Psychopathy P

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 defined. 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. widest sense of the term, the person may be called Furthermore, ' The psychiatrist learns a great deal a psychopath; if it is not, he is likely to be called about normal and abnormal psychology which is a chronic offender or recidivist. It is important to relevant to the treatment, or the prevention, of Postgrad Med J: first published as 10.1136/pgmj.39.447.12 on 1 January 1963. Downloaded from

I4 POSTGRADUATE MEDICAL JOURNAL Yanuary I963 some non-pathological states that are socially character strata', thus preparing for the concept deviant '. of psychopathy as a variation from the normal, the A distinction needs to be drawn between latter determined by statistical analysis of a cross- accepting medical responsibility for psychopaths section of the population. This was the standpoint as a whole, which in the present state of our know- of Schneider (I959) and Sj6bring (1923) and ledge may well be disastrous, for there is some Mayer Gross and his colleagues (I960), who believe evidence that psychiatrically derived treatment ' that men varied in their temperamental traits in may in a minority of cases do more harm than good many ways, by infinitesimal degrees and by wide (Adams I96I), and cooperating in their manage- extremes, and that we should look for the cause of ment and investigating representative samples of psychopathy in this normal variation '. psychopaths of every sort, in order to determine The psychopathies, therefore, are best con- which of them can be effectively dealt with. The sidered as the resultant of combinations of factors, probable mode of advance in our knowledge of varying in intensity as compared with the norm of psychopaths will be in the differentiation of types, that factor in the population. Often the factors are ideally by isolating specific pathological factors best regarded as a position between two poles-too but also by determining, empirically, different much or too little; for example over stress-reactive responses to treatment methods. Clearly it is and under stress-reactive (Tong and Murphy, impossible to differentiate the minority without I960), fast conditioners, slow conditioners (Franks, assessing the majority. Thus to confine ourselves, 1956), advanced or retarded in rate of develop- prematurely, to some supposedly 'typical' or ment, subjected to permissive or restrictive ' true' psychopathic type, a concept upon which handling, environmentally over- or under-stimu- few would have a similar notion, would be lated, etc., etc. The constellation, and timing, as retrograde. Rather than concerning ourselves well as the intensity of many factors is, of course, with the myth of the typical psychopath we should crucial, and we shall, in practice, have to take be investigating types and degrees of personality account of certain qualities or states which are deviation. To equate psychopathic personality not distributed in a ' normal' manner throughoutby copyright. with abrormal character is likely to result in the population, e.g. minor degrees of brain damage confusion, but it must not be forgotten that not to and of mental illness proper, which may colour do so may present an even more insoluble problem. the picture though not warranting ' primary Initial confusion is inevitable, and matters not so psychiatric diagnosis'. long as we organize our approach to it in a poten- In simplest terms, all these factors may be tially fruitful manner. Again, to suppose that there classified under four major headings: precipitat- is any fundamental difference between abnormality ing, inherited, psychiatric (organic brain damage of character or of personality and psychopathy, and the psychoses) and, lastly, environmental would retard progress. Whether we like it or not, factors affecting development. the study of psychopathy is already not only co- http://pmj.bmj.com/ extensive with psychiatry but is heavily involved Precipitating Factors with other disciplines as well, notably psychology, The behaviour of the psychopath is our one firm genetics, sociology and anthropology. The sooner point of reference. Behaviour may be said to this is accepted, with its implication for a multi- have predisposing and precipitating causes. If disciplined, team approach, the quicker will results an animal eats, the predisposing cause is hunger be obtained. Daunting as it may be, any factor and the precipitating cause the perception of a which contributes to the formation, deflection or specific piece of food. If a psychopath immediately on September 24, 2021 by guest. Protected destruction of the personality so long as it falls after promising to mend his ways, goes off and short of producing frank mental subnormality or steals something, the predisposing cause, for the psychosis, must have a bearing on psychopathy. sake of illustration, may be his specific weakness of personality, and the precipitating cause his in- The Variables Involved ability to stand the particular stress (perhaps The escape from the ever-increasingly compli- forced upon him by parental moralizing and the cated division of psychopaths into descriptive extraction of a promise) of contemplating the types (e.g. Kraepelin's (1904) excitable, unstable, enormous gap between what he knows himself to impulsive, eccentrics, liars, swindlers, the anti- be and what he and his parents would like him social, quarrelsome) as excellently reviewed in to be. Curran and Mallinson's article (I944), was fore- Psychopaths do not behave psychopathically all shadowed by Kahn (I93I), who described psycho- the time, and careful enquiry into the exact nature paths as ' discordant personalities which, on the of the precipitating factors is of the utmost im- causal side, are characterized by quantitative portance from at least three points of view: peculiarities in the impulse, temperament and understanding and assessing the nature and Postgrad Med J: first published as 10.1136/pgmj.39.447.12 on 1 January 1963. Downloaded from

