Postgrad Med J: first published as 10.1136/pgmj.30.346.399 on 1 August 1954. Downloaded from 399

PSYCHOPATHIC PERSONALITY By DENIS HILL, F.R.C.P. Physician for Psychological Medicine, King's College Hospital; Senior Lecturer, Department of Clinical Neurophysiology, Institute of Psychiatry, London

A Bristol physician, Prichard, is generally con- justment and leading to therapeutic nihili§m. The ceded to have been the first to recognize the class of diagnosis cannot be reached by a consideration of persons for whom the diagnosis of psychopathic any one episode of abnormal behaviour but only personality is now made. In I835 he described a by a longitudinal study of the life history of the condition in which ' there is a mental derangement patient. In these patients there is a long history in which the intellectual faculties appear to have of anti-social or asocial behaviour. The school sustained little or no injury while the disorder is records show average intellectual achievement manifested, principally or alone in the state of the marred by intolerance of discipline and authority, feelings, temper or habits.' He remarked that the persistent childhood misbehaviour, a lack of per- (moral and active principles of the mind are severance in any undertaking, irresponsibility and strongly perverted or depraved; the power of unreliability, untruthfulness, delinquencies of all self-government is lost or greatly impaired and the kinds and most important of all an apparent per- by copyright. individual is found incapable, not of talking or sistent inability to profit by experience whether reasoning upon any subject proposed to him, but this be success or failure, whether it be praise or of conducting himself with decency and propriety punishment. After school days the employment in the business of life.' Prichard emphasized first record shows a similar state of affairs. A great that the disorder of behaviour is persistent and number and variety of different jobs is the rule and lifelong, secondly that it is not dependent upon this alone may be an important symptom of the intellectual disorder, that is mental deficiency, and condition; 30, 40 or more jobs in an adult working thirdly that the disorder does not reach the degree life of io vears is not exceptional. In social re- of certifiable insanity, except episodically. Since lations, in work and in sexual relations the psycho-

that time a variety of terms have been coined for path is found to be unable to adapt. He cannot http://pmj.bmj.com/ this condition, each author demonstrating his view keep his friends, his jobs or his loves. He shows a of the aetiology. Thus Koch (I89I) and Kraepelin lack of responsiveness to the ordinary social de- (1915) emphasized the innate constitutional factors mands of honesty and truthfulness. His altruism by their use of the terms' psychopathic inferiority' is never developed. Sometimes possessing a be- and ' constitutional psychopathic states.' On the guiling charm he has been likened to flowers with- other hand more modern writers such as Partridge out scent. But he is unable to achieve a strong and (1930) decline to commit themselves to a pre- lasting relationship with any other human being. dominant aetiology and prefer a descriptive term- While professing to feel love and consideration, he on October 1, 2021 by guest. Protected ' sociopathic personality,' in this instance em- yet repeatedly demonstrates behaviour which hurts phasizing that the disorder lies in the relationship the feelings of others. between the patient and the society he lives in. Certain common factors need emphasis. The The psychoanalytic school favouring an acquired patient's behaviour when frustrated suggests that psychological causation prefer the term ' neurotic he acts on impulse, without any consideration for character' (Alexander, 1930). In this country the others or for the ultimate effects of his behaviour views of D. K. Henderson have been widely upon himself. He therefore has no prudence. His accepted. By the use of the term ' psychopathic needs must be met immediately and he is unable, states,' no emphasis upon either innate or acquired like the mature individual, to postpone their factors is laid. gratification. In this he shows an intense emotional reactivity and intolerance of stress and is liable to The Diagnosis episodes of brief explosive behaviour in which he This should not be lightly made, carrying as it may be impulsively violent and ill-tempered. He does a very poor prognosis for future social ad- may assault those who frustrate him, or become Postgrad Med J: first published as 10.1136/pgmj.30.346.399 on 1 August 1954. Downloaded from 400 POSTGRADUATE MEDICAL JOURNAL August I954 moody, sullen and make a suicidal attempt. Some Psychopathology of these are half-hearted but occasionally the psychopath succeeds. Not every psychopath is so Lowrey (i944) has pointed out that normal overtly violent either towards himself or others. behaviour