This astonishing defect in realization often seems genuine, as the patient protests in surprise against the idea that prison might be anticipated for him, as for others under similar circumstances. He frequently reacts to such an idea as if to something unexpected and totally inappropriate.

Some observers believe that what the psychopath expresses about himself and his situation constitutes insight and merits such a term. I cannot agree with this opinion. The chief and most valid connotations of the word disappear in such an application. Profoundly psychotic patients whose gross lack of insight would be admitted by all sometimes express opinions which, if fully meant and appreciated, would indicate an insight that is plainly not there. A few brief examples may help:

A young man with a very active manic psychosis was interviewed some years ago. He whistled, shouted, winked, expressed the belief that he controlled the movements of the sun by his glance, sang snatches of bawdy songs, announced himself as a "sort of Messiah," and laid claim to the sexual vigor of seven bulls. Leaping about in a hospital shirt he had torn almost to shreds, he found exposed wires at a place on the wall from which he had torn the electric fixtures.

Seizing and releasing them and seizing them again, he got good jolts of the city current, which he relished, apparently interpreting the sensation as a manifestation of his own vitality. When asked if he felt anything was wrong with him mentally, he shouted in glee, "Sure, Doc, I'm crazy as a coot! I'm nuts I tell you. Crazier than anybody you ever saw!"

Another patient on a closed ward, a man badly disabled for years by obvious schizophrenia, often shouted out to the passerby, "Simple case of dementia praecox, Doc, simple case of dementia praecox," pointing to himself several times. Despite the chance diagnostic accuracy of what he said, this patient, like the one just mentioned, had little grasp of his situation and almost no real appreciation of his disorder and its meaning. Another manic patient not only spoke words that correctly indicated a good deal about his situation but even hammered out with a metal object he had obtained these letters in deep gashes in the wood door: "Bug house nutty."

Indications of serious impairment of insight abound in the psychopath's reactions after his failures have been undeniably demonstrated or his antisocial acts detected. The persistent tendency to ask for recommendations from those they have every reason to know cannot furnish anything but a negative report fatal to their plans has been illustrated. Such decisions in highly intelligent people can hardly mean less than that something crucial is absent from the realization of their status.

The calm assurance with which they report a successful rehabilitation in the midst of egregious and immediate maladjustment often does not seem so much a real effort to deceive as an indication that the patient himself is greatly deceived. Despite his awareness of major facts, the pivotal significance of these facts seems not to be in his evaluations.

After a peculiarly overt and spectacular succession of failures, thefts, truancies, falsehoods, and expulsion from school, a young man had to be sent home to a distant state by his aunt and uncle with whom he had been staying. They had taken him in the hope that he might do better in another environment. His parents, after years of struggle, had found no solution.

All the details of his recent failure and disaster were factually known to him and had been discussed with his aunt and uncle. They made no effort to deceive him about why he had to be sent home. The physician to whom he wrote the letter which follows had also been frank with him. The letter was mailed a couple of days after he returned in what to another person could not have seemed less than total failure and disgrace.

Dear Doctor: Arrived home safe and sound. I really was astonished at the great change in this small, typical, mid-western town when I pulled into it on Sunday... I'm getting on fine here with Mother and Father. I feel like a different fellow. Dr.______ I don't know how I'll ever thank you for what you did for me down there. It was my chance to straighten out and I took it. I believe I can say I did a good job of it. I don't know whether I could have done it alone. But the main thing is it's done and I want you to know I appreciate your help. Well, I have to go now..........

He also mentioned in other correspondence that he was helping his brother, who had shown some delinquency, to see the light, explaining that if he himself had been able to do such a thorough job the brother might profit and direct himself by the example, might, indeed, pull himself together, and "be a real man too." While writing to this effect, he continued the typical behavior without modification.

Let us consider a man whose wife, after many years of struggle equal to that of others discussed in some detail here, had left him and was seriously considering divorce. It is difficult to imagine a situation in which the necessity of permanent separation could be more clear or imperative. Nor is it likely that any patient described here has given a marital partner more reason to feel this need or has more fully demonstrated that, no matter what he said, he would continue to behave, toward her and in general, just as he had since their marriage. A few excerpts from his letters to the wife are illuminating:

... You will never be happy either by yourself or with some other man.… we have too much in common... I have no reason to lie or to misrepresent things to you now, even though I did try to explain it to you before... There'll be another day, so I'm told and believe, and even though I don't expect to get proper judgment here on earth from you and yours I will up there and if I'm wrong I'm willing to suffer for eternity... I do love you. I've never loved anyone else since childhood... If I kill myself my blood will be on your hands ... it will be heavy on your heart and soul... All wrongs will be righted on judgment Day... You should have stuck by me-should never have left me… I've suffered now really more than I can stand... You think it will bring you happiness to be rid of me... I sincerely hope and pray that it does if you do such a thing. I wish I could feel likewise … and believe everyone is at fault but me.

