Reid J. Meloy - The Psychopathic Mind - Origins, Dynamics, and Treatment-Jason Aronson, Inc. (1988) PDF

THE PSYCHOPATHIC
MIND
ORIGINS,DYNAMICS,AND
TREATMENT
THE PSYCHOPATHIC
MIND
ORIGINS, DYNAMICS, AM)
TREATMENT
J. REID MELOY, Ph.D.
R O W M A N & LITTLEFIELD P U B L I S H E R S , INC.

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Meloy, J. Reid.
The psychopathic mind : origins, dynamics, and treatment / J. Reid Meloy.
p. cm.
Bibliography: p.
Includes index.
ISBN 0-87668-3 11-1 (paper) ISBN: 978-0-87668-3 1 1-8
1. Psychology, Pathological. 2. Psychiatry. 3. Psychotherapy. I. Title.
RC454.M37 2002
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Printed in the United States of America
@The paper used in this publication meets the minimum requirements of American
National Standard for Information Sciences-Permanence of Paper for Printed Library
Materials, ANSIINISO 239.48-1992.
About the Author
J. Reid Meloy, Ph.D., is a diplomate in forensic psychology of the

American Board of Professional Psychology. Former Chief of the
Forensic Mental Health Division for San Diego County, he now
devotes his time to a private civil and criminal forensic practice,
research, writing, and teaching. He is an associate clinical profes-
sor of psychiatry at the University of California, San Diego,
School of Medicine, and an adjunct professor at the University of
San Diego School of Law. He is also a Fellow of the Society for
Personality Assessment, and is currently President of the
American Academy of Forensic Psychology. In 1992 he received
the Distinguished Contribution to Psychology as a Profession
Award from the California Psychological Association.
Dr. Meloy has authored or co-authored over one hundred
papers published in peer-reviewed psychiatric and psychological
journals, and has written or edited four books: The Psychopathic
Mind (1988); Violent Attachments (1992); with Dr. Carl Gacono,
Rorschach Assessment of Aggressive and Psychopathic
Personalities (1994); and Contemporary Rorschach Interpretation
(1997). His fifth book, The Psychology of Stalking, will be pub-
lished in 1998. He is a sought after speaker and psychological con-
sultant on various civil and criminal cases throughout the United
States, most recently the Madonna stalking case and the Polly
Klaas murder case. In June 1997, he completed work as the foren-
sic psychologist for the prosecution in the United States v.
Timothy McVeigh .
To William D. Wilkins, Ph.D.,
psychologist, humanitarian, mentor, friend
Contents
Acknowledgments .................................................................xlu
...
Foreword by James S. Grotetein .........................................xvii
PART I
ORIGINS
Chapter 1. Introduction......................................................3
Historical Antecedents
The Psychoanalysts
Object Relations
Chapter 2. Dynamic and Biologic Origins ......................15

Biological Substrates
S u m m d g the Biological Matrix
Chapter 3. Developmental Origins ...................................39

Internalization
Grandiose Self-structure
Attachment
PART I1
STRUCTURE AND DYNAMICS
Chapter 4. Affective L i e and Death ................................63

Reptilian States
Conscious Experience of Emotion
Conclusions
Chapter 5. Unconscious Defense

and Conscious Choice ..................................115
Denial and Deception
Imitation and Simulation
Projective Identification
and Object Control
Splitting and Dissociation
PART 111
VIOLENCE, PSYCHOSIS, AND RELATED STATES
Clurpter 6. Modes of Aggression .....................................186
Aggression and Violence
Affective Aggression
Predatory Aggression
Psychopathy and Predatory Violence
Chapter 7. Psychosis and Psychopathy .........................243

CharactemlogicalTraits and Personality
Organbation
Paranoid Annihilation and
Manic Triumph
Malingering and Dissembling
Psychotic Modes of Aggression
Drug-Induced Psychosis
and Psychopathy
Mental Retardation and Psychopathy
PART IV
TREATMENT
Chapter 8. Psychotherapeutic Issues.............................307

Fundamental Premises
Countertransference
Predictable Resistances
During Psychotherapy
Appendix I: Jonathan Guard-Deception and Denial

in Psychopathy ..................................................................
341
Appendix 11: Louis Cypher-Paranoid Schizophrenia

and Psychopathy ...............................................................363
Appendix 111: The Rorschach Psychodiagnosis

of Psychopathy ..................................................................377
Index ......................................................................................461
Acknowledgments
The publishing of this book marks the celebration of an intellec-

tual communion: a communion of thought with those I have
known personally, and with those I have known by way of their
writings. This book, in a real sense, has come from me and
through me. Much of the thinking is original, and much of it is an
elaboration and extension of others' intellectual fmdings.
I would first like to thank those whom I have admired and
respected through their writings. Those individuals, of course,
are listed in the reference section.
On a more personal and collegial level, Drs. Jim Grotstein
and Bill Wilkins have been mentors for me, invariably suppor-
tive, encouraging, and challenging of my intellectual pursuits. I
will always be grateful to them for their faith in my capacities.
Drs. Carl Gacono, Judith Meyers, David Feinstein, Joan
Roth, Edward Calix, Katherine DiFrancesca, Ansar Haroun,
Gregg Michel, Gerard Neurnan, Lloyd Droske, Ben Bensoul,
William Vargas, Raymond Cameron, Tom Heaven, and Linda
Helinski have all been delightful and stimulating thinkers with
me during my writing of this book.
Drs. Phil Erdberg and Deborah Zambianco, my Rorschach
teachers and friends, both made major contributions to the
xiv AclmowtWgmmts
refinement of the Rorschach Appendix and are always a pleasure

to work with.
Ms. Sue Moritz, Ms. Annette Lau, and Mr. Eugene Schiller
extended to me their attention and critical thought in the review
of several portions of the book, and I am grateful for their
kindness. Ms. Joyce Eisen was always a loyal and attentive
friend during the final phases of the book; and Ms. Rosslyn
Morrison and Ms. Janet Rasco have earned my deepest respect
for assisting me by keeping the daily tasks going so that the
long-term dreams could be realized.
I want to thank all the professional and clerical staff of the
Psychiatric Security Unit, and other members of the Forensic
Mental Health Services division, for their competencein working
with some of the most difficult patients anyone could encounter.
To those patients, I also owe a debt of gratitude for being the
guiding lights, and the ominous shadows, of this book.
I thank Larry Siegel, Janet Houts, and Denise McGuire for
their wise counsel; and a special thanks to David Hawkins for his
polemics in matters pecuniary.
I also want to thank Drs. William Cox and Harold Mavritte,
of the Caunty of San Diego Department of Health Services, for
their support and their permission to use clinical and forensic
case material from my public work. (All opinions and interpreta-
tions expressed in this book are mine and do not necessarily
reflect those of the County of San Diego Department of Health
Services.)
Dr. Jason Aronson, Ms. Norma Pomerantz, and my produc-
tion editor, Mr. Nicholas Radhuber, are consummate publishing
professionals, and their guidance from contract signing to fin-
ished product has been immensely helpful.
I reserve my most important debt of gratitude for last. My
wife's daughters, Nancy and Kitty, and my lovely step grand-
daughter, Katie, gave me the caring and respect to be able to
think and write in silence. This was a gift of inestimable impor-
tance.
Finally, in the deepest sense, I want to thank Sally, my best
friend and lover, who also happens to be my wife, for her
multitudinous showings of love, caring, and respect throughout
the writing of this book.
Thsauthmgratefklly acknowledgesp e m ~ b 8 to
k reprint thefollowing
mat%rial:
"MarinKilleis Conspiracy Theory,"by Erik Ingram and Kevin Leary.

Copyright o San Francisco Chronicle, 1986. Reprinted by permission.
Excerpts from The Boaton St~angler,by Gerold Frank. Copyright o
1966by Gerold Frank.Reprinted by arrangement with New American
Library, New York; Jonathan Cape Ltd., London; and Gerold Frank.
Excerpts from Two of a Kind: The Hillside Stranglers, by Darcy
(YBrien. Copyright o 1986 by Darcy O'Brien. Reprinted by srrange-
ment with New American Library, New York; and William Morris
Agency, New York.
Excerpts from The Only Living Witws. Copyright o 1983by Stephen
G. Michaud and Hugh Aynesworth. Reprinted by permission of Linden
Press, a division of Simon & Schuster, Inc.
Excerpts from Cmfe88iuna of Son of Sam. Copyright o 1985 by David
Abraharnsen, M.D. Reprinted by permission of David Abrahamaen.
Excerpts from "Concept and Percept Formation in Object Relations
Theory,"by J. Reid Meloy. Psychoanalytic Pa ychlogy $,I :36,4$. Copy-
right o 1986 Lawrence Erlbaum Associates, Inc., Hillsdale, New
Jersey.
Foreword
The spotlight of current clinical and academic research seems to

be settling its focus on the personality trait disorders. Of these,
the antisocial personality is one of the most troubling, most
paradoxical, and most elusive of personality conceptualizations.
Psychopathy is now being sorted out from its enmeshment
with the narcissistic and impulse disorders, and its deeper nature
is becoming better understood thanks to new contributions on
the subject, especially this one by Dr. Meloy. He believes that
psychopathy constitutes a continuum of clinical disturbance and
can be understood as an aggressive subcategory of narcissistic
personality disorder for diagnostic and theoretical purposes.
According to the author, low levels or the absence of empathy, as
well as sadomasochistic interactions based on the motif of power
rather than attachment, characterize this condition.
Dr. Meloy has emerged from many years of intensive,
full-time experience with psychopathic patients in jails, hospi-
tals, and ambulatory settings, to offer us the rich harvest of his
experience with and reflections on these patients. He prefers the
term psychopathic to sociopathic or antisocial because of its
historic provenance and broad associations on the one hand, and
its signification of distinct psychopathology on the other. In
regard to the latter, the author proffers a conception of the
etiology of this disorder that spans psychobiological and psycho-
analytic dimensions. He writes, "Psychopathy is psychobiologi-
ally predisposed, but there are necessarily deficient and con-
flictual primary object experiences that give it phenotypic
expression."
With this dual-track orientation in mind, the author takes us
on a tour in which we visit a wealth of relevant, up-to-date
contributions from neurobiology and neuropsychology. We are
then presented with a rich, extensive, and in-depth survey of a
broad range of psychosocial and psychoanalytic formulations.
The author is at his best in explicating the object relations point
of view, and he is careful to distinguish between the contribu-
tions of the British and American schools of ego psychology.
One of the more impressive contribution8 Dr. Meloy makes
is his distinction between affectively evoked aggression, which is
more common in all of us, and predatory aggression,which seems
to be the hallmark of the psychopath. Another yield from this
work is the finding that psychopathic patients experience a
characteristic hyporeactivity of their peripheral autonomic ner-
vous system; to compensate they may pursue aggressive affec-
tive displays. "Predatory aggression," Dr. Meloy writes, "al-
though not androgen-dependent,may be socially disinhibited due
to the psychopath's pursuit of heightened autonomic arousal and
affective aggression." Along this line, the psychopath may en-
gage in violent behavior to enhance his sexual arousal. This
autonomic hyporeactivity also seems to be the culprit in the
psychopath's difficulty in learning from experience and in devel-
oping insight. He lacks the requisite anticipatory anxiety that
ordinarily develops in the presence of negative experiences.
One of the most interesting contributions to the theory of
abnormal personality development in recent years is that of the
"mad, omnipotent self," a construction by Herbert Roaenfeld,
which became modified by Otto Kernberg as the "grandiose s e F
typifying narcissisticpersonality disorders. The grandiose self is
comprised of the real self, the ideal self, and the ideal object. Dr.
Meloy builds upon these constructs and uses them as a basis for
his conception of the altered narcissistic personality disorder
typical of the psychopathic personality.
The author has already made an important contribution to
the literature; he has distinguished between intrapsychic selves
and objects as perceptual and conceptual representations. The
psychopath, like the narcissist, introjects abnormal conceptual
images of the object, and, like the narcissist, develops a patho-
logical grandiose self comprised of real self, ideal self, and ideal
object concepts, but not necessarily percepts. Unlike the narcis-
sist, however, the psychopath has an ideal self composed of a
"stranger selfobject," an archetypal preconceptual object, a no-
tion I hypothesized was the legacy of uncontained stranger
anxiety. The psychopath, according to Dr. Meloy, fundamentally
identifies with the stranger selfobject as a "hard" ideal object
that is no longer persecutory because of his identification with it.
The author's construction is a more complex variant of Anna
Freud's "identification with the aggressor," but one in which a
perverse grandiosity has taken hold of the personality.
This book represents the confluence of many streams of
thought and addresses the interest of the whole mental health
field in a way in which few others have.
-James S. Grotstein, M.D.
There are moments, psychologists tell us, when the passion for
sin, or for what the world calls sin, so dominates a nature, that
every fibre of the body, as every cell of the brain, seems to be
instinct with fearful impulses. Men and women a t such times lose
the freedom of their will. They move to,,their terrible ends as
automatons move. Choice is taken from them, and conscience is
either killed, or, if it lives a t all, lives but to give rebellion its
fascination, and disobedience its charm. For all sins, as theolo-
gians weary not of reminding us, are sins of disobedience. When
that high spirit, that morning-star of evil, fell from heaven, it was
as a rebel that he fell.
Callous, concentrated on evil, with strained mind and soul
hungry for rebellion, Dorian Gray hastened on. . . .
-Oscar Wilde,
The Picture of Dorian Gray
Part I
ORIGINS
Introduction
Psychopathy is a deviant developmental disturbance charac-
terized by-an inordinate amount of 6stinctual aggression and the
absence of an object relational capacity to bond. Psychopathy is a
process: a continuous interplay of factors and operations that are
implicitly progressing or regressing toward a particular end
point (Frosch 1983a), a fundamental disidentification with hu-
manity.
Psychopathy represents both a category or class of disor-
ders for diagnostic purposes, and a continuous psychological
disturbance that may vary in terms of treatment from one
individual to another in kind and degree. Hence the clinician will
find individuals in outpatient mental health settings with mild
psychopathic disturbances and individuals in inpatient and cus-
tody settings with moderate to severe psychopathic distur-
bances. Psychopathy will also distort other psychological prob-
lems, and will interact with and shape certain biochemical
disorders, such as schizophrenia and bipolar illness.
I want to emphasize both the categorical and the continuum
approach because psychopathic individuals, by virtue of their
behavior, evoke countertransference reactions in others that
compel classification and exclusion. It is much easier to deny
psychopathy in one's psychotherapy patient, or precipitously to
6 THE PSYCHOPATHIC MIND
label an individual as a psychopath in a forensic diagnostic

evaluation, than to ferret out the nature and extent of psycho-
pathic disturbance in each case.
I have also chosen the term psychopathy for some important
reasons. Although currently not in diagnostic vogue (American
Psychiatric Association 1980, 1987), the word conveys a distur-
bance of character that has important historical and clinical
implications: most notably the growing body of research that
supports a psychobiological dimension to psychopathy (Hare
1986, Reid et al. 1986). My theoretical and clinical hypothesis is
that psychopathy is psychobiologically predisposed, but there
are necessarily deficient and codictual primary object experi-
ences that determine its phenotypic expression. The American
Psychiatric Association's (1980, 1987) antisocial personality dis-
order criteria are too descriptive, inclusive, criminally biased,
and socioeconomically skewed to be of much clinical or research
use.
The Psychopcdhic Mind begins with the building of a psy-
chobiological foundation and then proceeds to develop object
relations constructs, in the tradition of Klein, Jacobson, Mahler,
and Kernberg, that expand this nomological network. My hope is
that such a task will lend construct validity to both lines of
research that, with few exceptions, are generally kept disciplines
apart.
Before I recapitulate the historical development of psycho-
pathy as a diagnosis and a process, I want to risk a further
sociological hypothesis. It is my impression, and fear, that psy-
chopathy, and psychopathic disturbance, is a growing clinical
and, therefore, socioculturalphenomenon. I cite only two statis-
tics among many for support: the higher proportion of stranger
homicides in the past decade (Riedel et al. 1986) and the in-
creasing frequency of serial murder in the past several decades
(Leyton 1986). These are facts illustrative of extreme and statis-
tically rare violence, and citing them may betray my own ethno-
centrism by being limited to the United States, but I am fearful
this is not the case. Gardner (1986) postulated that children
reared in a predominantly image-based, nonlinear, multimedia,
briefly attentive society may not develop the deeper, uncon-
scious levels of identity and meaning and therefore manifest a
low level of empathy and a higher level of generalized anxiety.
Perhaps the analytic focus upon narcissistic psychopathology
during the past two decades will need to shift to understanding
the varieties of psychopathic disturbance as we approach a new
century.
HISTORICAL ANTECEDENTS
Millon (1981) noted the historical vacillation between clinical
understanding and social condemnation of the psychopath. Pine1
(1801)first observed and documented a certain group of patients
who behaved in impulsive and self-destructive ways yet evi-
denced no defects in reasoning ability. He termed these patients'
disorders manie sans delire (insanity without delirium). A de-
cade later, the American physician Benjamin Rush (1812) char-
acterized Pinel's diagnostic group in a morally reprehensible
light and foreshadowed the writings of the British psychiatrist
Prichard (1835), generally credited as the originator of the term
mom1 insanity and the leader of generations that have contam-
inated scientific objectivity with moralizing. Millon (1981) noted
the striking similarity between Lombroso's exposition
(1872-1885) of the psychopath's behavior, Gouster's (1878) list of
symptom clusters, and the contemporary Diagnostic and Statis-
tical Manual of Mental Disorders: third edition, description of
the antisocial personality disorder (American Psychiatric Asso-
ciation 1980).
The German psychiatric community introduced the term
psycbputhic inferiority (Koch 1891) and attempted to define a
physical basis for a group of disorders whose discriminative
validity had become unmanageable because of the wide cluster of
symptoms that it attempted to embrace. Meyer (1908) separated

psychopathic cases, which he called "constitutionally psycho-
pathic inferior types," and psychoneurotic cases, which he be-
lieved were primarily psychogenic in origin. Likewise, Kraepe-
lin, in successive editions of his psychiatric text (1887,1889,1896,
1903-1904, 1915), developed the theory of psychopathy as both
biogenic in etiology and degenerative in moral stature.
Birnbaum (1914) introduced the term sockrputhic and em-
phasized the psychogenic nature of the disorder, a product of
social learning and deficient early environmental influences. De-
spite his focus, predominate clinical opinion espoused the bio-
genic and inferior nature of psychopathy through the first
quarter of the twentieth century.
The psychoanalytic theorists entered this arena of thought
with two major currents of scientific philosophy in motion: first,
a contamination of neutral observation and inductive theorizing
by moral judgments, and second, the divergence of two essen-
tially convergent, legitimate, and complementary lines of inquiry
into the behavior of the psychopath, the biogenic and the psycho-
genic.
THE PSYCHOANALYSTS
Freud had little to say about the psychopath, although his com-
ments pointed to the psychopath as an exception to the majority
of criminals: "Among adult criminals we must no doubt except
those who commit crimes without any sense of guilt, who have
either developed no moral inhibitions or who, in their conflict
with society, consider themselves justified in their actions"
(Freud 1916, p. 333).
Freud's thoughtful paper "Some Character Types Met with
in Psychoanalytic Work" (1916) stimulated Alexander to write
several papers spanning a decade that investigated the "robust,
expansive, instinctual life" (Alexander 1936,p. 279) of the psycho-
path. He elaborated both the psychogenic and biogenic origins of
psychopathy, although he preferred to conceptualize his discus-
sion along four rather general levels of psychopathology that he
labeled neurosis, neurotic chamcter, psychosis, and criminulit y
(Alexander 1923,1930,1935). Aichhorn (1925) published his sem-
inal text Wayward Youth during this same period and developed
an understanding of psychopathy that centered upon oedipal
configurations, narcissism, and the failure of early identifica-
tions. Coriat (1927) and Partridge (1927)postulated that infantile,
oral fmations explained the psychopath's behavior.
Wittels (1939, Karpman (1941)' and Levy (1951) developed
simple typologies of psychopathy based upon psychoanalytic
constructs. Wittels (1937) suggested that neurotic psychopaths
feared their bisexuality, whereas the simple psychopath in-
dulged it. Karpman (1941) discriminated between the idiopathic
psychopath (the true guiltless criminal) and the symptomatic
psychopath (the neurotic character described by Alexander
[19353), the latter synonymous with the individual motivated by
unconscious guilt (Freud 1916). Levy (1951) foreshadowed cur-
rent object relations theory and its understanding of narcissistic
pathology in his differentiation of the deprived and indulged
psychopath. Millon (1969) respectively termed these the aggres-
sive and narcissistic psychopathic types.
Cleckley published the first edition of Mask of Sanity in
1941 and psychodynamically attributed psychopathy to a con-
cealed psychosis. He introduced an alternative term, aemantic
dementia, to account for the pathological lying of the psychopath
and to delimit the use of the term p a y c ~ t hbut
~ ,it did not take
hold. Most important, he described sixteen behavioral criteria for
psychopathy, some of which had clear psychodynamic implica-
tions, such as a lack of remorse or shame, poor judgment and
failure to learn from experience, pathologic egocentricity and
incapacity for love, general poverty in mdor affective reactions,
and specific loss of insight. These criteria have been empirically
defined and measured most recently by Hare (1980). Later edi-
tions of Cleckley's book (19'76) reflected an evolution of his

thinking about the psychopath that was more closely allied with
Kernberg's (1984)borderline level, rather than psychotic level, of
personality organization; more specifically, ~tructuralcriteria
defined the psychopath's identity integration, defensive opera-
tions, and reality testing. Cleckley wrote,
My concept . ..postulates a selective defect or elimi-

nation that prevents important components of normal
experience from being integrated into the whole
human reaction, particularly an elimination or attenu-
ation of those strong affective components which ordi-
narily arise in major personal and social issues. .. .
Even his splendid logical faculties will, in real life
situations, produce not actual reasoning but that imi-
tation of reasoning known as rationalization. [Cleckley
1976, pp. 230-231 1
Horney (1945), Fenichel (1945), and Reich (1945), in pub-

lished editions of their books the same year,.made further signif-
icant contributions toward understanding the unconscious life of
the psychopath.
Horney (1945) commented on the interpersonal exploitation
of others by the psychopath that lessens "his own sense of
barrenness. When he defeats others he wins a triumphant elation
which obscures his own hopeless defeat" (pp. 206-207). Thus the
psychopath perpetuates his emotional states and reinforces his
feelings of omnipotence. Bursten (1973a) further refined this
psychodynamic as "putting something over on someone." The
shameful, worthless selfobject is expelled and projected onto the
actual victim; and the psychopath is subsequently exhilarated
during this perceived victory as the fantasied grandiose self is
cleansed and glorified. Libidinally a reparative introjective-
projective cycle with both anal-eliminative and phallic-exhibi-
tionistic themes was suggested.
Fenichel(1945) emphasized the inconstancy of the object in
the psychopathic character and the consequent deficits and dis-
tortions in early identifications. In what he called "instinct-ridden
characters," the isolation of the whole superego could result:
Experiences with the persons whose incorporation cre-

ated the superego have made it possible for the ego to
feel the conscience in one place a t certain periods . ..
but to be relatively free from the inhibiting influences
of the superego, when tempted by the irresistible urge
of strivings for instinctual gratification. [Fenichel1945,
p. 3741
Psychopaths were seen as managing their self-esteem by an-

swering narcissistic wounds with simple denial and a consequent,
protective increase in narcissistic tone, or "felt quality of perfec-
tion" (Rothstein 1980, p. 4). Instinctual behavior could resonate
with the superego's demands in unusual childhood milieus, or
there might develop a 'contradictory parasitic double" (Fenichel
1945, p. 504) of the normal superego in subsequent social-learning
environments for the individual. Fenichel kept reiterating that
identifications were essential for the development of any charac-
ter.
Reich's (1945) contribution to psychopathic psychodynamics
was his libidinal formulations concerning the phallic-narcissistic
character. This character type was seen as self-assured, some-
times arrogant, elastic, energetic, often impressive in his bear-
ing. He anticipated impending attacks with attacks by himself.
There was an absence of reaction formations to his openly ag-
gressive and sadistic behavior, and he expressed a typically
derogatory attitude toward women. There was pride in the
phallus and strong phallic aggression. Mother, as an internalized
object, was retained only with narcissistic attitudes and impulses
of revenge. The sexual act constituted a piercing or destroying of
the woman. This character was continually defending against
regression to more passive and anal stages of development.

There was an unconscious attitude of revenge toward the inter-
nalized, yet persecutory, heterosexual object representation.
Reich linked this character type to the sex murderers, or what I
would call the sexual psychopaths or serial murderers, of his
period.
In 1949 Eissler edited an important compilation of scholarly
papers entitled Searchlights on Delimpmcjy. Four of those
papers made notable contributions to the psychodynamics of
psychopathy. Eissler (1949) emphasized the alloplastic nature of
the psychopathic personality and hypothesized that destructive
acting out functioned intrapsychically as a reparative attempt to
bolster self-esteem and maintain reality testing. He also noted
the actual, concrete injustices that the delinquent often suffered
as a child, interfering with appropriate identification processes
and disinhibiting subsequent aggressive impulses. Schmideberg
(1949) shifted her focus to a disturbance in object relations,
rather than superego development, in the psychopath. She em-
phasized the role of anxiety and depersonalization in the activi-
ties of the antisocial individual. The behavioral absence of emo-
tional ties, implying an intrapsychic distortion or deficit of
appropriate identifications, and subsequent object representa-
tions of an unstable and predominately anhedonic tone, pre-
vented the development of a strong, yet flexible, superego.
Anna Freud (1949), drawing from both drive theory and
object relational hypotheses, centered on the first year of life and
the transition from primary narcissism to object love. When the
mother failed to be a stable and reliable source of emotional
supplies, what Mahler (1968) would later call the ordinary de-
voted mother, adequate identifications did not occur and the
transformation to object libido failed. Such deprivation was seen
as leading to the inadequate binding of aggressive impulses and
their consequent splitting off, or dissociation, from conscious-
ness. These impulses would intermittently return in aggressive
and antisocial behavior, rather than channeled, neutralized, and
sublimated with the development of higher-level defenses during
the oedipal period.
Johnson (1949) introduced the term superego lacunae to
circumscribe the selective deficits in superego functioning of
most psychopaths. In her clinical experience she found that the
child's superego deficits often corresponded with the parents'
and that the latter gained vicarious satisfaction from the child
acting out the parents' unconscious antisocial impulses. Johnson
hypothesized an intergenerational and sociogenic inheritance of
such superego deficits and noted that treatment failures oc-
curred most readily when the superego deficits were more glo-
bal.
OBJECT RELATIONS
The clinical and theoretical works of Klein (1957, 1964), Mahler

(1968, 1979), Jacobson (1964, 1971), and Kernberg (1975, 1976,
1980,1984) have provided a rich conceptual basis for the further
psychodynamic understanding of the psychopath. Of these four
psychoanalytic thinkers, Kernberg has referred explicitly to the
psychopath as a severe variant of the narcissistic personality
disorder (Kernberg 1975). Both Mahler (1979) and Jacobson
(1964), moreover, have elucidated empirically based theories that
invite retrospective hypotheses concerning the etiology of the
psychopath. I t is my intent to apply their work to understand the
experiential process of the psychopath, and to formulate both
structural and functional hypotheses regarding the psychopath's
dynamic configurations. Other psychoanalytic theorists that
have largely influenced my thinking include Searles (1960,1965,
1979), Grotstein (19'78, 1980b), Modell (1968), Frosch (1983a),
Meissner (1978), and Volkan (1976).
Psychodynamic theorists must seek empirical validation
from within and without if they are to have scientific respectabil-
ity. Recent work by a few psychoanalytic researchers is notable
(Reiser 1984,1986, Silverman 1986). I will not only illustrate the

psychopathic process with clinical cases, a time-honoredtradition
in psychoanalysis, but will also support these formulations with
current neuropsychological and neurophysiological research con-
cerning the psychopath. Such construct validation should anchor
these psychodynamic hypotheses in an economical and consistent
fashion.
I also will pay close attention to an area of empirical re-
search that is newly emerging yet promises to bring to object
relations theory a needed scientific objectivity. I am referring to
work regarding .the empirical measurement of object relations
phenomena with the Rorschach (Kwawer et al. 1980, Kissen
1986).
This book is divided into four sections and eight chapters,
and they may be read either sequentially or according to the
reader's interest. Each chapter should stand on its own merits
and is not wholly dependent on formulations from preceding
chapters.
Dynamic and Biologic Origins
Psychopathy describes an intrapsychic process that has both
structure and function. This process, although vulnerable to
various physiological and emotional states, is characterized by
enduring patterns, or traits, that are behaviorally expressed in
interpersonal relations over time. The structure and function of
psychopathy, both being necessary, and by themselves insuffi-
cient measures of the personality disorder, are describable in
both metapsychological (primarily structural) and clinical (prima-
rily functional) terms. Although psychoanalytic metapsychology
has come under intense fire in recent years (Schafer 1976, Holt
1985),inferred structures of the mind are amenable to construct
validity if carefully induced from clinical behavior; and moreover,
hypothetical metapsychological constructs can help one deduce
specific clinical behaviors.
The weight of clinical research supports the hypothesis that
psychopathic personality organization is one subtype of narcis-
sistic personality disorder, albeit an extreme and dangerous
variant. Likewise, narcissistic personality disorder represents
personality function and structure at a relatively higher develop-
mental level of borderline personality organization. I am refer-
ring here to Kernberg's (1984) three levels of personality organi-
zation -neurotic, borderline, and psychotic- and his differen-

tiation of respective structural criteria into identity integration,
defensive operations, and reality testing. Borderline personality
organization is evidenced by the lack of an integrated identity,
the predominance of primitive defense mechanisms, and the
maintenance of adequate reality testing.
The lack of an integrated identity refers to the maintenance
of ego boundaries. A perceptual discrimination between self and
others and a conceptual distinction between internalized repre-
sentations of self and others exist, yet constancy of these internal
images has failed and they remain "multiple, contradictory,
affective-cognitiverepresentations" (Kernberg 1984, p. 12). This
is postulated to be the result of severe early aggression that has
been activated.
The predominance of primitive defense mechanisms refers
to the use of splitting and other related defensive maneuvers.
Contradictory representations and affects concerning self and
others are actively dissociated, or kept apart, in consciousness,
and are alternately experienced. Other defensive derivatives of
splitting include primitive idealization, projective identification,
projection, introjection, denial, omnipotence, and devaluation.
The maintenance of reality testing refers to the "person's
capacity to evaluate appropriately the reality of phenomena
going on around and within him" (Frosch 1983a, p. 335). I t is not
to be confused with reality sense,although the latter appears to
support the development of reality testing (Ferenczi 1913). The
psychopathic individual, for instance, may have the reality sense
of being physically larger and intellectually more astute than he
or she actually is, yet his or her capacity to distinguish between
interoceptive and exteroceptive stimuli is quite adequate. Re-
ality testing is the siw qua non for differentiating between
borderline and psychotic personality organization.
Narcissistic personality disorders are differentiated from
borderline personality organization by a relatively smooth social
functioning, better impulse control, and what Kernberg (1975)
has called a pseudosublimatory potential, that is, a capacity for
consistent, active work in some area that permits gratification of
personal ambition and admiration from others. On an intrapsy-
chic level, the distinction arises in the presence of an integrated
but highly pathological grandiose self, the capacity for evocative
memory of object representations (Rinsley 1982), and the failure
to integrate ego ideal and superego (Volkan 1976). This "omni-
potent mad" self (Rosenfeld 1964) is a pathological condensation
of aspects of the real self, the ideal self, and the idealized object.
In the case of the psychopathic character, the result would be a
primary identification with the aggressor and a renunciation of
weaker, more benign, and perhaps more nurturing object repre-
sentations.
Psychopathic personality organization, as a variant of nar-
cissistic personality organization, is distinguished from the latter
by the following characteristics:
1. The predominance of aggressive drive derivatives and the

gratification of aggression as the only significant mode of
relating to others.
2. The absence of more passive and independent modes of
narcissistic repair.
3. The presence of sadistic or cruel behavior, inferring the
activation of primitive persecutory introjects, or "sadistic
superego precursorsn (Kernberg 1984, p. 281).
4. The presence of a malignant ego ideal with developmental
roots in a cruel and aggressive primary parental object.
5. The absence of a desire to morally justify one's behavior,
which would imply the presence of superego precursors of a
more socially acceptable ego ideal.
6. The presence of both anal-eliminative and phallic-
exhibitionistic libidinal themes in the repetitive interper-
sonal cycles of goal conflict with others, the intent to deceive,
the carrying out of the deceptive act, and the contemptuous
delight when victory is perceived (Bursten 1973a).
7. The emergence of paranoid ideation when under stress,

rather than a vulnerability to depressive affect.
BIOLOGICAL SUBSTRATES
Psychic structure and function are built upon the biological

substrates of the human organism, which are largely determined
prior to and independently of the early parenting environment.
Kernberg referred to these substrates as "biologically deter-
mined inborn affect dispositions together with inborn perceptual
and behavior p a t t e d (Kernberg 1980, p. 108).
Psychodynamics, of course, do not exist in an intrapsychic
vacuum, and Kernberg is scientifically correct, if rather brief, in
acknowledging the biological influence upon all intrapsychic and
interpersonal behavior. Two important questions follow Kern-
berg's acknowledgment: Are there specific biological substrates
that predispose the development of a psychopathic character? If
so, what are those substrates? I would certainly answer ges to
the first question, although specifying what those biological
variables are can be only tentatively addressed.
The empirical research presents us with an additional
problem by mixing independent variables according to psycho-
pathy, criminality, or aggression. Therefore, two other assump-
tions need to be questioned before the empirical data in this area
can be summarized. The first assumption is that there exists a
significant relationship between criminality and psychopathy.
This is supported by research data that indicate psychopathy as
a personality disorder positively correlates with criminality as a
social and legal concept (Wilson and Herrnstein 1985, Hare 1981).
The second assumption is that there exists a significant relation-
ship between psychopathy and aggression. This is also supported
by research data that indicate a positive correlation between
psychopathy and violence (Hare 1981). Psychopaths generally
commit more crimes than nonpsychopathic criminals (Hare and
Jutai 1983); they are more prone to recidivism (Ganzer and
Sarason 1973); and they engage in more violent and aggressive
behaviors than other individuals, including nonpsychopathic
criminals (Kozol et al. 1972, Hare and McPherson 1984).
Beginning with these empirically based assumptions that
positive and significant correlations exist among psychopathy,
criminality, and aggression, I will analyze research findings
according to neuroanatomical structure, genetic predispositions,
neurochemical set, hormonal influences, and autonomic re-
activity.
Neuroanatomical Structure
I have not found any studies that prospectively address the

relationship between early infant neuroanatomical structure and
the later development of psychopathy. The obstacles to such a
lengthy and tedious study are obvious. Retrospective studies of
habitually violent individuals using electroencephalogram meas-
ures as a means of infeqing neuroanatomical irregularities are
available. Results suggest that the prevalence of EEG abnormal-
ities among violent individuals ranges from 25 to 50 percent
(Mednick et al. 1982). EEG abnormalities among normal popula-
tions range from 5 to 20 percent m i et al. 1978). EEG activity
in habitually aggressive individuals is characterized by an excess
of slow activity (theta range, 4 to 7 Hz) or fast activity (beta
range, 13to 40 Hz), a seemingly bimodal distribution (Mednick et
al. 1982).
A few prospective studies addressing the relationship be-
tween EEG activity and later criminality have been done. Med-
nick and colleagues (1981) examined 265 Danish children, age 11
to 13years, for EEG patterns. Seven years later the cohort was
divided into three groups: noncriminal, one-time offender, and
multiple offender. The multiple offenders exhibited slower alpha
frequencies than either of the other two groups. The researchers
then parceled out seventy-two subjects who had psychiatrically

disturbed parents; statistical analysis of the remaining subjects
with normal parents found that slow alpha EEGs afforded
greater predictability of delinquent behavior among normals
than among boys with psychiatric involvement. An independent
study of twenty-two recidivist property offenders in Sweden
replicated Mednick's results (Mednick et al. 1982).
Utilizing neuropsychological measures of brain functioning,
which allow inferences concerning localization and lateralization
of dysfunction, Yeudall(1977) found that approximately 91 per-
cent of psychopaths exhibited significant neuropsychological im-
pairment. His findings, and those of others (Bach-y-Rita et al.
1971, Blurner et al. 1974) implicate frontal and temporal area
brain dysfunction. Attempts to establish a relationship between
violent behavior and lateral dysfunction have been more ambig-
uous (Fitzhugh 1973, Flor-Henry 1979, Andrew 1980).
Genetic Predispositions
The differentiationof genotypic and phenotypic influencesis best

approached through the use of twin and adoption studies. Twin
studies allow for the measurement of concordance between pairs
and the comparison of identical (monozygotic, MZ) to fraternal
(dizygotic, DZ) twins across a particular variable or set of vari-
ables. In this case, most of the work has addressed the variable of
criminality, the identification of an individual as criminal through
the perusal of prison, police, and court records. Wilson and
Herrnstein (1985) pooled the data from eight studies of crimi-
nality concordance (Christiansen 1977a) and found that for MZ
twins it was 0.69 and for same-sex DZ twins it was 0.33. This
supports the hypothesis of a substantial genetic loading in crim-
inal behavior. The most well-designed study of twin concordance
for criminality used the national criminality register in Denmark
and studied all twins (N = 3,686) born in a well-defined area
between 1881 and 1910 (Christiansen 197713). I t reported 35
percent concordance for male MZ pairs and 13 percent concor-
dance for male DZ pairs. Although Christiansen's results account
for less of the criminality variance than the pooled data, the
presence of some genetically determined biological variable is
suggested.
Adoption studies provide an even more robust method for
the separation of genetic and environmental influences. Schul-
singer (1977) identified fifty-seven psychopaths from a sample of
5,483 Copenhagen adoptees by studying both psychiatric records
and police files. He matched them with fifty-seven nonpsychopa-
thic adoptee controls for gender, age, social class, neighborhood
of rearing, and age of transfer to the adopted family. Among
biological relatives of both groups, he found the psychopathic
adoptees' relatives, socially unknown to the adoptees, manifested
the rnost psychopathy.
In the largest systematic adoption study to date, Mednick
and colleagues (1984) drew a sample of 14,427 male and female
adoptees from all adoptions in Denmark between 1924 and 1947.
A cross-fostering analysis of the 4,065 adopted males in the final
sample found that the highest proportion of adoptees with one
criminal conviction came from the group with both biological and
adoptive criminal parents; the next highest proportion of males
with one conviction came from the group with only biological
parents who were criminal. This study strongly supported the
hypothesis that biological contributions to criminality were more
important than environmental contributions. I found several of
the other findings particularly interesting: About a quarter of
the adoptees were placed in their adoptive homes immediately
after birth, another half by the end of the first year, and another
13 percent by the end of the second year. The age at placement
exerted no effect on the strength of the relationship between
biological parent and male adoptee criminality. The time at which
the biological parents committed their crimes (before or after the
birth of the child) also had no effect on the adoptee's criminality.
Both twin and adoption studies strongly support the hy-

pothesis that an unknown genetic factor predisposes an indi-
vidual to engage in criminal behavior. I assert that psychopathic
character organization also has a necessary but not sufficient
genetic loading, the specifics of which are not yet known. Med-
nick and colleagues (1982) defined this biosocial interaction:
Where the social experiences of an antisocial individual

are not especially criminogenic, biological factors
should be examined. The value of the biological factors
is more limited in predicting antisocial behavior in
individuals who have experienced criminogenic social
conditions in their rearing. [p. 551
Neumchemical Set
Considerable research evidence supports the notion that differ-

ences in emotionality are inherited (Hall 1941, Broadhurst 1957,
Wilcock 1968, Valle 1970, Valzelli 1981). Environmental factors
interact with and modify the biologically determined emotional
predispositions of the individual (Masur 1972, Henderson 1973,
King and Appelbaum 1973, Russell and Williams 1973, Archer
1974). Emotionality and its clinical presentation called aflect
differentiate mammals from reptiles and appear to motivate such
uniquely mammalian behaviors as parenting, the acquisition of
material goods in anticipation of future consequences, and social
behavior.
Neuronal circuits that biologically define the parameters of
all behavior utilize a variety of neurotransmitters, which in turn
biochemically interact with one another (Blondaux et al. 1973,
Kostowski and Valzelli 1974). The most salient behavior that
provides us with a link between psychopathy and neurochemical
set is aggression.
Many attempts have been made to classify aggressive be-
havior, the most notable being Moyer's (1968) seven categories:
predatory, intermale, fear-induced, irritable, territorial, mater-
nal, and instrumental. Such a wide range of aggressive behaviors
can be alternately classified as either affective or preuhtory
aggression, two general categories of aggression with distinct
neuroanatomical pathways and controlled by different sets of
neurotransmitters (Eichelman et al. 1981).
Affective aggression is the result of external or internal
threatening stimuli that evoke an intense and patterned activa-
tion of the autonomic nervous system, accompanied by threat-
ening vocalizations and attacking or defending postures. Many of
the pathways are tied closely to the spinothalamic tract and the
periaquaductal gray.
Predatory aggression is directed toward the destruction of
prey, usually for food gathering in subhuman species. I t involves
minimal autonomic arousal and vocalization and no elaborate
behavioral rituals. There may be a selective suppression of other
sensory input and species-specifickilling patterns. Neuroanatom-
ical pathways appear to project from the hypothalamus into the
ventral midbrain tegrnentum (Eichelman et al. 1981).
When a household cat is cornered and threatened, the
neurochemical set produces a display of affective aggression:
hissing, hair standing on end, dilating pupils, active clawing,
arching back. When the same cat is stalking a bird in the back-
yard, predatory aggression dominates: quiet stalking of the prey,
the absence of ritualistic display, and focused attention on the
target.
Predatory aggression is the hallmark of the psychopathic
individual, whether it is a primitive act of violence against a
stranger or a technically sophisticated act of revenge against a
business associate. I will explore in detail this mode of aggression
of the psychopath in a subsequent chapter, but my focus here is
the neurochemical set of predatory aggression and its emergence
as a possible biological substrate of psychopathic character orga-
nization.
Four neurotransmitters appear to play a major role in

aggression. Serotonin, the catecholamines norepinephrine and
dopamine, and acetylcholine each correlate in a distinctive
manner with behavioral displays of affective and predatory ag-
gression.
Serotonin appears to correlate with the inhibition of both
predatory and affective aggression (Valzelli 1981). Circadian
(daily) and ultradian (seasonal) rhythms in whole-brain serotonin
level have also been described (Valzelli 1978).
The catecholaminesnorepinephrineand doparnine appear to
correlate positively with affective aggression and negatively
with predatory aggression. The differential effects of these neu-
roregulators on two forms of aggression could reflect the sepa-
rate action of neuronal groups releasing an identical regulator or
a difference in receptor sites in discrete brain regions (Eichelman
et al. 1981).
Acetylcholine, or activation of the cholinergic system, ap-
pears to positively correlate with both predatory and affective
aggression (Eichelman et al. 1981, Valzelli 1981). The modulation
of brain acetylcholine by both dopaminergic and serotonergic
projections has also been demonstrated (Butcher et al. 1976).
Table 2-1 summarizes the correlations described among
these four neuroregulators and two general forms of aggression.
The results noted above are generalized from an accumula-
tion of animal research. Few comparable human research studies
Table 2-1
Correlations between Four Neurotransmit-
ters and Affective-PredatoryAggression
Affective Predatory
Serotonin -
Norepinephrine +
Dopamine +
Acetylcholine +
are available. Among those that have been done, however, the
results validate the animal neuroregulation research. Greenberg
and Coleman (1976) found that in 83 percent of their patients
studied, hyperactive and aggressive behaviors were associated
with a fall of blood !5-hydroxyindoles (serotonin metabolites).
Brown and colleagues (1979) reported statistically significant
correlations of cerebrospinal fluid biogenic arnine metabolites
with independently scored aggression rating scales in a sample of
personality-disordered military personnel. Results indicated ag-
gressiveness negatively correlated with Shydroxyindoleacetic
acid (serotonin) and positively correlated with 8methoxy-
4-hydroxyphenylglycol (norepinephrine); 80 percent of the vari-
ance in aggression scores was accounted for by the serotonin
metabolites in the cerebral spinal fluid.
Hormonal Influences
Hormones are the slow behavioral cousins of the neuron. They

may function as neuromodulators by setting the biochemical tone
for synaptic activity (Eichelman et al. 1981). The biological fact
that the "neurological system for aggression is sensitized by
hormones derives from evidence that a reduced androgen level
raises the threshold for aggressive displays" (Valzelli 1981, pp.
114-116). All forms of aggression in animal studies, with the
exception of predatory aggression, appear to be androgen depen-
dent and sustained by sex-specific gonadal hormones (Valzelli
1981).
Aggression in humans is also a male-dominated activity and
appears to be one of the few biological differences between the
sexes. Maccoby and Jacklin (1980) reviewed thirty-two studies of
children under six years of age and found no instances of girls as
a group manifesting greater aggression than boys as a group.
Aggressiveness appears to be gender-related prior to the full
impact of socially learned, imitative behavior of parents or peers.
Olweus (1975) found that levels of aggression in nursery school

predicted aggressive behavior throughout childhood and adoles-
cence. Mednick and colleagues (1982) hypothesized that circu-
lating blood levels of testosterone influence aggression in adults,
and prenatal circulating androgens biochemically predispose the
fetal brain to later heightened aggression.
Testosterone levels and aggression do correlate in adult
samples, but are confounded by the variable of social dominance,
particularly during adolescence and young adulthood (Persky et
al. 1971, Kreuz and Rose 1972,Ehrenkranz et al. 1974, Rada et al.
1976, Swamella and Brown 1978). Persky and colleagues (1971)
attempted to differentiate between "trait" and 'state" aggres-
sion, highlighting the production rate of testosterone in their
subjects compared with the periodic secretory "bursts" of
testosterone that may trigger momentary feelings of hostility.
In female samples the premenstrual period may result in
actual irritative aggression. Prison records that have been
studied indicate a significant increase in violent crimes during
the premenstrual week (Dalton 1961). The premenstrual period is
characterized by a fall in progesterone level (Hamburg et al.
1968)and a concentration of estrogen (Bardwick 1971). ~ l e i a t e d
prolactin levels coupled with low progesterone levels may also
contribute to anxiety or irritative aggression (Carroll and
Steiner 1978).
I t is precipitous, however, to assert an empirical relation-
ship between psychopathic character organization and a hor-
monal substrate such as elevated circulating levels of testoster-
one, despite my hypothesis of predominant aggressive drive
derivatives in the psychopathic character. Predatory aggression
does not appear to be androgen-dependent in animal studies;
there is no empirical evidence linking circulating fetal hormone
levels to later displays of aggressive behavior that would rule out
the influence of social learning; and there are no studies, to my
knowledge, that have differentiated psychopathic from nonpsy-
chopathic prisoners and subsequently investigated the relation-
ship between their social dominance and testosterone levels.
Yet a strong correlational relationship would seem to exist.
Interpersonal dominance and aggression play primary roles in
the object relations of the psychopathic character. Psychopathic
processes may predominate among males if the correlations
among psychopathy, criminality, and aggression are valid and
reliable. Other forms of aggression that involve affective displays
and autonomic arousal are endogenous to the psychopath, and
such individuals may vigorously pursue these to compensate
for their autonomic hyporeactivity, as I will elaborate in the
next section. Predatory aggression, although not androgen-
dependent, may be socially disinhibited as a result of the psycho-
path's pursuit of heightened autonomic arousal and affective
aggression.
The sexual psychopath, whether a sadistic rapist (Groth
1979) or a serial murderer, engages in violent behavior that
enhances his sexual arousal. The neurological proximity of the
sexual and aggressive centers within the hypothalamus and the
shared influence of the androgens appear to be implicated (Zill-
mann 1984). The sexual arousal and intense pleasure that sexual
psychopaths feel during the commission of violent acts is ubiqui-
tous in the case studies of their subjective experiences (Krafft-
Ebing 1965, Abrahamsen 1985, O'Brien 1985). Likewise, castra-
tion has been reported to be effective in controlling certain
violent criminals (Bremer 1959, Campbell 1967). Estrogens and
other antiandrogenic drugs, such as cyproterone and medroxy-
progesterone, appear to reduce both aggression and some sexual
offenses (Chatz 1972, Laschet 1973). More empirical research
with well-definedpsychopathic samples is necessary to test these
hypotheses.
Autonomic Reactivity
Dwing the past twenty-fiveyears a number of researchers have

investigated the relationship between peripheral measures of
autonomic nervous system functioning and behavioral measures
of psychopathy. Research findings have strongly and consis-

tently supported the hypothesis that psychopathic individuals
are autonomically hyporeactive, at an electrodermal level, when
compared with other nonpsychopathic population samples.
Peripheral autonomic functioning may appear, at first
glance, to be a distant cousin of psychopathic character pathol-
ogy, but if it is viewed as a psychophysiological mediator of
emotionality and emotional responsiveness to self and others, its
link to personality disorder becomes more tenable. Furthermore,
autonomic hyporeactivity holds crucial implications for the indi-
vidual's capacity to learn from experience, that is, the develop-
ment of insight; his capacity to develop anticipatory anxiety in
the face of negative experiences; and his propensity to lead a
sensation-seeking, extroverted life-style.
Measures of autonomic baseline and reactive levels have
most commonly used skin conductance, or galvanic skin re-
sponse, as an electrodermal indicator of autonomic arousal. I t is a
reliable and valid measure, and there is a sizable methodological
literature for its use (Venables and Christie 1975). Most of the
research concerning autonomic measurements of the psychopath
have used galvanic skin response as the indicator of arousal.
The psychopathic character's emotionality and emotional
responsiveness has been inferred by studying his autonomic
baseline when compared with other matched samples; his spon-
taneous autonomic reactivity in the absence of external stimuli;
and his autonomic reactivity to external stimuli, mostly of a
noxious or unpleasant variety.
The autonomic baseline activity of the psychopath has been
found to be consistently lower than other nonpsychopathic sarn-
plea, but the difference is not always significant (Hare 1978a).
One prospective study (Loeb and Mednick 1977) did find that
significantly lower autonomic baselines in a small group of
Danish adolescents did predict a record of delinquency ten years
later.
Spontaneous autonomic reactivity in the absence of external
stimuli occurred to a lesser, but not significant, degree in psycho-
pathic prisoners when compared with nonpsychopathic prisoners
(Hare 1978a).The replication of these studies with the addition of
nonprison control groups might produce significant differences.
Autonomic reactivity to external stimuli, usually unpleas-
ant, has been found to be consistently and significantly less in
psychopathic groups when compared with nonpsychopathic
groups. Although most of the studies were retrospective in
design, that is, the individuals' psychopathic histories and behav-
iors occurred prior to measurement of their autonomic function-
ing, the electrodermal hyporeactive hypothesis appears to be
quite reliable (Hare 1972, Schalling et al. 1973, Hare and Craigen
1974, Hare 1975). One prospective study (Loeb and Mednick
1977) found that the mean response amplitude of seven young
adolescent subjects contributed to the prediction of delinquency
records a decade later. The amplitude of their autonomic reac-
tivity to stimulation was five to ten times less than the nondelin-
quent controls. A prospective finding such as this adds great
validity to the retrospective body of research and supports the
notion that autonomic hyporeactivity may predispose an indi-
vidual to antisocial behavior, rather than result porn the aver-
sive consequences of such behavior.
The psychopathic individual also shows significantly less
autonomic arousal when anticipating a negative experience.
Laboratory-induced negative events are usually the infliction of
pain, shock, loud noise, or exposure to photographs of injured or
mutilated people. There is a reliable body of research supporting
this hypothesis when the aversive stimulation will be felt by the
self (Lykken 1957, Hare and Craigen 1974, Wadsworth 1975,
Hare 1978a) or perceived that it will be felt by others (Sutker
1970, Hare and Craigen 1974, House and Milligan 1976). Wads-
worth (1975) designed one of the few prospective studies in this
area and found that significantly slower increases in pulse rate
when anticipating a negative experience in a group of 11-year-old
boys contributed to the prediction of their delinquency records
ten years later. This research supports my psychodynamic infer-

ence that the psychopathic character feels significantly less an-
ticipatory anxiety when faced with an unpleasant, or even trau-
matic, situation; and even more important, it points toward an
autonomic correlate, or biological substrate, for the psychopath's
lack of empathy, the incapacity to identify with another's emo-
tional pain. On the other hand, the psychopath gains autonomic
support for his object relational and defensive inclination to
detach from, or disidentify with, the emotional experience of his
victim.
The autonomic hyporeactivity of the psychopath led Med-
nick and colleagues (1982)to develop a biosocial theory to explain
why the psychopath fails to learn from punishment. He hypothe-
sized that a reduction of fear of punishment powerfully reinforces
the inhibition of aggression in the nonpsychopathic individual.
Psychopathic individuals do not inhibit their aggressiveness be-
cause the reduction of fear as a negative reinforcer is diminished
or absent. They have an inadequate fear response, only mildly
anticipate a fearful event, and, most significant, dissipate what
fearful response they experience in a slower manner.
The slow dissipation of fear was inferred by the slower "skin
conductance recovery" of the psychopath. This peripheral
measure of autonomic activity implies that psychopaths return to
their autonomic baseline much more slowly than normal individ-
uals once they have reacted to stimuli.
Mednick's biosocial theory prompted several researchers to
analyze their data again and measure skin conductance recovery
within their psychopathic and nonpsychopathic groups. The sig-
nificantly slower autonomic recovery of the psychopath was
found to be quite reliable (Siddle et al. 19'73, Hare 1976, Hare et
al. 1978). Hare (1978b) found a significant correlation between
skin conductance recovery and the prediction of recidivism in a
study of psychopathic and nonpsychopathic prisoners.
The learning failures of the psychopathic character disorder
appear to be limited to autonomic nervous system mediated
negative consequences. The psychopath appears to respond nor-
mally to both autonomically mediated positive conditioning and
other learning tasks that do not involve autonomic or emotional
arousal (Schrnauk 1970).
Despite the autonomic hyporeactivity at a peripheral level,
it appears that psychopaths show normal cardiovascular reac-
tivity to both pleaaant and aversive stimuli (Hare and Quinn
1971, Hare and Craigen 1974, Hare et al. 1978). Hare (1986) has
interpreted these findings by drawing on a model proposed by
Lacey and Lacey (1974) that heart-rate acceleration and in-
creased carotid pressure are associated with decreased cortical
arousal and sensory rejection, a "defensive response" to the
environment. In other words, cardiovascular reactivity plays an
important role in the modulation of sensory input. This pattern in
the psychopath may reflect an active coping mechanism and, as a
consequence, the inhibition of fear arousal. Venables (1985) ar-
gued that this sequence of events is physiologically tenable; that
is, cardiovascular reactivity can occur quickly enough to inhibit
electrodermal reactivity to a significant degree.
The psychodynamic implicationsof these findings are formid-
able. First, the psychopathic individual's anticipation or experi-
ence of unpleasant, negative affect will have little or no behav-
ioral consequence. Second, insight may be imitated and quickly
learned, but will exist without an affective dimension such as
shame, guilt, or remorse. Third, predominant aggressive-drive
derivatives will be less inhibited by the psychopathic personality
despite their aversive consequences for the individual and oth-
ers. Fourth, subsequent positive affect may strongly reinforce
these aggressive-drivederivatives. And fifth, punishment of the
psychopathic criminal exists only as a public projection.
A body of research that validates the autonomic hyporeac-
tivity hypothesis, but is less well known in psychoanalyticcircles,
is the work of experimental psychologists with the personality
construct extroversion (Claridge 1967, Eysenck 1967, Gray
1972).
Extroversion has been established as an independent di-

mension of personality that is both genetically loaded and highly
reliable (Eysenck 1947,1957,1967, Shields 1962, Scarr 1966).The
traits of sociability and impulsiveness have been identified as
subfactors in extroversion and appear to correlate about 0.50
with each other (Eysenck and Eysenck 1963).
Eysenck proposed a biological construct to explain this
personality dimension, based upon findings that extroversion
correlated positively with lower cortical arousal, higher stimu-
lant thresholds, and lower sedative thresholds (Eysenck 1967).
Subsequent research supported his hypothetical construct (Cla-
ridge 1967, Gray 1972).
Based upon his own research, as well as that of MacLean
(1960) and Gellhorn and Loofbourrow (1963), Eysenck (1967)
hypothesized that differences in extroversion were related to
differential thresholds in various parts of the reticular formation.
Differences in "neuroticism," an orthogonal personality dimen-
sion that he empirically defined, were produced by differential
thresholds within the visceral brain, or limbic system.
Eysenck proposed a corticoreticularloop in which ascending
afferent pathways projected into the cortex and the reticular
formation; the latter would send arousal messages to the cortex,
and the cortex would respond with more arousal or inhibition
messages back to the reticular formation. In the same manner, a
visceroreticular loop provided information processing between
the limbic structures and the reticular formation. Thus auto-
nomic activation, seated in the hypothalamus, was partially de-
pendent on diffuse cortical arousal through the corticoreticular
loop. Cortical arousal, however, might occur without autonomic
activation. Activation equaled arousal only under extreme stirn-
ulus conditions, whether internally or externally cued (Eysenck
1967). Eysenck further postulated that introverts would tend to
have a higher level of inherent cortical arousal than extroverts;
and extroverts would have a higher inherent level of cortical
inhibition than introverts. Conditionability, or learning, was
Origins 35
demonstrated to occur more quickly in introverts than extro-

verts (Eysenck 1962).
Drug experiments to test Eysenck's theory of cortical exci-
tation clearly validated the inherent arousal differences between
extroverts and introverts. His drug postulates stated that de-
pressant drugs would have an extroverting effect on behavior
through reduced cortical arousal. This was inherently lower in
extroverts and thus would occur more readily. Stimulant drugs
would have an introverting effect on behavior through increased
cortical arousal. This was inherently higher in introverts and
thus would occur more readily. Psychopharmacologicalresearch
supported the introverting effects of the stimulants and the
extroverting effects of the depressants and the differences in
cortical arousal between extroverts and introverts (Franks and
Trouton 1958, Rachman 1961, Holland 1963, Sinha 1964).
Gray (1972)modified Eysenck's theory by asserting that the
reticular formation, the medial septum, the hippocampus, and
the orbital frontal cortex were all part of the central nervous
system determinants of extroversion and that conditionability
among extroverts and introverts should be understood as sus-
ceptibility to punishment. He proposed that introverts had a
more reactive septohippocampal "stop system" and extroverts
had a more reactive medial forebrain bundle and lateral hypotha-
lamic "go system" (Gray 1972).
Studies confirmed that extroverts have higher pain thresh-
olds (Haslam 1967), may be less sympathetically responsive
(Meikle 1970), condition less readily to words (Gupta 1970); and
have smaller pupillary responses to taboo words (Stelmack and
Mandelzys 1975).
Prisoners as a group are significantly more extroverted
than adult normal populations (Eysenck and Eysenck 1968).
Eysenck proposed a strong positive correlation between psycho-
pathy and extroversion. Aspects of his definition of the extrovert
have high face validity for the psychopath: "He craves excite-
ment, takes chances, often sticks his neck out, acts on the spur of
the moment and is generally an impulsive individual . .. tends to

.
be aggressive and to lose his temper quickly . . not always a
reliable person" (Eysenck and Eysenck 1968, p. 6). Extroversion
also appears to positively correlate with sensation-seeking
(Farley and Farley 1967).
Extroversion in adults appears to be a highly reliable trait.
The Minnesota Multiphasic Personality Inventory Scale 0 (Social
Introversion) has high temporal reliability in adult populations
(Dahlstrom and Welsh 1960). The most closely related index in
the Rorschach to extroversion is the e r l e b n i s t g p (EB). This
indicator, a ratio of movement to weighted color responses,
reflects the manner in which a person's resources are used and
may not correlate with behavioral indices. Nevertheless, the
extratensive individual habitually manifests affect to his or her
world more routinely than does the introversive and is inclined to
gratify basic needs via external objects rather than through
internal experience (Exner 1986a). Psychopathic character disor-
ders would appear to be more extratensive in interactional style.
The EB is remarkably stable in adult population samples in both
psychiatric and normal groups (Exner 1986a).
Extroversion, as a behavioral reflection of lowered central
nervous system arousal in the psychopath, has several psychody-
namic implications. First, it validates the autonomic hyporeac-
tivity hypothesis and may correlate with the dampening of pe-
ripheral autonomic baseline measures and reactivity potentials
at a primitive and vegetative level. Second, conditioning and
learning problems, particularly in relation to punishment, are
increased by the degree of extroversion. Third, extroversion
appears to contribute to a lack of psychological mindedness, or
capacity for insight, and may manifest in an extratensive style of
dependency on external objects for gratification. Fourth, extra-
version correlates with a sensation-seeking interactional pattern
to compensate for lowered reticular arousal during the individu-
al's waking hours. Fifth, extroversion will correlate with a pref-
erence for syrnpathornirnetic drugs, such as methamphetamine
and cocaine, rather than central nervous system depressants.
The psychopath's propensity to abuse alcohol (Schuckit 1973), a
depressant, is probably due to its initial disinhibiting, and highly
reinforcing, effects.
SUMMARIZING THE BIOLOGICAL MATRIX
I am certain that a necessary, but not alone sufficient, biological

substrate must exist for the development of a psychopathic
character disorder. The five dimensions that I have explored
retrospectively support psychobiological differences within the
psychopathic personality that correlate with, and undoubtedly
influence, early developmental experience with significant ob-
jects.
First, neuroanatomical variances are suggested in the psy-
chopath through electroencephalographic and neuropsycholog-
ical measures of localized frontal and temporal area dysfunction.
The few prospective studies that have been done, however, reach
back only to adolescence; and there is, as yet, no data supporting
neuroanatomical differences prior to the separation-individua-
tion stage of development.
Second, twin and adoption studies reliably support the
hypothesis of a genetic loading for criminality. This genetic
predisposition appears to affect more of the variance in later
criminal and psychopathic behavior when early parental or social
conditions are not particularly criminogenic. On the other hand,
the lack of an opportunity for the child to internalize appropriate
superego constraints, perhaps because of the absence of available
parenting, would appear to override the child's predisposition to
resist such internalizations and subsequent superego integra-
tion.
Third, although no empirical data exist specifically linking
psychopathy and neurotransmitters influencing aggression, the
relationship is quite tenable and needs further research. I am
especially intrigued by the predominance of predatory aggres-

sion in the psychopathic process and its cholinergic substrate in
the peripheral and central nervous systems.
Fourth, a strong and positive correlational relationship
would seem to exist among the psychopath's aggression, social
dominance, and testosterone levels, especially during late adoles-
cence and young adulthood. But no retrospective, or prospective,
research with carefully defined psychopathic samples has been
done.
And fifth, I have constructed a nomological network that
links the psychopath's autonomic hyporeactivity, lowered central
nervous system arousal, extroversion, sensation-seeking, per-
ceived lack of empathy, and abuse of sympathomimetic drugs.
There appears to be strong construct validity for such a psycho-
biological and psychodynamic model. Both retrospective and
prospective studies from early adolescence lend empirical sup-
port.
Developmental Origins
T h e developmental origins of narcissistic object relations, and
psychopathy in particular, cannot be understood without differ-
entiating concept and percept formation within the mind (Meloy
1985). Perception is a primary, immediate, subjective, and bi-
modal activity that organizes interoceptive and exteroceptive
sensory-neural impulses and the contact-linking barrier between
the two. Percept formation developmentally and phenomenolog-
ically precedes concept formation. Grotstein (1980b) emphasized
the primary role of the perceptual background in his construct,
the "background object of primary identification."
The mother provides the perceptual background as a pri-
mary object of identification for the infant prior to any conceptual
knowledge of the "mother" by the infant or any idea of separate-
ness from her. Percept formation provides for the infant a begin-
ning, subjective sense of "I." The concept of self, thrust to the
interpersonal foreground by the verbally assertive toddler, rep-
resents the birth of a conception that becomes limited and de-
fined as a foreground experience. The conceptual sense of self is
the foreground dependent upon the primary background percep-
tual experience of a sense of "I," which, in turn, is the perceptual
heir to the "background object of primary identification," the
biological mother.
Concept formation is the process that objectifies experi-

ence. It may have perceptual properties, but these are not
necessary. It is an active process that is central to the secondary
autonomous ego functions of memory, symbolization, judgment,
abstraction, comprehension, and insight. In the context of object
relations theory, concept formation objectifies and limits the
perception of self and other. It is not a bimodal experience; it is a
modal "frame of referencen for the self and object that has both
form and value (Spiegel 1959).
Concept formation is free to be wedded to percept formation
at a concrete level of thought or imagery; or it can be divorced
from perceptual experience at an abstract or symbolic level of
thought. The distinguishing criterion between concept and per-
cept formation is the capacity of the former to proceed without
sensory-perceptual data. Because of this capacity for autono-
mous functioning, concept formation represents a developmen-
tally higher, yet secondary, level of cortical functioning. Percep-
tion, attention, sensory-motor integration, and skin-boundary
cohesion are biological-perceptual factors that precede the for-
mation of self and object concepts (Mahler 1958, Ornitz and Ritvo
1968a, 196813, Ornitz 1969,1970, Grotstein 1980a, 1980b).
The preverbal and preconceptual experiences that, con-
tribute to the psychopathic process are highly speculative, yet
the presence of early physical and emotional abuse in the case
histories of psychopathic individ~ialsis common (Morrison 1978).
The early sensory-perceptual experience of the psychopathic
individual can be characterized as one of premature psychological
birth.
Tustin (1981) noted that one of the earliest integrations that
needs to occur is that between "hard" and "soft" sensations. Soft
sensations correspond to that which is pleasurable and comfort-
able; hard sensations correspond to that which is displeasurable
and uncomfortable. Optimal holding and suckling of the infant at
this time results in an integration of receptivity ("taking in,"
softness) and enter@ ("thrusting," hardness) and the germina-
Origins 43
tion of adaptability and resiliency in the infant, a beginning sense

of psychological well-being.
Precocious separation, or "twoness," accompanied by a pre-
dominance of "hard" or uncomfortable sensations, could result in
the excessive projection of "hard not-me" sensations outside the
nascent self-boundary. The primitive skin boundary separating
interoceptive and exteroceptive stimuli could become preco-
ciously aligned with the excessively vulnerable "soft me" inside
the skin boundary and the "nameless dreads" (Bion 1984) of the
"hard not-me" outside the skin boundary. In other words, "the
child has experienced 'twoness' too harshly, too early, too sud-
denly for him" (Tustin 1981, p. 190).
This precocious separation may not be solely the responsi-
bility of the parent figure. The infant's autonomic hyporeactivity
or innate aggressiveness may render the mother's enveloping
symbiosis less potent, less caretaking than she would like it to be.
On the other hand, the mother's discomfort with symbiosis may
compel her to hold on and then push the infant precipitously into
autonomy (Mahler 1967).
This harsh sensory-perceptual experience with the mother
may combine with an atavistic fear of predation and predispose
the formation of a narcissistic shell that will callous over the
excessively vulnerable "soft-me." Herein may lie the skin-
boundary precursor of character armor as described by Reich
(1945), more specifically, the phallic-narcissistic character struc-
ture of the psychopath.
I t is also probable that such early sensory-perceptual pre-
dispositions may catalyze the use of persecutory introjects as "ad
hoc scaffolding" to form an outer defense perimeter against
malevolently perceived others. These persecutory objects would
serve as a "form of stimulation and painful sensory immediacy"
(Grotstein 1982, p. 62) for the infant.
An organismic distrust of the environment subsequently
unfolds. Basic trust (Erikson 1950) of the holding environment
(Winnicott 1962) is weakened as a result of the absence of a
consistent, predictable, and predominantly nurturant mothering

experience.
The relative presence or absence of trust of the holding
environment, begun at a primitive sensory-perceptual, skin-
boundary level of pleasure-displeasure, also provides the emo-
tional color for the subsequent processes of internalization. The
presence of a safe and trustful containment by the mother allows,
and perhaps catalyzes, the internalization of more hedonically
toned, nurturant, and benign objects, both as introjects and
identifications. The absence of safety in containment, or a lack of
adequate containment, will foster the internalization of more
anhedonic, aggressive, and malevolent objects or constrict the
internalization process itself (Gardner 1986).
INTERNALIZATION
Hartmann (1939) called the process of internalization an evolu-
tionary and phylogenetic transfer of functional-regulatory mech-
anisms from the external world to the internal world of the
organism. Schafer (1968) defined internalization as "all those
processes by which the subject transforms real or imagined
regulatory interactions with his environment, and real or imag-
ined characteristics of his environment, into inner regulations
and characteristicsn(p. 9).
I t is my hypothesis that the psychopathic process is funda-
mentally a virtual failure of internalization. There appears to be
a paucity of deep and unconscious identifications with, initially,
the primary parent figure and ultimately the archetypal and
guiding identifications with the society and culture and human-
kind in general.
The failures of internalization begin, as mentioned above,
with the organismic distrust of the sensory-perceptual environ-
ment. Throughout this early sensorimotor period (Piaget and
Inhelder 1969), and corresponding to the symbiotic phase of
Mahler and colleagues (1975), occur early incorporative failures. I
am using Schafer's (1968) definition of incorporation as a specific
and wishful primary process ideation of taking in the actual
object through the mouth or other body orifice. It expresses the
primitive wish to introject the other person within the self, and
therefore carry on a relationship, or the wish to modify the self
through union with the part of the object that is perceived, the
process of identification. Incorporation is the developmental heir
to empathy, and with early incorporative failures, the ground is
fertile for subsequent failures and distortions of the internaliza-
tion process and its twofold expression through identification and
introjection.
Let us pause here briefly and c l w the use of the terms
identifiation and introjection. Identification is "that modifica-
tion of the self which is caused by union with an object" (Grotstein
1982, p. 74). Schafer (1968) similarly defined identification as the
modification of the self or behavior to increase resemblance to
the object. In my words, it is the nascent self-representation
becoming like the perceived object.
Introjection is a process by which perceived objects are
internalized as representations yet continue to carry on a rela-
tionship to the self. I am inclined to agree with both Schafer
(1968) and Volkan (1976) that introjections are likely to occur in
times of distress and crisis for the infant when object supplies are
urgently needed but not available. Volkan (1976) rightfully cau-
tioned that the metaphorical implication of the term should not
be forgotten, despite its obvious use in conceptualizing what the
patient experiences as an internal presence separate from the
subjective sense of "I." I would classify the term introject as an
"object percept" that is often experienced as a visual image "seen"
in the mind, or as an auditory sound "heard" in the mind, yet that
is subjectively experienced as "not-I" (Meloy 1985). An introject
is both primitive and relational and is oftentimes confused with
an auditory hallucination by both patient and doctor unless care
is taken to locate the "sound" and describe its perceptual charac-
teristics. This appears to happen quite often with patients when

there is disagreement concerning the proper diagnosis of severe
borderline psychopathology or schizophrenia.
The failure of incorporation in the psychopathic process,
however, is not complete or even obvious. The incorporative
failure is due to a predominance of "hard" objects that are
experienced as painful by the infant, such as ill-timed or unduly
rough feeding and holding experiences. A predominance of un-
pleasant incorporative orifice experiences, beginning orally, yet
tactilely experienced over the entire skin boundary as a hostile
envelope, leads to a dearth of soothing internalization experi-
ences. The absence of actual soothing experiences and later the
distrust of available soothing experiences because of the antici-
pation of malevolence in others, contributes to an unconscious
disavowal of the need for soothing internalizations, whether
identifications or introjects.
What occurs instead is the infant's identification with the
stranger selfobject (Grotstein 1982), a preconceived fantasy that
helps the infant anticipate the presence of the predator in the
external world, or the prey to whom the infant is to eventually be
the predator. Grotstein (1982) viewed this selfobject as an a
pimi representation that "designates the unconscious pre-
awareness of the enemy which is believed to be both within
ourselves and to have an external counterpart" (p. 63). I t is most
obvious in its projected form during the infant's experience of
stranger anxiety, of which there are tremendous variations in
timing, quality, and quantity (Mahler et al. 1975).
But in the psychopathic process, the stranger, or predator,
selfobject as a narcissistic identification is the predominant,
archetypal internalization of the infant. It will later shadow the
development of the grandiose self-structure, within which is the
child's identification with the aggressive parent. The stranger
selfobject will be interpersonally expressed in the asocial, if not
antisocial, behavior of the psychopath as an adult, unknown to
others on an intimate level, yet feared because of a conscious lack
of a need for affection and attachment to others.
This identifiation with the stranger selfobject, reinforced
by the actual experience with the parent as a "stranger" and
predisposed by more aggressive and autonomically hyporeactive
biological characteristics in the infant, is distinctively different
from the borderline patient's internalization of the stranger
selfobject as a persecutory introject, an internal object to which
the borderline individual relates in a fearful and, at times, rageful
fashion. In the psychopathic process, the stranger selfobject
becomes an integral part of the child's self-esteem, whereas
without the psychopathic process the stranger selfobject is expe-
rienced by the borderline individual as a source of anxiety and
terror and is projected onto the environment and behaviorally
expressed as persecutory fears of others. The narcissistically
disordered adult will also show strong identifications with the
stranger selfobject, but in a more independent, benign, and less
aggressive manner than the psychopath.
GRANDIOSE SELF-STRUCTURE
Kernberg (1976) distinguished the narcissistic personality from

the borderline personality by the presence in the former of a
pathological grandiose self. This condensation within the devel-
oping ego structure is composed of the real seK the "specialness"
of the child that is supported by early experiences; the d e a l seK
compensatory self-percepts that the small child has formed to
balance severe oral frustrations, rage, and envy; and the ideal
object, perceptual images in the child's mind of an ever-loving and
accepting parent, in contrast with the actual behavior of the
parent.
I consider the self to be a supraordinate and structural
entity, in disagreement with Kernberg's view that the self is a
substructure of the ego (Kernberg 1982). I am in agreement with