is that which is satisfying, healthy and More subtle episodic disturbances of behaviour socially acceptable. The behaviour of the patient are seen in occasions of pathological hypersexuality with a neurosis is unsatisfying but socially ac- or alcoholism. In many patients the intervals be- ceptable. The behaviour of the patient with a tween episodes of abnormal behaviour are charac- psychosis is both unsatisfying and socially un- terized by an expressed but rather glib appreciation acceptable. On the other hand the behaviour of of their difficulties and behaviour and by an the patient with psychopathic personality is satis- apparent firm determination to mend their ways. fying to him but is socially unacceptable. In Particularly is this so when the psychopath is seen neurosis the individual self or ego is itself in con- in prison or in hospital. These good intentions flict and while the social behaviour remains count for nothing when the patient next meets acceptable, his symptoms express his conflict and frustration. defend him from overt expression and awareness of their forbidden character. In psychopathy on the other hand the ego would appear to act out Classification directly in behaviour the drives which the neurotic The term psychopathic personality describes a manages to control. In these cases there would group of personality disorders, which while they seem therefore to be a failure of those psycho- show many of the common factors already des- logical forces, described by Freud as the super-ego, cribed, superficially differ from one another. Most which exercise an inhibiting influence upon the classifications have been made upon descriptive ego. Most of the writers who have investigated differences of behaviour. The complex and over- the psychopathology of the psychopath have been burdened categories of the early workers were not impressed both by the essential childishness of mutually exclusive. Since the same type of per- much of his behaviour and by the noxious psycho-by copyright. sonality disorder may result from brain damage logical stresses which in the majority of cases have early in life, particularly following head injury, been found to have been present early in life. Out- encephalitis and sometimes epilepsy, there is some standing among these is the very frequent occur- point in speaking of symptomatic psychopathy or rence of grossly disturbed parental relationships secondary psychopathy for such cases. Compared or the absence of a secure home background. with the idiopathic variety, these cases are, how- Various authors have reported that about 50 per ever, infrequent. The American Psychiatric cent. of illegitimate children become psychopathic. Association grouped such patients into three Broken homes are common. Often there is an classes: Those with pathological sexuality; those aggressive alcoholic parent. Such histories are, however, by no means with pathological emotionality, e.g. persistent invariable. Bowlby (I951)http://pmj.bmj.com/ schizoid, cycloid or paranoid persons; and those has emphasized the importance for normal de- with asocial or amoral trends, e.g. pathological velopment of the age period three to five years of liars, ' moral defectives.' Unfortunately these a secure relationship between the child and the classes are again not mutually exclusive, since any mother. In his experience ambivalent behaviour of them may be amoral or asocial or show patho- by the mother during this period in which she logical emotionality. Another approach is that alternately rejects and deprives the child of love which attempts to describe a difference in terms of and care and then lavishes these upon him is par- the direction of the aggressive tendencies. Sir ticularly liable to result later in psychopathic on October 1, 2021 by guest. Protected David Henderson proposed the categories of those personality. who (i) are predominantly aggressive towards Psychoanalytic writers emphasize a number of others or themselves, including drug addicts and special aspects of the psychopathology. The child, alcoholics, (2) those who are predominantly passive who is to become the psychopath as a result of or inadequate; their aggressiveness being confined maternal rejection and deprivation, never develops to mild threats, to sulks, minor delinquencies, petty an adequate attachment to or identification with thieving and swindling, and (3) those who are the parents or the substitutes for them. Dis- predominantly creative. This last category, the appointments lead to hostility, a feeling of worth- least satisfactory, includes those outstanding per- lessness and a deep distrust of other people's sonalities whose general adjustment is obviously affection. The growing individual seeks then, by psychopathic but who possess some special gifts of fair means or foul, to obtain what he feels has been value by which the world remembers them. or is being denied to him or, alternatively, he rages Henderson's