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  • 8/13/2019 Psychiatric Bulletin 1982 Whitlock 5

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    10.1192/pb.6.4.57Access the most recent version at DOI:1982, 6:57-59.Psychiatric Bulletin

    F. A. WhitlockA Note on Moral Insanity and Psychopathic Disorders

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    Note on Moral In sanity and P sychopathic isordersF . A. WHITLOCK,ro fe sso r o f Psych ia try , Un ive rs ity o f Queens land, Aus tral ia

    De sp it e a good d ea l o f a rg ument t o t he c on tr ar y (Maugh s,1 94 1; Hun te r a nd Ma ca lp in e, 1 96 3; Wa lk , 1 95 4; Wa lk a ndWa lk er , 1 96 1; C ra ft , 1 96 5; Wh it lo ck , 1 96 7) i t is s til l c ommonl y b el ie ve d t ha t P ric ha rd 's 'm or al in sa nit y' ( 18 35 ) w asth e f or eru nn er o f o ur p re se nt- da y c on ce pt o f p sy ch op ath ic( so ci op ath ic ) p er so na li ty ; t he mo st r ec en t e xamp le o f t hisa pp ea rin g i n t he p ap er b y Dav ie s a nd F eldman ( 19 81 ), w how rite: 'In 1 80 1 P in el de sc rib ed a co nd ition te rm ed b y h imm a ni e s an s d eli re , t he n ot ab le fe at ur e o f w h ic h w a s th at t hes uf fe re r s howed bou ts o f e xt reme v io le nc e but w it h no s ig nso f p sy chos is . .. P ri ch ar d con fi rmed P in el 's o bs er va ti on andc oin ed th e term m oral in sa nity w hic h le d to a m ark edp erve rsion o f th e n atu ral im pu lses .' A n um be r o f m od erntextbooks (Sim , 1974; F riedm an et al, 1975; Slater andRot h, 1 97 7; T re th owan . 1 97 9) a ls o a pp ea r to re ga rd mor ali ns an it y a s t he p re cu rs or o f p sy chop at hi c d is or de r, a lt ho ughT reth ow an c orre ctly n oted h ow the w ord 'm ora l' d en ote d'a ff ec ti ve ' a nd was n ot b ei ng u se d in th e u su al e th ic al s en se .He went o n, h oweve r, t o w r it e t ha t P ri ch ar d d es cr ib ed c as esshowing an ti soc ia l o r even c rimina l behav iou r.A ca re fu l ex am in atio n o f th e c ase s m en tio ned b y P in el( 1801 ) a nd by P ri ch ar d should make i t a bund an tl y c le ar t ha te xc ep t f or t he fi rs t o f t he th re e p at ie nts c it ed b y P in el , t he rew as n ot t he r emot es t r es embl an ce b etw ee n t he ir e xamp le sand w hat today w ould be classed as psychopathic perso na lity . N or d o th e au th ors' g en eral d eline ation s o f th ed iso rde r conju re up the p ic tu re o f p resent -day psychopa thy .Why , on e m ig ht ask , h as the e rror p ersisted ? O ne m ig htc on je ct ure t ha t few o f th e w ri te rs who main ta in t he id en tit yo f mo ra l i ns an ity a nd p sy ch op at hy h av e t ro ub le d t o r ef er t ot he o ri gin al t ex ts . A no th er s ou rc e o f c on fu si on i s th e wor d'm oral' as used in the early part of the 19th century. W alk(1954) and Craft (1965) comm ent on how 'moral' wasemp lo ye d in t hr ee w ay s: a s p sy ch ol og ic al in , f or in st an ce ,'mor al t re atmen t' o r mo ra l c au se s o f i ns an it y; a s a ff ec ti ve o remo tio na l a s o pp os ed t o in te lle ct ua l o r r at io na l; a nd i n t heethical sense of right or w rong. W alk and C raft find thatP ric ha rd u se d th e t erm t hr ou gh ou t h is t re ati se to d es cr ib ec as es o f i ns an ity who se emo ti on al a nd a ff ec ti ve f ac ult ie swe re d is tu rb ed , a nd only l at er , a nd i nc id en ta ll y, u se d i t i n t heethical sense. 'It is hardly justifiable,' C raft w rites, 'toa tt ri bu te t he f ir st d es cr ip ti on o f p sy chop at hy t o P ri ch ar d onthe s tr en gt h o f t hi s o ne p as sa ge .'O f P in el's t hre e p ati en ts g iv en a s e xamp le s o f m an ie s an sdlire dlireere m ea nin g d elu sio n o r illu sio n a sP ric ha rd c al ls i t) th e f ir st a pp ea rs t o h av e h ad a l if e- lo ngp ropens it y f or u nb ri dl ed v io le nc e and impu ls iv e b eh av io uroriginating in childhood. In the absence of any data onp ossib le ce reb ral d am ag e as a c au se o f th is b eha vio ur, it isl ik el y t ha t h e would b e c la ss ed a s a n agg re ss iv e p sy chop at h

