M e d Sei. Law (1975) Vol. 15, No.

51

The Medicolegal Implications of the Terms

'Psychopath', 'Psychopathic Personality' and
'Psychopathic Disorder'
DONALD BLAIR,
Consultant

M A , M D , BCh, FRCPsych, D M J

Psychiatrist,

124 Harley Street,

SUMMARY
T h e difficulty in d i a g n o s i n g various types of p e r s o n a l i t y
is c o n s i d e r a b l e . W h a t a r e t h e dividing lines bclvtreen
t h e so-called O r d i n a r y p e r s o n a l i t y ' , ' t r e n d d i s t u r b a n c e s
of p e r s o n a l i t y ' , ' t r a i t disorders of p e r s o n a l i t y ' a n d
' p s y c h o p a t h i c disorders of p e r s o n a l i t y ' . T h e r e a r e n o
b o r d e r lines a n d t h e qualities of o n e m a y s h a d e i n t o
those of a n o t h e r .
F r o m t h e medicolegal p o i n t of view, h o w e v e r , it is
obviously essential t o d e t e r m i n e w h i c h disorders of
personality, if a n y , m a k e sufferers n o t legally fully
responsible for their actions. I t is e v i d e n t t h a t o n l y
p s y c h o p a t h i c disorders qualify for legal disposals t h a t
recognize their lack of legal responsibility t o o n e d e g r e e
or a n o t h e r . O n t h e o t h e r h a n d , t h e l a t i t u d e of i n t e r p r e
t a t i o n of this diagnosis since it was recognized legally
in t h e M e n u l H e a l t h Act 1959, h a s led to its use in
t h e c o u r t s b e i n g in m a n y cases of n e b u l o u s a n d d o u b t
ful v a l u e . If t h e c o n c e p t i o n of this e n t i t y is n o t to b e
abolished a l t o g e t h e r t h e r e will in m y e s t i m a t i o n h a v e
to b e a m o r e exclusive a n d n a r r o w m e a n i n g signified
b y p s y c h o p a t h i c d i s o r d e r a n d this article presents
provocative suggestions h o w this m a y be a c h i e v e d as
well as a precise description of all aspects of psycho
pathy.
T h e snags a n d illusions w h i c h h a v e so far resulted in
t h e m l e of o p i n i o n r e g a r d i n g t h e w h o l e of this
m a t t e r a n d t h e influence this h a s h a d o n t h e custodial
a n d t h e r a p e u t i c disposal of this g r o u p of antisocial
offenders a n d criminals will b e discussed in a further
article to b e p u b l i s h e d in a s u b s e q u e n t issue of this
journal.

The word 'psychopath' is a noun (derived

from the Greek words psychos and pathos,
Chambers' Dictionary) meaning literally a
derangement of the mind but by custom
referring to a person suffering from a derange
ment with a specific connotation. 'Psycho
pathic' is the adjective derived from the noun
psychopath and it is well to realize as a
prelude to our deliberations that a 'psycho
path' is a person suffering from a 'psycho
pathic personality', a 'psychopathic disorder'

London

or a 'psychopathic state' and that all these

terms are synonymous.
The words 'psychopath' and 'psychopathic'
are in common use today with little appreci
ation of their exact meaning either in
everyday conversation or on the mass media.
Many crimes, and especially crimes of vio
lence, are nowadays attributed to psychopaths
and one might logically expect doctors and
lawyers working in the medicolegal field to
be fully cognizant with the implications
involved, yet one seldom meets a member of
the legal profession who has more than a
vague notion of the type of person a psycho
path is supposed to be or a doctor who can
adequately define one. Even psychiatrists
vary considerably in their interpretations of
this condition. It is surely desirable for all
members of the medical and legal professions
concerned with crimes of violence to be well
acquainted with the prevailing picture of
psychopathy. A consideration of the history
of the development of the conception of this
entity throws some light on the medicolegal
problems involved.
Psychiatry is a young specialty and indeed
has only emerged during the last two cen
turies. Its origin is rooted, on the one hand,
in laws which compelled the local authorities
to build asylums to accommodate the insane
within their precincts and, on the other, in
the advent of mesmerism and hypnosis. In
asylums alienists had the opportunity to
study the psychoses and the physical aetiology
of mental illness, whereas mesmerism and
hypnotism led to a study of the psychoneuroses and psychopathology. However, the
first task was to formulate descriptions of