classification has been generally ac- against those he believes have or will frustrate him cepted in Britain (Henderson, I939). and such persons will include not only all those Postgrad Med J: first published as 10.1136/pgmj.30.346.399 on 1 August 1954. Downloaded from August I1954 5HILL: Psycopashic Personqli4 401 whom he feels exercise a role of authority but also suggested a failure of cerebral maturation pro- those whom he may wish to love. HIaving been cesses in some of these patients, particularly those indulged too much at one stage he never developed showing predominantly aggressive hostile be- 'inhibitions in his behaviour and when this was haviour. In 14 out of i8 murderers in whom the followed by excessive severity in handling against murders had appeared inexplicable and in- which he rebelled, he never developed a sense of adequately motivated the E.E.G. was abnormal in identification with the attitudes and feelings of the mild degree (Stafford-Clark and Taylor, 1949). parent. A sense of having been treated unfairly The finding, confirmed by many workers, that the develops as well as a need for acceptance and a E.E.G.s of persons of psychopathic personality sense of guilt. ' In so far as guilt and the feeling show an excess of slow rhythms for their age, is of rejection are aroused they get translated into made of even greater interest by the recent study irresponsible acts, either to obtain what the in- of KnAott et al. (I953) that there is a statistically dividual wants or in order to be detected and significant tendency for the parents of such in- punished' (Maslow and Mittleman, x95X). It dividuals to show similar abnormalities of their would seem, therefore, that in psychopathological records. In this study 54 per cent. of the patient terms the disorder is to be understood as a failure group and 30.2 per cent. of the parent group of the individual to obtain mastery over his in- showed abnormal E.E.G.s A study attempting to fantile ways of loving and hating, which then per- relate the E.E.G. patterns of foster-children to sist into adult life. This failure is due to the lack those of the foster-parents failed to show any of development and integration within his per- meaningful relationship. sonality of socially acceptable ideals and the com- Electroencephalographic data make it clear, plex of sentiments and inhibiting attitudes, however, thgt there is no specific pattern to be collectively known as the ' super-ego.' As a result found associated with psychopathic, personality of this the psychopathic individual of later years that is not found in some incidence throughout the does not show, nor experience, the guilt feelings groups of patients suffering from neuropsychiatric which constrain the behaviour of normal persons. disorders and in fact in a proportion (about io per by copyright. The gratification of the individual's needs is con- cent.) of the normal population. It is certain that sonant with the demands of the super-ego and no other factors, besides the probable constitutional conflict can occur. For this reason psychopathic ones evidenced in the E.E.G. of many cases, are persons have been called 'instinct-ridden necessary to the development of the particular dis- characters.' order of the patient. In some cases early brain damage must be implicated and in yet others, Constitutional and Physical Factors in probably the majority, noxious psychological Aetiology factors arising out of disturbed parental handling The early writers emphasized their almost are to blame. unanimous opinion that the psychopathic per- sonality was a ' defect state from birth,' analogous Social Implications http://pmj.bmj.com/ in the sphere of emotional development to the While the figures given by investigators from state of mental deficiency in the sphere of intel- different countries differ markedly about the in- lectual development. Genetic factors have often cidence of psychopaths among various social prob- been implicated but it is clear that no known form lem groups it is clear that such persons constitute of morbid inheritance is responsible-no evidence a proportion of those who are repeatedly at logger- for genetic unity. In a small but famous study of heads with society. At some time or another in

