itself throughout the course of this work with sufficient sharpness and clarity to be recognizable as a pathologic entity, little doubt will remain that it presents a sociologic and psychiatric problem second to none.
The man who develops influenza or who breaks his arm nearly always thinks at once of calling his doctor. The unconscious victim of a head injury is promptly taken by his family, his friends, or, lacking these, by casual bystanders to a hospital where medical attention is given. Persons who develop anxiety, phobia, or psychosomatic manifestations are likely to seek aid from a physician. Even those who demur and delay since they fear they will be called weak or silly because of symptoms commonly classed as psychoneurotic can be, and usually are, persuaded by their families after varying periods of reluctance to ask for help.
Children, of course, often seek to avoid both the pediatrician and the dentist, despite the advice of parents. But the parent seldom fails, when need of treatment is a serious matter, in getting the child, with or without his willingness, into the hands of the doctor. Many patients ill with the major personality disorders we classify as psychoses do not voluntarily seek treatment. Some do not recognize any such need and may bitterly oppose, sometimes by violent combat, all efforts to send them to psychiatric hospitals. Such patients, however, are well recognized. Medical facilities and legal instrumentalities exist for handling the problem, and institutions are provided to accept such patients and hold them, if necessary against their own volition, so long as it is advisable for the patient’s welfare or for the protection of others.
When we consider, on the other hand, these so-called psychopathic personalities, we find not one in one hundred who spontaneously goes to his physician to seek help. If relatives, alarmed by his disastrous conduct, recognize that treatment, or at least supervision, is an urgent need, they meet enormous obstacles. The public institutions to which they would turn for the care of a schizophrenic or a manic patient present closed doors. If they are sufficiently wealthy, they often consider a private psychiatric hospital. It should here be noted, also, that such private hospitals are necessarily expensive and that perhaps not more than two or three per cent of our population can afford such care for prolonged periods. No matter how wealthy his family may be, the psychopath, unlike all other serious psychiatric cases, can refuse to go to any hospital or accept any other treatment or restraint. His refusal is regularly upheld by our courts of law, and grounds for this are consistent with the official appraisal of his condition by psychiatry.
Nearly always he does refuse and successfully oppose the efforts of his relatives to have him cared for. It is seldom that a psychopath accepts hospitalization or even out-patient treatment unless j some strong means of coercion happens to be available. The threat’ of cutting off his financial support, of bringing legal action against him for forgery or theft, or of allowing him to remain in jail, may move him to visit a physician’s office or possibly to enter a hospital. Subsequent events often demonstrate that he is acting, not seriously and with the understanding he professes, but for the purpose of evasion, whether he himself realizes this or not. He usually breaks off treatment as soon as the evasion has been accomplished.
Since medical institutions refuse to accept the psychopath as a patient, and since he does not voluntarily, except in rare instances, seek medical aid, it might be surmised that prison populations would furnish statistics useful in estimating the prevalence of his disorder. It is true that a considerable proportion of prison inmates show indications of such a disorder.28, 161, 216 It is also true that only a small proportion of typical psychopaths are found in penal institutions, because the typical patient, as will be brought out in subsequent pages, is not likely to commit major crimes that result in long prison terms. He is distinguished by his ability to escape ordinary legal punishments and restraints. Though he regularly makes trouble for society, as well as for himself, and frequently is handled by the police, his characteristic behavior does not include felonies which would bring about permanent or adequate restriction of his activities. He is often arrested, perhaps a hundred times or more. But he nearly always regains his freedom and returns to his old patterns of maladjustment.
Though the incidence of this disorder is at present impossible to establish statistically or even to estimate accurately, I am willing to express the opinion that it is exceedingly high. Certainly it is hundreds of times more common than poliomyelitis, and its results are usually more disastrous. On the basis of experience in psychiatric out-patient clinics and with psychiatric problems of private patients and in the community (as contrasted with committed patients), it does not seem an exaggeration to estimate the number of people seriously disabled by the disorder still listed under this ambiguous term as greater than the number disabled by any recognized psychosis except schizophrenia. So far as I know, there are no provisions made in any public institution for the care of even one psychopath.{‡‡}
CHAPTER 4. METHOD OF PRESENTATION
Before attempting to define or describe the psychopath, to contrast him with other types of psychiatric patients, or to make any attempt to explain him, I would like to present some specimens of the group for consideration.
This procedure will be in accord with the principles of science in method at least, since, as Karl Pearson pointed out in The Grammar of Science, this method always consists of three steps:103
1. The observation and recording of facts;
2. The grouping of these facts with proper correlation and with proper distinction from other facts;
3. The effort to devise some summarizing or, if possible, explanatory statement which will enable one to grasp conveniently their significance.
Several decades ago, keeping these steps clearly in mind, Bernard Hart gave an account in The Psychology of Insanity103 of personality disorder that has, perhaps, never been surpassed for clarity and usefulness. Psychopathology has not been a static field, and many new concepts have arisen which make Hart’s presentation in some respects archaic and unrepresentative of viewpoints prevalent today in psychiatry. This point notwithstanding, the method followed by Hart remains an example of how the problems of personality disorder can be approached with maximal practicality, with minimal risks of mistaking hypothesis for proof or of falling into the schismatic polemics that, scarcely less than among medieval theologians, have confused issues and impeded common understanding in psychiatry. Without claims to comparable success in the effort to follow Hart’s method, I acknowledge the debt owed one who set so excellent an example more than thirty years ago.
The most satisfactory way in which such clinical material could be presented is, in my opinion, as a series of full-length biographic studies, preferably of several hundred pages each, written by one who has full access to the life of each subject. Only when the concrete details of environment are laid in, as, for instance, in an honest and perceptive novel, can the significance of behavior be well appreciated. Certainly no brief case summary, and probably no orthodox psychiatric history can succeed in portraying the character and the behavior of these people as they appear day after day and year after year in actual life.
It is not enough to set down that a certain patient stole his brother’s watch, that another got drunk in a pool room while his incipient bride waited at the altar, etc. To get the feel of the person whose behavior shows disorder it is necessary to feel something of his surroundings. The psychopath’s symptoms have been said to be primarily sociopathic.209, 210, 211 It is true that all, or nearly all, psychiatric disorder is in an important sense sociopathic, in that it affects adversely interpersonal relations. In most other disorders the manifestations of illness can, however, be more readily demonstrated in the isolated patient in the setting of a clinical examination. In contrast, it is all but impossible to demonstrate any of the fundamental symptoms in the psychopath under similar circumstances. The substance of the problem, real as it is in life, disappears, or at least escapes our specialized means of perception, when we remove the patient from the milieu in which he is to function.
All