There is more in all this than simply false promises and fraudulent efforts to persuade the wife not to get a divorce. There is also indication of inability in his fundamental reactions to size up normally what he has done, what he is, and what he has been.

The psychopath cannot be depended upon to show the ordinary responsiveness to special consideration or kindness or trust. No matter how well he is treated, no matter how long-suffering his family, his friends, the police, hospital attendants, and others may be, he shows no consistent reaction of appreciation except superficial and transparent protestations. Such gestures are exhibited most frequently when he feels they will facilitate some personal aim. The ordinary axiom of human existence that one good turn deserves another, a principle sometimes honored by cannibals and uncommonly callous assassins, has only superficial validity for him although he can cite it with eloquent casuistry when trying to obtain parole, discharge from the hospital, or some other end.

As in attempting to delineate other aspects of the psychopath, we find ourselves again confronting paradox. Although he can be counted on not to be appreciably swayed in major issues by these basic rules, we often find him attentive in small courtesies and favors, perhaps even habitually generous or quasi-generous when the cost is not decisive. Occasionally his actions may suggest profound generosity in that large sums are involved or something presumably of real value is sacrificed. Usually, however, these appearances are deceiving.

The psychopath who squanders $1,000 on a lady of the night usually seems not to share very actively in the distressing worry and deprivation that his wife and children (or his parents) may experience quite substantially. The motives of a boy at boarding school who casually sells his new clothes to buy candy bars and Coca-Colas (for the whole dormitory) seem to lack an important dimension of magnanimity. This dimension could be presumed if after his extravagance the boy set to work assiduously in efforts to carry the burden he had created.

In relatively small matters psychopaths sometimes behave so as to appear very considerate, responsive, and obliging. Acquaintances who meet them on grounds where minor issues prevail may find it difficult to believe that they are not highly endowed with gratitude and eager to serve others. Such reactions and intentions, although sometimes ready or even spectacularly facile, do not ever accumulate sufficient force to play a determining part in really important issues. The psychopath who causes his parents hardship and humiliation by repeatedly forging checks and causes his wife anguish by sordid (and perhaps halfhearted) relations with the housemaid, may gain a considerable reputation in the community by occasionally volunteering to cut the grass for the frail old lady across the street, by bringing a bottle of sherry over now and then to bedridden Mr. Blank, or by leaving his work to take a neighbor's injured cat to the veterinarian.

Outward social graces come easy to most psychopaths, and many continue, throughout careers disastrous to themselves and for others, to conduct themselves in superficial relations, in handling the trivia of existence, so as to gain admiration and gratitude. In these surface aspects of functioning, the typical psychopath (unlike the classic hypocrite) often seems to act with undesigning spontaneity and to be prompted by motives of excellent quality though of marvelously attenuated substance.

Although some psychopaths do not drink at all and others drink rarely, considerable overindulgence in alcohol is very often prominent in the life story. Delirium tremens and other temporary psychoses directly due to alcohol were not commonly found in the hundreds of patients observed by me.

The view of some professional moralists to the effect that demon rum is the fundamental cause of disaster such as that of the psychopath appears to have little claim to validity. It has been pointed out already that an irreconcilable difference in primary aim appears to exist between the ordinary person who drinks too much and the psychopath. This may be restated briefly as follows: The ordinary drinker gets into trouble by drifting with enthusiasm into the opinion that if two or six or eight drinks have made him feel so good, another (or two more or perhaps five more) will make him feel just so much better. Such rationalizations may assist the normal drinker, especially if he has serious fundamental conflicts, in a progress toward becoming a neurotic drinker or toward an alcoholic breakdown.

I cannot say that it is impossible in certain persons for a state of mental disorder identical with that described here as psychopathic personality to be reached eventually in this way. Often, however, these neurotic drinkers, in sharp contrast with the psychopath, worry about their state when sober, are capable of making an earnest effort to get well under psychiatric treatment, and lack most of the deeper personality features of the psychopath. Even in the neurotic drinker it is more often an independent and preexisting personality maladjustment rather than the alcohol which is primarily causal. Many psychiatric observers make this vividly clear and no less convincing.