13 pairs of monozygotic twins by Lange (I93I), their lives, if not repeatedly, about 50 per cent. of on October 1, 2021 by guest. Protected one twin was a psychopathic criminal in all cases such individuals come in contact with the courts and in ten of the pairs the other twin was so also. for vagrancy, quarrelling, assaults or threats. The fact that statistical studies tend to show a pre- Severe chronic alcoholism is often a manifestation ponderance of males has suggested that cerebral of the disorder. About a third of the prostitute trauma at birth may be a cause. It is well known population is made up of such persons. Drug moreover that severe head injury early in life, addiction, sex perversion and economic instability encephalitis and the association of epilepsy in some are also other problems presented by many such cases may result in personality disorders in- persons. Homosexuality should not of itself, distinguishable from those in which no such factors however, be regarded as evidence of the disorder, have been known to occur. Electroencephalo- but among chronic sex offenders, exhibitionists, graphic studies on psychopaths have also shown sadists and incendiarists the proportion of psycho- abnormalities of a type suggesting the persistence paths is large. A careful study at the Massa- into adult life of patterns normal for younger chusetts Reformatory by the Gluecks (I930) persons (Hill and Watterson, 1942), and have indicated that i8 per cent. ofthe young delinquents Postgrad Med J: first published as 10.1136/pgmj.30.346.399 on 1 August 1954. Downloaded from 402 POSTGRADUATE MEDICAL JOURNAL August 1954 were psychopaths, but the proportion among adult could easily pay, and manages to have herself offenders and recidivists is probably much smaller. arrested as she leaves the shop! While at Sing-Sing Prison in I9I8, B. Glueck found a I9 per cent. incidence of psychopaths among Medico-Legal Aspects 6o8 admissions. Bromberg and Thompson (I937) It is clear that persons of psychopathic per- reporting on nearly io,ooo persons after conviction sonality and other persons who have developed a or after a plea of guilty, examined at the New York psychopathic reaction frequently appear on charges Court of General Sessions, found a 6.9 per cent. in the criminal courts. Psychopathic personality incidence of psychopathic personality. No similar is not, however, a defence in law. The diagnosis figures can be quoted from this countryv Probably does not in any way reduce the responsibility of a less than io per cent. of murderers in this country man for his actions. In fact, of course, the mental should be placed in this category. Suicidal at- health of an accused person is not usually raised tempts, particularly where there are repeated by the defence except when the issues are of the attempts, are a common manifestation of the most serious nature-usually only in murder cases. disorder. The courts in this matter are governed by the famous M'Naghten Rules. A defence of insanity can be supported if it is possible to show that the Episodic Psychopathic Reactions guilty person did not know what he was doing or, Curran and Mallinson (I944) draw a useful dis- if he did, that he did not know that what he did tinction between the continuous psychopathic per- was wrong. These rules have been much criticized sonality in which the disorder of social relation- on the grounds that the ideas inherent in them ships is seen throughout life and the occasions of (which were conceived ioo years ago), bear no re- psychopathic behaviour which are sometimes seen lation to modern views about mental disorder. It as ' short-circuit ' reactions in some persons under is evident, however, that the diagnosis of psycho- great stress whose histories do not reveal the pathic personality does not reduce the culpability usual evidence of psychopathy. These impulsive of the accused in murder cases in this country.by copyright. episodes of psychopathic behaviour may take the The recent Royal Commission on Capital Punish- form of suicidal or homicidal attacks, sudden in- ment (I953) gave prolonged consideration to the explicable delinquencies such as the stealing of matter of the mentally abnormal, but not certifi- articles which are not of themselves needed or of ably insane murderer. In this class psychopathic trivial worth, attacks of amnesia, alcoholism or personalities are a prominent group and the Com- sexual misbehaviour. It is probable that the mission recommended that although not ;ustifying majority of unsuccessful suicidal attempts are made a defence of insanity, the diagnosis ' ought to be by persons in this situation. An intolerable ex- given due weight in deciding whether the death ternal situation involving frustration, loss of or fear penalty should be carried out.' It is anticipated for this of loss of self esteem or security matches an that the building of a special institution http://pmj.bmj.com/ internal neurotic conflict to which the ego defences type of prisoner, in which research and study can had previously proved adequate and the whole be carried out, will be started in the present year. balance of controlling forces is upset. The Occasionally in the defence of a severely psycho- patient acts out his needs in a direct or symbolic pathic murderer the old concept of ' moral im- way (e.g. stealing) without relevance either to the becilitv' or ' moral defect' is raised. This was reality of social mores or to the usual demands of established in England as a legal concept in the his super-ego. Following the episode the patient Mental Deficiency Act of 1913, which stated that appears to be relieved of much of the tension which such