The Mask of Sanity

“Psychopathy is a disorder characterised by antisocial behaviour, reduced empathy and remorse, narcissism and impulsivity (Hare, 1991). Elevated psychopathic traits have been linked to atypical neural functioning in brain structures that include the amygdala, orbitofrontal cortex and striatum (Birbaumer et al., 2005; Rilling et al., 2007; Dolan and Fullam, 2009; Jones, et al., 2009; Harenski, et al., 2010; Finger et al., 2011; Marsh et al., 2011a). These disruptions are thought to underlie emotion processing deficits in psychopathy, particularly disruptions in recognising and responding to fear-relevant stimuli such as fearful facial expressions…

Psychopathy has long been associated with an increased willingness to engage in behaviours that cause fear in victims, like threats, bullying and violence (Blair, 2005).
The present study demonstrated that psychopathy is associated with aberrant amygdala responding during judgments about causing others fear….

Participants with high psychopathy scores showed reduced amygdala activity relative to participants with lower psychopathy scores. These results are consistent with the modern construct of psychopathy, initially developed by Cleckley, who, in describing the prototypical psychopath, stated:

‘In the disaster he brings about he cannot estimate the affective reactions of others which are the substance of the disaster. . . the real psychopath seems to lack understanding of the nature and quality of the hurt and sorrow he brings to others’ (Cleckley, 1988, p. 322).”

EXTRACT FROM Abigail A. Marsh & Elise M. Cardinale. (2014). When psychopathy impairs moral judgments: neural responses during judgments about causing  fear. Soc. Cogn. Affect. Neurosci. 9, 3–11.


Extracts from “The Mask of Sanity” by Prof Hervey M Cleckley 

“Master deceivers who secretly possess no moral or ethical restraints, yet behave in public with excellent function”

