reports of a psychiatric examination to find conclusions listed as follows:
(1) No nervous or mental disease.
(2) Psychopathic personality.
The broadness of the familiar diagnostic term and the conflicting attitudes of different psychiatrists toward those so labeled are reflected in the varying concepts it implies and in its plainly diverse referents.{§}
Several decades ago, a large group of abnormalities, mental deficiency, various brain and bodily malformations and developmental defects, sexual perversions, delinquent behavior patterns, chronically mild schizoid disorder, etc., were all classed as constitutional psychopathic inferiority.106 After the ordinary mental defectives and most of the cases with demonstrable brain damage or developmental anomalies were distinguished, a considerable residue of diverse conditions remained under the old classification. Since many of these patients left in the group did not show evidence of congenital pathology and lifelong disorder, another term, constitutional psychopathic state, was devised.
Many psychiatrists still prefer these two terms, which, in their abbreviated form (C.P.I. and C.P.S.), are used most often to designate psychopaths but literally refer to a good many other conditions at the same time.
Talk about the C.P.I. and the C.P.S. still figures prominently in staff room discussion. It is not surprising that confusion flourishes and sharp differences of opinion prevail about what may be one or several subjects simultaneously.
As time passed and psychiatric study continued, an increasing number of observers felt that the term constitutional was scarcely justified for some of the several disorders listed in the categories mentioned above. Eventually these were officially discarded in our country and psychopathic personality adopted, not only for the type of patient to be discussed in this volume, but for a good many others easily distinguished from him in life but only with difficulty in the nomenclature.
In the revised Standard Nomenclature for Diseases of the Psychobiologic Unit, published in 1952, the familiar psychopathic personality has been discarded. In its place we find the category of personality disorders. These, distinguished in the revised nomenclature from psychotic disorders and psychoneurotic disorders, include, sometimes under slightly altered names, all the various pathologic states formerly placed in the category psychopathic personality.62
At present many feel that all the conditions until recently listed under psychopathic personality are hereditary deficiencies, while others see little convincing evidence for this assumption.219 During the last few decades increasing attention has been paid to interpersonal and environmental factors or influences almost entirely ignored before the beginning of Freud’s work, and the tendency to attribute personality disorder wholly and simply to inborn defect has been less prevalent.
Some time after the period during which it was generally assumed, by the physician as well as by the clergyman, that abnormal behavior resulted from devil possession or the influence of witches, it became customary to ascribe all or nearly all mental disorder to bad heredity. Even in the early part of the present century this practice was almost universal.181 Before relatively recent developments in psychopathology and before any real attempt had been made to understand the meaning and purpose of symptomatology, the invocation of inborn deficiency or “hereditary taint” was, it would seem, grasped largely for the want of any other hypothesis.
Another factor contributing to the popularity of belief in hereditary causation lies, perhaps, in the fact that families of all patients in state hospitals were investigated and all deviations recorded. Most of these histories revealed aberrant behavior, if not in a parent or grandparent, at least in some great uncle or distant cousin. It is surprising that some investigators gave such little consideration to the fact that few men stopped on the street could account for all relatives and antecedents without also disclosing one or more kinsmen whose behavior would attract psychiatric attention.{**} This is not to say that there is no possibility of genogenic factors playing a part, perhaps a major part, in the development of the psychopath. It is to say that one is not justified in assuming such factors until real evidence of them is produced. If such evidence is produced, these factors must be weighed along with all others for which there may be evidence and not glibly assumed to be a full and final explanation.
In recent years a contrary tendency has become prominent in psychiatry, a tendency to make, on the basis of symbolism and theoretical postulates, sweeping and unverifiable assumptions and insist that these prove the cause of obscure personality disorders to lie in specific infantile, or even intrauterine, experiences.82, 146, 215
After many years of work in psychiatry as a member of the staff in a closed hospital devoted to the treatment of mental disorders, and after many other years in charge of the psychiatric service in a general hospital, I believe that these curious people referred to as C.P.I.’s, C.P.S.’s, or psychopaths, in the vernacular of J the ward and the staff room, offer a field of study in personality disorder more baffling and more fascinating than any other. The present work has been attempted because of an ever-growing conviction that this type of disorder is far less clearly understood than \ either the well-defined psychoses or the neuroses, and that this lack of understanding is, furthermore, not sufficiently recognized and admitted. While the writer does not pretend to achieve a final explanation of so grave and perplexing a problem, it is hoped that a frank and detailed discussion may, at least, draw attention to the magnitude of the problem.42
The chief aim of this study is to bring before psychiatrists a few of these cases, typical of hundreds more, who have proved so interesting to the writer, so difficult to interpret by the customary standards of psychiatry, and all but impossible to deal with or to treat satisfactorily in the face of prevalent medicolegal viewpoints. Many of these cases have been classified consistently as psychopathic personality by not one but a number of expert observers, usually by several staffs of psychiatrists, and nearly always with unanimity. Others are so similar and so typical that few, if any, experts could find grounds to question their status. It is my belief, however, that this diagnosis, as it is authoritatively defined and as it is generally understood, fails to do justice to the kind of patients considered here.
It is hoped that such a presentation may be of interest to physicians in general practice, and, perhaps, to medical students, as well as to those whose work is confined more specifically to personality disorders. It is, indeed, the physician in general practice who will most often be called on by society to interpret the behavior of such patients as these and to advise about their treatment and their disposition.
These people, whom I shall call psychopaths for the want of a better word, are, as a matter of fact, the problem of juries, courts, relatives, the police, and the general public no less than of the psychiatrist. Referring to such cases Henderson says:
“It is often much against his better judgment that the judge sentences a man whose conduct on the face of it indicates the action of an unsound mind to serve a term of imprisonment. But he is almost forced to do so because, according to our present statutes governing commitment, the doctor may not feel that he is justified in certifying the individual as suitable for care and treatment in a mental hospital.”110
It is important that the average physician at least be aware that there is such a problem. According to the present standards of psychiatry, such patients are not eligible for admission to state hospitals for the psychotic or to the numerous hospitals of the same type maintained by the federal government for war veterans. They are classed as sane and competent and, theoretically at least, are held responsible for their conduct. Being so classed, none of the measures used to protect other psychiatric patients (and their families and the community) can be applied to bring them under any sort of treatment or restriction, even when they show themselves dangerously disordered. By many psychiatrists they are, in a technical sense, considered to be without nervous or mental disease. There are many arguments that can be brought forward