persons ' from an early age display some per- on October 1, 2021 by guest. Protected led up to it. This relief of feeling provided by the manent mental defect coupled with strong vicious psychopathic reaction is witnessed in many patients or criminal propensities on which punishment has following suicidal attempts, alcoholic orgies, de- had little or no deterrent effect.' ' Moral de- linquent episodes and not infrequently following a ficiency,' contrasted with intellectual deficiency, murder. There can be no doubt that from the has, of course, no scientific meaning, but this Act point of view of the ego of the patient, if only for associated the two and the definition clearly makes a short time, the psychopathic reaction provides a mental deficiency, i.e. intellectual defect, a neces- way out from an intolerable situation. But deeper sary prerequisite to the diagnosis of ' moral de- motives, such as the need for self-punishment and fect.' This, therefore, is not the same type of self-humiliation, are often at work as well in these moral defect described by Prichard, nor indeed can patients. An example of this type is the middle- one identify the concept with that of psychopathic aged or menopausal woman in comfortable or personality, in which by definition intellectual de- well-to-do circumstances who steals from a shop fect is not a feature. If one examines the concept a number of articles of small worth for which she of ' moral imbecility' as a person who is not sub- Postgrad Med J: first published as 10.1136/pgmj.30.346.399 on 1 August 1954. Downloaded from August I954 HILL: Psycopathic Personality 40.3 normal or mentally diseased, yet devoid of moral episodes of emotional tension and insomnia. feeling, one can only agree with Healy (1915) that Sedative drugs should not be used for bad temper the condition does not exist.' and irritability. The amphetamine drugs can be tried for this and, in fact, many aggressive psycho- Treatment and Prognosis pathic persons can tolerate high doses of am- Once the diagnosis of psychopathic personality phetamine sulphate (e.g. 15 to 25 mg. a day) with has been made with confidence, the future of the benefit; temper and irritability may be less and the patient is too often viewed with unrelieved mis- patient's sense of well-being enhanced. A good giving. Most of those who are concerned with the therapeutic test is to find out if 5 mg. of the drug care of delinquent psychopaths in prison frankly keeps the patient awake if given in the evening; if believe that nothing can be done for their con- this is so it is unlikely that the patient's temper will dition. 'Yet even among this very difficult group, benefit. In Denmark and Sweden castration is expert observers such as the Gluecks, have noticed occasionally carried out for the criminal psycho- the ameliorating factor of the ageing or maturation path who has committed sex offences-but only at process. As the patient gets older there is a re- his own request. A modification of this method of duction in irritability, emotional reactivity and an reducing the motivational needs of the male patient apparent greater tolerance of frustration. This is is to exhibit oestrin in large dosage. This produces probably more important among the predominantly a great decline in libidinal excitation, some sense of aggressive psychopaths than among the inadequate fatigue and lassitude but usually does not result in group. It is of interest that this maturation pro- complete impotence. Tab. stilboestrol has been cess can be detected up to the age of 40, a period used by the writer in doses up to 8 to io mg. a day of life in which the E.E.G. maturation defects, so for periods up to three months at a time. Painful prominent among any group of adolescent psycho- enlargement of breast tissue in some degree can be paths, have declined to little more than the ex- expected in the majority of patients. The written pected incidence for the normal population. Some consent of the patient and of any responsible rela- adjustment, some decrease in the intensity and tive should be obtained before treatment can beby copyright. frequency of the antisocial episodes can be ex- undertaken, the effects and objects of which should pected with the passage of years, but from this be made quite clear. The writer has only advocated expectation should be excluded those who have this method of ' reversible castration' when the become addicted to drugs or alcohol. The passive aggressions and savage behaviour of the patient inadequate psychopath constitutes a less serious have for a long time produced a desperate social threat to society but is likely to become an economic situation. A few months respite for the patient liability, either on his parents or on the State. It and his family may increase the chances, small is probable that the present therapeutic nihilism though they may be, of a final settlement and could be modified if early diagnosis of this con- adjustment.