A major point about the psychopath and his relation to alcohol can be found in the shocking, fantastic, uninviting, or relatively inexplicable behavior which emerges when he drinks - sometimes when he drinks only a little. It is very likely that the effects of alcohol facilitate such acts and other manifestations of the disorder. This does not mean, however, that alcohol is fundamentally causal. Good criteria for differentiation between psychopaths and others who drink, moderately or excessively, can be found in what tendencies emerge after similar amounts have been consumed.

A peculiar sort of vulgarity, domineering rudeness, petty bickering or buffoonish quasi-maulings of wife, mistress, or children, and quick shifts between maudlin and vainglorious moods, although sometimes found in ordinary alcoholics with other serious patterns of disorder, are pathognomonic of the psychopath and in him alone reach full and precocious flower. Even in the first stages of a spree, perhaps after taking only two or three highballs, he may show signs of petty truculence or sullenness but seldom of real gaiety or conviviality. Evidence of any pleasurable reaction is characteristically minimal, as are indications that he is seeking relief from anxiety, despair, worry, responsibility, or tension.

Alcohol, as a sort of catalyst, sometimes contributes a good deal to the long and varied series of outlandish pranks and inanely coarse scenes with which nearly every drinking psychopath's story is starred. Free from alcohol, such a patient would scarcely sit under a house all night idly striking matches, or, concealing himself behind book stacks, urinate from the window of a public library on passersby in the street below. Nor would he, like the psychopathic son of a prominent family, suddenly, as a prank, decide to climb into a tree at a busy street corner, where he deliberately undressed, shouting wildly and puerilely to draw public attention. This man could not be persuaded to withdraw until the local fire department was called to remove him. The alcohol probably does not of itself create such behavior. Alcohol is not likely to bring out any impulse that is not already potential in a personality, nor is it likely to cast behavior into patterns for which there is not already significant subsurface predilection. The alcohol merely facilitates expression by narcotizing inhibitory processes.136 In cases of this sort very little narcotizing may be needed. The oil which lubricates the engine of an automobile neither furnishes the energy for its progress nor directs it.

Psychopaths often indulge in these strange performances after drinking relatively little. They know perfectly well what they have done before when drinking and, with these facts squarely before their altogether clear and rational awareness, decide to drink again. It is difficult indeed for me to see any substantial grounds for placing the responsibility for the drinking psychopath's deeds primarily on alcohol instead of on the disorder which, in ways no less serious even if less spectacular, he shows also when entirely sober.

Although his most theatrical exploits in public are usually carried on when drinking, the psychopath, even after he has been free from all alcohol for months, as for instance, when he is in a psychiatric hospital, retains all the essential personality features which have been mentioned. These show little or no tendency to diminish when he cannot drink. These words translated from Aeschylus, "Bronze is the mirror of the form; wine of the heart," express something pertinent about alcohol and man, whether the man be ill or well.

All the curious conduct reported in patients who drank and who were presented here occurred in the absence of delirium tremens, alcoholic hallucinosis, or any other of the well-known psychoses due directly to intoxication. Of course, such psychotic conditions may occur in psychopaths and in neurotic drinkers. It is important to keep such symptoms separate, since they are clearly due to another type of mental disorder.

Most of this asocial, unacceptable, and self-defeating behavior associated with the psychopath's drinking seems to occur without the benefit of extreme inebriation. If actual confusion from alcohol prevailed or states of genuine amnesia were induced before the grotesque shenanigans began, intoxication could more plausibly be suspected of playing a larger causal role. The psychopath often reacts in this typical way while in perfect orientation, with unclouded awareness and in anything but the deeply drugged state thought by some to be a prerequisite.

For whatever reason the psychopath may drink, it is true that, in contrast with others who use alcohol to excess, he hits upon conduct and creates situations so bizarre, so untimely, and so preposterous that their motivation appears inscrutable. Many of his exploits seem directly calculated to place him in a disgraceful or ignominious position. He often chooses pranks and seeks out situations that would have no appeal for the ordinary person, whether the ordinary person be drunk or sober. The observer sometimes wonders if a truly astonishing ingenuity, or an actively perverse inventiveness is directing him, so consistently does he bring off scenes not only uncongenial but even unimaginable to the average man.

Furthermore, these exploits seem to such little purpose, almost as hard to understand on the assumption that they are for amusement or play as on the grounds of utility. One patient with numerous other outstanding incidents in his career, while sitting at a formal dinner party given by friends in honor of his birthday, turned coolly and spat with deliberation on the cake as it was brought to his side for him to cut.