Meissner's (1977,1981, 1983,1986) theoretical formulations that
the self must involve personal agency and subjectivity. I t is a
vehicle for the articulation of qualities that reflect complex
integrations of substructural components of the personality or-
ganization, one such quality being the formation and functioning
of values. Internalizations, carrying with them some functional
aspects of all the psychic systems, are primarily relevant to the
organization of the self.
I also want to note the difference between self as structure
and as representation (Boesky 1983). In the context of the psy-
chopathic process, I would assert that the grandiose self, as
structure, is inherently unconscious; that is, it cannot be ob-
served by the personality as the representations within it can.
The actual self-representations, ideal self-representations, and
ideal object representations within the grandiose self-structure
can be observed and reflected upon, but they are not agents of
action. These self-representations within the grandiose self-
structure would correspond to the self-as-object in Schafer's
(1968) usage. The grandiose self-structure, as personal agent, is
only consciously experienced as an affective state, known deriv-
atively, but not internally imaged, as expansive, omniscient, and
omnipotent.
In contrast to Kohut's (1971) view that the grandiose self is
a fixation of an archaic, but normal, primitive self, Kernberg
hypothesized the structural origins of the grandiose self as a
pathological process distinctively different from normal infantile
narcissism:
Idealized object images which normally would be inte-

grated into the ego ideal and as such, into the superego,
are condensed instead with the self-concept. As a re-
sult, normal superego integration is lacking, ego-super-
ego boundaries are blurred in certain areas, and unac-
ceptable aspects of the real self are dissociated and/or
repressed, in combination with widespread, devas-
tating devaluation of external objects and their repre-
sentations. Thus, the intrapsychic world of these pa-
tients is populated only by their own grandiose self, by
devaluated, shadowy images of self and others, and by
potential persecutors representing the non-integrated
sadistic superego forerunners, as well as primitive,
distorted object images onto whom intense oral sadism
has been projected. I t needs to be stressed again that
these developments occur at a point when self and
object images have been sufficiently differentiated
from each other to assure stable ego boundaries, so
that the pathological condensation occurs after the
achievement of the developmental stage which sepa-
rates psychotic from nonpsychotic structures. [Kern-
berg 1975, p. 2821
I generally agree with Kernberg's analysis of the origins of the

grandiose self, but must note several contradictions in his state-
ment. First, the pathological condensation of the grandiose self
precludes the blurring of ego-superego boundaries, because de-
velopmentally there is no superego. There is no clear differenti-
ation between ego and superego structures a t the borderline
level of personality organization because this assumes at least a
partial resolution of the Oedipus complex. Kernberg is correct,
however, in noting the presence of "sadistic superego forerun-
ners," which precede the fusion of ideal self- and ideal object
representations to form the integrated ego ideal, the second
broad layer of superego formation described by Jacobson (1964).
The precursors of superego formation in the narcissistic person-
ality, and in the psychopathic process, contribute to the forma-
tion of the grandiose self and interfere with later development of
the superego as a third layer of internalization, namely the
realistic, demanding, and prohibitive aspects of the parents
during the oedipal period (Jacobson 1964).
Second, I would contend that unacceptable aspects of the

real self are only dissociated, and not repressed, since there is no
repression as a defense in the narcissistic, or psychopathic,
personality structure. Moreover, there is no differentiation be-
tween the ego and the id as structures since there is no repres-
sion (Kernberg 1980). This is fundamental to the work of both
Kernberg and Jacobson, although often overlooked in attempts
to reconcile, or at least juxtapose, a dyadic theory of self- and
object relations with a tripartite theory of personality structure.
It is implicit in their work that there is no tripartite structure to
the personality of the child until repression as a defense signals
the differentiation between ego and id and the integration of
ideal self- and ideal object representations as the ego ideal signals
the differentiation between ego and superego. When one speaks
of the structural characteristics of the preoedipal personality,
one is referring only to dyadic self- and object representations
that are either condensed (as in the formation of the grandiose
self) or displaced somewhere else (as in the defensive process of
splitting). Condensation and displacement, as the genotypes of
the primary process, also appear to link self- and object repre-
sentational maneuvers and the phenotypic expressions of formal
thought disorder (Meloy 1986b).
My third criticism of Kernberg's structural origins of the
grandiose self begins with a fundamental contradiction: How can
"self and object images (that) have been sufficiently differenti-
ated from each other to assure stable ego boundaries" (Kernberg
1975, p. 282) become condensed whereby the boundaries are lost
in the grandiose self yet remain differentiated?
I do not think this is necessarily a contradiction if a distinc-
tion is made between the percept and the concept of the self- or
object representation (Meloy 1985).The distinction between per-
cept and concept formation, as I defined earlier in this chapter,
offers the hypothesis that self- and object percept differentiation
in the narcissistic personality disorder is normal. How then do I
explain the condensation of self- and object representations
within the grandiose self-structure? Precise19 because the f i s h
occurs between self- and object concepts and remains divorced
from the developng and separate self- and object percepts. In
other words, the distinction between the subjective and prima-
rily background sense of "I" and "not-I" is perceptually clear. The
manner in which the self and its relation to others is conceived,
however, is distorted and exaggerated, reflecting the fusion of
self- and object concepts. The conceptual other becomes a psy-
chological extension of the conceptual self.
The fused selfobject concepts remain an insular, autono-
mous psychic process within the grandiose self that becomes
clinically evident in fantasies of achievement, power, admiration,
perfection, and entitlement-fantasies that will be acted out by
the more aggressive psychopath. As one 40-year-oldmale patient
said to me in the face of personal bankruptcy, 'I don't aspire to
greatness; I claim it."
Achievement for the narcissistic personality disorder can
proceed relatively unhampered since the differentiated self- and
object percepts support ego skills that are socially and financially
rewarded in the nonintimacy of the workplace: decisive and
autonomous judgments, emotional detachment, objectivity,
"coolness," high self-regard, and pragmatism.
The fused self-object concepts within the grandiose self-
structure become most problematic when issues of intimacy
disrupt the life of the individual with narcissistic personality
disorder, or the psychopathic variant. Suddenly good reality
testing, that is, self- and object percept differentiation, is not
enough. Sustained intimacy requires empathy, an acknowledg-
ment of worth of the other, and a realistic appraisal of one's
self-concept in relation to others in the world. The fused self-
object concept of the narcissist, which has heretofore remained
submerged as an exaggerated yet inherently supportive self-
representation, now intrudes into intimate relationships as an 'I"
that is entitled, angry, and grandiose. The fused selfobject con-
cepts within the grandiose self necessitate that others remain
without separate worth and empathic regard. The presence of

value in others must be denied or enveloped to be, in a Piagetian
sense, assimilated by the fused selfobject concepts of the narcis-
sistic personality disorder (Piaget 1954).
But is there a distinction between the grandiose self within
the narcissistic personality structure and its more severe and
aggressive variant, the psychopathic personality? Clearly, there
is. First, the real self-conceptwithin the grandiose self-structure
is the "specialness" of the child who is precociously experienced
as "twoness" and is synonymous with separateness. Second, the
ideal self-conceptswithin the grandiose self-structure, the selfob-
jects of the future or destiny (Grotstein 1982), are formed
through identifications with the stranger selfobject. Instead of
these identifications forming a primitive layer for the develop-
ment of the superego structure, separate from the ego structure,
they contribute to the conceptual confusion, as it were, within the
grandiose self-structure. The ideal self-concepts, therefore, are
representational modifications of the self to be like the stranger
selfobject, an internalization of the actual cold, distancing be-
havior of the primary parent, instinctually fueled by an atavistic
fear of predation, or attack, from others outside the skin bound-
ary. This sensory-perceptual experience at the skin boundary,
however, has receded in psychological importance as internal
structuralbation becomes more apparent during the separation-
individuation phase of development. Third, the idealized object
within the grandiose self-structure is an aggressive introject to
which the real self and the ideal self form an intrapsychic rela-
tionship. But since the ideal self is fundamentally the stranger
selfobject and is representationally quite similar to this aggres-
sive introject, this hypothesized relationship within the gran-
diose self-structure becomes a conceptually fused identifiation.
This intrapsychic identification between the ideal self and
the idealized object is interpersonally expressed as identification
with the aggressor (A. Freud 1936). It is an intensely bound
identification for the psychopathic character, since any clinical
attempts to modify the ideal self in a more socially adaptive or
affectional direction would cause a disidentification with the
idealized object and a reactivation of the idealized object as an
aggressive introject within the grandiose self-structure. This
would phenomenally be experienced by the psychopathic char-
acter as a subjective sense of being under attack, as the aggres-
sive introject would then be in relation to, rather than identifid
with, the real and ideal self-concepts. Psychotherapeutic maneu-
vers would be quickly thwarted, and identification between ideal
self and the idealized object would be reassured by projecting the
aggressive introject onto the clinician. Anxiety would lessen, and
the grandiose self-structure would refuse, having warded off a
regressive threat to its equilibrium. This may be the funda-
mental psychodynamic within the psychopathic process that
impedes psychotherapeutic change.
I want to reiterate that the fusion, and refusions, within the
grandiose self-structure are conceptual, not perceptual, self- and
object representations. Perceptual distinctiveness at an in-
trapsychic level, expressed in the psychopathic personality's
capacity for adequate reality testing, is developmentally pre-
served despite the fusion of real self-, ideal self-, and idealized
object representational concepts. At lower levels of borderline
personality organization, self- and object percepts may be some-
what undifferentiated and could be clinically measured by poor
form level responses to the Rorschach (Sugarman 1986). Border-
line patients closest to a psychotic level of perceptual distortion
are prone to respond with quite primitive confabulations to the
Rorschach. For example, to Card X:
two blue crabs .. . almost looks like they have human

..
faces . and you know how a scorpion has a long claw,
it's like a mixture of parts of a monster. ...
Higher-level borderline patients would be more likely to evi-
dence fabulized combinations, such as "a man with wings" to Card
I (Smith 1980). I have found that contaminations, the most

serious of perceptual distortions within the Rorschach process
(Johnston and Holzman 1979), are very unusual in the psycho-
pathic process unless a psychotic disorder is also present. The
conceptual fusions within the grandiose self-structure usually
become clinically evident in the transference relationship with
the psychopath.
ATTACHMENT
The psychopathic process crystallizes toward the later sub-

phases of separation-individuation with the failure of object
constancy and a primary narcissistic attachment to the grandiose
self-structure. A specific dysfunctional direction of development
(Eagle 1984) coalesces in the child's deactivation of a need for
attachment (Bowlby 1980)and his or her narcissistic choice of the
grandiose self to subserve individual survival.
Bowlby (1969) wrote that attachment is mediated through
five instinctual behaviors: sucking, smiling, clinging, crying, and
following, organized and maintained through proximity-seeking
behavior toward the mother. From an evolutionary perspective
such behavior enhances species survival by protecting the child
from predators. Bowlby (1973) argued that attachment to the
mother is primary, and anger is a response to separation. The
experience of the mother figure as an aggressive predator, or
more benignly as a passive stranger, leaves the child no choice
but to disavow a primary emotional attachment to an actual
object outside the child's skin boundary. Willock (1986) termed
one facet of this child's narcissistic vulnerability "the disregarded
self" and postulated that much of this child's aggressive and
antisocial behavior can be understood as an attempt to cope with
and defend against hurt, anxiety, and anger associated with this
primitive, inteinalized object relational paradigm.
Other researchers have noted that most hyperaggressive
children have experienced some degree of emotional abuse or
neglect (Field 1940, Red1 and Wineman 1951, Bandura and Wal-
t e r ~1958). Tooley (1974, 1976) studied a sample of mothers of
aggressive children and noted their nonresponsiveness; they
would sit impassively and gaze vacantly while their children
sought attention. Minuchin and colleagues (1967) observed alter-
nations in mothers' behavior between enmeshment and disen-
gagement in delinquent families. At the point when family ten-
sions and stress were highest, mother was most prone to
abandon her role as parent to protect her own emotional equilib-
rium. They also observed that mother and child often felt a
complete lack of connection when they were not directly inter-
acting.
I must note, moreover, the reciprocal nature of the parent-
child relationship and the ways in which the child can contribute
to parental neglect and detachment. Willock (1986) argued that
both excitability and nonconsolability (Aleksandrowicz and Alek-
sandrowicz 1976) in the infant, psychobiological factors that
would aggravate parents' attempts to console and infants' at-
tempts to soothe themselves, could grossly interfere with attach-
ment or bonding. Stott and colleagues (1975) postulated that a
distinctive feature of aggressive, antisocial children was an over-
reacting temperament. This inhibitional impairment would impel
the parents to attack the child or distance themselves in an
extreme and inappropriate fashion. A child who is behaviorally
aggressive and autonomically hyporeactive could easily fail to
resonate with parents genuinely committed to a protective,
holding environment, and capable of providing such an environ-
ment for a less aggressive, autonomically normal child. On the
other hand, an aggressive, psychopathic parent would only exac-
erbate the psychobiological propensities of the child.
The psychodynamic marker of successful, normative attach-
ment behavior is object constancy. It is "the capacity to feel and
use the psychological presence of the primary love-object even
when he or she is not present or, if present, not approving" (Solnit
1986, p. 2). Object constancy is the process by which later oedipal

and postoedipal identifications take place; it is the bedrock of
socialization. Object constancy implies an affective, libidinal in-
vestment in the object, which reinforces the evocative recall of
the object concept. It is dependent upon object permanency, the
perceptual-mnemonic characteristic of the infant to evoke a
memory of the actual object in its absence (Rinsley 1982) and to
differentiate actual objects from the manipulation of them
(Piaget 1954). Object constancy is the intrapsychic paragon of
safety for the child. I t is more closely allied to the conceptual-
affective sphere, rather than the perceptual sphere, of self- and
object relations. In the midst of overwhelmingly frightening or
rageful feelings within the self, the child is aware of a loving,
constant, approving presence. It is the tearful child's diminishing
need to ask, "Mommy, do you still love me?"
Object constancy enables the young child to complete the
passage through separation-individuation with an emotionally
available and inherently supportive primary parent. Psycho-
pathic character formation infers the absence of such a figure.
Instead of the child's emergence into the third and fourth year of
life with internally stable, affectively gratifying, and clearly
delineated self- and object representations, the fused self- and
object concepts within the grandiose self-structure help the child
defensively maneuver through the blighted landscape of defi-
cient parenting.
When the primary parent is physically or emotionally sadis-
tic, the child will usually establish a sadomasochistic primary
attachment (Solnit 1986). In borderline individuals the develop-
mental struggle for object constancy may be associated with a
provocative, pain-inflicting constant object:
In these instances, tension reduction is preceded by

sudden storms of painful aggression as compared or
contrasted to gradual tension reduction associated
with object constancy in which the love object repre-
sentation is predominately cathected with affectionate,
pleasurable, self-esteem-promoting libidinal energies.
..
These theoretical inferences . are useful in ex-
plaining the strong, life-threatening attachment be-
havior displayed by children who are violently abused
physically andlor sexually. [Solnit 1982, p. 2101
Donald Lunde, in his preliminary research with a small

sample of sexual psychopaths who engaged in serial murder,
noted the close association between violence and eroticism in
their early childhood histories. In one example, the child was
physically beaten by his father after school, whereas his mother
would fondle his penis in an eroticized, soothing gesture after he
went to bed.'
A fuller understanding of psychopathic structuralization is
gained by applying a dual-track theory of development (Grotstein
1980b). The infant is subject to two modes of experience, one of
total separateness and one of continuing primary narcissism or
identification. What Mahler and colleagues (1975) referred to as
periods of autism and symbiosis can be conceptualized as permu-
nent stages consisting of physiological rhythms and drives that
coexist with states of separation-individuation throughout the
life cycle. The normal infant is in contact with the reality prin-
ciple and the pleasure principle from the beginning, and the two
optimally work in harmony as well as dialectically (Grotstein
1980b).
The psychopathic process is an extreme and deviant varia-
tion of the dual-track theory of development. On the one hand,
primary narcissism and identification are conceptually glorified
in the grandiose self-structure; on the other hand, states of
relatedness are aggressively and sadomasochistically pursued to
find the heretofore missing constant object.
'This case was presented at the California State Psychological Association

Annual Convention, San Francisco, March 2, 1986.
These coexisting processes of sadomasochistic attachment,

or aggressive attempts to bond, and profound detachment from
one's own and others' affective experience, telescoping back from
adulthood to suggest paranoid-schizoid (Klein 1957) issues in
early infancy, are often clinically apparent in the psychopathic
character:
R was a 30-year-old black male charged with murder

and "special circumstances" following an armed rob-
bery in which he shot and killed the proprietor of the
store in front of the proprietor's wife and child. He was
admitted to our acute forensic inpatient unit following
several suicide threats and one attempt while in cus-
tody. Psychological testing revealed an individual with
a full-scale IQ of 80. The Rorschach indicated a severe
borderline personality organization with much aggres-
sive and primary process thought content. R's thinking
was pervaded with the belief that he would be "gassed
or electrocuted," and therefore he should commit sui-
cide. This paranoid belief persisted despite his knowl-
edge that no one in California had been executed for a
crime in over a decade, and he would probably not be
the first. He showed virtually no affect while on the
inpatient unit except for a teasing smile when he would
explain to the nursing staff his latest plan for suicide.
He was quite asocial, and had no verbal interchanges
with other patients. He would delight in handing over
various pieces of string, metal, and bandages to the
nurses that he reportedly had not decided to use in a
suicide attempt. Following his conviction for first-
degree murder without special circumstances, and
prior to his transport to prison, he stated to me, "My
unconscious wants to terminate my life but my con-
scious wants to prolong it." Not once during his two-
month inpatient stay did he mention the victim or the
victim's family.
Origins 59
This case illustrates both the paranoid and schizoid processes in

the psychodynamically quite transparent and intellectually
below-average psychopathic personality. R's paranoia, or sado-
masochistic pursuit of attachment, was evident in the totally
unwarranted and sadistic killing of his victim and his resolute
belief that; he would be "gassed or electrocuted." His schizoid
characteristics, betraying a profound detachment from the affec-
tive experience of self and others, were evident in his benign
indifference to self-inflicted pain, his lack of any expressed emo-
tion, and his absence of empathy toward the victim or his family.
CONCLUSIONS
The developmental origins of the psychopathic personality are

characterized by a precocious separation from the primary
parent during the symbiotic phase of maturation; failures of
internalization that begin with an organismic distrust of the
sensory-perceptual environment; a predominate, archetypal
identification with the stranger selfobject that is central to the
conceptual self and object fusions within the grandiose self-
structure during the period of separation-individuation; a failure
of object constancy and a primary narcissistic attachment to the
grandiose self; and states of relatedness (separate from the traits
of primary narcissistic attachment) that are aggressively and
sadomasochistically pursued with actual objects. This coexist-
ence of benign detachment and aggressively pursued, sadistic-
ally toned attempts to bond is pathognomonic of the psychopathic
process.
These five developmental themes coalesce in the psycho-
pathic personality structure to distinguish it from a more benign
narcissistic disturbance. Developmental origins of the psycho-
path, however, should still be conceptualized within the range of
borderline personality organization (Kernberg 1984).
Part I1
STRUCTURE AND
DYNAMICS
Affective Life and Death
D a v i d Berkowitz, known to himself and millions as 'Son of
Sam," was convicted of the serial murdering of five young women
and a man in New York City from 1976 through 1977. He was
initially diagnosed as paranoid schizophrenic, but careful evalu-
ation revealed that he was malingering much of his psychotic
symptomatology, and he was more appropriately diagnosed as a
psychopathic personality with paranoid and hysterical traits
(Abrahamsen 1985).
He confided to David Abrahamsen, M.D.,at Kings County
Hospital:
I was literally singing to myself on my way home, after
the killing. The tension, the desire to kill a woman had
built up in me to such explosive proportions that when
I finally pulled the trigger, all the pressures, all the
tensions, hatred, had just vanished, dissipated, but
only for a short time. I had no sexual feelings. I t was
only hostile aggression. I knew it when I did it it was
wrong to do it. I wanted to destroy her because of what
she represented . .. a pretty girl, a threat to me, to my
masculinity, and she was a child of God, God's creation.
I couldn't handle her sexually. [Abrahamsen 1985, p.
1781
The emotional experience of the psychopathic personality is

a baffling, and at times shocking, phenomenon. It compels the
psychoanalytic thinker to understand both the absence of affect
when its presence would be predicted in a more socialized,
empathic individual and the presence of intense, unrnodulated
affect that is dramatized by its unpredictability and capacity to
arouse an atavistic fear in others.
My attempt to understand the emotional dynamics of the
psychopathic character begins with two questions: First, what is
the psychopathic personality's biological capacity for emotion? Is
it conceivable that biochemical and neuroanatomical abnormali-
ties in the deep limbic structures of the brain could predispose an
individual to a "reptilian" state of mind and a subsequent absence
of capacity to experience any emotion? And second, what is the
psychopathic personality's conscious experience of emotion or
affect? I must pause here to note that any deductive attempts to
conceptualize emotions do not do justice to the idiographic sub-
tleties of individual emotional experience; but I will delineate
common characteristics of the most salient affects ,within the
psychopathic process, such as boredom, envy, exhilaration, con-
tempt, sadistic pleasure, sexual sadism, anger, and the vicissi-
tudes of depression.
REPTILIAN STATES
The common denominator among mammals, including humans,

for the experience and expression of emotion appears to be the
limbic system. First called the "great limbic lobe" by Broca (1878)
and later defined by MacLean (1952) as the limbic system, it is a
phylogenetically old cortex that surrounds the brainstem struc-
tures. This diverse group of brain structures forms the medial
edge of the cerebral hemispheres as well as the subcortical
telencephalic areas that partially envelop the deep gray matter
of the basal ganglia (Damasio and Van Hoesen 1983). Beginning
Structure and Dynamics 67
with Papez's (1937) theory of emotion and MacLean's (1949)

reformulation of it, the functional importance of the limbic
system is its high level of integration of interoceptive and exte-
roceptive inputs, sensations, perceptions, and affects (Valzelli
1981). Although arguments have continued over the validity and
heuristic value of the limbic system concept (Brodal 1981), the
central role of the limbic structures in emotions and affects
appears to be a reliable and valid clinical observation (MacLean
1952,1973, Penfield and Jasper 1954, Damasio and Van Hoesen
1983).
More recent studies have supported the hypothesis that
parts of the limbic lobe project not only to areas of the motor
system, but to the primary and secondary associational areas of
the cerebral cortex (Pandya et al. 1981). I t also appears that key
elements of the limbic structure receive a large proportion of
their input from associative areas of the cerebral cortex (Herzog
and Van Hoesen 1976). I t is highly probable that the limbic
structures are affected not only by immediate associational re-
sponses to sensory stimuli, but to memories of events that have
influenced the organism in the past. This, of course, would
provide psychobiological support for an aspect of the psychoan-
alytic concept of transference.
I t is beyond my intent and capability to review in detail the
structure (see Valzelli 1979) and function (see Livingston and
Horneykiewicz 1978) of the limbic system. The articles cited
contain further explication. I do want to emphasize, however, the
fundamental role the limbic system plays in both conscious affec-
tive experience and the capacity for emotional relatedness.
Although shared among mammals (Papez 1958), limbic
structures subserving the expression and modulation of affect
are generally absent in reptiles. The reptilian cerebrotype, de-
scribed by MacLean (1976) as the first evolutionary step in the
development of the human triune brain, is centered primarily on
the striatal complex and neuroanatomically supports several
basic and genetically transmitted behaviors, such as home site
selection, establishment and defense of territories, hunting, feed-

ing, mating, competition, dominance, aggression, and imitation
MacLean 1962, 1964, 1972). The latter imitative behaviors are
generally repetitive, compulsive, highly ritualized, and automa-
tized. What is absent in the reptilian cerebrotype is a parental
response to its offspring, hoarding, and social behavior.
The parental or maternal drive is one of the most strongly
motivated behaviors in mammals (Stone 1942). It is absent in
most reptiles and is one of the distinguishing behavioral charac-
teristics between mammals and reptiles (Cockrum and McCauley
1965). As I have noted earlier, parental abuse or neglect is
ubiquitous in the childhood histories of psychopathic individuals.
Hoarding, a distinctively mammalian behavior, is the
storage of food in excess of immediate needs. It is absent in
reptiles and implies a capacity to project into the future and
anticipate aversive consequences. The psychopathic individual is
autonomically hyporeactive when anticipating negative conse-
quences, and this, in turn, appears to lead to deficits in new
learning.
Social behavior-the interpersonal expression of the indi-
vidual's early internalizations, successful attachments, and de-
veloping capacity for empathy-is the consummate failing of
psychopathic individuals in the eyes of others. They are the
embodiment of the antisocial personality, the stranger in our
midst. They share with the reptilian cerebrotype an inability to
socialize in a consciously affectionate and genuinely expressive
manner.
In animal studies, removal of the hippocampus and ablation
of the neocortex appear to extinguish nest building, grooming,
and social behavior (Kolb and Nouneman 1974, Shipley and Kolb
1977). Valzelli (1981) called this a reptilelike behavioral regres-
sion that is due to the functional prevalence of the reptilian brain
structures.
Although there is absolutely no neuroanatomical or neu-
rophysiological research to support a correlation between psy-
Structu~eand Dynamics 69
chopathic behavior and the functional prevalence of the reptilian

cerebrotype, the conceptual parallels are striking. I would hy-
pothesize that the term reptilian state describes the functional
psychobiology of certain primary, psychopathic characters. The
etiology of such behavioral regression, or perhaps genetically
predisposed limbic dysfunction, is, however, unknown.
I first had contact with T. G. when he was brought to

psychiatric "sick call" in the local custody facility. Sick
call took place in a six by eight foot room within which
the psychiatrist, nurse, deputy, and myself stood
around a small table. When T. G. entered the room he
filled it. He was a 24-year-old Caucasian male, six feet
four inches tall, and probably weighed 280 pounds. He
wore no shirt, and his large, fat chest and abdomen
cascaded in sweaty folds down toward his cotton pants.
His wrists were cuffed and attached to a metal chain
around his waist. His legs were shackled in chains so he
walked with a decided shuffle. T. G. had his head
shaved and wore a Fu Manchu moustache.
As soon as he sat down he began hounding the
psychiatrist for Valium. When this didn't work, he
tried Libriurn and Restoril. He finally settled for Tho-
razine.
As I learned more about T. G. I began to develop
a clinicalpicture of a young man who could be described
as a "walking impulse." He was housed in an individual
cell and always moved in restraints because of his
extremely poor impulse control and unmodulated af-
fect. In fact, he was more instinctual than affective. If
he felt aggressive he would physically assault others; if
he felt sexual, he would attempt to rape whatever
animate object was available. He was the raw expres-
sion of primitive libidinal and aggressive drives. He
showed no capacity for affection, or even an inclination
to mimic emotional relatedness that I found in more

intelligent psychopaths. He showed no symptoms of
psychosis, but his social judgement was virtually ab-
sent and his intelligence was estimated to be mildly
retarded (full-scaleIQ 55-70). His personality, without
formal psychodiagnostic testing, appeared to be orga-
nized at a borderline level. His thoughts were marked
by projection and denial. He showed no motivation or
capacity to even rationalize his behavior. T. G. had
been taken into custody by the state shortly after his
birth and his mother's failure to provide basic maternal
care. He was contained by various homes and institu-
tions throughout his childhood, and began contact with
various criminal justice and psychiatric systems in
adolescence. He was a biogenic and sociogenic tragedy
who now presented a continuous danger to others.
The other clinical observation, or perhaps more specifically

a countertransference reaction, that supports the hypothesis of a
reptilian state among certain primitive psychopathic characters
is the absence of perceived emotion in their eyes. Although this
information is only intuitive and anecdotal, it is my experience in
forensic treatment and custody settings to hear descriptions of
certain patients' or inmates' eyes as cold, staring, harsh, empty,
vacant, and absent of feeling. Countertransference reactions
from staff to this perception of the psychopath's eyes have
included, "I was frightened . . . he's very eerie; I felt as if he was
staring right through me; when he looked at me the hair stood up
on my neck." This last comment is particularly telling since it
captures the primitive, autonomic, and fearful response to a
predator. I have rarely heard such comments as these from the
same experienced inpatient staff during highly arousing, threat-
ening, and violent outbursts by other angry, combative patients.
It is as if they sensed the absence of a capacity for emotional
Stwture and L?ynamics 71
relatedness and empathy in the psychopathic individual, despite

his lack of actual physical violence at the moment.
Although the perception of eyes, or the sense of being
watched by eyes, is pathognomonic of paranoid mechanisms
during projective testing, I have found little in the research
literature, either theoretical or empirical, that attempts to un-
derstand this act of visual predation in the psychopathic process
(Webbink 1986, Hymer 1986).
The popular media, both fictional and nonfictional, is quite
adept, however, at capturing the reptilian, predatory, and emo-
tionless stare of the psychopath. The reader is encouraged to
study newspaper and magazine photographs of such contempo-
rary sexual psychopaths as Charles Manson, Theodore Bundy,
and Richard Ramirez.' Steven RailsbacKs portrayal of Manson
in the film 'Helter Skelter" was an exquisite capturing of the
reptilian stare. Other popular film actors such as Clint Eastwood,
Charles Bronson (artistically representing morality and justice),
Bruce Dern, Anthony Perkins, and Rutger Hauer (personifying
evil) have successfully exploited the larger-than-life visual image
on the screen to convey the absence of emotion and the presence
of more primitive instinct through their eyes.
The reptilian, predatory eyes are, in a sense, the antithesis
of the affectionate mirroring of the infant in the eyes of mother.
The nascent self is reflected as an object of prey, rather than an
object of love. The fmated stare of the psychopath is a prelude to
instinctual gratification rather than empathic caring. The inter-
action is socially defined by parameters of power rather than
attachment.
'Richard Ramirez is alleged to be the "night stalker" responsible for fourteen

murders in California in 1986. At the time of this writing, he is standing trial in
Los Angeles County Superior Court and is individually incarcerated in the Los
Angeles County Jail in a "high power" area. Custody officials have used the
words "manic psychopathn[see Chapter 71 in describing his observed behavior
to me.
Scoptophilia, the sexualization of the sensation of looking,

may be a predominant component of the reptilian stare. The
psychopathic character may want to see in order to destroy the
object in a fantasied, sexually sadistic manner. The unconscious
fantasy of incorporation through the eyes may also be present
(Fenichel 1945).
Condensed sexual and aggressive instincts communicated
through the eyes of the psychopath will induce not only fear but
shame in the perceived victim. The individual subjected to such a
stare may feel physically caught by it, yet ashamed and not
wanting to be seen. He or she may hide or avert the stare,
suggesting the magical belief that anyone who does not look
cannot be looked at (Fenichel1945); a physical sensation of heat
may wash over the face and body.
In another paper, Fenichel(1935) emphasized the oral sa-
dism of the staring eye; it is not only actively sadistic in the
folklore sense of "casting a spell" (Elworthy 1895), but is pas-
sively receptive to the fascination of the victim, who is at risk of
metaphorically being turned into stone or salt. This latter danger
finds its mythological roots in the legend of Medusa and the
biblical story of Lot and the destruction of Sodom. The physio-
logical basis for such a legendary transubstantiation appears to
be the muscular rigidity that may overwhelm a person who
suddenly sees something, or someone, terrifying.
As the sun rose over the land and Lot entered Zoar,
Yahweh rained on Sodom and Gomorrah brimstone
and fire. . . . He overthrew these towns and the whole
plain, with all the inhabitants of the towns, and every-
thing that grew there. But the wife of Lot looked back,
and was turned into a pillar of salt. [Genesis 19:23-261
The original Sicilian fear of the "evil eye" is analogous to the

visual act of predation. I t is mentioned by Mahler and colleagues
(1975) in reference to a child not wanting people to see his baby
Structure arid Dynamics 73
sister, thus acting out his wish that the baby be invisible and
perhaps warding off his own wish that the baby be afflicted by
the 'evil eye." Freud (1900) referred to his mentor Ernst Brucke's
"terrible blue eyes. ... No one who can remember the great
man's eyes . . . and who has ever seen him in anger, will find it
difficult to picture the young sinner's emotions" (p. 422). Later,
Freud (1919) theorized that the functional significance of
watching or being watched in manifest dreams was a product of
superego formation. Peto (1969) asserted that this representa-
tion of archaic superego elements by the threatening eye was a
remnant of the earliest phases of childhood sensory-perceptual
experience. In a thoughtful argument incorporating the work of
others (Hartmann 1924, Hermann 1934, Szekely 1954), he
stressed the significance of the Cyclopean glaring eye, specifi-
cally the primary perception of a red glowing eye, for the subse-
quent structuralization of anxiety in a biologically determined
real danger situation for the infant. This external traumatic
agent becomes internalized as a parental introject, or in my
terms, an object percept (Meloy 1985). Regression to the psy-
chotic level of elementary visual hallucinations of red (Hartmann
1924)or the archaic primary perception, urwahmzehmungen, the
red glow of the retaliatory parental eye (Hermann 1934), is
illustrated in the following case of a nonpsychopathic patient:
F.C. was a 20-year-old Hispanic male in an acute schiz-

ophrenic psychosis when admitted to our forensic inpa-
tient unit. He was charged with the murder of a 52-year-
old female prostitute. He responded rapidly to
neuroleptic medication, and subsequent psycho-
diagnostic testing and clinical observation revealed a
hysterical character organized at a borderline level of
personality. F. C. quickly developed a strong emotional
attachment to the staff and the other patients. During
the course of psychotherapy he recalled that a week
prior to the murder he had seen a dog with glowing red
eyes which chased him and barked at him. The patient

delusionally believed the dog was an agent of Satan. On
the day of the murder, F. C. met an older woman who
invited him to her apartment. Once they were un-
dressed she taunted and teased him about the size of
his penis. As he became more ashamed and angry, he
noticed her eyes were glowing red. He was convinced
she was also a demon and proceeded to stab her repeat-
edly with a kitchen knife.
The psychopathic individual, in the absence of psychosis, is

able to unconsciously project an annihilatory stare that is intu-
itively felt by others receptive to a predatory introject to be
omniscient and omnipotent. The absence of modulated emotion
warns of behavior devoid of empathic constraint and suggests
the functional prevalence of the reptilian cerebrotype.
CONSCIOUS EXPERIENCE OF EMOTION
The psychopathic process allows the conscious experience of

emotion, but emotion is structured by severe narcissistic psycho-
pathology, more specifically, the grandiose self-structure. Emo-
tions felt in the presence of others are, by necessity, contami-
nated by selfobjects that provide the projective-introjective
medium through which actual others are perceived, and subse-
quently defensively conceived, as extensions of the grandiose
self. The particular selfobject that is activated is dependent upon
certain characteristics of the actual person that is perceived; for
instance, an actual woman may behave in ways that remind the
psychopathic individual of his teasingly erotic, yet abandoning
mother with whom he identified as a child for defensive purposes
and internalized as a wished-for and idealized selfobject concept.
Emotions consciously felt by psychopaths when alone are
still intensely narcissistic but are activated and directed by more
Structure and Ltynamics 75
grandiose and less defensively motivated fantasies; they are no

longer constrained by the perceptually quite accurate, and reality-
bound, perceptions of others in their presence. David Berkowitz,
the sexual psychopath, wrote, "I always hope to be the first one
to go to heaven, one of the first fruits. I do feel more important to
God than other people. This is probably why I am alive today
because, despite my anger towards God, he still loves me the
mostn (Abrahamsen 1985, p. 173).
But how does one reconcile the "reptilian staten hypothesis
with my seemingly contradictory assertion that the psychopath
consciously experiences emotion?
The reptilian state is not a characterological trait. I t is a
functional psychobiological state that momentarily may exist
with its object relational and instinctual correlates. The enduring
psychopathic process, or structured psychopathic character, pre-
disposes the individual to psychodynamically, and psychobiologi-
cally, assume a reptilian state of mind. At other times, in less
behaviorally regressive and instinct ridden situations, the psy-
chopathic character may manifest a wide range of modulated,
consciously felt emotion, but it never progresses beyond an
intensely narcissistic developmental stage. In a sense both onto-
geny and phylogeny are evident in the psychopaths' shift be-
tween the reptilian and mammalian cerebrotypes and their indi-
vidual emotional vacillations with their limiting narcissistic
envelope. There undoubtedly exist, however, certain primitive
psychopathic characters who do not experience emotion as we
know it; in other words, the reptilian state is actually an enduring
trait. T. G., described earlier, may be such an individual. Such
case studies are the exception to the hypothetical rule.
Pleasure
The conscious experience of pleasure in the psychopathic process

is distinguished by the absence of empathy and affectional bonds,
an inability to repress painful affect, the absence of love for the

anticipated pleasurable object, and, if alone, difficulty over-
coming a predominately tense, anhedonic state without overt
behavior that contains an aggressive or sexual dimension.
Pleasure is distinguished by the presence of dominance-
submission behavioral patterns, the use of dissociative defenses
such as splitting to ward off painful affect, gratification of sadistic
impulses through the intentional infliction of emotional or phys-
ical pain upon others, sexual and aggressive "fueling" of the
pleasurable event, and sensation seeking. Psychopaths do not
experience pleasure by empathically responding to the joy in
others. Their perception of others' pleasure arouses only envy
and greed in themselves.
Sexual sadism, the conscious experience of pleasurable
sexual arousal through the infliction of physical or emotional pain
on the actual object, is characteristic of the sexual psychopath.
Attempts to categorize and understand such behavior have gen-
erally been limited to descriptive and behavioral paradigms
(Krafft-Ebing 1966, Groth 1979, Revitch and Schlesinger 1981).
The etiology of such behavior is unknown, but I have posited
that the neurological proximity of the sexual and aggressive
centers within the hypothalamus may provide the biological
substrate for early conditioning or limbic dysfunction that results
in the expression of sexual psychopathy as an adult (Meloy 1988).
I mentioned earlier the verbal report of Donald Lunde con-
cerning the temporal proximity of eroticism and violence in the
childhood histories of several sexually psychopathic "serial mur-
derers." Such case examples, and the unconditioned, reflexive
nature of sexual arousal, support my notion that classical condi-
tioning (Pavlov 1927) may explain the first pairing of violent
behavior and sexual arousal in these individuals.
If the child passively observes violence in the home that is
habitually accompanied by sexual acting out, he or she may later
be genitally aroused when witnessing only violence. More specif-
ically, if the child is physically or emotionally abused by a parent
and then in the midst of consciously felt fear, rage, shame, or

actual physical pain, is "soothedn by the parent fondling or
caressing the child's genitals, the pairing of these interoceptive
sensations will not easily extinguish with more highly differenti-
ated hormonal development. With such a classical conditioning
paradigm'the later experience of violence (the conditioned stim-
ulus) in the absence of direct sexual stimulation (the uncondi-
tioned stimulus) becomes sexually arousing (the conditioned re-
sponse) as a result of the early temporal pairing of both stimuli.
Frank (1966) wrote of such experiences in the childhood of
Albert DeSalvo, the Boston Strangler:
"My father," DeSalvo spoke dully. "We used to have to

stand in front of him, my brother Frank and me, every
night and be beaten with this belt. I can still to this
very moment tell you the color of the belt and just how
long it was-two inches by 36-a belt with a big buckle
on it. We used to stand in front of him every night and
get beaten with that damn thing-every night,
whether we did anything wrong or not. We were only
in the fourth or fifth grade. . . ." "My father used to go
around with prostitutes in front of us . . . my sisters
always had black eyes . . . When you're under the
.
environment of sex all day long . . you go up on the
roof of our building and there'd be a couch up there. . . .
They'd give you a quarter and say, 'Beat it, kid.' . . .
Always in the bedroom something being done. . . ."[pp.
316-3171
Abrahamsen (1985) noted the voyeurism and fantasy that

may precede actual sexual sadism. As the sexual psychopath
becomes a more conscious actor in gratifying his impulses, rather
than a victim of classical conditioning as a child, an operant
conditioning model (Skinner 1953) becomes conceptually more
relevant. The individual begins to experiment with the infliction
of physical pain and finds himself intensely gratified, or posi-

tively reinforced, by his own interoceptive feelings of sexual
arousal and his perception of the victim's fearful, enraged affec-
tive state. Operant conditioning has taken over, and the sexual
psychopath is likely to repeat his behavior with increasingly
greater frequency as a result of the intermittent or variable
reinforcement schedule of his antisocial and clandestine acts
(Hilgard and Bower 1975).
Such conditioning models are, of course, most germane to
the relationship among instinctual, visceral, and affective states;
they are probably less relevant when considering important
linkages among internal representations of self and others at
higher cortical perceptual and conceptual levels. For instance,
the sexual psychopath, during an act of violence and increasing
sexual arousal, may become psychotic at an object concept level
and actually conceive his victim as a ragefully devalued "mother"
introject that internally taunts and criticizes him. Yet at an
object percept level he is not psychotic; he can perceptually
distinguish between his actual victim and his actual mother, and
there is no loss of reality testing between interoceptive and
exteroceptive sensations.
In contrast is the violent paranoid schizophrenic who may
be quite psychotic at a sensory-perceptual level of experience,
perhaps delusionally believing that his actual victim is his mother
while at the same time experiencing the introject of her as an
auditory hallucination due to a collapse of ego boundaries; in
other words, her taunting is heard as an actual voice coming from
outside his mind and is believed to originate from the actual,
biological mother. This is a very important diagnostic distinction
in assessing the state of mind of a psychopathic versus psychotic
individual during the commission of a violent act.
The psychopath's experience of pleasure through somato-
sensory stimuli appears to be devoid of more affectionate yearn-
ings and is linked to more highly charged and circumscribed
sexual sensations. Sexual psychopaths appear to prefer acts of
Structure and L3ywrnics 79
violence that necessitate skin contact with the actual object

(Levin and Fox 1985). This may momentarily represent a point of
adhesive identification (Bick 1968, Meltzer 1975) between the
sexual psychopath and victim wherein he projectively identifies
at their now common skin boundary and briefly gratifies a
symbiotic wish for reunion with the precociously separate
mother; yet the violence, and its accompanying affects, ward off
any primitive fear of engulfment by the mother as a not-
to-be-trusted stranger selfobject.
The texture (T) response to the Rorschach represents a
compelling somatosensory analog of the affective experience of
emotional or dependency needs (Exner 1986a). The T response is
the interpretation of the shading features of the inkblots as
representing "tactualn stimuli. The elaboration carries with it
such tactual features as soft, hard, smooth, rough, silky, grainy,
furry, cold, hot, sticky, or greasy. Implicit in the T response is the
perceptual representation of somatosensory stimuli.
Klopfer and colleagues (1954) suggested that it was related
to needs for affection and dependency. T also appears to correlate
with the presence of a childhood transitional object (Exner et al.
1980, Exner and Chu 1981). Other research has supported the
hypothesis that the absence of T means the affective experience
of emotional or dependency needs has become "neutralized," and
if this occurs, it seems to take on a durable characteristic (Leura
and Exner 1976, Pierce 1978, Exner 1986a).
Although there is currently no available data on the preva-
lence of T among psychopathic subjects, I would hypothesize that
such a carefully selected sample would produce predominately
"T-lessn(see Appendix 111)protocols. Exner's (1986a) normative
sample and psychiatric reference groups lend support to such a
hypothesis as illustrated in Table 4-1. The "character problemn
sample is undoubtedly the most psychopathic of all four groups.
It is composed of 121 males and 79 females, ranging in age from
18 to 47. The protocols were all collected in outpatient settings,
and the majority (124) had histories of drug and/or alcohol abuse;
Table 4-1
Comparison of Texture (T) Responses among Four
Sample Groups (Exner 1986a)
-- --
Texture (T) Responses Mean S.D.

Character problems ( N = 200) 0.44 0.67
Inpatient schizophrenics (N = 320) 0.49 1.15
Inpatient depressives (N = 210) 0.93 1.42
Nonpatients ( N = 600) 1.16 0.80
113 had been involved in at least one legal dispute. No subject in

this sample was hospitalized more than ten days, and the ma-
jority were single, separated, or divorced.
As suggested, the character problem sample averages the
least number of texture responses and has the smallest variance
of T responses. Such data lend support to my suggestion that the
psychopathic individual is devoid of affectionate yearnings, and
does not seek pleasure through the gratification of dependency
needs or, more specifically, the expression of affection and caring
through somatosensory stimulation.
The conscious experience of pleasure in the psychopathic
process is inextricably linked to either sensation-seeking or sa-
distic impulses. Careful analysis of the psychopath's pleasure
seeking and pleasure gratification will usually uncover one or
both as motivational factors. The MacDonald triad (MacDonald
1963, Hellman and Blackman 1966) identified bed wetting, fire
setting, and cruelty to animals in childhood as predictive of adult
criminality. Although not as empirically reliable a predictor of
psychopathy as was hoped (MacDonald 1968), fire setting and
cruelty to animals in the childhood histories of some psychopaths
suggest respective motivational dynamics of sensation-seeking
and sadism as avenues to pleasure. Revitch and Schlesinger
(1981) noted that specific cruelty to cats was often prognostic of
the sexually motivated compulsive murderer who targeted
women as victims. They asserted that cats are symbolic of the
feminine and oftentimes represent the displaced matricidal

wishes and oedipal conflicts of this endogenously motivated
murderer. Feltous and Kellert (1986) found a significant associa-
tion between a pattern of substantial abuse of vertebrate animals
in childhood and later recurrent, protean personal violence in
adulthood. They suggested that variety of cruel acts, variety of
species victimized, and inclusion of socially valued species, such
as cats, are meaningful areas of investigation in the clinical
assessment of aggressive adults.
Anger
The conscious experience of anger in the psychopathic process is

distinguished by the predominance of projective mechanisms
that, at times, may be characterized as delusionally paranoid.
Meissner (1978) noted that the paranoid hostility of the psycho-
path is usually more general and diffuse than the hostility of the
paranoid personality disordered individual.
H. V. was arrested for driving under the influence and

reckless driving. He was a 25-year-old Turk who had
the misfortune of being arrested several days after the
American bombing of Libyan targets on April 14,1986,
during a heightened public fear of terrorist reprisals by
radical Arabic individuals in the United States. De-
spite his incarceration in a maximum security setting
surrounded by mistrustful, and sometimes overtly hos-
tile, law enforcement personnel, H. V. would continu-
ally scream obscenities at the staff. Despite his physi-
cally small stature and fractured left knee, he would
threaten to kill any'person he saw in a uniform, arro-
gantly insist he had done nothing wrong, and hurl
invectives a t anyone who passed by his individual cell.
Our initial evaluation of H. V. did not reveal any
systematic delusional thought content. His rage was

diffuse, yet the obvious projective mechanisms were
refractory to any verbal interventions. His judgment
and insight into his behavior were absolutely lacking,
despite the absence of any psychotic or affective dis-
order diagnosis.
Contact with H. V.'s relatives revealed a quite
arrogant and irresponsible young man who had irnrni-
grated to the United States in 1981. He was the
youngest of four siblings, and they felt he "had been
spoiled" by his middle-class Turkish parents. He had no
prior psychiatric history, yet had not been able to hold
a job since his arrival and had lived intermittently with
friends and cousins until they asked him to leave.
After three days of raging, with no diminution of
affect, H. V. was involuntarily treated as a danger to
himself with chlorpromazine. The neuroleptic suc-
ceeded in sedating, and therefore modifying H. V.'s
behavior. Within a week H. V. was very compliant, no
longer sedated, and at times obsequious toward psychi-
atric and security personnel. He would occasionally,
however, challenge other patients, security guards,
and even his attorney to fight for no apparent reason.
Psychopathic anger is also contaminated by an attitude of

righteous indignation that betrays the felt "specialness" and
entitlement of the grandiose self. I t is here that the narcissistic
core of the psychopathic process is most readily apparent. Typ-
ical countertransference reactions to such infantile displays, if
one is physically safe from the individual, include annoyance at
the behavior, an impulse to aggressively retaliate, or a passive-
aggressive desire to withhold further gratification.
The aftermath of anger in the psychopathic process, with
the diminution of autonomic arousal, is accompanied by the use of
rationalization as a defense. Perhaps the most plebeian rational-

ization following the expression of such rage is T h e y had it
coming." Although not limited to the psychopathic process, such
a statement implies an attribution of malevolence to the object, a
devaluing attitude that implies the rage was deserved. Psy-
chodynamically a past innocuous event, a small insult may pro-
vide the seed that the psychopath fertilizes with paranoid ide-
ation. The insult and its originator become intrapsychically a part
of a more diffuse conspiratorial grouping, perhaps only defined as
"they" but condensed and identified with sadistic introjects that
provide a projective lens through which actual persons are per-
ceived as familiar yet conceived as malevolent, attacking objects
deserving of the psychopath's rage. Angelo Buono, one of the two
"Hillside Stranglers" responsible for the rape, torture, and stran-
gulation of ten young women in Los Angeles from October 1977
to February 1978, remarked, "Some girls don't deserve to live"
(O'Brien 1985, p. 119).
The conscious experience of anger in the psychopathic pro-
cess has a greater probability of resulting in violence because of
the absence of superego structuralization and appropriate mod-
ulation of intensely felt affect. Such affective violence will be
studied in detail in Chapter 6, particularly in contrast with
predatory violence, a more focused, intentional, and goal-
directed behavior with distinct neuroanatomical pathways and
neurochemical catalysts (see Chapter 2 for a biochemical intro-
duction to this distinction). I would hypothesize that such affec-
tive violence in the psychopathic process could be usefully con-
ceptualized as "episodic dyscontrol" (Monroe 1981), especially if
remorse is absent following the violent event.
The assessment of episodic dyscontrol if primarily defined
as a neurological impairment through a self-report questionnaire
in prison samples (Monroe 1981) has virtually no validity. The
higher prevalence of psychopathy in prisons and the propensity
of psychopaths to project responsibility for their behavior onto
other people and things, such as neurological impairment, ren-

ders such an instrument almost useless. A sample of questions
from the Monroe Scale (Monroe 1981) will illustrate my point:
1. I have had the experience of feeling confused even

in a familiar place.
4. I do not feel totally responsible for what I do.
5. I have lost control of myself even though I didn't
want to.
8. My speech has been slurred.
9. I have had blackouts.
Such self-report measures, in the absence of objective neuropsy-

chological data, only validate the projective defenses within the
psychopathic process. I would advocate the use of the term
episodic dyscmtrol to describe violence that results from 'affec-
tive arousal and a lack of developmentally appropriate superego
formation. I would differentiate a subgroup within this dyscon-
trol syndrome that had a primary neurological trigger only on the
basis of neuropsychological or neurological indices. Reliability
among self-report measures and between self-report and clinical-
behavioral measures in criminal populations is very poor (Hare
1985a).
Consciously felt anger may be used in the psychopathic
process to control or dominate the actual object in a manipulative
fashion. Higher-functioning psychopathic individuals, as mea-
sured by both intelligence and stability of the grandiose self-
structure, may recognize their ability to control others with their
anger and may be quite talented mimics of rageful behavior when
it is not genuinely felt. In contrast with this is the consciously felt
anger of the nonpsychopathic adult, which in an attachrnent-
affectionate context, carries with it the fear of retaliation or
abandonment by the actual object at whom the anger is targeted.
This close autonomic-sympathetic and psychodynamic link be-
tween anger and fear, supported by higher-level repressive
defenses, is common in everyday experience in the hesitancy of

openly expressing anger toward someone of emotional value;
value as defined by emotional attachment, rather than dominance-
submission. The psychopath's conscious intent is to put some-
thing over on someone (Bursten 1972) by using anger as an
affective and effective controlling mechanism of the other's be-
havior. The paradigm of power and control, rather than attach-
ment and bonding, is center stage.
P. C. was transferred to the acute forensic inpatient

unit following an assault against another patient at the
local Veteran's Administration Hospital. P. C. had
struck the patient with his forearm cast and had seri-
ously injured the victim. Three weeks prior to the
assault, P. C. had attempted suicide by trying to cut his
femoral arteries, his throat, and his left forearm ar-
tery. P. C. had been a paramedic prior to his series of
hospitalizations, wherein he had been diagnosed as
paranoid schizophrenic.
P. C. presented himself as a 25-year-old Caucasian
male, tall in stature, mesomorphic, and quite hand-
some. His first words to the attending psychiatrist and
to me were, "I'm a paranoid schizophrenic." In a very
lucid and coherent manner, with no indications of
formal thought disorder, P. C. told us of his multiple
hospitalizations since age 20, his two years in the
service, and his pending 100 percent VA disability
claim. He was in quite good contact and control,
showed no indications of systematic delusions, and was
bright-normal in intelligence. His singular presenting
symptom was complaints of auditory hallucinations
commanding him to hurt himself and others. We noted
that despite his subjective complaints of depression his
mood was quite expansive and his thought content was
generally grandiose. He denied illicit drug use, but
reported "having tried" methamphetamine and co-

caine.
The VA hospital transfer notes, despite the
nursing s t a s written skepticism, indicated that the
resident psychiatrist diagnosed P. C. as paranoid schiz-
ophrenic.
The attending psychiatrist and I conferred, and
we concluded that the young man was not paranoid
schizophrenic, but quite psychopathic. We informed
the patient that he would be placed in full restraints
and seclusion due to his imminent danger to self and
others, but that all neuroleptic medications would be
stopped. P. C. greeted this news with a somewhat
surprising indifference. He was instead prescribed Be-
nadryl as a p.r.n. for anxiety or agitation and was
allowed one phone call before he was restrained.
Within thirty minutes I received a telephone call
from the patient's father, whose opening comment was
a rageful, "How dare you discontinue my son's medica-
tion! That is medical incompetence!!" His tone and
telephone demeanor were openly sarcastic, caustic,
and threatening. I was used to such encounters, how-
ever, and reassured the father that, in our judgment,
we were behaving quite competently, and, of course, it
was our decision what his son's treatment would be.
The father's voice suddenly became calm and con-
trolled, and he asked me to please spell my full name
and the name of the treating psychiatrist, along with
our addresses and type of professional licenses. I felt
an immediate surge of anxiety, but knew that my
reaction was symptomatic of a psychopathic attempt to
manipulate and intimidate the wished-for-victim, in
this case, myself. I had been telling my students for
several years that the subjective feeling of actually
being under a patient's thumb was oftentimes diag-
Structure and &narnics 87
nostic of the psychopathic process: a countertransfer-

ence reaction to the repetitive dominance-submission
ritual of the psychopathic personality.
P. C.'s father assured me that I would hear from
him again and calmly ended the conversation. Within
several hours I had received three phone calls from
three separate administrative-political authorities that
exercised power and control over my direction of the
forensic program; each agency, because of their histor-
ical trust of my judgment, asked only for hints as to
managing this irate father who was incessantly calling
their offices and complaining of his son's treatment by
our program.
P. C.'s complaints of auditory hallucinations rap-
idly diminished once we explained to him that, in our
opinion, he was not genuinely hallucinating and was
not paranoid schizophrenic. He did not assault anyone
on the unit following his initial restraint and seclusion
for twelve hours and our admonition that if he did, he
would immediately be returned to isolation. His expan-
siveness, grandiosity, and demands for attention per-
sisted. His thoughts turned to worry lest he not be
granted the VA disability pension that both he and his
father were anticipating. He wondered if one acute
inpatient unit's assessment of him, so drastically dif-
ferent from the multiple diagnoses of paranoid schizo-
phrenia he had already received, would jeopardize his
chances for the guaranteed income.
Due to the lack of repression in the psychopathic process

and the predominance of more primitive defense mechanisms,
rage may be dissociated, or "split off," from conscious experience.
This has been described in higher-functioning sexual psycho-
paths as a "compartmentalizing" of the perverse and violent
acting out: The sexual psychopath may lead a quite normal and
routine life with the appropriate social accouterments such as

job, spouse, and family, yet unbeknownst even to his spouse he is
surreptitiously carrying on his sexually violent activity. Albert
DeSalvo, the Boston Strangler, spoke of his secretiveness with
his wife, Irmgard:
'What did I tell her?" DeSalvo asked himself aloud.

"Did I tell her I was going fishing? No . . ." Then:
"That's it! I know." He was employed at the time by
Russell Blomerth's construction firm as a maintenance
man, and it was his job to keep kerosene heaters
burning over the weekend at construction sites so that
newly poured cement would not freeze and crack. "I
volunteered to go down and keep them lit-this was in
Belmont. I'd go out early Sunday to Belmont, get the
burners going, then shoot into Boston. I came to this
building . . . it all happened before 8 A.M. I was home
before 9 A.M." Then again, as if to himself: 'Why did I do
it to her? She treated me like a man." He looked up . . .
he seemed on the verge of tears, but he controlled
himself and was returned quietly to his cell. [Frank
1966, p. 2931
And following DeSalvo's strangulation-murder and necro-

philic rape of Joann Graff, age 23, in Lawrence, Massachusetts,
his twelfth victim,
"I had supper, washed up, played with the kids until
about eight o'clock, put them to bed, sat down and
watched TV-it came over about her . . . I knew it
wasn't me. I didn't want to believe it. It's so difficult to
explain to you. I knew it was me who did it, but why I
did it and everything else- I don't know why. I was not
excited. I didn't think about it; I sat down to dinner and
didn't think about it at all." [Frank 1966, p. 3021
Structure and mnarnics 89
The dissociation of rage may also be apparent prior to and

during the act of sexual sadism. Sexual psychopaths may have no
conscious experience of anger during the stalking, or predatory,
period prior to their actual assault on the victim; and subsequent
physical contact with the victim, although highly autonomically
arousing, may still not precipitate consciously felt anger. Yet the
atrocious degree of violence acted out on the victim betrays the
intensity of the dissociated affect. The predatory and affective
modes of aggression as mutually exclusive psychobiological con-
structs for understanding violence (see Chapter 6) appear to
interact with defensive processes in ways that remain hypothet-
ical, yet are strongly correlated.
Again Albert DeSalvo evokes the experience of dissociated
rage in his own words:
I t was all the same thing, always the same feeling . . .