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Med. Sei. Law(1975) Vol. 15, No. 1

mental illnesses as diagnostic entities. Originally the classications were too complicated
and profuse but gradually by the processes of
simplification and amalgamation, descriptions of the psychoses and the psychoneuroses
closely resembling those generally recognized
today emerged. It became recognized by a
few psychiatrists of outstanding clinical
acumen and vision, however, that there
occurred some cases of mental abnormality
with a common pattern which did not coincide with that of any of the psychoses or
psychoneuroses.
It was the famous French psychiatrist
Pinel (1801) who, in the days when the mind
was described in terms of its faculties, asserted
that a person could be deemed insane if his
faculties of will and emotion were sufficiently
disturbed even if his powers of reasoning
remained intact. This was a revolutionary
doctrine since it had always been assumed
that disturbances of reason and intellect were
a sine qua non of insanity. Benjamin Rush
(1812) of the United S u t e s envisaged 'moral
derangement' as a condition due either to a
congenital defect or to a disease and used
these words, 'In all these cases of innate
preternatural moral depravity there is probably an original defective organization in
those parts of the body which are occupied
by the moral faculties of the mind. . . How
far the persons whose disease has been
mentioned should be considered as responsible to human or divine laws for their
actions, and where the line should be drawn
which divides free agency from necessity and
vice from disease, I am unable to determine'.
Prichard (1835), an English psychiatrist, first
referred to persons of this same type as
'moral imbeciles' and his definition of 'moral
imbeciles' is concise and apposite: 'There is
likewise a form of mental derangement in
which the intellectual faculties appear to
have sustained little or no injury, while the
order is manifested principally or alone in the
state of the feelings, temper or habits. In
cases of this iiature, the moral and active
principles of the mind are strongly perverted
or depraved: the power of self-government is
lost or greatly impaired, and the individual
is found to be incapable, not of talking or

reasoning upon any subject proposed to him,

for this he will often do with shrewdness and
volubility, but of conducting himself with
decency and propriety in the business of
life'.
The words 'moral' and 'imbecile' were
unfortunate and for many years psychiatrists
disputed their meaning in relatioiiship to
'moral imbecility' or 'moral insanity' as
diagnostic entities.
German psychiatrists in the second half
of the nineteenth century, concentrating on
the somatic aetiology of mental illness,
sought for a physical causation of this condition and it was Koch (1889) who first introduced the word 'psychopathic' and referred
to the condition 'psychopathic inferiority' as a
constitutional predisposition to psychopathy,
whilst also attributing it to such acquired
syndromes as brain injury.
Equally renowned German psychiatrists
Kraepelin (1909) and Kahn (1931) tried to
describe the condition as a specific trait
syndrome.
In this country Henderson's (1939) book
Psychopathic States created a profound impression but he stretched the conception of the
term 'psychopath' even further than previously by describing three types: the
predominandy inadequate; the predominantly aggressive and the creative. The
creative psychopaths he describes as eccentric,
peculiar, unstable individuals who could be
bizarre geniuses of whom Lawrence of
Arabia was a prototype, and the inadequate
and aggressive groups as both being volatile,
impulsive, irresponsible and lacking in affection or love but the former being prone to live
off society by invalidism, swindling or pilfering and the latter to serious aggression
(including homicide, suicide), alcoholism,
drug addiction and sexual perversions.
Army psychiatrists (1939-46) divided
psychopaths into three groups: antisocial,
emotionally unstable and sexual, and Curran
and Mallinson (1964) also described three
groups: the vulnerable (similar to Henderson's inadequate), the unusual or eccentric
(similar to Henderson's creative) and the
sociopathic (similar to Henderson's aggressive
and to the American use of that word today.)

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Blair: Implications of Psychopathic Terms

Whereas in Britain 'psychopath' was

being extended to embrace a conglomeration
of oddities, certain psychiatrists in the
United States were trying to evolve a more
limited and precise idea of this abnormality.
Bleckley (1941) emphasized the psychopath's lack of feelings of affection, love or
guilt, his impulsiveness and his egocentricity
but despite this his charm of manner and
flair for impressing other people. The
McCords (1956) pointed out the increasing
restriction of the term 'psychopath' and
conunented 'unless the individual exhibits the
two critical psychopathic traitsguiltlessness
and lovelessnesshe should not be categorized as psychopathic'
It will be seen later how the ideas prevailing in the Royal Commission (1954-57) on
the law relating to mental illness influenced
the attitude to psychopathy adopted in the
Mental Health Act of 1959.
The climate of psychiatric opinion existing
at any time regarding the facts and fancies of
the diagnosis, prognosis, aetiology and treatment of mental illnesses in general and of any
specic illness in particular has, of course,
helped to mould the concepts of psychopathy
prevailing. One has seen the parts played by
faculty psychology, nosology, typology and
trend syndromes in this respect.
As psychiatry has progressed in all its
aspects over the decades more and more
attention has been paid to the effects of
various physical and mental stresses and
strains on various types of individuals, and
nowadays understanding the constitution of
the personality of any patient is considered of
paramount importance. As a result of this
personality cult it is considered by many
psychiatrists that they have now found the
missing link in the categorical classification of
mental abnormalities and illnesses, namely
the group of condition^ grouped under the
heading 'personality disorders'. In these
disorders the personality concerned in his
efforts to adjust himself to the exigencies of
his life, utilizes patterns of action and
behaviour instead of the patterns of physical,
mental and psychosomatic symptoms seen in
the psychoses, psychoneuroses and subnormalities. Psychopathy essentially implies a