dition was more often made. Indeed this may be http://pmj.bmj.com/ very difficult. Society has made excellent- pro- vision for the physically and intellectually handi- BIBLIOGRAPHY ALEXANDER, F. (I930), Int. Jr. Psycho-Anal., 2,"29g. capped and their education aind care during the BOWLBY, J. (I955 ), ' Maternal Care and MentaliHealth', W.H.O. years of their development is a responsibility ac- Monograph No. 2, Geneva. BRONBERG, W., and THOMPSON, C. B. (I937), J. crim. Law cepted by society. Earlier diagnosis would lead to Criminol., 28, x. CURRAN, D., and MALLINSON, P. (I944), 'Recent Progress in greater understanding of the meaning of psycho- Psychiatry,' J. ment. Sci., 90, 266. GLUECK, B. (I9I8), Ment. Hyg., N. Y., 2, 85. pathic personality--of the significance of being Criml GLUECK, S. S., and GLUECK, E. T. (1930), '500 on October 1, 2021 by guest. Protected emotionally handicapped, and provision iFor this Careers,' New York. HEALY, W. (I915), ' The Individual Delinquent,' Boston. class of patient might eventuate. HENDERSON, D. K. (1939), ' Psychopathic States,' New York, Psychotherapy, even prolonged and intensive Norton. HILL, DENIS, and WATTERSON, D. (1942), J. Neurol. Psychiat., psychoanalysis, probably does not justify the effort S, 47- KNOTT, J. R., PLATT, E. B., ASHBY, M. C., and GOTTLIEB, and cost in this class of patient. Psychotherapeutic J. S. (I953), E.E.G. Clin. Neurophysiol., 5, 3, 363. support is always helpful and necessary but the KOCH, J. L. A. (I89I), 'Die Psychopathischen Minderwertig- keiten Ravensburg,' Maier. psychotherapeutic goal can only be very limited, KRAEPELIN, E. (9I's), 'Psychiatrie,' 8th edition, Band IV, Leipzig, Barth. probably confined to preventing the worst effects LANGE, J. (I93I), 'Crime as Destiny,' London. of the disorder. Very often the' psychopath is at LOWREY, L. G. (I944), 'Personality and the Behaviour Dis- orders, 2, 794, Ed. Hunt, Ronald Press. loggerheads with his parents and family; for their MASLOW, A. H., and MITTLEMAN, B. .(I95s), 'Principles and for' the of Abnormal Psychology,' Harper, New York. sakes, for the stability of the family PARTRIDGE, G. E. (I930), Amer. J. Psychiat., I0, 53. patient himself, it may be-better for him to live' PS1CHARD, J. C. (1835), 'Treatise on Insanity,' Sherwood, Gilbert and Piper, London. ITAL away from home. Drugs should only be used re- REPOR~T. F T~EROYAL, COMMISSION ON CAPIA - Bar- E NISHMENT (I953), H.M. Stationery Office, London. luctantly because of the danger of addiction. STAFFORD-CLARK, D., and TAYLOR, F. H. (19), Y. Neurl. biturates have no place in treatnent except during -Neurosurg. Psychiat., 12, 325.