You was there, these things were going on and the
feeling after I got out of that apartment was as if it
never happened. I got out and downstairs, and you
could of said you saw me upstairs and as far as I was
concerned, it wasn't me. I can't explain it to you any
other way. I t just so unreal . . . I was there, it was
done, and yet if you talked to me an hour later, or half
hour later, it didn't mean nothing, it just didn't mean
nothing. . . . [Frank 1966, pp. 307-3081
If I did this-well, for a sex act, or hatred, or for what
reason. . . I think I did this not as a sex act, but out of
hate for her-not her in particular, but for a woman.
After seeing her body, naturally the sex act came in.
[Frank 1966, p. 2921
Implicit in this acting out of dissociated rage through sexual

sadism is the absence of superego structuralization that could
inhibit, or at least modulate, the behavior once the impulse was
felt. This paucity of internal structure is endemic to the psycho-

pathic process and accounts for the gross failures of inhibition,
binding, and neutralization (Holt 1967) of primitive sexual and
aggressive impulses in the psychopath. As a genotype of primary
process, condensation may also be used to conceptually under-
stand the psychodynamic blending, the confusion, of sexual and
aggressive feelings in socially unacceptable ways by the psycho-
path (Gill..1967,Meloy 198613).
What is most striking is the psychopathic individual's in-
ability to consciously feel anger in any empathic sense. Wit-
nessing the physical or emotional abuse of another, the violation
of someone else's rights or the degradation of their dignity,
evokes no feeling of righteous indignation in the psychopathic
character. This is symptomatic of early failures of internalization
and a consequent inability to spontaneously identify with the
plight of another.
The more intelligent psychopathic individual, however, may
be able to simulate such anger, most publicly apparent in ex-
pressed allegiance to a particular political or ideological group
representing an oppressed segment of a society. The psychopath,
hidden behind a facade of ideological commitment, may therein
find intensely gratifying, sensation-seeking experiences. Inter-
national terrorist groups who target civilian populations will
provide certain violent psychopathic characters with outlets for
the expression of sadistic impulses if they can tolerate the ideo-
logical fervor and ritual (Cooper 1978, Post 1984, Shaw 1986).
Psychopathic individualswithin an extremist political group
will disinhibit others through their risk-taking and violence.
Their absence of superego constraints, aggressiveness, grandi-
osity, paranoia, and capacity to disidentify with any victim pro-
vide a powerful characterological template for uncharacteristic
modeling behavior by other group members.
The risk to the extremist group, however, is the probability
that such psychopathic individuals will ascend to a leadership
position and threaten both the ideology and physical safety of
their followers. They are overtly aggressive variants of the
pathologically narcissistic leader whose internalized object rela-

tions evoke "in the network of the organization a replication of his
internal world of objects populated only by devalued, shadowy
images of others and by images of dangerous potential enemies"
(Kernberg 1980, p. 364).
Once they have encouraged adulation and required submis-
siveness from their followers, yet remaining vulnerable to feel-
ings of intense envy toward those they perceive as challenging
their leadership, psychopathic leaders will aggressively defend
their position without reference to values or empathic constraint.
The transference illusion that they compel in their followers is
that they do care for their welfare and are ideologically com-
mitted to their cause.
The end result of psychopathic leadership is destruction of
the group. Followers are aggressively controlled to function as
gratifying selfobjects and sources of narcissistic mirroring. Split-
ting within the group will occur as those who refuse to carry the
grandiose projections of the psychopath begin to challenge his
leadership and are perceived, perhaps quite accurately, as per-
secutory and malevolent forces by the psychopath. The primitive
defenses of the psychopathic process are acted out in the group
behavior, rather than higher-level compromise of opinion and
modulation of affect that a less pathological leader could facili-
tate. The complete absence of internalized values and emotional
attachment to the group members may result in utterly cruel and
ruthless acts by the psychopathic leader toward both his submis-
sive followers and perceived enemies. The psychopathology of
Reverend Jim Jones and events leading to the collective suicide
of hundreds of his followers and the murder of several perceived
enemies is a horrific example of this group behavior (Reiterrnan
and Jacobs 1982).
Depression
The conscious experience of depression as an affect within the
psychopathic process probably does not exist. It is psychodynarn-
ically improbable for the psychopathic character to consciously

feel depressed for the following reasons: first, depression neces-
sitates a failure of denial, an operative defense without which the
psychopathic process does not exist. Second, depression necessi-
tates a discrepancy between actual self- and ideal self-represen-
tations that, by definition, does not exist within the grandiose
self-structure. Third, depression is linked to a capacity to mourn
for lost object or self-representations (Jacobson 1971)that must
be perceived as partially whole, integrated, and the source of
both goodness and badness. Such combining of opposite-valence
self- and object percepts is not possible with a predominance of
dissociative defenses, most generically splitting, in the psycho-
pathic process. Without the appearance of ambivalence and a
beginning capacity for repression, the affect of depression, and
its more mature, object-directed emotions such as concern, guilt,
and mourning, are impossible to achieve.
The synthesis of internalization systems with contra-

dictory affect valences promotes drive neutralization
which, in agreement with Hartmann, Kernberg sees as
providing the most important energy source for re-
pression. Thus, the developmental relationship be-
tween splitting and repression is reflected in their
metapsychological relationship: splitting keeps oppo-
site valence introjections apart, which prevents neu-
tralization, thereby depriving repression of the contin-
uously flowing energy source which it requires. This
leads to a weakened ego, which falls back on more
primitive splitting defenses. [Greenberg and Mitchell
1983,p. 3331
Fourth, anaclitic depression (Blatt 1974)as a primarily oral

form of childhood deprivation necessitates a valuation of the
object for its capacity to provide need gratification. The predom-
inance of devaluation as a clinical phenotype of splitting within
Structure and Dgnumics 93
the psychopathic process has "emptied the world of people and of

values" (Kernberg 1980, p. 146). The appearance of symptoms of
anaclitic depression in a heretofore diagnosed psychopathic char-
acter would, by definition, raise questions concerning the validity
of the diagnosis or signal dramatic therapeutic progress. For
these reasons I would disagree with Blatt and Shichman (1981)
that the psychopath is an extreme variant of anaclitic delin-
quency.
And fifth, introjective depression (Blatt 1974) in the psycho-
pathic process is fundamentally a contradiction due to the neces-
sity of higher-level defenses, the consolidation of the phallic-
urethral phase, and at least partial resolution of oedipal conflicts
for this type of depression to manifest. Introjective depression
involves feelings of being unworthy, unlovable, guilty, and
having failed to live up to others' expectations (Blatt 1974). These
are explicit and reality-based superego demands that do not exist
in the psychopathic process. At most, the psychopathic character
will consciously feel attacked by primitive sadistic introjects, but
the response is always one of persecutory anxiety and rage,
rather than profound dysphoria.
Yochelson and Sarnenow (1977) described a "zero state"
within the criminal personality that is composed of a self-
deception of worthlessness, a belief that thoughts and feelings
are transparently real to others, and a belief that the state is
permanent. They also noted that it is usually accompanied by an
increase, rather than a decrease, in psychomotor activity. They
wrote, "Depression in the criminal is basically an angry state in
which he blazes at the injustice of the world" (p. 270). This
conscious experience of the "zero state," or inner feelings of
emptiness, is the closest the psychopathic character will come to
the experience of depression. Moreover, this sense of emptiness
appears to be an actual interoceptive derivative of the ongoing
devaluation process that is occurring both consciously as habitual
cognitions (one psychopath perseverated, "It's the middle-class
fuckin' wi'me")and unconsciously as defense process.
This devaluation of actual objects, or introjects outside the

grandiose self-structure that are not identified as "I" and that
may be complained about as hallucinations (particularly if the
psychopathic individual has been admitted to an acute inpatient
hospital) both adapts to and perpetuates this internal sense (zero
state) of emptiness. The adaptation is the unconscious fantasy,
occasionally consciously expressed, that there is nothing of value
to internalize. This is also supported by the fused representa-
tions within the grandiose self-structure of the originally ideal-
ized and identified stranger selfobject.
Devaluation perpetuates the emptiness by warding off any
new attempts by actual objects to empathize with the plight of
the psychopathic character. But why must the psychopath con-
tinually devalue? If the devaluation does not occur, the individual
is vulnerable to conscious feelings of both envy and greed and
may be compelled to both incorporate and destroy the actual
object. The unleashing of such oral rage and aggression is likely
to be accompanied by sadism and may result in the actual
destruction of the object. Such a loss, if the object was conceived
as whole, could lead to depression and mourning, and paradoxi-
cally improved reality testing. Invariably, however, the psycho-
pathic character will fall back to a psychodynamic position of
devaluation once the object, whether actual or fantasized, has
been destroyed.
This intrapsychic phenomenon is most vividly illustrated by
the sexual psychopath who will ward off others by continually
devaluing them, yet quite predictably will be endogenously mo-
tivated (Revitch and Schlesinger 1981) to seek out an initially
idealized target. Once contact with the victim is made, the
incorporative greed and envy will usher in both rage and sadism
and the victim will be injured or killed as the intrapsychic
devaluing process once again establishes a primitive and defen-
sive equilibrium.
But depressive anxiety is not attained (Klein 1935). There is
no concern for the fate of the object as a genuine expression of
love and regret. There is no attempt at reparation of the object

through restorative fantasies or behaviors. Fantasized omnipo-
tence is not used in the service of love and repair (Greenberg and
Mitchell 1983). Omnipotent fantasies occur only as memories to
gratify recurrent desires. David Berkowitz, when asked about
his sexual dreams, stated in 1980 after his conviction and impris-
onment, 'They are restless dreams, when I wake up the cover is
off. In my dreams I see a couple of my victims. The girl looks very
.
attractive . . I feel alright afterwardsn (Abrahamsen 1985, p.
182).
Suicidal attempts within the psychopathic process are affec-
tively triggered by the commingling of acute dysphoria and
narcissistic rage, oftentimes precipitated by the psychopath's
perception of being unjustly contained by a malevolent authority.
This authority is commonly the criminal justice system, perhaps
legal sanctions against the individual, or sudden, unexpected
arrest and jailing. Invariably these affective states are intention-
ally denied to the examiner, but do appear to be consciously felt
by the psychopathic individual. I have never had psychopathic
characters describe suicidal gestures in words that imply a
dissociative experience; my questioning of the event is usually
answered with words that suggest gross projection and denial,
for example, "It was an accident . . . I don't know what happened
. . . somebody did it to men (see also Appendix I).
This sudden containment by punitive external sanctions
placed upon the grandiose self may cause splitting between the
ideal self- and ideal object representations (the stranger selfob-
ject) within the grandiose self-structure. Such splitting renders a
heretofore identifying and stabilizing process an introjective and
destabilizing process, wherein the aggressive, stranger selfob-
jects are now experienced as internal persecuting thoughts not
belonging to "In that are condensed with other sadistic introjects
outside the grandiose self-structure, projectively identified with
the actual external authority, and may precipitate self-
destructive behavior.
Ironically the internal world of the psychopath during these

brief periods of self-concept fragmentation will be much more
immediately punishing than reality-based civil and criminal sanc-
tions. This is due to the absence of higher-level and modulated
superego structures (Jacobson 1964)in the psychopathic process,
in contrast with the presence of such moderating "due process"
variables in the procedures of the publicly sanctioned criminal
justice system.
Accidental death during self-mutilationor suicidal gestures
by psychopaths betray outrageously poor reality testing at a
conceptual level, supporting psychopaths' grandiose belief in
their own immortality and their lack of capacity to appreciate the
vulnerability of their physical selves.
R. B. was diagnosed as both paranoid schizophrenic

and antisocial personality disorder. He had a lengthy
history of felony incarcerations, usually for assault
against a police officer. He was extremely ambivalent
toward any form of psychiatric treatment and would
take prescribed neuroleptics only for very brief periods
of time. When clinically at his worst, R. B. would
exhibit extremely paranoid thought content, but
without the fantastic elaboration of paranoid schizo-
phrenia. It was usually directed toward law enforce-
ment, contained a kernel of truth due to their suspicion
of him when out of custody, and was usually accompa-
nied by rageful, but controlled, affect. He showed mild
indications of formal thought disorder at times. His
body was covered with self-inflictedwounds and scars;
usually there were recent cigarette burns and scabs
where he had attempted to remove old tattoos. Prior to
his last arrest he had cut off his ear lobes to "alter his
identity," as he expressed it.
R. B. was a 30-year-oldBritish male who had been
born and raised in Liverpool. He was fostered in var-
Stmture and Dynamics 97
ious juvenile and institutional settings and had an

unverifiable and rather confusing psychosocial history.
His biological family's history remained unknown to us,
and he had no stable employment history or local social
support system.
R. B. would occasionally consent to voluntary
inpatient treatment and would acquiesce when invol-
untary treatment was forced upon him following epi-
sodes of self-mutilation. His most consistent effort at
treatment was attending a twice-weekly psycho-
therapy group whenever he was in custody.
R. B.'s object relations indicated a consistent ideal-
ization of women and a devaluation of male authority
figures. He showed some indications of intense, but
ambivalent, attachment to females, and would treat
them with a curious deference and politeness. This
behavior aroused rather strong countertransference
feelings in the female nursing staff to help and nurture
R. B., attempts that were usually met with polite
rejection. His devaluation of male authority figures
was most evident in his verbalized hatred of "cops," his
paranoid condensing of "their" attitude toward him,
and his frank expression of homicidal intent toward
them. When I would confront his aggressive sadism
and its accompanying pleasurable affect, R. B. would
initially deny my perceptions and then slowly smile
with contemptuous delight during my empathic inter-
pretation of the pleasure he felt in moments of physical
violence.
During one group psychotherapy session, he
placed his lit cigarette against his forearm in a moment
of verbalized anger. I found myself reacting in a sud-
denly angry and parental manner, admonishing him
that he was not to do that again- that there were other
less physically destructive ways to manage emotion.
R. B.'s last arrest followed an alleged attempt to

cut the throat of a female companion. He was psychi-
atrically evaluated several hours after his arrival in
custody and it was determined that he did not need
involuntary treatment; he refused voluntary treat-
ment. Several days after his arrest, R. B. asked to see
the psychiatrist, but assured the floor deputy he was
not intent on suicide. He was scheduled to be seen at
1300; he was found dead at 1200, having hung himself
with a sheet in his cell.
Despite this patient's exceedingly dangerous be-
havior and threats, and my relief that no one else had
died with him as he had predicted, his death evoked
sadness in me. There was a sense of tragedy sur-
rounding this individual, an expressed vulnerability
that endeared him to others, yet a capacity to engage in
extreme sadomasochistic behavior toward himself and
others.
By any diagnostic criteria he was psychopathic,
yet there was a cyclothymic component to his self-
esteem, the affects supporting his grandiose self-
structure. He would rapidly oscillate between feelings
of depression and rage, the latter supported by gran-
diose self-concepts and paranoid projections onto the
law enforcement body. There was also an active, but
highly ambivalent, seeking of dependency toward fe-
males. He never presented as a stable and well-defined
psychopathic character, whose grandiosity and aggres-
siveness would shield him from more depressive and
masochistic impulses. I would speculate that his sui-
cidal act was the result of sadistic introjects outside the
grandiose self-structure overwhelming the latter, per-
haps consciously rationalized as a wished for and ideal-
ized final peace.
Structure and Llynamics 99
Klein (1935) postulated that anxiety about the fate of the

object and attempts to make it whole again through love become
the predominate force within the personality. Yet the psycho-
pathic process prevents the depressive position, as the metapsy-
chological construct for all subsequent depressive symptomatol-
ogy, from unfolding.
The attempts to save the love object, to repair and

restore it, attempts which in the state of depression are
coupled with despair, since the ego doubts its capacity
to achieve this restoration, are determining factors for
all sublimations and the whole of the ego-development.
[Klein 1935, p. 2901
Exhilaration and Contempt
The conscious experience of exhilaration and contempt, which

are usually simultaneous affective states in the psychopathic
process and which may clinically appear as contemptuous de-
light, is a distinctive feature of psychopathy.
Bursten (1972) described this affect state as one of several
steps in the intentional manipulative behavior of the psycho-
pathic individual, destined to continually "put something over" on
the actual object. First, there is a goal conflict with the actual
object. Second, the psychopathic individual intends to influence
the other through the use of deception. Third, the deceptive act is
carried out. And fourth, the psychopath experiences a conscious
sense of exhilaration, a contemptuous delight, if the deception is
successful. This latter affect state distinguishes the psychopathic
process from other situation-specific behaviors that nonpsycho-
pathic individuals, from time to time, might choose. Like the
psychopathic pattern, an individual might progress through the
first three stages of the manipulation; but unlike the psycho-
pathic pattern, any momentary feelings of exhilaration and de-

light would be quickly overshadowed by feelings of guilt, shame,
or remorse. The presence of these emotions, of course, implies
some level of superego structuralization and capacity for em-
pathy that is absent in the psychopath.
The tone of contemptuous delight is illustrated in the fol-
lowing portion of a letter written by a psychopathic individual to
his girlfriend:
After a few weeks (in jail module 3B) I tied my sheet

around the light fixture, then nervously sat down to eat
a pack of oatmeal cookies, a Milky Way, a Baby Ruth
and two fruit punch drinks, as I listened for the sound
of the deputy's keys. When I heard the deputy ap-
proaching my cell, I quickly sprang to my feet, grabbed
the dangling end of the sheet and proceeded to tie a
noose, as I repeatedly knock against my cell door to
assure attracting his attention. When asked what I
thought I was doing, I replied, "I have nothing to live
for, so I'm going to die," as I got the noose around my
neck and began climbing up the cell bars. As I had
planned the deputy rushed in, placed me in hand cuffs
and I was taken to the Psychiatric Security Unit . . .
where I was seen by a psychiatrist. I, in all the drama
of depression, inform him "I just want to be left alone,
so I can die." He order (sp) that I remain in the Psy.
Security Unit at the County Jail, for two weeks obser-
vation and take an anti-depressant twice daily.
Well my plan had worked. I was taken to the Psy. S.
U. . . with twenty-two certified crazies . . . daily ses-
sions with the quack psyc. (sp) . . . and plenty of atten-
tion from a host of unqualified staff.
Joseph (1960) described this affective state as a "mocking, con-

trolling attitude" (p. 528). Inherent in this feeling is a devaluing of
the actual objects and an enhancement of the psychopath's gran-

diosity and felt superiority.
Abrahamsen (1985) described the deception and contemp-
tuous delight of David Berkowitz during the time of his serial
killing:
He never aroused any suspicion. At the Post Office, for

instance, where his co-workers often discussed Son of
Sam and whether or not he was insane, Berkowitz
never told them Son of Sam was insane. "I was only a
casual listener. Sometimes I asked, 'What do you think
of the guy? Is he crazy or what?' " With a triumphant
voice he added, "Nobody really figured out that I was
Son of Sam."
He played his double role with incredible coolness: "I
would walk into work at the Post Office one day after a
shooting. I would see the faces of confusion and fear.
Then I would say What happened? Gee, that's too bad.
I hope they catch the bastard.' " [Abrahamsen 1985, p.
1891
The contemptuous delight of the psychopath restores his

pride. The manipulative cycle both enhances his narcissism and
protects his vulnerability. I t is necessarily repetitive because the
threat of intrapsychic rupture within the grandiose self is always
present; more specifically the identifications among the actual
self-, ideal self-, and ideal object representations within the
grandiose self-structure are most vulnerable to the sadistic, "badn
introjects, affectively toned by envy and rage, outside the gran-
diose self that are warded off by varieties of vertical, or dissocia-
tive, defenses. Bursten (1973a) described this as a p d i c a t i o n
process. The bad objects are projected onto the victim of the
manipulation, an anal-eliminative purging of the shameful selfob-
jects within the mind occurs, and consequently a reunion, or
reidentification, among the actual self-, ideal self-, and ideal
object representations is ensured. Bursten (1973b) described this

as the characteristic mode of narcissistic repair of the psycho-
pathic process.
Frank (1966) portrayed strikingly similar behavior in Albert
DeSalvo, the Boston Strangler:
"This is going to be comical," he was saying. 'We're all

at a New Year's Eve party, the family, see? Well, I find
out one of my sisters is taking judo to protect herself-
against the Strangler! She and her friends, they all get
together and they're taking lessons at a gym. I says,
'Sure you can handle the Strangler if you get him?' She
says, 'Oh, I'm pretty well prepared for him.' I says,
What would you do if he got you in this hold?' And
before she knew it I had her in that hold. She couldn't
do nothing. She says, Well, I'm learning.' "
He looked up with his boyish grin. "Her husband has
eleven sisters, all beautiful-fabulous! I tried to make
all eleven of them."
He began to chuckle. "One of them says to me one
day, You know what I think you are? I wouldn't be
surprised if you ain't the Boston Strangler. The way we
remember you as the Measuring Man, and how fast and
sharp you are with all those women, and now this guy is
operating the same way ... Bah, it can't be you!'"
Hugely delighted, he mimicked her. [Frank 1966, p.
2961
Albert DeSalvo had an extensive juvenile record and was

once committed to Lyman School, a well-known institution for
juvenile delinquents in Massachusetts. In 1958 and 1959 he was
arrested for numerous breaking and enterings. In 1961he began
posing as a representative for a modeling agency and would visit
college-age girls at their apartments in the Cambridge area.
Invariably they would allow him to physically measure their
breasts, waists, and hips: hence, the police label "the measuring
man." DeSalvo was arrested on March 17,1961, and, at that time,
was married with two small children and living in suburban
Malden, Massachusetts. He was psychiatrically examined at
Westborough State Hospital and was diagnosed as a sociopathic
personality. On May 4, 1961, he was sentenced on conviction of
Assault and Battery, brought by some of the women he had
measured, and Attempted Breaking and Entering. Due to De-
Salvo's good behavior in custody and his attorney's plea that his
family needed him, he served eleven months and was released in
April, 1962. Two months later DeSalvo killed and raped his first
victim, 55-year-old Anna Slesers (Frank 1966).
I have already written of the relationship of envy and greed
to devaluation, the defense necessary to ward off unconscious
fantasies of oral rage and destruction. Devaluation both adapts to
and perpetuates the interoceptive feeling of emptiness, but at
great affective cost to the psychopath.
More commonly the psychopath will repetitively navigate
this unconscious affect-impulse-defense triad (envy-greed-
devaluation) through the conscious pursuit of behaviors that
result in feelings of exhilaration and contempt. But what is the
psychodynamic relationship between unconscious envy and
greed and conscious exhilaration and contempt?
Joseph (1960) wrote of the psychopath, 'What he gets he
spoils and wastes; he feels frustrated and deprived and the greed
and demands start again" (p. 527). Envy is commonly assumed to
be a derivative of oral aggression (Kernberg 1980) and contains
within it the infant's hatred of the actual object as actively
withholding supplies. This hatred creates wishes to destroy the
object, which, in turn, would eliminate the envy. Klein (1957)
understood the importance of envy as hatred of the good object,
in contrast with the infant's immediate dislike of unpleasant
sensory-perceptual experiences, which would be internalized and
eventually conceptualized as bad objects. Greed, a desire rather
than an affect, was a wish to have all the contents of the good
object. Destruction was the motive of envy and the consequence

of greed. Klein (1957)used the infant's sensory-perceptual aware-
ness of the mother's breast and the impulse to suck as the
metaphor for understanding the infant's envy and greed. Despite
the mother's breast as being an inherently satisfying sensory-
perceptual experience and the supplier of warming and filling
interoceptive sensations, sooner or later it would be withheld and
this would frustrate.
Paralleling the infant's actual relationship to the mother
was the internalization of objects and their demarcation into
pleasant and unpleasant, frustrating and gratifying representa-
tions. Yet at times the good object representations were felt as
actively withholding, and thus were envied and hated. The infant
wished to both have and spoil the pleasant (later conceptualized
and valued as "good") object representations, but at a great price.
The defensive process of splitting was undermined by envy
because it destroyed the good object representations. A conse-
quence of such representational destruction was a decrease in
the mnemonic traces of good object experiences, decreased con-
scious feelings of protection and safety that were unconsciously
supported by a net of satisfying internalizations, and increased
persecutory anxiety. In a real sense, "envy destroys the possi-
bility of hope" (Greenberg and Mitchell 1983, p. 129) because
object and self-representational development is dependent on a
predominance of perceptually satisfying and later conceptually
"good" internalizations.
Envy is most apparent in patients who hate goodness itself.
Psychotherapeutic interpretations will be turned into useless
and hurtful experiences. I t is as if the patient must destroy hope
because the sense of hopefulness is too painful. Psychopathic
individuals who never enter psychotherapy are paradigms of this
hatred of goodness. Perhaps the envious destruction of their
meager supply of "good" internalizations early in their develop-
ment foreshadows their characterization by others in adult life as
destroyers of goodness, in other words, as evil.
I must reiterate that envy is usually not consciously felt in

the psychopathic process. I t is warded off, dissociated, and
defensively protects the grandiose self-structure from oral rage.
Behind the envy is the rage toward that which is idealized but
cannot be possessed. But a product of this split-off envy and
greed is a compulsion to "put something over on someone." In
other words, envy is the destructive motivation for behaviors
that initiate Bursten's (1973a) sequence and lead to conscious
feelings of exhilaration and contempt.
Implicit in envy is an idealization of the actual object or
projections of the ideal object within the grandiose self that are
carried by an actual object, projections that must be reintrojec-
ted, or brought back into the grandiose self-structure, to restore
the narcissistic equilibrium that is always threatened by sadistic
introjects outside its boundaries. Thus Bursten's (1973) sequence
begins with an idealization of the actual object, which is projec-
tively identified with the ideal object within the grandiose self;
continues with the envious and greedy spoiling of the actual
object to reintroject the ideal object projections; and ends with
the contemptuous devaluation of the actual object as sadistic
introjects that continually threaten the grandiose self are pro-
jected onto it. I t is an aggressive taking in and throwing out,
incorporative and eliminative, cycle that begins with the con-
scious thought "I must have" and ends with the conscious thought
"it was not worth having." As Kernberg (1980) noted, what
appears as distance and uninvolvement on the surface in the
narcissistic personality disorder is underneath an active process
of devaluation, depreciation, and spoiling. The actual object must
be devalued after it has been spoiled to ward off feelings of
depression, mourning, and a wish to repair. Such reparation in
the normal child, fostered by mother's willingness to be consoled,
leads to a toleration of guilt and eventually a capacity for concern
(Winnicott 1965).
The defensive use of Bursten's (1973a) manipulative cycle to
ward off the conscious feeling of envy, and subsequently the
expression of oral rage, poses an important question: If the

psychopathic individual cannot repetitively, and compulsively,
act out this manipulative cycle and experience the highly valued
feelings of exhilaration and contempt, what can be predicted?
I hypothesize that the inhibition of such conscious behavior,
for whatever reason, would eventually precipitate both conscious
envy and rage and appreciably lower the psychopathic threshold
for violence. David Berkowitz again provides a cogent example in
his own writing:
I have often noticed just how unobservant people are.

It's been said that parents are the last to know. This
may be true in my case, for I wonder how I, at ages
nine, eleven, thirteen, etc., managed to do so very
many negative things and go unnoticed. It is puzzling,
indeed. And I think you will agree it is sad. [Abra-
hamsen 1985, p. 2021
Deprived of the affective experience of contemptuous delight as
his deeds appeared to go unnoticed, he writes,
I t took me 24 years to erupt, to explode like a volcano.
I t took me 24 years before I reached the ultimate
destiny -murder. This is the ultimate climax-murder.
..
I reached this point . where I couldn't keep it in-I
wanted to, but I couldn't. So I gave up resisting. [p. 2061
The desires to do it, to kill, had filled me up to such
explosive proportions, it caused me such turmoil in-
side, that when it released itself, it was like a volcano
erupting itself, and the pressure was over, for a while
anyhow. [p. 2041
Boredom
The conscious experience of boredom in the psychopathic process
is a complex affective state that is a product of object relational,
perceptual, and biological factors within the personality. I t is a

restless, anhedonic feeling that is acted out through aggressive,
hypomanic activity. Boredom in the psychopathic process is
virtually identical to boredom in the narcissistic personality in
general, but is coped with more aggressively in the former.
Svrakic (1985) conceptualized boredom at two different
structural levels in the narcissistic personality disorder. First,
boredom is felt at a primary, or deeper, level as a mild, pervasive
sense of restlessness and emptiness. I t is continually present, felt
as "a small distant part of (oneself). . .the clinical trace of the real
self existing deep inside the narcissistic personalityn(p. 722). This
pervasive, although mildly sensed, mood of boredom is the pri-
mary emotional dimension of the actual self-representations
within the grandiose self-structure. The structural shell of the
fused ideal self- and object representations both insulates and
isolates the actual self-representations from the immediacy and
novelty of genuine emotional interaction. What once was intoler-
able as an infant is predicted to occur again as an adult, hence the
shell, the character armor of the grandiose self, and the boredom
of the imprisoned core self.
At a secondary level, boredom is felt more intensely, al-
though intermittently, during "idle intervals," Svrakic's (1985)
expression for the moments when narcissistic personality disor-
dered individuals have exhausted all existing narcissistic sup-
plies without and are left within themselves. These feelings of
intense boredom, in contrast to the pervasive, primary, but
milder mood of boredom, originate within the grandiose self-
structure as a product of the defensive interplay between the
fused ideal selfobject representations and the actual objects that
carry the projective-introjective material during cyclical modes
of narcissistic repair. When external objects are unavailable, or
existing ones are spoiled and devalued, the narcissistically dis-
turbed individual must wait for replenishment; the psychopathic
process, however, transforms this idle interval into a more ag-
gressive pursuit of narcissistic supplies where the absence of
superego restraints is more disinhibiting of behavior.
A correlate of this secondary, manifestly more intense,

boredom is Svrakic's (1985) "pessimistic mood," closely paral-
leling Yochelson and Samenow's "zero state" (1977). It is the
affective result of narcissistic decompensation, the recognition
that desired grandiosity is illusory and self-satisfaction through
omnipotent strivings is unreachable. Svrakic (1985) described
five characteristics of this mood state: futility, the absence of
grandiosity as a value criterion of meaningful life, paradoxical
displays of superiority and arrogance despite one's felt mood,
intrusiveness toward others in attempts to establish omnipotent
control over the environment, and dysphoria with intervals of
subjective relief. This pessimistic mood is most apparent in the
psychopathic process during long periods of incarceration when
there are few actual objects upon which to project and introject
psychic material that will support the illusion of grandiose striv-
ing.
Theodore Bundy, a contemporary sexual psychopath con-
victed of several murders and awaiting execution on Florida's
Death Row, revealed his grandiose strivings in his own words,
I know a lot of guys wonder what I might do if pushed

far enough . . . I had this one man who put his arm
around a woman and escorted her past my cell . . . She
was just scared to death! Other people have this fasci-
nation, too. They stand and look at me. I can look in my
television and see their reflections. They all cluster
around in big groups; not one at a time, but four or five
at once. Then I turn around and they scatter! michaud
and Aynesworth 1983, p. 2773
Boredom motivates an attentional search for something of

interest within or without. The narcissistic, or psychopathic,
individual is hampered in this task because actual objects are
never perceived in an objective, empathic sense; they function
only as containers of projected and devalued representational
Structure and L?gnumics 109
contents. Consequently, familiar actual objects are perceptually

dulled; there is nothing fresh or novel about a familiar and
devalued actual object. Instead of noticing and feeling a sense of
anticipated pleasure in the sensory-perceptual fit of an actual
object of love, the psychopathic character is bound to the pursuit
of continual novelty in perception and relinquishes any hope of an
enduring emotional attachment. This pursuit, moreover, is ini-
tially enhanced by the idealizing defenses, yet is quickly eroded
by the devaluation that follows. Again, the perceptual distinc-
tiveness between self- and object internalizations remains, yet
the conceptual fusion and envelopment of the occasionally novel
actual object as an extension of the grandiose self-structure is
omnipresent (Meloy 1985).
Hartocollis (1983) noted that boredom, more than any other
affect, is experienced as a disturbance in the sense of time. There
is an impatience with the sense of self and the environment, a
sense of dissatisfaction, and a vague want of something ideation-
ally unknown. Fenichel(1953) described boredom as the presence
of instinctual tension, but the absence of instinctual aim. Bibring
(1953)theorized that boredom, depression, and depersonalization
all represented states of mental inhibition, but only depression
involved a reduction in self-esteem. Hartocollis (1983) took issue
with this, and distinguished boredom from depression according
to the experience of time; "the subjects, describing their discom-
fort either as boredom or depersonalization, find it difficult to
experience time as either past or future. They experience them-
selves in a slow-moving, almost immobile present, which they
obviously do not enjoy, yet find preferable-'safer'-than either a
past or a future orientationn (p. 70). Grinker and colleagues (1968)
described boredom as an "affectless" depression.
Narcissistic, and specifically psychopathic, individuals are
prone to boredom because of the insulation of the actual core self,
the aggressive devaluing of actual objects during cyclical modes
of narcissistic repair, and the predominance of W e intervals"
when additional supplies outside the self are not forthcoming.
Nonpsychopathic, higher-functioning individuals are not im-

prisoned by the idle moment. They will project into the future
through the use of purposeful daydreaming (Schafer 1954) or
reflect upon intentionally evoked memories. In both cases the
absence of narcissistic gratification from without is met with a
smoothly turning inward to thought that will evoke pleasant or
unpleasant affect that is, in a sense, timeless, but can be reexpe-
rienced to fill the moment.
The need for immediate libidinal or aggressive gratification
in the psychopathic process imprisons individuals in the present.
Brenda Spenser, a psychopathic adolescent living near Cleveland
Elementary School in San Diego, California, was the subject of
this reporter's file:
A 16-year-oldgirl fued a shotgun from the window of

an upper floor apartment, killing and wounding several
adults and children on the grounds of an elementary
school below. She calmly told a newspaper reporter by
telephone that she was "doing it for fun." He quoted her
as saying: "I don't like Mondays. This livens up the day.
I just started shooting for the fun of it." The reporter
said the girl's voice carried no apparent remorse or
sorrow. "She was obviously a kid," he wrote. "She was
calm. She was not laughing." When he asked, "Do you
realize that you almost shot two or three people?" she
replied, "Is that all? I thought I shot twelve." [The New
York Times, January 30,19791
The psychopathic individual, as a variant of the narcissistic

personality, is most vulnerable to chronic feelings of boredom
because he or she aggressively empties the world of meaningful
relations to ward off feelings of envy and greed. Ironically, this
need to devalue is only matched by the hunger for direct instinc-
tual gratification through narcissistic supplies from without;
when these are unavailable, "their world becomes a prison from
which only new excitement, admiration, or experiences implying

control, triumph, or incorporation of supplies are an escapen
(Kernberg 1975, p. 218).
If psychopathic individuals are consciously aware of their
heightened sense of boredom when compared with others, they
render it acceptable by redefining it as a superior attribute of
their personality. Others may be characterized by them as
leading sedentary or mundane lives, yet their benchmark is
always risk taking through overt behavior, rather than satisfac-
tion through emotional experiences within themselves and with
others. Emotional relatedness is sadly absent in the psychopathic
process; and consequently psychopathic individuals are unable to
experience loneliness, the longing for and awareness of the
possibility of emotional closeness.
The prevalence of boredom in the psychopathic process
finds psychobiological support in the work of several research-
ers. Electrodermal differences between psychopathic and
nonpsychopathic subjects (Hare 1970) may be associated with
lower levels of central nervous system arousal that are both state
specific and trait generic. Hare (1970) and Quay (1965) both
argued that the psychopath's behavior is the result of cortical
underarousal and pathological sensation-seeking.
Zuckerman (1978) discussed the psychopath as a sensation-
seeker, needing higher levels of sensory stimulation to reach
comparative levels of cortical arousal in the nonpsychopathic
individual. Eysenck (1967) postulated a biological theory of ex-
troversion (see Chapter 1) that correlates personality trait with
reticular formation arousal. The extroverted individual is contin-
ually seeking external stimulation to compensate for lower levels
of cortical arousal. Much of Eysenck's work has been validated by
pharmacological research (Claridge 1967, Gray 1972).
Boredom as a phenomenological experience appears to be
closely linked to the behavior of sensation-seeking and the per-
sonality trait of extroversion (Farley and Farley 1967). I hypoth-
esize that the psychopathic paucity of whole self- and object
representations, an intrapsychic precipitant of boredom and its

behavioral corollary sensation-seeking, may, in part, be due to
cortical underarousal. This psychobiological difference would
validate the dynamic and structural characteristics that predis-
pose boredom as both a mood and an affect in the psychopathic
process.
I have noted three factors in the production of boredom in
the psychopathic process: fwst, decreased levels of central ner-
vous system arousal; second, habitual devaluation of actual ob-
jects that results in perceptually dull exteroceptive experiences
and a conceptually inflated reality sense; and third, a dearth of
whole self- and object representations within the mind that
could, if available, provide stimulation during idle intervals.
This last factor, however, is somewhat paradoxical if one
reflects on the grandiose proclivities of the psychopath. Why
would representations of self and others within the mind, if
capable of such grandiose elaboration, be so limiting and unsa-
tisfying?
To paraphrase Kris (1952), the psychopath's grandiose im-
agery is regression in disservice of the ego. Representations of
self and others are grossly distorted, polarized, and flat; even if
conceptually idealized, they are shorn of the variety and com-
plexity of actual affective and representational experiences tied
closely to reality. New experiences likewise are stripped of their
potential for colorful and rich elaboration of memory and fantasy.
This must occur for both devaluing and defensive purposes to
ward off envy, greed, and oral rage that is dissociated from the
grandiose self-structure. In a real sense psychopaths are easily
bored with their own grandiosity, yet are conscious of no other
way to recreate themselves.
As the psychopathic individual ages, his memory becomes a
defensive idealization of the past with a lessening of grandiose
strivings for the future. In the same way, evocative memory is
subject to splitting and collapsed into a one-dimensional progres-
sion of idealized and devalued events (Grotstein 1978, Meloy
1984). But even the idealized memories are not experienced as
safe, for they conjure up feelings of envy for "the person who once
was" and therefore must be devalued to ward off oral aggression.
The aging psychopath may yearn for an early death as he
realizes the cumulative failures of his emotional life and the
incessant cycles of greed, spoiling, and devaluation prompted by
boredom. The young psychopath may idealize death and com-
mingle it with his own grandiose strivings, wishes that defend
against the fear of an empty, futureless life. As I began this
chapter with a quote from David Berkowitz, I will let him end it
in his own words:
As a child I had tremendous fascination with death.
When I thought about dying, I thought of being trans-
ported into a world of bliss and happiness. . . . When I
arrived at Stratford Avenue [in the Bronx] I used to
stand looking out our window with a fantastic view.
Throughout the year, rain, snow, or cold, I would look
out the window and pray to God to kill me, that I would
be hit by lightning. I begged to God for death, I used to
sit on the fire escape and thought of throwing myself
down, wanting to jump. . . . After Pearl's death, after
my [adoptive] mother died, I never had these suicidal
thoughts. I still wanted to die, but with heroism, with
honor. I wanted to die while saving lives, battling a
blaze. This is why I wanted to become a fireman,
helping people, rescuing them, and being a hero, or
possibly dying in the blaze. [Abrahamsen 1985, p. 311
I do love death. I've always loved it. I've wished for it,
and tried to understand it. Death is fascinating . . . its
power, its hold; it is wonderful. [Abrahamsen 1985, p.
%I
CONCLUSIONS
The psychopathic process is not devoid of conscious affect, but it
is emotionally colored in intensely narcissistic hues. Psychopaths
may be quite aroused by others, but they do not emotionally

relate to them in an empathic, caring sense. Their affect is
experienced in relation to the grandiose self-structure, wherein
others are perceptually distinct, but conceptually are only exten-
sions of their expansive sense of self. The psychopathic character
has no empathic capacity, but has an exquisite ability to malig-
nantly identify with the actual object and if intelligent enough,
can sensitively manipulate the actual object by resonating with
its more nefarious, and pathologically narcissistic, characteris-
tics. Psychopathic individualsknow well within themselves these
feelings of righteous anger, sadistic pleasure, contemptuous de-
light, sudden dysphoria, and, deep within, a profound, disqui-
eting boredom.
Unconscious Defense and
Conscious Choice
T h e psychopathic process brings into relief a larger question
that has both theoretical and clinical ramifications for the psy-
choanalytic researcher: What is the relationship between con-
scious choice and unconscious determination in human behavior?
Psychodynamic theory attempts to probe the latter dimension of
intrapsychic activity, but the reality of conscious choice, at least
as a phenomenological experience, is difficult to reconcile with a
purely deterministic view of human nature. Free will and deter-
minism also describe the fundamentally different premises of
legal scholarship and psychological science in general, American
jurisprudence and psychoanalytic thought in particular.
An interesting clinical example of this issue is a case that
was decided by the United States Supreme Court, Colmado v.
Connelly (No. 85-660) in which the respondent, a diagnosed
paranoid schizophrenic, argued that the state's use of his sponta-
neous and incriminating statements made in a noncustodial set-
ting, or its use of incriminating statements made subsequently
by him following waiver of his "MGandanrights, violated the due
process clause of the Fourteenth Amendment because he was
acting in response to auditory hallucinations commanding him to
confess. The American Psychological Association submitted an
a r n k curiae brief on March 14, 1986, and wrote, in part,
". . . Behavioral science does not use or rely upon the concepts of
'volition' or 'free will.' Accordingly, Dr. Metzner was not testi-
fying as a scientist when he testified that respondent's command
hallucinations impaired his 'volitional capacity.' Furthermore,
even if Dr. Metzner only meant to testify that command halluci-
nations are, in a statistical sense, coercive, his testimony finds no
support in the professional literature, and is contrary to clinical
experiencen(Ennis 1986, pp. 25-26). The Supreme Court ruled
that the Miranda warning was designed only to protect suspects
from coercive tactics of the police, not from any internal psycho-
logical pressures.
The psychopathic process is clinically relevant to this ques-
tion because of the commonly held belief, oftentimes correct, that
psychopaths lie a lot. Their deceit is consciously and intentionally
chosen. Most clinicians with whom I have discussed this question
vigorously defend this "conscious choicen hypothesis, simply be-
cause they have observed psychopaths' ease with which they can
choose, given the correct interpersonal determinants, not to lie,
or more dynamically, to also undo a lie.
One psychopathic patient told me an elaborate reconstruc-
tion of a distressing childhood event that he felt explained much
of his current behavior. When I challenged the credulity of it, he
laughed and said, 'Well, doc, would you believe this?" and pro-
ceeded to unravel an equally compelling tale of woe.
In a forensic setting the complex interplay between con-
scious choice and unconscious defense is most apparent when
questions of malingering are asked. There is not, as yet, any
psychological technique to detect malingering with any reason-
able certainty, but several researchers (Beaber et al. 1985,
Brandt et al. 1985, Schacter 198613) have begun to analyze this
perplexing clinical phenomenon.
Conscious choice and unconscious defense are also implicit
in the historical differentiation between malingering and facti-
tious disorder in descriptive psychiatry. The DSM-111-R (Arner-
ican Psychiatric Association 1987) postulated conscious intent in
the former and unconscious, compulsive repetition in the latter,

more closely allied with a severe personality disorder.
My purpose in this chapter is to explore the existence of
both conscious choice and unconscious determinants, particularly
defenses, in the psychopathic process. It is my hope that the
acknowledgment of such a dialectic will pay homage to the
relationship between conscious and unconscious topography in
the mind and will avoid the excommunication of one in sacerdotal
devotion to the other (Shapiro 1981).An excellent example of this
dialectical argument when applied to expert testimony is to be
found in Bonnie and Slobogin (1980) and Morse (1982).
I will analyze the interdependence and interrelationship of
conscious choice and unconscious defensive structuring of the
personality in the psychopathic process. I have suggested this
blending of cognitive style and dynamic motivation in the pre-
vious chapter with my analysis of conscious manipulation by the
psychopath and its unconscious motivation as a defense against
envy and oral rage.
Likewise I hope to address a more general question. What
constellations of defenses render emotional experience uncon-
scious, outside of awareness, in the psychopathic personality?
Instead of simply reviewing the nature and extent of defenses
within the narcissistic personality (Kernberg 1975), I will focus
on the idiosyncratic role of several of these defenses in the
psychopathic process and their relationship to conscious think-
ing, emotion, and behavior.
Several avenues of inquiry will be pursued. First, what is
the relationship between unconscious denial and conscious decep-
tion? Second, what is the nature and extent of consciously imi-
tated and unconsciously simulated (Glasser 1986) affect? Third,
what role does projective identification play in the capacity of the
psychopathic character to be both exquisitely charming and
sadistically violent? And fourth, what are the varieties of disso-
ciative defenses, such as splitting, that pervade the psychopathic
process; and how do these unconscious dissociative maneuvers
help us to understand hysteria, dissociative states, and malin-

gering in the psychopath?
DENIAL AND DECEPTION
Deception is ubiquitous within the psychopathic process. I t is a

necessary stage in the carrying out of the manipulative act
(Bursten 1973a) because contemptuous delight a wished-for
affect cannot be felt unless deception has established within an
external object the fertile ground for shaming and devaluing. In
other words, the conscious act of deception "sets upn the actual
object to receive and contain the purged psychic material that
threatens to devalue the grandiose self if not projected. This
continuous process of deception, to facilitate the unconscious
purging cycle, is endogenous to the psychopathic character. I t
has virtually no relationship to situational factors and will re-
cur regardless of the degree of therapeutic efficacy or secure
control of the psychopath's environment. I t is, in a sense, a
compulsion that the psychopath may actively overcome only by
risking the development of anxious and hypochondriacal symp-
toms. Such endogenous deceptive behaviors should be distin-
guished from exogenous deception; both types are conscious
behaviors, but the latter, tied to situational factors, is more
intentionally chosen by the psychopath when he desires improve-
ment of circumstances. This exogenous deception would most
likely result in a diagnosis of malingering in a clinical context:
E. D., a 22-year-old Caucasian male, was admitted to

our forensic unit with symptoms of major depression.
Perusal of his clinical record indicated no prior history
of treatment for depression, but an extensive history of
criminal activity, usually involving drugs and property
offenses, and a disruptive family history. E. D.'s ex-
pressed reason for his depression was his family's
ouster of him from their home and his mother's ter-

minal cancer and impending death. The patient, how-
ever, refused to sign a release of information that
would have allowed us to discuss his clinical situation
wjth his parents.
E. D. showed little response to pharmacological
and psychotherapeutic treatment. The characterolo-
gical nature of his depression became more obvious to
the inpatient staff. After two weeks of inpatient care,
E. D. announced, with much tearful affect, that he had
been told in a phone conversation with his father that
his mother had died. He wished that we could help him
with arrangements, through his attorney and the Su-
perior Court, to attend her funeral.
The clinical staff became increasingly skeptical of
E. D.'s verbiage. The treatment plan was reformu-
lated, and the patient was told that since much of his
current distress, by his own report, was due to family
trauma, it was imperative that he allow us to talk with
his father by telephone; otherwise we would no longer
treat him. E. D. reacted with intense anger, but within
hours admitted that his mother did not have cancer and
had not died. Shortly after that he began threatening
suicide if he was discharged from the inpatient unit.
Deception within the psychopathic process is characterized

by intent, goal direction, and a facility to change both the logical
content and the target of the deceit as necessary. Logical content
describes the false information and rationalizations that are used
by the psychopath to consummate the deceptive act; clinically
speaking, however, the deceptive act may appear quite illogical,
but only in reference to motivation, not content. The motivation
is particularly baffling in endogenous deceit when the psycho-
path may appear to have everything he wants, yet continues,
quite predictably, to commence the manipulative cycle. Here the
logic of the motivation can be understood only if the unconscious

dynamics are seen (refer to Chapter 4). The logic in exogenous
deceit, both as motivation and as content, is much more easily
comprehensible, as in the case of E. D. noted above.
The target of the deceit may be either an animate or an
inanimate object, but in both cases is "possessed" as an extension,
on a conceptual level, of the grandiose self-structure and is
devalued of all attributes except those that facilitate the
projective-introjectivecycle. A loss of perceptual distinctiveness
along with the conceptual fusion of self- and object representa-
tions would render the individual psychotic. This is pathogno-
monic of both a psychopathic character disorder and a psychotic
disorder, the coexistence of which will be discussed in Chapter 7.
Denial, in contrast with deception, is an unconscious pro-
cess. It is not consciously chosen or intentionally employed by the
individual, and it is, by definition, a theoretically deterministic
construct rather than a product of free will.
Freud spoke of denial within the neuropsychoses of defense
(1894), as a defense within the psychoses (1911,1924a), as analo-
gous to repression to facilitate the ego's detachment from ex-
ternal reality (1924b), as different from negation (1925), and as a
distinctive mechanism within the splitting of the ego (1938) that
should be separated from defenses against internal instinctual
demands. Throughout his writings he emphasized that denial
was a defense against objective, external sources of anxiety and
displeasure.
Anna Freud (1936) reiterated her father's position and spec-
ified that denial occurred through fantasy and through word and
act. She emphasized that an inherent incompatibility existed
between denial and reality testing as the child developed, since
denial through word and act meant a reversal of real situations.
Such reversals could not exist without a disturbance of reality
testing. In other words, the capacity to test reality was inconsis-
tent with the maintenance of denial, a position also taken by
Freud (1938). Anna Freud (1936) noted another characteristic of
Structure and l3gnamics 123
denial in word and act that is especially relevant to both narcis-

sistic and psychopathic pathology:
The method of denial in word and act is subject to a

second restriction, which does not apply to denial in
fantasy. In his fantasies a child is supreme. So long as
he does not tell them to anybody, no one has any reason
to interfere. On the other hand, dramatization of fan-
tasies in word and act requires a stage in the outside
world. So his employment of this mechanism is condi-
tioned externally by the extent to which those around
him will fall in with his dramatization, just as it is
conditioned internally by the degree of compatibility
with the function of reality testing. [p. 911
Such is the case of the psychopathic character, an aggres-

sive variant of the narcissistic personality disorder wherein
"word and act" are more familiar than "fantasy" as products of
denial. The narcissistic individual, as I have noted earlier, will
choose more benign and independent modes of repair. Denial in
fantasy of real-life situations, and the concomitant elaboration of
idealized fantasies that do not exist in reality, are more easily
utilized than expressions through word and act. The psycho-
pathic process, however, compels a more alloplastic expression of
denial through word and act. The most common expression I
have heard in forensic settings is "I am not a criminal. . . I do not
belong with these individuals." But such words and actions are
restricted by the nature and extent of acquiescence by others,
and challenges to this overt and grandiose conceptualization of
self are usually met with righteous anger or quiet disdain by the
psychopath. Perhaps the most familiar example of this psychody-
narnic in public life was the phrase uttered with great frustration
and anger by then President Richard Nixon in 1974, "I am not a
crook!" His expression and words have been parodied by count-
less individuals, made all the more appalling by the existence of
actual evidence to the contrary obviously known to him at the

time and consciously hidden from the public.
Jacobson (1957, 1971) viewed denial as a primitive and
archaic mechanism directed against both internal and external
reality. She accomplished this theoretical broadening of the
defense by hypothesizing a regression to a "concretistic infantile
stage" in which external and internal were treated in the same
manner. Because of primitive introjective and projective mech-
anisms, unacceptable inner realities could be treated as if they
were external. In other words, the boundary between internal
and external reality was lost, therefore the distinction between
denial as a defense against instinctual threat or actual external
event became irrelevant.
Although neurotic denial may involve processes of

disconnection, isolation, and collective joining of psy-
chic elements, which turn them into quasi-concrete,
imagelike units, the latter do not lose the quality of
being psychic in nature. The line of demarcation be-
tween internal and external reality is maintained, even
.
in view of such introjections and projections. . .
In psychotics, however, the pathological process
leads to a real fragmentation, splitting, a concretiza-
tion, and externalization of psychic manifestations, to
the point of lending them truly concrete qualities.
Consequently we find an equation between what is
abstract and psychic and what is concrete and physical
in nature. [Jacobson 1971, pp. 133-1343
Frosch (1983a) also noted that denial in the psychotic is

much more concrete than denial in the neurotic. It is in the
service of self-preservation and restitution and is coeval with a
massive loss of reality testing.
I am in partial agreement with Jacobson's formulations, but
do not believe they are clear enough in distinguishing between
denial as a defense at the borderline and psychotic levels of

personality organization. In the former, subserving both narcis-
sistic and psychopathic character formation, perceptual distinc-
tiveness is maintained between internal and external reality, and
thus intrapsychically between self- and object representations.
What is confused, and thus vulnerable to projective-introjective
cycling, is the psychic material contained in either the self or
object, internal and external. The boundaries of the psychic
container remain intact, yet the thought and affective contents
within and without are subject to exchange.
Bion's (1977a) metaphor of the container and contained is
most germane to understanding this distinction. In psychotic
personality organization, the container is lost, while in borderline
personality organization that which is contained oscillates be-
tween self and object on both an intrapsychic and inte~personal
level. The notion of concept and percept formation in object
relations (Meloy 1985) is somewhat analogous to the contained-
container metaphor; that is, the conceptual extension and distor-
tion of the contents of the grandiose self to embrace actual others
as gratifying selfobjects through projective identification (the
contained) proceeds without necessarily a loss of sensory-
perceptual boundaries (the container).
But is denial expressed in more primitive and mature forms
across a developmental continuum? I believe that this is the case,
denial representing a genotypic defense that is developmentally
expressed through a variety of phenotypic forms, ranging from
mild to grossly psychotic distortions of reality. Lichtenberg and
Slap (1972) saw a developmental continuum wherein denial "be-
comes progressively refined to more subtle disavowals of the
drive derivatives and of the memory links associated with the
percept" (p. 785). At the most primitive level there is a complete
denial of distressing sensory-perceptual stimuli. Denial would
both precede and assist repression at a higher level of neurotic
organization and be phenotypically expressed through negation,
isolation, detachment, and rationalization through fantasy, or
word and act. At a borderline level denial would be expressed

through splitting and other derivative forms, such as dissocia-
tion, devaluation, and idealization. At a psychotic level denial
would be expressed through the infantile, concretistic symptoms
of delusions and hallucinations. Implicit in this latter symptom-
atic expression of psychotic phenomena is the disavowal, or
verleugnung (Sandler and Freud 1985), that the psychotic symp-
toms do not actually exist in external reality.
M. came to me for individual psychotherapy when he

was 30 years old. He was a young man of superior
intelligence who was beset with obsessional thoughts
of violence and lingering fears that at any moment he
would lose control. When treatment began, M. was
ingesting 10 to 15 mg of diazepam daily, but intention-
ally withheld this information from me until he "con-
fessed" approximately three months after we initiated
treatment. He also deceived me into thinking that he
managed an avocado grove in a small town near the
clinic; after several months he admitted that the grove
was owned by his father, and he was "allowed" to live
on the property in a small cottage if he did some of the
daily property maintenance.
M. had no prior criminal record or psychiatric
treatment. He had reportedly never been violent to-
ward anyone. He had received a bachelor's degree with
honors in music and composition from a major local
university.
M. spent three years in weekly individual psycho-
analytic psychotherapy with me and very slowly was
able to understand the dynamics of his obsessive-com-
pulsive personality, organized at a borderline level. His
defensive functioningmatured as he explored the vicis-
situdes of his inner life, heretofore very frightening for
him, and its links to his early childhood experiences.
Ms! parents were both alcoholics. His father also

appeared to have many antisocial, psychopathic traits
in his characteristic business dealings and marital de-
ceptions. M.'s early memories consisted of watching his
mother and father physically assault each other late at
night, seeing his mother unconscious on the floor, and
witnessing his father burn his mother with cigarettes.
His early experiences, similar to his sister's, were
marked by familial violence, intense fear, and preoe-
dipal rage.
His personality structure had been shaped by
these events in ways that allowed him to deny much of
his emotional life. He was able for years, through the
combined effects of minor tranquilizers and borderline
defenses, to detach from, dissociate, ward off, negate,
and most fundamentally, deny painfully unpleasant
affective states. Fortunately for him his defensive
structuring was not completely impervious, and obses-
sional fears of becoming violent drove him to seek
psychotherapy.
Early childhood memories for M. became more
accessible in treatment, and the unpleasant affects
accompanying these object and self-representations
resurrected from his memory were reexperienced and
understood in a more developmentally mature form.
But a curious phenomenon began to occur: M. sought
out corroboration from his sister that these early vio-
lent childhood events had actually happened, and she
completely denied them. As other family members in
the area joined in this collective denial and railed
against M.'s memories, he began to question their basis
in reality and ruminated as to whether they were only
products of his "fantastical, psychotic mind."
M. had now been living away from his parents for
one year and determined to demonstrate to me that his
memories were real, even though I had never ques-

tioned them. He enlisted his girlfriend to "stake out"
the parents' home with him to hopefully witness a
reenactment of the violence he remembered as a young
boy.
M. asked me one day if his girlfriend could accom-
pany him to a psychotherapy session. I consented, and
the hour was spent with both M. and his girlfriend
recounting a violent episode between his parents that
they had both witnessed late at night while surrepti-
tiously observing the household. M. passionately told
of the assault he had now observed as an adult, relieved
that he was "not as crazy as everyone thought." Such
actual recapitulation of a childhood trauma-memory in
adulthood allowed M. to further separate, with his
reality testing intact, from his highly pathological
family.
M.'s case illustrates the varieties of conscious deception and

unconscious denial that can exist both intrapsychically and
within a highly disturbed family system. His initial deception
with me was exogenously motivated by a desire to appear more
in control, characteristic of his compulsive personality structure,
which was, at that point, quite dysfunctional. His conscious
deceptions quickly gave way to the gradual exploration of his
borderline manifestations of denial: polarized, split-off represen-
tations of his father's badness and his mother's goodness, and his
own self-representation as a violent monster who must, at all
costs, be kept under control. He would deny intense affective
states quite apparent to me and, for a period of time, was able to
dissociate the rage he felt toward his parents that would then
only return in his obsessional and violent fantasies toward
strangers. M. experienced through fantasy what his parents, and
entire family, continued to deny through word and act.
As M. developmentally matured in psychotherapy, there
was no further need for deception. Denial, moreover, became
Structure and &numics 129
phenotypically expressed at a higher, neurotic level: M. would

negate the need for further treatment and for brief periods would
cancel sessions; he would rationalize his parents' behavior and
attribute some of their acting out to his behavior as a child; and
he would continue to ruminate about ways he could detach from
his affective life and literally "not feel."
As M. progressed, his family's pathology intensified, partic-
ularly as he confronted them both individually and as a group
with their fabrications. Their primitive denial mechanisms also
became more apparent to him as he was able to use his keen sense
of analysis and circumspection in an adaptive, rather than defen-
sive, fashion. Although his father was psychopathic, M. never felt
a desire to act out this process as his father had. Once his fears of
such self-explosiveness dissipated, he was content to experience,
and creatively shape, his violent fantasies, now considerably
diminished, in ways that allowed him both passive-aggressive
entertainment and genuinely new insight.
Kernberg (1975), discussing denial from the perspective of
Edith Jacobson, characterized denial as a broad group of defen-
sive operations within borderline personality organization. He
did not distinguish between denial as a defense against external
threat or unconscious affect, and further emphasized the mutu-
ality implicit in denial when two emotionally independent areas
of consciousness took their turns being considered irrelevant by
the patient, despite persistent memory of each:
Denial in the patients I am considering may also man-

ifest itself only as simple disregard for a sector of their
subjective experience or for a sector of the external
world. When pressed the patient acknowledges his
intellectual awareness of the sector which has been
denied, but again he cannot integrate it with the rest of
his emotional experience. Wernberg 1975, p. 321
Rinsley (1982) noted, however, that evocative memory is

impaired or deficient in the borderline personality and is not so in
the narcissistic personality. He attributed this important diag-

nostic difference to the degree of obsessional character organiza-
tion in the narcissistic personality disorder and its reliance on
affective-isolative defenses:
Whereas the future borderline personality is threat-

ened with a cut-off of essential libidinal supplies, that
is, with abandonment, if he pursues separation-
individuation, the future narcissistic personality is so
threatened only if separation-individuation compro-
mises the integrity of the symbiotic selfobject (i.e., the
tenaciously introjected pathogenic maternal part-
object). In this latter case, an obsessional character
organization develops as a defense against the regres-
sive wish for symbiotic reunion or refusion. Basic to
this character organization is the prematurely evolving
capacity for evocative image recall, which is dissoci-
ated from the affect linked to the pathogenic maternal
introject. [pp. 165-1661
What is theoretically expectable and clinically evident is the

borderline patient's inability to evoke the memory of a particular
thought, percept, or affect while in the midst of a discordant, and
oftentimes completely opposite, affective state. Verbal
prompting by the psychotherapist redefines the task as one of
recognitive memory, and the borderline patient is able to remem-
ber. Kernberg himself shifted the mnemonic task from evocation
to recognition in the paragraph quoted above, expressed in his
words, "when pressed." The expectable correlate in the border-
line personality is that developmentally more primitive uses of
denial will be accompanied by increasing evocative memory
problems.
The narcissistic personality, in particular the psychopathic
character, has a much greater capacity for evocative recall of
discordant or opposite ego states, yet their emotional irrelevance
to the individual is just as striking, if not more so, because of the

absence of affect and the presence of an apparently coherent,
"adultomorphic" false self without evocative memory problems
(Winnicott 1960, Rinsley 1982).
Because of the development of this grandiose self-structure,
and implicit within it the refusion and identifications among the
real self, ideal self, and idealized object (in the psychopath, the
more aggressive stranger selfobject), a curious clinical phenom-
enon has occurred: Denial as an unconscious defense is readily
used, even in a very primitive manner by grossly denying large
segments of external reality, yet at the same time evocative
recall shows little impairment. The psychopathic process allows
the individual to cultivate varieties of denial, developmentally
ranging from almost psychotic forms to higher-level rationaliza-
tions, while at the same time showing no abnormal evocative
memory impairments at the lower end of this continuum.
How can this patient show no evocative memory impair-
ment yet evidence such primitive forms of unconscious denial?
The answer appears to lie in the grandiose self-structure and its
defensive capacity to ward off, through varieties of dissociative
mechanisms, highly unpleasant and persecutory introjects, and
their accompanying affect states, which could interfere and dis-
rupt evocative recall. Even if intensely unpleasant affect is
clinically apparent, the grandiose self-structure provides an iso-
lative, perhaps in some cases obsessional, shell within which the
secondary autonomous ego function (Hartmann 1958)of memory
is sustained and even perhaps precociously developed. I think
these higher-level isolating defenses, forms of denial if one uses
the latter in a genotypic sense, are most apparent in the intelli-
gent, socially adaptable, and interpersonally facile psychopathic
character.
Appendix I is a detailed and cogent example of a psycho-
pathic individual whose use of unconscious denial and conscious
deception is vividly illustrated during a five-month period prior
to his recommitment to a state hospital. I have included in the
appendix my psychological evaluation, which addresses the ques-

tion of current dangerousness, and portions of the court hearing
transcript during which a determination was made as to whether
the patient constituted a danger. I invite the reader to analyze
the ways in which exogenous deceit, endogenous deceit, and
unconscious denial interrelate in this psychopathic character of
superior intelligence.
Forms of conscious deception and unconscious denial per-
vade the psychopathic process because there is always an ex-
ternal threat; projected aspects of the superior and deprecatory
attitude of the individual's grandiose self-structure are perceived
in those who are needed (Kernberg 1980). The psychopathic
character is haunted by the shadow of his own grandiose self, for
the ways in which he induces shame and humiliation in others
may always be done to him.
IMITATION AND SIMULATION
The psychopath is an imposter (Greenacre 1958). Shorn of any

deep and abiding identifications with others and primarily iden-
tified, if at all, with only the stranger selfobject of an aggressive,
narcissistic parent, much of his subsequent behavior as an adult
involves the conscious imitation and unconscious simulation of
other people's thoughts, affects, and activities.
Unlike the person with narcissistic personality disorder
who consciously feels, at times, a sense of being a fake (Kernberg
1975), the psychopathic character has no awareness of this "false
self" (Winnicott 1960) or the 'as-if' quality (Deutsch 1942) of his
phenomenal experience. He does not merely play the role, ob-
serving the limits of his character, but lives the part, sometimes
oblivious to the deceptions promulgated by his behavior.
The psychopath makes widespread use of these pseudoiden-
tification processes. Glasser (1986) called the processes simula-
tions and defined them as the unconscious modeling of attitudes
or behaviors on that of the object, whether external or introjec-

ted, without any change in the structure of the self. A simulation
is located on the continuum of internalization processes between
intentional copying, or imitation, juxtaposed with introjection, or
the internalization of an object that remains possessed but in
relationship to the self, and before identification, or the modifi-
cation of the self-representation to be like the originally incorpo-
rated object (Schafer 1968, Meissner 1970, 1971, 1972). I t is
fundamental to the defensive structure and dynamic functioning
of the psychopath.
I am using the term imitation to describe the intentional,
conscious mimicking of another person's attitudes or behavior.
Despite the unique and rather idiosyncratic ways imitation has
been defined by others (Gaddini 1969), I am in agreement with
Glasser (1986) that this term conjures up choice, intent, and
conscious mental activity; and to avoid ambiguity and confusion,
I will retain this common-sense usage. Furthermore, if I asso-
ciate imitation and simulation, once again there emerges the
complex interplay of conscious choice and unconscious activity,
or defense, that is so important in understanding the psycho-
pathic, if not all psychopathological, processes.
Gaddini's paper "On Imitation" (1969) should not be dis-
missed, however, as just an unusual understanding of the term
imitation. If I dare take the liberty of reading simulationinstead
of imitation throughout his important analysis, the develop-
mental and dynamic basis of the process can be better under-
stood.
Gaddini (1969) noted that simulations represent and are only
concerned with unconscious, omnipotent fantasies, the latter a
clinical marker in most character disturbances. They also seem to
be originally connected with perceptions, and in my schemata
would be closely linked to both self- and object percepts (Meloy
1985). These simulations, and their mnemonic traces, have their
prototypes in the "hallucinatory image" (Rapaport 1951)that the
infant experiences as reality in the absence of the actual grati-
fying object and for the purpose of ending emotionally or viscer-

ally painful interoceptive experiences. This "primordial psychic
(simulation)" (Gaddini 1969, p. 476) establishes itself in the ab-
sence of the object and its aim seems to be magical and omnipo-
tent fusion between the self- and object percept.
On the other hand, introjective processes that are concur-
rently operative with simulations and begin in the symbiotic
phase of development (Mahler et al. 1975) represent what one
would like to possess, rather than what one would like to be
(Freud 1925). These parallel processes also represent the twofold
attitude taken toward the object:
The primitive (simulative) perception seems to lead to

the hallucinatory image, to the phantasies of fusion
through modifications of one's own body, and to (simu-
lations), in the direction of the wish to be the object.
Oral incorporation seems to lead to the phantasies of
fusion through incorporation and to introjections, in
the direction of hawing, of possessing, the object. [Gad-
dini 1969, p. 4771
The affects of envy and rivalry, pervasive in narcissistic distur-

bances, also become more comprehensible if rivalry is under-
stood as the affective expression of the simulative-perceptive
model, what one would like to be; and envy is understood as the
expression of the incorporative-introjective model, what one
would like to possess.
Gaddini (1969) viewed identifications as a higher develop-
mental station in which the simulative phenomena of the sensory-
percepts and the introjective phenomena of the oral libidinal
zones become integrated in the service of reality and the pro-
cesses of ego adaptation. Gaddini's (1969) understanding of sim-
ulations, which predominately obey the pleasure principle and
are the sensory-perceptual precursors of identifications, the
latter adhering to the reality principle, seems eminently sensible.
I find in simulations the prototype of the narcissistic relationship

in which the object percept, and later the object concept, is
experienced in the service of the self-representations, whether
perceptual or conceptual. Furthermore, simulations, or pseudoi-
dentifications, function as regressive, or perhaps furated, de-
fenses against actual identification with the object.
This actual identification with the primary parental object
and subsequently with other actual objects throughout early
development and perhaps the life cycle is impeded because of the
"core complexn (Glasser 1986). This central and coherent struc-
ture is comprised of a longing for intimate gratification and
security, persecutory and annihilatory anxiety, and aggression
that has been transposed into sadomasochistic behavior toward
the object.
Longings for gratification and security within the mother
are characteristics shared by all infants, but in the "core complex"
are met with parental responses that are perceived as intrusive,
enveloping, or noxious. The infant, in short, is caught on the
horns of a sensory-perceptual dilemma. On the one hand, the
parental object is the sole source of his gratification; yet on the
other hand, it is threatening annihilation and must therefore be
negated. One solution is the early sexualization of aggression.
Aggression, as a self-preservative response to any physiological
or psychological threat to the infant's homeostasis, is converted
to sadism, wherein the attitude toward the object has as its aim
the infliction of suffering. The intent to destroy, or negate, the
object is transformed into a wish to hurt and control the object.
The object is preserved and the viability of the relationship
is maintained, but in sadomasochistic terms. The object can then
be intensely engaged on the condition that intimacy and union
are never experienced (Glasser 1986). The prospect of momen-
tary intimacy brings with it intense annihilatory anxiety, which
is quickly warded off by engagement in sadistic acts toward the
object to hurt and control, and thus the self remains safe from
engulfment.
Governed by these "core complex" anxieties, the psycho-