7an'uary I963 SCOTT: Psychopathy I5 severity of the precipitating factors throws light behaviour) before he departed to another part -of on the whole problem; it is a good initial approach the country. He will almost certainly turn up to a therapeutic relationship, for 'the patient can again one day and the process will have to be understand what you are about, and is not rendered continued. too resistant by this preliminary investigation of In considering precipitating factors we are the here-and-now; it may be possible in some concerned with factors in the present, the pressures cases, even if any fundamental alteration of the which pull the trigger, but we must not make the person is impossible or impracticable, to remove mistake of supposing that these factors, most of the precipitating factor, or to teach the patient how which will be ' social ' factors, only act in the to avoid it. here-and-now. The very same factors may have These three points could be expanded very had an effect throughout the individual's life, extensively. Frequently the precipitating factor is and moreover, may also have had their effect on highly specific. A certain ' aggressive psycho- his fellows and his parents. Consider for example path ' had frequently been in trouble for attacking the life of an adolescent in a new housing estate: people, usually women; he would make some Professor Roger Wilson (I96I) points out that he preliminary remarks to a stranger and follow it with is no longer tied to the locality for recreation or some inept and clumsy proposal, which of course courting, he doesn't share common experiences would be rejected, and he would then hit the and insecurities with his neighbours many of person. Investigation showed that he had never whom will work far away from the estate; the succeeded in making a satisfactory loving relation- stimulus of bigger and better equipped schools, ship, he had hated and feared his mother, yet he the possession of money and the influence of was intensely lonely and impelled to try and make television, glossy magazines and newspapers, human contacts; when rejected, his shame, dis- and the lack of primary social controls in his appointment and hate were discharged in the immediate community, must all have a very great assault. Throughout several prison sentences he immediate effect upon him. But very similar had never given the slightest trouble, presumably factors must have influenced his parents while by copyright. because his specific test-situation never arose; in this individual was young enough to be dependent prison he could be sure of steady, if superficial, upon them and while he was receiving his social acceptance by other prisoners and a relationship education from them. To quote Professor Wilson with the staff which was governed by easily under- ' The evidence is that there are no clearly defined standable rules; in this regime he could make a and acceptable standards, high or low' in the good adjustment, but outside there was always the training of children by the parents on these possibility of a deeper friendship, and there were estates. Mothers care a lot, but have no strong women and the unknown possibilities of a sexual neighbourhood pattern to give them support; the his ' ... lack of common practice is a very great relationship-all of which heightened feeling http://pmj.bmj.com/ of inadequacy and made him feel isolated and contribution to stress and strain '. A minority anxious. He was an intelligent man and a good find ' the stress of taking any consistent line worker, but was so subject to reactive depression- about conduct is more than they can manage ' and feeling that he had nothing to work for-that he the resulting ill-discipline of their children frequently left his work or just lay in bed most of heightens the anxieties of all the mothers on the the day. One cannot, in a case such as this, estate. Social factors may therefore constitute not assume that because of the bad relationship with only precipitating factors but also the soil in his mother, the whole etiology was environmental; which delinquent and psychopathic states develop. on September 24, 2021 by guest. Protected there may have been genetic factors in both mother and patient preventing or undermining a satisfac- Inherited Factors tory relationship, and of course the frustrations Important studies of the degree of concordance attendant upon such a relationship, acting through- of criminality in pairs of uniovular and binovular out the critical periods of his development, may twins (Rosanoff, 1941, Stumpfl, 1936, Kranz, have produced irreversible changes in his person- I936) show that personality is dependent to ality. Nevertheless the indications for treatment some extent upon hereditary factors but that the were clear enough-to surround him with as many environment may largely control the expression of supporting relationships as possible (evening dis- the personality. Slater (1948) confirms thai cussion group in a psychiatric clinic, probation heredity is an important factor in the genesis of officer) and to place him in a controlled and, to schizophrenia, the affective and some organic some extent, sheltered environment (a hostel). psychoses and. some forms of mental deficiency, This regime succeeded in keeping him out of and that these may depend upon single genes of trouble for ii months (a considerable feat con- large effect. In the case of the neuroses and the sidering his -previous rapid deterioration of psychopathic states however 'Wherever we Postgrad Med J: first published as 10.1136/pgmj.39.447.12 on 1 January 1963. Downloaded from