53

disorder of personality and it is thus that the

terms 'psychopathic personality' and 'psychopathic disorder' arose, although it is plain
that the latter should read 'a psychopathic
disorder of personality'.
The problem of describing personalities
accurately and in detail has proved more
baffling for psychiatrists than might have been
anticipated. Whereas in everyday language
personality is defined as 'that which distinguishes a person from a thing, or one person
from another; individuality' {Chambers' Dictionary), endeavours in the fields of normal
and abnormal psychology and psychiatry to
describe the entity of personality in exact
terms have resulted in fifty different definitions {Encyclopaedia of Psychiatry for General
Practitioners, 1972). Furthermore, classifications of personality disorders vary from one
to another. Broadly speaking the disorders
may today be divided into three groups:
disorders of pattern, disorders of trait and
antisocial disordersand one of the classifications is the following (Kolb, 1968):
1. Disturbances of pattern: cyclothymic;
hypomanic;
melancholic;
schizoidall
personalities.
2. Disturbances of trait: compulsive;
hysterical; passive-aggressive; emotionally
unstable; inadequateall personalities.
3. Antisocial
disorders:
sociopathic
personality.
Group 1 is said to resemble the personality
organizations seen in manic-depressive and
schizophrenic illnesses but in contrast to
those illnesses ego functioning and reality
tests remain intact.
The so-called 'unmodifiable behaviour patterns' of group 2 are believed to be explicable
on a psychogenic or psychopathological basis.
In group 3 the term 'sociopathic personality' refers to those chronically antisocial
individuals without the capacity to form
significant attachments to other individual
people, to groups of people or to codes of
living. It is to be noted that the authors of
this classification state that the passiveaggressive, emotionally unstable, inadequate
and sociopathic subdivisions of personality
were previously all contained under the
heading 'psychopathic personality'.

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Med. Sei. Lew (1975) Vol. 15, No. 1

This scheme of classification of personalities

does have a claim to composite and comprehensive stature, although many psychiatrists
would dispute its validity, but other writers
are less exact in their approach, a situation
which has been referred to as follows, 'The
psychopathic personality is of medicolegal
interest and there have been occasions when
judges and juries have had to listen to lengthy
evidence upon what is such a person'. It may
briefly be said that some writers include
under the term almost every variant personality that is not insane, neurotic, intellectually
defective or epileptic, when the concept is so
wide as to be meaningless. Many authors
include the sexually deviate, the alcoholic
and the drug addict, either under the general
term or as sub-types. Paranoid personalities
are by some authors referred to as paranoid
psychopaths. Some authors similarly dene
schizoid psychopaths and hysterical psychopaths in terms that are synonymous with what
other authors refer to as schizoid and hysterical personalities, although with the added
implication of delinquent behaviour. It is
evident that in much of the literature upon
the subject the word psychopath means little
more than that the individual is a 'peculiar'
or 'problem' person, who cannot be readily
fitted into any other diagnostic category.
There is, nevertheless, general agreement
that an uncommon but characteristic type of
individual exists marked by the following
features:
1. A consistent lack of evidence of a normal
conscience and of the ability to feel in a
normal way for other people and to feel guilt
or remorse.
2. An habitual tendency from an early age
to act impulsively in antisocial ways with no
prudent forethought of the inevitable consequences.
3. A failure to profit from experience and
therefore a failure to be deterred by punishment.
4. Freedom from any other form of mental
disorder.
When such characteristics are shown to a
marked degree the individual would by most
psychiatrists be called an aggressive or
antisocial psychopath. Implicit in such a

