Well into the eighteenth century, the only types of mental
illness - then collectively known as "delirium" or "mania"
- were depression (melancholy), psychoses, and delusions. At the beginning of
the nineteenth century, the French psychiatrist Pinel coined the phrase
"manie sans delire" (insanity without delusions). He described
patients who lacked impulse control, often raged when frustrated, and were
prone to outbursts of violence. He noted that such patients were not subject to
delusions. He was referring, of course, to psychopaths (subjects with the Antisocial
Personality Disorder). Across the ocean, in the United States, Benjamin Rush
made similar observations.
In 1835, the British J. C. Pritchard, working as a senior
Physician at the Bristol Infirmary (hospital), published a seminal work titled
"Treatise on Insanity and Other Disorders of the Mind". He, in turn,
suggested the neologism "moral insanity".
To quote him, moral insanity consisted of "a morbid
perversion of the natural feelings, affections, inclinations, temper, habits,
moral dispositions, and natural impulses without any remarkable disorder or
defect of the intellect or knowing or reasoning faculties and in particular
without any insane delusion or hallucination" (p. 6).
He then proceeded to elucidate the psychopathic (antisocial)
personality in great detail:
"(A) propensity to theft is sometimes a feature of
moral insanity and sometimes it is its leading if not sole
characteristic." (p. 27). "(E)ccentricity of conduct, singular and
absurd habits, a propensity to perform the common actions of life in a
different way from that usually practised, is a feature of many cases of moral
insanity but can hardly be said to contribute sufficient evidence of its
existence." (p. 23).
"When, however, such phenomena are observed in
connection with a wayward and intractable temper with a decay of social
affections, an aversion to the nearest relatives and friends formerly beloved -
in short, with a change in the moral character of the individual, the case
becomes tolerably well marked." (p. 23)
But the distinctions between personality, affective, and
mood disorders were still murky.
Pritchard muddied it further:
"(A) considerable proportion among the most striking
instances of moral insanity are those in which a tendency to gloom or sorrow is
the predominant feature ... (A) state of gloom or melancholy depression
occasionally gives way ... to the opposite condition of preternatural
excitement." (pp. 18-19)
Another half-century was to pass before a system of
classification emerged that offered differential diagnoses of mental illness
without delusions (later known as personality disorders), affective disorders,
schizophrenia, and depressive illnesses. Still, the term "moral insanity"
was being widely used.
Henry Maudsley applied it in 1885 to a patient whom he
described as:
"(Having) no capacity for true moral feeling - all his
impulses and desires, to which he yields without check, are egoistic, his
conduct appears to be governed by immoral motives, which are cherished and
obeyed without any evident desire to resist them." ("Responsibility
in Mental Illness", p. 171).
But Maudsley already belonged to a generation of physicians
who felt increasingly uncomfortable with the vague and judgmental coinage
"moral insanity" and sought to replace it with something a bit more
scientific.
Maudsley bitterly criticized the ambiguous term "moral
insanity":
"(It is) a form of mental alienation which has so much
the look of vice or crime that many people regard it as an unfounded medical
invention (p. 170).
In his book "Die Psychopatischen
Minderwertigkeiter", published in 1891, the German doctor J. L. A. Koch
tried to improve on the situation by suggesting the phrase "psychopathic
inferiority". He limited his diagnosis to people who are not retarded or
mentally ill but still display a rigid pattern of misconduct and dysfunction
throughout their increasingly disordered lives. In later editions, he replaced
"inferiority" with "personality" to avoid sounding
judgmental. Hence the "psychopathic personality".
Twenty years of controversy later, the diagnosis found its
way into the 8th edition of E. Kraepelin's seminal "Lehrbuch der
Psychiatrie" ("Clinical Psychiatry: a textbook for students and physicians").
By that time, it merited a whole lengthy chapter in which Kraepelin suggested
six additional types of disturbed personalities: excitable, unstable,
eccentric, liar, swindler, and quarrelsome.
Still, the focus was on antisocial behaviour. If one's
conduct caused inconvenience or suffering or even merely annoyed someone or
flaunted the norms of society, one was liable to be diagnosed as
"psychopathic".
In his influential books, "The Psychopathic
Personality" (9th edition, 1950) and "Clinical Psychopathology"
(1959), another German psychiatrist, K. Schneider sought to expand the
diagnosis to include people who harm and inconvenience themselves as well as others.
Patients who are depressed, socially anxious, excessively shy and insecure were
all deemed by him to be "psychopaths" (in another word, abnormal).
This broadening of the definition of psychopathy directly
challenged the earlier work of Scottish psychiatrist, Sir David Henderson. In
1939, Henderson published "Psychopathic States", a book that was to
become an instant classic. In it, he postulated that, though not mentally
subnormal, psychopaths are people who:
"(T)hroughout their lives or from a comparatively early
age, have exhibited disorders of conduct of an antisocial or asocial nature,
usually of a recurrent episodic type which in many instances have proved
difficult to influence by methods of social, penal and medical care or for whom
we have no adequate provision of a preventative or curative nature."
But Henderson went a lot further than that and transcended
the narrow view of psychopathy (the German school) then prevailing throughout
Europe.
In his work (1939), Henderson described three types of
psychopaths. Aggressive psychopaths were violent, suicidal, and prone to
substance abuse. Passive and inadequate psychopaths were over-sensitive,
unstable and hypochondriacal. They were also introverts (schizoid) and
pathological liars. Creative psychopaths were all dysfunctional people who
managed to become famous or infamous.
Twenty years later, in the 1959 Mental Health Act for
England and Wales, "psychopathic disorder" was defined thus, in
section 4(4):
"(A) persistent disorder or disability of mind (whether
or not including subnormality of intelligence) which results in abnormally
aggressive or seriously irresponsible conduct on the part of the patient, and
requires or is susceptible to medical treatment."
This definition reverted to the minimalist and cyclical
(tautological) approach: abnormal behaviour is that which causes harm,
suffering, or discomfort to others. Such behaviour is, ipso facto, aggressive
or irresponsible. Additionally, it failed to tackle and even excluded
manifestly abnormal behaviour that does not require or is not susceptible to
medical treatment.
Thus, "psychopathic personality" came to mean both
"abnormal" and "antisocial". This confusion persists to
this very day. Scholarly debate still rages between those, such as the Canadian
Robert, Hare, who distinguish the psychopath from the patient with mere
antisocial personality disorder and those (the orthodoxy) who wish to avoid
ambiguity by using only the latter term.
Moreover, these nebulous constructs resulted in co-morbidity.
Patients were frequently diagnosed with multiple and largely overlapping
personality disorders, traits, and styles. As early as 1950, Schneider wrote:
"Any clinician would be greatly embarrassed if asked to
classify into appropriate types the psychopaths (that is abnormal
personalities) encountered in any one year."
Today, most practitioners rely on either the Diagnostic and
Statistical Manual (DSM), now in its fifth, revised text, edition or on the
International Classification of Diseases (ICD), now in its eleventh edition.
The two tomes disagree on some issues but, by and large,
conform to each other.
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