I6 POSTGRADUATE MEDICAL JOURNAL Yanuary I963 approach the issue we find normal distributions activity may have altered, the style remains un- and differences in degree. Furthermore, there changed'. Similarly Renaud and Estess (I96I) is the factor of non-specificity. When the rela- show that individuals may function at distinctly tives of neurotics or psychopaths of any particular above-normal levels despite those environmental kind are investigated, we find not only an excess of factors in their early lives which are commonly personalities with abnormal reactions of an exactly blamed for adult maladjustments. similar kind, but also an excess of those showing Clearly, with this conflicting evidence we are not abnormal reactions of different, although to some in a position to make dogmatic statements as to degree, related kinds', which leads him to reject the relative importance of inherited and en- the single gene hypothesis in favour of multi- vironmental factors, except to say that it is the factorial inheritance. ' There is no point' he interaction of both, rather than either one which is continues, 'in distinguishing too narrowly be- important. Taking an overall picture, environ- tween, for instance, the genetical make-up and mental factors, especially their effect in the early factors of an environment,al kind. . . . At any formative years, have always to be considered one time we can only usefully consider what is the and are increasingly acknowledged in the results constitution at that time, and not what its of modern genetical research. theoretical components might be'. In his later monograph Slater (I953) writes, 'The dividing Psychiatric Factors line between adjustment and maladjustment is J. and W. McCord (I959) in their analysis of not so wide as that between sanity and insanity the origins of crime found that of all physical and more easily overstepped, so that chance, disorders only ' distinct neurological disorder ' whether favourable or unfavourable, is more and acne correlated significantly. Acne may important. Once maladjustment has begun, it simply indicate that the subject is male and may contribute to its own continuance '. adolescent-both being states known to correlate Kallmann quotes Hutchinson (I959) as stating highly with crime. Damage to the central nervous that the most probable mode of operation of gene- system, for instance, the famous ' crowbar case'by copyright. specific components with a pleotropic effect may in which an iron bar was driven through the skull be 'on the rates of development of neuropsycho- destroying the prefrontal cortex of a workman, logical mechanisms involved in identification or the cases of epidemic encephalitis following the processes and other aspects of object-relationships first World War, has long been known to bring in infancy'. This holds promise of a possible about permanent changes in the personality, common meeting-ground, or meeting-time, be- sometimes producing explosive violence, morose- tween genetic, psychoanalytic and learning-theory ness and loss of moral sense. Such damage may approaches, and directs attention to critical or opti- produce a psychopathic picture by the 'release '

mum periods oflearning. Wilkins (i960), studying of pre-existing tendencies, just as cerebral de-http://pmj.bmj.com/ the relationships between rates ofjuvenile crime and pressants such as alcohol may sometimes do; this social disturbances, concludes ' There appears to is the standpoint of Bender (I953)-' Even an be something particularly significant in social dis- organic brain lesion does not produce funda- turbances occurring in the fourth and fifth year of mentally new trends but it merely underscores a child's life'. specific psychological problems'. Sometimes, The study of the correlation of certain qualities, however, certain drugs, for instance amphetamine known to be inherited, with crime also sheds some (Connell, 1958), and certain brain lesions may light on this subject. For example, the meso- produce a specific effect. This may best be illus- on September 24, 2021 by guest. Protected morphic build (Sheldon, I949, Glueck and trated from the field of sexually abnormal be- Glueck I956) has been shown to predominate in haviour, a frequent component ofpsychopathic per- certain samples of criminals, and abnormalities sonality. Krafft Ebing (I93i) described fetishism of the electroencephalogram have a very definite in association with frank epilepsy. Erikson's correlation with aggressiveness (Hill and Watter- (1945) female patient had a tumour involving the son, 1942). medial surface of the right cerebral hemisphere From another approach, Birch (I960), studying and developed nymphomania and, as an aura to the organismic variability in a series of I05 her seizures, had a ' passionate feeling' over the infants, found that, despite great differences from left side of her body. A man developed trans- child to child, the formal characteristics of each vestism in association with cerebral cysticercosis child remained remarkably constant throughout and temporal epilepsy (Davies and Morgenstern, a two-year follow-up and sometimes for as long as I960). The well-known case of Mitchell, Falconer five years. Little effect on these characteristics was and Hill (I954) demonstrated that a safety-pin produced by stresses such as parental death, fetishism, which became associated with psycho- separation, birth of sibs, ' although the form of motor epilepsy, was cured by temporal lobectomy. Postgrad Med J: first published as 10.1136/pgmj.39.447.12 on 1 January 1963. Downloaded from

