science notes / book review

Antisocial personality disorder and Hervey Cleckley's The Mask of Sanity

Is psychopathy a disease? What are the differences between psychopaths, sociopaths, and psychotics?
by T.J. Nelson


W hether we recognized them as such or not, we have all known psychopaths. Indeed, after reading the research literature on the subject, it seemed that a sizable number of my friends and co-workers, the majority of my relatives and neighbors, all my bosses, and every politician who ever lived would be classified as a psychopath.

The challenge we face is that assessment of others' mental states as pathological means passing judgment on their behavior, so discussion of sociopaths and psychopaths always turns political. To some extent this is true of all personality disorders. But it is especially true of disorders that have a negative connotation: disgruntled employees may characterize their bosses as psychopaths and vice versa.

But there is evil in the world. Most people would agree that John Wayne Gacy and Jeffrey Dahmer were psychopaths. But to say that about a political figure like Vladimir Putin or Saddam Hussein is more problematic. Calling political leaders psychopaths transfers responsibility from the political system to the leader. If we call Stalin a psychopath, people can conclude that we are saying communism was not really evil, and the USSR just got unlucky.

Hervey Cleckley

Dr. Hervey Cleckley hypothesized that psychopaths have a functional brain defect that prevents them from feeling affinity with other humans. He likened it to a type of aphasia, where instead of an inability to recognize speech it was empathy and remorse that are impaired. They do not hear voices—unlike psychotic patients, they are fully connected to reality—but the part of their brain that allows them to imagine that another person exists or may be suffering is simply not functioning.

Cleckley's book is available online as a PDF file. It was originally published in 1941; the fifth edition (1988) was published four years after his death. His writing is easily understandable by a layman. Much of it consists of case studies from which he tries to differentiate the concept from other behavior patterns. His idea of a psychopath as someone with a deficiency in ability to feel empathy, extreme egocentricity, and poor self-control has been very influential.

Some people are of the opinion that Hitler, Stalin, and Saddam Hussein were psychopaths, and a certain other wanna-be dictator, whose name is all too familiar to us, may also be one.

Psychopaths gravitate to power, and corrupt political systems attract psychopaths. Attributing the evils of these men to psychopathology instead of ideology has become popular. It is natural to try to enlist every available weapon in the fight against tyranny. But declaring tyrants to be psychopaths puts your case against them on thin ice: if your opponent can prove the dictator is not a psychopath, then since you have implicitly conceded that ideology is irrelevant, it means the dictator was just exhibiting the characteristics of his native culture. Cultural relativism takes care of the rest.

Psychopaths vs. Sociopaths

For many reasons, then, we need to know what makes a person a psychopath. Unfortunately the DSM-5 has muddied the waters by conflating sociopathy and psychopathy under the blanket term antisocial personality disorder, or ASPD. Some psychologists believe there is significant overlap between the two. However, to criminologists, they are completely different. What's the difference?

Sociopaths are are often uneducated and unable to hold a job. By contrast, a psychopath can be well educated, employed, often charismatic, even a leader, but has no ability to feel affinity with other humans. Psychopaths regard people as things—toys for their own amusement. They lie without guilt. Unlike narcissists, psychopaths know they're lying, but they just don't care.

In other words, a sociopath will push you in front of a subway train because he or she hates you. A psychotic will do it because they think you are a monster. A psychopath will do it just for fun, and will dismiss it afterward as inconsequential.

In unguarded moments, psychopathic parents will say to their children: “You are not a person—you're a thing!” They will psychologically or physically abuse the child. A child growing up under such circumstances is surprised to learn that this is not how every parent talks and, not having learned that there is such a thing as parental love, may abuse their own children. Thus, psychopathic parents => sociopathic children.

Criminologists often call criminals sociopaths, while psychologists define them as being similar to psychopaths. Sociopaths are often victims of childhood abuse, and exhibit impulsive behavior and have impaired social response.