pathic process impedes identifications because they are experi-
enced as something invasive or possessive, potentially annihi-
lating the self-representations. Any characteroiogical traits
beyond the grandiose self-structure, which is fundamentally a
narcissistic defense against annihilation, are built upon simula-
tion and its conscious, facilitating counterpart, imitation.
The paradox in the adult psychopathic character is that he
has a limited capacity to form any genuine identifications and has
developmentally struggled against identification (Greenson 1954)
with the stranger selfobject; and yet he hungers for, and easily
develops simulations, or pseudoidentifications, with actual ob-
jects that he attempts to engage in sadomasochistic relation-
ships. The more deeply identified the psychopath is with the
stranger selfobject, the less rapid and arbitrary the simulations
appear to be.
Greenacre (1958)noted several characteristics in her clinical
cases of imposturing, a form of simulation: a dominant and
dynamically active "family romance," that is, fantasies that have
in common a relationship to the ancestry of the person creating
them (Freud 1909); an intense and circumscribed disturbance in
the sense of identity; an infarction in the sense of reality charac-
terized by a sharp and quick perceptiveness, yet a failure to
protect against detection; a strong sense of exhibitionism and
voyeurism; pathological development of the superego; a compul-
sive urgency to perpetuate fraud; and a polymorphously per-
verse sexual organization characterized by sadomasochistic ex-
citement. Most of these characteristics are evident in the
psychopathic process and suggest both failures of oedipal identi-
fication and defenses against maternal annihilation:
The study of the lives of these versatile gentlemen has

led to the conclusion that sustained imposture serves
two important functions in the life of the pretenders. It
is the living out of an oedipal conflict through revival of
the earliest definite image of the father. In so far as the

imposture is accomplished, it is the killing of the father
through the complete displacement of him. I t further
serves to give a temporary feeling of completion of
identity (sense of self) that can be more nearly achieved
in this way than in the ordinary life of an individual so
impaired from having been psychologically incorpo-
rated by his mother.[Greenacre 1958, pp. 370-3711
The psychopathic process may be characterologically ex-

pressed in individuals whose simulationswould be best described
as schizoid, the "as-if'personalities of Deutsch (1942). In Chapter
3, R. is a clinical example of the schizoid and psychopathic
personality. Patients similar to R. manifest a pervasive sense of
emptiness and lack of individuality in both their emotional life
and moral structure. They are quite suggestible, and despite
their obvious antisocial behaviors, they often act in a passive-
aggressive manner. In a rather primitive example of this behav-
ior, one such patient, suffering from intermittent nose bleeding,
would wipe his blood on one of the walls of the forensic inpatient
unit, rather than secure tissues readily available to him. The
objectless, affectively deficient internal life of these psychopathic
individuals is most apparent in their absence of internal distress
and the invariable presence of conflict that they create in the
external environment; the hallmark event being the sudden,
sadistically violent act that will result in arrest and custody,
immediately followed by a quiet return to a passive-aggressive
and schizoid mode of existence.
The psychopathic process may also be expressed by individ-
uals whose simulations are so adept, whether they be cognitive,
affective, or behavioral, that there is absolutely no suspicion
whatsoever that pseudoidentifications may be occurring. This is
especially difficult to assess in the socially engaging and intelli-
gent psychopath because of the transient nature of his or her
relationships. Any successful assessment of the nature and gen-
uineness of identifications in these individuals must be largely

dependent upon corroborative information from relatives, fam-
ily, acquaintances, and other clinicians.
T. D., a probationer, was a 16-year-old Caucasian male

of superior intelligence. He was currently held in juve-
nile custody, but was allowed certain day trips with his
probation officer to facilitate planning and placement
upon his release. On one such day trip the probation
officer was amazed and pleased to find out that T. D.
shared with her an interest in metaphysics. In fact, he
displayed a remarkable intellectual command of the
writings of Alfred North Whitehead, one of her most
favorite philosopher-theologians. They conversed for
several hours while riding in her automobile, and sub-
sequently the probation officer found herself much
more closely !.dentiiied with and sympathetic toward
the plight of T. D. His intellect also became a personal
strength that she noted with high regard in her written
recommendation to the court.
Several weeks following these events, the proba-
tion officer learned from a colleague that T. D. had
specifically inquired of others to find out her personal
interests; and when he learned of her metaphysical
avocation, he acquired numerous books which he read
in preparation for his encounters with her. She later
found out that he was asking questions about his new
resident manager with ostensibly the same purpose in
mind. The probation officer consciously felt h1u-t and
angry toward T. D., but also acknowledged to me her
continuing admiration of his prowess and intellect.
T. D. imitated the probation officer's intellectual interests to

pursue his own ends. There was no coincidental, reciprocal sense
of emotional resonance and intellectual exchange between them.
Structure and N n a w ~ i c s 139
The well-honed, imitative, and mirroring aspects of T. D.'s be-

havior, in this case in the intellectual sphere, enhanced the
probation officer's self-esteem. Her narcissistic admiration of her
own metaphysical knowledge increased as she identified with,
and consciously admired, the metaphysical understanding
of T. D.
This case illustrates a process that I call malignant pseu-
doiclentilfication. I t is the process by which the psychopath
consciously imitates or unconsciously simulates a certain be-
havior to foster the victim's identification with this individual,
thus increasing the victim's vulnerability to exploitation. Malig-
nant pseudoidentification involves transference and counter-
transference phenomena wherein the psychopath simulates the
more subtle narcissistic characteristics of the victim at an earlier,
and unconscious, developmental level.
Mental health and legal professionals are most vulnerable to
malignant pseudoidentification during work with the psychopath
when the interactional content concerns their competency, au-
tonomy, or knowledge. The goal of the psychopathic character is
to increase the professional's genuine empathy for the individu-
al's plight through pseudoidentification with the professional's
narcissism.
The most common example of this is the client-patient who
will compliment the professional for his competency or knowl-
edge. On a more subtle level the psychopathic individual will
simulate affects and mannerisms of the victim, and both mir-
roring and twinship (Kohut 1971) transferences will be acted out
in an alloplastic, or destructive, manner. I t is not unheard of for
defense attorneys, enamored by the perceived helpfulness and
competence of intelligent psychopathic clients, to find them-
selves considering ethical violations, and perhaps even illegal
behavior, in the service of their defendants. Again, the victim's
felt quality of perfection (Rothstein 1980) is enhanced, and a
strong empathic bond is developed with the psychopath through
his imitation and simulation of the victim's narcissistic invest-
ments. The victim will oftentimes be deluded into thinking that

the psychopath shares this feeling of identification and bonding.
In a legal setting the adversarial roles that attorneys play will
foster ongoing processes of intrapsychic splitting so that twin-
ship alliances between attorney and psychopathic defendant may
render whole sectors of reality testingunavailable to the attorney-
victim.
Individuals who deny their own narcissistic investments
and consciously perceive themselves as being "helpersn endowed
with a special amount of altruism are exceedingly vulnerable to
the affective simulation of the psychopath. Empathy is fostered
in the victim through the expression of quite visible affects that
infer a transference dependency on an original object. The pre-
sentation of tearfulness, sadness, longing, fear, remorse, and
guilt may induce in the "helper" a strong sense of compassion,
while unconsciously enhancing the "helper'sn narcissistic invest-
ment in self as the embodiment, or at least a whole representa-
tion, of goodness. The psychopathic expression of such simulated
affects may be quite compelling to the observer and difficult to
distinguish from deeply cathected emotion. I t can usually be
identified, however, by two events: First, the clinical observer
who has analyzed the narcissistic roots of his own empathic
responses will feel little or no compassion during this outpouring
of emotion by the psychopath. In fact countertransference ele-
ments of a sadistic nature may be felt by the observer, tele-
scoping back to hateful feelings of the biological parent toward
this once vulnerable child. Second, the psychopath will recom-
pensate much too quickly following such affective expression,
leaving the clinical observer with the impression that the play
has ended, the curtain has fallen, and the imposture, for the
moment, is finished.
The psychopath, in brief, has no capacity for empathy. But
there is an exquisite capacity for simulation and imitation of
others' narcissistically invested self-concepts, whether they be
expressed through ideation, affect, or mannerisms. The adept-
ness and social facility of such simulation and imitation appear to

correlate with the psychopath's intelligence.
PROJECTIVE IDENTIFICATION AND

OBJECT CONTROL
The role of projective identification as a defensive and intrapsy-

chic process in psychopathy undergirds simulative and imitative
dynamics. I t is a process in which affective and ideational com-
ponents of the individual are attributed to another, while at the
same time the other actual person is controlled, or attempted to
be controlled. Projective identification, by necessity, implies
both false attribution and object control.
In a more precise sense in the psychopathic process, I must
speak of projective pseudoidentification or simulation. The
projective-introjective cycle is a recurrent one involving repeti-
tive simulations, and it is closely tied to incorporative and expul-
sive libidinal themes. The psychic content involved in projective
pseudoidentification comes from within and without the gran-
diose self-structure.
From within the grandiose self-structure, ideational and
affective material from the various fused self- and object con-
cepts may be subject to projective identification. This material
is potentially more easily available to consciousness because it is
more ego syntonic for the psychopath and is characterized by
attitudes of perfection, grandiosity, and power. This form of
projective identification with the actual object is more easily
tolerated and hedonic for the psychopath because, in a sense, it is
psychic bathing under the narcissistic light that is also illumi-
nated and extended through the shadow of the other.
From without the grandiose self-structure, projective iden-
tification may mobilize anxiety and discomfort during the psy-
chopathic process. Ideational and affective components from this
ego dystonic sphere of psychic life originate from the persecu-
tory, and oftentimes sadistic, introjects that continually threaten

the homeostasis of the grandiose self-structure. Such material is
characterized by attitudes of envy, greed, rage, sadism, acute
dysphoria, contempt, and arrogance. There is usually a paranoid
theme present. This is projected as a means to attain psychic
distance, yet must be controlled through pseudoidentification
with the aggressor to prevent its monstrous exaggeration in the
mind of the psychopath as a fearful predator.
A compelling example of such use of projective identifica-
tion was found in the case of a 34-year-old sexual psychopath,
whom I evaluated following thirteen years of hospitalization as a
mentally disordered sex offender in California. He had been
originally committed for the bondage, forced oral copulation,
rape, electrocution, and strangling to death of a 15-year-old
female stranger. These are excerpts from my report:
Hitchhiker # 3 was the victim. C. V. stated that he

picked her up with the intent of "getting sex* but he
also felt awkward and shy. She came to his apartment
and they shared two joints and engaged in small
talk. . . .She then asked him to leave with her to attend
a concert with several of her friends. V. reported
feeling very paranoid after smoking the joints . . . he
stated, 'We merged by the front door, I kissed her
.
impulsively . . . she pushed me away . . I snapped . . .
I was watching myself, I was possessed by this pure
evil, I couldn't do anything about it and I dragged her
back into the room."
Although V. does not consciously feel his dis-
sociated affect, he is prone to projecting it; that is,
attributing it to other people and places. Several weeks
ago he commented to his mother that he felt "a lot of
evil" while in jail. He also reported to Dr. A. that he had
"sensed evil" in his one-room apartment several weeks
prior to the offense. This reasonably establishes a
Structure and Llymmics 143
thirteen-year history of dissociated affect that is still

present yet consciously unknown to him. These emo-
tions were once expressed in a violent and sadistic
manner, yet, in a sense, remain timelessly alive and are
now felt by V. in a projected form that assumes for him
the meaning of "evil."
In both cases, from within and without, the psychopath

attempts to resonate with the actual object, and in this process
may unconsciously manipulate for a particular identified goal.
The unconscious motivation is to maintain the homeostasis of the
grandiose self-structure, which is always tenuous because of the
necessity of continuous externalizing and internalizing of psychic
content. Stability of psychic content, which is not available to the
psychopath, appears to follow stability of psychic structure in
normal development.
Is conscious imitation easier for the psychopathic individual
because of the predominance of projective pseudoidentification?
I think that it is. The young toddler very smoothly simulates with
little conscious effort and no conscious awareness. The varieties
of vertical dissociability (Kohut 1971), what I genotypically refer
to as splitting, allow for the compartmentalizing of alternative
means of interpersonal expression, which find their roots in
discrete affective and ideational components. Practicing, or the
"elated investment in the exercise of the autonomous functions"
(Mahler et al. 1975, p. 69), is an easier process for the toddler
precisely because of the dissociative flexibility of consciousness
at that subphase of separation-individuation. Conscious imita-
tion in the defensively more mature adult is more difficult be-
cause of the predominance of horizontal (repressive) rather than
vertical (splitting) defenses (Kohut 1971).
There is no repression, or horizontal defensive operation, in
the psychopathic process; paradoxically there is thus no potential
for the interfering emergence of this preconscious, or uncon-
scious, repressed material during periods of imitation or simula-
tion. The pathological residue of separation-individuation diffi-

culties allows the psychopath to continuously practice varieties
of ideational and affective states through pseudoidentification
and projective pseudoidentification. The verticality of defenses is
most helpful when alternative, and perhaps very contradictory,
affects and ideations are imitated or simulated; for there is no
conscious sense of ambiguity or contradiction in the psychopath's
phenomenal experience of self. This may account for the chame-
leonlike effect of certain psychopathic individuals (Bauder 1985).
The distinction between projection and projective identifi-
cation is that the latter involves a controlling relationship be-
tween the individual and the object of the projection. The concept
reflects combinations of Klein's work (1946) concerning projec-
tive and introjective processes between mother and child and
Bion's (1955) elaboration of her work through his metaphor of the
"container" into which psychic content can be placed. Finell (1986)
noted that the term projective identification has quasi-magical
overtones and "describes the mysterious interplay of two psy-
ches around projection and introjection, merger, and telepa-
thy. . . ."(p. 103). Whipple (1986) quite persuasively argued that
projective identification is only a metaphor, and to write as if
psychic contents are actually put into someone else, that one
literally becomes a container for an evacuated product, is reifica-
tion (Dorpat 1983). Grotstein (1981) hypothesized that projective
identification is the defensive process by which feelings are
communicated that are too primitive to be verbally expressed.
He wrote, "I have come to the belief-and insist upon the defini-
tion-that all projection is projective identification, from the
vanthge point of the projector" (p. 202).
The psychopathic process that is predominately expressed
through sexual sadism on the part of a male toward a female
provides a compelling illustration of projective identification and
the sequential shift that occurs prior to, during, and followingthe
sexually sadistic act. The victim who is characteristically tar-
geted is initially selected for her stereotypical and perceptual
Structure and Qnumics 145
"goodness of fit." During this beginning period of predation she is

conceptualized as a representational object that is ideally loved
and capable of expressing ideal love. The victim is projectively
identified with traits of the ideal object within the grandiose self-
structure, which, by virtue of the fusions that have occurred
within the grandiose self between the real self-, ideal self-, and
ideal object representations, are experienced as an extension
of "I."
Again, I want to reiterate that this is not a psychotic
identification or a mergence of ego boundaries that implies a loss
of perceptual separation between self and object. The identifica-
tion, or more precisely, the malignant pseudoidentification, is
between conceptual representations of ideal self and object
within the grandiose self-structure. The sexual psychopath a t
this point of initial projective identification will consciously feel
expansive, exhilarated, and in omnipotent control of his behavior
and that of the victim being stalked. This experience may be
enhanced by the use of cocaine hydrochloride or methampheta-
mine hydrochloride, psychostimulants that pharmacologically
fuel this sense of expansive pleasure.
At the moment of physical contact with the victim, idealized
attributions with which the psychopath projectively identifies
are suddenly challenged by the reality test of the victim's actual
verbal or physical resistance. The victim may be a stranger, and
affects associated with the stranger selfobject (Grotstein 1982)
such as envy, rage, and persecutory fear are mobilized within the
psychopath. The projective content then shifts to psychic mate-
rial outside the grandiose self-structure that is persecutory and
oftentimes sadistic. Affective tones of envy and oral rage emerge
as the need for omnipotent control intensifies in the face of an
actual physical struggle with the victim. Intrapsychically the
persecutory introjects, the "not-I" content of the mind, are being
projected onto the victim, and the stranger selfobject within the
grandiose self-structure is being identified with to preserve the
conceptual fusions and homeostasis of the grandiose self.
Interpersonally the victim is now perceived as a devalued

and highly threatening actual object because she now carries the
persecutory introjects of the psychopath. Psychodynamically the
sexual psychopath has identified with the aggressor, the
stranger selfobject, and a tremendous amount of sexual aggres-
sion is mobilized to protect himself from the perceived "monster"
that he must omnipotently control and devalue at all costs. The
violence that follows must shame, humiliate, degrade, and per-
haps destroy the actual victim to sufficiently devalue the in-
trapsychic material that has threatened the grandiose self-
structure.
Whereas the victim began as an idealized conceptual exten-
sion of the grandiose self, she is transformed into a monstrous
object that carries the persecutory projections of the psychopath
and therefore must be devalued to be controlled. When projec-
tive identification shifts from within to without the grandiose
self- structure, sexualized aggression is mobilized and expressed
to defend against the predominately unconscious affects of envy
and greed. In a sense, the violence of the sexual psychopath
reconstitutes the grandiose self-structure in the face of annihila-
tory and persecutory fear. Projective identification returns to a
more ego-syntonic defensive operation within the grandiose self-
structure once the actual victim has been devalued.
Other narcissistically disordered individuals will use projec-
tive identification in a similar manner, but usually only in fan-
tasy. The aggressive, alloplastic expression of projective identi-
fication in a violent form is the sole province of the psychopathic
process. The affective dimension of such an intrapsychic defense
grows exponentially because interpersonal reality is engaged.
But does the sexual psychopath become psychotic at any
point in the sequence that I have hypothesized? This question
also has important ramifications in forensic evaluations con-
cerning the temporary insanity of the sexual psychopath.
If we define psychosis as a loss of reality testing (Frosch
1983a), I think not. I have had the opportunity to clinically
Structure and L&namics 147
explore in detail with several dozen sexual psychopaths the

sequence of their conscious thoughts, affects, and behavior
during episodes of violence. In those individuals, I did not see
complete loss of reality testing. In the absence of psychotic
content, such as hallucinations and delusions, there is, instead,
the striking presence of altered structure during these events,
most clearly described as varieties of splitting or dissociability of
consciousness. I will explore this in detail in the next section of
this chapter. Suffice it here to say that self- and object concepts
are radically altered during violence, most notably in the sequen-
tial idealizing and devaluing of the victim as a conceptual exten-
sion of the grandiose self, and then as a conceptual extension of
the persecutory introjects. But the perceptual distinctiveness
between self and other, both at a representational level and an
interpersonal level, is never lost. The victim, for instance, may
assume the monstrous characteristics of the sexual psychopath's
mother, but she never becomes the mother, as may be the case in
the "sudden murder" (Lunde 1975)of the paranoid schizophrenic.
John Wayne Gacy, Jr., was arrested on December 21,1978.
He had lived quietly in a small house at 8213 Surnmerdale in
Norwood Park, an unincorporated area north and west of Chi-
cago. During the six years prior to his arrest Gacy sadistically
assaulted, raped, and murdered thirty-three boys, and buried the
majority of them in the crawl space underneath his house.
During his trial, Richard Rappaport, M.D., a private fo-
rensic psychiatrist, gave expert testimony linking Gacy's sexu-
ally psychopathic behavior and projective identification and
placed them in the larger context of a borderline personality
organization:
In the scenario, "he brings. . .young boys to his home,"

where he can star in a play scripted by himself, and the
play itself is an example of the second primitive ego
defense common to borderlines: projective identifica-
tion. "First," Rappaport said, "he begins to act as a
.
father to them. .acts tenderly. . .tries to show them
that he has a fatherly instinct and they are boys he can
..
take care of. As I mentioned, these are . young men
and boys who are at the height of the oedipal them-
selves, who have the characteristics of the developed
.
phallus. . they are boys. . . he can identify with, who
he recognizes as having qualities that he feels. ..
"Now, he'd get these boys and he would begin to
project onto them the qualities that he had inside
himself and that he didn't like . . . He could say that
they are selling themselves, as he sold himself to try
and impress his father. He could say that they were
degraded. . .dehumanized as his father made him." He
begins to feel it is not himself he is hating, but the
young men.
At first, Rappaport said, Gacy would have been at
least unconsciously aware that the familiar hatred he
sensed in the boys actually existed within him. But "at
some point in the scenario that he goes through" Gacy
would progress from simple projection to projective
identification. "He then feels that these qualities . . .
exist in the other person. They are no longer a part of
him. They are in this other person and he feels ex-
.
punged or cleansed . . Now he sees these persons as
.. . ..
. bad . . homicidal . threatening. . .
"He is then the father in identifying with the aggres-
sor, and these victims, these boys, are then himself. He
.. ..
can . kill them . and in a way rid himself forever of
these qualities that are inside of himself: the hostile
threats and frightening figures that pervade his uncon-
scious. He is so convinced that these qualities exist in
this other person, he is completely out of touch with
.
reality . . and he has to get rid of them and save
.
himself . . he has to kill them." [Cahill 1986, pp.
339-3401
Structure and Qmurnic8 149
SPLITTING AND DISSOCIATION

D. W. Winnicott wrote in 1964, 'It is not possible to conceive of a
repressed unconscious with a split mind; instead what is found is
dissociation . . . it is not possible for a split mind to have an
unconscious" @. 453).
Satinover (1986) noted that Jung (1907,1916) was the first to
attempt to conceptualize psychic dissociability through self-
analysis of his own narcissistic and preoedipal ~ i c u l t i e s .He
called these "personified autonomous complexes" and they were
always demarcated into stereotyped opposites (Jung 1916).
Freud (1938) articulated the difference between psychic
dissociability and repression, the former more commonly termed
splitting. Kohut (1971) crystallized this distinction by conceptu-
alizing vertical, rather than horizontal, splits in the psyche of the
narcissistic personality. He wrote that there is
a specific, chronic structural change to which I would
like to refer in a modification of Freud's terminology as
a vertical split in the psyche. The ideational and emo-
tional manifestations of a vertical split in the psyche-
in contrast to such horizontal splits as those brought
about on a deeper level by repression and on a higher
level by negation-are correlated to the side-by-side,
continuous existence of otherwise incompatible psy-
chological attitudes in depth. [pp. 176-1773
. . . We are not dealing with the isolation of circurn-
scribed contents from one another, or with the isolation
of ideation from affect, but with the side-by-side exist-
ence of cohesive personality attitudes with different
goal structures, different pleasure aims, different
moral and aesthetic values. [p. 1831
Kernberg, although viewing primitive splitting as a defen-
sive process rather than a regressive deficiency as Jung and
Kohut did, similarly wrote,
. . .What are completely separated from each other are

complex psychic manifestations, involving affect, ide-
ational content, subjective and behavioral manifesta-
tions . . . actually, we might say that there exist alter-
nating "ego states," and I use the concept "ego state" as
a way of describing these repetitive, temporarily ego
syntonic, compartmentalized psychic manifestations.
[1976, p. 201
There appears to be a general consensus in the psychoana-

lytic literature that one of the fundamental features of borderline
ego functioning is the presence of unconscious dual or multiple
identity processes (Fast 1974, Searles 1986). In fact, the term
borderline itself may hold within it the metaphor of dual or
multiple lines of demarcation that separate distinguishable
states of mind: intrapsychic experiences of self and object that do
not interpenetrate opposite valences, but instead vertically de-
scend as "psychological deep structure" (Ogden 1986) to a primi-
tive psychotic core. This so-calledpsychotic core is quite clinically
apparent in transient psychotic states (Singer 1977), mild formal
thought disorder (Singer and Wynne 1965), and indications of
primary process structure and content in the borderline person-
ality disorder (Urist 1980) because of an absence of horizontal
defenses to protect conscious "ego states" from an upsurge of
psychotic material.
Interpenetration occurs, instead, among these hypothe-
sized horizontal levels, such as the absence of a distinction
between ego and id, since without repression the latter cannot
exist (Jacobson 1964, Kernberg 1980). And specific to the psycho-
pathic process, the fusions that occur within the grandiose self-
structure between real self-, ideal self-, and ideal object repre-
sentations preclude a horizontal demarcation between real self
and ideal selfobject representations as forerunners of superego
development (Jacobson 1964, Kernberg 1980). Such varieties of
dissociability, or vertical splits in the psyche, and horizontal
Structure and Dgnamics 151
fusions are pathognomonic of borderline ego functioning in gen-

eral, narcissistic conditions and the psychopathic process in par-
ticular.
Dissociation is, in my view, a phenotypic defensive process
that expresses the genotypic defensive operation of splitting; it is
ubiquitous in the psychopath. Note, however, that I am not just
referring to a dissociative state, such as depersonalization or
derealization; neither am I implying that amnesia is necessarily
present as a product of the dissociative defense.
Yet varieties of dissociability in the psychopathic process,
pathognomonic of borderline ego functioning and aggressive
narcissism, invite several intriguing questions whose answers
shed further light upon the psychopathic individual. First, if
dissociative experiences, such as derealization and depersonali-
zation as defined in DSM-111-R (American Psychiatric Associa-
tion 1987) are extreme clinical manifestations of dissociation as a
common defensive process in psychopathy, are these clinical
experiences found in the phenomenology of the psychopath?
And, if so, when? Second, if dissociative experiences are common
to hysteria in its many forms (hysterical conversion reactions,
hysterical personality, histrionic personality, somatization disor-
der, Briquet's syndrome), is there an empirical relationship be-
tween psychopathy and hysteria? And third, if varieties of split-
ting, or dissociability, are common to the subjective experience
of the psychopath, could a more intelligent psychopathic indi-
vidual malinger multiple personality, an extreme form of disso-
ciative state with its attendant amnesic periods, to avoid respon-
sibility for his or her intentional acts?
Depersonalization and Derealization
Dissociation as a defensive process is, by definition, ego syntonic

because of its developmental role in character formation. Disso-
ciative experiences such as depersonalization and derealization
are usually clinically identified by their ego-dystonicnature. The

individualphenomenally experiences an alteration in the sense of
reality (Frosch 1983a) without a concomitant loss of reality test-
ing. There is an intrapsychic change in the self-percepts (deper-
sonalization) or the object percepts (derealization) that is un-
usual."The symptom of depersonalization involves an alteration
in the perception or experience of the self in which the usual
sense of one's own reality is temporarily lost or changed" (Amer-
ican Psychiatric Association 1987, p. 275). Likewise, derealiza-
tion is manifested "by a strange alteration in the perception of
one's surroundings so that a sense of the reality of the external
world is lost" (American Psychiatric Association 1987, p. 276).
The intrapsychic boundaries between self- and object per-
cepts are not lost, which would render the individual psychotic;
instead, the boundaries are distorted and are phenomenally
experienced as a change of temporal or spatial contiguity, both
interoceptively and exteroceptively. Dissociative experiences
are transient sensory-perceptual states that do not necessarily
affect self- or object concepts.
Ego-dystonic dissociative states are accorded a place in the
diagnosis of borderline personality disorders (Kernberg 1975,
Gunderson and Kolb 1978, American Psychiatric Association
1980,1987).Dissociative states, however, are noted to occur in 30
to 70 percent of the normal population (Lehman 1974, American
Psychiatric Association 1980,1987)and should be diagnosed as a
psychiatric problem only when they impair individual or inter-
personal functioning.
Noting this considerable overlap between normal and
pathological groups, Ludolph (1983) compared two samples of
borderline and normal subjects for the presence of dissociative
states, the adaptive value and affective intensity of the experi-
ences, and the psychopathology of the reported experiences. She
found that 73 percent of the control group (N = 24) reported at
least one dissociative event, while only 41 percent (N = 18)of the
inpatient borderline subjects reported dissociative states. The
Structure and I)ldnamics 153
borderline sample, however, was much more likely to have

chronic dissociative experiences if they admitted to any at all,
and the dissociation was more likely to be intense, painful, and
maladaptive, sometimes severely impairing reality testing or
causing a life-threatening loss of impulse control. Of the border-
line sample, 22 percent reported a completely discontinuous
sense of self, feeling at times that they became an entirely
different person. Additionally important was the finding that one
third of the borderline sample adamantly denied any dissociative
experiences. They expressed this extreme defensiveness against
such experience in an anxious or angry manner. Ludolph (1983)
hypothesized that these "extreme defenders" could be the most
pathological dissociators and could represent one of two bimodal
distribution points of dissociation among borderline personality
disorders; that is, one group exhibits chronic and highly dysfunc-
tional symptoms of dissociation and another group rigidly de-
fends against such impending experiences. She found virtually
none of these characteristics in the normal sample and, in fact,
determined that 40 percent of the controls described dissociative
states that were largely adaptive. Ludolph (1983)concluded,
Borderlines plagued as they are with difliculties in the

transition from narcissistic to objective reality, from
symbiosis to separation, would experience the dissocia-
tive tendency as highly disorganizing, threatening to
pull them back into psychotic or near psychotic disor-
ganization. Borderline personalities do not have a sure
enough grasp of reality to play with or electively sus-
pend their sense of what is real. [p. 141
I t appears to me that normals maintain the integrity of

whole self- and object percepts during dissociative experiences;
but a t the level of borderline personality organization dissocia-
tive states contain highly valenced part self- and object percepts
that are, in a sense, experientially magnified and therefore are
affectively felt as threatening, anxiety provoking, and poten-

tially psychotically disorganizing.
Dissociative states also appear to correlate with high levels
of affective or autonomic arousal. The psychopathic process is
peculiarly suited to dissociative states for several reasons. First,
the psychopath has a proclivity to seek sensation, or high arousal,
because of general peripheral autonomic hyporeactivity (see
Chapter 2). Second, the impaired capacity to form attachments
and deeply internalize objects of identification renders conscious
experiences of dissociation, or separateness from self or reality,
unusual but quite tolerable. Dissociative states enhance and
exaggerate the psychopath's normal feelings of detachment or
removal from actual objects or surroundings. Dissociative states
would accelerate the propensity of the psychopath to disidentify
with his or her external reality.
Third, during periods of actual physical violence, the victim
would be perceived as a two-dimensional, perceptually flat, ste-
reotyped object, rather than a whole, multidimensional human
being. In certain cases, the dissociative state may even be par-
tially controlled to ensure that the victim remains derealized and
flat, without emotional depth, usually by preventing or mini-
mizing conversation between the psychopath and the victim. And
fourth, memories of dissociative experiences can be used as
rationalizations for avoiding responsibility for one's actions and
choices, or they may support denial of certain events because of
their dreamlike, unreal quality. This latter phenomenon illus-
trates the way in which dissociative states may dynamically
support splitting and other dissociative defenses. The unusual-
ness of a memory renders it easily compartmentalized as, per-
haps, a dream that did not actually occur in reality at all. An
attenuation in the sense of reality impairs the individual's ability
to test reality in memory.
Derealization and depersonalization in the psychopathic
process are most clinically evident in descriptions of subjective
experience by the psychopath during periods of predation or

actual violence.
The following case material illustrates depersonalization,
derealization, and dissociative defenses in an individual who had
forcefully orally copulated, raped, electrocuted, and strangled to
death a 15year-old female stranger. I evaluated this individual
thirteen years after the crime during his civil trial to consider
release from hospital commitment. He had originally been found
to be a mentally disordered sex offender in 1973 in California
(Penal Code Section 6316 et seq., repealed in 1982). This is the
same case I used to illustrate projective identification earlier.
Here I excerpt other portions of my evaluation to the court:
He stated, "I was watching myself, I was possessed by

this pure evil, I couldn't do anything about it and I
dragged her back into the room."
V. became increasingly tearful at this point and
began to cry. I encouraged this, and he began to sob
deeply and uncontrollably. He stated again that he has
had problems talking, that it feels like a drug, a pain-
killer, when he tries to talk.
With my insistence he returned to his memory of
the crime. He stated that he had his hand around her
mouth and waist, and they fell on the bed together. She
lay on her stomach, and he tied her hands with a string
from her halter top. She said in a terrified voice,
"please let me go." He remembered getting a rope from
his chest of drawers, and felt scared and panicky, like
he was "in a dream." He tied her legs spread-eagled to
the bed, and then had the thought, "you stupid dummy
.. .you don't even know how to rape a person right."
He felt humiliated, untied her legs, took her jeans off,
and retied them to the bed. T h e demonic person was
taking control." He reported that he then performed
cunnilingus on her, and she kept saying, 'Tlease let me

go. I won't tell." He stated to me that [the victim] was
symbolic of other women, and there were "elements of
degradation and humiliation there, but not to [the
victim] herself." He straddled her waist, and told her to
lick and kiss his penis, which she did. At this point he
reported his first conscious feelings of sexual arousal,
and his penis became erect. He penetrated her vagin-
ally and reached orgasm. "The orgasm came quick, her
vagina was small, lots of feeling."
V. began to sob again, "I felt disgust, regret, the
dark side of me liked it." He expressed at this point
what I consider deep remorse and emotion for the
victim, her family, and his family.
"I began to panic, she was crying, my mind was
racing. I went to the kitchen to get a cord. The dark
side is telling me, ?rill her, kill her.' I couldn't do
anything about it. I put a pillow over her face, attached
alligator clips to her nipples, and plugged the cord into
the wall. The radio was playing, I couldn't hear any-
thing. I was thinking, 'kill her quickly.' She was still
breathing when I removed the pillow. Her chest was
moving, so I strangled her." V. then reported that as he
was straddling and strangling her, he looked in the
mirror and saw his face. He said it was "evil, contorted,
demonic, another personality took over and I was
watching this, but I couldn't control it." He stated that
he heard his own voice speak, but it did not sound like
him.I t only matched his face in the mirror. His voice
then said, "Oh, boy, you're going to get the gas chamber
now."
Objective personality profiles like V.'s have a
probability of being associated with an alcoholic father,
and of having been physically abused by him. Such
individuals are inclined to develop a dissociative re-
Strmcture and Dynamics 157
sponse as an adaptation to the stress of violence when

.
they were young children. . . At a deeper, intrapsy-
chic level, V. is usually quite detached from his own
affective, or emotional, experiences. He feels person-
ally isolated from others, and sees himself as alien and
different from other people. He has great difficulty
consciously managing his feelings when they do sur-
face, and will experience them as overwhelming,
frightening, and controlling.
His emotions are not well controlled at all by his
thinking process, and he will feel led by them. He will
deal with early, primitive oral aggression by distancing
from it, making it static or depersonalized, and will
reestablish control by focusing on details in his ex-
ternal surroundings.
V. oftentimes feels an impending sense of loss of
control which is due to unconscious affects of a sexual
and aggressive nature that remain largely unknown to
him. Because of this, he is not able to read affectively
charged situations very well, and may arrive at sur-
prisingly inappropriate interpretations of reality fol-
lowing these situations. V. dissociates, or wards off to
an extreme, early and intense feelings of hostility and
rage toward his parental figures. He has no conscious
insight or understanding concerning this dissociated
&ect and continues to understand it as the "darker,
evil side" of him. He blandly characterizes his early
family experience, and has little insight into connec-
tions between his instant offense, his poorly formed
representations of his mother and father in his mind,
and pathological rage toward his parents. Again, these
feelings are not consciously felt, but remain a part of
his psychology in a highly-charged and dissociated
state. . . .
V. is generally inept at securing his affectional
needs in a socially appropriate manner. When faced

with his own ineptitude, he will devalue both himself
and the person from whom he is seeking affection, and
at that moment may become vulnerable to the rage
against the affectional object that he usually succeeds
in dissociating completely from his consciousness. Any
antisocial behavior that would result from the loss of
control of these dissociated affects would be reactive
rather than proactive. This is illustrated by the initial
sequence of events prior to the murder. The young girl
orally gratified him with her marijuana cigarettes, he
sought further direct sexual gratification, her rejection
of his advances became his mother giving and denying,
and, in his own words, disinhibited by the marijuana,
he "snapped."
Despite V.'s contention that the crime was due
partly to difficulties with girlfriends, he described car-
rying on an active sexual relationship with a neighbor-
hood girl right up until days prior to the crime. Concur-
rently with this normal sexual activity and dating, V.
developed a subterranean fantasy life involving sado-
masochism, and also began to act it out with hitchhik-
ers. This concurrent activity, extremely compartmen-
talized and separated in real life, is another indication
of the dissociative and splitting aspects that are highly
prevalent and pathological in compulsive murder. . . .
This case graphically illustrates the ways in which uncon-
scious defensive operations of a dissociative nature lend support
to the ego-dystonic experience of a dissociative state during
actual violence.
Theodore Robert Bundy is, perhaps, the quintessential se-
rial murderer and sexual psychopath. A veritable cottage in-
dustry has sprung forth on the lecture circuit and in the popular
press around this man who probably sexually molested and

murdered several dozen young women in the states of Washing-
ton, Utah, Colorado, and Florida between 1974 and 1978. He
currently awaits execution on Florida's Death Row.
Michaud and Aynesworth(1983)accumulated extensive tape-
recorded interviews with Theodore Robert Bundy that capital-
ized on his inclination to dissociate and ironically revealed much
of his dissociative psychopathology. They interviewed Bundy at
Florida State Prison following his conviction and death sentence
for several murders he committed on January 15,1978,in the Chi
Omega sorority house, Florida State University.
Michaud and Aynesworth (1983) enticed Bundy to discuss
with them during the course of their interviews the hypothesized
psychopathology of a compulsive murderer. The condition of
their discussions rested upon the use of the third person so that
Theodore Bundy could not be personally implicated through any
untoward use of the manuscript. Such a journalistic arrangement
was wholly conducive to the detachment and disidentification of
the psychopathic process. I have taken excerpts from the tran-
scripts in Theodore Bundy's own words to illustrate elements of
the dissociative process, both as unconscious defense and clinical
event:
.
. . But the significance of this particular occasion was
that while he stayed off the streets and vowed he'd
never do it again and recognized the horror of what he
had done and certainly was frightened by what he saw
happening [italics added], it took him only three
months to get over it. . . .(p. 110)What happened was
this entity inside him was not capable of being con-
.
trolled any longer . . at least not for any considerable
period of time. I t began to try to justify itself, to create
rationalizations for what it was doing. Perhaps to sat-
isfy the rational, normal part of the individual. One
element that came into play was anger, hostility. But I

don't think that was an overriding emotion when he
would go out hunting, or however you want to describe
it. On most occasions it was a high degree of anticipa-
tion, of excitement, or arousal. It was an adventuristic
kind of thing. . . .
The fantasy that accompanies and generates the
anticipation that precedes the crime is always more
stimulating than the immediate aftermath of the crime
itself. He should have recognized that what really
fascinated him was the hunt, the adventure of
searching out his victims. And, to a degree, possessing
them physically as one would possess a potted plant, a
painting, or a Porsche. Owning, as it were, this individ-
ual. [p. 1111
Bundy spoke of the hypothetical conversations between the

psychopath and his victim:
There'd be some. Since this girl in front of him repre-

sented not a person, but again the image, or something
desirable, the last thing we would expect him to want
to do would be to personalize this person . . . [p. 1151
But once the individual would have her in a spot where
he had, you know, security over her, then there would
be a minimum amount of conversation which would be,
you know, designed to avoid developing some kind of a
.
relationship [pp. 128-1291 . . to remove himself from
the personal aspects of the encounter, the interchange.
Chattering and flattering and entertaining, as qseen
through a motion picture screen [italics added]. He
would be engaging in the pattern just for the purpose
of making the whole encounter seem legitimate. . . .
[p. 1251
Strmcture and Dgnamics 161
He commented on the use of alcohol to disinhibit and perceptu-

ally dull the experience:
..
Well, drinking has an effect on both parties. . on the
one hand, the more intoxicated he became, the more
repressed his normal codes of behavior. And the more
she drank, the more she would lend herself to stereo-
types. . . .[p. 1261
The victim was derealized from a whole object deserving of
empathy to a part object for narcissistic gratification:
They wouldn't be stereotypes necessarily. But they
would be reasonable facsimiles to women as a class. A
class not of women, per se, but a class that has almost
been created through the mythology of women and
how they are used as objects. [p. 1181
In his own handwriting Bundy scribbled the following notes
during the January 7,1980, jury selection for his murder trial of
14-year-oldKimberly Leach:
I'm getting writer's cramp which is a small price to pay
for missing the proceedings. I just looked up and heard
some guy with moon-crater cheeks say that he had
formed an opinion of my guilt, but that he would put it
aside. Now Africano [Bundy's attorney] is questioning
the man. His personal opinion is that Mr. Bundy is
guilty. Blah. It's just entertainment. I will feel and act
like an interested bystander. None of this has anything
to do with me. [p. 2821
Psychopathy and Hysteria

The empirical evidence for an association between psychopathy
and hysteria has been accumulating for nearly a century. Mora-
vesik (1894) reported a high prevalence of criminal histories

among hysterical subjects, and Kraepelin (1915) noted the fre-
quent mingling of antisocial and hysterical traits in his patients.
Psychodynamic links between the two disorders were con-
structed by several writers (Rosanoff 1938, Vaillant 1975, Cho-
doff 1982).
Hysterical conversion reactions and somatization disorders,
as variants of the generic hysterical process, have also been
empirically correlated with psychopathy (Robins et al. 1952,
Guze 1964, Robins 1966, Cloninger and Guze 1970, Maddocks
1970, Guze et al. 1971a, 1971b, Spalt 1980).
Psychopathy and somatization disorder appear to be famili-
ally related. Several studies (Ljungberg 1957, Arkonac and Guze
1963,Woerner and Guze 1968)found a high prevalence of psycho-
pathy among the first-degree relatives of their hysterical patient
sample. Cloninger and Guze (1975) reported that mothers of
female criminals had high rates of hysteria and that hysteria was
present in more than 75 percent of the daughters of psychopathic
fathers. Cloninger and colleagues (1975)were the first to propose
a multifactorial threshold model of shared genetic liability apong
female hysterics and male and female psychopaths. Adoption
studies have also supported an association between the two
disorders (Cadoret 1978, Cloninger et al. 1984).
With the advent of DSM-I11 (American Psychiatric Associ-
ation 1980), a descriptive typology emerged that differentiated
somatization disorders, dissociative reactions, and histrionic per-
sonality disorder. Briquet's syndrome, hysterical conversion re-
actions, and hysterical personality are included, respectively, in
these three diagnostic groups.
Lilienfeld and colleagues (1986) completed a landmark study
to attempt to replicate the association between antisocial person-
ality disorder and somatization disorder, clarify the role of
gender as a moderator variable, and explore the relationship of
histrionic personality disorder to both somatization disorder and
antisocial personality. Drawing from a sample of 250 psychiatric

patients in a variety of inpatient, outpatient, and consultation
settings, they reported the following significant findings: first,
somatization disorder and antisocial personality disorder were
significantly correlated (p < .001) within both male and female
subjects; second, somatization disorder and histrionic person-
ality disorder were significantly correlated (p < .001) within
individuals; third, a significant correlation (p < ,001) within
individuals was found between antisocial personality disorder
and histrionic personality disorder; and fourth, alcoholism
showed a significant correlation (p < ,001) with both antisocial
and histrionic personality disorders, but not with somatization
disorder. They hypothesized that 'an individual with histrionic
personality is likely to develop either antisocial personality or
somatization disorder, with the outcome dependent primarily on
the sex of the patient. Antisocial personality and somatization
disorder may thus constitute sex-typed alternative pathways for
the expression of histrionic personality" (p. 721).
In related neuropsychological research, Flor-Henry (1974)
argued that left-hemisphere (dominant) dysfunction may be a
factor in psychopathic male behavior and hysterical female be-
havior. Tucker (1981)proposed a model of specific and lateralized
arousal systems in the brain to explain the differential cognitive
capacities of the two cerebral hemispheres. He proposed that the
hemispheres may be specialized for both the type and valence of
emotion and may reciprocally inhibit each other. Noting the poor
left hemisphere contribution to the intellectual performance of
psychopaths, Tucker (1981) suggested that the hypothesized
inhibitory and self-regulating function of verbal and sequential
ideation is deficient in these individuals. Low arousal of the left
hemisphere is accompanied by the absence of anxiety and ration-
ality and an exaggeration of the right hemisphere's role in emo-
tion.
Tucker (1981) further suggested that the left hemisphere is
underaroused in both psychopaths and hysterics and cited etio-

logical and dynamic studies that support a similar cognitive-
behavioral style between the two: little overt anxiety, excessive
somatic complaints, egocentricity and sexual provocativeness,
theatrical or play-acting behavior, exaggerated emotionality,
and social imperturbability (Shapiro 1965).
Fedora and Fedora (1982) noted that psychopathy may also
be associated with an underarousal of the dopaminergic system,
citing evidence for the lateralization of the dopaminergic arousal
system to the left hemisphere. They hypothesized that Tucker's
model provided a more specific central nervous system substrate
for the hyporeactivity theory of Hare (1970).
Such a hemispheric laterality theory that associates hys-
teria and psychopathy to left hemisphere dysfunction and, con-
versely, obsessive-compulsive disorders to dysfunction of the
right hemisphere does not account for the clinical presence of
obsessional and compulsive features in a variety of psychopathic
individuals, most evident in the compulsive murderer (Revitch
and Schlesinger 1981). Such a theory of laterality would also
contraindicate the prevalence of obsessional character organiza-
tion and its affect-isolatingdefensive structure, which allows the
psychopathic individual to dissociate from the pathogenic ma-
ternal introject (Rinsley 1982).
Despite the shortcomings of the laterality theory, there is a
growing empirical basis for the hypothesis that some varieties of
dissociative states are significantly related to psychopathy and
that psychopathic and histrionic personality disorders are signif-
icantly correlated. Such research supports my psychoanalytic
construct that varieties of dissociability, both as characterolo-
gical defense and ego-dystonic state, are fundamental to the
psychopathic process.
The following is a brief postmortem psychological analysis
of a 32-year-old male psychopath who was shot to death by an
off-duty policeman who found him holding a female hostage in the
back seat of a car with a knife to her throat.' This incident

occurred three months after his release from Vacaville Medical
Facility, a maximum security prison hospital in California. This
individual was also suspected of murdering his wife and her
friend in 1983, but charges were never filed because of insuffi-
cient evidence:
T. R. had an early history of sexual involvement and
aberrant parenting by his principal caregivers. He
claimed that his stepfather had been abusive and had
raped him on many occasions. He further stated that he
had been forced to engage in sexual activities with his
sister.
T. R.'s mother had been arrested for child endan-
germent stemming from charges that she misappropri-
ated welfare funds to buy "witches' paraphernalia"
rather than food for her children. I t was alleged that
the stepfather was also charged with sexually mo-
lesting the children. T. R. was first arrested for re-
ceiving stolen property at the age of 17 and became a
ward of the court. Subsequent investigation uncovered
a history of forced sexual activity by T. R. with his
stepsister and another younger female, a neighbor,
both age 12. T. R. had also reportedly held a knife to
their throats during these assaults. He was placed in a
boys' ranch until age 18, then released. He was ar-
rested again in 1981, at age 27, for child molestation. A
state hospital commitment was recommended, but in-
stead, T. R. was held in jail, served five months of a
six-month sentence, and was released on probation to
attend psychiatric day treatment. He complied for a
brief period of time, and then was terminated by the
'My thanks to Eugene Schiller, L.C.S.W.,
for this postmortem psychological
vignette.
program for insufficient motivation. T. R. was subse-

quently arrested for forcible rape in 1983 and was
detained for three months in the Psychiatric Security
Unit, a maximum security inpatient treatment pro-
gram, for suicidal ideation and intent. Clinical records
indicate he was narcissistic, attention-seeking, and
childlike. He reported to several staff members a his-
tory of work as a professional clown in a traveling
circus. He was also quite adept at theatrical perform-
ances while on the unit. He was prescribed several
medications, and finally discharged to the mainline
portion of the jail on Sinequan 50 mg q.i.d. and Thora-
zine 50 mg t.i.d. While on the unit, it was clinically
documented that T. R. spent much time drawing, and
on one occasion the subject had been nude women. The
psychiatrist wrote that T. R. had dreams of "cutting up
women and eating them." He had stated to a nurse,
"I'm not gonna get involved with a woman again when
this is over because it's always got me in trouble."
There were several instances of T. R. acting out while
on the unit by pushing the panic alarm, somersaulting
over chairs that resulted in facial abrasions, and fist-
fighting with a male patient that resulted in seclusion
and restraints. He was also noted to have been "flirta-
tious with staff." T. R. was discharged with a diagnosis
of mixed substance abuse and borderline personality
disorder with histrionic and dependent features.
T. R. showed an extensive history of violence
toward women, more specifically, sexual sadism that
involved elements of compulsiveness and psychopathy.
The overt behavioral displays throughout this young man's

life that imply both histrionic and psychopathic processes, in the
relative absence of any intrapsychic data, are compelling.
I have also found anecdotal evidence that histrionic-

personality-disordered females are particularly attracted and
vulnerable to psychopathic males. Although I have no empirical
studies to support this hypothesis, the few case studies available
of criminal psychopaths in relationship contain historical ac-
counts of their intimate associations with hysterical females
(Mailer 1979, Michaud and Aynesworth 1983, O'Brien 1985). I
would suggest several psychodynamic reasons for such hetero-
sexual liaisons between histrionic females and psychopathic
males who may socially, or antisocially, behave quite differently,
but object relationally share similar characteristics.
The hysterical-personality-disordered female is likely to be
enamored of the psychopath. Organized at a borderline level of
personality function, she can easily carry, as a projective con-
tainer, his alternating idealizing and devaluing psychic material.
She is able to assimilate his highly affectively charged and
opposite-valenced object percepts of her since they are fully
consonant with her own reality testing and self-percepts. Her
inability to integrate good and bad self-concepts into more real-
istic, ambiguous, and modulated self-representations resonates
with the psychopath's propensity to dichotomize reality into
goodness and badness.
She is able, at the same time, to reciprocate in this projective-
introjective cycle by predominately idealizing the psychopathic
character. Her need for attachment and dependency comple-
ments his drive for detachment and autonomy; she perceives
others as all-giving and benevolent, and he perceives others as
all-taking and malevolent. But why would the psychopathic char-
acter foster such bonding by the hysterical female to him? It is
precisely because her primary idealization of the psychopath
accentuates his grandiose self-percepts and heightens his omnip-
otent control of her as a submissive object.
The hysterical female is cognitively vulnerable toward the
psychopath for several reasons. First, the global and diffuse
nature of hysterical thought (Shapiro 1965) makes her quite

susceptible to believing the psychopath's rationalizations of his
behavior and disinclined to study carefully, perhaps with some
obsessive detail, the illogic of his thought. She would also be
immune to developing a healthy suspicion when details and
circumstances don't fit, or do not corroborate, the psychopath's
oral version of his history. Second, the hysterical use of denial as
a defense to ward off conscious experience of certain sectors of
reality, perceived by others as evil, badness, pain, malevolence,
or simply unpleasantness, allows her to judge the psychopath's
most abhorrent behavior in a benign, optimistic, and pollyan-
naish manner.
The hysterical female is also affectively vulnerable to the
psychopath. She will undoubtedly display affects with great
frequency and ease and although they may be quite superficial,
will nonetheless be arousing, perhaps even exciting, for the
psychopathic character with a psychobiologically higher
threshold for autonomic arousal. Her superficiality of affects may
also be appealing because of his pseudoidentification with them
as a model of adept role-playing, or imposturing, to accomplish
certain social manipulations. He may learn to imitate or simulate
her affective displays.
The hysterical personality-disordered female's sexual inno-
cence, whether feigned or genuine, with its concurrent flirta-
tiousness, will complement the psychopath's sexual fantasies,
pervaded with themes of dominance and submission. He may
believe her innocence betrays her unconscious desire to submit
to him. They may act this out in reality through sadomasochistic
activities initiated by either partner.
Theodore Bundy received this letter from a woman named
"Janet" while on Florida's Death Row in September 1979 after
responding once to her many missives:
I got the letter you sent me and read it again. I kissed

it all over and held it to me. I don't mind telling you I
am crying. I just don't see how I can stand it anymore.

.
I love you so very much, Ted. . I adore you and I just
can't stand not hearing from you. It's absolutely
tearing me apart. You are so precious to me. I want you
so much I can almost taste it. What I wouldn't give to
have an hour alone with you. I would show you in every
way how much I love you. There's nothing I wouldn't
do. [Michaud and Aynesworth 1983, p. 2781
This letter is remarkable in its portrayal of the histrionic

style of its author. We must be mindful that this woman had
never met Theodore Bundy and only received one letter from
him. His letter seems to carry the psychological import of a
transitional object for her, as she holds it, kisses it, and cries. She
conveys a masterful sense of the hyperbole in her exaggeration of
love, adoration, fmality, and distress. She facilely moves from
romantic innocence to sexual provocativeness in an implicit scat-
ological reference to boundless sadomasochism. I t typifies the
histrionic-psychopathic heterosexual dynamic.
The psychopathic character will also find a correlate of his
own extroversion in the histrionic partner's propensity to be
outgoing, social, and gregarious. Like him she will aggressively
pursue object relatedness, but in a more overtly dependent and
socially acceptable manner. Her affectional needs will highly
arouse the psychopath's sexual and aggressive desires, particu-
larly since she will allow him to exercise omnipotent control in
their expression and use of her physical self.
R. W. was a 32-year-old Caucasian female who was

diagnosed by me as a severe borderline personality
disorder with histrionic traits. Initially in psycho-
therapy she was timid, seductive, and fearful. She had
been married five times, and currently was living with
a dominating and emotionally abusive male who barely
tolerated her twice weekly visits with me.
During the course of my psychosocial history

taking and psychodiagnostic interviews, she revealed
that she had met her first husband in a laundromat. He
had threatened her, dragged her into his car, and asked
her to marry him. She consented, and they drove to
Utah and exchanged vows. He then locked her in his
remotely located mobile home for a week, and only
gave her a small mount of food and water. She stated
to me that after five days of this, she thought that
maybe she had made a mistake and was in some
trouble.
The hysterical female may also be quite unconsciously fas-

cinated with the overt violence of the psychopathic character.
This may be her way to vicariously express her own forbidden
aggressive impulses through projective, almost adhesive (Bick
1968), identification with the psychopath.
Psychopathy and Multiple Personality Disorder
The psychological and psychiatric communities have recently

begun to acknowledge the credibility and frequency of multiple
personality disorder (Kluft 1985). Given the empirical and psy-
chodynarnic relationship between hysteria and psychopathy, it is
only logical to hypothesize that psychopathy and multiple per-
sonality disorder may clinically coexist in the same individual,
although I have yet to evaluate such a patient. Multiple person-
ality disorder case histories, moreover, often identify a subper-
sonality with clear-cut antisocial behavior and its accompanying
affect states (Schreiber 1973, Bliss 1980, Keyes 1981, Howe
1984).
Janet (1889) was the first to link dissociation to multiple
personality disorder. Breuer and Freud (1893-1895) identified
what they considered abnormal "hypnoid states" of consciousness

that were associated with a splitting, or dissociation, of memories
of early childhood trauma. Fliess (1953) characterized this phe-
nomenon as a hypnotic evasion that protected against the work of
remembering early trauma; and Loewald (1955) theorized that
dissociation was unconsciously chosen as an alternative pathway,
instead of abreaction or associative absorption, to cope with early
trauma.
The weight of current knowledge indicates that multiple
personality disorder has both biological and social learning deter-
minants (Spiegel and Spiegel 1978, Bliss 1980, Braun 1984).
Braun and Sachs (1985) emphasized two necessary criteria for
the eventual clinical manifestation of multiple personality disor-
der. First, a natural-born capacity to dissociate must exist. And
second, childhood exposure to severe and sadistic trauma is
frequent, unpredictable, and inconsistent. Silber (1979) spelled
out the psychodynamic relationship between childhood sexual
abuse and hypnoid states in adult patients.
If psychopathic individuals are more vulnerable to multiple
personality disorder as an extreme dissociative state, they are
also more likely to consciously malinger such dissociative pa-
thology to disavow responsibility for their actions. Their subjec-
tive sense of consciousness may seem quite discontinuous
(Hilgard 1980), particularly given their imitation and simulation
of others' behavior through projective identification. Their
memory of self, both perceived and conceived (Meloy 1985), may
be both sentimentalized and compartmentalized, owing to the
idealizing and splitting processes of their psychology. Such het-
erogeneous representations of self, and their accompanying
opposite-valenced affects, predispose the psychopathic character
to feign more ego-dystonic dissociative states, from psychogenic
amnesia to multiple personality disorder, in the search for excul-
pation in a forensic setting. In a sense, real dissociative traits
may intentionally serve illusory dissociative states.
Bradford and Smith (1979) studied thirty persons who had

committed murder and found that nearly two-thirds (60 percent)
claimed amnesia for their alleged crime. Lynch and Bradford
(1980) attempted to use polygraphy to determine which persons
claiming amnesia for their offenses were telling the truth. They
concluded that 30 percent of those without major psychiatric
illness and 63 percent of those with personality disorders had
used deception. Polygraph measures of such variables as malin-
gering, however, have been criticized for their limited reliability
and validity (Schacter 1986a). Nevertheless, claims of amnesia by
persons accused of homicide range from 40 to 70 percent (Howe
1984) and may be due to organic, psychogenic, a combination of
organic and psychogenic causes, or conscious malingering
(Suarez and Pittluck 1975, Whitty and Zangwill 1977, Simon
1977).
The psychopathic character may also use the hypnotic inter-
view to fake multiple personality disorder. Even a deeply hypno-
tized individual can retain the ability to lie (Orne 1961). If an
individual is pretending to be hypnotized (Schacter 1986b) and
faking multiple personality disorder, the likelihood that he will
go undetected is considerable (Hilgard 1977, Orne 1977, Diamond
1980, Orne et al. 1984). The relationshipbetween various forms of
genuine and simulated amnesia is poorly understood (Schacter
1986~).
The most recently celebrated case of malingered multiple
personality disorder occurred during the jailing of one of the
"Hillside Strangler" suspects, Kenneth Bianchi, in 1979. Age 26
and 44 at the time they began killing women in Los Angeles,
Kenneth Bianchi and Angelo Buono were cousins who raped,
tortured, strangled, and murdered ten young women and girls
between October 1977 and February 1979.
When Bianchi was apprehended in Bellingham, Washing-
ton, and charged with the murder of two Whatcom County girls,
he claimed amnesia for the evening of the killings, January 11,
Structure and Oynamics 173
1979 (O'Brien 1985). Both his defense attorney and psychiatric

social worker suspected a psychiatric problem, and they retained
Donald Lunde, M.D., a forensic psychiatrist from Stanford Uni-
versity, to evaluate him. Bianchi had done considerable reading
in psychology and psychiatry and was also fortunate enough to
view the movie "Sybil," based upon the book of the same name
that portrayed a multiple personality disorder (Schreiber 1973),
broadcast on BCTV, March 9,1979, two days prior to his inter-
view with Lunde.
Lunde, however, did not evaluate the presence or absence
of multiple personality disorder, but suggested that either hyp-
nosis or sodium amytal be used to probe Bianchi's claimed amne-
sia. Schacter (1986~)called this form of forgetting "limited amne-
sia" and defined it as a pathological inability to remember a
specific event, or small number of events, from the recent past.
Bianchi's attorney subsequently retained John Watkins,
Ph.D., a psychologist from the University of Montana and re-
puted expert in the field of dissociative reactions. Watkins began
his interview of Bianchi on March 21, 1979, stating, "Maybe I
could be of some help to you. I don't know if I can or not but
maybe if we talk a little bit together, I could be of some help"
(O'Brien 1985, p. 233).
I find this particularly striking as an example of professional
role confusion. The psychologist was attempting to establish a
psychotherapeutic, "helping" context, whether feigned or real,
and if the doctor wasn't confounded about his role as a psycho-
therapist, in contrast with the role of a forensic psychological
investigator (Shapiro 1984), it surely established a questionable
premise for any individual being examined for diagnostic, rather
than treatment, reasons.
After exploring with Bianchi his childhood and attitudes
toward hypnosis through the use of such leading statements as
"John [Bianchi's social worker] was telling me a little bit about
your life . . . I understand it's been kind of a rough one, it hasn't
been all peaches and cream, your life, all together. . . ."
(O'Brien
1985,p. 234)' Watkins proceeded with his thirty-minute hypnotic
induction of Bianchi, which suggested the emergence of a sepa-
rate personality:
. . . I've talked a bit to Ken, but I think that perhaps

there might be a r t o h part of Ken that I haven't
talked to, another part that maybe feels som~what
difserently from the part that I've talked to. And I
would like to communicate with the other part . ..
Part, would you please come to communicate with me?
And when you're here, lift that left hand off the chair to
signal to me that you are here. Would you please come,
Part, so I can talk to you. Another Part, it tinotjust the
same part of Ken I've been talking to . . . Part, would
you come and lift Ken's left hand to indicate to me that
you are here? [italics added]. [O'Brien 1985, p. 2361
Bianchi's left hand rose from the chair. Watkins had provided
ample opportunity for Bianchi to consciously imitate a multiple
personality disorder and furthermore created a supportive envi-
ronment in which Bianchi's unconscious simulative processes
could begin to work. Watkins proceeded to establish a receptive
atmosphere for Bianchi to exaggerate the opposite-valenced
affects of splitting, or dissociative defenses, with which he was
probably quite familiar:
Watkins:Part, are you the same thing as Ken, or are

you different in any way?
Bianchi: I'm not him. . .
W You're not him.Who are you? Do you have a
name?
B: I'm not Ken.
Structure and Dgnumics 175
W: You're not Ken. Okay. Who are you? Tell me

about yourself.
B: I don't know.
W: Do you have a name I can call you by?
B: Steve.
W Huh?
B: You can call me Steve.
.
W . . tell me about yourself, Steve. What do you
do?
B: I hate him.
W You what?
B: I hate him.
W You hate him. You mean Ken.
B: I hate Ken.
W: You hate Ken. Why do you hate Ken?
B: He tries to be nice.
W . . . how do you mean-
B: I hate a lot of people.
W You hate a lot of people.
B: He tried to be friends.
W He tried to be friends. Who do you hate?
B: I hate my mother.
[O'Brien 1985, pp. 237-2381
Bianchi then established a motive for "Steve" as a subpersonality

unknown to Ken, to compel him to kill:
Biawhi: I made men] think all these real morbid

thoughts.
Watkim: Like what?
Biunchi: Ah, like there was nothing wrong with
killing cause it was like getting back at his mother, and
I made sure he didn't really know what was going on
. . . He thought it was his mother and he thought it was

people he hated. [p. 2391
O'Brien (1985) noted that at this point Bianchi had erred in his
deception, since Bianchi had already said that "Ken" did not hate
anyone and was always kind and polite. Watkins, moreover, gave
no indication in the transcript of noticing this slip. Moments later
Bianchi repeated his mistake, "cause Ken hates women," but
quickly interjected in the feigned role of Steve, "I mean, I hate
women" (p. 239).
Bianchi appeared to draw on his cousin, Angelo Buono, for
his characterization of "Steve." This suggests that quite con-
scious imitation, as well as the unconscious process of malignant
pseudoidentification, existed throughout his apparent depen-
dency on Buono during their sadistic killings in Los Angeles.
Bianchi also fashioned "Steve" after one of the subpersonalities of
Sybil, portrayed by Sally Field in the movie he had viewed for the
second time on March 12,1979.
During the psychiatric and psychological investigations of
Bianchi's feigned multiple personality disorder, he implied ther-
apeutic "progress" through his jail diary:
The name Steve that keeps popping into my head has

been familiar. I think I know something now about
myself- there is another stronger person inside of me.
I think he calls himself Steve. He hates me- hates my
mom-hates a lot. I feel this person wants to get me.
I've had dreams of someone who is a twin but he was
exactly opposite from me-for the past few days I feel
like my insides were at war-for the past two nights
just as I'm about to fall asleep bits and pieces have been
forming- the name -the struggle, me against him -in
my dreams it felt like the body of the twin was exactly
mine but the attitude totally foreign. I feel stronger
Structure and Llgnumics 177
but scared. I feel hate but I don't feel like reacting to

..
the feeling . Why does he hate me so much? Where
did he come from? [O'Brien 1985, pp. 249-2501
Bianchi also began writing poems on April 17,1979, suggestive of

an anxious, somatizing patient struggling to integrate an unfa-
miliar and despicable part of his personality:
I'm scared
my stomach hurts
there's no place to run
now,
it was easy to run away
before.
I feel strong, in control
but still unsure
of someone I've come to know,
someone I don't understand
as well as I know myself now. ..
I'm so alone now, somewhat
I feel naked.
I'm knowing me.
I wish I were free of him.
I want help.
I don't care for him
and he doesn't like me.
I feared confinement but
I'm thankful for it now.
[pp. 250-2511
Ralph Allison, M.D.,a psychiatrist without forensic experience

at the time, but an expert in multiple personality disorder, was
brought in by the defense to evaluate Bianchi on April 18,1979.
Allison's leading, suggestive questions are reminiscent of Wat-

kins, but now without hypnotic induction:
Allison: Did you ever hide inside your own head?

Bianchi: Sometimes, just to get away.
Allison: What do you do in there?
Bianchi: Talk.
Allison: Anybody else in there to talk to?
[p. 2531
Meanwhile Dr. Watkins ended his sessions with Bianchi as he

had begun them, as a psychotherapist rather than an investiga-
tor: 'You, Ken, are getting stronger every day, I don't know how
everything's going to come out, but I suspect youll be able to
handle things better" (p. 259).
Bianchi had identified "Steve Walker" as his one and only
subpersonality. Subsequent police investigation determined that
Bianchi had sent a letter to the registrar at California State
University, Northridge, asking for a diploma with the name not
filled in, and had signed it "Thomas Steven Walker." Bianchi had
enclosed a $90 money order, which the school accepted and then
mailed the diploma. Bianchi also had California State University,
Northridge transcripts with his name on them. The transcripts
and social security number were determined to match those of an
actual Thomas S. Walker. Walker was located in Van Nuys,
California, and he told the police that he had responded to an ad
in the Los Angeles Times for a psychological assistant, for-
warding his transcripts to a "Dr. R. Johnson" who happened to
reside at Bianchi's Verdugo Avenue address in Los Angeles.
Bianchi had erred, victimized by his own grandiosity and arro-
gance, by identifying his one subpersonality with the actual name
of an individual he had deceived to secure fraudulent transcripts
and a college degree (O'Brien 1985).
The prosecution retained Martin Orne, M.D., Ph.D., a psy-

chiatrist and psychologist from the University of Pennsylvania
and an international authority on hypnosis, to investigate Bian-
chi's multiple personality disorder. Orne initially addressed the
question of Bianchi's actual or feigned hypnotic state. Orne had
developed procedures for uncovering malingered hypnosis that
he called double hallucination, single hallucination, suggested
anesthesia, and source amnesia (Orne 1961).
Orne invited Bianchi, in a claimed hypnotic trance, to visu-
ally hallucinate his defense attorney in an empty chair. Bianchi
did so, and Orne pointed out the actual presence of his defense
attorney in an adjacent room. Bianchi reacted to this by stating
that the hallucinated man had disappeared, and wondering quite
vociferously, while still hypnotized, how the same person could
exist in two different places at the same time. Orne was cognizant
of the evidence that a hypnotized subject will accept the reality of
the suggested hallucination despite circumstances that violate
Aristotelian logic, that is, the paralogic (Von Domarus 1944)that
A can physically exist in two places at the same time (Meloy
198613). Bianchi also shook hands with the visual hallucination
without any hesitancy, suggesting the unprecedented spatial and
temporal contiguity of a visual and somesthetic hallucination.
Orne's (1961)suggested anesthesia procedure also depended
upon empirical evidence that hypnotized subjects rely on the
paralogic of the hypnotized state, even if it violates Aristotelian
logic. He drew an imaginary circle on the back of Bianchi's hand
and told him he would feel pressure when touched outside the
circle, but not when touched within it. Bianchi was instructed to
say "yes" when touched outside the circle and "no" when touched
within the circle. Bianchi had been placed in a double bind and a
logical contradiction: how could he say "no" when he wasn't
supposed to feel anything? He chose to say nothing when touched
within the circle, yet was mistaken. The genuinely hypnotized
subject would say "no" when touched within the circle, accepting
the logical contradiction as the moment's reality as defined by the

hypnotist, despite its illogic. Bianchi had fallen prey to the
Aristotelian law of contradiction, that A cannot be both A and B
at the same time (Von Domarus 1944).
The source amnesia test was inconclusive. Orne completed
his investigation by testing the hypothesis that Bianchi's mul-
tiple personality disorder was genuine. He suggested to Bianchi,
much as Watkins and Allison had done, but now using suggestion
as a conscious investigatory tool, that usually more than two
personalities existed in a multiple personality disorder. He did
this without Bianchi being hypnotized, further hinting that there
might be a problem with the diagnosis as a defense unless more
than two personalities were present.
Following Orne's hypnotic induction several hours later,
Bianchi produced a third personality, "Billy." Orne was now
convinced that Bianchi had not only feigned hypnosis, but had
consciously malingered these "multiple personalities."
Distressed by these untoward events in his attempts to
build an insanity defense, Bianchi wrote a will while in jail, quite
pathognomonic of his psychopathic process:
I, Kenneth A. Bianchi, being of sound mind and body,

do hereby writ3 this, my last will and testament. To my
son Ryan I leave all my worldly goods, as little as that
may be, it goes to him with my deepest love. It is
profound to me that I have had to experience more
confusion and mistrust and insincerity in society, if
only the right people had been wise enough to follow
through with their responsibilities, during the years of
forming me into the mold of adulthood, I wouldn't be
where I am now. There's a sadness in misunderstand-
ing, an emptiness like a hollow egg. The egg which can
produce life in two ways, one in creation and one in
Structure and L?ymrnics 181
sustenance and not realizing the potential of either.

