Postgrad Med J: first published as 10.1136/pgmj.39.447.12 on 1 January 1963. Downloaded from POSTGRAD. MED. J. (1963), 39, 12 PSYCHOPATHY P. D. SCOTT, M.D., D.P.M. Consultant Psychiatrist, Maudsley Hospital, London, S.E.5 ('Nothing is more like an honest man than a rascal' adolescence, and when the patient was five years Proverb) old his father had made an extended 'business Description trip' following a serious matrimonial quarrel; MR. P., at the age of 25, has just been released mother's early life had been dominated by an from his third prison sentence. He had a record alcoholic father. of eight convictions, which included embezzle- These cases, in which gross behavioural disorder ment, larceny, hire-purchase offences, and passing is totally unsupported by any other evidence of worthless cheques. Many more offences would mental illness have attracted the attention of have appeared in the list but for his parents' efforts psychiatrists since Pinel at the end of the eights.7 to pay his debts and make restitution to his eenth century found that madness could exist victims. As a youth, he could, on many occasions, without delirium or delusion. have been charged in a Juvenile Court as ' beyond A good description of these disorders, not, control ' for he habitually stole from home and bettered in over a hundred years, is that of the absented himself for long periods without in- Bristol physician, James Cowles Prichard (I835) forming his parents. He had failed to make use of . ' the moral and active principles of the mind his expensive education. He truanted persistently, are strongly perverted or depraved; the power of and finally was expelled from his school. After self-government is lost or greatly impaired and the each episode of misbehaviour he would appear individual is found to be incapable not of talkingby copyright. convincingly remorseful, would promise to mend or reasoning upon any subject proposed to him, his ways, and, for a while would do so, often but of conducting himself with decency and obtaining excellent jobs and earning high praise propriety in the business of life'. Later, Mercier from his employers; but always, after a short (I902) filled in the picture' There are persons who while and without apparent reason, he would indulge in vice with such persistence, at a cost of commit some similar offence in a manner which punishment so heavy, and so prompt, who incur made detection inevitable. Yet he was a present- their punishment for the sake of pleasure so able, highly intelligent young man, welcome trifling and so transient, that they are by common a wide circle of and consent among acquaintances, regarded considered insane although they exhibithttp://pmj.bmj.com/ as charming and good company. He could discuss no other indication of insanity'. his behaviour sensibly and would state that he was ruining his own life and making his parents ill. Definition He knew the penalties which lay ahead, and could In the now enormous literature on the subject, forecast the probable length of any subsequent many attempts at definition have been made. sentence. He was physically healthy and showed Henderson (I947) holds that psychopaths . no evidence whatever, either at the examination, ' conform to a certain intellectual standard, some- or in the detailed life-history, of any formal times high, sometimes approaching the realm of on September 24, 2021 by guest. Protected psychiatric symptom or illness. His brother and defect but yet not amounting to it, who throughout sister were stated never to have given the slightest their lives, or from a comparatively early age, have trouble, and his well-to-do parents could not give exhibited disorders of conduct of an anti-social or any clues either in the family history or in their asocial nature, usually of a recurrent or episodic son's personal history, as to why he should have type, which, in many instances, have proved developed along these lines. difficult to influence by methods of social, penal Without doubt he was an excellent example of a and medical care and treatment and for whom we psychopathic personality, and would have con- have no adequate provision of a preventive or fidently been diagnosed as such by the majority of curative nature '. In this definition, as in clinical psychiatrists. The fact that, after three months of practice, failure to respond to treatment is an treatment, entirely new facts came to light (as is important element. Hence the somewhat pessi- very frequently the case, especially in intelligent mistic aura which attaches to psychopaths, despite families with a ' position ' to defend), did nothing the fact that there is little solid knowledge of the to change the diagnosis; the brother and sister course of these disorders and that some really had been more than usually difficult during gross psychopaths have been known to resolve Postgrad Med J: first published as 10.1136/pgmj.39.447.12 on 1 January 1963. Downloaded from Yanuary I963 SCOTT: Psychopathy I3 spontaneously. Perhaps