    t od ay . Th e s ec ond p at ie nt wa s p ro bably sub je ct t o a tt ac ks o ft empor al l ob e epi le psy w it h c ha ra ct er is ti c e pi ga st ri c s en sat io ns r is in g in to th e n ec k a nd h ea d, b ut w it ho ut p ro ce ed in gt o a g ra nd mal c on vu ls io n. H e was a man o f g oo d c ha ra ct er ,we ll awar e o f h is t en dency to v io le nc e dur in g t he se e pi so de s,an d m ade e very effo rt to a vo id h arm in g o the rs b y w arnin gthem of his attacks. The third patient, the one w ho w aslib era te d b y a m ob to w hom h e ap pea red ratio nal, b ut th enb ec ame inf ec te d by the p re va il in g exc it ement a nd l ai d a bouth im w ith a sw ord w ith fata l e ffe cts, w as alm ost ce rta in lysu ffer ing f rom man ia as now unde rs tood.P ri ch ar d' s c as es we re a ls o d ia gnos ti ca ll y h et er og enou s.Th ey inc lu ded c as es o f mani a, mani c- de pr es si ve p sy chos is ,ep ilepsy, obsessiona l neurosi s, two poss ib le schizophrenicsan d a 4 6-y ea r-o ld m an w ho alm ost c ertainly w as sh ow ingea rly sig ns o f d em en tia . N on e of the se pa tie nts h ad s ho wnl ife- long an ti soc ia l behav iou r. The case desc rip tions aboundin t es timon ia ls t o t he p at ie nt s' p re vi ou s good cha ra ct er ' ag en tl eman r ema rk ab le f or t he wa rm th o f h is a ff ec ti on s' : ' he rna tu ra l d isp osition w as stea dy an d in dus trio us '; 'a m an o fs ob er a nd d omes tic h ab its '; a nd s o o n. Onl y o ne , a p ro ba blem an ic , c ou ld b e s aid t o h av e b ee n a gg re ss iv e a nd i ra sc ib le .Du ri ng h is i ll ne ss h e a ss au lt ed a c le rg yman o f h is p ar is h, b uthe made a complete recove ry wi thout res idual de fec t.Faced by diagnoses of this kind one has to search fors ome c ommon f ea tu re whi ch u nit ed t hem u nd er t he r ub ric o fmo ra l i ns an it y. One thi ng i s c er ta in ; a nt is oc ia l, a gg re ss iv eand crim inal behaviour w ere conspicuously absent inind iv idua ls who , un ti l the ir i llne sse s ,had led b lame le ss l ives.Taking Pinel's concept of m anie sans delire as a guide,P rich ard w as c le arly d esc rib in g in div id ua ls w ith m ajo ra ffe ct iv e ('m or al') d is tu rb an ce s w ith ou t 'a ny r em ar ka bl ed is or de r o r d ef ec t o f t he i nt el le ct , o f k now ing and r ea soningfa cu lties , a nd pa rticu larly w ith out an y in sa ne illus io n o rh allu cina tio n.' T he ir co nd uct is d istu rb ed a s w ell as th eirfee lings , bu t these symptoms a re c lo sely a ll ied : 'Propensi ti esare so n ea rly a llied to p as sio ns an d emo tio ns th at th ey a reg en er al ly r ef er re d t o t he s ame d iv is io n o f t he f ac ul ti es . I n myc la ss if ic at io n, d is or de rs o f ( bo th ] a re c omp rehend ed und erthe designa t ion o f Moral In san ity. '