[O'Brien 1986,p. 2741
Bianchi began plea bargaining with the Los Angeles County

District Attorney's Office, agreeing to testify fully and truthfully
against his cousin, Angelo Buono. He subsequently did neither.
Part I11
VIOLENCE, PSYCHOSIS,
AND RELATED STATES
Modes of Aggression
T h e Sun Fmncisco C h i c l e published this article on Friday,
November 21,1986:
Malcolm R. Schlette was absolutely convinced that he

was the victim of a conspiracy in 1955 that kept him
behind bars for 20 years for a $6 arson fire.
'There can be no doubt that a conspiracy existed in
this case in which criminal overt acts were committed
from such a conspiracy by persons herein named,"
Schlette wrote at one point, naming fow of the five
men who ultimately ended up on his death list.
The 72-year-old ex-convict exploded in a vengeful
rage Tuesday and killed the man who prosecuted him
31 years ago. After gunning down the first man on his
death list, former Marin County District Attorney
William Weissich in San Rafael, Schlette swallowed
poison and died.
In April 1955, Schlette was convicted of arson for
burning six wooden beer crates stacked against the
Bleu Baie Tavern a t Marshall, a bar run by his es-
tranged wife.
The damage done in that fire, which occurred in
September 1954, amounted to $6, according to the

court records contained in two trunks sent to The
Chronicle by Schlette.
A second charge in the same case that he subse-
quently burned the Seaside Tavern to the ground in
February 1965, was dismissed after a jury could not
arrive at a verdict.
Schlette (pronounced Shlettuh) was charged in the
bar fires after being arrested and questioned as a
suspect in a March 9, 1955, fatal motel fire that left
eight dead. He insisted on his innocence in that case
too, and a grand jury refused to indict him.
While in custody, Schlette confessed to the bar fires.
He claimed that the confession was coerced during a
nightlong interrogation in which authorities promised
to free his brain-damaged 13-year-old son, who was
being held in Juvenile Hall, in exchange for his confes-
sion.
In the reams of documents, a picture emerges of a
disturbed man who believed he was unjustly prose-
cuted for crimes he did not commit. The volurninous
records detail his long-festering allegation of a "mon-
strous wrong" inflicted on him by the courts.
Whether Schlette's conspiracy theory was a figment
of his tormented mind or not, court records show that
Weissich and the sentencing judge, Thomas Keating,
feared him and wanted him put away for as long as
possible.
On the day he received a two- to 20-year sentence for
the beer crate fire, Schlette stood in open court and
promised to kill Keating and prosecutor Weissich.
"I believe he is a dangerous psychopath," the late
Judge Keating said in one document forwarded to state
parole authorities in 1955.
In the same document, Weissich urged that Schlette
Violence, P8.llch08i8, and Related States 189
be held until prison psychiatrists could assure that "he

no longer is a menace to society."
"Should this assurance not be forthcoming. . . then it
is my opinion that he should be held in custody until the
law compels his release," Weissich wrote in 1955.
During two decades in prison, Schlette repeatedly
denied any wrongdoing in appeals to higher courts and
letters to family members and friends. The documents
in the trunks weigh 470 pounds.
His agonizing pleas for justice read like pages from
"Les Miserables," the Victor Hugo classic about a man
senteneed to a long prison term for stealing a loaf of
bread.
In 1971,after being in prison for more than 16years,
Schlette said that he was being punished far more
severely than others convicted of similar crimes.
T h e average time for release in this type of convic-
tion is about 2.5 years," he told the parole board. "Thus
my present confinement exceeds the average by about
14 years, and this has been done without my having a
criminal record prior to this conviction."
Schlette noted in one of his many appeals that all
charges against him at one point were dismissed by
both Keating and a municipal court judge.
The charges were reinstated only after Weissich
obtained an indictment from the grand jury.
"The district attorney knowingly used perjury and
subornation of perjury to obtain an indictment of the
same two charges, circumventing the rulings of the
municipal and superior court dismissals by having
three witnesses lie to the grand jury," Schlette argued
in a 1967 petition for freedom.
Schlette, who had a long history of mental illness,
was paroled after 11years in prison.
He failed to report to his parole officer and instead
traveled to Los Angeles, where he attempted to buy

guns to kill the five men he believed had "framed" him
in 1955.
He was captured after five days and sent back to
prison to serve the remainder of his twenty-year term.
Seething with a fury nurtured during his long years
in prison, Schlette was released in 1975 when authori-
ties could no longer legally keep him behind bars.
Human beings are particularly adept at intraspecies killing.

The tendency of H m sapiem to mass murder one another has
resulted in the death of over 59 million individuals from wars or
other disputes between 1820 and 1945 (Richardson 1960). The
total number of individuals killed during the past 35 years ex-
ceeds the total number of soldiers killed in both world wars in this
century and is estimated to be an additional 25 million people
(Cafiero 1979). In California the homicide rate (the intentional
killing of another) is 10.6 per 100,000 individuals (California
Department of Justice 1984), in contrast with the Interpol world
homicide average, which is 1.7 per 100,000 individuals. The
homicide rate in Los Angeles in 1985(17.6 per 100,000)was very
close to the homicide rate in Lebanon in 1982 (18.8 per 100,000).
Individuals awaiting legally sanctioned execution in the United
States, and residing on Death Row, attained a homicide rate of
73.3 per 100,000 during the 1977-1982 period (Lester 1986).
Despite the relative statistical rarity of homicide in partic-
ular, and violence in general, its continuous and variable expres-
sion among individuals has compelled numerous researchers to
attempt to classify modes of aggression in both animals and
humans from a variety of sociological, psychological, and biolog-
ical perspectives (Valzelli 1981).
My intent in this chapter is to understand this seemingly
diverse range of human aggressive and violent behaviors as
broad categories of either affective or predatmy aggression (Ei-
chelman et al. 1981). This simplified classification system has
Violence, Psychosis, and Related States 191
primarily evolved from animal research with cats and their

underlying neurochemical and neurophysiological mechanisms
during aggressive behaviors (Flynn 1967, Flynn et al. 1970, Chi
and Flynn 1971a, 1971b, Flynn and Bandler 1975). Affective and
predatory aggression appear to have distinctive neuroanato-
mical pathways and to be under the control of different sets of
neurotransmitters (see Chapter 2).
This system of classifying aggression as either affective or
predatory has yet to be empirically applied to the study of human
aggression and therefore should not be considered a reliable and
valid measure of human aggression. I t does, however, appear to
have important conceptual relevance for the clinical study of
human violence and to be a rich source of hypotheses that await
further investigation.
I will also present the psychoanalytic hypothesis that the
psychopathic process predisposes, precipitates, and perpetuates
the expression of predatory violence. In other words, the psycho-
pathic character is particularly suited to predatory violence for a
variety of object relational and psychobiological reasons.
AGGRESSION AND VIOLENCE
The distinction between aggression and violence is critical to a

clear understanding of both behavioral constellations. I am bor-
rowing a definition of aggression (Valzelli 1981) that is psycho-
biologically grounded yet behaviorally measurable: "Aggressive
ness is that component of normal behavior which, under different
stimulus-bound and goal-directed forms, is released for satisfying
vital needs and for removing or overcoming any threat to the
physical andor psychological integrity subserving the self- and
species-preservation of a living organism, and never, except for
predatory activity, initiating the destruction of the opponent" (p.
64). This definition includes two psychobiological principles
common to most attempts to delineate aggression: maintenance

of internal homeostasis and self or species preservation.
I will use a much narrower definition of violence (Megargee
1976)that makes no psychobiologid or object relational assump-
tions yet clearly defines violence as a behavioral act with certain
consequences: acts characterized by the application or overt
threat of force that is likely to result in injury to people,
The reader should note that modes of aggression may in-
clude acts of violence, but not necessarily, On the other hand,
aggression is a necessary component of all acts of violence.
Neither definition addresses issues of intent, psychopathology,
or morality, which are appropriately left to further scientific and
philosophical investigation.
AFFECTIVE AGGRESSION
This first mode of aggression subserves aggressive displays that
have traditionally been characterized as irritable, intermale,
territorial, or maternal. It is the most common mode of aggres-
sive vertebrate behavior and the mode of aggression that under-
lies most human violence. It begins with an intense and pat-
terned sympathetic activation of the autonomic nervous system
due to external or internal threatening stimuli. It is accompanied
by threatening and defensive postures and increased vocaliza-
tion. Often it is an end in itself and seldom correlates with feeding
or predation in animals. It may, however, sequentiallyprecede or
follow predatory aggression in humans.
I t appears that neuronal pathways mediating affective ag-
gression are widely distributed in the central nervous system of
vertebrates. Many of the pathways are closely related to the
spinothalamictract and periaquaductal gray, which may neuroa-
natomically explain the close association between affective ag-
gression and pain responses (Eichelman et al. 1981).
As noted in Table 2-1 (p. 26) circulating levels of serotonin
appear to negatively correlate with affective aggression, while

relative neurotransmission levels of norepinephrine, doparnine,
and acetylcholine appear to positively correlate with affective
aggression.
Affective aggression, specifically affective violence in hu-
mans, has a number of discrete characteristics, which I will now
elaborate on.
1. I n w e sgmpathetic arousal of the aui!orumic nervous
system. The sympathetic mobilization of the autonomic nervous
system in preparation for an increase in voluntary muscular
activity precipitates all affective violence. The release of epi-
nephrine by the adrenal medulla and adrenocorticotropic hor-
mone by the anterior pituitary breaks down protein and in-
creases glucose levels in the blood. Breathing accelerates,
increasing blood oxygen levels. Glucose and oxygen flow to the
voluntary musculature is increased by elevated heart rate and
arterial constriction (Schneider and Tarshis 1975). Physiologi-
cally the organism has entered an initial alarm state (Selye 1950)
because its internal environment's cellular homeostasis is being
threatened. The purpose of the sympathetic arousal is to return
the organism to an optimal state of cellular activity as soon as
possible.
The behavioral clues that signal autonomic arousal and that
may foreshadow affective violence include increased and shallow
breathing, skin flush, muscular rigidity, pupil dilation, increased
perspiration, attacking or defending postures, and increased
frequency and loudness of vocalizations.
2. The subjective experience of conscious emotion. Not-
withstanding the historical controversies concerning the neural
basis of emotion (James 1884, Lange 1885, Cannon 1927, Lashley
1938, Duffy 1941, Lindsley 1951, Schachter and Singer 1962,
Wasman and Flynn 1962), an individual who has engaged in
affective violence will usually retrospectively report intense
emotional states, described as either anger or fear.
3. Reactive and immediate wiolence, if present. There is a
close temporal contiguity between affective aggression and vio-

lent behavior due to the reactive nature of the behavioral se-
quence. Violence will follow within seconds or minutes of sympa-
thetic arousal if it is to be considered a product of affective
aggression. Psychobiologically the human organism is not
equipped to sustain a high level of sympathetic arousal. It is
predisposed to return to a state of homeostasis as quickly as
possible in the service of cellular efficiency. When forced to
maintain intense levels of autonomic arousal, the organism will
enter a state of resistance (Selye 1950),which has an immunosup-
pressant effect.
4. An internal19 or external19 perceived threat. Affective
violence is a reaction to a stimulus that threatens the ho-
meostasis of the organism. The perceived threat may impinge
the organism at a biological or psychological level, the former
referring to states of self- or species preservation, the latter
primarily referring to self-esteem, or affective, regulation.
The threat may originate in an actual object that is attended
to through the sensory-perceptual apparatus, or it may be an
intrapsychic representational object, usually an object percept,
that is phenomenally experienced as "not-I." The most common
clinical manifestation of internal threats are auditory, or verbal,
hallucinations. Such formed ideational experiences,whether psy-
chogenic or physiogenic in origin, have phenomenological, psy-
chological, dynamic, emotional, logical, and interpersonal dirnen-
sions (Lothane 1982).
In a minority of cases, command hallucinations compel the
paranoid schizophrenic to act (Ennis 1986). Most individuals with
auditory hallucinations will resist those that command activity,
but hallucinations of a persecutory nature may precipitate such
autonqrnic arousal and be perceived as so imminently threat-
ening that affective violence results.
F. S. had completed junior college, was married, and

had no criminal history. At the age of 22 he began
hearing "the voice of Satan" and sought the help of his

wife and minister to eradicate this troublesome expe-
rience. For a brief two months he also visited a psychi-
atrist and was given medications, but his wife and their
entire coqgregation, a Christian fundamentalist group,
persuaded him that only prayer would be effective. He
stopped the psychiatric care, and despite a worsening
of psychotic symptoms, embarked on a futile journey to
exorcise the "demons" through daily prayer meetings
with his wife and church members. Two years after the
onset of the acute paranoid schizophrenic symptoms he
developed a delusional identification with the Devil.
The command hallucinations intensified. One evening
he heard the voice of "Satan" tell him to "kill the one
you love the most." In a frightened and extremely
agitated state, he ran into the bedroom. His wife
screamed, "In the name of Jesus, Satan be gone!!!" He
assaulted her and strangled her to death. He then sat
down and called the police. F. S. was admitted to our
forensic inpatient unit in an acutely psychotic and
agitated state.
Delusional thought content may also be perceived as in-

ternal threatening stimuli in the absence of auditory, or other
sensory-perceptual, hallucinations, precipitating autonomic arou-
sal and subsequent affective violence.
D. T. was a 28-year-old Caucasian male who was found

guilty of second-degree murder and willful cruelty to a
child, and Not Guilty By Reason of Insanity in the
death of his girlfriend, P., on September 20, 1986.
As the patient entered the house of his girlfriend,
P., on Friday evening, September 19,he saw her 6-year-
old son playing in the living room. The boy said to the
patient, "Hey, there, hotshot, how are ya?" The boy
then said to his mother, within earshot of the patient,

"Mom, I want an Uzi machine gun, a real one." The
patient stated that at this point he believed that the
company he was working for in Los Angeles was tied to
the Mafia, the Mafia was a functional arm of the devil
on earth, and the boy had become a "beast" of the devil.
During these early hours Friday evening, P. suppos-
edly behaved toward the patient in a terse and very
cold manner. They went to bed and had no sexual
contact. The patient woke up in the middle of the night
and reported a spontaneous thought, "I've got to kill
the boy." He stated that while P. was sleeping, her left
leg crossed his as he was lying there awake, and he
thought, "I'm terrified, she knows what I'm thinking."
He stated that he had planned to get a pitchfork and do
away with the boy, but because of P.'s leg resting on
his, he was stopped from doing this. He stated he then
went back to sleep, believing that P. was controlling
him and being very fearful of her son.
On Saturday morning, September 20, the patient
found himself compelled to behave in a very docile and
dependent manner toward P. and her son throughout
the day. He delusionally believed that they were both
possessed and he had no other recourse than to follow
their orders. He recounted several events during that
Saturday that indicate ideas of reference and the pa-
tient's propensity to delusionally believe that his
thoughts were being controlled: He stated that he
attempted to use a spray bottle to clean appliances, the
spray did not work, and he knew this was a sign from
the devil that he should not be cleaning those appli-
ances; he took a shower, the water was pulsating, and
he knew the devil was pulsating the water, and there-
fore he did not have P.'s permission to take a shower;
he entered the laundry room, attempted to do the
laundry, noted that the cycles of the machine were

"rather odd," and knew that the devil was controlling
the laundry machine. When P.'s son woke up, he
wanted to roughhouse with the patient. He did this,
but was quite passive, believing that the son was the
beast of the devil and was in control of the patient's
responses. They attended a soccer game during which
one of the bystanders pointed toward a woman in a red
dress. The patient believed this was a reference to the
devil. He heard church bells ringing and knew that this
was a sign from God to "break out of this tailspin." He
then drove with the son to return home, and during this
car trip, several other events confirmed his psychotic
delusions concerning the son's identity. The son ap-
peared to make an engine noise stop by moving his arm
up and down; he made shadow animals with the sun-
light coming into the car, and the patient thought this
was a sign of "the jackal, the beast." The son wanted to
look at an old scar on the patient's hand that had been
caused by a drilling accident a year prior, and the
patient knew at that moment that the son had caused
the accident. He believed the son tried to control his
thoughts by playing music on the car stereo tape deck
over and over again. He knew the son made a car stop
at a median pedestrian crosswalk when they stepped
onto it. The patient and the son then went to a discount
store with the intent of buying a Bible and to some
degree fend off the demonic control he was feeling.
Later that evening, in a state of intense autonomic
arousal, the patient got out of bed, picked up the son's
pet tarantula, took it into the kitchen, and began cut-
ting it in half with a spoon. P. awoke, came into the
kitchen, and started screaming. She grabbed at him
and pushed him away. He reported that "things began
to speed up." He began to rapidly eat a peach from the
refrigerator, hoping it would give him more energy. He

remembered repeating the phrase, "The Father, the
Son, and the Holy Ghost." He hoped that by saying
this, he would "bathe in protective words." P. report-
edly ran into the room with her son and attempted to
hide. The patient broke down the door, grabbed her,
and attempted to knock her out with a wooden box on
the bookcase. He stated that if he could control her, he
could take her the next day to a local church and have
her exorcised. He took both P. and her son to the
garage, choked P. into a semiconscious state, and
bound both of them with Mylar tape. He described
binding their legs, hands, waists, and mouths. P. re-
gained consciousness and began to panic. He strangled
her to death, and remembers thinking, "that boy made
me kill his mother because I wouldn't be recruited into
the devil's brigade." He stated that he was not con-
sciously aware of any emotion during the actual stran-
gling, but remembered being covered with sweat.
Koehler (1979) distinguished between pseudohallucinations

as "an experience in the head" and true hallucinations as "an
experience in external space . . . substantially in objective
space." Although the localization of hallucinatory phenomena is
primarily metaphorical, I think it has important phenomenolog-
ical implications for the patient that may determine the correct
diagnosis.
Borderline personality-disordered individuals may subjec-
tively experience persecutory introjects as "voicesn that are
distinguished from the auditory hallucinations of the schizo-
phrenic process by two characteristics: first, the "voices" are
localized within the mind by the patient but are experienced as
ego dystonic, or "not-I," object percepts rather than self-
percepts; and second, despite the alien nature of the phenomena,
such patients, if asked, attribute the origin of the "voices" to their
Violence,Psychosis, and Related States 199
own psychological processes. This, of course, is a paradox, and it

is determined by the defensive, splitting processes that foster
such contradictions in the verbalized cognitions of the borderline.
In contrast, hallucinating schizophrenic patients will localize the
"voices" within or outside their mind and will usually disavow
the "voices" as a product of their psychological processes.
Borderline-personality-disordered individuals, including
those identified as psychopathic, nevertheless may be autonom-
ically aroused to affective violence through the internally threat-
ening stimuli of persecutory introjects. Such threatening in-
trapsychic material, however, usually arises in the midst of an
intensely negative transference reaction with an actual object,
unlike the auditory hallucinations of the schizophrenic, which are
not as dependent upon such actual transference arousal. The
schizophrenic's hallucinations may, in fact, phenomenologically
diminish once interpersonal dialogue begins.
5. Goal is threat reduction. The immediate objective of
affective aggression, or affective violence, is to reduce or elirni-
nate the perceived threat so that the organism can return to a
state of biological efficiency and psychological homeostasis. This
is usually done through behavioral repertoires involving fight or
flight and is emotionally accompanied by anger or fear, respec-
tively.
6. Rapid displacement of the target of aggression. High
levels of autonomic arousal and its accompanying affect states
seem to precipitate the rapid displacement of the perceived
threat from one actual object to another. In other words, during
states of sympathetic arousal immediately prior to affective
violence, the intrusion of a third party into an escalating situation
between two individuals may result in an assault against the
third party. I t is an accepted convention, supported by empirical
data (Moorman 1986), that peace officers are at substantial risk of
physical harm when intervening in domestic, or family, distur-
bances. I t is ordinary police practice to immediately separate the
individuals and remove them from each others' sensory-
perceptual sphere to facilitate a parasympathetic return to base-

line.
The internalized representation of the threatening object as
the intrapsychic vehicle for the actual displacement of the threat
seems to lose sensory-perceptual clarity as autonomic and affec-
tive arousal increases. This would render the threatening repre-
sentational object more vulnerable to displacement among actual
objects as the "goodness of fit" becomes less perceptually rigor-
ous. The loss of sensory-perceptual definition as an object repre-
sentation would invite such displacement and projection on a
variety of dissimilar actual objects:
R. M. first began using cocaine in 1975-1976in conjunc-

tion with his wife and other friends. It was also at this
time that he began to exhibit signs of jealousy and
suspicion toward his wife for having extramarital af-
fairs. I t is possible that these beliefs had some basis in
reality.
R. M. also became involved in the selling of co-
caine. This activity reached its peak in 1980 when the
patient was independently trafficking cocaine from
Florida to Los Angeles and was also identified as a
threat to established cocaine dealers in his neighbor-
hood. He reports that he engaged in this activity be-
cause "it was easy to make a lot of money," and he did
not consider any grave consequences that might occur.
He reports that his marriage began to fall apart at this
time, and they divorced when he was certain L., his
wife, was having an affair. R. M. states that he was
threatened and harassed by established cocaine
dealers during this period, and there appears to be
some basis for believing that this actually occurred.
This is not to discount the fact, however, that the
patient was also becoming increasingly paranoid and
delusional. The recent history since 1982 clinically
Violence, Psychosi8, and Related States 201
supports the age-old maxim, "even paranoids have

enemies."
The most recent focus of R. Me's difficulties has
been a neighbor named J. D. I t appears that J. D. was
an optimum target for the patient's paranoid fears
since J. D. is described by many people as an explosive,
aggressive, and unpredictable individual who was
quick to respond to any aggressive behavior by the
patient. For the past year they have engaged in mutual
harassment of each other that has included the slashing
of tires, throwing a brick and a fish through glass
windows, J. D. chasing the patient down the street
with a gun,and J. D. threatening the patient's 16-year-
old son in court as he shoved the patient's attorney.
During the course of these actual neighborhood
conflicts, the patient became increasingly paranoid. He
believed that J. D. "and others" were putting Nair in
his shampoo, injecting needles into his heel, harassing
him with electronic signals in the air, and poisoning his
food. On one occasion he visually hallucinated J. D.
coming through his bedroom wall. In response to his
increasing paranoid delusions and the actual conflict
with J. D., the patient purchased a 9 millimeter semi-
automatic pistol, a -45 Colt, a .32 caliber revolver, a
shotgun, and two .22 caliber rifles.
The patient also acted out his psychosis in a quite
obsessive-compulsivefashion: on one occasion he froze
some of his fecal material to have it tested for semen,
believing that he had been sodomized while he slept; on
another occasion he found a piece of lint on his couch,
thought it was a parasite, and took it to the Public
Health Department to have it analyzed since he was
sure it had been deliberately placed in his home. He
was undaunted when Public Health told him he was
overreacting.
This case illustrates the displacing of affective aggression

onto a variety of targets over a period of time and implies the
sensory-perceptual diffuseness of the threatening object repre-
sentations, facilitating the displacement process, when under
intense levels of arousal. It is also unusual because of the multiple
perceived threats, both internal and external, actual and fanta-
sied, that reactivated the aggression, and because of the use of a
potent psychostimulant that would heighten the autonomic
arousal. I diagnosed this individual as having a chronic paranoid
disorder in addition to his episodic cocaine abuse. There was also
some evidence that the patient had a paranoid personality dis-
order prior to any use of illicit drugs.
7. A time-limited behavioral sequence. Since affective vio-
lence is fueled by intense levels of sympathetic arousal, it is
always circumscribed and can usually be measured as a discrete
behavioral event lasting seconds or minutes. As I mentioned
earlier in this chapter, the biological organism's capacity to
sustain this "alarm" state is limited, and if the perceived threat
continues, it will psychobiologically adapt through a "resistance"
state with certain immunosuppressant effects (Selye 1950).
8. Prefaced by public ritual. I am defining public ritual as
stereotyped attacking and defending postures characteristically
displayed prior to the actual affective violence, the goal of which
is to reduce or eliminate the perceived threat. The display is
public because it is meant to be observed by the threatening
object; otherwise, it would lose its utilitarian value.
The public ritual is usually a parody of fighting or fleeing.
The attacking or defending postures display the organism as
fiercer or more timid and helpless than it actually is. On an object
relational level, the intent of the public ritual is to disrupt the
threatening person's perceptual "goodness of fit* of the target,
rendering the latter an unworthy object of attack.
Characteristic behaviors of individuals engaging in public
ritual prior to affective violence include certain demeaning ges-
tures, challenging and obscene language that is intended to
intimidate or humiliate the threat, clenching of the fists, certain

physical posturing intent on protecting the more vulnerable,
ventral side of the body, expansion of the abdominal-thoracic
region to visually appear larger than usual, and vocal displays
that are louder, higher pitched, and harshly toned.
Behaviors that are publicly ritualized to parody flight or
submission include fawning or officious language, exposure of the
ventral portion of the physical body to symbolize surrender, hand
gestures intent on establishing a submissive alliance with the
threat, contraction of the abdominal-thoracic region, and vocal-
izations that are quieter, lower pitched, and gently toned.
9. A primary affective d i m i o n . As the descriptive adjec-
tive implies, affective violence fundamentally correlates with
affective arousal and display, whether consciously felt as emotion
or uncor~sciouslydefended against.
Subjects who engage in affective violence and retrospec-
tively report consciousness of emotion may describe themselves
as being "carried away" or metaphorically transported by the
intensity of the emotion into the violent behavior. Psychobiolo-
gically, the intensity of the affect may disinhibit impulse control
to the degree that shock and disbelief by both the perpetrator
and observers follow the violent event. I t may be perceived as a
completely "out of character" display as the characterological
defenses against such impulses have been momentarily overrun.
Emotion that is present yet unconsciously defended against
may only be inferred by the degree of violence that is observed.
The borderline personality organization is particularly suited to
the dissociation, or splitting off, of affect during episodes of
violence. Higher-level neurotic personality organization sup-
ports the capacity of the individual to consciously experience
emotion during affective violence, and, retrospectively, to both
remember and process the emotional state.
The narcissistic defense against affects within borderline
personality organization may also keep emotion out of awareness
during episodes of affective violence. Model1 (1975) has termed
this a "massive affect block" (p. 275) that is common among

narcissistic personalities in the initial phases of psychoanalysis.
He differentiates it from isolation, which is a more focused
intrapsychic defense against the overwhelming intensity of the
affects. An "affect block" is motivated by a fear of closeness to the
actual object.
Although the context in which I am applying the term afSect
block is different, it is useful in further explaining the absence of
conscious emotion during affective violence in narcissistically
disturbed, especially psychopathic, individuals. It deepens our
understanding of the patient C. V. described earlier and his use
of dissociation during the murder of the stranger female hitch-
hiker.
The narcissistic affect block is invariably supported by a
fantasy of grandiose self-sufficiency. The degree of nonrelated-
ness to the actual object paradoxically correlates with the inten-
sity of the object hunger. In an affectively violent situation, the
insatiable, possessive hunger of the narcissist, heretofore de-
fended against through detachment (Bromberg 1979), is acted
out through the expression of hate that is sadistic, remote, and
determined. The hate, above all else,feels real and preserves the
grandiose self-structure by expressing the individual's "entitle-
ment to survive" (Buie and Adler 1973). The narcissist's fear of
his own devouring greed and the perceived retaliatory desires of
the actual object are ironically managed through his affective
violence, which once again establishes a detached control over
the interpersonal sphere.
The dynamics of affective violence in the psychopathic pro-
cess are virtually identical, but oftentimes are distinguished by
the presence of predatory violence before or after the affective
aggression. The psychopath may also express affective violence
in a more sadistic manner than the narcissistic personality
without psychopathic characteristics. This is correlated with the
degree of childhood violence the psychopath experienced and the
consequent intensity of annihilatory fear encapsulated in the
grandiose self-structure. This fear may be expressed as rage in

order to hurt and control (Glasser 1986),rather than destroy, the
maternal introject, for a moment projected onto, and perceived
within, the actual victimized object.
10. Heightened and d i m e sensory awareness. Affective
violence is marked by the individual's hypervigilance to all
stimuli in the external environment. A diffuse, exteroceptive
attentional set, a scanning of the environment to ferret out all
perceived threats, is characteristic of affective violence.
This diffuse awareness facilitates the displacement of the
perceived threat onto other actual objects that may be quite
noninvasive and benign. I t is akin to the hypervigilance of the
paranoid individual who must remain in a state of readiness
against the perceived malevolence of any, and perhaps all, actual
objects (Shapiro 1965, Meissner 1978). The paranoid individual's
diffuse attentional set is distinguished, however, by its chronic-
ity. The scanning hypervigilance of the affectively violent indi-
vidual diminishes as autonomic arousal lessens.
11. Self- and object percept dediflmentiation. Intense levels
of autonomic arousal and affective violence may be accompanied
by an intrapsychic loss of distinction between self- and object
percepts. Self-percepts are the "I" represented in dreams, day-
dreams, purposeful visualizing, sexual and aggressive fantasies,
intentional or spontaneous visual images, or auditory sounds
"heard" in the mind and embraced as a part of "I." They are
phenomenally located as coming from within the self and are
identified as belonging to the self. Object percepts encompass the
"not-I" represented in dreams, daydreams, purposeful visualiz-
ing, sexual and aggressive fantasies, and intentional and sponta-
neous visual images or auditory sounds "heard" in the mind.
Although phenomenally experienced as coming from within the
self, they are identified as not belonging to the self, hence, an
object (Meloy 1985).
This self- and object percept dedifferentiation can be psy-
chobiologically understood as a limbic domination of the higher
cortical primary and secondary associational areas. This momen-

tary collapse and fusion of self- and object percepts is character-
istic of acute personality regression to a psychotic level of func-
tioning (Mahler 1960). The loss of intrapsychic boundary between
self- and object percepts would affectively transport the indi-
vidual vulnerable to psychosis, such as the borderline personal-
ity, to intensified levels of annihilatory fear and subsequent
violence. There would be a momentary loss of the sensory-
perceptual distinction between past and present time, self- and
other image, and thus the safety of a bulwark against invasive
psychic material.
The self- and object dedifferentiation may also chronically
exist in the psychotic individual with schizophrenia, schizoaffec-
tive, or bipolar disorder that is refractory to treatment. Such
patients have usually abandoned all actual relations with others
in the service of dedifferentiated self- and object representations
that have no sensory-perceptual fit with external reality. Actual
relationships may exist only toward the nonhuman environment
as perceived by the patient:
. . . Violent acts which are so typically latent among
schizophrenic patients . . . are in part referable to the
patient's poor differentiation between the living and
nonliving, human and nonhuman ingredients of the
world in which he lives. Thus the violent act can be
thought of as made possible by the patient's failure to
distinguish, for example, between a living baby and an
inanimate doll, and at the same time as expressing his
effort to achieve such a differentiation, as part of his
undying struggle to establish a more mature ego func-
tioning and a better relationship to reality. [Searles
1979, p. 3271
Such affective violence usually has no pattern of victim selection
and may be quite random, arbitrary, and therefore, extremely
dangerous:
J. M. had a ten-year history of chronic paranoid schizo-

phrenia. He was unpredictably assaultive and hurtful
of others. Neuroleptics and lithium carbonate resulted
in a tenuous stability of behavior, but no diminution of
his auditory hallucinations, persecutory and grandiose
delusions, and formal thought disorder. He could be
observed, when standing alone, becoming very angry,
listening intently, laughing hysterically, or arguing.
Victims of his affective violence were usually unlucky
individuals who happened to be physically close to him
at the moment of his motor aggression.
We found that the most frequent and severe histories of affective

violence in a sample of chronic schizophrenics were accompanied
by organic impairment when measured by standardized neuro-
psychological testing (Adams et al. 1987). Such impairments were
localized in areas of the cortex associated with social adaptation,
such as expressive speech, reading, and writing.
12. Possible loss of reality testing. As suggested by the
intrapsychic loss of self and object differentiation that may occur
during affective violence, the violent individual may be clinically
judged to have lost contact with reality and therefore be consid-
ered psychotic at the time of the affective violence.
Reality testing is the sine qua non of all psychoses, regard-
less of etiology (Frosch 1983a). I t is the capacity to measure
intrapsychic experience against the actual and immediate inter-
personal experience; and when this capacity is lost, a failure of
reality testing has occurred. Reality testing, however, is to be
carefully distinguished from reality sense, distortions of the
latter pathognomonic of dissociative states and sensory-
perceptual illusions (see Chapter 5; Frosch 1983a).
Individuals who can adequately test reality have the ca-
pacity to delineate between their internalized object world, re-
gardless of how bizarre it is, and their actual relations with
others. There is no confusion concerning what affects, ideations,
or impulses are contained within the self, such as occurs at a

borderline level of personality organization. There is also no
confusion as to the boundaries of the self, such as occurs a t an
episodic moment or chronic level of psychotic personality orga-
nization.
I would like to introduce the concept of psychotic envelop-
ment to metaphorically suggest the various degrees to which the
psychotic portion of the personality impairs the ego's capacity to
reality test, along which a point exists where reality testing is
completely lost. The following case is illustrative of this phenom-
enon, which is critical to understanding the relationship between
escalating levels of affective violence and toss of reality testing:
K. I. had chronic paranoid schizophrenia for twenty

years. He knew well that the first sign of his psychosis
returning was the "space commander's voice" telling
him what to do. His history of affective violence, how-
ever, had usually been directed toward himself. During
the past decade, when psychotic, K. I. had severed his
ear lobe and his penis.
One year ago, while living alone in a studio apart-
ment, he heard once again the space commander's voice
telling him to burn down his room. Frightened by his
familiar auditory hallucination, and recognizing it as a
symptom of his impending psychosis, he called both the
police and fire departments and told them he had a
"compelling urge" to burn down his apartment and he
needed help. The dispatcher recorded his conversation
but did not respond to the call. Several hours later, as
the psychosis, in the form of an auditory hallucination,
and now the added delusion that the space command-
er's voice was real, enveloped K. I., he lost all capacity
to test reality and resist his impulses. He set the fire,
ran for help, and was subsequently arrested and
charged with Felony Arson.
Although the prosecution had ample evidence

through the recorded telephone calls that K. I. could
distinguish right from wrong immediately prior to the
crime, the case did not go to trial and K. I. was found
Not Guilty By Reason of Insanity.
K. I. had initially been able to test reality despite the

presence of a familiar auditory hallucination. Yet as the psy-
chosis enveloped him, he lost the capacity to test reality, that is,
to recognize that the hallucination was a symptom of his paranoid
schizophrenia, and delusionally believed that it was real and its
imperatives must be followed. This psychotic envelopment ap-
peared to correlate with increasing levels of autonomic and
affective arousal, contributing in K. I.'s case to conscious feelings
of terror and help seeking. The affective violence occurred at the
point where K. I.'s reality testing was lost. Prior to that point in
time K. I. was able to contain the psychotic portion of his
personality and recognize its symptomatic expression as a
product of his schizophrenia.
The concept of psychotic envelopment has both temporal
and spatial dimensions. The temporal dimension implies that
psychotic symptoms, such as hallucinations and delusions, may
be present yet the time has not been reached when the individual
cannot distinguish actual, interpersonal reality from these symp-
toms. The approximate time at which reality testing is lost
usually correlates with a loss of socially adaptive behavior. In the
case of K. I., this resulted in affective violence directed toward
his property.
The spatial dimension is metaphorical, but has conceptual
importance and some empirical validity (Grotstein 1978, Meloy
1984, Ogden 1985, Stewart 1985, Szekacs 1985). It is implicit in
several commonly used clinical descriptors, such as encapsu-
lated, contained, and concealed psychotic symptoms.
Grotstein (1977, 1978) described psychic space as a "veri-
table workbench of thinking" (1978, p. 65). He conceptualized the
psychotic as experiencing an actual closing of the space he is in

because of a defect in his perceptual capacity to organize and
represent internal space. This is caused by a regressive disorga-
nization of both ego boundaries and reality-testing apparatus, as
well as a dysfunction of the vestibular apparatus.
Grotstein's concept chiefly involves the ontogenesis of a
sense of space from zero dimension to one dimension, to two, and
three dimensions. In the zero dimension of psychosis the uni-
verse is mathematically that of a point and is experientially that
of boundless, infinite space "where all phenomena relate to the
.
self and all causation radiates from the self. .the collapse of the
walls of psychic space with consequent dysdimensionalization is
. . . a true invariant of psychosis. . . . " (Grotstein 1977, p. 440).
Psychosis can be conceptualized as mental content without a
container.
In a small empirical study (Meloy 1984), I found that a
sample of biological parents of schizophrenics showed significant
negative correlations between variance of primary process ma-
terial in their dreams, a measure of one-dimensionalspace, and a
measure of formal thought disorder when awake. Such a constric-
tion of variability in primary process content of manifest dreams
could be a regressive marker that is clinically validated by the
presence of an increase in formal thought disorder. As Grotstein
(1977) wrote, "Thoughts, like armies, need space in which to
manoeuvre. When psychic spatial collapse ensues, the ma-
noeuvring of thoughts becomes handicapped and the thoughts
'freeze' as concretions" (p. 436).
This capacity to experience internal space appears to be a
primary apparatus of ego autonomy (Hartmann 1939), and with
psychotic envelopment and the ensuing collapse of internal
space, self- and object representations are dedifferentiated and
reality testing is lost.
The reverse of psychotic envelopment is the partially re-
compensated schizophrenic individual who is still experiencing
psychotic symptoms but has regained the capacity to test reality.
In other words, such individuals recognize their symptoms as

such and are able to measure them against actual interpersonal
reality and distinguish between the two. This is, of course,
prognostically quite favorable, especially when the fully recom-
pensated schizophrenic individual has the evocative memory
capacity to reflect on his or her psychotic experience and learn
from it.
I t is, however, potentially destructive when schizophrenic
individuals are able to dissemble, or conceal, their psychotic
symptoms because they have regained the ability to recognize
what behaviors are socially acceptable. This is particularly ma-
lignant in forensic settings when restoration of sanity or compe-
tency issues are in the forefront and it is to the patient's advan-
tage to appear fully recompensated. The individuals' thoughts
may be pervaded by private delusions, yet they can choose to
vocally express only those thoughts that will be perceived by
others as logical and sensible. I have seen this phenomenon on
several occasions when a paranoid schizophrenic is able to
present himself in an affectively appropriate and cognitively
organized manner until his actual object relationship to me
precipitates a delusional upsurge of paranoid content that can be
sudden, fantastic, and quite threatening. Such immediate psy-
chotic envelopment is usually accompanied by autonomic arousal
and the heightened probability of affective violence.
13. Lowered selfesteem. The perceived threat that always
precedes affective violence is related to either the biological or
psychological homeostasis of the organism. In the latter case,
affective regulation, or self-esteem, is involved. Lowered self-
esteem, the affective complex that correlates with the self-rep-
resentations and bathes the subjective experience of self with
certain negative valenced emotions, may be impinged upon
during an affectively violent event in two characteristic ways:
First, the individual's defensive operations that maintain the
homeostasis of the self-affect are directly assaulted by the per-
ceived threat and are phenomenally experienced as confusion,
fear, anger, or acute anxiety immediately prior to or during the

affective violence; or second, the individual's affectively violent
behavior results in profound feelings of guilt, remorse, and
shame in the aftermath of the event, causing a more negatively
valenced emotional state surrounding the subjective sense of
self. This affective descent in self-regulationis clinically apparent
in symptoms of depression and implies the presence of superego
elements in the personality. I t contraindicates any psychopathic
object relational structure.
Affective violence in the psychopathic process may be fol-
lowed by periods of acute dysphoria and narcissistic rage, partic-
ularly if the individual is involuntarily contained through com-
mitment or custody (see Chapter 4). These affects, however, are
closely associated with the grandiose self-structure and convey
no sense of empathy toward the victim. Occasionally in the
psychopathic process, one will observe the individual feigning
remorse for the victim as an imitative, self-serving gesture.
Interpretation and confrontation of this irnposturing will usually
surface the righteous indignation and profound contempt that
has been consciously suppressed.
PREDATORY AGGRESSION
The second mode of aggression characteristically results in the

destruction of prey. In animal models its primary purpose is to
secure food. Unlike affective aggression, it involves minimal or
no autonomic arousal, vocalization, or elaborate behavioral dis-
plays. It is not associated with increased irritability, and the
animal may be so attentionally riveted to the prey that there is a
selective suppression of other sensory input (Hernandez-Peon et
al. 1956). Predatory aggression usually occurs between species,
with humans being the exception. There are characteristic,
Violence,Peychouh, and Rehted States 213
species-specific killing patterns. For example, most land mam-

mals stalk their prey and attack with lethal strikes to the dorsal
side of the neck (Eichelman et al. 1981).
Neuroanatomical pathways of predatory aggression remain
to be defined, but they appear to project from the hypothalamus
into the ventral midbrain tegmentwn. For example, frog killing
by the rat is facilitated by intracerebral injections of cholinergic
agents or electrical stimulation of specific sites within the lateral
hypothalamus, thalamus, and ventral midbrain (Bandler and
Moyer 1970).
As noted in Table 2-1 (p. 26), the neurotransmitters sero-
tonin and the catecholamines appear to inhibit predatory aggres-
sion. Cholinergic agents, such as acetylcholine, appear to facili-
tate predatory aggression. The anatomy of the cholinergic
pathways subserving predatory aggression may overlap the
central cholinergic systems described by Shute and Lewis (1967).
Predatory aggression, specifically, predatory violence in
humans, has certain characteristics that correlate with, yet are in
contrast to, those I have used to define affective violence.
1. Minimal or absent autonomic arousal. There is a
striking absence of sympathetic arousal of the autonomic nervous
system prior to or during acts of predatory violence. A conse-
quence of this lack of an "alarm state" (Selye 1950) is a dearth of
behavioral indicators that precede, and therefore predict, pred-
atory violence.
Predatory violence, however, may occur sequentially with
affective violence, the latter's presence indicated by high levels
of sympathetic arousal. Skin-boundary contact with the victim
may correlate with a shift to affective violence that has been
preceded by a period of predation. This is a common occurrence
among sexual psychopaths who will be predatorily violent until
they are in actual physical contact with the victim and then
psychobiologically shift to a state of affective aggression and
violence due to the sensory-perceptual triggers of the victim; in a
sense, the victim may be perceived as invading the psychopath's
visual, auditory, olfactory, gustatory, and somesthetic fields

despite his aggression, leading to high levels of sympathetic
arousal.
On the other hand, predatory violence may follow a period of
affective violence. This most commonly occurs among psycho-
pathic or narci~sist~ic
individuals who will fmd themselves in the
midst of an explosive, affectively violent episode and as auto-
nomic arousal subsides, the pattern of violence will shift to a
predatory mode. The psychobiological and psychodynamic alter-
ation in aggressive paradigms is precipitated for one of several
reasons: The individual may want to gratify sadistic impulses by
exploiting the already existent suffering of the victim through
the infliction of additional emotional or physical pain, or the
individual may intentionally carry out acts of predatory violence
to deceive forensic investigators and conceal the true motives of
the affective violence. This sequential shifting between modes of
affective and predatory violence may be determined by a variety
of interpersonal and intrapsychic factors.
2. No conscious experience of emotion. The predatorily
violent individual will retrospectively report an absence of con-
scious emotion. If any emotion is experienced, it will usually be
described as feelings of exhilaration, and it is most prevalent
during time periods prior to the actual violence when the victim
is being stalked. The conscious feeling is embedded in defensive
processes of projective identification and omnipotent control,
and this usually conveys a clinical sense of the magnitude of the
grandiose self-structure. Conscious affect in predatory violence,
however, appears to subserve, rather than dominate, the
cognitive-conative complex of predatory violence (criterion
number 9 below). As Theodore Bundy, the convicted sexual
psychopath, stated, "The fantasy that accompanies and gener-
ates the anticipation that precedes the crime is always more
stimulating than the immediate aftermath of the crime itself"
(Michaud and Aynesworth 1983, p. 111). This is in contrast to the
Violence, Psgchsis, and Related States 215
affectively violent individual who will feel literally transported

by the intensity of the emotion.
3. Planned and purposefil violence, if present. Predatory
violence is intentional, consciously planned, and purposeful. It is
a unilateral activity, rather than one that is precipitated by a
perceived threat.
I t is intentional in the sense that the predator chooses when
the violence occurs, against whom, and to what degree. Con-
scious intent, however, may be eroded by other less conscious,
instinctual, or defensive processes. Predatory aggression in sub-
human species is usually intended as food-seekingbehavior and is
precipitated by interoceptive sensations of hunger; it is virtually
always an interspecies behavior. Predatory violence among hu-
mans, notwithstanding the collective predation that is sanctioned
as armed strategy between nation states, and despite its con-
scious intent, may have several unconscious or defensive pur-
poses. I t may be used to gratify certain vengeful or retributive
fantasies. I t may be subjectively experienced as a repetitive,
necessary behavior that would be clinically assessed as compul-
sive.
This type of intentional erosion is most apparent in compul-
sive murderers (Revitch and Schlesinger 1981),who will usually
commit homicide in a serial fashion, and it is oftentimes dynami-
cally explained as displaced matricide. The intent, however, is
still quite present, but the choice to kill is exercised against a
background of intrapsychic "fueling" by the unconscious wish, or
repetition-compulsion. Theodore Bundy provides a telling ex-
ample of this blending of background compulsivity and fore-
ground intentionality in his own words, but using the third
person:
In the wake of a particular crime ... he was not in a

state of remission. That is, he actively wanted to go out
and seek a victim. But he knew that he could not afford
to do so without creating an intolerable amount dmore

public frenzy and panic, as well as police activity. . . .
.
Frequently after this individual . . committed a
..
murder he would lapse . into a period of WOW,
remorse, et cetera. And for a period of time he would
do everything to overcome and otherwise repress the
.. .overt behavior. Indeed, on one particular oecttsion
he went to extraordinary lengths to do this following a
crime, and he felt that he had succeeded, that the
abnormal course of conduet had just sort of. . . extin-
guished itself.
But in this instance, the cracks in the facade, as it
were, began to appear. He then would attempt tu
channel the desire within him into a different area, into
..
something which was still . improper, immoral, ille-
gal, but something that was less serious, less severe
.. . and so he in sort of a compromise decided that
rather than go out and inflict this mortal injury on
someone he would search out a victim in such a way
that there would be no possibility of detection and he
would not be forced into a position of having to kill. In
essence, he compromised into just going out and per-
forming an act of rape, as it were.
So he .. . began to just go out driving around the
. ..
suburbs . . in this city . that he was living in, and
one particular evening he's driving down a fairly dark
street and saw a girl walking along the street. . . .
Because the area was dark and she was alone, he
decided to select her as the victim for this intended act
of sexual assault. He parked his car down the street
and . . .then ran up behind the girl. Just as he came up
on her they were at a place where there was an or-
chard, or a number of trees or something. As he came
up behind her she heard him. She turned around and he
.
brandished a knife . . and grabbed her by the arm and
Violence, Psycho&, and Related States 217
told her to do what he wanted her to do . . . to follow

him.
He pushed her off the sidewalk into this darkened
.
wooded area and. .told her to submit and do what he
wanted her to do. She began to argue with him and he
kept telling her to be quiet. She said she didn't believe
he would do anything to her, anyway. . . .
Then he began to try to remove her clothes and she
..
would. continue to struggle in a feeble manner. And
also voice verbally her objections to what was going on.
..
And then . the significance now is that his intent
with this wictim was not to harm her. He thought this
was going to be a significant departure; perhaps, even
a way of deconditioning himself, to climb down that
ladder or, I can't think of a good word, de-, de-escalate
this level of violence to the point where there would be
no violence a t all. Even no necessity for that kind of
encounter a t all. . . .
But he found himself with this girl who was strug-
gling and screaming . . . not screaming, but let's say
just basically arguing with him. There were houses in
the vicinity, and he was concerned that somebody
might hear. And so, in an attempt to stop her from
talking or arguing, he placed his hand over her mouth.
.
. . She stopped and he attempted to remove her
clothes and she began to object again. At this point, he
was in a state of not just agitation, but something on
the order of panic. He was fearing that she would
arouse somebody in the vicinity. . ..
So, not thinking clearly, but still intending not to
harm her, let's say he placed his hands around her
.
throat . .just to throttle her into unconsciousness so
that she wouldn't scream anymore. She stopped strug-
gling and it appeared she was unconscious. But not, in
his opinion, to the point where he had killed her. . . .
Then let's say he removed her clothes and raped her

and put his own clothes back on. At about that point he
began to notice that the girl wasn't moving. It ap-
peared, although he wasn't certain, that he'd done what
he promised himselfhe wouldnt do, and he had done it
really almost inadvertently [italics added]. [Michaud
and Aynesworth 1983, pp. 132-1351
This hypothetical analysis also illustrates the sequential shift

from predatory to affective violence, a psychobiologic and psy-
chodynamic alteration seemingly triggered by physical contact
with the resistant victim.
Intent may also be fueled by a need to exercise omnipotent
control over the victim through compulsive manipulation and
deception (Bursten 1973a; see also Chapter 6). Omnipotent con-
trol may also need to be exercised for instrumental gain, rather
than just intrapsychic reasons. Such is the case in acts of preda-
tory violence where the intent is monetary profit or expediency.
Levin and Fox (1985) noted that violence against prosecution
witnesses who intend to testify about illegal activities is a
common form of expedient violence. In a personal conversation,
Richard Rappaport, M.D.,noted the political and monetary ex-
pediency of predatory violence committed by organized crime
members and mercenary operatives. Revitch and Schlesinger
(1981) would classify this form of violence as "socially and envi-
ronmentally stimulated homicides" and would view it as the most
exogenously motivated form of murder. Such typological charac-
teristics are useful, but are one step removed from the intrapsy-
chic structure that allows such predatory violence and the psy-
chobiology that supports it.
4. No or minimal perceived threat. The immediacy of a
perceived threat, and the consequent reactivity of the violence, is
absent in the predatory mode. In predatory violence, the ag-
gressor must initiate motor activity to be in close physical prox-
Violence, Psychosis, and Related States 2 19
imity to the victim. The target of the violence is actively sought,

rather than reactively attacked. The term stalking is oftentimes
used to describe this quiet, unobtrusive predation.
5. Multidetermined and variable goals. Unlike affective
violence where the singular goal is to reduce the perceived
threat, predatory violence may be stimulated by a variety of
conscious and unconscious objectives: the gratification of
vengeful fantasies, relief from compulvive drives, the gratifica-
tion of sadistic desires, the repetitive exercise of omnipotent
control to evacuate persecutory introjects, relief from psychotic
symptoms such as paranoid delusions or auditory hallucinations,
the attenuation of jealous or envious emotion that is pathogno-
monic of narcissistic disturbance, the satisfaction of perversions,
the consummation of command hallucinations, or the resolution
of a chronic catathymic crisis (Wertham 1937, Revitch and Sch-
lesinger 1981). The latter situation is particularly interesting,
and refers to violence within the framework of an ego-
threatening relationship. The chronic catathymic crisis occurs in
three stages: incubation, violent act, and relief. The predation is
apparent during the first stage when the idea that violence must
be committed is compelling. The predation is marked by obses-
sive preoccupation with the victim, depression, and frequent
formal thought disorder wherein suicidal ideation intermingles
with homicidal plans. The incubation period may last several
days to a year (Revitch and Schlesinger 1981):
C. C. was a 28-year-old Caucasian male charged with

second-degree murder in the death of his 60-year-old
mother. He was admitted to our forensic treatment
unit due to suicidal ideation and intent following his
arrest.
C. C. had been living alone with his mother for the
past year following the dissolution of a marriage and
difficulty holding jobs for any period of time. He was
reportedly argumentative and suspicious with all em-

ployers and would accuse fellow employees of belittling
and betraying him.
Approximately six months prior to the instant
offense, C. C. became convinced that the only two
choices he faced in his current situation were to kill his
mother or himself. He found her degrading and provoc-
ative, as she would angrily accuse him of the failures in
life that were becoming increasingly apparent to him.
He was an only child; the father had left the family
when C. C. was a small boy.
C. C. began increasing his daily usage of cocaine
and became obsessively preoccupied with thoughts of
suicide and homicide. One evening he decided to kill his
mother, and following a brief conversation with her
while she was in bed, he drew a .22 caliber revolver
from a cabinet in the hallway, returned to her room,
and shot her in the forehead. He cleaned up as best he
could, pulled the covers up around her neck, and left
her face up, reclining against her pillows.
C. C. stayed in the house with his mother for two
months. He would leave the house to secure food and
cocaine, but otherwise remained. As putrefaction
began to occur, he stuffed towels around the bedroom
door and attempted to seal off the room. He watched
home movies in the adjacent living room, films of his
dead mother, his abandoning father, and himself.
Neighbors involved the police, and C. C. was
subsequently arrested at home and charged with his
mother's murder.
Psychodiagnostic testing and interviews revealed
a schizoid personality disordered individual who sub-
jectively experienced relief following the shooting
death of his mother but was otherwise quite detached
from any conscious feeling states. He showed no guilt
Violence, Psgchosis, and Related States 221
or remorse for his act and evidenced a heightened level

of arrogance and narcissistic disturbance once he had
adjusted to the maximum-security environment. His
suicidal ideation rapidly remitted, and he was dis-
charged from the forensic treatment unit a week after
his admission.
His indifferent attitude toward his crime fright-
ened members of the treatment staff, and he was
jokingly characterized as a perfect understudy for
Norman Bates in Alfred Hitchcock's 'Tsycho."
This case accentuates two structural personality character-

istics that are invariably present in individuals who are violent as
a result of a chronic catathymic crisis: a borderline personality
organization that facilitates a limiting and polarized perception of
reality, in this case a symbiotic envelope that allowed only the
death of self or selfobject, and psychopathic processes within the
borderline personality that facilitate the predatory planning and
intent that accompanies the catathymic buildup of tension and
distress.
The goals of predatory violence may also be primarily de-
termined by environmental and situational factors. Ideological
commitments, religious beliefs, cultural values, commercial
media and television, organized criminal activities, youth gangs,
terrorist groups, criminal subcultures, family systems that dis-
inhibit aggression, and acute socioeconomic stressors may all be
primary catalysts in the perpetuation of predatory violence.
Leyton (1986) approached the recent phenomenon of serial
murder in the United States from a cultural-anthropological
perspective in his study of six well-known cases. He hypothe-
sized that the primary mission of the modern serial murderer
was to wreak vengeance upon the established social order. His
small sample appear, from a sociological perspective, to be
among the very class conscious, obsessed with nuances of status
and power.
Yet both serial and mass murderers are overwhelmed

with a profound sense of alienation and frustration
stemming from their feelings that no matter how fierce
their ambitions may be . . . no matter what they might
do, they could not achieve the place in society to which
they aspired. ... They aim high, these multiple mur-
derers: they have not, like Durkheim's contented man,
accepted their station in life. . . . In such a milieu, a
sense of personal mission begins to incubate. [Leyton
1986, p. 301
Leyton's fmt case is illustrative of his hypothesis. Edmund

Kemper murdered his grandmother and grandfather when he
was 14. He was incarcerated until the age of 21, when he was
paroled to his mother against the advice of his treating psychia-
trists. After two years of "rehearsal," that is, picking up pretty
female hitchhikers in the Santa Cruz, California, area, he began
an eleven-month murdering spree that left eight additional
women dead, all young, attractive coeds, except for his final two
victims, his mother and her best friend. Kemper mutilated,
decapitated, and sexually assaulted after death, most of his
victims. Leyton noted that he killed in perfect symmetry: first
two kin, then six beautiful young women, and then concluded
with a kinswoman, his mother, and quasi-kin, her intimate friend.
Kemper stopped his serial murdering, and was finally able to
convince the local law enforcement agency that he was the
perpetrator.
Leyton (1986) interpreted Kemper's murders as a task with
which he confronted the social order with the fact of his excom-
munication; he chose young women for victims because they
were "the front line. . .the flamboyant sexuality" of the class that
humiliated him through their acts of indifference. He completed
what Leyton referred to as a trilogy of communal, sexual, and
familial revenge, establishing his identity in the social order.
I find Leyton's work compelling, since predatory violence,
in this case serial murder, does occur in a sociocultural milieu that

undoubtedly influences the nature and extent of the aggression
itself. Leyton's work, however, is flawed for several reasons:
First, it does not account for the false positives, that is, the
multitude of individuals who have experienced virtually com-
plete social and self-alienation yet do not resort to the task of
extreme and predatory violence; and second, the capacity of an
individual to carry out acts of predatory violence must always
and fundamentally return to the personality structure of the
individual, regardless of the sociocultural milieu that may predis-
pose such behaviors. And, of course, this personality structure
has dynamic processes that are both quite characterologically
predictable by adulthood and are undergirded by certain psycho-
biological substrates. If the goal of predatory violence is prima-
rily extrapsychic, which may be the case, the clinician must be
careful to appreciate that personality structure always provides
the vehicle for the violence itself, regardless of the motivational
or instrumental context.
This confusion of personality structure with functional con-
tent is a common public misconception. When Richard Rarnirez,
the alleged "night stalker" responsible for fourteen serial mur-
ders in California in 1985, was apprehended, most of the public
media focused upon his association with satanism and attributed
his behavior to witchcraft, devil worship, and heavy metal rock
music, sociocultural phenomena that could then be judged as
"'
"spreading signals of societal disintegration. Again, the failure
to explain the false positives, those adults or adolescents in-
tensely involved in satanism and heavy metal rock music who do
not become serial murderers, is obvious.
6. Minimal or absent displacement of the target of aggres-
sion. The defensive operation of displacement does not appear to
play a signif~cantrole in predatory violence. The actual target of
the aggression fits a more rigorous sensory-perceptual object
'Sunday J w d - S t a r , Lincoln, Nebraska, September 22,1985.

representation, or object percept; the latter being more imper-

vious to vicissitudes of autonomic and affective arousal. The
actual object of predation, irrespective of motivation, will be
much more tenaciously pursued, and less quickly abandoned,
than objects of affective violence.
Several variables account for this phenomenon: First, min-
imal or absent autonomic and affective arousal appears to sup-
port the enduring clarity of higher cortical representational
constructs. Second, multidetermined goals of predatory violence
are more object specific than the goal of affective violence. In
other words, they require a more disciplined "goodness of fit"
within the perceptual-motorapparatus to initiate predation. And
third, the selective suppression of other sensory input (see crite-
rion number 10 below) supports a focused, "tunnel" effect linking
both object percepts and actual objects of predation.
7. A time-unlimited behavioral sequence. In the absence of
intense levels of autonomic and affective arousal, the organism is
not temporally limited in its behavioral sequence. The initiation
and termination of predatory violence has no physiological re-
strictions other than the capacity of the aggressor to actually
inflict the violence. Human predation may be momentary or it
may last for years. The opening case study of this chapter is
illustrative.
8. Preceded or followed by private ritual. The distinctions
between public rituals during affective violence and private
rituals associated with predatory violence are twofold. First,
private ritual in predatory violence is intentionally hidden from
the target of the aggression; and second, the private ritual,
despite its stereotype, is more pervaded with quasi-magical and
symbolic meaning than the public ritual of affective violence.
The goal of private ritual associated with predatory violence
is not to reduce or eliminate a perceived threat, but is, in fact, to
gratlfy certain pathognomonic narcissistic wishes that usually
remain unconscious. In preparation for the predatory violence,
the individual may select certain objects, such as clothing, figu-
rines, jewelry, charms, unusual weapons, makeup, masks, reli-
Violme, Psychosis, and Related States 225
gious symbols, nationalistic emblems, and so on, that enhance

feelings of grandiosity. Unconscious fantasies of omniscience,
omnipotence, infallibility, and immortality are revitalized
through the use of private, ritualistic devices that defensively
ward off residues of fear and anxiety. These objects may be
anthropomorphized and imbued with quasi-magical powers, ren-
dering them transitional objects (Winnicott 1963). Such preda-
tors, in a sense, create their world in which their ritualistic items
are felt to be subjective objects completely under their control
and pave the way for their targets of aggression to be experi-
enced as selfobjects also under their control. Omnipotence be-
comes a matter of experience (Winnicott 1962).
Private ritual may also involve the ingestion of certain
drugs, usually psychostimulants, which also enhance feelings of
grandiosity and omnipotence. These psychostimulants, com-
monly cocaine or methamphetamine hydrochloride, are also
quintessential transitional objects. The drug is physically held
and controlled by the subject, it can be used or set aside when-
ever necessaq, it carries the grandiose projections of the sub-
ject, it can be orally incorporated whenever wished, and once
ingested, its real chemical properties create a subjective state of
self-confidence,perceived omnipotence, and heightened cortical
arousal.
The symbolic magic . . . of the transitional object is

extremely primitive. Belonging to the earliest period
in life, it offers an illusory bridge-or bridges; it com-
forts and fortifies the young venturer in taking his first
steps into the expanding realities of the outer world. . .
It offers a cushion against distress of frustration before
reality testing is at all secure, and provides dosages of
omnipotence according to infant needs. [Greenacre
1969, p. 1611
The transitional object as a symbolic link prior to or during

predatory violence has both a progressive and a regressive side
(Model1 1968). It facilitates both distancing, or disidentification,

with reality and the imagined object of aggression, while at the
same time ensuring that the imagined object is perceived as a
further extension of the grandiose self-structure, a selfobject
imbued with certain projective characteristics that heighten the
predator's sense of omnipotent control. It becomes a Janus-faced
symbol that both disavows and heightens differences.
The transitional object of the predator may also become a
fetish that is linked with the delusion of a maternal phallus
(Winnicott 1953, Greenacre 1969,1970). Such "objects as fetish"
may rekindle sexual fantasies that are then acted out during the
predatory violence with the actual victim. This may be gro-
tesquely apparent during sadistic rape when the victim may have
certain phallic objects thrust into her vagina or anus, and, if
death occurs, may be left with certain objects protruding from
her vagina or anus, suggesting a sadistic mockery of, or delu-
sional attempt to display, the maternal phallus.
Fintzy (1971) and Volkan (1973) theorized and clinically
supported the presence of transitional fantasies in borderline,
especially narcissistic, patients. In an autonomous and recurrent
manner, a particular fantasy becomes a transitional object and is
perceived as both separate and symbiotically linked to the indi-
vidual's wishes.
The transitional fantasy in predatory violence maintains the
illusion of omnipotent control and may function as a rehearsal
fantasy for the predatory individual. This is most common in
sexual psychopaths who will render their future victims one-
dimensional, gratifying objects in their minds and glorify and
idealize their own sexual abilities. This may occur months, if not
years, before any actual predatory violence begins. David Berk-
owitz, the convicted sexual psychopath responsible for the
shooting death of five young women and a man in New York City,
recounted his transitional fantasies:
..
Almost every waking moment . I find myself fanta-
sizing... .
But I'm greatly troubled by my fantasies.
Violence,Psychosia, and Related States 227
They are almost all either sexual in nature or violent.

