In the 1800s, Philippe Pinel first used the French term manie sans delire ("mania without delirium") to designate those individuals engaging in deviant behavior but exhibiting no signs of a cognitive disorder such as hallucinations or delusions.
Cleckley had worked for a number of years at a United States Veterans (military) Administration hospital, before taking up full-time teaching responsibilities at the University of Georgia School of Medicine.
[4] The Mask of Sanity, fifth edition, presents clinical theories as well as case studies, written in the form of dramatic, novelistic descriptions of 13 individuals, an amalgamation of those he had observed.
He notes that many types of people hold beliefs that he and much of society would consider irrational, such as mysticism, pseudoscience, praising of unintelligible or immoral works (e.g. acclaim for the novel Finnegans Wake containing only "erudite gibberish" or for the writing of André Gide on pederasty), and religious faith.
Cleckley argues under a subsection titled "Not as single spies but in battalions" (a phrase appearing in Hamlet[5]), that although reliable statistics are hard to come by, there are various reasons to suspect both psychiatric and prison admission rates are an underestimate, and the incidence of the condition is in his opinion "exceedingly high".
He does present some statistics from a survey whereby he and nine other psychiatrists diagnosed 1/8th of patients as having psychopathic personality without any other mental disorder that might explain the condition, and considers that quite a few others classified as alcoholic or drug addicted would actually have qualified too.
Their survey is further detailed in the book's appendix, where Cleckley clarifies it took place between 1937 and 1939 at a federal Veterans Administration hospital, located on the Southeastern seaboard, for the care of ex-service men, mainly from World War I.
He critiques the 'benign policy' of the VA of not diagnosing more psychopathic personality due to giving the benefit of the doubt to issues such as neurasthenia, hysteria, psychasthenia, posttraumatic neuroses, or cerebral trauma from skull injuries and concussions.
He concludes they have "records of the utmost folly and misery and idleness over many years" and if considering the number in every community who are protected by relatives, "the prevalence of this disorder is seen to be appalling."
He also says his method takes inspiration from that used in an earlier work, The Psychology of Insanity, by English physician Bernard Hart (First edition published in 1912 and now open access.[6]).
He rails against the counterculture antihero and gives as an example the novelist Alan Harrington[7] for suggesting a socially necessary role for psychopathy in modern times, calling the idea "perverse and degenerate".
[12] He states that the psychopath very seldom takes much advantage of any gain, has an obscure or inconsistent purpose, usually puts himself unnecessarily in a shameful position as much as causing trouble for others; and usually does not commit the most serious or violent crimes, but usually does end up harming himself.
He notes that many respectable mature productive citizens can look back on short periods of unprovoked social misconduct, including such things as property damage, racism, bestiality, voyeurism, rebellion, and promiscuity.
In surveying some noted literary works embodying what he describes as "malignantly perverse attitudes", such as by Paul Verlaine, Dostoevski, Marquis de Sade, Baudelaire and Swinburne (some associated with the Decadent movement), he suggests that it might be a form of psychopathy, and might appeal to similarly disordered people or to "new cults of intellectual defeatists and deviates" such as certain avant garde groups.
He concludes that Alcibiades "had the gift of every talent except that of using them consistently to achieve any sensible aim or in behalf of any discernible cause" and he "may have been a spectacular example of...the psychopath", that "still inexplicable pattern of human life".
[1] Starting in 1972, newer editions of the book reflected a closer alliance with Kernberg's (1984) borderline level of personality organization, specifically defining the structural criteria of the psychopath's identity integration, defensive operations and reality testing.
As an example to explain the kind of distinction he was drawing between an ability to appear superficially normal despite a core deficit in meaning, he made an analogy to a neurological language disorder known as semantic aphasia.
Having called it a defect, he notes that it would be "one that affects complex mechanisms of integration in a subtle and abstruse manner", and as such could actually sometimes be a positive trait or ability which could nevertheless end up bringing about personal problems in society.
While noting the issue of the protection of liberty, he argues that better ways must be found to do the latter for their own good and that of society, on the primary basis of demonstrated disability and need, perhaps within psychiatric units but segregated from other patients.
Cleckley's work is often considered a seminal contribution to the psychiatric definition of psychopathy, and continues to act as a cornerstone to subsequent lines of research and clinical practice.
Others point out that persistent antisocial behavior was considered characteristic, and "Without exception, all the individuals represented in his case histories engage in repeated violations of the law—including truancy, vandalism, theft, fraud, forgery, fire-setting, drunkenness and disorderly conduct, assault, reckless driving, drug offences, prostitution, and escape.
"[22] Some researchers have concluded from a convergence of findings that Cleckley's concept is probably not a distinct clinical entity, although may represent one important dimension of personality disorder, and has failed to clarify the field in the way he hoped.
[21] One early psychoanalytic reviewer described the Cleckley's viewpoint as presenting a paradox, in that his "keen clinical observations" were not integrated into a meaningful psychological model.
[23] Perri and Lichtenwald have argued that Cleckley was blinded by cultural myths about male aggression and female innocence, and thus tended to overlook or minimize psychopathic behaviors in women.