    In fa ct P rich ard b rin gs o ut th is w id ely d iv ers e symp tomat olo gy , w it h a bs en ce o f i nte ll ec tu al d is ord er a s t he o nl yc ommo n lin k, in th e follow in g p assa ge: 'T he va rie ties o fm oral insanity are perhaps as num erous as the m odifications of feeling or passion in the hum an m ind. T he m ostf re qu en t f orms , h owev er , o f th e d is ea se a re th os e whic h a rec ha ra cte riz ed e ith er b y t he k in d o f e xc it em en t a lr ea dy d esc ri be d o r b y t he oppos it e s ta te o f me la ncho ly d ej ec ti on . Oneo f th ese is, in m any in stan ces, a pe rm ane nt s ta te , b ut th erea re c as es i n whi ch t he y a lte rn at e o r s up er se de e ac h o th er .. .

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    The p re va le nt c ha ra ct er o f t he d is or de r i s s ome times d er iv edfro m th e co nstitu tio nal disp ositio n o f th e ind iv id ual, b utt he re a re i ns ta nc es i n wh ic h i t i s s tr ik in gl y d if fe re nt f rom thi snatural tem peram ent.' A gain, in his later book (1847)P ri ch ar d wro te , ' Th e exi st en ce o f mo ra l i ns an it y i s p al pa bl eand easily recognized only in those instances in w hich itcom es on, as it often does, after som e strongly m arkedd is or de r a ff ec ti ng t he b ra in a nd t he g en er al s ta te o f h ea lt h,such as a slight attack of paralysis and w hen it displays as ta te o f m ind s tr ik in gl y d if fe re nt f rom the p re vi ou s h ab it ua land na tu ral character o f the ind ividua l. 'M o re ov er , i n P ri ch ar d's v iew, i f a p at ie nt s uf fe ri ng f rommora l in sa nity d ev elo ped some d elu sion al ide a, th e ca sebecam e one of m onom ania. H e introduces such cases,c la ss if ie d a s mon oman ia , a s b ei ng o ne s i n whi ch 'th e a ct ua ls up er vent io n o f e rr on eous b el ie f o r i ll us io n on a p re vi ou sl ye xi sti ng mor al i ns an ity w as c le ar ly m ark ed a nd a dm it te d o fn o d ou bt', a nd as illu stratin g 'th e c onn ectio n b etw een th etw o fo rm s of d ise as es an d th e tra nsition from o ne into th eother'.

    T hus it is clear that, w ith few exceptions, the cases ofmo ra l i ns an it y d es cr ib ed by P ri ch ar d, we re i nd iv id ua ls who,u nt il t he y d ev el op ed b eh av io ur al a nd a ff ec ti ve c hang es , h adn ot b ee n n ot ewor th y f or a nt is oc ia l o r o th er u na cc ep ta bl ebehaviour. It would be rare for our contemporarypsychopath to be aw arded such a character reference asthose men tioned abovea far c ry f rom the ind iv idua l whosep ro pens it ie s h av e o ft en b een obs er ved i n l at e c hi ld hood andado le sc en ce and g en er al ly d o not r em i t o ve r a s ho rt p er io d o ft ime wi th ful l r ecovery o f no rma l behav iou r.For an account of the evolution of m oral insanity intop sy ch op ath ic d is or de r th e r ea de r is r ef er re d to a n e xc ell en to ne by Maughs ( 1941 ). However , s ome add it io na l p oi nt s a reworth mentioning.A t t he time whe n P ri ch ar d w as w rit in g, le ga l c on ce pt s o fi ns an it y r eq ui re d a d emons tr at io n o f d is tu rb an ce s o f r ea so na s s hown b y th e p re se nc e o f d elu si on . A s B att ie ( 17 58 ) a ndErski ne i n Hadf ie ld 's c as e ( 1800 ) r ema rk ed , 'De lu si on i s t hev er y h al lma rk o f i ns an it y' . Cons equent ly , i nd iv id ua ls whocommit ted o ffences wh i le su ffer ing f rom affec tive d iso rde rsb ut n ot e xh ib it in g d el us io n ( il lu si on ) o r h al lu ci na ti on wouldb e u nab le to p lea d in sa nity in th eir d efen ce. U nde rsta ndably, w hen psychiatrists of the day introduced the term'mo ra l i ns an ity ' i n t he ir e vid en ce , j ud ge s a ss umed t ha t th ewor d was b ei ng u se d in it s e th ic al s en se a nd d is lik ed it o n th egro un d th at it c ou ld lea d to p lea s o f irre sis tib le im pu lse.H ow , o ne m ig ht a sk , w as mo ra l i ns an ity t o b e d is tin gu is he df rom ordinary depravi ty?I t wa s a point wh ic h Maud sl ey con si de re d ( 1874 ) w i th ou tr ea ch in g a ny v ery c le ar -c ut c on cl us io ns . N on e th e le ss , h ed id n ot g en er all y s ee mor al in sa nit y a s a l if e- lo ng d is or de r,for he observed how 'there has been an alteration in thet empe r a nd h ab it i n c on se qu en ce o f d is ea se o r o f a s uf fi cie ntcause of disease'. H e also w rote, 'Perhaps the strongeste vid en ce o f the n atu re o f m ora l in sa nity a s a d ise ase o f the