I'm really quite perverted . . . I do believe, however,
that others fantasize the same things as me. If I could
be absolutely sure they do, I'd be greatly relieved. [p.
1681
.. . I do fantasize about women and my fantasies are
not violent. That is, when I'm making love to them in
these daydreams. I envision myself as a lover who is
passionate, well endowed, and is able to please my
mate by giving her a multitude of orgasms. I picture
myself as one who has no qualms about performing oral
sex with the female genitals. In fact, I know I would
enjoy it very much. I would also be able to prolong
(delay) my ejaculation for hours until my partner has
numerous orgasms and is begging for mercy. . . . My
violent fantasies are miles apart from my heterosexual
fantasies. [p. 1761
Berkowitz's last female victim was Stacy Moskowitz on July 31,

1977:
I watched Stacy on the swing and then they stopped

swinging. Her and her date then started to kiss pas-
sionately for several minutes. At this time, I too, was
sexually aroused. I had an erection. Shortly after their
deep kissing, they went back to the car . . . I had my
gun out, aimed at the middle of Stacy's head and fired.
One bullet struck her head and another nicked her. I
didn't even know she was shot because she didn't say
anything nor did she moan. Then I got in my car and
drove off. [Abrahamsen 1985, pp. 176-1771
Private ritual that occurs during or after the predatory

violence generally is motivated by two factors. First, the indi-
vidual is attempting to act out sadistic fantasies that have been
previously rehearsed with imagined victims. These sadistic fan-
tasies defensively heighten the predator's grandiosity and sense

of omnipotent control through humiliation and degradation of the
victim. The acting out of such fantasies renders the actual object
a more suitable receptacle for his projected, persecutory psychic
material that he wishes to expulsively discharge, or ritualistic
postmortem behavior indicates a reidealization of the victim.
There is evidence that Theodore Bundy, the convicted serial
murderer and sexual psychopath, on at least one occasion kept
the body of one of his victims for several days, moving her
between a closet and a bed as his sexual desires waxed and
waned, and would redo her makeup and shampoo her hair (Mi-
chaud and Aynesworth 1983).
The second factor that motivates ritualistic behavior during
or after predatory violence is a desire to taunt or mock the
individuals, usually authority figures, that will find the victim.
Albert DeSalvo, the so-called Boston Strangler, would decorate
his female victims with a necktie and then position them with
their genitals exposed in such a manner that the first individual
entering the crime scene would be visually assaulted by the sight
to the point of physical revulsion and nausea (Frank 1966).
The following case (Douglas et al. 1986) illustrates the com-
mingling of these two motivational factors in ritualistic behavior
during and following an act of predatory violence:
A young woman's nude body was discovered at 3:00

P.M. on the roof landing of the apartment building
where she lived. She had been badly beaten about the
face and strangled with the strap of her purse. Her
nipples had been cut off after death and placed on her
chest. Scrawled in ink on the inside of her thigh was,
"You can't stop me." The words Tuck you" were
scrawled on her abdomen. A pendant in the form of a
Jewish sign (Chai), which she usually wore as a good
luck piece around her neck, was missing and presumed
taken by the murderer. Her underpants had been
pulled over her face; her nylons were removed and

very loosely tied around her wrists and ankles near a
railing. The murderer had placed symmetrically on
either side of the victim's head the pierced earrings she
had been wearing. An umbrella and inkpen had been
forced into the vagina and a hair comb was placed in
her pubic hair. The woman's jaw and nose had been
broken and her molars loosened. She suffered multiple
fractures caused by a blunt force. Cause of death was
asphyxia by ligature strangulation, There were post-
mortem bite marks on the victim's thighs, as well as
contusions, hemorrhages, and lacerations to the body.
The killer also defecated on the roof landing and cov-
ered it with the victim's clothing. . . .The investigative
profilers noted that the body was positioned in the
form of the woman's missing Jewish symbol. [pp.
415-4181
The murderer in this scenario both acted out sadistic ritual

fantasies that resulted in his sexual gratification and also dis-
played and mutilated his victim in a manner that contemptuously
mocked his persecutory objects, now actualized as law enforce-
ment authorities.
The case I have referred to earlier (see Chapter 5) con-
cerning the rape, electrocution, and suffocation of the adolescent
hitchhiker also illustrates the expression of private ritualistic
and sadistic fantasy, but in a manner that was not conscious and
was not intended as an afterthought to mock authority. The
perpetrator attached alligator clips to the victim's nipples while
she was bound and alive and subsequently ran an electrical
current through them. This heinous act is highly symbolic of
condensed unconscious fantasy. The perpetrator's self-esteem
was closely tied to his skill with electrical components and his
employment in an auto service garage. This condensing of
electrical-mechanical skills regressively telescoped back, in the
midst of a highly aroused dissociative state, to a primitive and

condensed fantasy of the breast as both a part-object of nurtur-
ance in infancy and sexual arousal in adulthood. The breast as
part-object became the literal symbiotic attachment of his infan-
tile sadism and could be devoured by the electrical current. At
the same time, the victim, completely subjugated, would con-
vulse in a parody of orgasm, gratifying his sexually sadistic
fantasies as a genitally active adult.
As Shapiro (1981) noted, sadomasochistic sexuality is a
highly ideational matter. The ideas and symbols of erotic sensu-
ality are exciting, especially in their most concentrated, extreme,
and detached forms. It is consistent with rigid character because
it is a sexuality of purpose, of the will, where the idea of subju-
gation is so erotic because the actuality of sexual abandonment is
inimical.
9. A primarg cognitive-conativedimension. Predatory vio-
lence in humans appears to be highly dependent on vicissitudes of
higher cortical functioning, such as purposeful ideation and fan-
tasy, and intentional behavior, such as planned, goal-directed
activity. Affective arousal, if present, clearly plays a secondary
role in predation.
This delimitation to the cognitive-conative spheres, rather
than the affective sphere, of mental activity underscores the
planned, purposeful nature of the violence (the case of C. C.
discussed earlier in Chapter 6), its multidetermined and variable
goals, and the use of fantasy during private ritual.
10. Heightened and focused sensoyl awareness. The most
easily observed naturalistic example of this criterion is the im-
mutability of the stalking animal. This attentional fixation, and
consequent absence of distractability, appears to have a physio-
logical basis. It was characterized by Hernandez-Peon and col-
leagues (1956) as a selective suppression of other sensory input.
This focused sensory-perceptualphenomenon partially accounts
for the minimal or absent displacement of predatory violence
onto another actual target (the case described by Douglas et al.
1986 above), a characteristic that is quite common during affec-

tive violence.
This object specificity during predation by humans appears
to have certain psychodynamic correlates that Brenman (1985)
conceptualized as a singular and cruel narrowrnindedness of
purpose. The obliteration of the whole object representation to a
part object that the predator owns restricts both conscious love
and guilt. The world is representationally reduced to a cruel and
loveless place, and demands can be foisted upon the actual target,
or object, to be idealized or vengefully pursued. There are
usually elements of sadism in human predation, and the primacy
of the paranoid-schizoid position in the developmental life of the
predator succeeds in breaking up these whole object representa-
tions. Predatory violence is most M ~ c u l for
t those who have
developmentally reached the depressive position because of the
latter's toleration of whole objects and its affirmation of love
while knowing hate (Bion 1963). Brenman (1985) noted that
cruelty is maintained because omnipotence is felt to be superior
to love, depression is defended against, and grievance and re-
venge are sanctified.
This heightened and focused sensory awareness is notable
in a letter written by David Berkowitz:
While shooting these people, I actually became trans-

fixed with the event. The report of the gun, the
screams, the shattering of glass and windshields, the
blaring horn, it all just possessed my mind so that I'd
take no notice of anything else. During the first inci-
dent, I had become so transfixed that I could not move
until that car horn started blasting in the quiet night.
That horn brought me back to reality in a way. I got
back my senses and realized what I had done and just
took off running to my car. I don't mean that I departed
reality. I knew what I was doing. [Abraharnsen 1985,p.
1791
11. Self- and object concept dedvferentiation. During an act

of predatory violence the target of the aggression is likely to
become a conceptual extension of the inflated and expansive self.
This is particularly true among narcissistic and psychopathic
individuals wherein others are habitually regarded as conceptual
extensions of the grandiose self-structure.
This dedifferentiation between self- and object concepts,
however, does not necessarily mean a dedifferentiation of self-
and object percepts. Therefore reality testing, if defined as a
capacity to distinguish between internal and external sensory-
perceptual experience, remains unimpaired (see Chapter 3).
Self- and object concepts refer to a modal "frame of refer-
ence" that have both form and value (Spiegel1959). They may be
associated with perceptual experience, but are usually more
abstract and symbolic representations of self and other. Self-and
object concept representations implicate meaning and value,
rather than perception and sensation (Meloy 1985).
Again, the serial murderer provides a cogent example. He
will usually select his victims for their "goodness of fit" to a
particular physical stereotype, the latter an interpersonal ex-
pression of an internal object percept. This visual image in the
mind could be a derivative of the biological mother or a flam-
boyant and sexually provocative representation of a certain,
unattainable social class (Leyton 1986).
Along with the perceptual selection, in many cases quite
predictable according to certain physical typologies, the actual
target is conceptualized on a more abstract and symbolic level.
Self- and object concept dedifferentiation transposes her into a
ragefully devalued, or enviously idealized, object, despite the
predator's lack of any emotional attachment to the victim. There
may be a condensing of values, attitudes, and judgments from
past experiences with women that form an aberrant, perhaps
even delusional, concept of who she is distinct from the relatively
accurate perception of how she appears. This is why a serial
murderer's selection of his victims may be perceptually quite
Violence,Pttychosis, and Relabd States 233
predictable, yet his violence against the person is so obviously

psychotic in proportion.
This schism between conceptual fusion and perceptual dis-
tinctiveness is supported by another paradoxical process that is
stimulated by private ritual: the use of transitional objects that
both distance the predator from the object of violence while at
the same time ensuring the actual object is conceived as a further
extension of the grandiose self-structure. This concurrently pro-
gressive and regressive process may be phenomenally described
by the predatory individual as both a compulsion to act and a
dissociative state of mind during the act itself.
12. Unimpaired realitg testing. The capacity of the indi-
vidual to distinguish between interoceptive and exteroceptive
sensory-perceptual stimuli remains intact during predatory vio-
lence. Indications of impaired reality testing strongly suggest
the presence of a psychotic disorder that may catalyze predation,
but usually introduces additional affective dimensions to the
violence (see Chapter 7).
Adequate reality testing, however, should not preclude the
search for the presence of self- and object concept dedifferentia-
tion during the act of predation. This is highly probable- in
aggressively narcissistic and psychopathic characters since the
grandiose self-structure predisposes such representational fu-
sion at a conceptual level.
This narcissistic regression or fixation can be seen in the
typical pattern of violent psychopathic behavior where motiva-
tion is evident, such as instrumental gain or vengeance, but the
proportionality of violence is such that a reasonable person finds
it abhorrent. Psychopaths do not conceptualize others as sepa-
rate individuals deserving of empathic regard, but as psychody-
namic extensions of their grandiose conceptual self-repres-
entations:
Two youths robbed a woman of ten dollars near her

apartment. She put up no resistance, and, almost as an
afterthought, one of the young men had her kneel down

and shot her in the back of the head with his .22 caliber
"Saturday night special." When arrested and ques-
tioned, he freely admitted his act, saying only that he
"felt like it. It was no big deal."
Because of the preservation of perceptually accurate self-

and object percepts, psychopathic individuals present a dilemma
to the diagnostician when reality testing is addressed. Clinical
investigation should focus on their conception of others. Is there
sufficient evidence through reminiscences, evaluations, judg-
ment, and affective responses that they conceptualize others as
three-dimensional, whole, and separate individuals? Or do they
reflect, a t best, a narcissistic self-absorption, or a t worst, a
callous disregard for the thoughts and feelings of others? The
interpersonal history is the most critical data source for under-
standing the psychopath's object relations, reality testing, and
reality sense. I will address the use of the Rorschach in assessing
these areas in Appendix 111.
13. Heightened selfesteem. Predatory aggression in hu-
mans is usually accompanied by increased self-esteem. Private
ritual involving transitional fantasies or actual totems, fantasied
rehearsal of the violence, psychostimulant use, goal attainment,
and predisposing narcissistic personality structure all contribute
to a subjective sense of confidence and expansiveness during the
entire sequence of predatory violence.
Predation appears to solidify the narcissistic defenses of
projective identification, devaluation, and omnipotent control. It
provides a behavioral channel for the affective experience of
sadistic pleasure and contemptuous delight (see Chapter 4). I t
necessitates the conscious exercise of deception, simulation, and
object control (see Chapter 5) to be purposeful and successful.
Table 6-1 summarizes and compares the thirteen criteria
that define and differentiate affective and predatory violence.
Table 6-1
Criterion Comparison of Affective and Predatory Modes of Aggression and Violence
Affective Predatory
1. Intense sympathetic arousal of the ANS. Minimal or absent ANS arousal.
2. The subjective experience of conscious emo- No conscious experience of emotion.
tion.
3. Reactive and immediate violence, if present. Planned or purposeful violence, if present.
4. An internally or externally perceived threat. No or minimal perceived threat.
5. The goal is threat reduction. Multidetermined and variable goals.
6. Rapid displacement of the target of aggres- Minimal or absent displacement of the target of
sion. aggression.
7. A time-limited behavioral sequence. A time-unlimited behavioral sequence.
8. Prefaced by public ritual. Preceded or followed by private ritual.
9. A primary affective dimension. A primary cognitive-conative dimension.
10. Heightened and diffuse sensory awareness. Heightened and focused sensory awareness.
11. Self and object percept dedifferentiation. Self and object concept dedifferentiation.
12. Possible loss of reality testing. Unimpaired reality testing.
13. Lowered selfesteem. Heightened self-esteem.
PSYCHOPATHYANDPREDATORYVIOLENCE
I t should be apparent that the psychopathic process is particu-

larly suited to predation. It is my hypothesis Ulat the psycho-
pathic process predisposes, precipitates, and perpetuates preda-
tmy violme by virtue of its s t w t u m l and dynamic
chamcteristics.
The absence or minimization of autonomic arousal during
predatory violence is supported by the peripheral autonomic
hyporeactivity of the psychopathic process. Psychopaths are
psychobiologically well suited to the predatory task because
their autonomic baseline and evoked responses do not interfere
with, and, in fact, sustain, the hyporeactive sequence during
predation. This should be contrasted with individuals who are
not autonomically hyporeactive yet attempt to consummate an
act of predatory violence; their autonomic reactivity may pub-
licly betray, through behavioral cues (see the case of D. T. above),
the predatory intent and thus minimize its effectiveness.
The varieties of dissociability that defensively organize the
psychopathic process support the splitting, or warding off, of
affect during predation. The psychopathic process sustains the
absence of conscious emotion during predatory violence and may
contribute to feelings of exhilaration and contemptuous delight
during the stalking phase of the violence prior to any actual
physical contact with the victim. These subjective feelings are
products of projective identification and omnipotent control,
further defensive operations that necessitate splitting, and imply
the presence of a grandiose self-structure. Repressive opera-
tions in the neurotic personality organization (Kernberg 1984)
during an act of predation will usually catalyze conscious feelings
of anxiety and fear because of the instinctual threats from within
and the environmental threats from without.
The perceived malevolence of actual others by the psycho-
path, implying sadistic introjects outside the grandiose self-
structure, will oftentimes sustain the planned, purposeful, and

goal-directed nature of predatory violence. Since there is no time
limit to predation, in contrast to the "alarm state" of affective
violence, an individual carrying out a predatory act is subject to
many antecedents that may moderate, or even extinguish, the
desire to engage in predation. Such diminution of intent to plan
and carry out a violent act is less likely in the psychopathic
process because of the sustained malevolence that is consistently
perceived in others.
This hypervigilant suspicion, which may reach paranoid
dimensions, can be developmentally traced to the fused selfob-
ject concepts within the grandiose self-structure, in particular
the stranger selfobject, the object of primary identification (see
Chapter 3) for the psychopath. Predators are unconsciously
fearful of being the victims of predation because of the projective-
introjective cycling of their own aggressive and sadistic material.
But this fear and its allied defenses, such as projective identifi-
cation and omnipotent control, sustain the predatory planning
and intent despite actual moderating variables from the environ-
ment; in other words, experiences that might soften the neurotic
personality's desire to engage in predation, since ambiguous
realities and the accompanying ambivalent emotions can be per-
ceived, are consistently devalued by the psychopathic process.
The absence of an immediate threat in predatory violence
begs the motivational question; but the psychopathic process
answers it. The predatory violence of the psychopath, regardless
of the precipitant, such as revenge or monetary gain, is always
carried out against a background of intrapsychic threat that is
projected onto others; potential warring factions that must be
enveloped by the grandiose self-structure to be rendered impo-
tent yet also remain sources of envy and greed.
The time-unlimited nature of predatory violence is also
supported by the blending of intentional choice and compulsivity
that may coexist in certain psychopathic individuals (see the case

of C. C. described earlier in this chapter). This manipulative
cycling (Bursten 1972) may be highly sexualized and compulsive,
exemplified by the serial murderer, yet still subserve affective
arousal to the degree that it can be postponed, altered, or
stopped for periods of time. David Berkowitz provides a cogent
example of this capacity for delay of gratification, despite the
compulsive nature of his killing:
I went out . . . to the Hamptons in the first week of

August. I had instructions to kill many people in Sou-
thampton. In the afternoon I looked at a map to drive
out there. I had the guns with me and came to South-
ampton . . . late in the afternoon. I drove to the beach,
Asparagus Beach, Arnagansett. I sat on the sand a
couple of hours. I had to wait until nightfall. I t started
to rain and I had to go then. The operation harl to be
postponed to the following weekend. Disappointed.
Ten o'clock. I was very tired when I came back to town
and had something to eat and went to bed. [Abra-
hamsen 1985, p. 1071
My italicized portion of this quote is to note Berkowitz's

subtle shift from the first-person active to the third-person
passive when the act of murder is directly addressed. This
indicates the intrapsychic tension between his intent and compul-
sion, and his disidentification and detachment from the act itself.
This further suggests his remarkable dissociative and simulative
defenses, and imitative abilities, which reached their highwater
mark in his partially successful feigning of paranoid schizo-
phrenia but eventual diagnosis as a psychopathic personality
with paranoid and hysterical traits.
The lack of attachment, or affectional bonding, in the psy-
chopathic process is particularly suited to predatory violence for
several reasons. First, there is no empathic identification with
the actual victim to interfere with the projective-introjective

cycling and polarized idealizing and devaluing of the targeted
object. These splitting processes must distort reality in order to
work. The absence of empathy also disinhibits the pursuit of
sadistic gratification through actual violence. Second, the coex-
isting processes of sadomasochistic attachment, or aggressive
attempts to bond, and profound detachment from others' affec-
tive experiences (see the case of R. described in Chapter 2)
behaviorally predict recurrent, aggressive, and cruel interac-
tions with others where there is little affection and a large
capacity for predation. And third, disidentification with the vic-
tim, or with anyone for that matter, magnifies the impact of
transitional objects during the private ritual of predatory vio-
lence (see the case of C. V. described in Chapter 5). Malignant
pseudoidentification (see the case of C. V. described in Chapter
5), however, may be quite apparent during predatory violence
where the narcissistic characteristics of the victim are simulated
and fuel fantasies of oral aggression and greed.
The grandiose self-structure of the psychopathic process
contributes in many ways to the consummation of predatory
violence. I have alluded to it earlier, but want to underscore
several primary characteristics that directly relate to it as a
corollary of predation. First, the conceptual fusion between the
ideal self- and ideal object representations as a stranger selfob-
ject sustain an understanding of self as alien, aggressive, and
perhaps perverse, yet endowed with a multitude of grandiose
characteristics. This sense of self as a stranger in a hostile land
predisposes both a rationale for predatory violence and a safe-
guard against being the victim of predation.
Second, the grandiose self-structure is predisposed to the
heightened expansiveness that can be artificially induced
through the use of various transitional objects during the private
ritual of predatory violence. The ingestion of psychostimulants
prior to predatory violence is particularly common among psy-
chopathic individuals and is a clinical reminder of the continual
aggrandizement of the grandiose self-structure that is defen-

sively necessary in the psychopathic process.
Third, the rehearsal fantasy that often precedes predatory
violence, imbued with grandiose conceptions of self as omniscient
and omnipotent, finds rich fertilization in the fused self- and
object concepts of the grandiose self-structure (see Chapter 3).
The object of predation is conceptualized as an extension of the
grandiose self-structure and not as an object concept separate
from the self-concept. At the same time, self- and object percepts
remain distinctive and relatively accurate, so that the predation
can proceed with adequate reality testing.
Fourth, the act of predation itself, particularly if it attracts
media attention and catalyzes both public fear and fascination,
will reinforce in actuality the psychopathic individual's defensive
conception of self as larger than life.
The Ivan Boesky insider trading scandal on Wall Street in
the fall of 1986 is one example of nonviolent predation that
captured national media attention by virtue of its sheer enor-
mity. The J. David Dorninelli Ponzi scheme in La Jolla, Califor-
nia, 1982-1984, that bilked a thousand investors of $80 million, is
another (Bauder 1985). These nonviolent acts of predation and
the dynamic characteristics of the individual perpetrators, some
of whom are clearly psychopaths, often have much in common
with the more overtly violent acts of predation. The ideation and
affect of the murderer, however, are a much greater public
curiosity than the mind of the arbitrageur.
One does, at times, find convergence. The following article
appeared in the Los Angeles Times on March 17,1987:
The Securities and Exchange Commission on Monday

rejected the application of a killer who had hoped to run
an investment counseling business from the Colorado
penitentiary.
The SEC refused to register Herbert David Marant,
Violence, Psychosis, and Related States 24 1
who was convicted in 1981 of first-degree murder and

conspiracy in the contract killing of his former wife.
While not unmindful of Marant's desire to build a
.
future for himself while still in prison . . the major
concern is whether the record reflects that Marant can
be trusted to adhere to the high standards of conduct
required of an investment advisor," said Warren E.
Blair, the commission's chief administrative law judge.
Marant filed the application Dec. 22 under the name
Michael David Marant, seeking permission to counsel
investors as .the Light Investment Co. Marant dis-
closed his murder conviction, the SEC said, but he did
.
conceal a few pertinent facts. . .
In a real sense, the popular media may mythologize preda-

tors to the degree that they do become a legend in their own
minds. This verification in reality of that which heretofore had
only been experienced in fantasy leads the psychopath to con-
sider predation as the sole means to achieve notoriety.
Psychosis and Psychopathy
Psychologists and psychiatrists have historically resisted the
diagiostic jktapositioi of psychosis and psychop~thy.This was
no more apparent than in the DSM-I11 (American Psychiatric
Association 1980), which stated, "Severe mental retardation and
schizophrenia preempt the diagnosis of antisocial personality
disorder, because at the present time there is no way to deter-
mine when antisocial behavior that occurs in an individual with
severe mental retardation or schizophrenia is due to these more
severe disorders or to antisocial personality disorder" (p. 319).
This is particularly revealing and contradictory, given the
American Psychiatric Association's historical support of the in-
sanity defense and its cognitive, and sometimes volitional,
prongs, which state that a specifi antisocial behavior is the
"result of a mental disease or defect" and can be so determined,
through expert testimony, by the trier of fact.
Despite historical changes in the insanity defense since the
M'Naghten Case (10 C. & F. 200,8 Eng. Rep. 718 [H.L. 18433),
such as the Model Penal Code (Section 4.01 [I9611 of the Amer-
ican Law Institute), every legal definition of insanity has implic-
itly assumed that a mental disorder, if one exists, can be diag-
nosed, and correlated with, a specific antisocial behavior that
resulted in criminal prosecution.
Some of the reasons for the clinical unwillingness to link

psychosis and psychopathy are found in the historical distinction
between autoplastic and alloplastic adaptation. Ferenczi (1919,
1930) defined autoplastic adaptation as an alteration in the or-
ganism itself, whereas the environment is altered through flight
or defense in alloplastic adaptation. Furthermore, neurosis was
interpreted as an autoplastic alteration and symbolic distortion
of psychic reality, whereas in character disorder external reality
was used for direct instinctual gratification in an alloplastic
manner (Frosch 1983a). This dichotomizing of adaptational
modes, in my view, has resulted in an unfounded, but pervasive,
clinical hesitancy to recognize the fundamentally alloplastic ad-
aptation of both psychosis and character disorder and their
interactive patterns. Frosch (1983a) noted the alloplastic nature
of psychosis in its modification of both psychic and material
reality and a consequent loss of reality testing, what he called an
ego-syntonic and reality-dystonic adaptation. The alloplastic ad-
aptation of the character disorder, however, was the denial and
minimalization of reality, but it would not be replaced, as in
psychosis, by autistic productions. The distinction between the
psychotic and characterologic expressions of alloplasticity was
reality testing.
Frosch (1983a) seemed to find, however, his own distinction
between psychosis and character disorder adaptation somewhat
. ..
ephemeral: ". . patients with character disorders. will not for
any consistent period replace [reality], as psychotics do . . ."
(p. 415). "In the alloplasticity of some character disorders the
capacity to test reality may wear thin under certain cireum-
stances, but it is never really lost" (p. 415). "In the antisocial and
impulse-ridden characters we may have an ego-syntonic yet
reality-dystonic adaptation not too unlike the psychtic, but
reality testing (although a t times minimal and somewhat im-
paired) is not basically lost" (p. 416, italics added).
Frosch (1983a) also noted the confusion between alloplastic
and autoplastic adaptation that is engendered by the lack of
definition of external and internal environments. Is one talking

about material reality, psychic reality, or both, when adapta-
tional alterations are being proposed? If there is no expression of
a patient's delusion and the patient makes no attempt to act out in
material reality his or her delusional thoughts, and, in fact, is
quite functional as a result of the encapsulation of the delusion,
has an alloplastic adaptation occurred?
This lack of clarity between autoplastic and alloplastic ad-
aptation and the close association of alloplastic adaptation within
psychotic and characterologic traits are precisely the reasons
why an attempt to understand the interactive relationship be-
tween psychosis and psychopathy is so critical.
Furthermore, the convention of ruling out antisocial person-
ality disorder when a severe and chronic psychotic disorder is
present appears to have little basis in clinical reality, despite the
dearth of empirical literature addressing the differential diag-
nosis of psychosis, whether state or trait, and psychopathy in the
same individual. In fact, there appears to be only one empirical
report (Meloy 1986a) in the research literature that delineates
this issue. In that paper a differential scheme was presented for
the rapid classification of the functionally psychotic individual in
custody, using two predictor and eight criterion variables. The
Type I1 Mentally Disordered Offender was distinguished by the
presence of an Axis I psychotic disorder and an Axis I1 person-
ality disorder, usually antisocial, narcissistic, histrionic, or bor-
derline.
I will pursue in this chapter the relationship between psy-
chosis and psychopathy by exploring several quite pertinent
questions. First, are there fundamental psychodynamics that
link psychosis and psychopathy? Second, are there characteristic
avenues of psychotic expression, such as paranoia and mania, in
the psychopathic process? Third, what are the clinical manifesta-
tions of schizophrenia and affective disorder in the psychopathic
character? Fourth, in what manner and under what circum-
stances will the psychopathic character dissemble or malinger
psychosis? Fifth, what is the relationship between affective

violence, predatory violence, psychosis, and psychopathy? Sixth,
what is the clinical and theoretical relationship between organic
psychotic states, perhaps caused by a known psychoactive sub-
stance, and psychopathy? And seventh, are there characteristic
patterns of relationship between mental retardation and psycho-
pathy?
CHARACTEROLOGICAL TRAITS AND

PERSONALITY ORGANIZATION
Kernberg (1975, 1976, 1984) took the lead in proposing a two-

dimensional, perhaps orthogonal, approach to the systematic
understanding of character and personality organization. On one
dimension are various characterological traits, such as hysteria,
narcissism, dependency, masochism, infantilism, obsessionalism;
and on the second dimension are three levels of personality
organization: neurotic, borderline, and psychotic. Each predom-
inate characterological trait could hypothetically be organized at
any one of the three levels of personality, discriminated on the
basis of identity integration, defensive organization, and reality
testing (Kernberg 1984).
The relationship between psychosis and psychopathy puts
Kernberg's two-dimensional, object relational approach to the
test. Is it theoretically parsimonious, and clinically sound, to
describe psychopathic character formation at a psychotic level of
personality organization? I think that it is.
Several caveats are in order. Recall that Kernberg's (1975)
hypothesis, and mine, is that psychopathic character formation is
a more aggressive and deviant form of narcissistic character. I
have outlined in Chapter 2 the criteria that differentiate this
subtype from the more generic narcissistic character disorder.
Furthermore, despite this chapter's focus on psychosis and psy-
chopathy, I find it exceedingly difficult to propose a psychopathic
character at a neurotic level of personality organization, prima-

rily because of the absence of superego formation and the pres-
ence of a grandiose self-structure. Implicit in neurotic person-
ality organization are sharply delimited, whole object
representations and the capacity for object constancy; the oper-
ation of repression and other higher level defenses; and pre-
served reality testing with a capacity for insight. Any one of
these psychological processes would rule out the diagnosis of a
psychopathic character. Despite my reluctance, however, to
apply Kernberg's scheme to psychopathy and neurotic person-
ality organization, the task being addressed is psychotic person-
ality organization and the psychopathic process.
Identity Integration
At a psychotic level of personality organization self- and object

representations are poorly delimited and emptied of any polar-
ized values. Fusions of self- and object representations at both a
conceptual and perceptual level (Meloy 1985)will occur. Because
of the absence of boundaries among internal representations of
self and others, actual experience of others and self may be
delusional. In the psychopathic character this is marked by
delusional identification with the aggressor:
S. T. was a 28-year-old black male admitted in a chron-

ically psychotic state to our forensic inpatient unit
following a charge of possession of marijuana for sale.
His chiefly articulated symptom was the hallucinated
voice of his father which bothered and disturbed him.
The patient was nonresponsive to neuroleptic
medication. Psychosocial investigation revealed an in-
dividual who was raised in foster homes following the
death of his mother when he was 5 years old. This
traumatic event, subsequently corroborated by the
staff, involved the patient's father shooting his mother

to death while she was holding him.
Psychological testing indicated an individual with
a full-scale IQ of 84. He had a historical diagnosis of
schizophrenia, chronic, undifferentiated type, and
adult antisocial behavior. The Bender-Gestalt sug-
gested additional signs of right parietal lobe organicity.
As the patient became more comfortable on the
unit, he began to discuss his delusional belief that he
was his father and his command hallucinations to kill
his girlfriend. He reassured himself that this wouldn't
happen, because whenever he purchased any weapons,
his girlfriend would quickly take them away from him.
Gross identity disturbance is also sometimes seen in the

confusion within memory of fantasy and reality. In the psycho-
pathic and psychotic character, grandiose and aggressive fanta-
sies that have repeatedly occurred will be remembered as actual
events and adamantly defended as reality. One psychopathic
patient, who was also quite delusional, recalled events when he
was a 1-year-oldinvolving malevolent treatment by his parents.
He vociferously defended a striking visual fantasy as an actual
reality that was perpetrated against him. Sometimes such
striking commingling of reality and fantasy in memory in the
psychopathic character organized at a psychotic level of person-
ality are revealed in more abstruse ways:
R. T. was a 32-year-old Caucasian male seen by me in

weekly outpatient individual psychotherapy for one
year. He had served as a Marine Recon in Vietnam for
two tours of duty, and his primary tasks involved the
infiltration of enemy territory and the planned assassi-
nation of certain identified Viet Cong leaders.
During the initial clinical assessment, R. T. was
diagnosed as schizophrenic, paranoid type, chronic. He
was prescribed chlorpromazine, 200 mgs. h.s. prior to

beginning psychotherapy with me. He gladly accepted
the psychiatrist's medication and was initially quite
compliant with treatment, although he preferred ses-
sions at odd hours so he did not have to sit in the
waiting room with other individuals. He usually at-
tended sessions dressed in a black t-shirt, camouflage
drawstring pants, and combat boots.
As the supportive psychotherapy continued, R. T.
revealed a remarkable, although quite marginal, adap-
tation to his current reality. He lived with his two
teenage sons on an avocado grove several miles from
the nearest neighbor. He bought food for himself and
his sons at a supermarket where the cashier would
always open an additional checkout line so R. T. did not
have to wait; this also happened regularly at the bank
where he deposited his V.A. disability check.
R. T. was of short stature and very muscular. He
clearly frightened nearly everyone he encountered. He
was quite adept in the martial arts, which included the
use of certain oriental weapons, and had an M-16 as-
sault rifle and .45 caliber semiautomatic pistol at home
for protection.
R. T. revealed to me that he also was taking 15
mgs. of diazepam daily. He secured this anxiolytic drug
by periodically walking in to a local HMO outpatient
setting where he had received his first prescription and
demanding it.
R. T.'s favorite weapon was his crossbow. He
would construct "targets" with bales of hay throughout
the avocado grove, dress in his combat fatigues, and
enter a state of "combat reverie" where his memories of
Vietnam would blend into a quite psychotic and gran-
diose reality. At one point in the psychotherapy R. T.
stated to me that when he was most angry at me he
would imagine my face on one of the bales of hay. I was

quite concerned by this psychotic condensation of ha-
tred that was developing as a transference factor in the
treatment.
Over a period of several months R. T. recalled
with both intense pleasure and pain his combat experi-
ence. I was struck, however, by my familiarity with
some of his memories, particularly since I had never
been in combat nor in Indochina. Certain villages res-
onated with me, but I was not dumbfounded until he
mentioned his association with Colonel Kirk.
Joseph Conrad's Heart of Darkness. The film
"Apocalypse Now." T h e horror, the horror, the hor-
ror." I was momentarily swept away by this patient's
utterances and the psychotic, perhaps psychopathic,
implications that he was revealing to me. I began to
question his potential for malingering such a psychosis,
as well as his capacity to continue to function as an
outpatient with such pervasive delusional material.
Subsequent clinical questioning through weeks of
psychotherapy gleaned little in the way of new inform-
ation. R. T. denied any literary or cinematic source for
his reminiscence and angrily denied the absence of a
basis in actual reality for Colonel Kirk. His psycho-
therapy continued to be a blend of extremely grandi-
ose, paranoid, and aggressive memories that were sub-
jectively experienced and valued as actual events yet
were clearly a confusion of intrapsychic psychosis and
interpersonal trauma.
It has also been my clinical experience that a recompensated

individual's capacity to recall his psychotic state and identify it as
such is a favorable prognostic indicator. In the psychopathic
character organized at a psychotic level of personality, this is an
extremely rare event. When I have observed this in psycho-
pathic individuals, it is usually an adaptation to the wishes of the

treatment team and may be a "malignant pseudoidentification"
on the part of the psychopath to secure certain advantages (see
Chapter 5).
Defensive Organization
Borderline defenses predominate in the psychopathic character

organized at a psychotic level of personality, but they serve
different functions (Kernberg 1984). In the borderline person-
ality organization, these defenses protect against intrapsychic
conflict, but at the cost of weakened ego functioning. In the
psychotic personality, these defenses protect the patient from
further disintegration of boundaries between the self and object,
both intrapsychic perceptual representations and actual
interoceptive-exteroceptive discriminatory sensory-perceptual
experience. Such defensive operations will manifest themselves
as auditory hallucinations, grandiose and persecutory delusions,
and formal thought disorder. Each of these symptom complexes
dynamically shores up the grandiose self-structure with a conse-
quent loss of reality testing.
Auditory hallucinations in the psychopathic character are
usually identified with an aggressive object and further prompt
the individual's identification with that aggressor. Characteris-
tics of the hallucinating object will resemble the grandiose self-
structure in a grossly exaggerated and fantastic form. The psy-
chopathic individual will perceive the auditory stimulus as ex-
ternal to his physical and psychological self, or in cases of severe
borderline pathology where a differential diagnosis of psychosis
is difficult, the individual may complain of persecutory introjects
heard within the mind as "voices" but experienced as "not-I," an
alien object percept (Meloy 1985). Despite the subjective experi-
ence of the hallucination as foreign and outside the self experi-
ence, the psychopath will be quick to identify with the sensory-
perceptual stimulus as its agent or provocateur, rather than as a

victim of its commands.
This allegiance to the auditory hallucination may catalyze
aggressive behavior and result in the perpetuation of predatory
or affective violence during the psychosis. In other words, the
psychopathic process disinhibits the behavioral expression of
auditory, or command, hallucinations since there is a profound
absence of superego constraint. Acts of danger, particularly
toward others, can be exercised without moral or judgmental
hesitation and with recurrent sadistic pleasure. This is in stark
contrast to the vast majority of schizophrenic patients who
successfully resist command hallucinations, if they occur, and
show no greater frequency of assaultive behaviors despite their
command hallucinations to do so (Hellerstein et al. 1987).
N. G. was booked into custody for attempted rape

following his attack against an inpatient nurse on the
psychiatric ward to which he was committed. He had a
history of chronic paranoid schizophrenia, but did not
appear to be psychotic at the time of his arrest. I asked
the patient if he was hearing voices at the time of the
assault and attempted rape, and he responded, "Yes,
they told me if I tore off her panties, I'd get a surprise."
When asked if the voices told him anything else, he
said, "Yes, they told me I did not know the difference
between right and wrong."
This patient's rather creative and humorous use of one prong of

the M'Naghten test of insanity (10 C. & F. 200, 8 Eng. Rep.
718 [H.L. 18431) as the articulated content of his hallucinations
was only matched by his grossly poor judgment in reporting
it to me within hours of his offense. Such dramatic, aggressive,
and, at times, humorous exaggerations of psychotic symptoms
are typical of the psychotically disturbed psychopathic
character.
The following excerpts are from a psychological evaluation1

of a 39-year-old Caucasian male found Not Guilty By Reason of
Insanity to a charge of Assault with a Deadly Weapon. The
patient was diagnosed as both chronic paranoid schizophrenic
and antisocial personality disorder:
According to records provided to the examiners, on

August 12,1986, J. C. entered an eating establishment
in San Diego and stabbed a woman who was seated at a
nearby table. At the time, the defendant indicated that
God had told him to stab this individual. J. C. was
subsequently arrested and placed in San Diego County
Jail.
J. C. alleges that he does not remember details
about the stabbing. However, later in the interview
process, the defendant stated that he had hallucinated
that the victim was a "snake." As he said this, the
defendant laughed and it was noted that he had told
another examiner previously that he had hallucinated
that the woman was a "dragon."
. . .J. C. alluded to experiencing aural hallucina-
tions consisting of "noises and voices." The defendant
also was questioned regarding other hallucinatory ex-
periences and stated that he experiences olfactory
hallucinations. The defendant experiences these smells
as "garbagelike odors," or odors that smell like feces.
The defendant also stated that he realizes that he
becomes agitated, and that this has a negative effect on
people with whom he comes in contact. In this regard,
however, it must be noted that the defendant seemed
to enjoy the idea that he could scare or intimidate
others with his actions.
'Many thanks to Annette Lau, L.C.S.W.,and Gregg Michel, Ph.D., for

permission to use excerpts from their evaluation.
According to information contained in the report

by Dr. J., J. C. has experienced a pattern of violent
actions, which appear to be spontaneous, with little or
no premeditation or planning. Since 1985 he has had
four assaults-two in San Diego on unsuspecting
women whom he had never met. He repeatedly fails to
demonstrate even minimal judgment in terms of taking
responsibilities for his own actions. He has in the past
.
made statements such as "God told me to. . ."
J. C. demonstrated inappropriate and somewhat
grandiose ideas regarding future goals to the under-
signed examiners. He stated that he believed he could
get out of jail, and hoped to become a police officer in
San Diego. In this regard, the defendant stated, "I
think it would be real enjoyable if I could become a
policeman in San Diego. It would set things right. . . ."
He is impulsive and acts out in violent acts of
aggression. The undersigned examiners concur with
Dr. J's observation that this patient "hides behind" his
pathology; that is, his "craziness" gives the defendant,
in his own mind, a license as well as an explanation for
a lack of responsibility for his own actions. J. C. does
not exhibit any remorse toward his victims, and fur-
ther, emotionally is not, at the present time, capable of
generating guilt. This makes him extremely unpredict-
able and very dangerous. ...
While he does experience severe psychopathol-
ogy, he amplifies this pathology in order to defend him-
self against it. For instance, when he becomes con-
fused, or hears any auditory hallucinations, the patient
will explain that by saying, "I enjoy hallucinating be-
cause I see God, Jesus, Angels, all the evil against
them, too, you know?" The patient, in effect, romanti-
cizes the more bizarre aspects of his symptomatology.
Violence, Psgchosia, and Related States 257
This case illustrates the fundamental psychodynamic and

behavioral link between psychosis and psychopathy: the psy-
chotic state will be aggressively expressed and malevolently used
to p q t u u t e the sadomasochism of the grandiose self-stwture,
within which the stranger selfobject has malignantly grown to
fantastic and delusional proportions. Aggression will persist
until the psychosis disorganizes the personality to such a degree
that conscious intent is severely impaired or the behavior be-
comes so outrageous that external social and legal sanctions bind
the aggression.
The delusions of the psychopathic character who is also
psychotic parallel the dynamic implications of the hallucinatory
experiences. As a fmal defensive operation against massive psy-
chological disorganization, the delusions are the confused self-
and object concepts of the grandiose self-structure, expressed in
a fantastic and unrealistic manner. The delusions also concretize
the stranger selfobject, the primary identification of the psycho-
pathic process.
Delusional thought content that suggests a psychopathic
character organized at a psychotic level is distinguished by the
lack of superego constraint apparent in its behavioral expression;
the sadistic pleasure experienced during and following the acting
out of the delusion; tenacious attempts to rationalize or deny the
presence of the delusion in situations where such dissembling
will yield impressive gains; suggestions within the delusion of
projective identification with evil and its metaphors, such as
demons, Satan, the devil, the fallen angel, the Antichrist, or the
forces of darkness; accompanying dysphoria during recompensa-
tion, usually because of involuntary treatment, since the delu-
sional material is less accessible; and heightened self-esteem as a
result of the grandiose content of the delusions.
The following description illustrates several of these char-
acteristics. The patient was a 31-year-old black male found Not
Guilty By Reason of Insanity to one count of Burglary. These are
excerpts from a psychological evaluation2 to determine whether

the patient should return to the community following a three-
year commitment to the state hospital. The patient was diag-
nosed as paranoid schizophrenic and antisocial personality dis-
order:
R. D.'s arrest history began when he was 12 years

old. He was charged with Assault with a Deadly
Weapon and committed to the California Youth Au-
thority. In 1970 and 1972 he violated parole and was
returned to the CYA on both occasions. In 1974 he was
charged with Burglary. In 1976 he was arrested for
Possession of a Deadly Weapon, Petty Theft, and Re-
sisting an Officer. In 1977he was found Incompetent to
Stand Trial and was committed to Patton State Hospi-
tal. In 1978 he was charged with Robbery with a Gun,
and in 1979 for being Under the Influence of Drugs and
escape from Chino Prison . . .
On or about January 27,1984, R. D. pried open the
door of a house with a crowbar and went inside. He was
found in the basement wearing a fatigue jacket be-
longing to one of the residents. When arrested he
claimed he had millions of dollars, that the house be-
longed to him, and that he was a famous football play-
.
er. . . The most salient feature that emerges from a
review of his records is his delusional system. He
committed the instant offense actually believing that
the owners were his aunt and uncle, and they had given
the house to him. From time to time he believed him-
self to be King Tut and other mythical figures, as well
as famous sports stars . ..
R. D. presents as a tall, muscular black man who
2My thanks to Judith Meyers, Psy. D., and Eugene Schiller, L.C.S.W.,for
permission to use portions of their evaluation,
.
appears slightly younger than his stated age. . . He
was oriented in all three spheres. There were, how-
ever, periods when he did evidence mild disorganiza-
.
tion and confusion. . When asked about the instant
offense, he states: "I was suffering from a delusion
about the people who lived in the house. I thought that
they were my aunt and uncle. They were trying to sell
it, and I wanted to buy it. I was not looking for any-
thing. I had a delusion that I lived in the house before."
When asked why he committed the crime he
stated that voices were telling him to do it. He stated
the voices had given him the combination to the
.
safe. . . R. D. was questioned about the delusions that
he was King Tut and famous baseball players. He
smiled, denying he currently thought he was King Tut,
"I do not have a logical explanation." He indicated that
he just wanted to be great, but thought these identities
were basically harmless.
R. D. was asked if he had any regrets or remorse
about the crime. He stated that he did. "If I could turn
back the hands of time, I'd rather be without the
incident. I regret losing three years of my life for
something that is not mine. I could have been on the
street."
R. D. was asked about an incident in 1985during a
psychotherapy group while in custody. At that time he
had expressed a desire to return to the house and kill
the occupants. When confronted with this, he stated he
was not serious and was "just trying to make people
.
laugh. . ."
R. D. denied any drug or alcohol abuse at any time
..
in his life .as he relaxed, however, anxietal interfer-
ences to memory lessened. There were gaps and incon-
sistencies, however, in his reporting, probably due to
his denial system . . . he reports a history of antisocial
behavior which began at age 11when he shot a girl in

the eye with a BB gun for beating up his brother. "They
locked me up for two years." R. D. reports being
expelled from high school at age 16 for running a
burning flag up the flagpole. He states he was cele-
brating the last day of school. He smiled slightly when
he recounted the incident, but appeared to barely
.
grasp the inappropriateness of the act. . .
When asked why he would continue [treatment if
released], he stated, "If I don't, I11 wind up dead
somewhere."
R. D. was administered the Minnesota Multiphasic Person-

ality Inventory and the Rorschach. Not surprisingly, he pro-
duced a two-point 49 profde on the MMPI (T=81 [Scale 41; T = 74
[Scale 93). The Rorschach produced 13 responses, including 1
human response that was spoiled, 1reflection response, 1aggres-
sion response, and 1morbid response. I interpreted the psycho-
logical test results as follows:
R. D. would. have a high probability of interpreting

reality differently and idiosyncratically from others
around him. He also would be inclined to confuse ex-
ternal reality with his internal wishful images and
perceptions. Although not overtly psychotic at
present, the patient shows some signs of confusion of
reality in recalling what he considers memories that in
actuality are only fantasies that tend to reach quite
grandiose proportions . . .R. D. has minimal interest in
other people. He has little capacity to empathize with
others, and to understand, appreciate, and respect
other people's feelings and actions. He is distrustful of
other people, yet also dependent upon them to gratify
his momentary wants. This would tend to keep him
internally in conflict, as he both seeks gratification and

does not trust the source of the gratification.
He does not identify with conventional social
values and rules. In fact, he is excited by antisocial
behavior and derives satisfaction in doing things
against the law. There is a marked absence of con-
science, but he is able to verbalize conventional rules of
conduct if he senses it would please the interviewer or
derive gain for him.
The patient evidences chronic anger which he
attempts to control and deny within himself. He is
moderately impulsive, and will tend to rationalize,
blame, and project responsibility onto others for his
behaviors, and in circumstances he finds himself.
He has a generally narcissistic attitude toward
others in the world, which is exhibited through a sense
of entitlement and indignation. He has learned, how-
ever, to control this to some degree since he recognizes
it will work against his release from custody. His
aggressive impulses, and derivative emotions, tend to
be unmodulated and intense. He will be inclined to
generalize these feelings, and the emotions themselves
will perceptually "flood" him and distort his under-
standing of reality. He does show an ability to think
logically and perceptually organize his environment
when not emotionally aroused.
R. D. recognizes fully the behaviors that should be
manifest to increase his chances of being released from
custody. He is quite skilled at dissembling, or conceal-
ing, any thoughts or feelings that he considers indica-
tive of pathology and that might work against him.
Three days prior to the evidentiary hearing to determine

whether he should be released to the community, and several
months after these evaluations, R. D. stated in a psychotherapy
group that he owned a Lear Jet, had twenty children, and used to
play professional football when he was 12 years old.
Formal thought disorder in the psychopathic character is
also pathognomonic of psychotic personality organization. The
most striking and revealing example of formal thought disorder
expressed to me by a psychopathic personality was the patient
who blurted, "I have skeptophrenia." Here a neologism uncon-
sciously betrayed the individual's intent to malinger and exag-
gerate certain symptoms for behavioral gain; and, in a prescient
manner, foreshadowed my own doubt as to his credibility.
The multiple variations of formal thought disorder are the
phenotypic expressions of the primary process mechanisms of
condensation and displacement (Meloy 1986b):
The shift toward formal thought disorder through the

mechanisms of primary process can be conceptualized
on two dimensions. First, the primary process of con-
densation is a horizontal condensing of abstract, func-
tional, and concrete representations that violates con-
ceptual boundaries of Aristotelian logic and compels
identification and equivalence of only similar represen-
tations. Second, the primary process of displacement is
a vertical shift from abstractions (connotations) to ob-
jects and functions (denotations) to phonemes (verbal-
izations). [p. 541
The use of the term f m l thought disorder also implies the

maladaptive use of such paleologic thinking. Thought organiza-
tion is embedded in a social, or object relations, context, and can
only be judged disordered when it sabotages the reality-adaptive
tasks of the individual (Johnston and Holzman 1979).
Formal thought disorder appears to have significant trait
characteristics, especially in the schizophrenias (Holzman 1986).
When treated with neuroleptics, thought disorder in chronic
schizophrenia does not reduce to normal levels, but the most
severe levels are affected (Spohn et al. 1986). And, most germane
to the psychopathic process, formal thought disorder appears to
be qualitatively, rather than quantitatively, distinctive when
comparing manic and schizophrenic psychoses (Andreasen and
Grove 1986, Holzman et al. 1986).
I have not seen any clinical expression of formal thought
disorder in the psychopathic process that distinguishes it from
thought disorder in the absence of psychopathy. Its differential
expression in mania and schizophrenia, particularly paranoid
schizophrenia, however, does facilitate the oftentimes difficult
diagnosis of type of psychosis when seen in the context of a
psychopathic character. I t is especially relevant to a hypothesis
that I will elaborate later in this chapter; namely, that the
characteristic avenues of expression of psychosis i n the psycho-
pathic process are mania or paranoia.
Andreasen and Grove (1986) examined the frequency of
thought disorder in 100 psychiatric patients, including two sam-
ples of twenty-five manic disordered patients and twenty-five
paranoid schizophrenic disordered patients, using their Scale for
the Assessment of Thought, Language, and Communication (An-
dreasen 1978). Considering the eighteen types of thought abnor-
malities, the manic sample most frequently displayed the fol-
lowing types (in descending order): pressure of speech,
derailment, loss of goal, perseveration, circumstantiality, illogi-
cality, incoherence, and distractible speech. The paranoid schiz-
ophrenic sample most frequently displayed the following types
(in descending order): derailment, poverty of speech, loss of goal,
incoherence, perseveration, circumstantiality, tangentiality, and
pressure of speech. They concluded that patients with mania
tend to be more fluent and disorganized, with a more prominent
"positive" thought disorder, whereas patients with schizophrenia
tend to be more empty and disorganized, with a more prominent
"negative" or impoverished thought disorder. Among the schizo-
phrenias the degree of disorganization may differentiate
subtypes; on the other hand, across the entire range of functional
psychoses, fluency and productivity may differentiate between

affective and schizophrenic disorders.
Holzman and colleagues (1986) reached similar conclusions
to those of Andreasen and Grove (1986) in their study of manic,
schizophrenic, and schizoaffective patients using the Thought
Disorder Index (Johnston and Holzman 1979). The TDI was
based on the work of Rapaport and colleagues (1946) and Watkins
and Stauffacher (1952) using verbal protocols from the Ror-
schach. In its most current revised form, it identifies twenty-
three categories of thinking disturbance at four levels of sever-
ity. Previous work indicated the TDI was highly elevated in all
psychotic populations (Johnston and Holzman 1979). Nonpsy-
chotic hospitalized patients, such as personality disorders, had
the lowest levels. Gender, ethnicity, social class, and intellectual
level did not account for differences between groups (Haimo and
Holzman 1979).
The Holzman and colleagues (1986) study identified five
factors that embraced fourteen of the TDI categories and best
discriminated the schizophrenicand manic patients. In Table 7-1,
I and I1 indicate the manic factors; 111, IV, and V indicate the
schizophrenic factors. They wrote,
Manic thought disorder manifests itself as loosely tied

together ideas that are excessively and immoderately
combined and elaborated. Often, there is a playful,
mirthful, and breezy quality to their productions. In-
trusions of incongruous ideas into social discourse is
one consequence of this propensity.
.
Schizophrenic thought disorder. . . shows. . fluid
thinking, interpenetrations of one idea by another,
unstable verbal referents, and overly concise and con-
tracted communications Cgiving] the impression of
inner turmoil and confusion.
There is, moreover, a set of thinking disorders that
appears to be nonspecific. . . vagueness, loss of set,
and inappropriate distance. [p. 3691
Violence, Paychosia, and Related States 265
Table 7-1
Factors Discriminating Manic and Schizophrenic Patients
TDI Categories
I. Irrelevant intrusion 2. Flippant
13. Looseness
11. Combinatory thinking 8. Incongruous combinations
14. Fabulized combination
15. Playful confabulation
111. Fluid thinking 9. Relationship verbalization
17. Fluidity
21. Contamination
IV. Confusion 5. Word finding difficulty
12. Confusion
18. Absurd responses
22. Incoherence
23. Neologism
V. Idiosyncratic verbalization 4. Peculiar verbalization
Both of these studies suggest qualitative differences between

formal thought disorder in manic and schizophrenic psychosis.
Andreasen and Grove (1986) noted the particular difference
between mania and paranoid schizophrenia, while Holzman and
colleagues (1986) were able to discriminate between manic and
schizophrenic thought disorder using several factor analytic ap-
proaches. Viewed against a background of psychopathic char-
acter formation, the nature of the formal thought disorder be-
comes a clinical marker for determining whether the manic or
paranoid mode of psychosis is evident.
RealiQ Testing
The relative presence or absence of reality testing is the third

psychogenic structure noted by Kernberg (1984) to distinguish
between borderline and psychotic personality organization.
Exner (1986b) compared eighty schizophrenic and eighty-four
borderline subjects and found that the X-%, his Rorschach

measure of perceptual inaccuracy, was significantly different
(p< .01) between the two groups. The mean X-% for nonpatients
is 6 percent; in the borderline sample it was 13percent, and in the
schizophrenic sample it was 34 percent. Usually, an X-% that
exceeds 15 percent indicates problems in perceptual accuracy
significant enough to interfere with psychosocial functioning.
One-fourth of the borderline subjects (27 percent) exceeded this
percentage, perhaps accounting for the presence of transient
psychotic states in borderline patients (Kwawer et al. 1980),
whereas 90 percent of the schizophrenic patients exceeded this
percentage.
I have referred to reality testing in the psychopathic pro-
cess in several different contexts earlier in this book. For the
sake of brevity, I will summarize my earlier points, with appro-
priate references, concerning the distinctive characteristics of
impaired reality testing in the psychopathic process.
First, reality testing is the sine qua non of all psychoses,
regardless of etiology (Frosch 1983a). When this capacity to
measure intrapsychic experience against the actual and imrne-
diate interpersonal experience is lost, the psychopathic character
is considered psychotic. Reality testing must be carefully distin-
guished from reality sense, distortions of the sensory-perceptual
experience, which is pathognomonic of dissociative states in
psychopathy (see Chapter 5). Alterations in reality sense, such as
depersonalization and derealization, are quite common during
acts of both predatory and affective violence in the psychopathic
character and must not be misconstrued as a loss of reality
testing, hence a psychotic state.
Second, a loss of reality testing in psychopathy implies
boundary loss among intrapsychic conceptual and perceptual
representations. The psychopathic process developmentally im-
plicates the conceptual fusion of self- and object representations
within the grandiose self-structure (see Chapter 3),but psychotic
personality organization brings with it the additional dedifferen-
tiation, or confusion, of self- and object percepts both intrapsy-

chically and interpersonally.
Third, the primitive defenses within the psychopathic pro-
cess, such as denial, projective identification, simulation, and
splitting, and their parallel conscious processes of deception,
control, and imitation call for the continuous and massive incor-
poration and evacuation of psychic material (see Chapter 5).
These processes, however, never imply a loss of sensory-
perceptual boundary in and of themselves. What is exchanged is
that which is contained, not the container itself (Bion 1977a). The
loss of the container, that is, self- and object percept dedifferen-
tiation, heralds psychosis, since the distinction between intero-
ceptive and exteroceptive stimuli is also lost.
Fourth, psychotic enve1q;pment (see Chapter 6) in the psy-
chopathic process suggests a gradual loss and recovery of reality
testing. Appendix I1 graphically illustrates the ways in which
psychosis can recurrently envelop a psychopathic individual and,
at the same time, be used by that individual to perpetuate the
sadomasochism of his grandiose self-structure.
This factor is particularly dmcult to assess in a forensic
context since conscious intent and unconscious psychotic defense
may be inextricably bound. I t is most relevant to the legal
question of insanity and oftentimes goes to the heart of the
cognitive prong of the insanity defense: could this individual
understand and appreciate the criminality of his act or know that
what he was doing was wrong? As noted earlier (see Chapter 6),
psychotic envelopment has both temporal and spatial dimension,
the former most important to the determination of sanity: De-
spite the presence of psychotic symptoms, at what point in time
did the individual lose the capacity to distinguish between these
symptoms and actual, interpersonal reality? As noted in Ap-
pendix 11, there is usually much to be gained for the psychopathic
character with a psychotic personality organization to both ma-
linger and dissemble his psychosis. The malingering usually
precedes the finding of insanity; the dissembling precedes the
finding of restoration of sanity. I t is all the more baffling since

psychotic envelopment may be only partial, and a semblance of
ego control allows such individuals to use their genuinely psy-
chotic disorders for personal gain. Oftentimes a careful sequen-
tial analysis of the violent offense itself, focusing on both the
subjective experience of the perpetrator and independent evi-
dence gathered by the criminal investigation, will reveal pat-
terns of affective andlor predatory violence that unravel these
issues.
PARANOID ANNIHILATION AND MANIC TRIUMPH
The characteristic avenues of psychotic expression in the psycho-

pathic process are paranoia or mania. From a descriptive psychi-
atric perspective (American Psychiatric Association 1980, 1987)
the most common diagnoses involving both psychosis and psy-
chopathy are schizophrenia,paranoid type, and antisocialperson-
ality disorder, or atypical bipolar disorder and antisocial person-
ality disorder. Note, however, that the first Axis 1-11diagnosis,
although commonly seen in forensic settings, is technically not
allowed according to standards established by the DSM-I11
(American Psychiatric Association 1980), but it is allowed in
DSM-111-R (American Psychiatric Association 1987).
The atypical bipolar disorder Axis I diagnosis, for lack of a
better fit, is used to describe the manic or hypomanic psychotic
personality seen in forensic settings. This individual shows no
complete bipolar cycle and oftentimes appears to remain in a
rather stable manic or hypomanic state with no history of depres-
sive cycling.
Paranoid Annihilation
The psychosis envelops the psychopathic process with paranoid

delusions that naturally, although deviantly, exploit the preda-
tory fear of the grandiose self-structure. The early childhood

identification with the aggressor in psychopathy, and its inter-
nalization within the grandiose self as the stranger selfobject,
leaves a projective residue that continually haunts the psycho-
path; that is, this individual perversely and aggressively does to
others as a predator what may, at any time, be done to him.
This sense of being abandoned by the love object, or invaded
by the hate object, has its ontogenetic link in the knowledge of
being outside the family or group as a stranger, alienated and
subject to predation. This proliferation of predatory anxiety is
striking in the hallucinations and delusions of the paranoid schiz-
ophrenic (Grotstein 1986); and when linked to the psychopathic
process, predatory behavior becomes a vehicle to end such anni-
hilatory fears.
The grandiosity and omnipotence of the defensively orga-
nized grandiose self-structure also supports the paranoid delu-
sional material of the psychosis. The grandiosity implicit in
paranoid ideation when reality testing is lost is only an enhance-
ment of the legendary self-concepts that already inhabit the
grandiose self-structure as fusions of ideal self- and object repre-
sentations (Kernberg 1975).
In a real sense, the psychotic grandiose self-structure be-
comes a caricature of aggression and malevolence that has lost
contact with reality and is "creepy crawlinf3 in a world of
predatory shadows, once persecutory introjects in the individu-
al's mind, now projected onto and into others. (I am grateful to
q h i s expressionwas used by followers of Charles Manson to describe a series

of activities that were, in retrospect, rehearsals for the killings of seven
individuals known as the Tate-LaBiancamurders in Los Angeles, August 1969.
Members of the Tarnily" would surreptitiously enter a home while the occu-
pants were sleeping, and silently "creepy crawl" throughout the home, rear-
ranging as much furniture and belongings as possible without waking the
inhabitants. Then they would leave. It markedly increased the Family mem-
bers' sense of omnipotence, grandiosity, and predatory skill (Bugliosi and
Gentry 1974).
Paul Lerner, Ph.D., [personal communication] for this important

distinction between projection [onto] and projective identifica-
tion [into] through the use of different prepositions [see also
Klein 19461. It captures the countertransference difference be-
tween projection and projective identification: When feelings
and percepts are projected onto another, there is little counter-
transference reaction. When feelings and percepts are projeo
tively identified into another, there is a tormenting and uncom-
fortable sense of being controlled, of now being burdened with
certain internal states that one has no choice but to contain for
the moment, and a desire to evacuate the alien state as soon as
possible. During interactions with the psychotically paranoid
psychopath, the operation of projective identification is quite
apparent. One suddenly knows that he or she is the target of
predation and explicitly feels a sense of weakness, vulnerability,
and foreboding.)
Many of the structural and functional relationships between
paranoid psychosis and psychopathy are apparent in the case of a
31-year-oldCaucasian male who was found Not Guilty By Reason
of Insanity for the murder of his father and stepmother. I have
had four years of contact with this individual, immediately fol-
lowing the killings in 1983 until his most recent attempt to seek
release from his state hospital commitment.
P. S. has been descriptively diagnosed as schizophrenic,
paranoid type, chronic, and mixed personality disorder with
narcissistic and schizoid features. He has both an individual and
familial history of antisocial behavior.
P. S.'s criminal record goes back to age 25 when he was

charged with Possession of Controlled Substances. He
was also charged with Disorderly Conduct and Prosti-
tution. At age 27 he was charged with Possession of
Controlled Substances and drunk driving. At age 28 he
was charged with Forgery of credit cards as an accom-
plice to a woman he was going with at the time. At age