definition is that the psychopath is not to be

recognized by any one act, however heartless,
antisocial or impulsive it may be: his
psychopathy is an habitual pattern of
behaviour (Wiley and Stallworthy, 1962).
If the diagnosis psychopathic disorder
(which as has been pointed out is a personality disorder) is to receive general
medicolegal acceptance and to rank with the
psychoses and subnormalities (of intelligence)
as a condition warranting equivalent legal
considerations and disposals, it must have
firmly recognizable characteristics and present a definite and unmistakable clinical
picture. It was presumably for this reason
that in the classification of personality
disorders cited above the word 'sociopath'
was used to separate and clearly differentiate
severe antisocial personalities with a specific
pattern of abnormal behaviour. The term
'sociopath' is not in use in this country but
it would seem to me that it would be a
distinct advance in the medicolegal field if
the words 'psychopathic disorder' were reserved
diagnostically for a comparable entity. This
would enable the so-called 'passive-aggressive', 'emotionally unstable' and 'inadequate
personalities' to continue as personality trait
disorders, conditions of comparatively little
legal import, and psychopathic disorder to
emerge as a clearly unmistakable condition
(to lawyers as well as doctors) of much legal
significance. A full consideration of that condition as, in the author's estimation, it ought
to be is as follows.
PSYCHOPATHIC DISORDER
T h e Clinical Picture
The cardinal features of this condition which
have already been mentioned are, in broad
terms:
1. Lack of a normal conscience.
2. Absence of such normal feelings for
other people as love, affection, sympathy and
condolence.
3. A tendency to antisocial impulsive acts
with no forethought of the consequences.
4. A failure to learn by experience and to
be deterred from crime by punishment.
5. Freedom from any other form of mental
disorder.

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Blair: Implications of Psychopathic Terms

From these basic characteristics one may

elaborate a full picture. The intelligence of
psychopaths varies from very dull to very
bright and their intelligence quotients accord
ingly, but wherever the particular psychopath
may stand on the intelligence parabola he is
unable to describe in a normally rational way
the motivation for his crimes and for the
impulsive manner in which they have been
executed. About other matters, however, he
is adept at apparently rational conversations
and descriptions. Their emotional reactions
are unstable and unpredictable. Trivial
incidents may provoke disproportionate
swings in mood. They may for no ostensible
cause veer suddenly from elation to depres
sion (or vice versa) or explosively from
peaceful tranquillity to turbulent wrath.
Characteristically they seek immediate grati
fication for every hedonistic whim, fancy,
urge or need, irrespective of the consequences
to themselves or to others. T o them the end
justifies the means no matter how much pain
or suffering this may cause to other people.
Nothing must thwart their desires and from
early childhood onwards they refuse to con
form to the moral and ethical standards
prevalent in their society. They are extremely
egotistical and to attain their objectives will
indulge in any unscrupulous, dishonourable
or deceitfiil act, on the one hand, or callous,
brutal or cruel one, on the other. Kindness
they will repay with unkindness and trust
with betrayal. They know not the meaning
of the word honour and exhibit neither shame,
remorse or guilt for any suffering their
nsbehaviour may have inflicted on others,
even including their own parents and
family.
With regard to occupation and recreation
their ambitions are ill defined and incon
sistent and they lack tenacity of application
and precision of goal. Their employment
records are chequered and they quite often
lead a nomadic existence.
Sexually their development may be re
tarded or abnormal and perversions of all
types are common amongst them. Their
marriages are usually transient affairs ending
in total failure.
They are inveterate liars, capable of

55

extravagant fabrication and preposterotis

confabulation. With glib tongue and mis
leading conviviality they may induce their
victims to befriend them, only to reward this
by defrauding, cheating and swindling them.
Their crime records are likely to include
crimes of all types including in particular
theft, embezzlement, fraud, forgery, sex and
violence. They loathe discipline and are a
source of indiscipline and disobedience in
any society to which they belong. For this
reason one of the principle tasks of military
psychiatrists during the last war (1939-45)
was to effect their diagnosis and discharge
from the armed services.
The above is the general pattern of this
condition but the characteristic symptoms
will vary in quality and quantity from one
case to another. The psychopath is not
involved in crime every day of his life and his
mood and demeanour may vary greatly from
one time to another so that he can frequently
present an air of plausible cheerfulness and
geniality and appear to all intents and purprases normal. He may thus sometimes obtain
quite responsible jobs. For example, Neville
Heath, the notorious psychopathic murderer,
was commissioned in the RAF and for a
while flew with a fighter squadron. Although
court-martialled for the theft of a car and
discharged from the RAF he then duped the
army and was commissioned in the R A S C in
the Middle East and duly court-martialled
again, this time for forgeries. After dismissal
from that service he enlisted in the South
African Air Force, was commissioned once
more and served in it for three years. Miles
Gifford, another notorious murderer, who
was also diagnosed as a psychopath, was a
seaman on a North Sea destroyer for four
years.
A remarkable feature of the psychopath is
the course which his affliction runs. Typical
symptoms, which may present themselves in
early childhood, tend to become more
pronounced and explosive during adolescence
and early adult life when they reach their
zenith. Thereafter they tend gradually spon
taneously to diminish in intensity and
frequency so that by the time he is in his
forties the psychopath's viciousness and