  1. These people, whom I shall usually call psychopaths for 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… It is important that the average physician at least be aware that there is such a problem. It is difficult, however, for society to hold these people to account for their damaging conduct or to apply any control that will prevent its continuing. (p14)
  2. Many of these people, legally judged as competent, are more dangerous to themselves and to others than are some patients whose psychiatric disability will necessitate their spending their entire lives in the state hospital. Though certified automatically as sane by the verbal definitions of law and of medicine, their behaviour demonstrates an irrationality and incompetence that are gross and obvious. (p3)
  3. These people called psychopaths present a problem which must be better understood by lawyers, social workers, schoolteachers, and by the general public if any satisfactory way of dealing with them is to be worked out. Before this understanding can come, the general body of physicians to whom the laity turn for advice must themselves have a clear picture of the situation. (p14)
  4. Let us remember that his typical behaviour defeats what appear to be his own aims. Is it not he himself who is most deeply deceived by his apparent normality? Although he deliberately cheats others and is quite conscious of his lies, he appears unable to distinguish adequately between his own pseudo-intentions, pseudo-remorse, pseudo-love, and the genuine responses of a normal person. His monumental lack of insight indicates how little he appreciates the nature of his disorder. (p383)
  5. The psychopath’s unreliability and his disregard for obligations and for consequences are manifested in both trivial and serious matters, are masked by demonstrations of conforming behaviour, and cannot be accounted for by ordinary motives or incentives. (p342)
  6. Despite the extraordinarily poor judgment demonstrated in behaviour, in the actual living of his life, the psychopath characteristically demonstrates unimpaired (sometimes excellent) judgment in appraising theoretical situations. (p346)
  7. In complex matters of judgment involving ethical, emotional, and other evaluational factors, in contrast with matters requiring only (or chiefly) intellectual reasoning ability, he also shows no evidence of a defect. So long as the test is verbal or otherwise abstract, so long as he is not a direct participant, he shows that he knows his way about. He can offer wise decisions not only for others in life situations but also for himself so long as he is asked what he would do (or should do, or is going to do). When the test of action comes to him we soon find ample evidence of his deficiency. (p346)
  8. Be it noted that the result of his conduct brings trouble not only to others but almost as regularly to himself. To take still another point of view and consider him on a basis of those values somewhat vaguely implied by “intellectuality,” “culture,” or, in everyday speech, by “depth of mind,” we find an appalling deficiency. (p39)
  9. I think, however, that the roots of this attitude lie deeper, probably in the core of the psychopath’s essential abnormality – perhaps in a lack of emotional components essential to real understanding. (p173)
  10. His subjective experience is so bleached of deep emotion that he is invincibly ignorant of what life means to others. (p386)
  11. The psychopath feels little, if any, guilt. He can commit the most appalling acts, yet view them without remorse. The psychopath has a warped capacity for love. His emotional relationships, when they exist, are meagre, fleeting, and designed to satisfy his own desires. These last two traits, guiltlessness and lovelessness, conspicuously mark the psychopath as different from other men… (p410)
  12. He is unfamiliar with the primary facts or data of what might be called personal values and is altogether incapable of understanding such matters. It is impossible for him to take even a slight interest in the tragedy or joy or the striving of humanity as presented in serious literature or art. He is also indifferent to all these matters in life itself. Beauty and ugliness, except in a very superficial sense, goodness, evil, love, horror, and humour have no actual meaning, no power to move him. (p40)
  13. He is, furthermore, lacking in the ability to see that others are moved. It is as though he were colourblind, despite his sharp intelligence, to this aspect of human existence. It cannot be explained to him because there is nothing in his orbit of awareness that can bridge the gap with comparison. (p40)
  14. He can repeat the words and say glibly that he understands, and there is no way for him to realise that he does not understand. (p40)
  15. These concepts in which meaning or emotional significance are considered along with the mechanically rational, if applied to this man, measure him as very small, or very defective. He appears not only ignorant in such modes of function but stupid as well. (p40)
  16. His awareness of hypocrisy’s opposite is so insubstantially theoretical that it becomes questionable if what we chiefly mean by hypocrisy should be attributed to him. Having no major values himself, can he be said to realise adequately the nature and quality of the outrages his conduct inflicts upon others? (p386)
  17. The psychopath shows a remarkable disregard for truth and is to be trusted no more in his accounts of the past than in his promises for the future or his statement of present intentions. (p341)
  18. He gives the impression that he is incapable of ever attaining realistic comprehension of an attitude in other people which causes them to value truth and cherish truthfulness in themselves. (p342)
  19. Typically he is at ease and unpretentious in making a serious promise or in (falsely) exculpating himself from accusations, whether grave or trivial. His simplest statement in such matters carries special powers of conviction. Overemphasis, obvious glibness, and other traditional signs of the clever liar do not usually show in his words or in his manner. Whether there is reasonable chance for him to get away with the fraud or whether certain and easily foreseen detection is at hand, he is apparently unperturbed and does the same impressive job. (p342)
  20. Candour and trustworthiness seem implicit in him at such times. During the most solemn perjuries he has no difficulty at all in looking anyone tranquilly in the eyes. (p342)