    b ra in i s f urn is he d b y t he f ac t t ha t it s s ympt om s s ometime sp re ce de f or a t ime the symp toms o f i nt el le ct ua l d er angemen ti n a s ev er e c as e o f u ndoubt ed i ns an it y a s, f or e xampl e, a c as eo f a cu te mani a o r o f g en er al p ar al ys is o r o f s en il e d emen ti a' .H e c on tin ue d: 'I t i s in te re sti ng in de ed t o n oti ce t ha t a t le as to ne o f D r P ric ha rd 's c as es , o n whic h h e f ou nd ed h is d es cr iptio n o f th e d ise ase , w as rea lly a ca se o f g ene ral p araly sis'.Maud sl ey wa s p ro bably i nc or re ct , a s t he p at ie nt i n q ue st io n,who mad e a g oo d r ec ov er y, w as a lmos t c er ta in ly s uf fe rin gf rom man ia .A ft er e la bo ra ti ng f ur th er o n t he n atu re o f th e p ro blem, h ew ro te : 'I n th e mo st t yp ic al c as e o f mor al in sa ni ty whi ch h asc ome und er my obs er va ti on t he re h ad b een p re vi ou s a tt ac ksof m elancholia, and it is upon one of these that the m orald er angemen t d ir ec tl y f ol lowed . S uch c as es c ommonly end ind emen ti a, t he d is ea se o f t he m in d p as si ng i nt o d es tr uc ti ont he re of .' H er e a ga in th e r an ge o f c on dit io ns t hi s a ut ho r d esc ri be d c an b e d ia gn os ed w it ho ut d if fic ult y a s e xamp le s o fr ec og ni za ble c lin ic al d is or de rs , f or th e mos t p ar t d ev oi d o fpsychopa th ic featu re s o f long dura tion.Th es e c omment s b ri ng up a s ec ond point o f impo rt an ce . I tis q uit e c le ar t ha t w rit er s li ke P ri ch ar d, M a ud sl ey a nd Hac kT uke (1885; 1892) w ere convinced that m oral insanitygenerally developed on a background of brain disease,inc lud ing ep ilepsy o r a ffec tive psychos is . Tuke wro te (1885)'th e c as es r ec ord ed ... a ff or d e xamp le s o f mor bid c er eb ra lc on dit io ns in whic h th e men ta l s ympt om s d is pl ay ed a re th eem otional and the m ost autom atic rather than those concerned in cognition and may be referred to the form ofmen ta l de rangement usua lly termed moral insani ty , a lthoughth e m o ra l s en tim en ts m a y th em se lv es b e f re e f ro m d is ea se(my ital ics) .Tuke (1892), like M audsley, w as clearly puzzled byexamples o f moral in san ity d iagnosed in ind ividua ls invo lvedi n c rim in al p ro ce ed in gs , b ut h e wa rn ed aga in st a n exc es si vep re oc cupa ti on w it h i ts a ss oc ia ti on w it h c rime and went o n t od is cu ss c as es c ha ra ct er iz ed by sudden a tt ac ks o f d ep re ss io nf or n o c au se a s we ll a s a bnormal b eh av io ur a s t he p re cu rs or sof coarse brain disease. T his is in m arked contrast to theideas of m odern w riters on psychopathy; Scott (1960)specif ically excluded individuals with epilepsy, organic braind is ea se a nd p sy chos is f rom h is c ri te ri a f or s uch a d ia gnos is .N one the less, it has to be adm itted that during the 19thce ntu ry op in io ns a bo ut th e n ature o f m oral in sa nity w ered iv id ed and con fu se d. S ome autho rs w idened the con cept t oinc lude ind ividua ls wi th l if e- long tendenc ie s to commit an tis oc ia l a nd c rim in al a ct s a tt ri bu te d t o s ome i nn at e f ail ure o fd ev el opme nt o f 't he mo ra l f ac ult y'. T he y c ou ld h av e f ou ndsom e support in the one passage in Prichard's later book(1847 ) i n wh ic h, v er y t en ta ti ve ly , h e s ugge st s s ome th in g o fth e k ind . H e sa ys : 'It m ay b e w orth w hile to rem ark , th oug hit is not easy to apply the observation to any practicala dv an ta ge , t ha t m an y o f th os e i ns ta nc es i n whi ch th e who lech ara cter of a n in div id ual th ro ug h life h as b ee n n ote d fo rr ec kl es sn es s a nd abandon ed d ep ra vi ty a re p er haps i n r ea li ty

