerous characters in fictional works that he considers to be portrayals of psychopathy. He concludes by addressing figures in history, excluding
Adolf Hitler and others from his definition but highlighting
Alcibiades, a
military general and politician in
Ancient Greece. He describes a fascination with him growing out an old conviction in the "paradoxical" nature of his life, since learning of it in high school. He concludes that Alcibiades "had the gift of every talent except that of using them consistently to achieve any sensible aim or in behalf of any discernible cause" and he "may have been a spectacular example of...the psychopath", that "still inexplicable pattern of human life".
Profile Cleckley then summarizes the material and provides a 'clinical profile', describing 16 behavioral characteristics of a psychopath (reduced from 21 in the first edition): •
Superficial charm and good intelligence • Absence of delusions and other signs of irrational thinking • Absence of nervousness or
psychoneurotic manifestations • Unreliability • Untruthfulness and insincerity • Lack of
remorse and
shame • Inadequately motivated
antisocial behavior • Poor judgment and failure to learn by experience • Pathologic
egocentricity and incapacity for
love • General poverty in major affective reactions • Specific loss of
insight • Unresponsiveness in general interpersonal relations • Fantastic and uninviting behavior with drink and sometimes without •
Suicide threats rarely carried out •
Sex life impersonal, trivial, and poorly integrated • Failure to follow any life plan. Some of the criteria have obvious
psychodynamic implications, such as a lack of remorse, poor judgment, failure to learn from experience, pathological egocentricity, lack of capacity for love, a general poverty in major affective reactions, and lack of insight into his own condition.
Pathology and causes In Section Four, "Some Questions Still Without Answers", Cleckley discusses his concept of "semantic" dementia (used today to refer to a
medical disorder unconnected to Cleckley's meaning) or, in later editions, semantic disorder or deficit. He referred to a
hypothesized neurological condition which would be the underlying
pathology linking together and explaining all the different personalities classed as psychopathy by Cleckley. By semantic he meant the ability to emotionally experience or understand "the meaning of life as lived by ordinary people". He acknowledged there was no proof or even evidence that this was the underlying condition, but believed that it helped explain the traits and behaviors he observed. As an example to explain the kind of distinction he was drawing between an ability to appear superficially normal despite a core deficit in meaning, he made an
analogy to a neurological
language disorder known as semantic
aphasia. Cleckley concludes from his clinical experience that the cause of the disorder of psychopathy is probably not, in general, demonstrably
psychodynamic or even
psychogenic, although life influences may play a role in some cases and he notes the progression of the disorder can seem like a kind of social and spiritual (but not actual) suicide, or "semi-suicide". He suggests rather that a subtle yet profound defect at a fundamental biological level, probably
inborn in some sense but not
hereditary (gives the example of
agenesis of the
embryo) could be the main cause. He admits "This, too, is still a speculative concept and is not supported by demonstrable evidence." Having called it a defect, he notes that it would be "one that affects complex mechanisms of integration in a subtle and abstruse manner", and as such could actually sometimes be a positive trait or ability which could nevertheless end up bringing about personal problems in society.
Treatment or control Cleckley writes in the fifth edition that he remains, since before the first edition, profoundly struck both by the lack of response to treatment of those he classes as psychopathic, and by the legal difficulty of trying to detain them in hospital. While noting the issue of the protection of liberty, he argues that better ways must be found to do the latter for their own good and that of society, on the primary basis of demonstrated disability and need, perhaps within psychiatric units but segregated from other patients. He notes that neither psychological therapy or physical methods such as
shock therapy or
lobotomy appear to be a real solution to the problem, but suggests that more opportunity to control and direct the person may help psychiatrists treat them in the long-run. He also considers the issue of
competency hearings and the
insanity defense when crimes are committed. He expresses concern that his prior equating of psychopathy with psychosis was not intended to imply that psychopaths should be automatically found not guilty. However he also expresses dissatisfaction with sending psychopaths to prison which he believes will inevitably fail to correct the behaviour due to the underlying abnormality or masked 'insanity'. ==Reception and legacy==