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Med. Sei. Law (1975) Vol. 15, No. 1

liability for brutality and violence may have

modified and possibly almost disappeared.
H e even tends in later life to become socially
responsible and reliable. This trend of events
does not always occur and some psychopaths
remain prone to serious crime all through
their lives.
There are many psychopaths who are
totally unable to identify theniselves with the
society to which they belong and its laws and
who experience pleasurable satisfaction in
their criminal activities. Any form of punish
ment they consider as unjust and unwarran
ted and it has no deterrent effect on their
committing future crime. Few psychopaths
believe that they are mentally abnormal and
fewer still that they are mentally ill.
Diagnosis
Accurate diagnosis of a psychopathic dis
order is of the utmost medicolegal importance
and should never be made unless the picture
is definite. For optimum diagnosis a detailed
life history is essential and the more one
knows about the person under consideration
the better. The cardinal features (described
above) of this condition must always be
present and be followed by a life history
whose characteristics fall within the bounds
of the clinical description just given.
There are four conditions par excellence
from which psychopathic disorder must be
differentiated:
1. Personality disorders.
2. Severe psychoneurosis.
3. Ordinary adolescents.
4. Hardened criminals.
With regard to the first condition the
evolution of the concept of personality
disorder has already been described. Its
value is questionable especially from the
legal viewpoint. Throughout the history of
psychiatry there has been one recognized
condition after another which has tended to
be the dump-heap for cases of uncertain
diagnosishysteria, neurasthenia, mental
defectiveness, schizophrenia, psychopathy
and now personality disorder (and one may
perhaps include with it so-called 'character
disorder' or 'behaviour disorder'). Disturb
ance of personality patterns and personality

traits may be of some clinical interest but the

personality of each individual is an extremely
complex entity with very many facets and it
is, to say the least, very doubtful whether a
disturbance of personality pattern or trait is
of appreciable consequence in assessing a
person's legal responsibility for his actions.
In the terms of the classification which have
been given, and to which the author adheres,
it is to be noted that so-called 'passiveaggressive', 'emotionally unstable' and 'in
adequate personalities' are distinguished
from sociopathic personalities synonymous
with psychopathic personality as presented
here. This is important because it removes
from the mle of conditions that had
previously been so often assembled under the
heading psychopath those paler and less
discriminate shades of undesirable personality,
leaving the real, pernicious, obnoxious,
antisocial psychopath (as envisaged in this
article) separate from them.
The diagnostic difference between these
psychopathic disorders (of personality) and
the patterns of trend and trait disorders is to
be found in the absence of the firmly estab
lished criteria and symptoms of psychopathy
in the latter groups.
In the second condition it is usually not
very difficult to diagnose a psychopathic
disorder from a neurotic one, but there are
some cases of severe neurotic maladjustment
amongst juveniles and adolescents who can
behave very egotistically, aggressively and
antisocially and who require to be distin
guished from genuine psychopaths. Such a
diagnosis will depend on a full history when
there will be evidence that the neurotic still
has some feelings of love and sympathy, a
conscienceeven if it is dormantlittle
impulsiveness and an ability ultimately to
learn by experience.
In condition 3 the dividing line between
the emotionally unstable, sexually irrespon
sible, aggressively rebellious attitudes and
actions of many so-called 'normal adoles
cents' and the perniciously callous and shame
lessly brutal ones of the true psychopath may
be narrow. Caution is needed to diagnose
the genuine psychopath from the much more
common adolescent miscreant, and again a

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Blair: Implications of Psychopathic Terms

detailed life history will almost certainly

assist towards the right answer.
The hardened criminal in condition 4,
who is free from any abnormality or disease
of the mind, may well have a grudge against
society and select crime as a mode of life.
The motives for his crimes are such obvious
ones as avarice, lust, or vengeance and the
mode in which they are executed usually
indicates some intelligent planning and some
ability to learn by past experience. He may
be a good husband and father and have
genuine love for his wife and children. The
life histories of'ordinary' recidivists may vary
greatly in their characteristics but will not
resemble the typical saga of the psychopath.
It is sometimes difficult to decide whether
a patient is suffering from psychopathic
disorder, real schizophrenia or a schizo
phreniform reaction. This occurs in particular
when a psychopath is in a sullen intro
verted mood without real insight into his
state of mind or circumstances. Early stages
of schizophrenia may certainly present a real
diagnostic problem only to be solved in the
light of thorough histories and perceptive
observation and investigations.
It must be appreciated that patients
suffering from a psychopathic personality
disorder may sometimes develop a super
vening psychosis. Once the psychosis is
successfully treated the veracity of the
psychopathy will become evident.
Aetiology
A tremendous amount of research has been
performed to try and determine the causes
of this condition and numerous medical
articles have been written indicating the
results of such research. Although there are
very many factors involved in the constitution
of each person's unique personality, it had
been hoped that certain important aetiological attributes might prove common to
the emergence of psychopathy.
However, the outcome of all efforts in this
direction has been singularly disappointing,
although perhaps not more so than similar
efforts regarding the aetiology of alcoholism,
drug addition and all forms of crime. This is
partially due to the tremendous variations