30 he was charged with public nudity. . . .
I t is stated that P. S.'s brother had also been in jail
and his uncle, a half-brother of his father, was con-
victed of the murder of his own wife. The grandmother
was said to be obsessed with voodoo and kept voodoo
dolls about with one rolled up in a rug, impaled with a
pin.
The patient had a history of syrnpathomimetic
drug abuse, namely methamphetamine and cocaine. He
also had experimented with LSD and heroin, but the
psychostimulants were his preferred drug. This is
highly unusual in just paranoid schizophrenia and is
usually pathognomonic of an additional personality dis-
order with both antisocial and narcissistic features
(Meloy 1986a).
The patient's psychotic disorder appeared to
begin following the death of his mother of cirrhosis of
the liver when he was 26 years old. At this time the
patient was obese, and during the next year, he lost 100
pounds. He reports, and psychiatric records corrobo-
rate, that he was hounded by anxieties, phobias, and
incipient beliefs that people were making fun of him.
Records indicate brief and multiple contacts with var-
ious providers of psychiatric services.
He lived away from home with various women
and acquaintances during the next several years,
holding jobs for brief periods of time, but generally
finding himself unemployed. He moved back home in
February 1982, at the age of 30, reportedly feeling
depressed and isolated. His father had remarried a
woman named Helena, but was also suffering from
severe back problems.
In May 1982, P. S. was taken by his father to the
psychiatric hospital, reporting that he had ''lost his

temper." The patient admitted hearing voices, telling
him he was "lazy, a fag, a queen, and fat." The father
reported he needed back surgery, but was afraid to
leave P. S. alone in the house with his stepmother. He
was prescribed antipsychotic medications, but did not
voluntarily continue them.
P. S. "house sat" during 1982 and worked at a local
Xerox shop. His father entered the hospital in January
1983, and the patient reported being frightened. He
perceived his father as ''losing all the goals in his life"
and his stepmother being partially responsible for this.
When his father returned home in March 1983, he
appeared "weak, slow moving." P. S. began to halluci-
nate again.
He first heard the voices of his stepmother and
father, W e want you to leave but we're not going to let
you go." He began to feel rectal sensations, most no-
ticeably at night. These sensations he later described
as a "ball being thrown a t your rectum," and delusion-
ally believed that his stepmother was promoting them.
He called this sensation, "rectal esophagus."
He continued to be tormented by auditory hallu-
cinations throughout the day, W e want you to be a
homo . . . we want you to kill us . . . we will kill you by
giving you a heart attack." He confronted his father
with his molestation by his stepmother, and the father
adamantly denied it.
In early May 1983, P. S. purchased a 12-gauge
shotgun and began target shooting. He reportedly had
never owned a gun before. On Wednesday night, May
27, 1983, he loaded the gun and heard voices in the
middle bedroom. He became frightened, returned to
his own room, and unloaded the gun. His stepmother's
daughter visited the family the following day, and P. S.
believed she was also afflicting him. On May 29, he was

hired as a park aide by the state of California. He drank
a six-pack of beer throughout the day, but couldn't
sleep that evening. The voices were telling him, "Kill us
if you can, kill Helena, kill J. J." He was angry and
agitated.
At 0230 on Saturday morning, May 30,1983, P. S.
entered his father and stepmother's bedroom. He shot-
gunned his father to death while he lay on his back; he
vividly remembers then seeing his stepmother smile
with her eyes closed before he fired upon her. He then
shot his father one more time and called the police.
When P. S. was admitted to our forensic inpatient
unit he was acutely psychotic. He did not respond to
neuroleptic medications, however, and his hallucin-
atory-delusional symptom complex changed dramati-
cally. He believed that his muscles were being stripped
from his bones, and he could actually feel the tearing as
a somasthetic hallucination. This may have been a
psychotic embellishment of actual dystonic reaction to
the neuroleptics. P. S. now reports that once he left the
forensic treatment unit and was committed to the state
hospital, these sensations disappeared and have never
returned.
The state hospital report concerning his response to treat-

ment, written three years after his commitment in February
1987, reads,
His progress in therapy has been slowed by several

factors. He is schizoid and has difficulty relating to
others. Thus in groups he is reluctant to reveal his own
problems and does not "connect" emotionally with oth-
ers, and therefore does not benefit much when they
talk. He reacts to feedback from both the therapist and
peers as criticism and becomes argumentative. He is

quite rigid and very reluctant to change. He minimizes
..
his problems. . He has difficulty relating to others.
He socializes very little and has no close friends. He
spends most of his free time alone or sleeping. When he
..
does interact it is to get his own needs met. . When
he talks about his crime he does so in a very matter of
fact way. He expresses little grief or emotion, and
seems more concerned about the fact he islocked up.
He is just beginning to understand intellectually why
he did it, but does not understand his feelings. For a
long time he said it was "opportunisticn in that his
father and stepmother just happened to be there. He is
now beginning to realize that he resented his father
remarrying and the fact that he could not talk to his
stepmother since she spoke little English. . . and . . .
he identified with his father's helplessness. He needs to
work more on understanding his sexual delusions a t
.
the time of the crime. . . He feels that his problem will
be worked out by getting married, yet he has great
difficulty even talking to women, but denies this.
The psychopathic process was not as apparent in P. S. prior

to the murder of his father and stepmother. Yet, in retrospect,
much of his behavior emerges as an interaction of both his
paranoid psychosis and his psychopathic process. Although vir-
tually nothing is known about P. S.'s early environment, four
factors stand out that suggest psychopathy in addition to the
insidious psychotic disorder: first, a familial antisocial pattern
involving first-degree blood relatives of his father; second, an
individual antisocial pattern; third, the use of a variety of illicit
drugs, but a strong preference for psychostimulants, or more
specifically, syrnpathomimetics such as cocaine and methamphe-
tamine; and fourth, a polymorphous and perverse sexual history.
This last factor is based on the cumulative experiences of seven
years of homosexual activity, a prostitution arrest, a public

nudity arrest, and multiple transient and sequential hetero-
sexual arrangements prior to the murders. The sexuality of P. S.
plays a prominent role in the psychosis and predatory violence
that ensues and even takes on a perverse negation: P. S. states
that he has had no sexual contact with anyone since the murders
and adamantly denies that he masturbates. He reports a com-
plete absence of sexual feeling toward males or females and
believes that when he marries it will then be time to be sexual
again. Clinical records over the past several years support P. S.'s
asexual existence. This pattern of perverse sexuality, from poly-
morphous expression to schizoid abstinence, is typical of the
psychopathic process because of the incapacity to form an em-
pathic, caring bond to the eroticized object. This absence of
attachment behavior leads to sexual expression as sen-
sory-perceptualnovelty without intimacy: the continual pursuit
of eroticized skin contact without whole object relatedness.
The psychosis and predatory violence were highly sexual-
ized. The homosexual object choice of P. S., which he had allo-
plastically expressed years earlier, was transformed into con-
scious hate and was the basis for his paranoid psychosis (Freud
1911). The articulation of the somesthetic hallucination as "rectal
esophagus" suggests a condensation of anal and oral libidinal
areas, a regression to a point of maximal sadism for the develop-
ment of paranoia (Abraham 1954,Klein 1964). "Rectal esophagusn
conjures up images of forced incorporation and evacuation of
feces-penis-fwd: a psychotic condensation of both objects and
aims.
The paranoid psychotic behavior of P. S. also mirrors an
aspect of evolutionary aggression Neurnan (1987) called the "pa-
ternal male-male power root." The origins of this strong male
(the so-called alpha bull) and the weaker, effeminized male (the
so-called beta bull) relationship are found in the higher mamrna-
lian task of defining the hunting territory and protecting the
group, and thus a pecking order of strength must be established.
An aspect of this competitive male-male interaction, with

strong undercurrents of homosexual dominance and submission,
is the rage of the beta male, effeminized by forced rectal inter-
course. Neuman (1987) noted the phylogenetic roots of this rage
and the ways in which it was both sublimated and perverted in
Greek, Roman, Nordic, and Christian cultures.
In a real sense, the psychotic regression of P. S. recapitu-
lated this alpha-beta bull root form of aggression in his paranoid
rage against the father for attempting to anally invade him and
transform him into an effeminized, homosexual male.
His rage toward the father was also toward the father's
weakness. P. S.s' anger toward the insufficient mother who had
died was now displaced to the weak father who could no longer
protect him from predation outside the family or provide protec-
tion from the devouring, incorporating (step)rnother within the
family.
The oedipal dimensions of this paranoid psychosis are strik-
ing. P. S. kills his father and perceives the stepmother to smile at
him. The maternal introject of the biological mother was projec-
tively identified into the stepmother at that moment, resulting in
the perceived smile. The pleasure of the maternal introject,
communicated to P. S. through a projective identification during
the act of patricide, becomes a talismanic expression of the
sadism inherent in the oedipal wish.
This acting out of the oedipal wish in the most violent
fashion is empirically supportive of the persistence of oedipal
conflict in preoedipal, in this case psychotic, regression. Perhaps
more cogently, it suggests a rooted oedipal myth existent at a
symbioticlevel of dyadic relationship to the mother (Mahler et al.
1975). This "oedipal myth preconception" (Grinberg 1981) is a
precursor of ego functioning that discovers psychic reality and
leads to investigation of the relationship with the parental cou-
ple. This "private Oedipus myth" (Bion 1963) within P. S. suffers
destructive attacks due to the envy, greed, and sadism of the
Violence, Psychosis, and Related Slates 277
psychotic personality organization and results in both intrapsy-

chic and interpersonal catastrophe.
P. S. is initially tormented by the stranger selfobject, phe-
nomenally experienced by him as auditory and somesthetic hal-
lucinations: the taunting command to become homosexual and
later to kill his stepmother and father. The transformation that
occurs because of the psychopathic process is the gradual identi-
fication with the auditory hallucination, or stranger selfobject,
and its reintegration into the grandiose self-structure as concep-
tually fused with the ideal self. The auditory hallucination re-
mains as a sensory-percept coming from outside the self, yet the
self becomes an agent provocateur of the command hallucination
and identifies with its purpose. The intrapsychic transformation
is the conceptual fusion of real self + ideal self + ideal object
(stranger selfobject) = grandiose self-structure at a psychotic
level of expression where perceptual distinctiveness has also
been lost among self- and object representations. This contrasts
with only the loss of concqtu~j~l self- and object differentiation in
the narcissistic personality's grandiose self-structure (Meloy
1985).
In the interpersonal sphere, reality testing is gone and
violence is acted out in a most primitive fashion through a
restitutional attempt to symbiotically penetrate and join,
through hatred (H), both the stepmother and the father. P. S.
shoots his father in the back and his mother in thefimt.
But is there empirical support for these intrapsychic trans-
formations that set them apart from a paranoid decompensation
without the presence of psychopathy? There are several. First,
P. S. was an active homosexual prior to the torment of the
auditory hallucinations and had alloplastically expressed himself
in several polyrnorphously perverse ways before he became
psychotic. Second, unlike the vast mry'ority of schizophrenic
individuals (Hellerstein et al. 1987),he did not resist his command
hallucinations, but instead became their agent of action. Third,
he engaged in purposeful activity, whether conscious or not, to

secure both the weaponry and skill necessary to carry out the
command hallucinations. Fourth, he showed indications of preda-
tion (see Chapter 6) during the two weeks prior to the murders.
Fifth, he describes the killings as "opportunistic" and when
questioned as to his meaning, states only that his stepmother and
father happened to be in the house and that is why they were
killed. And sixth, P. S. is very resistant to developing any insight
into the nature of his psychotic personality organization. He is
continually argumentative and defensive when approached psy-
chotherapeutically and perceives others as psychologically at-
tacking him.
In a rather unusual psychopathic maneuver, P. S. developed
a pattern of reporting to subsequent psychiatric investigators
that the prior investigator "misinterpreted" what he said. More
specifically, he contended that his memories of psychotic symp-
toms were misinterpreted as present psychotic symptoms by
each psychologist or psychiatrist that talked to him. He did
acknowledge that such psychotic phenomena may have occurred
once, but had not occurred since the killings, despite ample
documentation of the latter. This rationalization of psychosis as
only a memory of psychosis is pathognomonic of the dissociative
defenses and states that are rampant in the psychopathic process
(see Chapter 5). In such states of mind, actuality may be only a
memory, and a memory may have only been a dream. It grossly
attenuates a sense of responsibility for experience, yet facilitates
the grandiose elaboration of the self as agent in a fantasy-laden,
and projectively identified, world (Grotstein 1981, Cahill 1986).
The most recent MMPI profile of P. S. yielded a two-point 94
code type (T= 70), with a MacAndrew score of 27 and a moder-
ately "fake good" validity scale configuration. Such a profile
suggests an individual who is moderately prone to alcohol and
drug addiction and is a poor candidate for psychotherapy because
of both conscious defensiveness and unconscious denial of psy-
chological problems. Such individuals with this configuration are
not symptomatically psychotic, but are impulsive, energetic,

extroverted, and aggressive. They are unconventional and may
behave in antisocial ways. They are not depressed, anxious, or
ruminative and are quite content with their own sense of self.
They are alienated from their family and show a marked degree
of social imperturbability.
Manic Tn'umph
The alternative avenue of psychotic expression in the psycho-

pathic character is mania. It is usually diagnosed as an atypical
bipolar disorder (American Psychiatric Association 1980) since
there may be a lack of siflicant depressive cycling. Affective
cycling in the manic psychopath oftentimes is quite subtle, and
clinicians will find hypomanic character disorders with no ap-
parent cycling (Eckblad and Chapman 1986).
The mania of the psychopath is the expression of predatory
triumph. It is the elation following the killing of the predator.
Mania provides the affective vehicle, which may reach psychotic
proportions, that defensively triumphs over the persecutory and
sadistic introjects that lie in the shadows outside the grandiose
self-structure.
The manic psychopath is fearless. Identification with the
stranger selfobject within the grandiose self-structure reaches
such grandiose proportions that persecutory introjects pale in
comparison. Such individuals truly fear no evil because they have
become the grandiose, malignant force once perceived in others.
The fear of annihilation is disavowed through conceptual and
perceptual fusion with the annihilator, a psychotic caricature of
the stranger selfobject.
The biological predisposition to manic-affective states fuels
the grandiosity inherent in the psychodynamic construction of
the self in the psychopath. Mania is consciously welcomed be-
cause of the autonomic hyporeactivity and consequent sensation
seeking of the psychopath (see Chapter 2). I t is oftentimes

artificially sought through the ingestion of psychostimulants
such as methamphetamine hydrochloride. The manic psychopath
is notoriously noncompliant with prescribed medications, such as
lithium carbonate, intended to stabilize and dampen an affective
disorder.
The cruelty and sadism of the psychopath will also be
exaggerated in states of manic excitement. The desire to control
and degrade the actual object, which may be projectively identi-
fied as the container of persecutory introjects, may be fueled by
the mania, which, in turn, may be fueled by the sadistic pleasure
inherent in the behavior. This interactive effect of the manic
state and sadistic arousal, spiraling upward in a vicious pattern of
behavior, will oftentimes be assessed by the individual, in retro-
spect, in a quite flippant manner:
M. P. was charged with kidnapping. He was diagnosed

as an atypical bipolar disorder and antisocial person-
ality disorder. When I asked him what he had done, he
stated that he had handcuffed his girlfriend to the
stickshift of his sportscar and drove, despite her pro-
testations, to Las Vegas from California. When I asked
him why he did this, he said, "It was my Italian way of
saying, 'I love you.' "
The loss of reality testing in manic psychosis is usually

signaled by delusional identification with a warlike force, a pred-
ator of mythological proportions. In the case I will analyze below,
B. L., in states of manic psychosis while in custody, would dress
himself as an Indian warrior using his feces as warpaint. Similar
to the paranoid avenue in psychopathy, the loss of reality testing
in manic psychosis is the perceptual fusion of real self, ideal self,
and ideal object (the stranger selfobject) within the grandiose
self-structure, in addition to the already fused conceptual self-
and object representations, a correlate of narcissistic personality
disorder. The manic psychopath is not similar to, but identifies

with, the myth of the warrior. The primary process of condensa-
tion violates conceptual boundaries of Aristotelian logic and
compels psychotic equivalence of only similar representations
(Meloy 1986a). The manic psychopath is truly a Dionysian figure.
The manic avenue of psychotic expression in the psychopath
is vividly illustrated by a 26-year-old Caucasian male whom I
have clinically known for the past three years. He has historically
been diagnosed as bipolar disorder, mixed type, and antisocial
personality disorder. Despite his superior intelligence, educa-
tion, and family background (his father is a urologist), B. L. has a
history of medication noncompliance and violent behavior toward
authority figures since age seventeen.
For the past two years, B. L. has nurtured in fantasy a
highly erotic and aggressive relationship toward an attractive,
female Superior Court judge with whom he initially had brief
criminal dispositional contact. The situation escalated to the
point where his conditions of probation explicitly forbade him to
send any correspondence to the specific judge or to enter any
courthouse in the state of California without his attorney, proba-
tion officer, or conservator present.
Despite these conditions, B. L. continued to send written
correspondence and several audiotape recordings to the judge,
which resulted in his probation violation in 1987 and commit-
ment. His psychodynamics that blend both mania and psycho-
pathy are quite apparent in samples of correspondence that he
sent the judge:
Red blood out and black blood in, my Nannie says I'm a
child of sin. How did I choose me my witchcraft kin?
Know I as soon as dark's dreams begin. Shared is my
heart in a nightmare's gin. Never from terror I but may
win.
This poem reflects the patient's identification with evil,
intrapsychically represented by the fusion of ideal self and the
stranger selfobject within the grandiose self-structure. It is a

defensive refuge against a paranoid condition that he is unable to
master (Klein 1935).
On March 17,1987, he sent her the following messages:
As I sit in sunny Poway, California, I jerk off just

thinking about you.
a Zen Kom
I love you because you've got the balls to wear black.
Ten days later his sexually distasteful, but clever, notes

became more grandiose and aggressive, expressing the sense of
omnipotence that foremost characterizes mania:
For America, for this righteous nation, Let's show the

world we're not licked and then I'll fuck you so hard and
so strong you won't walk for a week (God willing).
Two days later he had decompensated to the point of forsaking all

eroticism and wanting only to aggressively master and control
his internalized objects, projectively identified with the female
judge. He denied the importance of his good object representa-
tions, while at the same time betraying the menacing qualities he
felt from his persecutory introjects (Klein 1935).
The question was, how does a man become so dashing,

so strong, so smooth, so debonnaire, so suave, so cool
and collected under pressure, so loving, so giving, so
altruistic, so sensitive, and yet remain so humble?
Well, very simply, it's none of your fucking business,
and if you don't get that pud out of my face I'm going to
put your ass through a wall.
love, B. L.
Klein (1935)also noted that the manic masters his internal

objects to not only prevent them from injuring him, but also from
damaging each other during dangerous sexual intercourse. This
could result in the death of both good and bad object representa-
tions, both within and outside the grandiose self-structure. The
manic psychopath's hunger for objects, what Freud (1921)called
the feast of mania, finds this prospect intolerable. He is both
contemptuous of his internalized objects, yet also hungers for
them. This intrapsychic phenomenon is curiously illustrated in
another letter written by B. L.:
Judge -, your objection is overruled. The fact

that you are already married is irrelevant. What you
are going to do is tell the old man that you love him
deeply and always will and that you would like to
have an open arrangement for awhile. Teach me,
-, teach me.
The threatening letters and tapes that the judge communi-

cated to me presented an obligatory clinical situation in which I
felt it necessary to evaluate the patient to determine whether or
not he represented a substantial threat of serious physical harm
to her. Below are excerpts from that report that further illus-
trate the dynamic relationship between the psychopathic process
and manic psychosis:
I t is my professional opinion that B. L. does pose an

imminent and serious personal threat to you a t the
present time. I have based my opinion on the following
facts and opinions.
First, B. L. has a criminal history dating to No-
vember 8,1978,that includes four different episodes of
violence and two dangerous weapons charges. At least
two of these episodes involve violence toward au-
thority figures, and on at least one occasion a peace
officer was injured. I have also personally observed B.

L. threaten and physically intimidate psychiatric staff,
security staff, and other inmates while in custody on
several occasions since 1983.
Second, B. L. has a documented history of car-
rying weapons, especially knives, and also has received
training in the martial arts. His actual skill as a martial
artist, however, is unknown to me.
Third, B. L. has a history of affective disorder
since age 17, generally of the manic type. When he is in
a manic and psychotic state, he is grandiose, threaten-
ing, impulsive, and is inclined to be violent toward
others. I have personally observed this behavior when
he has been in custody.
Fourth, despite B. L.'s intelligence, which is esti-
mated to be in the superior range; the support of his
family of whom his father is a physician; his six-year
license as a Psychiatric Technician in the state of
California; and his comprehensive knowledge of his
affective disorder and appropriate treatment for it, he
is regularly noncompliant with his medication. In other
words, he chooses to stop taking his medications as
prescribed, usually lithium carbonate, and then decom-
pensates within a two- to four-week period into a psy-
chotic state.
Fifth, in addition to his affective disorder, B. L.
also has a personality disorder which can best be
described as narcissistic and antisocial. This increases
his risk of violence because he has little genuine em-
pathy for others, he tends to disparage acceptable
social conduct, and he has a very self-centeredorienta-
tion to others and the world. Hispersonality disorder is
such that he is able to consciously use his psychotic
disorder for his own pleasure, and to frighten and
intimidate others, until he becomes so disorganized
that he can no longer function. I have personally ob-

served him malinger and exaggerate certain psychi-
atric symptoms to frighten others and to gain certain
gratifications. He has refined this ability quite well,
and it substantially increases his violence risk.
Sixth, B. L. appears to have a capacity for both
predation and sadism. In other words, he appears to
derive pleasure from both inflicting emotional distress
on others, as well a8 planning certain aggressive be-
haviors. I have observed this when he is in custody, and
his aggressiveness and sadism are clearly apparent in
his letters and tape recordings to you.
Seventh, he has futated upon you as a hated, yet
erotic, sexual object in his mind. This fixation, at
present, has a two-year duration, including escalation
in March 1987 to direct threats of violence toward you
("I'm going to put your ass through a wall") and explicit
sexual obscenities ('You're so prim and proper I'll bet
you have lilacs for pubic hairs, you whore.") The recent
escalation is also supported by his risking sending you
audiotapes that indicate his extreme and sudden emo-
tional lability when he believes he is communicating
directly to you. He has taken the step of communi-
cating to you on a more intimate and direct level. He
clearly feels rebuffed and rejected by you as a once
idealized, and now ragefully devalued, female object.
Eighth, B. L. is willing to exercise deception to
secure what he wants. One example is his deception of
his probation officer to seek her permission to send
further correspondence to you.
Ninth, he refused to follow a request by the court
not to write to you, showing some disdain for the
authority of the court, as well as a willingness to taunt
it with sexual references ("I love you because you've
got the balls to wear black").
Tenth, B. L. refused to cooperate with me when I

attempted to interview him on April 20, 1987. He
remained intentionally mute, but did nod when I asked
him if he was choosing to be mute and refusing to talk.
I did not inform him of the purpose of my interview and
made no statements concerning his threats toward
you. At present he continues to take his medication
voluntarily, his lithium blood levels were in therapeutic
range as of April 16, and he currently shows no signs of
psychosis. It must be remembered, however, that the
medication does not treat his personality disorder,
other than to allow him to organize and better control
his behavior.
Eleventh, B. L. prides himself, partially because
of his martial arts training, in having a "warrior men-
tality." This is ominous. I t means that he probably
derives pleasure from adversity, especially when faced
with threats from authorities he perceives as quite
powerful, such as judges; and he will strive to have
little conscious regard for his own personal safety,
holding forth for some higher ideal instead. I have no
idea what this "idealnmight be, or how it would change
when he becomes psychotic.
The alternative avenues of psychotic expression in psycho-

pathy, in my clinical experience, rarely overlap. This may be due
to the independent biological loading for the schizophrenias and
affective disorders that has some empirical support (Andreason
et al. 1987).
In summarizing the distinctions between paranoid and
manic psychosis in psychopathy, I find several pertinent charac-
teristics: first, both exaggerate certain functional, but different,
patterns of the grandiose self-structure. The paranoid psychosis
exaggerates the fear of annihilation from persecutory introjects
outside the grandiose self, whereas the manic psychosis exagger-

ates the grandiosity and omnipotence within the grandiose self.
Second, manic psychosis serves a defensive function against
paranoid decompensation. I t could be viewed as a developmen-
tally higher level of psychotic expression since there is an object
hunger, although expressed in a cannibalistic, incorporative
fashion (Klein 1935).
Third, both paranoid and manic psychoses involve identifi-
cation with the stranger selfobject, the ideal object within the
grandiose self-structure. This identification, however, takes on
psychotic proportions since there is a loss of both conceptual and
perceptual boundaries among object representations. The pur-
pose of such psychotic identification in manic psychosis is to
master and control; in paranoid psychosis the purpose is to
destroy.
And fourth, the psychopathic process intensifies and facili-
tates the alloplastic expression of these intrapsychic maneuvers.
In other words, actual reality provides a stage upon which these
primitive object relational conflicts can be acted out, sometimes
in a most violent and heinous manner. Paranoid psychopaths,
however, will express their psychopathology in a most virulent
and angry way; manic psychopaths will be more teasing, arro-
gant, and sadistically playful.
MALINGERING AND DISSEMBLING
A very important clinical question is the degree to which the

psychopathic character can dissemble or malinger functional
psychosis. As noted above, the concealment of a psychosis has
particularly important rMications when forensic issues of dis-
position are being considered. Malingering issues usually arise in
forensic settings during periods of preconviction or presenten-
cing. Several authors have recently addressed these issues from
a clinical perspective (Shapiro 1984, Cavanaugh and Rogers 1984,

Rogers 1986). I wish instead to focus on a more subtle, and
inferential, question: Given the presence of a functional psycho-
sis, and given the presence of a psychopathic character structure,
can the clinician reasonably expect malingering or dissembling?
And if so, why?
Malingering
I have already explored the psychopathic inclination, and defen-

sive predisposition, to malinger various psychopathological
states such as amnesia and multiple personality disorder (see
Chapter 5). I have found clinically that psychopathic individuals
are usually dismal failures when they attempt to malinger a
psychotic disorder when, in fact, no such disorder exists. Here I
am concerned with the psychopathic individual who actually does
have a functional psychotic disorder at times, but will use knowl-
edge of this disorder to feign or exaggerate symptoms for the
purpose of avoiding behavioral responsibility.
Such an individual, diagnosed as paranoid schizophrenic and
antisocial personality disorder, is the focus of my evaluation in
Appendix 11, and this report should be reviewed before pro-
ceeding further.
In cases such as this, especially in a forensic setting, the
clinician should reasonably expect malingering, or at least exag-
geration, of psychotic symptoms. In fact the forensic clinician,
during the pretrial period of time, should rigorously attempt to
dkpmve the psychotic hypothesis through all clinical and inves-
tigatory means available to him or her. One should assume
malingering unless there is clear and convincing evidence that
the psychosis genuinely exists at the time of the evaluation.
In evaluation situations where a retrospective analysis of
the patient's mental state is in order, such as a Not Guilty By
Reason of Insanity plea, it is critical that the clinician not make
the following assumptions without strong clinical support: that

the crime (or behavioral event) occurred during a psychotic state
because the person has a history of psychosis; that the crime was
a direct result of the psychosis because the person was evi-
dencing psychotic symptoms at the time of the crime; that reality
testing was lost, and the person was completely enveloped by his
psychosis, because he evidenced psychotic symptoms at the time.
Each of these assumptions, in a pretrial forensic context, must be
carefully tested as hypothesis and fail to be disproved before it
can be accepted as clinical fact.
For instance, an individual who reports command hallucina-
tions as the reason for his criminal behavior, in the absence of
other psychotic symptoms such as formal thought disorder or
delusional thought content, puts himself in a very small norma-
tive group and should be viewed with much suspicion: Most
functionally psychotic individuals do not experience command
hallucinations, and of those who do, they generally successfully
resist them (Hellerstein et al. 1987). Furthermore, hallucinations
are usually accompanied by other psychotic symptoms (Amer-
ican Psychiatric Association 1980,1987).
The intentional exaggeration or malingering of a psychotic
state in the psychopathic character with a history of psychosis
serves several intrapsychic functions: I t facilitates the manipula-
tive cycle (Bursten 1972) and through the deceptive act leads to
conscious affective states of exhilaration and contempt; it allows
for the denial of whole sectors of reality as a fundamental defense
in the psychopathic process; it provides an opportunity to imitate
and simulate (see Chapter 6) psychotic behavior, whether it has
been learned from the psychotic portion of the self or from other
psychotic patients that the psychopath may be exposed to on
acute psychiatric inpatient wards; it allows for the further dis-
avowal of responsibility by transforming memories into psy-
chotic experiences and perhaps psychosis into dream; it allows
the psychopathic character to identify with the stranger selfob-
ject during periods of psychosis and thus seek such pseudoiden-
titication a t other times as a defensive operation against perse-

cution from without or within; and the psychosis may simply
provide a rationalization for behavior in a situation where one is
demanded.
Dissembling
The concealment of psychosis by the psychopathic character is
most commonly seen in forensic commitment settings where
issues of restoration of competency or insanity are being consid-
ered. The positive reinforcement for such behavior is usually the
prospect of transfer to a less restrictive environment.
As with malingering, the clinician should assume dissem-
bling in a psychopathic character with a history of psychosis,
especially in postconviction, commitment settings. Rigorous clin-
ical attempts should be made to disprove the hypothesis that the
patient is no longer psychotic. The following assumptions should
not be made without strong clinical support: The patient is
symptom-free because he no longer verbalizes hallucinations or
delusional thought content; the patient's reality testing is ade-
quate because he verbalizes an understanding of his psychotic
disorder; the absence of reported hallucinations means the ac-
companying delusions have remitted; the patient would tell the
clinician if he was still experiencing psychotic symptoms; the
patient does not have the ego control to intentionally conceal his
psychotic symptoms; the psychosis either exists or it doesn't -
there is no such thing as psychotic envelopment or partial rernis-
sion.
The case of R. D. described earlier illustrates the capacity of
the psychopathic character to dissemble psychotic symptoms.
His dissembling was revealed by careful perusal of his hospital
records, conversations with several hospital staff members over
a period of time, and administration of the Rorschach and MMPI
as complementary projective and objective personality meas-
ures.
Violence, Ps.ychosis, and Related States 29 1
The case of P. S. also illustrates dissembling in a psycho-

pathic character with a history of paranoid schizophrenia. I noted
the unusual clinical manner by which P. S. would attempt to
convince subsequent evaluators that reports of his psychotic
symptoms were only misinterpretations of his reported memo-
ries of psychotic symptoms.
The uncovering of concealed psychosis usually requires, as
in these cases, the use of both psychological testing and a 24-hour
behavioral database. I have found the Rorschach most useful in
assessing the reality testing of the individual since it is done by
measuring sensory-perceptual convergence with a normative
group that is independent of the patient's efforts to conceal
thought content. The Rorschach can be "beaten," however, by
giving so few responses that the test is invalid (Exner 1986a).
Such behavior should alert the clinician to a patient who does not
want his psychological operations explored, which would in-
crease the probability of dissembling. The MMPI is an excellent,
complementary self-report measure of personality variables and
psychiatric symptomatology. Its usefulness in issues of dissem-
bling is twofold: to confirm or disconfii Rorschach hypotheses
and to yield validity scales, such as "fake good" and "subtle-
obvious" cofligurations, that may support a dissembling hypoth-
esis.
Dissembling serves several intrapsychic functions: to carry
out the manipulative cycle (Bursten 1972) through deception,
leading to affective states of exhilaration and contempt; to deny
whole sectors of reality, in this case the psychotic portion of the
personality; to heighten a sense of control (Doren 1987) over the
environment and the perceived sense of self; to imitate or simu-
late the psychological health the patient perceives in those he
envies and devalues; to protect the grandiose self-structure from
annihilation, especially in states of partially remitted paranoid
psychosis; and to support the dissociative or splitting aspects of
the psychopathic character by encapsulating or containing psy-
chotic experience.
PSYCHOTIC MODES OF AGGRESSION
The two modes of aggression detailed in Chapter 6, affective and

predatory, are both available to the psychopathic character or-
ganized at a psychotic level of personality. An analysis of each
discrete violent event to determine whether it is predominately
affective or predatory should be done independently of the psy-
chodiagnostic configuration.
A microanalysisof the violent event may also yield a pattern
of sequential change between modes of aggression. For example,
a psychopathic individual may repeatedly engage in acts of
predatory violence that are motivated by an encapsulated delu-
sion that contains a number of fantasied persecutors. At the
moment of actual physical contact with a victim, however, the
predatory mode of aggression gives way to an affective mode,
and the paranoid psychopathic individual is intensely autonomi-
cally aroused, reactive, and threatened; in other words, most of
the criteria for affective violence listed in Table 6-1 (p. 235) will
be met. In both modes of aggression, however, the psychopathic
character continues to be psychotic and delusional, but psycho-
pathy has facilitated the use of predatory violence.
The sequence may be reversed. A psychopathic individual
who is psychotic may engage in a sudden, unplanned, and reac-
tive episode of affective violence; in the aftermath of the physical
violence, he may quickly shift to a predatory mode of aggression.
This could result in planned, purposeful, and sadistic abuse or
mutilation of the victim or in carefully planned maneuvers to
disguise the affective violence or establish evidence that some
other individual perpetrated the act. Throughout the sequential
shift, however, the individual could still remain quite psychotic.
The use of predatory violence by a paranoid and psycho-
pathic individual is illustrated by the case in Appendix 11. The
pattern in this case of an individual who engages in repeated acts
of predatory violence, motivated by paranoid delusions, and then
is able to use his paranoid schizophrenia to be found Not Guilty

By Reason of Insanity, is classic.
The case of P. S. illustrates a slightly different pattern of
aggression. Here the predominant mode of aggression is affec-
tive, but the psychopathic character of the patient supports the
planned and purposeful nature of the predatory behavior that
eventually leads to the murder of his stepmother and father. In
the case of B. L., the manic psychopath, on the other hand, the
patient is predominately predatory toward the female judge
despite his enveloping manic psychosis.
All of these cases underscore the fundamental independence
but interactional relationship between modes of aggression and
levels of personality organization. Affective and predatory rep-
resent the poles of the aggressive dimension, borderline and
psychotic represent the poles of the personality dimension. I
have said earlier, however, and it bears repeating, that preda-
tory violence is not independent of the psychopathic process,
and, in fact, appears to be quite dependent upon psychopathy as
a characterological template for its expression. Affective vio-
lence may also be supported by the psychopathic need for com-
pensatory autonomic stimulation.
Returning to the Kernberg (1984) distinction between char-
acter type and level of personality organization, modes of aggres-
sion appear to correlate with the former and function indepen-
dently, although they interact, with the latter. This apparent
distinction is critical for accurate psychological evaluations, par-
ticularly in forensic settings involving criminal responsibility.
DRUG-INDUCED PSYCHOSIS AND PSYCHOPATHY
As I have noted throughout this book, the psychopathic process

supports the use of psychostimulants. I have found this hypoth-
esis clinically valid through my own experience, and it gains
construct validity through its close relationship to the psycho-

path's peripheral autonomic hyporeactivity, sensation-seeking,
and use of such drugs as transitional objects. Antisocial behavior
in individuals who abuse central nervous system depressants
such as barbiturates and opiates is usually not caused by a
psychopathic process, but is secondary to an economic need to
support a drug habit.
The illicit drugs of choice for the psychopathic character
appear to be cocaine hydrochloride and various forms of amphet-
amine and methamphetamine. All of these chemical substances
share psychostimulant, or sympathomimetic, properties, and all
may induce states of psychosis in the abusing individual.
The psychodynamic impact of these substances on the psy-
chopathic process is essentially identical to the functional psycho-
ses. When enough of these substances are introduced into the
central nervous system a loss of reality testing occurs and the
individual is clinically psychotic. The alternative manic and para-
noid functional avenues of psychotic expression in the psycho-
pathic process may, however, corningle when artificially induced
by a chemical substance. Acute intoxication with methampheta-
mine will clinically mimic paranoid schizophrenia, but the accom-
panying autonomic arousal will also mimic manic or hypomanic
syrnptomatology. Chronic abuse of methamphetamine appears to
induce paranoid delusions or, at least, a hypervigilant, suspicious
attitude toward the environment that will sometimes persist for
three to six months following the last ingestion of the drug. This
last finding is suggested by anecdotal clinical experience and has
not, to my knowledge, been clinically researched in any system-
atic fashion. One colleague of mine, Ben Bensoul, M.D.,has
hypothesized that trace elements of the metamphetamine metab-
olites may remain in the cerebral spinal fluid and cause such
residual personality alterations.
Acute and chronic use of cocaine hydrochloride also inter-
acts with the paranoid and manic avenues of psychosis in the
psychopathic character. Acute intoxication may precipitate para-
noid rage reactions with concomitant affective violence. Chronic

abuse of cocaine will usually signal the development of a paranoid
state, symptomatically expressed in irritability, labile moods,
hypervigilance, suspiciousness, ideas of reference, and persecu-
tory delusions. The violence that may ensue during chronic use of
cocaine will oftentimes be predatory in nature, but is motivated
by delusional thought content that usually centers upon the
illegal possession and sale of the substance.
The clinical properties of both methamphetamine and co-
caine exaggerate the characteristics of the grandiose self-
structure: An already conscious sense of self as being larger than
life is further inflated; windows of ego vulnerability are tempo-
rarily closed; a sense of omniscience and omnipotence is height-
ened; and actual others can be regarded, without the intrusion of
reality, as conceptual extensions of the self. On the other hand,
the psychodynamic relationship between the grandiose self-
structure and persecutory introjects outside the grandiose self is
intensified to a paranoid degree: The evacuation of these perse-
cutory introjects into the environment is more easily accom-
plished because their projective fit is no longer constrained by
reality testing; actual objects assume psychotic identities as
conspirators and persecutors of the psychopath; autonomic reac-
tivity is heightened, therefore affective violence is more likely;
and the inclination to engage in predatory violence may find its
rationale in paranoid delusions.
The following excerpts from a forensic case are illustrative.
This individual was diagnosed with a cocaine delusional disorder
and mixed personality disorder with antisocial and paranoid
traits. This precommitment report was done following a finding
of Not Guilty By Reason of Insanity to charges of Attempted
Murder, Assault with a Deadly Weapon, Use of a Gun, and
Ex-Felon in Possession of a Gun.4
'Many thanks to Judith Meyers, Psy.D., and Edward Calix, Ph.D., for these
excerpts from their report.
According to police records, B. W. broke several win-

dows in an apartment where he was living at the time,
and began to throw furniture toward the outside. He
was yelling for others to call the police, as he believed
someone was trying to kill him. When uniformed police
officers came to the door, the defendant refused to let
them in. When they heard three gunshots inside the
apartment, they left the area and called the SWAT
team. When the SWAT team arrived, they tried to
contact the defendant, with no results. Eventually they
entered the apartment after they threw tear gas and
found B. W. barricaded in the bathroom. At that time
gunfiie was exchanged and B. W. was shot seven times
by the officers.
B. W. spent the entire night before the instant
offense "coking." He was staying with his girlfriend,
Mathilda, and their daughter. At 0600 he asked them to
leave. He believed he saw two men lurking outside and
was protecting his family, as well as himself.
Once his family left, B. W. believed that he saw
the windowshades moving, and the closet door sliding
in the bedroom. He was sure that men were going to
kill him and were hiding in the closet. Within 10 or 15
minutes, he believed that the gas had been turned on
outside of his apartment, and was becoming dizzy from
the smell. Not knowing what to do, he began to break
out the windows with a chair. I t was then that he
believed he saw the outside door begin to move. He felt
an attack was imminent. He indicated that in a state of
terror he began to scream for his life, pace back and
forth and break windows to get the attention of others.
He was sure that he heard voices saying, "There is no
way out, motherfucker. Why don't you make a run for
it." In the process of breaking windows, he cut himself
and was bleeding profusely.
B. W. eventually barricaded himself in the bath-

room. He was growing weaker. When the SWAT team
arrived, he did not believe they were really the police.
He recalled shots being fired back and forth and that he
fired three shots 'straight up in the air" in an attempt
to get help from "the real police." During this time, B.
W. believed that the real men hiding in the closet made
a getaway and escaped the detection of the SWAT
team.
Evaluations that were done following the offense
all came to the same conclusion-that B. W. was suf-
fering from cocaine delusional disorder at the time of
the offense. Dr. A. stated, "The paranoid psychotic
state, with delusions, ideas of reference, false percep-
tions, and misinterpretations of reality" characterized
B. W. at the time of the offense. 'Although from the
SWAT team point of view it looked like he was at-
tacking them, he was in his delusional reality defending
himself against being murdered by a gang of drug
dealers."
Dr. K. stated, "B. W. is an intelligent young man
with both antisocial and paranoid personality traits.
The latter made him vulnerable to the long-term ef-
fects of cocaine, and he developed a psychotic, para-
noid, delusional state, which went beyond the acute
intoxication effects of cocaine in both quality and dura-
tion."
Dr. F. stated, 'Typical of cocaine psychosis, B. W.
developed ideas of reference in an organized, persecu-
tory delusional system, that came to encompass more
and more of what went on around him in the environ-
ment. He became increasingly sensitive to environ-
mental events that fit in with his initial premise and
ignored those that did not."
B. W. is a 34-year-old Hispanic male. His initial
presentation was somewhat arrogant and defensive,

but he became less so as our interview progressed.
He was asked to recount the instant offense. He
stated, "1 got shot by the SWAT team. There was a
contract out on my life. I wasn't dealing drugs, though."
B. W. went on to say that he felt people were out
to kill him due to their thinking he had informed on
them. Leading up to the day of the shooting, he had
gone to the bank and withdrawn money to send to his
wife in Los Angeles. He also had a gun. That same day
he was sure that he saw drug dealers from San Ysidro
on his block. He became increasingly frightened, and
by 0600 the following morning, he had his girlfriend
and daughter leave.
He described his pacing around the room,
checking the house, and believing others were there.
He heard someone state, "Go ahead and try to make a
run for it, you motherfucker." He tried to fire his gun,
but it jammed. He felt this was further evidence that
he was being framed.
He went on to describe how he broke the windows
as a way of getting attention. I got excited and tried to
jump out a window. I cut myself bad. I tied a tourni-
quet on my arm and went into the bathroom. I laid on
the floor. I felt that was the only way I could defend
myself. The cops came with tear gas. They knocked the
door in. I didn't know they were cops, so I shot. The
door was still closed when I shot." B. W. was then
asked why he pled insanity. He admitted he did no feel
that he was psychotic, "just hysterical." He felt that he
had been using too much cocaine, and had a "break-
down."
B. W. was asked whether he felt he overreacted.
He stated that he did not think that he overreacted. At
the time of the interview he still believed that drug
dealers thought him an informant, and that he was just

trying to defend himself. He also believed that the
police were partly at fault for what happened. He felt
they should have announced themselves. He felt it was
a ridiculous situation that he wound up shooting the
police. "I was the guy calling the cops."
B. W. went on to state that he had believed for a
long time that he was vulnerable. He stated that he had
written a letter naming men who would be out to kill
him. He stated that he gave this letter to his girlfriend
.
in case he got killed. This letter is in his police file . . .
B. W. was oriented in all three spheres. He pre-
sented as intelligent and cogent. His thoughts were
logical and goal-oriented. He did not appear to be
delusional at this time, but he has little insight into his
crimes. He believes that he was justified in his actions,
and that the conspiracy on his life did, in fact, exist.
B. W. does not understand the effects that drugs
have on his behavior. He stated that he could benefit
from a drug rehabilitation program, but only to remove
him from a drug life-style, not necessarily the effects of
the drugs. "Yes, coke started the whole thing, but not
the effects of the drug. I t was the people." When
further questioned about the emotional side effects of
taking cocaine, he stated, "It makes you docile. I'm not
going anywhere on cocaine."
MENTAL RETARDATION AN11 PSYCHOPATHY
Psychosis and mental retardation do not necessarily correlate in

any clinical population, but they have both been woefully ne-
glected as areas of research adjunctive to psychopathy.
The mentally retarded psychopath does not fit the clinical or
popular stereotype of the psychopathic character; such individ-
uals are not socially facile, charming, or highly intelligent. More-

over, they will usually present as socially inept, transparent in
their manipulation, and predisposed to impulsive violence when
frustrated.
The research concerning the mentally retarded psychopath
is quite limited. Heilbrun (1979, 1982) hypothesized that the
unsocialized qualities and lower intelligence of the psychopath
correlated with violent and impulsive crime, and he outlined
several models in which cognitive and psychopathic factors com-
bine to precipitate several types of violence. Heilbrun based his
selection of psychopaths, however, on self-report measures that
have been shown to be quite unreliable in determining psycho-
pathy (Hare 1986a).
Hare and McPherson (1984) used a twenty-two item check-
list (Hare 1980)to differentiate ninety-eight inmates into psycho-
pathic, nonpsychopathic, and mixed groups. They further differ-
entiated them into high (>102) IQ and low (< 102) IQ groups
based upon the Weschler Adult Intelligence Scale and the Re-
vised Beta Examination. They found that the relationship be-
tween violence and psychopathy was unaffected by intelligence,
except for frequency of weapon use. The high IQ psychopathic
group used a weapon significantly more often (p< .01) than the
low IQ psychopathic group. These results, however, were oppo-
site to those that would be predicted from Heilbrun's (1979,1982)
findings.
Bailey (1987) argued that intelligence is a major mediator in
his theory of phylogenetic regression-progression: "High intelli-
gence .. .provides the potential for progressing beyond animal
needs into the world of ideas and reflection. Low intelligence, on
the other hand, limits the possibilities for phylogenetic progres-
sion" (p. 52). MacAndrew and Edgerton (1964) associated ex-
tremely low intelligence with an impaired capacity for encultu-
ralization. Other researchers have argued that the mentally
retarded individual has a greater reliance on subcortical mecha-
nisms such as territoriality and dominance (Paluck and Esser
Violence, Psychosis, and Relabd States 301
1971, Hereford et al. 1973) and a heightened sensitivity to phylo-

genetically conditioned releasing stimuli such as the predatory
stare (Bailey et al. 1977). The male with lower than average
intelligence has been noted to be at higher risk for regressive
acting out in the form of juvenile delinquency (Sagarin 1980),
physical violence or murder (Holland et al. 1981, Holcomb and
Adams 1982), and sex offenses such as rape (Rada 1978).
In my own anecdotal clinical experience, I have found that
mentally retarded individuals brought into custody are invari-
ably charged with one of two felony offenses: child molestation or
arson. The former may be due to a developmental "felt twinship"
between the offenders and their chronologically younger victims,
expressed through their biologically mature sexual impulse; the
latter offense, arson, may be attributable to anger that is passive-
aggressively expressed through this particularly dangerous "set
and run" behavior.'
Research concerning the prevalence of the mentally re-
tarded offender is also quite limited. Brown and Courtless (1971)
found the prevalence rate of mentally retarded inmates across
state institutions to range from 2.6 percent to 24.3 percent, with
a national mean of 9.5 percent. Denkowski and Denkowski (1985),
however, found in a more recent and carefully designed study
that the national rate of mental retardation in state prisons, as
derived through a Weschler Adult Intelligence Scale-Revised
diagnosis using an IQ cutoff of < 70, did not exceed the 3 percent
level that characterizes society in general. This rate (2 percent
prevalence average among twenty state prison systems) was
one-third the magnitude of those prisons using group IQ testing
to identify retarded inmates (6.2 percent prevalence average
among ten state prison systems).
Although several research efforts have been made to diag-
nose psychopathology among mentally retarded adults (Sovner
'1 would like to thank Richard Rappaport, M.D., and Park Dietz, M.D., for
this adept description of some arsonists.
and Hurley 1983, Senatore et al. 1975), diagnosis of coexistent

psychopathology is complicated by "overshadowing," in which
clinicians predominantly focus on the patient's intellectual defi-
ciencies rather than signs of emotional disturbance (Reiss et al.
1982).
Studies that investigate any psychological, biological, or
social aspects of the mentally retarded psychopath using empir-
ically derived measures to define the population, such as Hare's
(1980) psychopathy scale and the Weschler Adult Intelligence
Scale-Revised, have yet to be done. But I would like to offer some
clinical observations and psychodynamic formulations con-
cerning the relationship between psychopathy and mental retar-
dation.
There does not appear to be any correlation between psy-
chopathy and intelligence, but interactive effects clearly exist.
Mentally retarded psychopaths are not socially facile and inter-
personally charming. They will clinically present as fundarnen-
tally instinctual individuals whose behavioral repertoire is pri-
marily sexual or aggressive in nature. There will be no
refinement of emotionality; in other words, in addition to an
absence of empathy, there is little capacity for the internal
experience of various gradations of emotion. Furthermore, the
motivation or capacity to cognitively process such emotional
vicissitudes, if they existed, is virtually absent.
A lack of immediate gratification will often result in impul-
sive, antisocial behavior that is usually channeled through sexual
or physical violence. This behavior, however, is quite trans-
parent and is consequently much more predictable than in the
intelligent psychopath who has learned to use deception as a
social instrument. Although the mentally retarded psychopath is
more predisposed to predatory violence than the mentally re-
tarded nonpsychopath, the planning, preparation, and rumina-
tion are usually more obvious. Such individuals will also be more
prone to affective violence than the intelligent psychopath as a
result of reduced capacity to cognitively inhibit their impulses.
The internalized object relations of the mentally retarded

psychopath parallel those of psychopathy in general but will not
have the same conceptual refinement. Immediate self- and object
percepts will play a more predominant intrapsychic role, with
concomitantly less capacity to abstract and remember conceptua-
lizations of self and others. The grandiose self-structure will
consequently be more vulnerable to interpersonal and intrapsy-
chic attack, which lowers the threshold for perceived persecution
by others and retaliatory violence. Both grandiosity and paranoia
will be clinically displayed by the mentally retarded psychopath
in a transparent and gross manner.
The defensive operations of the mentally retarded psycho-
path are virtually identical to the psychopathic process. Such
individuals are organized at a borderline level of personality and
will verbalize their defensive operations in a very direct and
concrete manner. They will not, however, use the conscious
corollaries of their unconscious defenses in such an adept fashion
as the more intelligent psychopath. In other words, deception,
imitation, and object control will be attempted but often ineptly
presented (see Chapter 5).
Most important and basic, the mentally retarded psycho-
path is a clinical fact, rather than a psychopathological fiction.
Such individuals are most distressing because they stir a
countertransference reaction that is both largely sympathetic of
their cognitive deficits and very suspicious of their predatory
behavior.
Part IV
TREATMENT
Psychotherapeutic Issues
T h e psychopathic process is not immune to psychotherapy,
but it does present major countertransference and resistance
issues to the mental health professional. The response of most
clinicians to the psychopathic patient is to question the possi-
bility of psychotherapeutic change, which may be either a
countertransference reaction to psychopathic devaluation or a
realistic decision based upon sound clinical judgment.
My purpose in this chapter is to identify and discuss issues
pertaining to the psychotherapeutic treatment of psychopathi-
cally disturbed individuals, regardless of treatment orientation
or technique. Although my own practice is psychoanalytic psy-
chotherapy, and it is my opinion that long-term, intensive psy-
chodynamic psychotherapy is the treatment of choice for pre-
oedipal disturbances, I am not going to propose a new model for
treating the psychopath. Extensive reviews are available con-
cerning the nature and efficacy of treatment approaches to
antisocial behavior (Reid 1978, Reid et al. 1986).
FUNDAMENTAL PREMISES
For those clinicians that have both the heart and soul to attempt
psychotherapeutic treatment of psychopathically disturbed indi-
viduals, there are fundamental premises that should be under-

stood. These premises define the parameters of treatment with
these individuals and also predict areas of conflict and adversity
that will undoubtedly occur.
Treatment versus Evaluation
The premise of treatment is to heal. I t incorporates an attitude of

caring, empathy, and optimism for the eventual well-being of the
patient. This is fundamentally different from the premise of
evaluation, particularly forensic evaluation, wherein the purpose
is to gather valid and reliable information to address certain
psycholegal questions. I have found this to be an area of confu-
sion, especially for beginning professionals who are defining their
roles as clinicians and do not, as yet, have the experience to shift
smoothly from one attitude to another. I t also may be apparent in
seasoned clinicians, as I have discussed in the case of Kenneth
Bianchi (see Chapter 5). Clarifying roles is necessary, if not
crucial, to the treatment of psychopathically disturbed individ-
uals because of the inclination of these patients to deceive others.
Mental health professionals, whether they be psychologists,
psychiatrists, or social workers, are implicitly taught throughout
their training to believe what patients tell them. This is sup-
portive of the role of healing, but it is very unrealistic in a
forensic context where deception may be characterologically
expectable or institutionally reinforced. Psychologists or psychi-
atrists functioning as forensic investigators know this and will
make allowances for deception through careful corroboration of
their data. In fact, my assumption in doing forensic work is that
the individual being evaluated will deceive me and therefore I
must disprove my hypothesis to arrive at the truth. This is a safe
and reasonable way to approach forensic psychological investiga-
tions, but it is sometimes antithetical to psychotherapy.
Psychopathically disturbed individuals being considered for
Treatment 311
psychotherapy consequently present a dilemma: They should be

believed, yet the prediction is that they will deceive. There is no
simple answer to this conundrum, and the psychotherapist who
has made the conscious decision to treat, rather than evaluate,
the psychopathically disturbed patient must recognize both his
or her commitment to healing and honesty and the nature of the
character disturbance to be treated. The conscious tolerance of
these ambiguities will innoculate the clinician against the
countertransference impulse to polarize, split off, and devalue
the psychopathically disturbed patient as untreatable, a practice
that Lion (1978) called therapeutic nihilism.
Psychopathy as Process
Throughout this book I have emphasized that psychopathy is a

deviant developmental process that is manifest as a disturbance
of personality function. From a treatment perspective it is most
usefully conceptualized on a hypothetical continuum, ranging
from mild to severe. This premise is particularly important for
avoiding the already-noted countertransference reaction to psy-
chopathy: The patient is a psychopath, therefore he is untreat-
able. Here the clinician has fallen prey to his own disidentifying
and dehumanizing impulse, a predictable, and common, reaction
to psychopathy.
The clinical perspective of human behavior as continuous,
rather than dichotomous, is more amenable to psychotherapeutic
formulations. I think it is also more representative of actual
reality, and it is important in refining our understanding of
psychopathic disturbance.
Severity of Psychopathic Disturbance

The more severe the psychopathic disturbance, the more likely
psychotherapy will fail. The severity of psychopathic disturbance
3 12 THE PSYCHOPATHIC MIND
also dictates the necessary restrictiveness of the treatment ap-

proach; for example, mild psychopathically disturbed patients
may benefit from weekly individual psychotherapy, in contrast to
severe psychopathically disturbed patients who will need a
highly structured inpatient milieu to derive any treatment ben-
efits.
Treatability of psychopathically disturbed individuals cor-
relates with their capacity to form attachments and their degree
of superego pathology. Both characteristics should be assessed to
determine the least restrictive environment within which treat-
ment will be attempted.
The capacity to form attachments is related to the degree to
which the patient can form a genuine emotional relationship to
the psychotherapist, regardless of the transference distortion
within that relationship. Since psychopathy signals severe defi-
cits of internalization, the nature and extent of object represen-
tations, and their respective introjected or identified character-
istics, need to be scrutinized. Patients, for example, who
evidence a strong identification with the stranger selfobject
within their grandiose self-structure, manifest in continuous
cruel and aggressive behavior with no attempt to justify their
activities or paranoia concerning their consequences, would be
exceedingly poor candidates for psychotherapy. On the other
hand, patients who evidenced intermittent grandiosity and ag-
gressiveness, but at other times expressed dependent and mas-
ochistic features, such as suicide attempts in the face of perceived
rejection by their psychotherapist, would suggest a more con-
flictual internal object world with both grandiose identifications
and introjected, persecutory objects. Such an internal represen-
tational world would predict a capacity to attach, albeit in a
self-effacing and masochistic manner, and would suggest a more
ambivalent relationship to the internal stranger selfobject.
These patients would be better candidates for psychotherapy.
The patient's degree of superego pathology is also a prog-
nostic indicator of psychotherapeutic success. Psychopathically
Treatment 313
disturbed individuals evidence a range of superego pathology,

which should be evaluated on the basis of their internal relation-
ship to the social environment, rather than according to legal
definitions of social conduct (Kernberg 1984).
Jacobson (1964) outlined three layers of normal superego
development that focused on internalization processes and inte-
gration of structure: The first layer is composed of sadistic
superego precursors that are essentially projected aspects of the
infant's own persecutory objects, cast out in an effort to deny its
own aggression in the midst of parental frustration; the second
layer is composed of the fusion of ideal self- and ideal object
representations, heretofore called the ego ideal; the third layer is
composed of the realistic, demanding, and prohibitive character-
istics of the actual parents that signal a dampening of the pre-
vious two layers and mark the superego as integrated structure
during the oedipal period.
Kernberg (1984) used Jacobson's (1964) layers of superego
development and formulated six levels of superego pathology, or
failure. These levels provide important benchmarks for the as-
sessment of superego functioningalong the continuum of psycho-
pathic disturbance.
The first level is the antisocial personality proper, what I
would designate as the severely psychopathic individual. These
individuals are only identified with the grandiose self-structure,
the stranger selfobject, and their primary mode of relatedness is
aggression, usually experienced by them as sadistic pleasure.
Kernberg (1984) posited a continuum between the passive, ex-
ploitative, parasitic psychopath and the frankly sadistic criminal.
He warned that enactment of an overtly sadistic triumph
through extreme depreciation of the psychotherapist may render
this patient extremely dangerous.
These individuals will verbalize full knowledge of the moral
requirements of society, but do not understand what it means to
internalize such standards. Fusions within the grandiose self-
structure are complete, and identification with the stranger
selfobject is primary. Kernberg (1984) wrote, "It is as if the

patient identified himself with a primitive, ruthless, totally im-
moral power that can obtain satisfaction only through the expres-
sion of unmitigated aggression and requires no rationalization for
its behavior" (p. 281). The only hint of sadistic superego precur-
sors is the necessity of sadism to achieve pleasure. Such individ-
uals are not amenable to psychotherapy and, if treated, should be
seen only in a highly structured and secure inpatient setting.
The second level is the narcissistic personality with antiso-
cial features. These individuals are differentiated from the first
level by their paranoid features in the transference, the enraged
quality of their antisocial behavior, and subtle dependencies in
psychotherapy. They will also conjure up readily available moral
justifications for their sadistic and exploitive behavior. The latter
suggest the intrapsychic presence of a primitive ideal, although
omnipotent and cruel, and mark a slight evolution from the
sadistic precursors of the first level. These patients convey
through psychotherapy an identification with a cruel and aggres-
sive primary parental object that was internalized out of fear of
annihilation. It is probable that this second level of superego
pathology is more sociogenic than the first level and therefore
more treatable. The severe psychopathic disturbance of the first
level appears to be more biogenic in etiology.
The third level is represented by the borderline patient who
is dishonest in treatment but shows no overt antisocial behavior.
Kernberg (1984) noted the largely protective nature of these sins
of commission and omission and their shame avoidance, uncon-
scious denial, and conscious deception motivations. The origins of
such behavior may be quite complex, but the behavior also
reveals both a capacity for attachment, perhaps out of retaliatory
fear, and an awareness of punitive consequences.
The fourth level is represented by the narcissistic person-
ality without antisocial behavior. It is clinically characterized by
the denial of moral responsibility for one's actions. These patients
maintain what Kernberg (1984)called an "affective discontinuity"
Treatment 315
(p. 2M), an aspect of splitting that protects them from both

anxiety and guilt. This moral abdication is quite ego-syntonicand
may disarm the psychotherapist in the absence of overtly illegal
behavior. There is an arrogant "participant-observer" quality to
these patients' lives, and a consequent absence of any object
relations in depth. Their relationships are emotionally vacuous,
but they seem emotionally content. Moral responsibility is a moot
question because they have ceased comparing good and bad
objects, the intrapsychic genesis of superego development and
morality. Kernberg (1984) argued that these patients have not
internalized Jacobson's (1964) third level of superego formation,
the realistic parental prohibitions and demands. Sadistic and
idealized superego precursors have been minimally integrated,
so that conventional morality may be imitated, but actual com-
.
munication may be "false, cynical, and hypocritical . . frag-
menting all intense emotional involvements with significant oth-
ers" (Kernberg 1984, p. 286).
The fifth level is represented by the majority of borderline
personality organized patients without antisocial or narcissistic
features. They are aware of strong and contradictory impulses
thatare uncontrollable and are able to articulate their unaccept-
able nature. The psychopathic disturbance at this level is found in
the role that splitting and dissociation play in the expression of
unacceptable behavior that would not be tolerated in another ego
state. These patients show a capacity for concern for themselves
and others and will express remorse following aggression toward
actual objects. They will clinically present in a more chaotic,
dependent, and affectively charged manner than preceding lev-
els, but this may convey a capacity for object relations and an
internalization of more realistic parental representations. Psy-
chotherapeutic management of these patients may be Micult,
but the prognosis is much more positive +an earlier levels of
superego pathology.
The sixth and final level of superego pathology is repre-
sented by the neurotic personality with an excessively severe
and sadistic superego. Freud (1916) referred to these patients

who commit antisocial acts as "criminals from a sense of guilt,"
and, unfortunately, they appear to be rather rare in criminal
populations. Kernberg (1984) saw these patients as suffering
from an unconscious dominance of infantile morality coupled with
an oedipal fixation on parental prohibitions and demands. Be-
cause of the existence of a superego structure and the absence of
borderline defensive operations, these patients would not tech-
nically be considered psychopathically disturbed. Unlike others
with more severe levels of superego pathology, they are treat-
able with psychotherapy.
The preceding six levels of superego pathology provide
markers for the location of particular patients along a continuum
of psychopathic disturbance.
Assessment of Severity
The severity of psychopathic disturbance can be assessed both

quantitatively and qualitatively. This is necessary during the
initial contacts with the prospective patient to determine the
usefulness of psychotherapy, if any, and the least restrictive
alternative for treatment.
The quantitative assessment of psychopathic disturbance
can be accomplished through the use of Hare's (1985b) psycho-
pathy checklist, a twenty-item objective instrument derived
from extensive research to empirically refine Cleckley's (1941)
original sixteen criteria of psychopathy (Hare 1980,1981,198Sa,
Hare and Jutai 1983, Hare and McPherson 1984). This checklist
has high internal consistency and interrater reliability when used
as a research instrument with criminal populations (Hare 1985a);
and there is a growing body of research concerning its validity
(Hare 1985a, Gacono 1988, Heaven 1988).
The checklist items (Hare 198Sa) are scored on a 3-point
ordinal scale (0,1,2) and are listed as follows:
Treatment 317
1. Glibnesslsuperficial charm
2. Grandiose sense of self-worth
3. Need for stimulation/proneness to boredom
4. Pathological lying
5. Conninglmanipulative
6. Lack of remorse or guilt
7. Shallow affect
8. Callousllack of empathy
9. Parasitic lifestyle
10. Poor behavioral controls
11. Promiscuous sexual behavior
12. Early behavior problems
13. Lack of realistic, long-term goals
14. Impulsivity
15. Irresponsibility
16. Failure to accept responsibility for own actions
17. Many short-term marital relationships
18. Juvenile delinquency
19. Revocation of conditional release
20. Criminal versatility
Items that do not apply are scored 0; items that apply to a

certain extent or for which a fit is uncertain are scored 1; items
that apply and are a reasonably good match are scored 2. Hare
(1985b) noted that it is very important that both a structured
interview and corroborative data be used when scoring this
instrument; this will attenuate the patient's potential deception
and manipulation.
Hare (1985a) stated that a cutting score of 30 should be
used to differentiate nonpsychopathic from psychopathic indi-
viduals. The maximum attainable score is, of course, 40. In
keeping with a continuous, rather than a dichotomous, theory
of psychopathic disturbance, I would propose the clinical
grouping of individuals according to severity of psychopathic
disturbance:
Mild psychopathic disturbance 10-19

Moderate psychopathic disturbance 20-29
Severe psychopathic disturbance 30-40
These three groupings can be used by the clinician to quantita-

tively measure the severity of psychopathic disturbance. Al-
though Hare (1985a) has limited his use of the psychopathy
checklist to research with criminal populations, I am proposing
its use as a clinical instrument for both treatment and evaluation
purposes. The clinician should be forewarned, however, that
there is no validity, as yet, for this instrument outside of criminal
populations. Its predictive validity in relation to treatment has
yet to be demonstrated. Definitions and scoring criteria for each
of the twenty items are available in the scoring manual (Hare
1985b).
The severity of psychopathic disturbance can also be quan-
titatively assessed using the Rorschach technique and scoring
according to the Exner Comprehensive System (1986a). The
criteria that I have derived in Appendix 111 can be used to
establish a percentage of agreement with the predicted psycho-
pathic indices.
The qualitative assessment of psychopathic disturbance and
treatment implications centers around the clinical interview with
the patient. I have found Kernberg's (1984) structural interview
most helpful in gathering information relevant to the diagnostic
and treatment decisions concerning the patient.
Kernberg wrote,
The structural diagnostic interview, then, combines a

psychoanalytic focus on the patient-interviewer inter-
action with a psychoanalytictechnique for interpreting
conflictualissues and defensive operations in this inter-
action in order to highlight simultaneously the classical
anchoring symptoms of descriptive psychopathology
and the underlying personality structure. [1984, p. 301
Treatment 319
Rather than beginning with a decision-tree model of inter-

viewing, the structural interview is cyclical in nature, exploring
anchoring symptoms of psychopathology that allow for a return
to those symptoms in a different context and from a different
perspective. For example, the patient described in Appendix I
illustrates my cyclical focus upon the patient's pathological lying
as a characterological trait. I returned to the event in question,
the suicide or homicide attempt, on several different occasions to
test the veracity of the patient's statements and his capacity to
hold accurately in memory his confabulated story. This cycling
was premised on my early hypothesis in the interview that
pathological lying was a core psychopathic trait of this individual,
which subsequently was proven to be accurate.
In addition to a structured approach that allows for recy-
cling of material, Kernberg (1984) also posited a linear frame-
work to the interview which consisted of three phases. The first
phase involves questions that are close-ended in nature and
allows for the assessment of more obvious descriptive and behav-
ioral pathology. Within this first phase a mental status exam or
psychosocial history taking might be quite appropriate. The
evaluation of the psychopathically disturbed patient during this
phase is usually uneventful, unless severe psychopathy is
present and questions concerning descriptive symptomatology,
such as the presence or absence of hallucinations, evoke an
intense and primitive defensive operation. The psychopathic
individual will usually produce normative findings during this
phase of interviewing unless the psychopathy is accompanied by
another mental disorder, such as an organic or functional psycho-
sis. Psychosocial and psychiatric history taking, however, may
reveal contradictions or omissions that the interviewer will want
to return to in subsequent phases of the interview.
The second phase of the structured interview is more open-
ended and focuses upon pathological character traits: difficulties
in interpersonal relations, adjustments to the environment, and
internally perceived needs (Kernberg 1984). This immediately
moves the interview to a deeper personality level and usually

begins with a question such as 'Now I'd like to know more about
you as a person. Can you tell me about yourself?" In psychopathic
disturbance such a question will signal the mobilization of narcis-
sistic and borderline defenses, and depending upon the severity
of the disturbance, certain reactions may be evoked. Some pa-
tients may respond in an aggressive and paranoid manner; others
may see this as an opportunity to further "put something over"
(Bursten 1973a) on the interviewer and may simulate certain
descriptions in a deceptive fashion.
This is the point in the structural interview when clinicians
should pay close attention to their own affective reaction to the
patient. This is critical to understanding the object relationship
that has been activated in the patient and it is fundamental to
constructing the transference dispositions and countertransfer-
ence dispositions between the patient and clinician. The affective
dispositions of the patient create concordant or complementary
affective dispositions in the clinician (Racker 1968).
While attending to their own affective reactions, clinicians
are beginning in the second phase to explore the patients' inner
representational world through their questions. They will also be
forming mental representations of how patients perceive them-
selves, and, as questions move toward patients describing signif-
icant others in their lives, a mental representation of how pa-
tients perceive others will also be forming.
Psychopathically disturbed individuals, unless they are
quite adept at imitating normative interpersonal attitudes, will
usually reveal elements of their grandiose self-structure and
aggressive impulses toward their representations of others. The
more severely psychopathically disturbed the individual, the
greater difficulty the individual will have in containing this
activated self-object constellation, and the more likely it will be
acted out in the clinical interview. This will be countertransfer-
entially felt by the clinician as either anger or fear. If carefully
explored by the clinician, the anger will probably have sadistic
Treatment 321
elements to it. The fear will be atavistic in nature and may be felt
quite primitively as a sense of predation. One severely psycho-
pathic patient whom I evaluated for treatment while in custody,
and who was ostensibly quite revealing, told me at the end of the
interview that I now 'knew too much" about him, and such
knowledge had gotten other people killed. For a moment I was
frozen because I could not evacuate the knowledge he had given
me about himself, and it had suddenly become a malignant threat
to my well-being rather than a benign source of clinical informa-
tion. This experience of projective identification, where a portion
of his mental content, in this case self-knowledge, was placed in
me, I could not expel it, and he could use it to control me, was
quite disconcerting.
Attempts to evoke representational images of others that
are affectional will usually be unsuccessful. Since the object
concepts of the psychopath are so vacuous, if the clinician per-
sists the descriptions of others become descriptions of the self.
When one psychopathically disturbed patient was asked to de-
scribe his wife, he said, "she's head-over-heels in love with me."'
As the clinician proceeds through the second phase of the
structural interview, transference and countertransference pre-
dictions for treatment should be more apparent. As primitive
defenses are mobilized during this probing of character pathol-
ogy, the clinician may feel a loss of a sense of freedom in
interacting with the patient (Kernberg 1984). With psychopathi-
cally disturbed patients, this may be experienced as a sense of
being "under his thumb." The clinician may also feel an inner
sense of devaluation, affectively experienced as a diminution of
self-esteem, without being able to pinpoint any behavioral
trigger by the patient. A sensitivity to spontaneous and fleeting
sadomasochistic visual images in the mind of the clinician may
also be diagnostic of the transference-countertransference par-
adigm that will be intensified during treatment.
'My thanks to Linda Helinski, Ph.D., for this patient's comment.