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    cases of moral m adness... I have alluded to this m erely forcom ple teness and scarcely in the m ost distant ex pectation o fa ny p ra cti ca l r es ult .'By the turn of the century 'm oral' was thought of entirelyin the sense of 'ethical', but at last a distinction was being

    drawn between acquired 'm oral insanity' and congenital'm ora l im be cility ', to w hic h c ate go ry th ese lif e-lo ng d ev ia ntsw ere now assigned. 'M oral idiocy or im becility' had a lrea dybeen included by Skae (1863) in his fam ous 'aetiological'classifica tion. H e described his group as c onsisting of c asesof 'congenital moral perversion, instinctive cruelty,destructiveness and theft'. He continued: 'M any of our m ostnoted kleptom aniacs have been m oral im beciles; in fact, asfar as I know, all have been so; and when we meet withkleptomania in cases of insanity it is only one of manysymptoms.' The two categories appear separately in theclassification adopted by the Medico-PsycologicalAssociation and the Lunacy Comm issioners. The RadnorComm ission of 1904-08 had before it evidence of the existence of both disorders, w ith suggested definitions. In theirReport they quoted that proposed for m oral insanity by DrsSavage and Mercier on behalf of the Royal College ofP hy sic ia ns a s f oll ow s:

    A mor all y i ns an e p er so n mea ns a p er so n w ho , a ft er m a ny y ea rso f r ep uta ble life , a ll a t o nc e u na cc ou nta bly e xh ib its v ic io usp ropens it ies o r t akes to cr iminal courses .Also one proposed by Sir Jam es C richton-Browne, m ore

    o rg an ic a ll y s lant ed :A m orally insane person is one w ho. by reason o f disease ordisorder of the brain, has underg one a chan ge of charac term an ife ste d in a c ou rs e o f v ic io us o r c rim in al c on du ct w ith ou tobvious impai rmen t o f in te l lec t.

    Sir Jam es also proposed a definition of m oral im becility,w hic h th e C omm is sio n c on sid ere d a dm ir ab le :

    The m oral im becile is a person who by reason of arrestedd ev elo pm en t o r d ise ase o f th e b ra in d atin g fro m b ir th o r e ar lyy ea rs d is pl ay s a t a n e ar ly a ge v ic io us o r c rim in al p ro pe ns it ie sw hi ch a re o f a n in co rr ig ib le o r u nu su al n atu re a nd a re g en er allyas soc ia t ed wi th some s light l imi ta ti on of in te ll ect .The Com mission did not think it necessary to m ake m oralinsanity a separate legal c ategory, but m oral im bec ility (laterrenamed moral deficiency) was incorporated in the 1913M en ta l D efic ie nc y A ct.B oth term s, m oral insanity and m oral de fect subseque ntlyfell into disrepute, but it is the latter group of cases that m oreclearly was the precursor of our contem porary antisocialpsychopath. It is arguable tha t, had this gra dual transform ation from moral insanity via moral deficiency to psychopathy not occurred, psychiatry today w ould not be saddled

    w ith the thankless task of trying to treat individuals w ho canhardly be said to be either 'insane' or 'im becile' in any genera ll y a cc ep te d s en se .

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