57

in the minute constitution of every individual

personality and partially to the innumerable
variables in the various environments to
which one is subjected every day of one's life.
All that can be stated with reasonable
substantiation is that certain obscure un
favourable genetic factors may be of conse
quence in some cases, brain damage, or
disease of the central nervous system in
others and seriously adverse interpersonal
relationships or circumstances within the
family (parental inconsistency, love depriva
tion, rejection, neglect, poverty, illnesses and
feeding problems) in many more. One, all
or any intervening number of these factors
may be present in an individual psychopath's
life history and the relative effect of each one
of them may vary from one case to the next.
Many postulations and theories have been
advanced from the psychopathological view
point to explain the mechanisms involved in
the production of psychopathic symptoms
but none of them are very convincing or have
much validity medicolegally. It is evident
that psychopathy entails an abnormality of
personality and a defect in maturation. The
mind of the psychopath is in many respects
firmly fixated at a childhood level although
why this should be remains a mystery.
Those who enthusiastically believe that the
origin of all mental abnormality is to be
found in one form or another of the body's
physical dysfunction have striven to find
physical explanations for psychopathic dis
order. It is true that psychopathic disorder
may be the direct result of such a lesion as a
brain injury, abscess or tumour or the
permanent effects of such an illness as
meningitis or encephalitis lethargica, but in
such instances the symptoms are those of
the physical ailment concerned and not of a
psychopathic personality in itself.
The advent of the electro-encephalogram
roused hopes of accounting for psychopathy
by abnormalities of abnormal tracings, but
the field has proved to be a very complicated
one and the only valid finding is that there
are certain abnormal tracings whose presence
confirm the diagnosis of aggressive psycho
pathy but whose absence does not exclude
such a diagnosis. Recent research into

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Med. Sel. Law (1975) VoL 15, No. 1

abnormal chromosomes amongst criminals

has proved inconclusive.
Treatment
Because psychopathic disorder is a disorder
of personality and because its aetiology is
still obscure it is difficult to devise successful
treatment for patients suffering from this
affliction.
It is generally agreed that the types of
dynamic psychotherapy which usually benefit
psychoneurotic patients are unsuitable for
psychopaths. Therapeutic efforts for the
latter must be directed towards recondition
ing their feelings and behaviour. Predomin
antly they require firm but sympathetic
discipline, and retraining and rehabilitation
are the cornerstones of their treatment, the
latter including general education classes
and special instruction in remunerative
trades. Needless to say the endeavours of
the medical and ancillary staffs treating
psychopaths are aimed at attaining a positive
rapport with them and at kindling in them
positive individual and social sentiments.
Individual counselling and group discus
sions are therapeutic measures of considerable
consequence and may result in the individual
psychopath developing some feeling of
responsibility to the group to which he
belongs.
Physical methods may have an important
place in the treatment of psychopaths.
M o d e m psychotrophic drugs may exert
valuable corrective and tranquillizing effects
on their behaviour and the administration of
suitable anticonvulsants may greatly mollify
the violence of aggressive psychopaths who
have a typical cerebral dysrythmia, as
revealed by EEG tracings. However, it must
be remembered that psychopaths may refuse
to take any medication. They have a legal
right to do so in prisons and borstals and even
when under a compulsory detention order in
a mental hospital it can be extremely difficult
to force their medication if it is refused al
though extreme excitement or violent be
haviour can be dealt with temporarily by
approximate injections.
It is comparatively easy to devise schemes
of treatment for the psychopath from the