  21. It is indeed difficult to express how thoroughly straightforward some typical psychopaths can appear. They are disarming not only to those unfamiliar with such patients but often to people who know well from experience their convincing outer aspect of honesty. (p342)
  22. After being caught in shameful and gross falsehoods, after repeatedly violating his most earnest pledges, he finds it easy, when another occasion arises, to speak of his word of honour, his honour as a gentleman, and he shows surprise and vexation when commitments on such a basis do not immediately settle the issue. The conception of living up to his word seems, in fact, to be regarded as little more than a phrase sometimes useful to avoid unpleasantness or to gain other ends. (p342)
  23. There seems little doubt that he grossly exaggerates and indulges in fantastic lies as he recounts his adventures. (p185)
  24. No one questions the plain fact that he is ill and gravely ill. Some psychopathologists believe that he is ill primarily (or largely) because of his unconscious hate for those he loves and his impulses to destroy them (p420) [more apt: “should love” or “cannot love”?]
  25. Another factor worth mentioning is the psychopath’s almost uniform unwillingness to apply, like other ill people, for hospitalisation or for any other medical service. Many patients ill with the major personality disorders we classify as psychoses do not voluntarily seek treatment. Some do not recognise any such need and may bitterly oppose, sometimes by violent combat, all efforts to send them to psychiatric hospitals. Such patients, however, are well recognised. (p17)
  26. When we consider on the other hand these antisocial or psychopathic personalities, we find not one in one hundred who spontaneously goes to his physician to seek help. (p19)
  27. If relatives, alarmed by his disastrous conduct, recognise that treatment, or at least supervision, is an urgent need, they meet enormous obstacles. (p19)
  28. The psychopath, unlike all other serious psychiatric cases, can refuse to go to any hospital or to 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. (p19)
  29. 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 hospitalisation or even outpatient treatment unless some strong means of coercion happens to be available. (p19)
  30. It is also true that only a small proportion of typical psychopaths are likely to be found in penal institutions, since the typical patient… is not likely to commit major crimes that result in long prison terms. He is also 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 behaviour does not usually include committing felonies which would bring about permanent or adequate restriction of his activities. He is often arrested, perhaps one hundred times or more. But he nearly always regains his freedom and returns to his old patterns of maladjustment. (p19)
  31. Much of the difficulty that mental institutions have in their relations with the psychopath springs from a lack of awareness in the public that he exists. The law in its practical application provides no means whereby the community can adequately protect itself from such people. And no satisfactory facilities can be found for their treatment. (p14)
  32. Although I still have no effective treatment to offer for the psychopath (antisocial personality), it has encouraged me to feel that this book has, perhaps, served a useful purpose in making clearer to the families of these patients the grave problems with which they must deal. (Preface)
  33. Apparently many psychiatrists, and many other physicians, have over the years advised relatives of psychopaths to read The Mask of Sanity. The response of these relatives has given me deep satisfaction and has helped me to feel that efforts to pursue this study are not in vain. Although we may still be far from the goal of offering a cure, perhaps something has already been done to focus general interest on the problem and to promote awareness of its tremendous importance. This must be accomplished, I believe, before any organised attempt can be made by society to deal adequately, or even cogently, with the psychopath. (Preface)
  34. Although it can be confidently predicted that his failures and disloyalties will continue, it is impossible to time them and to take satisfactory precautions against their effect. Here, it might be said, is not even a consistency in inconsistency but an inconsistency in inconsistency. (p342)
  35. This exercise of execrable judgment is not particularly modified by experience, however chastening his experiences may be. (p346)
  36. [ONE CASE] His repeated antisocial acts and the triviality of his apparent motivation as well as his inability to learn by experience to make a better adjustment and avoid serious trouble that can be readily foreseen, all make me feel that he is a classic example of psychopathic personality. I think it very likely that he will continue to behave as he has behaved in the past, and I do not know of any psychiatric treatment that is likely to influence this behaviour appreciably or to help him make a better adjustment. (p173)
  37. Can a person experience the deeper levels of sorrow without considerable knowledge of happiness? Can he achieve evil intention in the full sense without real awareness of evil’s opposite? I have no final answer to these questions. (p386)
  38. Attempts to interpret the psychopath’s disorder do not, of course, furnish evidence that he has a disorder or that it is serious. For reliable evidence of this we must examine his behaviour. (p386)
  39. Only here, not in psychopathologic formulations, can we apply our judgment to what is objective and demonstrable. Functionally and structurally all is intact on the outside. Good function (healthy reactivity) will be demonstrated in all theoretical trials. Sound judgment as well as good reasoning are likely to appear at verbal levels. Ethical as well as practical considerations will be recognised in the abstract. A brilliant mimicry of sound, social reactions will occur in every test except the test of life itself. In the psychopath we confront a personality neither broken nor outwardly distorted but of a substance that lacks ingredients without which normal function in major life issues is impossible. (p386)