Yanuary I963 SCOTT: Psychopathy I17 There is also convincing evidence from animal ably assume that the individual has to learn to experiments that sexually abnormal behaviour may adjust to society. Maladjustment, in this sense, be produced by specific lesions (Kluver and Bucy, may arise in four principal ways (Scott, I960). He I939, Green, Clemente and de Groot, I957). may have learnt his code of behaviour well, yet The work of Fraser and Wilks (I959), investigat- that code may be contrary to generally accepted ing the residual effects of neo-natal asphyxia, standards; this is likely to occur in antisocially showed that by 71 years minor disorders ofperson- oriented families, or, later in life, in certain sub- ality, perception and motor coordination were cultures to which the individual may belong. relatively common. Such disabilities could of Such a person is in no sense sick, and is likely to course significantly affect the child's capacity to be able to respond readily to correction, parti- learn and to relate to the important figures of its cularly if the others of his group are simul- background, and thus suggest a possible field for taneously 'treated'. He may have had no con- preventive efforts. sistent standards of behaviour presented to him The effect of physical disability of the child and, consequently, may emerge as one form of upon the parents must be considered. With those persons who lack an adequate conscience, adaptable and tolerant parents this may be small, and who therefore tend to be at the mercy of but even minor factors in the child may signi- delinquent opportunity and to acquire a long ficantly affect neurotic or intolerant parents. Thus record of mixed offences, but usually excluding the a mother may have a dread of some particular more serious offences against the person. Thirdly disfigurement of the child; a highly narcissistic he may have learnt a negative lesson too well; if parent may communicate her disappointment or this prevents him from expressing an instinctual disgust, or a father, frustrated in his own achieve- drive, he is likely to find a personal, circuitous or ments, and looking for vicarious gratification indirect way of expressing that drive, which may his sons, may reject the incompetent one. involve him in conflict with the law. For ex- through ample, if a child learns that women are dangerous

Certain children may have specific and un- by copyright. pleasant associations, having caused pain or per- and that close relationships with them are to be haps reminding mother of the father who deserted avoided, then when he reaches adolescence he her; the mother-child relationship may thus be may show some form of sexual perversion, per- blighted from the start. Furthermore, physical haps homosexuality. Such a person will require illness, especially at critical periods of development some form of psychotherapy and he may be may produce characteristic changes in the child's reluctant to abandon his carefully evolved re- personality, especially increased aggressiveness or parative pattern. Lastly the process of learning dependency, and ' once a child starts to be over- may have broken down in some way. He may dependent-or is perceived as being so by his develop a ' conditioned avoidance reaction' well mother-he becomes a stimulus to the mother and described by Jones (I958); faced with a recurring http://pmj.bmj.com/ influences her behaviour to him' (Sears, Maccoby traumatic situation the individual cuts short the and Levin, 1957), leading to a circular building- mounting anxiety by some action which brings of immediate relief; this successful avoidance re- up tension. action, of course, quickly reinforces itself as a Once again, therefore, we see the possibilities conditioned response and is therefore extremely of complex interaction between factors of entirely difficult to eradicate. The work of Maier (I949), different natures, any one of which might play a Marquhart (1948), and Patrick (1934) suggests significant role in the genesis of psychopathy. that if an animal or human be placed in a situation on September 24, 2021 by guest. Protected where he is strongly motivated to solve a problem Environmental Factors Influencing of discrimination which is in fact insoluble, and if Development he is prevented from escaping from the situation, Some points concerning this vast and little- then apparently useless, non-adaptive behaviour is known field have already inevitably been intro- likely to ensue and to recur whenever he meets duced in discussing the other factors. At least we that situation again. Once again, inherited dif- are now fully aware that the timing, as well as the ferences may be important in determining the combination and intensity of factors, is of great ease with which these maladaptive responses importance in relation to the variable rates of occur, and this is reviewed in an important paper development of the individual, and that many of by Tong and Murphy (I960). the factors, especially those involving the attitudes Bearing in mind that all these and other peculiar- and personalities of the parents, are subtle and ities of learning, and the previously cited pre- difficult to assess retrospectively. cipitating factors, inherited factors and psychiatric Of the many approaches, perhaps learning- factors, in clinical practice and observed to occur theory is the most satisfactory. We may reason- in different degrees and in complex combinations, Postgrad Med J: first published as 10.1136/pgmj.39.447.12 on 1 January 1963. Downloaded from i8 POSTGRADUATE MEDICAL JOURNAL January I963 it is not surprising that a tidy appraisal of psycho- be aware that the treatment-requirements of pathic personality is not possible. But at least psychopaths are likely to be as varied as the aetio- we may appreciate the difficulties realistically and logical factors.

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