theoretical point of view, but in practice

their successful application is a mammoth
task which will depend for results largely on
the age of the patient concerned, the severity
of his psychopathy, the environment in which
the treatment will take place and the duration
of time for which it will continue. It is not
very often that a severe psychopath will
seek any psychiatric treatment of his own
accord unless he has some severe inter
current symptom, such as depression, nor is
he likely to be induced to do so by relatives
or friends. Treatment therefore usually only
becomes available to him when his antisocial
behaviour brings him before a court and a
disposal is made compelling his admission
to an institution where such treatment is
performed;
1. Psychiatric units specializing in psycho
pathy.
2. Ordinary mental hospitals.
3. Hospitals for subnormals.
4. Special hospitals.
Psychiatric treatment is available today in
certain borstals and prisons and suitable
psychopaths as well as other patients may
be sent there.
T h e institutiozu specializing in psycho
pathic and other personality disorders are
exemplified by the Henderson Hospital,
Surrey, and the Balderton Psychopathic
Unit at Balderton Hospital, Nottingham
shire. Both units are in fact concerned
particularly with the treatment of psycho
pathic youths. The former only admitted
cases legally of volunUry status and of
average intelligence but in 1960 a proportion
of 30 per cent of court referrals were accepted.
It is an open unit and therefore restricted
to the less severe types of case, many of whom
might well qualify according to the classifica
tion given as trait disorders of personality.
In the type of patient treated, the kind of
crimes that have been committed are not of
the most serious nature. A community spirit
with group analytic meetings has been
established and the results obtained are
purported to have been quite good (Taylor,
1966). At Balderton the psychopathic unit
refers to one ward especially adapted for the
purpose within the grounds of Balderton

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Blair: Implications of Psycfiopathic Terms

Hospital for subnormals. The cases are of

voluntary status, provenly antisocial, aged
between 13 and 26 and with an IQ, of not
less than 60. Again the unit is an open one
within the hospital boundaries with stress on
self-governing groups and a psychothera
peutic approach. Some results have been
encouraging, some disappointing and Dr
Graft (1966), the Medical Director, has
stated 'The results of treatment do not
appear particularly promising'.
The extremely unsatisfactory results of
admitting offenders against the law with
symptoms typical of the diagnosis of psycho
pathic disorder into ordinary mental hos
pitals have been graphically demonstrated by
Dr Henry Rollin (1968) who says, 'The
dismal record of failixre in the attempt to
treat those stotutorily labelled as psychopaths
in a conventional mental hospital is self
evident . . . in totting up the cost of treating
this handful of society's sore thumbs, the
chaos created by them in the hospital itself
must be taken into account'. He agrees with
Dr John Bearcroft (1968) that 'the average
mental hospital seems limited in what it has
to offer the psychopath'.
Cases treated in hospitals for subnormals
may respond well where their antisocial
behaviour has in fact been due more to their
subnormality than to psychopathy. Some,
however, may require to be detained in
wards of maximum security until over many
years their social responsibility gradually
matures as far as their low degree of intelli
gence permits.
The antisocial behaviour of most pwychopathic personalities renders them a scourge
and nuisance to society and in them it seems
permissible for a degree of risk to be taken
in returning them as soon as possible to free
dom from any form of institutional confine
ment, a risk, however, which must diminish
with every further conviction for major
crime. In those cases who commit dangerous
crimes which threaten society the matter is
different. Such cases almost invariably gravi
tate to one of the special hospitals (Broadmoor,
Rampton, Moss Side) where they are treated
m conditions of maximum security and have
to associate with other patients who suffer

69

from different mental abnormalities. The

therapeutic problems facing the medical and
nursing staff" of such hospitals are enormous.
A nihilistic suppressive approach is to be
deplored, yet what risks should be taken in
patients who have committed honucide or
violent sexual crimes? Will they kill again
or will they assault again ? This is the dread
ful question. The deaths caused to members
of the public by Stratton and more recently
Young (the guinea-pig murderer) and others
point to the absolute tragedy of erroneous
judgements. Dr McGrath (1968), the Medical
Superintendent, has earmarked the current
difficulties in his many writings. On the one
hand is the ever present possibility of the
subtle development of institutionalization in
long-term patients, on the other, the risk of
further serious crime if they are discharged,
at least until they are forty years old or more.
Psychopathic offenders and criminals are
not all dealt with by the law in a manner
which ensures that they receive the oppor
tunity for treatment in one of the medical
establishments listed above. Many of them
are sentenced to terms of confinement in
borstals or prisons. The reasons for this are
many, as, for instance, the magistrate or
judge presiding at his trial believes that the
psychopathic offender or criminal concerned
must be considered legally responsible for
his actions and metes out a sentence accord
ingly; or the psychopath may prefer prison
with a definite length of incarceration to
hospital with an indefinite period of stay; or
he may consider himself mentally normal and
refuse to submit to any psychiatric assessment
or treatment. Lastly, it may not be possible
to find any hospital willing to accept the
psychopath concerned for admission although
a disposal under the Mental Health Act
1959 has been psychiatrically recommended.
Estimations of the proportion of psychopaths amongst the 32 000 approximate
daily prison and borstal population vary
from 2 to 15 per cent (Pickering, 1968).
Efforts are made by the staff of ordinary
prisons to distinguish psychopaths and treat
them as exceptions with as much tact and
understanding as possible. The prison medical
officers are vigilant in selecting prisoners