  40. If, in the so-called psychopath, we have a patient profoundly limited in ability to participate seriously in the major aims of life, how, we might inquire, did he get that way? … As time passed it was noted that typical psychopaths were also seen in families of very respectable, ethical, and successful people and were entirely free from all physical stigmata of degeneration. (p403)
  41. A very large percentage of the psychopaths I have studied show backgrounds that appear conducive to happy development and excellent adjustment… (p410)
  42. People may be fair, kind, and genial, may hold entirely normal or even admirable attitudes about all important matters and yet unknowingly lack a simple warmth, a capacity for true intimacy that seems to be essential for biologic soundness (substantiality) in some basic relationships. There are men and women of whom it might correctly be said that it is impossible for them ever to become really personal. This aspect (or ingredient) of human experience is difficult to describe or to signify accurately. We do not encounter it squarely in thinking but feel it in perceptive modes or at reactive levels not readily translatable into speech. Let us remember, however, that such qualities may be found in parents of those who are not psychopaths. (p411)
  43. Some who show only superior qualities in all their activities as citizens, in their work, and in all definable responsibilities seem to feel little need for the sort of specific attachment and affective closeness which perhaps constitute the core of deep and genuine love. They also seem to have little perception of such a need in others. (p411)
  44. Where intimacy is normally limited they may be spontaneous and show cordiality as real as anything appropriate for such occasions. Their inner formality and remoteness is not encountered until the observer approaches areas of privacy, deep levels of personal affect that ordinarily are only reached in relations between mates, between parent and child, or in the few other very intimate and cherished friendships or sharing of personal understanding and feeling that man never achieves in wholesale measure. (p411)
  45. [One Case]: “I can’t understand the girl, no matter how hard I try,” said the father, shaking his head in genuine perplexity. “It’s not that she seems bad or exactly that she means to do wrong. She can lie with the straightest face, and after she’s found in the most outlandish lies she still seems perfectly easy in her own mind.” (p48)
  46. “She never seemed sly or crafty,” the mother said, a little puzzled about how to express the impression, “not like the sort of person you think of as stealing and being irresponsible. [She] didn’t seem wild and headstrong.” Yet she often used remarkable ingenuity to conceal her misdeeds and to continue them. (p48)
  47. “I wouldn’t exactly say she’s like a hypocrite,” the father added. “When she’s caught and confronted with her lies and other misbehaviour, she doesn’t seem to appreciate the inconsistency of her position. Her conscience seems still untouched. Even when she says how badly she’s acted and promises to do better, her feelings just must not be what you take them for.” (p49)
  48. She seemed entirely untroubled, never by word or gesture giving indication that she might have something to hide or to be seriously worried about. (p50)
  49. Parents of this sort may give an impression of affording each other and the child all that is ideal, and affording it in abundance. One such parent will, however, leave the other (if normal) so deprived in essential needs that the child may be turned to for the exclusive and possessive intimacy normal between mates but full of pathologic potentialities in the other relationship. (p412)
  50. It is my opinion that no punishment is likely to make the psychopath change his ways. Punishment is not, of course, regarded as an appropriate measure in medical treatment. It is, however, often considered and administered by legal authorities. And it must be remembered that at present the law deals with these patients more frequently than physicians deal with them. (p346)
  51. These people called psychopaths present a problem which must be better understood by lawyers, social workers, schoolteachers, and by the general public if any satisfactory way of dealing with them is to be worked out. Before this understanding can come, the general body of physicians to whom the laity turn for advice must themselves have a clear picture of the situation. (p16)
  52. Little agreement was found as to what was actually the matter with them. No satisfactory means of dealing with them was presented by any psychiatric authority, and meanwhile their status in the eyes of the law usually made it impossible to treat them at all. (Preface)
  53. They continued, however, to constitute a most grave and a constant problem to the hospital and to the community. The overwhelming difficulty of finding facilities for their treatment has been no less urgent than the yet unanswered question of what measures to use in treatment. (Preface)
  54. Although still in the unspectacular and perforce modest position of one who can offer neither a cure nor a well-established explanation, I am encouraged by ever increasing evidence that few medical or social problems have ever so richly deserved and urgently demanded a hearing. It is still my conviction that this particular problem, in a practical sense, has had no hearing. (Preface)
  55. How to inform their relatives, the courts which handle them, the physicians who try to treat them, of the nature of their disorder has been no small problem. (Preface)
  56. The psychopath presents an important and challenging enigma for which no adequate solution has yet been found. (Preface)
  57. Interest in the problem was almost never manifested by the patients themselves. The interest was desperate, however, among families, parents, wives, husbands, brothers, who had struggled long and helplessly with a major disaster for which they found not only no cure and no social, medical, or legal facility for handling, but also no full or frank recognition that a reality so obvious existed. (Preface – first edition of which was 1941 before being updated up to the fifth edition in 1988, from which these extracts have been taken; though this perhaps could have been written centuries ago given the impact such “master deceivers who secretly possess no moral or ethical restraints, yet behave in public with excellent function” [Wikipedia, Cleckley] are likely to have played in many of society’s less savoury situations and events).