By contrast, psychopaths can seem almost lobotomized. But contrary to myth, not all psychopaths are mass murderers. Cleckley gives an example of a boy who falsely claimed, for no apparent reason, to have read all of Dickens' works. When confronted with proof to the contrary, he casually admitted making it up. Cleckley compares this to a person who was seen reading an earlier edition of his book, The Mask of Sanity, in court during his murder trial [p.267]. This is classic for a psychopath: a perfectly normal, and even perhaps somewhat laudable action in a context that demonstrates a lack of capacity for empathy or remorse.

Is psychopathy a disease?

The remarkable thing about psychopaths is how little their disorder shares with other psychopathologies. Indeed, Cleckley recognized that these patients cannot be diagnosed with any mental disorder, yet they made up a surprisingly high percentage of institutionalized patients. In many cases, it was clear that they were only pretending to have a psychiatric problem in order to get out of prison.

Today most of Cleckley's subjects would probably not be diagnosed as psychopaths. Psychologists would search for hidden motivations. The patients might, for example, have a subconscious desire to sabotage their own success. For whatever reason, the person derives some benefit out of failing and causing trouble. In particular, we are not supposed to diagnose juveniles as psychopaths—only with conduct disorder or oppositional defiant disorder. This is not to say psychopaths shouldn't be locked up when they commit a crime. The question is where.

Because it's so easy to miscategorize violations of social norms as pathological, and because, as Cleckley himself admits, the patients show no evidence of psychosis (trouble dealing with reality), dementia (impairment of mental function), or other recognized pathology, today we would demand that such a diagnosis be based on convincing physical evidence of brain dysfunction. The lack of behavioral inhibition in psychopaths is reminiscent of frontotemporal dementia, and some fMRI studies have found lower activation in the frontal lobes, but also in other brain areas, including the amygdala and the limbic system, which are involved in motivation and emotional memory.

Other research has found lower expression of monoamine oxidase A in psychopaths. MAO-A is the enzyme that gets rid of norepinephrine, dopamine, epinephrine and serotonin in the brain. (MAO converts primary and secondary amines to their corresponding aldehyde or ketone.) It is linked to the X chromosome, meaning that males would have more extremes in high or low activity. It is not clear how this would translate into ASPD, and research in this area is still at an early stage. Even our definitions are still in flux, and some studies have inadequately separated the subject populations, leading to questionable conclusions.

That's why it's so important to distinguish sociopathy and psychopathy in these kinds of studies. As Cleckley writes:

"When mentally defective patients, in all their degrees of disability, were not distinguished from the psychopath, while both were listed under the same official term, it is not surprising that many excellent observers found and reported physical abnormalities, stigmata of degeneration, and gross neural pathology in the general group." [p. 230]

In other words, when you mix two disorders together, you will draw the wrong conclusions and discover things that are not true.

Behavior as a symptom

In the absence of biochemical evidence, we are forced to use behavior as evidence of pathology. But this risks confounding political beliefs, actions, and speech with pathology. Making diagnoses of political leaders risks politicizing and thereby discrediting a branch of medicine that is still struggling to gain acceptance.

Using behavior as an index of pathology also creates many inconsistencies. The fact that the patient has eaten a sizable number of his former friends surely qualifies as antisocial behavior, and as such it is strongly frowned upon by society. But if some modes of behavior, such as homosexuality, political choice, and so forth, are not pathological, how can any behavior patterns be so categorized? Our social mores and emotional reactions to the crime are not useful guides in making diagnoses.

Psychiatrists sometimes try to wiggle out of this dilemma by saying behavior is a problem only if it interferes with the person's ability to function normally in society. In other words, it is only a problem if the psychopath is disturbed by it, which, as Cleckley ably demonstrated, never happens. So the only people in need of psychiatric treatment are those who believe they have something wrong with themselves. Which is ... nobody.

Part of what makes us so uncomfortable is that we're afraid of what it might say about us as a species. We want to believe it's a disease. Then we could dismiss Hitler, Stalin, and all the other psychopaths as aberrations. Doing so reassures us that such acts are not within the realm of human behavior. But until we can find a physical basis for it, we must leave judgments about social behavior to the legal system, and to politics.

dec 27, 2014; updated mar 25, 2015

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