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60

Med. Sei. Law(1975) Vol. 15, No. 1

suitable for psychiatric regime and treatment

in prison treatment units and especially at
Grendon Underwood Prison which is entirely
a treatment prison. It is also their task to
send severe cases to the special hospitals
under s.72 and s.73 of the Mental Health
Act 1959, but the numbers transferred are
small (varying in annual totals for the whole
prison service from 4 to 18 during the years
1963 to 1967). There are, of course, grades
of borstals and prisons, from the grades with
maximum feasible freedom to those of maxi
mum security. Psychopathic prisoners will in
common with other inmates be sent to the
grade thought to be most appropriate for
them.
Grendon Underwood Prison is worthy of
special mention. It was opened in 1962 with
the objective, as stated by Dr W. j . Gray
(1973), its Medical Superintendent, of
attempting, for the first time in an English
prison, a therapeutic community approach
to the psychiatric treatment of non-psychotic
recidivist offenders with moderate or severe
personality disorders. A certain degree of
selectivity has always been maintained and
the following groups of patients excluded:
1. Those 'certifiable' under the Mental
Health Act 1959.
2. Those suffering from permanent organic
changes.
3. Those showing intellectual inferiority
of such a degree as to render them incapable
of co-operating in treatment.
4. Those who do not exhibit a genuine
anxiety for cure, including those inmates
unwilling to co-operate in measures designed
to modify their abnormal practices.
5. Those whose attitudes suggest they had
ulterior motives for seeking treatment.
It has 220 inmates housed in 3 adult wings
and 3 boys wings. The staff: inmate ratio is
high70 uniformed staff in all including
7 psychiatrists, 4 psychologists, a psychiatric
social worker and 4 welfare officers. The
inmates accepted are in D r Gray's words 'a
highly disturbed group to judge by their
psychiatric and social histories, also by their
scores on tests of psychological disturbance
and by EEG records and they are a highly
recidivist group with a high average number

of previous convictions and considerable

penal and institutional experience and some
40 per cent have a history of inward or
outward violence'.
Treatment is based on therapeutic com
munity principles and involves mainly multiperson situations including frequent small
and large group meetings, the largest includ
ing all inmates in a winga 30 or 40 total.
The treatment is aimed at interesting patients
in the treatment of each other and in work
ing through interpersonal relationships. The
whole enlightened approach and efficient
regime is very impressive and the results
achieved to date are highly satisfactory
although an exact estimation of success is
not yet available. The success rate according
to reconvictions over 2 years after discharge,
does indicate that the longer the period of
treatment in Grendon, at least up to 20
months, the greater the success rate.
Dr Gray is reported to have considered
that at times as many as 70 per cent of the
population of Grendon have been psycho
pathic personalities but unfortunately his
diagnostic criteria are not specified. One is
left wondering how many are psychopaths
(according to the concepts adopted in this
article), how many personality disorders of
other types and how many Ordinary' well
established recidivists ?
Dr Gray remarks 'Grendon is not the
panacea for all disturbed offenders, some of
whom, because of immaturity and a low
intelligence, require a more structured regime
with closer supervision and intensive nursing
care for their protection and the protection
of others. Hence it has to work in close
liaison with other prison hospitals and with
the state hospitals at Broadmoor, Rampton
and Moss Side'.
PROGNOSIS
It is extremely diflScult to formulate a
reliable prognosis in any case of psychopathy
regarding the likely spontaneous future
course of the untreated case, the probable
response to treatment or the risk of relapse
after successful treatment and liability to
further crime, especially crimes of lethal
violence.

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Blair: Implications of Psychopathic Terms

The psychopath may change his mood and

his external demeanour frequently or may
have tranquil phases when he is ostensibly
free from his antisocial and criminal behavi
our. He is unreliable and dishonest and may
purposefully lie to deceive his doctor whose
attempts to prognosticate must always be
guarded. Some cases thought to be juvenile
or adolescent psychopaths will suddenly
cease all abnormal antisocial behaviour in
their late teens or early twenties. Relapses
may occur but often the change for the better
is permanent and one is left wondering if the
patient was in fact a genuine psychopath.
In general it may be said that the greater
the strength of the four cardinal criteria of
psychopathy the worse the prognosis and
vice versa. A detailed history is very impor
tant for prognostic purposes, and favourable
factors will be a history of the presence in
the past of any definite emotional warmth
and love whether towards his family or any
other person; any group identification; anti
social attitudes and actions not extreme;
some response to past therapeutic or correc
tive measures in a child guidance clinic,
approved school or borstal; a retention of
contact with parents, siblings, relatives; an
ability to do good work even if his employ
ment record is chequered; the absence of the
most serious crimes from his record (homicide,
violent rape, etc.); and a history of being a
nuisance, however exasperating, rather than
a danger to society.

61

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