One patient who developed typical symptoms early in life showed, long before he had ever touched anything alcoholic, prankish tendencies worth noting here. When taken into a store by his parents to be fitted with new clothes, he often allowed intestinal gas to pass quietly but with vivid olfactory manifestations. Considerable embarrassment and vexation were experienced by the clerks and by his parents, but he was never ruffled and apparently took mild or moderate pleasure in the situation. He occasionally resorted to these tactics while riding with his parents and dignified company in a car when the windows were tightly closed because of cold weather. A few times he discomfited his family considerably by the same means in church. At first the parents accepted his apologies after reprimands and they were inclined to believe his innocent-faced explanation that an involuntary lapse of control had occurred. The timing of events and the predilection for close places and special surroundings, as well as the emergence of other behavior, convinced them in time that these acts were deliberate.

Another young psychopath who had never encountered liquor of any sort did many things that would not attract the ordinary mischievous teenager. Finding time a little heavy on his hands (and his parents out of the house for a few hours), he took tools from the cellar and, working with no little skill and dispatch, got the connections of the bathroom toilet apart, put into the outlet pipe a small electric motor, and then carefully reconnected the fixture. The subsequent flooding, mess, trouble, and expense did not seem to give him hilarious mirth or vindictive satisfaction. Certainly he showed no evidence of such feeling in a degree to warrant his risking the punishment he received.

The pranks or buffoonery of the sober adult psychopath naturally differ somewhat from those typical of adolescence or earlier. With a few drinks the similarity of the adult's behavior often increases.

Despite the deep behavioral pattern of throwing away or destroying the opportunities of life that underlies the psychopath's superficial self-content, ease, charm, and often brilliance, we do not find him prone to take a final determining step of this sort in literal suicide. Suicidal tendencies have been stressed by some observers as prevalent. This opinion, in all likelihood, must have come from the observation of patients fundamentally different from our group, but who, as we have mentioned, were traditionally classified under the same term. It was only after a good many years of experience with actual psychopaths that I encountered my first authentic instance of suicide in a patient who could be called typical.

Instead of a predilection for ending their own lives, psychopaths, on the contrary, show much more evidence of a specific and characteristic immunity from such an act. This immunity, it must be granted, is, like most other immunities, relative.

Although suicide, then, cannot be named an impossibility among this group, its unlikelihood still merits strong emphasis. Since most psychopaths do not remain hospitalized or under other protective supervision, the rarity of this act becomes more significant. Also worth noting is the fact that most real psychopaths, not once or a few times but habitually, work themselves into situations that might strongly prompt the normal man to end his own life. Since suicidal threats, like promises and well-formulated plans to adopt a new course, are so frequently offered by these patients, there is good reason to keep in mind the fact that they are nearly always empty. Many bogus attempts are made, sometimes with remarkable cleverness, premeditation, and histrionics.

The psychopath's sex life invariably shows peculiarities. The opinion has already been expressed that homosexuality and the other specific deviations, though of course occurring in psychopaths, are not sufficiently common to be regarded as characteristic. Evidence of consistent, well-formulated deviation was extremely rare in a large group of male psychopaths personally observed in a closed psychiatric institution. Among male and female subjects seen as outpatients and in general hospitals, such complications, though more frequent, do not seem to be a distinguishing feature. If we take another viewpoint and consider the group who come or are sent to the physician primarily for sexual deviation, we find again some patients with behavior patterns resembling in various degrees that of the real psychopath. These patients are probably not typical of the deviate group as a whole, whose members much more frequently show different fundamental patterns of adjustment and maladjustment.

Unmistakable psychopaths who do not show evidence of strong or consistent deviated impulses but who nevertheless occasionally carry out abnormal sexual acts have been seen much more often than those in whom the two fundamental patterns seem to overlap. This is not surprising in view of the psychopath's notable tendencies to hit upon unsatisfactory conduct in all fields and his apparent inability to take seriously what would to others be repugnant and regrettable. The real homosexual seeking an outlet for his own impulses often finds it possible to engage the psychopath in deviated activities, sometimes for petty rewards, sometimes for what might best be called just the hell of it.

It has been said that some people whose sexual activities are normal under ordinary circumstances may, in the absence of normal opportunities, resort to immature or abnormal practices as a substitutive measure. It is not hard to believe that a man of orthodox sexuality, if stranded and alone for years on an uninhabited island, might develop impulses toward masturbation. Some studies of prisoners give the impression that mutual masturbation and far more abnormal relations occur in persons who, when not confined, sought only heterosexual intercourse.184,296 Surely every psychiatrist has seen people whose sexual aims are usually directed toward the other sex but whose orientation is so confused, and whose evaluation of sexual experience is so trivial, that they sometimes also engage in homosexual and other types of abnormal relations.

In psychopaths and in many other people who cannot be correctly placed with the well-defined homosexual group, there are varying degrees of susceptibility or inclination to immature or deviated sex practices.