the best known example realise that, over a wide area at the middle of this of such a spontaneous ' cure ' is that of the im- dichotomy, the differentiation between criminal poster, reported by Abraham (I935), who, after a and psychopath is very arbitrary. Anyone who has classically psychopathic career dating from early experience of both prison and hospital practice childhood, married and settled down in a very will know that, despite numerous statements to satisfactory manner. the contrary, no sharp line can be drawn between East (I949) from the medico-legal point of view, the two; this has very important administrative defines the psychopath as ' a person who, although implications, as will be seen. not mentally defective, psychoneurotic or insane, Nor can any meaningful line be drawn between, is persistently unable to adapt himself to social on the one hand, psychopaths, psychopathic requirements on account of abnormal peculiarities states, psychopathic personality, constitutional of impulse, temperament and character, which may psychopathic inferiority, and, on the other, require specialized medical and rehabilitative abnormal character and personality disorder. In treatment, instead of, or in addition to, the fact the American Psychiatric Association (1952), ordinary methods of punishment, before his social abandoned the term ' psychopathic personality' reclamation is effected'. in favour of ' personality disorder ' and its several Lastly of these definitions, in the Mental Health subdivisions. Act 1959, psychopathic disorder means ' a Now this raises very serious difficulties. Curran persistent disorder or disability of mind (whether and Mallinson (I944) make two important points: or not including subnormality of intelligence) ' Firstly, not all abnormal characters do in fact which results in abnormally aggressive or seriously develop what can be legitimately regarded as irresponsible conduct on the part of the patient, abnormal mental reactions or, in other words, the and requires or is susceptible to medical treat- possession of an abnormal character does not in ment '. Medical treatment for the purposes of the itself and necessarily constitute a medical problem Act includes nursing care. -unless of course it is most illegitimately so de- fined. A man can surely be abnormal or unusual Rather then memorizing these definitions it may or even persistently anti-social without being sick. by copyright. be sufficient to note that they all include four Secondly, to equate psychopathic personality with elements: an excluding clause-not primarily abnormal character is not only likely to result in mentally subnormal or psychotic (though of confusion for the reason just given, but approxi- course more than one diagnosis may co-exist); a mates perilously to making the study of psycho- clause indicating duration, usually covered by the pathic personality co-extensive with the major words persistent, from an early age, or recurrent; part of psychiatry '. a description of behaviour, e.g. abnormally All this is entirely agreed. Have we then to go aggressive or seriously irresponsible; a fourth on trying to delimit and restrict the clause indicating that society is impelled to do meaning of the term psychopath and with it our legitimate field of http://pmj.bmj.com/ something about it. The obvious ambivalence and medical intervention, and, if not, what justification uncertainty as to what this something should be is have we for encroaching upon an alarmingly wide well exemplified in East's ' specialized and re- field? habilitative treatment, instead of, or in addition to, The problem is discussed by Sir Aubrey Lewis the ordinary methods of punishment'. It is this (I953). ' The crucial difficulty arises with psycho- stirring of society to treat the individual which pathic personality. Every textbook of psychiatry differentiates, at least to a considerable extent, the discusses this abnormality, but almost always psychopath on one hand from the eccentric or ambiguously because the authors do not make clear on September 24, 2021 by guest. Protected unconventional and the thinker-ahead-of-his- why it should be regarded as an illness. It time on the other. would seem, then, that until the category is further The simplest definition, therefore, of a psycho- defined and shown to be characterized by specified path is one whose persistently anti-social or asocial abnormality of psychological functions, it will not behaviour cannot be primarily attributed to mental be possible to consider those who fall within it to subnormality or psychosis and stimulates society be unhealthy, however deviant their social be- to treat him. haviour'. He adds, however, 'that the doctor is not necessarily acting outside his proper scope if Relation to Criminality and Personality he attends to people who are not ill '; and he points Disorder out the several instances, including pregnancy and If the treatment decided upon is medical, in the childbirth, where such a function is accepted.