The third phase of the structural interview begins with the

question, 'What do you think I should have asked you and have
not yet asked?" (Kernberg 1984).This question gives patients an
opportunity to reveal information they think is important or that
the clinician should know. I t is also critical to further under-
standing of the psychopathic disturbance. Until this phase of the
interview, the clinician with the psychopathic patient may have
been forced to engage in a power and control struggle to deter-
mine who will direct the interview. This is quite pathognomonic
of psychopathy since the disturbance is manifest in relationships
premised on gradients of power rather than affection.
The third phase of the structural interview allows the clini-
cian to intentionally abdicate control of the interview and see how
the patient responds. A multitude of responses is possible,
ranging from intensified aggression and sadism toward the clini-
cian to a sudden loss of interest on the part of the patient because
the narcissistic pursuit, the struggle for control, has been accom-
plished.
This third phase also allows clinicians to experience them-
selves and the patient and think about the interview. The time to
think is often woefully inadequate in clinical and custody set-
tings.
At the conclusion of the structural interview, the clinician
should be ready to formulate a treatment plan, if one is possible,
and determine the least-restrictive alternative for such treat-
ment. Reasonable predictions should also be possible concerning
the transference and countertransference problems that will
arise once treatment has begun.
The Decision Not to Treat
There are individuals who are so psychopathically disturbed

that, in my opinion, no attempts should be made to treat them.
The decision not to treat should be as carefully made as the
Treatment 323
decision to offer treatment, but oftentimes the sources of data

are much more limited.
Two questions that are central to this decision focus upon
the individual's amenability to treatment and the danger the
individual poses to the treating professional. I t is, simply put, a
risk-benefit ratio.
Generally, those psychopathically disturbed individuals
who score r 30 on the Hare Psychopathy Checklist (Hare 1985b)
are not candidates for any form of individual psychotherapy on an
outpatient basis. If treatment is attempted with such an individ-
ual, a more restrictive alternative should be selected, such as an
inpatient, milieu, or custody setting.
Interpersonal and intrapsychic features of the patient that
contraindicate any form of treatment include the following:
1. Sadistic aggressive behavior in the patient's history that

resulted in serious injury, maiming, or death to the victim.
2. A c m p l e t e absence of any remorse, justification, or rational-
ization for such behavior.
3. Intelligence greater than or less than two standard devia-
tions from the mean. This would place the individual in the
very superior or mildly mentally retarded range of general
intelligence.
4. A historical absence of any capacity, or inclination, to form a
bmd or an emotional attachment to another person.
5. An atavistic fear of predation felt by experienced clinicians
when in the patient's presence without any overt behavior
precipitating such a countertransference reaction.
COUNTERTRANSFERENCE
Although there are many understandings of countertransference
in the literature, I will begin with the definition proposed by
Reich (1951) and Greenson (1974), namely, the psychotherapist's
countertransference reaction is his or her distorted and inappro-

priate responses to the patient derived from his or her unre-
solved, unconscious past conflicts. I believe this i s ~ endogenous
n
dimension of countertransference, and it underscores the neces-
sity of intensive psychotherapy or psychoanalysis during the
training of any psychotherapist.
There is, however, a reactive dimension to countertransfer-
ence, which is the therapist's experiential response to the pa-
tient's preverbal mode of communication, which oftentimes reen-
acts the patient's relationships to early parental objects. These
responses may be concordant (Racker 1968), and thus identical in
nature to the patient's own internal experience of affect and
defense, or they may be complementary (Racker 1968), and thus
different or opposite in nature from the patient's internal world.
Oftentimes the complementary, reactive countertransference
recapitulates an early parental reaction to the patient.
Countertransference, however, does not encompass the to-
tality of reactions to the patient. That would negate the impor-
tance of the real relationship to the patient (Greenson 1974). Such
a broad definition of countertransference, for instance, would
make it difficult to discriminate the working therapeutic alliance
from concordant identifications (Racker 1968) with the patient.
The discrimination of this real relationship, the therapeutic alli-
ance, however, is problematic in the treatment of psychopathi-
cally disturbed individuals for it is precisely this real relation-
ship that may be absent with the psychopathic individual. A
state of nonrelatedness may exist outside the boundaries of the
transference-countertransference paradigm.
Endogenous countertransference reactions, whether per-
sistent or transitory, are more clearly distinguished if assigned to
one of several types (Reich 1951): a simple impulse derivative,
such as identification with the patient's behavior; a defense
against an impulse, such as intense anger and a wish to punish the
patient who acts sadistically; general character problems of the
therapist, such as pathological therapeutic ambition (Greenson
Treatment 325
1974); and narcissistic gratification, such as highly sexualized

curiosity toward the patient. Racker (1968) also noted the funda-
mental importance of the Yaw of talion" in countertransference:
that is, for every positive or negative transference reaction on
the part of the patient, there is also a positive or negative
countertransference reaction on the part of the psychotherapist.
Reactive countertransference to the psychopathic indi-
vidual was the focus of several authors (Frosch 1983b, Stras-
burger 1986), and I would like to elaborate further upon their
work.
Therapeutic Nihilism
Lion (1978) noted this most common countertransference reac-

tion to psychopathically disturbed individuals. I t is the stereo-
typical judgment that all psychopathically disturbed individuals,
or antisocial personality disorders, as a class, are untreatable by
virtue of their diagnosis. Such a judgment ignores both indi-
vidual differences and the continuous nature of severity of psy-
chopathy. I have most commonly observed this reaction in public
mental health clinicians who are assigned patients on referral
from probation, parole, or the court; and assume, because of the
coercive nature of the treatment referral, that the patients must
be psychopathic and any psychotherapeutic gain is impossible.
Such reactions are often the product of attitudes that have
been internalized as an "oral tradition" during training from
senior, teaching clinicians. They are rarely the product of direct,
individual experience. I t is, in a sense, a mass retaliatory attitude
where moral judgment impinges on professional assessment. The
behavioral pathology of the psychopath, to devalue and dehu-
manize others, becomes the concordant identification of the cli-
nician doing to the psychopath what the clinician perceives the
psychopath doing to others.
However, judgments of untreatability based upon indi-
vidual assessments do commonly occur, and are absolutely essen-

tial at times, when evaluating psychopathically disturbed pa-
tients. Therapeutic nihilism is only suspect when a diagnostic
class of individuals is systematically excluded from treatment
opportunities without an individual structured interview.
Illusory neatment Alliance
The opposite countertransference reaction to therapeutic ni-

hilism is the clinician's illusion that a treatment alliance exists
when, in actuality, there is no such realistic bond between the
patient and psychotherapist. The therapeutic alliance is the
reality-based cement that bonds the psychotherapist and, at
least, a portion of the patient's personality to the task of matura-
tion, development, and healing.
This reaction is particularly insidious in treatment of the
psychopathically disturbed patient because the patient is predis-
posed to deception, compulsive manipulation, and malignant
pseudoidentification (see Chapter 5). The latter defense, an as-
pect of projective identification, is the patient's gratification of
the therapist's narcissistic wishes by simulating or imitating
desired thoughts, affects, and behaviors. The psychotherapist is
consequently enamored by the apparent progress of the psycho-
pathically disturbed individual, believing that a treatment alli-
ance has been formed. In actuality, however, the clinician is only
witnessing the chameleonlike quality of the patient to mirror the
narcissistic wishes of the primary parental object. The psycho-
therapist who readily desires change in the psychopathic patient
is most vulnerable to this countertransference reaction.
Fear of Assault or Harm

Strasburger (1986)noted the important distinction between real
and countertransference fear in work with psychopathic pa-
Treatment 327
tients. Reality-based fear must not be discounted and can be

distinguished by a careful assessment of the demographic char-
acteristics of the patient and his or her intrapsychic reality at the
time of the perceived risk (Meloy 1987). The clinician should also
be familiar with the distinction between predatory and affective
violence (see Chapter 6) and the psychopathic individual's pro-
pensity to engage in the former. A history of predatory violence
supports the reality-testing of the clinician's fear and a highly
secure treatment environment would be needed to attenuate this
risk. Any act of predatory violence in a history of affective
violence is also quite ominous and should convey to the therapist
the patient's capacity to suspend all empathic regard for his
victim.
Countertransference fear of the psychopathic individual is
an atavistic response to the predatory nature of the grandiose
self-structure. I t is the sense of being prey to the stranger within
the patient. I t is also the fear of being controlled by the sadism of
the patient, which is the manner in which the patient controls his
persecutory introjects. These fears, which are oftentimes felt in
a quite visceral and autonomic way, are diagnostic of the pre-
verbal, skin-boundary developmental experience of the patient
(see Chapter 3). Fear is usually a complementary, rather than
concordant, identification (Racker 1968) in the countertransfer-
ence field of the psychopath. The recognition of this counter-
transference reaction, however, should not rule out the possi-
bility of real danger. Both may, and probably do, coexist. The
clinician must be careful, in the midst of the regressive pull of the
psychopath's splitting defenses, to not treat countertransference
fear and real fear as mutually exclusive, polarized experiences.
Denial and Deception

I have elaborated upon these corollary unconscious and conscious
defenses in Chapter 5, but they can also surface as countertrans-
ference reactions in treatment.
Denial is most commonly seen in counterphobic responses to

danger when treating psychopathic individuals. Vulnerability to
predation, after all, is the ultimate narcissistic insult, and this
may trigger a reaction formation that one is physically invincible
(Maltsberger and Buie 1974). Lion and Leaff (1973) wrote that
denial is the most common defense against anxiety generated by
violent patients. Denial of danger when working with psycho-
pathic individuals may reflect the therapist's concordant identi-
fication with the grandiose self-structure of the patient. Psycho-
therapists may find themselves enamored with the stories,
perhaps exploits, that they hear from patients during treatment.
Instead of empathy for the victims of the psychopath's exploits,
they may find themselves identifying with the exhilaration and
contemptuous delight of patients as they recount their fantastic,
perhaps fantasized, history. These concordant identifications
may deny the interpersonal position that the psychotherapists
are unconsciously assuming the role of the prey.
Denial may also be apparent in psychotherapists' unwilling-
ness to participate in the prosecution of patients who have
committed felonious acts and have clearly endangered the lives
of treating professionals. This reluctance to acknowledge the real
dangerousness of certain patients is rationalized as antithetical
to therapy or damaging to the therapeutic relationship. Several
authors (Hoge and Gutheil1987, Miller and Maier 1987) recently
researched the positive value to both patients and clinicians of
using the criminal justice system in response to felonies com-
mitted by patients toward staff. In their judgment, aversive
conditioning, reality-testing and limit-settingfor the patient, and
the reinforcement of the value of the staff and their safety, were
a few of the positive outcomes of such action.
Deception of the patient by the psychotherapist should also
be noted. This is usually quite subtle in work with psychopathic
patients, but it is often used to manage anxiety engendered by
the patient's confrontation and devaluation of the therapist.
False reasons for altering the parameters of treatment, vague
Treatment 329
and misleading interpretations, and the withholding of certain

interventions because of their potentially explosive conse-
quences may all lead to a chronic pattern of deception of the
patient. Such behavior may indicate superego pathology in the
psychotherapist, the gratification of sadistic impulses, the avoid-
ance of signal anxiety, the management of fear, passive-
aggressive rejection of the patient, or concordant identification
with the psychopathic individual's deceptive skills.
The psychotherapist must be fiercely honest with the psy-
chopathic patient. Psychopathic patients will regressively sur-
face the psychopathic predispositions in their therapists if at all
possible. This is a product, once again, of the malignant twinship
(Kohut 1971) identifications that can unconsciously occur be-
tween patient and therapist. In the case of the psychopath these
identifications are fundamentally narcissistic and self-serving.
Honesty, however, does not mean self-disclosure. And self-
disclosure with the psychopathic patient should rarely be used.
Rigorous honesty may mean silence in the midst of an impulse to
rationalize, confrontation when mollification would be safer, limit-
setting when "flexibility" would be easier, empathy expressed
when felt, and adherence to one'sframe of doing psychotherapy
(Grotstein et al. 1987).
Helplessness and Guilt
The novice psychotherapist may feel helpless in the face of

massive resistance by the psychopathically disturbed patient and
subsequently may feel guilty that genuine change has not oc-
curred (Strasburger 1986). This may be an endogenous counter-
transference reaction, what Reich (1951) called the "Midas touch"
syndrome: the irrational belief that every patient the psycho-
therapist sees will show dramatic improvement. Or it may be a
reactive countertransference caused by the internalization of
devalued selfobjects projected by the patient into the clinician.
Strasburger (1986) argued that such a reaction may be trans-

formed into rage toward the patient that is passively expressed
as withdrawal or through a reaction formation that "smothers"
the patient with attention. Psychopathic patients will actively
solicit anticipatory guilt from the withholding and ungratifying
clinician:
H. approached me in the courthouse as I was leaving

for lunch. He was well known to me as a difficult,
psychopathic individual with a manic affective disor-
der. He greeted me kindly and told me that he had just
been released from the county jail across the street and
needed some money.
I told H. that I didn't. give money to anyone. He
began talking more rapidly, but softly, telling me that
brother and mother were exploiting him, and he just
needed twenty dollars for the weekend. When I re-
fused him again, his affect suddenly became angry, and
he said, "Listen, Meloy, I'll go out and rob somebody, or
a bank, if you don't give it to me right now!!" I told him
he could do that, but it probably wasn't very wise since
he had just been released from jail, and seemed to be
enjoying his newfound freedom. He walked away from
me in a disgusted and contemptuous manner.
I had a momentary feeling of dread and responsibility when he

threatened a crime in the face of my refusal to gratify him,
because I knew he was quite capable of such an act. Such
countertransference reactions are magnified by the real fear of
being held responsible for injury to third parties by recent
statutory and case law (Appelbaurn and Meisel 1986).
Devaluation and Loss of Professional Identity

If clinicians measure their competency only through the per-
ceived change in the patient, psychopathically disturbed individ-
Treatment 331
uals may be a source of continuous narcissistic wounding. Inex-

perienced therapists are especially vulnerable to feeling
devalued (Strasburger 1986) and may respond to such emotions
with an attitude of therapeutic nihilism. Psychotherapy may
begin with idealization of the clinician, but it will quickly shift to
devaluation because patients must aggressively purge them-
selves of persecutory introjects to maintain their narcissistic
equilibrium. Despite the most adept therapeutic management of
a patient's contempt, it is difficult to not feel despicable because
of the primitive and preverbal nature of this purging cycle
(Bursten 1972). The psychotherapist's responses to devaluation
may be retaliation, indifference, rage, masochistic submission, or
heroic attempts to "fix" t'he patient.
Hatred and the Wish to Destroy

Few other patients will compel psychotherapists to face their
own antipathy and destructive impulses (Galdston 1987). Psycho-
pathically disturbed patients may hate goodness itself and
through their envy and oral rage destroy all that the clinician
offers. The experience of pleasure is not reciprocal for the psy-
chopath (Strasburger 1986), and, in the most severe cases, it is
available only through sadistic channels of power and control (see
Chapter 4).
The psychotherapist may concordantly identify with the
patient's hatred, and in a talionic manner, respond in kind.
Hatred, however, is an affect (Giovacchini 1972) and may be the
only source of therapeutic work if the psychotherapist can recog-
nize his or her hatred as diagnostic of the preoedipal experience
of the patient (Searles 1965, 1979, 1986). Hatred may ironically
become the basis for a therapeutic alliance. I t is usually acted out
by the therapist only if it remains unconscious.
The Assumption of Psychological Complexity

The most subtle countertransference reaction to the psychopa-
thically disturbed patient is the assumption of psychological
complexity. It is the projective assumption by the clinician that

the patient has the psychological structure and function of the
clinician, which oniy has to be realized or discovered in psycho-
therapy. This is particularly common among novice clinicians
working with intelligent, but preoedipally disturbed, individuals
when there is no overt symptomatology and the patient may
initially present in a very logical and coherent manner.
The assumption that a relationship exists between intelli-
gence and ego functioning, moreover, has received little research
attention since Hartmann (1939). Allen and colleagues (1986), in
one of a few recent studies, found in a sample of inpatient
psychiatric subjects that Bellak and colleagues" (1973) ego func-
tions scale did have a significant global relationship to intelli-
gence as measured by the WAIS-R (Weschler 1981). The sub-
scales of autonomous functions and thought processes had the
strongest relationship to intelligence (p c .001), followed by
object relations, mastery-competence (p < .01). and reality
testing (p < .05). Intelligence, however, did not sifl~cantly
correlate with object constancy, superegoguilt, superego-ego
ideal, judgment, or drive regulation. These latter findings are
especially relevant to the psychopathically disturbed individual
since attachment and superego deficits are central to the psycho-
pathic process. In other words, intelligence does not necessarily
convey a personality structure organized at a neurotic level
(Kernberg 1984), and it may, instead, mask a borderline level
personality organization that is vertically, rather than horizon-
tally, structured (see Chapters 3 and 5). There is no tripartite
personality structure composed of id, ego, and superego pro-
cesses; but instead, the personality is composed only of dyadic
relations between self- and object representations both within
and without the grandiose self-structure that are polarized, dis-
sociated, and split off given certain psychobiological, psychody-
namic, and psychosocial contingencies.
The psychotherapeutic realization of this absence of struc-
ture is further confounded by the malignant pseudoidentification
Treatment 333
of psychopathic individuals. They will strive to imitate and sim-

ulate such structuralization for a variety of reasons, including
malingering, dissembling, and the initial establishment of a twin-
ship transference with the therapist. Evidence of neurotic per-
sonality structure (tripartite characteristics such as third-level
superego development and repression of unacceptable impulses)
should not be assumed in psychopathic patients unless corrobo-
rated by behavior outside the psychotherapy hour.
PREDICTABLE RESISTANCES
DURING PSYCHOTHERAPY
The psychotherapist treating the psychopathically disturbed pa-

tient should be cognizant of certain expectable resistances during
the course of psychotherapy. These resistances, expressed in
transference behavior, reflect core elements of the psychopathic
process which have been extensively reviewed elsewhere in this
book. They must be therapeutically managed if treatment is to
remain viable.
Manipulative Cycling
The patient will engage in a compulsive pattern of manipulation

of the clinician as set forth by Bursten (1972). This pattern
consists of a goal conflict, an intent to deceive, the carrying out of
the deceptive act, and contemptuous delight once the act has
been completed. I t is a cognitive-behavioral sequence that pro-
duces an affective state that is highly rewarding to the psycho-
pathic patient. Unconsciously it is the purging and evacuation of
devalued introjects that are projectively identified into the clini-
cian and thus maintain the safety and homeostasis of the gran-
diose self-structure, This process also wards off envy and oral
rage, which are affectively quite threatening when the object is
initially idealized. The devaluation inherent in the manipulative

cycle supports the destruction of the goodness of the actual
object and renders it a bad object that can be controlled.
Manipulative cycling is most common in forms of psycho-
therapy that plan or direct the course of treatment and assume
the goal definition of treatment for the patient. I t is less prob-
lematic in expressive psychoanalytic psychotherapy wherein the
work is defined by the material presented by the patient during
the hour. The manipulative cycle shadows the other resistances
noted below and can be pondered by asking the question: What
opportunities am I presenting for this patient to engage in a
manipulative cycle with me?
Deceptive Practice
Deception as a conscious and intentional behavior is central to

psychopathy. I t is important that the clinician attempt to distin-
guish between deception as a chosen behavior and denial as an
unconscious defense, although this may not always be possible.
Both deception and denial are linked (see Chapter 5) by their
alloplastic expression through words and acts.
Deception is an integral part of the manipulative cycle and
consciously devalues the psychotherapist by rendering him igno-
rant of the truth. Deception is unconsciously used to ward
off persecutory anxiety and to shore up the grandiose self-
structure.
The management of deception during psychotherapy is ex-
ceedingly difficult since it is hard to recognize and may trigger
intensely negative countertransference reactions. Like the ma-
nipulative cycle, however, it should be assumed to exist, like any
other resistance, with certain genetic, transferential, and inter-
pretative meanings. Oftentimes the acknowledgment of this gen-
eral suspiciousness toward the patient, and placing the burden of
proof upon the patient to convince the clinician he is being honest,
Treatment 335
is quite useful. This can be the first step in the patient's analysis
of his deception rather than its exploitation as a resistance to
treatment.
Malignant Pseudoidentification
The conscious imitation and unconscious simulation (see Chapter
5) of the psychopathic individual contribute to the process of
malignant pseudoidentification during psychotherapy. This re-
sistance is recognized by the internalization and reflection of the
clinician's narcissistic vulnerabilities for purposes of control.
The dearth of internalizations within the psychopathic pro-
cess prompts a hunger for such identifications, but this psycho-
logical appetite is tainted by three characteristics: The identifi-
cations will invariably be superficial and short-lived; they
resonate most easily with the nefarious and narcissistic charac-
teristics of others; and they are used for hurting and controlling
the object of identification, in this case, the psychotherapist.
In a sense, however, these malignant pseudoidentifications
are pathways toward the core identification of the psychopath,
the stranger selfobject (Grotstein 1982). This is oftentimes the
most deeply internalized selfobject representation, and it usually
has its roots in identification with a cruel and aggressive primary
parental object. The malignant pseudoidentifications can direct
the clinician to this core element of the grandiose self-structure
through interpretation and confrontation of their meaningless-
ness for the psychopathic individual.
The imitation and simulation of various affective states is
also pathognomonic of malignant pseudoidentification. Patients
will either consciously imitate the expression of certain affects,
usually through words to imply a certain feeling, or they will
unconsciously simulate certain feeling states, usually through
nonverbal channels, such as posturing or facial expressions.
The conscious imitation of affect begins with the patient
intentionally choosing certain feelings that he believes are so-
cially appropriate and desirable. The patient then will talk about
these feelings 'as if" they are genuinely felt. Usually a clinical
question such as "Tell me more about your feeling" or more
directly "How do you know you're feeling ? Can you
describe to me what it's like for you to feel ?" will
elicit material that will differentiate the genuinely felt emotional
state from the imitated one.
The unconscious simulation of affect is more difficult to
discriminate. I t is the psychopathic propensity to identify, in a
chameleonlike manner, with socially desirable emotional states
without having any understanding of the empathic or meaningful
dimensions of such emotion. The clinician's countertransference
reaction to such simulated affect is most diagnostic, but this
assumes training and education that allows the clinician to differ-
entiate between his own endogenous and reactive countertrans-
ference states.
Simulated affect on the part of the psychopathically dis-
turbed patient may leave the clinician feeling skeptical and
distant, rather than empathically resonant. The patient will not
gradually recompensate from the affective expression but will
end it as if the performance is over. Treatment of the psychopa-
thically disturbed patient, however, must embrace the possi-
bility of genuine affective expression, or therapeutic gain will be
impossible. Again, the sources of genuine affect are inextricably
bound to the stranger selfobject and are clinically characterized
by persecutory fear, hatred, envy, rage, sadistic pleasure, con-
temptuous delight, and boredom. Without accessing these affec-
tive complexes the treatment must remain at a superficial, pseu-
doidentification level.
Sadistic Control
Kernberg (1984) described a phenomenon he called "malignant

narcissismn in the treatment of narcissistic personalities who are
Treatment 337
undergoing resolution of the grandiose self-structure. The clin-

ical picture of malignant narcissism is characterized by a patho-
logical condensation of grandiose, sadistic, and aggressive striv-
ings.
He elaborated upon four characteristics of malignant narcis-
sism, all of which may occur in the treatment of the psychopathi-
cally disturbed individual: paranoid regression in the transfer-
ence, chronic self-destructiveness as a triumph over the
therapist, dishonesty in the transference, and overt sadistic
triumph over the therapist (Kernberg 1984). Each of these resis-
tances is a behavioral expression of the grandiose self-structure
attempting to regain control of the treatment situation in the face
of a perceived annihilatory threat, and two are most relevant to
sadistic control.
Chronic self-destructiveness as triumph over the therapist
is most clinically apparent in manipulative suicidal attempts or
self-mutilating gestures by the psychopathic individual. I re-
ferred in Chapter 4 to the patient who eventually committed
suicide but also prior to that engaged in continual self-mutilating
gestures, including burning his arm with a cigarette in front of
me during group psychotherapy. Such behaviors are clearly
masochistic, but the sadism derives from the pleasure inherent in
the act, which punishes the therapist who would threaten the
primitive identifications of the patient. Kernberg (1984) referred
to this fourth level of masochism as the most severe form, since it
represents an identification with a primitive, sadistic parental
image: what I would refer to as a stranger selfobject (Grotstein
1982) that is within the grandiose self-structure, that is a conden-
sation of both ideal self- and ideal object concepts, and is cruel and
aggressive. Any threat to the omnipotent control of this gran-
diose self-structure must be preemptively destroyed: conse-
quently the fantasized, or actual, attempts to destroy the good
object, the psychotherapist. Suicide attempts, in this case, are
understandable as a primitive, condensed, and grandiose fantasy
that if one destroys oneself, one destroys the goodness of the
world. I t is an omnipotent fantasy that may unconsciously moti-

vate individuals who commit mass murder and are compelled to
act out such a homicidal-suicidal dynamic. Postmortem psycho-
logical analyses of such individuals often suggest a history of
paranoid personality disorder.
Overt sadistic triumph over the psychotherapist was also
termed "maalignant grandiosity" (Kernberg 1984, p. 296). Such
displays are ego syntonic and may range from verbal devaluation
of the therapist to more overt forms of psychological and physical
aggression. The syntonic nature of this sadism toward the psy-
chotherapist is a key to treatment prognosis: In cases wherein
the sadism is not conflictual and no dependency is evident in the
transference, expressive or supportive psychotherapy should
not be continued. Such individuals, usually seen in probation or
parole settings, are not treatable, but may respond to strict
conditions of release where intensive supervision of overt be-
havior is the only mode of interaction between the individual and
the identified "professional." Heroic attempts at psychotherapy
will usually result in a profound dehumanization of the treatment
process and may place the clinician in actual danger because of
the perceived threat of the clinician's "goodness." Intolerable
envy of the good object will be warded off by devaluation or
destruction.
Sadistic control is also an element of perversion and is
pathognomonic of psychopathic disturbance that is usually un-
treatable by psychotherapy:
J. S. was evaluated at Atascadero State Hospital fol-

lowing his confinement for attempted murder and dis-
position as a mentally disordered sex offender. J. S.
had a histoiy of strangling women which began at age
10 when he attempted to choke a 9-year-oldneighbor.
J. S. is currently 36 and almost killed his most recent
victim.
He adamantly denied any sexual arousal during
Treatment 339
his strangling of his victims and attributes the activity

to a retaliatory impulse for being "put down" by the
woman. He denied any sexual activity other than mas-
turbation at the hospital. His psychologist, however,
reported that he was bisexual and currently in an
active homosexual relationship.
I t is clinically inconceivable, given the compulsive nature of this

activity, the antisocial history, the lack of remorse, and its
talionic motivation ("I just wanted them to feel the pain that I
felt, I didn't want to kill anybody"), that both aggressive and
sexual drives were not interwoven and consciously felt, despite
the patient's protestations.
Kernberg (1984) proposed that malignant narcissism illus-
trates a deep level of superego pathology. I would agree, but
would reformulate his considerationsas evidence of psychopathic
disturbance. In other words, the malignancy of the narcissism
signals the severity of psychopathic disturbance, with its con-
comitant superego deficits, internalization difficulties, attach-
ment deficits, and condensed sexual and aggressive drive deriv-
atives that are dedifferentiated and confused (Meltzer 1973,
Chasseguet-Srnirgel1978).
CONCLUSIONS
Ogden (1983) wrote that the analysis of transference derives

from the willingness of psychotherapists to expose themselves to
the insults of projective identification. This adage is no more
apparent, nor dramatically confirmed, than in the treatment of
the psychopathically disturbed individual.
Yet, if psychopathic disturbance is conceived as a deviant
developmental process, and therefore varies in severity and
degree, some individuals may be amenable to various forms of
treatment. Psychopathic disturbance may also be a secondary
problem for the patient and not the primary focus of clinical
concern. In such cases, an understanding of psychopathy as a
clinical problem, but not necessarily the overriding clinical con-
cern, is important to its containment and the resolution of other
symptomatic or more treatable conditions.
In this chapter I have focused on the hndarnental premises
when considering treatment of psychopathic individuals, expect-
able countertransference reactions during such treatment, and
predictable resistances to treatment. These premises and predic-
tions, despite their psychoanalytic grounding, are applicable to
all modes of treatment of psychopathy regardless of the partic-
ular technique that is being applied. If one is a mental health
professional, the interpersonal encounter with the patient funda-
mentally defines the humanity, or lack of humanity, of the treat-
ment: a task that is most rigorously tested when the psycho-
pathic patient is commonly perceived, at least in part, as
inhuman.
Appendix I
Jonathan Guard-Deception and

Denial in Psychopathy
Honorable Robert J. Donovan
San Diego County Superior Court
Department 46
RE: GUARD, JONATHAN

CR 56843 DA B96754
GENDER: male DOB: May 7,1948
Dear Judge Donovan:

Pursuant to your order dated August 15,1986, I am submit-
ting the following evaluation per Sections 1603 and 1604 of the
California Penal Code. The intent of this evaluation is to deter-
mine whether Mr. Guard would be a danger to the health and
safety of others, including himself, if under supervision and
treatment in the community.
I interviewed the patient on September 8,1986, for approx-
imately two hours in the Psychiatric Security Unit of the San
Diego County Central Detention Facility. I also consulted with
the following individuals: Michael B., L.C.S.W., Constance W.,
L.C.S.W., Cliff W., United States Secret Service, Donald T.
Ph.D., Program Manager for the Psychiatric Security Unit, and
Ben B., M.D., Staff Psychiatrist in the Psychiatric Security Unit.

I reviewed the following records:
1. The Patton State Hospital clinical records.

2. Letter by Constance W., L.C.S.W., dated July 30, 1986.
3. Letter written by Michael B., L.C.S.W., dated May 16,1986.
4. Psychiatric evaluation by Donald S., M.D., dated February 4,
1986.
5. Psychological evaluation by Katherine D., Ph.D., dated De-
cember 19,1985.
6. The Atascadero State Hospital assessment, dated October 1,
1985.
7. Psychiatric evaluation by Carl L., M.D., William V., M.D.,
and Bernard H., M.D., dated February 24,1977.
8. Psychiatric evaluation by Donald D., M.D., dated January 4,
1977.
9. Psychiatric evaluation by Dean A., M.D.,dated December
15, 1976.
10. The patient's United States Secret Service Records.
The following psychometric instruments were used in this

assessment: Minnesota Multiphasic Personality Inventory, the
Rorschach Projective Test, Forensic Adaptation of the Brief
Psychiatric Rating Scale, and the Hare Psychopathy Checklist.
I t is my understanding that Mr. Guard has one year and ten
months remaining of possible custody.
Mr. Guard was originally committed to Patton State Hos-
pital by the Superior Court of San Diego County on March 10,
1977, under Penal Code Section 1026, having been found Not
Guilty By Reason of Insanity for violation of Penal Code Section
211, Robbery. 'lko previous offenses of robbery were committed
while he was heavily involved in abuse of drugs, specifically
phencyclidine. He has a history of escaping from jails and also
Patton State Hospital. Over the past eleven years he has been
Appendix I 343
confined in a number of penal institutions in Texas and Cali-

fornia.
In September 1985 the patient was returned to Patton
under his P.C. 1026 commitment from San Diego County. On
September 18, 1985, he was transferred to Atascadero State
Hospital for security reasons, where he remained until his return
to San Diego County for proceedings consonant with his applica-
tion for a sanity hearing under P.C. 1026.2. On March 26, 1986,
the patient was found "not a danger to the health and safety of
himself, other persons, or their property," by a jury of the
Superior Court.
Mr. Guard was admitted to the Conditional Release Pro-
gram of Los Angeles County, and resided at Hillcrest Mental
Health Center, as ordered by the Court due to a lack of an
appropriate treatment facility in San Diego County. His release
began May 8,1986, and Ms. Constance W., L.C.S.W., director of
Hillcrest, reported that his adjustment to the program was
"highly satisfactory" up until July 24, 1986.
On that date Ms. W. reported that a telephone call was
received from the patient's brother-in-law, Dewey, indicating
that the patient had telephoned him stating he was depressed
and felt like killing himself. The brother-in-law further stated
that he believed the patient was delusional, suicidal, and possibly
should be hospitalized. He reported the patient fantasizing about
his niece, Andrea, and that he loved her and wanted to marry her.
I t was learned at that time that the patient's 15year-old niece
had accompanied him in his truck during his working hours.
When the patient returned to Hillcrest, he was questioned
about the telephone discussion with his brother-in-law. The pa-
tient denied that he was depressed or suicidal, stated he loved his
niece, but denied any romantic fantasies about her. His version of
the telephone call to his brother-in-law was that he became upset
after hearing a tape about suicide that his niece had played for
him, and he felt she was disturbed and needed help. He described
the whole conversation as a misunderstanding which had been
resolved, and this could be verified by telephoning his brother-

in-law. At this time Ms. W. reported that the patient was calm,
oriented, speech was coherent, and there were no symptoms of
depression or suicidal ideation. Neither the brother-in-law nor
the sister, Julie, supported the patient's explanation of the situ-
ation, and continued to state emphatically that he needed psychi-
atric treatment. They refused to disclose specifically the state-
ments the patient had made about returning to their home,
saying only, "It was personal," and they could not discuss it. At
this time they also stated that the patient could not return to
their home, nor should he attempt to contact them by telephone.
The sister felt Mr. Guard would be welcome at his brother
Joseph's home, and agreed to request that Joseph remove the
patient's clothing and personal possessions from their home. The
patient appeared surprised when informed of his sister and
brother-in-law's responses, and that their home was no longer
available to him. In the interim his brother Joseph called to
confirm that he had been contacted to remove the patient's
clothing, and that the patient could visit Joseph at his home.
Although Mr. Guard was requested not to report to his job
on Friday, July 26, 1986, in order to be available for further
evaluation and discussion of his family Miculties, he left Hill-
crest, leaving a note that he was needed at his job and would
return immediately after work. When the patient did not return
to Hillcrest by curfew, and there was no communication from
him, a Missing Persons report was filed with the Police Depart-
ment, and he was reported AWOL to the Secret Service on
Saturday, July 26. Ms. W. reported that a Secret Service agent
contacted her on Monday, July 28, 1986, and stated that a man
named Mr. Guard had stabbed himself during a rock concert on a
previous weekend. The identity of the patient was confirmed
through the Inglewood Police Department, and later in contact
with members of the treatment staff at UCLA Medical Center,
where he was medically stabilized. He was subsequently re-
turned to Patton State Hospital for approximately one week
Appendix I 345
after being brought into custody on July 27, 1986. He was

transported and admitted to the Psychiatric Security Unit in the
San Diego Central Detention Facility on August 8,1986, where
he remains today.
The patient's version of these events is quite different from
those reported by Ms. W. During our clinical interview, he
reported to me that he had never had sexual or romantic contact
with his niece, Andrea. The patient also denied threatening
suicide, and stated that he had never attempted suicide and has
never had any suicidal thoughts. The patient did confirm that his
brother had agreed to let him stay at the brother's home fol-
lowing his exclusion from his sister and brother-in-law's resi-
dence. He states he did return to Hillcrest Residential Center, in
contrast to the report of Ms. W., on July 25,1986. He stated to me
that he returned to the Center, signed out, and a staff member
told him that he should not go anywhere. He further stated that
he felt it was not important enough for him to stay there. Mr.
Guard told me that he spent Friday evening, Saturday and
Sunday, July 25 through 27, at his brother's house. He stated that
he went to "the beach, to Hollywood, I spent some of Saturday
night at my brother's." When I asked him if his brother could
confirm this, he told me that his brother was with his girlfriend,
Nicole, and would not be able to do so. He then stated that he had
his own key to his brother's residence.
Regarding what Ms. W. called a "suicide attempt," there is
also extensive contradictory data. The patient states to me in the
clinical interview that he did not attempt suicide. Instead he was
involved in a "knife fight" at the Forum in Los Angeles. When I
asked him about the specific event, he stated to me that he had
gone to a rock concert, to which he had purchased a ticket. When
he arrived at his seat, he found that a couple was occupying the
place, and when he asked the male partner to show him his ticket,
the man refused to do so. He states he then attempted to secure
an usher to settle the issue. Mr. Guard states to me that this male
then left, came back in approximately fifteen minutes, and con-
tinued to talk to his girlfriend. Mr. Guard then states that his
male individual left again, and came back, wherein he knelt in
front of his girlfriend, who at this time was sitting in the seat to
the left of Mr. Guard. The patient then tells me that at one point
during the concert, he stood up and began clapping for the band,
and this unidentified male lunged upward from a crouched posi-
tion in front of his girlfriend, and with his right hand thrust a
five-inch knife into Mr. Guard's abdomen. The patient states he
grabbed the perpetrator's hand and the knife and attempted to
hold onto the knife so that he could not be stabbed again. He
states, "I was trying to hold my stomach, I couldn't feel any-
thing." He then tells me he fell forward onto the floor, and was
there for approximately ten minutes. He also adamantly states
that he received only one stab wound from this assault.
Later in the interview I asked Mr. Guard to once again
detail for me this "assault" at the Forum. The patient essentially
reported the same details, but added that he had attempted to
force this unidentified individual out of his seat, and the indi-
vidual had said, "don't threaten me." The patient denied any loss
of consciousness during this entire event. He stated that he told
the authorities it was not a knife fight because he is currently on
prison parole, and this would be used against him. He denies any
prior knife fights, and reports this is the first time he has ever
been stabbed.
In my search to confirm whether the patient was assaulted
or whether these were self-inflicted wounds, I pursued several
avenues. I was unable to establish telephone contact with the
Inglewood Police Department or the UCLA physician that
treated Mr. Guard following the stabbing. I was, however, able
to speak with Ms. W. by telephone. She reported to me that she
also had not seen the police arrest report or the medical exarnin-
er's report. She reported that much of their information was
gathered from newspaper reports concerning this particular
event, and she read to me statements from the Daily News, a San
Fernando Valley newspaper dated July 29,1986: "Guard stabbed
Appendix I 347
himself nine times as teenagers cheered him a t a rock concert

.
Sunday night, police said . . he stood on a chair and drove a
hunting knife into his bare tattooed chest. As the crowd cheered
louder, he said he gained more energy, allowing him to shove the
knife blade deeper and deeper, Inglewood Police Department
Sergeant Norman B. said." I was unable to reach Sgt. B. at the
Inglewood Police Department (tel. 213-421-5210).
Michael B., L.C.S.W.,reported to me in a telephone conver-
sation on September 10,1986, that he was the social worker who
originally approved Mr. Guard's conditional release. He also
reported to me that he interviewed Mr. Guard on August 20,
1986, at Patton State Hospital, and the patient did describe
stabbing himself at the Forum. He stated to Mr. B. that he had
grabbed the knife from other people at the concert, and had
gotten carried away with the music and the crowd. Mr. B. also
reported to me that he had viewed a urine drug screen of the
patient two days after the concert, and it was negative for illicit
drugs.
I met with Cliff W., special agent for the United States
Secret Service, on September 8,1986. He allowed me to review
the Secret Service records concerning this patient. Those
records indicate that the patient was interviewed by the Secret
Service on July 29, and Mr. Guard stated to the interviewing
agent that he had stabbed himself because he loved Andrea. He
also stated to the agent that he wanted the world to know of his
love for Andrea by stabbing himself. He recalled that he stood on
the floor area near the stage, and the crowd cheered as he
stabbed himself, allowing him more energy to stab more deeply.
The agent indicated that the patient had nine stab wounds to his
chest and abdomen.
When the patient was confronted by me during the inter-
view with his contradictory information, he stated that he did not
want to report a knife fight because of thepossibility his parole
would be violated. He consented to show me the scars on his
chest and abdomen, and I brought in Ben B., M.D., to also
examine Mr. Guard's chest to see what scars were present. That
examination indicated that Mr. Guard had five scars on his
abdomen and thorax, all between 1 and 4 cm in length. The
patient acknowledged during this exam the presence of two
scars, and stated that one was for the abdominal surgery and one
was the original wound. When confronted by Dr. B. concerning
the other three scars in his thorax area, the patient attempted to
squeeze one of the scars, telling us, "it's a pimple." When faced
with our skepticism of his statement, he sat back in his chair,
pulled down his t-shirt, and said, "Oh, forget it."
In the absence of a police arrest report and the direct
testimony of the examining emergency room physician from
UCLA, it is not possible to determine beyond a reasonable doubt
whether Mr. Guard's wounds were self-inflicted or not. But the
preponderance of the evidence is that they were.
CURRENT INPATIENT TREATMENT
Mr. Guard was admitted to the Psychiatric Security Unit on

August 8, 1986. Review of those inpatient records indicates the
following entries:
August 8,1386, "hostile and demanding"; August 12,1986,"hos-
tile, angry, defensive"; August 15,1986, "hostile, arrogantn; Au-
gust 22,1986, "denies escape threats"; August 27,1986, "placed in
seclusion for being unable to follow directions and being verbally
abusive"; August 28,1986, "attitude continues to be one of supe-
riority towards peer and staff"; August 29,1986, "nursing staff
reports witnessing what appears to be this patient intimidating
or threatening another patientn; September 2,1986, "patient sat
laughing most of the time throughout group."
The patient's DSM-I11 psychodiagnosis is:
Axis I: Mixed substance abuse
Axis 11: Antisocial personality disorder
Appendix I 349
Borderline personality disorder

Axis 111: No diagnosis
Axis IV: 4
Axis V: 4
The patient is currently receiving no regular medications except

for a sedative-hypnotic on an "as needed" basis for sleep.
There is no indication from the Psychiatric Security Unit
inpatient records that he has been physically assaultive or psy-
chotic while in custody. In other words, the patient has been able
to maintain both contact and some semblance of control during
his stay in a maximum security inpatient unit. This is generally
characteristic of his history in other hospital and inpatient set-
tings.
I would like to quote from a progress note written by Mica
E., R.N., the patient's primary therapist, written on September
8,1986: "This patient keeps a low profile on the unit, but has made
his presence well known. His views on psychiatry are known to
all patients and have contributed significantly to hostility and
lack of cooperation from his peers. He is quite open and verbal
about his opinions. He feels psychiatric patients are treated as if
they are less than human, and that they have no rights. He goes
on to elaborate that psychiatric care givers are only interested in
persecuting their patients and dictating their own moral values.
He much prefers jail because he feels he is treated with respect
and has control of his life there. He gives the reason for this as,
'the guards don't hassle you because they know what will happen
to them if they do.' He felt he was allowed to do pretty much as he
pleased in prison. He told me of his respect for Charles Manson,
that %ell be locked up forever, but he's really got it made. People
all over the world write him and send him things-they feel he is
a political prisoner.' The patient feels he is the victim of a political
system intent on persecuting him for reasons he cannot compre-
hend. He has convinced several of his peers that they are also the
undeserving victims of the mental health system. He urges them
to rebel against the system by not cooperating whenever possi-

ble, and fighting for their rights as he feels he is doing. He has no
insight into his own responsibility for his current situation."
MENTAL STATUS EXAM
The patient is a 38-year-oldCaucasian male of medium height and

build. He is oriented to person, place, and time. He is alert. His
affect is somewhat blunted, but appropriate to his thought con-
tent. His mood remains mildly defensive and guarded throughout
the interview. The patient shows no indication of formal thought
disorder. There is no evidence of hallucinations or delusions. The
patient shows no impairment of remote, long-term, short-term
memory, or immediate recall. Concentration and attention are in
the normal range. The patient's intelligence is estimated to be in
the superior range (IQ 120-129). He shows no indication of
homicidal or suicidal ideation or intent while in custody. His
attitude toward the interviewer is one of begrudging coopera-
tiveness, colored by a sense of arrogance and superiority. From
statements the patient makes it is clear that he wants to present
himself in z very rational and positive light, and goes to great
length to explain, excuse, and rationalize his behavior. His pre-
dominant psychological defenses are projection, rationalization,
and denial. I t also appears that this individual has great facility in
being able to lie and intentionally deceive this examiner. When
the patient is asked about his behavior while in the Psychiatric
Security Unit, he tells me that he had had a personality conflict
with the social worker, "She doesn't like what I've said. I've
consistently said that I don't need medication." The patient also
begins the interview by asking me if I will provide for him a fair
and impartial examination. He then goes on to talk about his
"so-called disruptive behavior." He adamantly denies that he had
made any verbal threats to escape, despite this information being
Appendix I 351
documented by staff on the unit. He states, 'That's ludicrous,

why would I tell someone if I had a .38 and a box of shells? That
wouldn't be sophisticated." He goes on to further state, "I've been
..
kindly and generous . nothing but a father figure to these
.
patients . . I would never hurt them for anything in the world."
He reports this despite documentation of his threatening another
patient, and having to be placed in seclusion on August 27,1986.
He states to me that in his opinion, "I am not a danger to
anyone." He states that he was "working steadily and abiding by
the Hillcrest rules." When the patient is asked about his consis-
tent diagnosis of antisocial personality disorder throughout all
the evaluations and records that I reviewed, he states that, "I
think I was a sociopath, but it means nothing more than being
lazy. I spent eleven years in the pen in California and Texas . ..
as a child I used to shoplift, way down deep I think there is an
area in me that thinks it's kind of slick to be a criminal. But I've
seen for eleven years the pain that criminals cause, and I don't
want to do that."
The patient showed no residual effects of his extensive
history of drug abuse, which has been characterized by a prefer-
ence for psychostimulants. The patient denies any drug use
during 1986. He reports that he prefers psychostimulants, and
also phencyclidine, because he can talk very well and feels
euphoric when ingesting them. His experience with drugs would
be characterized as one of grandiosity and psychomotor acceler-
ation, typical of the psychostimulants such as methamphetamine.
When I asked him about what he had learned from this event at
the rock concert, he states, "I'm not going to any more rock
concerts. I wish I hadn't gone."
PERSONALITY PROFILE
Mr. Guard experiences minimal conscious anxiety or depression,

and is quite comfortable within himself. He also shows little
conscious need for affection from others. He may oftentimes be

openly hostile in social situations; and is generally suspicious and
distrustful of others. There are also indications of persecutory
thoughts which may have no basis in reality.
The patient has difficulty expressing emotion in a modu-
lated fashion, and will oftentimes use projection (attributing to
others one's own thoughts and feelings) to keep people at an
emotional distance. This individual would often be described by
others as tense and irritable, but he would deny these feelings if
confronted. He is likely to overreact to environmental stimuli,
and will often exhibit poor behavioral control and a heightened
general activity level. He may have a reduced ability to concen-
trate and organize his thinking in a logical, sequential, and
goal-&'ected manner. Explosive outbursts of aggression are a
distinct possibility.
There are strong indications of paranoia, grandiosity, and
self-aggrandizement. He is very facile in developing superficial,
casual relationships that have no emotional depth or substantial
meaning for him. Mr. Guard, however, will appear very comfort-
able in most social situations. He tends to have his own internal-
ized system of behavioral rules that would most likely be judged
by others as amoral.
He shows a moderate level of addiction-proneness to both
drugs and alcohol.
What is particularly disturbing is a lack of capacity to form
emotional attachments to others. He shows a pronounced ten-
dency to view other people as objects, and to have little empathy
concerning other people's feelings. There is also a strong indica-
tion that this individual will unconsciously deny aggressive im-
pulses, and has great difficulty, therefore, expressing them in
any kind of modulated fashion when they surface. Mr. Guard
would be characterized as having a psychopathic personality
disorder wherein others are viewed as extensions of his own
grandiose self. This pathologically narcissistic attitude toward
others in the world, coupled with impulsivity, hyperactivity, and
Appendix I 363
paranoid ideation, are chiefly characteristic of this individual's

current personality function.
Although no formal testing of his intelligence was at-
tempted, past psychological records indicate that this individual
has a superior IQ. This would contribute to his facility in de-
ceiving others by presenting rationalizations to those who would
choose to naively believe that he is not responsible for his actions.
Such manipulation would historically leave people feeling quite
angry, disappointed, and generally exploited by this individual.
ASSESSMENT OF DANGEROUSNESS
Based upon my evaluation of Mr. Guard, it is my opinion that he

does constitute a danger to the health and safety of others if
under supervision and treatment in the community. I have ar-
rived at this opinion for the following reasons:
1.The patient is a male psychopath. This fact alone, without
considering any other individual characteristics, demographi-
cally places him in a group which is at higher risk for violence
than nonpsychopathic criminals.
2. The events of July 27, 1986, indicate that this individual
was in a life-threatening encounter involving a weapon in a public
place. Regardless of whether the patient's wounds were self-
inflicted or other inflicted, such a documented event impresses
upon me this individual's poor social judgment, impulsivity, and
proneness to engage in situations in his very recent past that
clearly create an imminent danger to self and others.
3. The patient shows virtually no insight into his psycho-
pathic (antisocial) personality disorder. Specifically, an inability
to form emotional attachments, a lack of empathic capacity
toward other individuals, and a tendency to be deceptive and
manipulative of others, are not easy psychological areas for this
individual to reflect upon.
4. In addition to this individual's well-documented antisocial
personality traits is the heightened risk of danger due to his

current guarded, angry, and suspicious state. There is also a
distinct possibility that he harbors completely false persecutory
beliefs, that is, delusions, that he is intelligent enough to conceal
from this examiner at this time.
5. This individual's behavior in his most current inpatient
psychiatric setting has continued to support my conclusion that
he is rebellious against authority, blames other individuals for
situations of which he has at least a shared responsibility, and
will intentionally lie and deceive those people who are obligated
to provide him with mental health care.
6. Despite his lack of overt violence while in the Psychiatric
Security Unit, his disruptive behavior managed to land him in
seclusion on one occasion. This is remarkable, given the fact that
he is not psychotic, and is intelligent enough to recognize that his
clinical behavior has been carefully documented by the inpatient
staff and will be considered in this evaluation. It leads me to
conclude that, despite the fact that he is in a maximum security
inpatient setting, the most controlled treatment milieu in the
county, he still shows difficulties with his impulse control.
7. The patient has an extensive and versatile history of
criminal behavior, and does not appear to have any sense of the
impact on his victims of his acts, particularly the two robberies.
He shows no empathic understanding of the "force and fear" that
he was convicted of inflicting upon them.
8. Mr. Guard's violent behavior was done in a public place
when he was surrounded by strangers. The fact that he would
seek out such an arena, and the fact that he would engage
strangers in this behavior, either as perpetrators or as an audi-
ence, renders his potential victim pool, including himself, ex-
tremely large: much more extensive than the individual whose
potential dangerousness is limited to family members or friends,
We have here an individual who is quite inclined to act out
publicly during times of emotional stress, which increases the
probability of his violence potential and dangerousness.
9. The patient denies access to or ownership of any weapons;
Appendix I 355
yet there was a weapon involved in this July 27 incident. The

Secret Service reports also indicate that the patient, at one time,
had two Cobra .38 caliber revolvers at his wife's residence. The
patient denies this. Again, we have here an individual who denies
attraction to and use of weapons, yet has a history of criminal
offenses that supports his access to and possession of weapons.
His potential for violence is increased because of his propensity
to secure weapons and his deliberate lying that he has never
done so.
10. The patient is considered a threat to the President of the
United States by the Secret Service. Their records indicate that
these threats are not short-lived, but date back to December 1978
when Mr. Guard first threatened President Jimmy Carter. Their
records also document a history of involvement with Satanic
cults, a hatred of minorities, and generally a racist attitude, all
suggestive of paranoid ideation.
11. Despite his denial of any current alcohol or drug use,
both his history and psychological testing indicate a moderate
addiction-proneness to either alcohol or drugs. These facts, and
his personal preference for psychostimulants such as metham-
phetamine, correlate with dangerous behavior.
12. Mr. Guard is physically quite capable of inflicting vio-
lence on himself and others, particularly given his propensity to
secure or be in the possession of lethal weapons.
13. This individual has shown to this interviewer, as well as
to those involved in his case, a propensity to consciously deceive
and lie to others. I cannot overestimate this individual's ex-
tremely facile capacity for conscious deception. In order to im-
press this upon the court, I would like to give a brief example. I
will quote a paragraph from a psychiatric evaluation that was
done February 24, 1977, concerning this patient's precommit-
ment evaluation which found him Not Guilty By Reason of
Insanity:
The patient was then asked what is happening to him a t

the present time, if he still had the same experiences he
had before. The patient went on to say that he is

in contact with Satan, and hears Satan's voice some-
times. He states he sees faces of people. He claimed he
saw these faces "every day." He went on to say, "they
materialize." He claims the last time he had this expe-
rience of seeing the faces was when he was on the
"rack" in his cell in a meditation pose. He denies that he
sees just faces. He says he sees complete beings, and
they were touching him. Either these were two ene-
mies or two friends of his, he couldn't say. The patient
was asked about the last time he heard anything like
voices, and he remarked, "Only once since I was in San
Diego." The patient was asked if he felt the influence of
"Baphlomint," and he responded, 'Yes, that's my an-
gel."
Nine years later this patient reported to a Secret Service agent
on January 1, 1986, that his Satanic cult fixation, hallucinations,
and delusions were methods of manipulating the system in order
to get his insanity judgment, and it had worked. I t is my opinion
that this individual's skillful lying, although not directly tied to a
prediction of violence, heightens the probability of his not being
able to be successfully supervised in a conditional release outpa-
tient program.
RECOMMENDATION
I would recommend that Mr. Guard be recommitted to Patton
State Hospital and outpatient conditional release be revoked at
this time.
If you have any further questions, please do not hesitate to
telephone me at 544-2435.
J. Reid Meloy, Ph.D.
Community Program Director
Chief, Forensic Mental Health Services
San Diego County
CROSS-EXAMINATION OF JONATHAN GUARD
District Attomzep: Mr. J. G., you are a habitual liar, are you
not?
J. Guard: In your opinion, that's for sure.
D.A.: You haven't done a lot of lying recently?
J.G.: I have done a lot of eluding the truth recently.
D.A.: Is that a lie? Is eluding the truth a lie?
J. G.: I t depends on the context.
D.A.: Well, let's talk about a couple of contexts. You told the
Secret Service agent in January of 1986 that you had previously
used a satanic cult fixation to manipulate the system, correct?
J.G.: Yes, I think1 did tell him that.
D.A.: Which meant that sometime long ago you lied to
psychiatrists, correct?
J.G.: I've talked to so many psychiatrists, I'm sure that I
haven't told them all the absolute truth a hundred percent of the
time, but that doesn't mean that I was purposely out to lie to
them or to try to deceive them.
D.A.: You told Agent P. of the Secret Service that you were
in love with your niece and you wanted to show the world your
love for your niece so you stabbed yourself?
J.G.: I do not have any recollection of that. When the Agent
came to see me, I was in intensive care, heavily medicated. I don't
hardly remember him coming, much less what I talked to him
about.
D.A.: So those words came rolling off, your lies?
J.G.: I don't remember what I said to him.
D.A.: You told Mr. B. of L.A. County Mental Health that
you stabbed yourself, didn't you?
J. G.: That's true.
D.A.: And then you told Dr. Meloy that that was a lie, that
you really hadn't stabbed yourself, that somebody else had
stabbed you?
J.G.: Yes, I told Dr. B, that.
D.A.: Which one of those statements was a lie?
J.G.: When Dr. B -is that his name?

D.A.: Yes.
J.G.: When he came to see me, we talked about what he was
going to do. He said he wasn't going to come and testify here.
D.A.: Listen carefully to my question.
J.G.: Okay. Wait. Listen to my answer. And therefore I felt
that it would be to my best interests if I did not admit to Dr.
Meloy that I had tried to commit suicide, because it's almost
certain that I'm going to end up in Atascadero behind that action.
D.A.: Did you lie to Dr. Meloy?
J.G.: Yes, I did.
D.A.:You've been apparently telling other patients that
they should fight the system. Is that correct?
J.G.: I read the report.
D.A.: Well, is that correct or not?
J.G.:No, it's not correct. What I told them was that they
didn't have to take their medication if they weren't acting in a
violent or abrasive, abusive manner towards the staff or other
patients.
D.A.: Why did you feel you had the authority to tell them
that?
J.G.: They asked me that.
D.A.: You were their lawyer?
J.G.: In a sense.
Defendant's counsel: I'll object, that's an argumentative
question.
Court: Sustained.
D.A.: Did you perceive yourself as being in a position to give
legal advice to other patients?
J.G.: No, I do not.
Defendant's counsel: I'll object. The same objection.
Court: Overruled.
D.A.: I'd like just to read one statement and have you tell me
whether you agree with it or not. This is from page 11 of Dr.
Meloy's report, the top, paragraph 13: 'This individual has shown
Appendix I 359
to this interviewer, as well as those involved in his case, a

propensity to consciously deceive and lie to others. I cannot
overestimate this individual's extremely facile capacity for con-
scious deception."
J.G.: I don't know what he's saying.
Court: He says you lie a lot.
J.G.: Again, your honor, I have-I have twisted the truth
towards-and manipulated the facts of events to my gain a
number of times in front of psychiatrists, but I only did it out of
self-preservation. That was my motive, not because I'm a fucking
habitual liar.
D.A.: No further questions . . .
DECISION OF THE COURT
Court: Well, I tell you, the world is full of productive

sociopaths. Some of them hold high public office. Some of them
are lawyers. I t could be that a couple of them are judges, and
sociopathy by itself is not necessarily a dangerous condition. I t
can be productive. I think it was Clarence Darrow who corn-
mented on that . . .
There was no real way that that jury could know how Mr. J.
G. would do until he had a chance to do it. And there was no real
way to know whether he would be one of those manageable
sociopaths or a more unpredictable, volatile, dangerous one until
he was confronted with the realities of the outside world after
having been confined for as long as he was.
I think Dr. T. R. got conned. I felt that as I heard the trial.
I think Dr. T. R. felt he got conned but also had a reasonable
position to say that, "Even if I was, I still think that the man is in
a position to go outside based upon what we know today, not
what we knew nine years ago."
What we've now seen is something a bit more than a bad
weekend. I mean, I don't think anybody ever suspected-I cer-
tainly didn't-that Mr. J. G. would go out in the streets and
immediately turn into some kind of a raving lunatic. He has an

incredible capacity for controlling himself up to a point; and then
certain stressors, because of his personality structure, cause him
to lose his control. And what happens is those stressors arose. I t
might have been predicted. Everybody was hoping it wouldn't
happen. Some people have better impulse control than others.
He certainly doesn't.
Look what he did. Here's a man, spent all this time in the
hospital or whatever you want to call it, for a series of rather
bizarre crimes, under bizarre circumstances, at least, who prob-
ably, in my judgment -who perhaps not in the jury's-conned his
way into an insanity situation at a time when we probably
weren't as enlightened on such subjects as we are now ten years
later; but in any event, who has a history of some bizarre
behavior, unpredictable, explosive, bizarre behavior, who man-
ages for a brief period of time and then all of a sudden what do we
have? His whole life is riding on it. He's got two years in prison
riding on it, the kind of things that would motivate most of us in
the room to do the right things and tow the line.
And I was making a list . . .
First, there's this general demonstration of anger and dis-
satisfaction with the program. That's probably understandable.
He was anxious to be out. You could forgive that and not call it
anything important.
Then he goes AWOL from the program which is his umbil-
ical cord to the civilized world. I mean, without that program he's
back in prison. One would think you'd be cautious about that, but
he goes AWOL, for whatever stimulus. He confronted the au-
thorities at the program. He finds himself involved-or at least in
his mind involved romantically with a 14-year-oldrelative of the
very people who are harboring him, who are helping him, who are
again part of his umbilical cord, if you will. Is that an act which is
calculated to get yourself cut off? I hope to tell you.
You see, I'm convinced that he set himself up to go back. I
think he couldn't do it any better than to go to a rock concert and
Appendix I 361
try and stab himself in front of 20 or 30,000 people. Was it a

suicide attempt? Of course it wasn't. It was a gesture. If it was an
attempt, he would have killed himself. I t was easy. He had a big
knife. It's not that hard to do. And he gets up there and pokes
himself for a while. He got his attention. I t got him on the radio,
in the papers, got everything done. I t was teMific. . .
He then proceeds to lie serially to a group of psychiatrists,
with full knowledge after ten years in this system they don't
..
throw reports away. He lies to doctors that he knows are in
the specific program that's treating him, that I daresay he knows
are going to write a report to the court. He tells another story to
the next doctor.
I s that a man who's in control of his environment, a man as
intelligent as he is, as bright, articulate, and aware of those
things? He's got all the talents. He doesn't have the ability to put
it into a constructive use. That's why he can't make it on the
outside. That's why he can't be managed on the outside, because
they don't know what he's going to do next; he doesn't know what
he's going to do next, and he admits it.
All somebody had to do is try to take that knife away from
him in the wrong way at that concert, and God knows where we'd
be today; or if he had decided to act out this delusion with this
14-year-oldand he had gone off to Las Vegas with her, God knows
where he'd be today.
His time on the street was one giant flirtation with disaster,
and he finally succumbed to it and just decided it was enough and
went back. I think he decided it was beyond him and had to go
back, I think, for his own protection and the protection of the
community.
I was as willing as anybody to give him a try, not because I
thought he was not a danger, because I know enough about his
personality sorts to understand that he was; but you get to a
point after that number of years where you got to- I suppose you
owe him a shot. He's had a shot, but I don't think he's used it very
well. I don't think anyone in the room does . ..
He's clearly a danger to himself. He's demonstrated that.

And I think he's a danger to others, because I don't know what
hell do next when the proper stressors are put on. Maybe the
stressors of being out there are enough to make him a danger;
and I don't think he intends to be a danger to anybody, but he
gets upset with the world when things don't go his way, which is
what the doctors have described, and he can do things that are
.
not under his control . .
I will make the findings indicated and order that he be
recommitted to the state hospital as the law prescribes.
Anything further gentlemen? We're in recess.
Appendix I1
Louis Cypher-Paranoid
Schizophrenia and Psychopathy
Honorable Richard D. Jenkins
San Diego County Superior Court
Department 54
RE: CYPHER, LOUIS

CR 567812 DA 59867
GENDER:male DOB: October 7,1949
Dear Judge Jenkins:

Pursuant to Judge David G.'s order for my evaluation of
Louis Cypher, I am submitting the following report concerning
appropriate treatment at the present time for this individual per
Penal Code Section 1600 et. seq.
I reviewed the following clinical information in addition to
evaluating Mr. Cypher on August 8, 1986, in the Forensic De-
partment of the San Diego County Courthouse: County Mental
Health records; Psychiatric Security Unit discharge summaries;
the district attorney case file; psychiatric evaluations by the
following doctors: Thomas R., M.D., David B., M.D., Donald D.,
M.D., David B., M.D., Dean A., M.D., Bernard H., M.D., and
William V., M.D.; the United States Dept. of Justice FBI record
Number 678901; telephone conversations with Douglas E., M.D.,

on August 11,1986, the patient's current treating psychiatrist.
Mr. Cypher is a 37-year-old Caucasian male with an exten-
sive psychiatric and criminal history. A brief summary of his
psychiatric history indicates that the patient was first hospital-
ized at age 17following polydrug abuse of both LSD and metham-
phetamine~.I t is highly likely that these substances precipitated
his first acute schizophrenic episode. Since that time, the patient
has been hospitalized on several occasions at various state and
local hospitals: The United States Public Health Hospital in San
Francisco; Lima State Hospital in Ohio; Oregon State Hospital in
Salem, Oregon; Fulton State Hospital in Missouri; Atascadero
State Hospital and Patton State Hospital in California; San
Diego County Mental Health; and the Psychiatric Security Unit
in the San Diego Central Jail.
California State hospital records indicate that the patient
was first admitted to Patton State Hospital from January 9 to
February 7, 1969. His second admission was March 14, 1969, to
May 20,1970. His third admission was September 13,1972, and
due to multiple escape attempts, was transferred to the max-
imum security Atascadero State Hospital on April 13, 1973. He
was confined there until April 16, 1975, but during that time
escaped from December 23 to December 27, 1974. The patient
was rehospitalized at Patton October 3, 1976, to December 12,
1976, August 26,1977, to November 18,1977, and April 16,1982,
to February 17,1983. The patient has not returned to the state
regional hospitals since that time. All of his hospital comrnit-
ments were due to findings of Not Guilty By Reason of Insanity
on various criminal charges which will be elaborated below.
Local psychiatric history indicates that the patient was first
treated on April 2, 1972. Twelve hospitalizations followed be-
tween 1972 and 1982, which included six AWOLs from that
hospital. In 1983 the patient was seen twice at CMH Screening
and referred to extended care. In 1984 the patient was hospital-
ized twice in the Psychiatric Security Unit in the Central Jail,
Appendix ZZ 365
once between February 22 and April 24,1984, and a second time

between July 17,1984, and February 27,1985.
The patient was most recently hospitalized in the Psychi-
atric Security Unit June 13 to July 11, 1986, when he was
released by Judge Jones to hospital parole with the conditions
that he would contact CMH within ten days, a conservatorship
evaluation would be done, he would be tested for illicit drug use,
and he would take all prescribed drugs. The patient did visit
CMH Screening on July 21, 1986, exactly ten days after his
release from custody. At that time the patient was clinically
judged to not need further medication, and was referred to his
private psychiatrist. No recent conservatorship referral has
been made on this patient.
The adult criminal history of Mr. Cypher began at age 19
when he was charged with Malicious Mischief and Possession of
Marijuana. Multiple arrests have occurred since then with no
period longer than two years between criminal charges. Charges
have ranged from multiple drug offenses, including Possession
and Use, to Robbery and Battery of an Officer (1972), Assault
with a Deadly Weapon (1973), Forgery and Burglary (1975),
Burglary (1976), Burglary, Assault and Battery, Trespassing and
Reckless Driving (1977), Robbery (1978), a Murder charge in
Oregon (1979), which was dismissed, and Burglary (1981). The
instant offense to which he was found Not Guilty By Reason of
Insanity on July 13, 1984, was P.C. 597(a), Malicious Maiming,
Wounding, and Killing of a Living Animal, and P.C. 487(f),
Stealing a Dog.
It is my impression that charges have either been dismissed
or reduced primarily because of the patient's history of chronic,
paranoid schizophrenia. As noted earlier, the patient has been
found insane on several occasions following the commission of
felony offenses, and has subsequently been committed to various
hospitals. In addition to the patient's extensive psychiatric and
criminal history, there also is a pronounced history of drug and
alcohol abuse. The various records note that the patient has
reported multiple use of LSD in his late adolescence, addiction to

heroin in 1974, use of phencyclidine on one occasion, and recent
use of methamphetamine and cocaine. The patient, since I have
known him, has also used marijuana and alcohol on a regular
basis.
CURRENT SOCIAL SYSTEM
The patient is living at 1396 F Street, in an apartment complex

with a roommate named George whom the patient reports is on
probation. He does not know his last name. Mr. Cypher also has
a pet dog named "Dog" that was left in the apartment building by
another psychiatric patient that he had befriended. He lives in a
one-room studio apartment with his roommate, and until one
week ago, had a number of people living with him who had
promised to pay him $200 a piece if he provided them with food.
He did so, they refused to pay, and he "kicked them out." He
reports that girls visit him from the local board and care home,
and that he enjoys their company and does not have any feelings
of loneliness. He reports that his contact with his parents, who
live in Coronado, is "pretty good." I was unable to reach them by
telephone. The patient reports that he enjoys visiting his parents
because they are "the best friends I've got." He also has one
brother and sister in San Diego, but has no social contact with
them. When discussing contact with his parents, he reports that
multiple arrests have occurred on Coronado Island by the local
police department and states, "If I get a slick lawyer, I11 blast
them out of the universe." He shows anger congruent with his
thought content as he discusses how the local police do not want
him visiting the island, and that he has been transported by
police across the Coronado bridge on many occasions. The most
recent event reportedly occurred on August 5 or 6, when he was
securing money from his bank account a t California First in
Coronado and the police approached him and told him to leave.
Appendix II 367
He is quite angry at the police and attributes to them quite

malevolent intentions. At one point he states, "A Coronado cop
named Martinez threatened to cut my throat and cut my heart
out and shoot me. I want to sue the shit out of him." He states
that someone stole his kitchen knives and believes that someone
has a key to his apartment and is continuing to steal things from
him.
The patient states that his only major social problem is
needing a social worker to help him manage his money. He has
not been able to handle his money, so when he stocks food at the
beginning of the month after he receives his Social Security
check, he hopes to be able to provide for himself until the end of
the month. When I interviewed him on August 8, he had no
money left from his August 1 check. He currently receives $355
from Social Security Disability and $200 from Supplemental
Security Income, totaling $555 per month. Rent is presently $375
per month, leaving him with $180 per month for food and inci-
dental expenses.
When I asked Mr Cypher how he is spending his time, he
responds that he is "reading the Bible and a love book by
Buscaglia, playing with my dog, watching television, and lis-
tening to music." He reported that he plans to attend San Diego
City College in the fall and resume classes on September 2. He
hopes to take fourteen hours of coursework toward his associate
arts degree in cabinet making. He reportedly has two years of
school to his credit, but when asked what he would like to do if he
were able to, he reports that he would like to join the Merchant
Marines.
CURRENT PSYCHIATRIC TREATMENT
The patient is currently being treated by Douglas E., M.D. He is

taking Navane 15 mgs. t.i.d., Benadryl 25 mgs. t.i.d., and re-
ceives an intramuscular injection of Prolixin Decanoate, 1.00 cc.,
the last one on August 5. As the patient talks about his relation-
ship to the doctor, it is apparent he is quite angry and mistrustful
of him. He states he requested both Ritalin and Triavil from the
doctor. The former is methylphenidate hydrochloride, a mild
central nervous system stimulant. The latter drug, Triavil, is a
combination of antidepressant and antipsychotic. The patient
states, "The fusion (of Triavil) makes the beauty of the pill." He
admits to me that he doesn't trust Dr. E. and would prefer to be
treated by Ernest G., M.D., a psychiatrist that he first met when
admitted to the Psychiatric Security Unit in 1984. The patient is
especially angry at Dr. E. for not injecting him with a "golden
yellow" Prolixin that Mr. Cypher had brought to his appoint-
ment; and instead, the doctor injected him with some of his own
"crystal clear" Prolixin.
I have had two telephone conversations with Dr. E. and he
generally concurs with my assessment of this patient. He has
been treating Mr. Cypher for several years, and feels knuch less
comfortable with him than he used to. He feels Mr. Cypher is
much more guarded and hostile in recent months. I advised Dr.
E. of the patient's anger toward him, and he agreed to telephone
me following the subsequent appointment by the patient. I t is
clear that Dr. E. no longer wants to treat this patient.
MENTAL STATUS EXAMINATION

Mr. Cypher arrived on time for his interview on August 8,1986,
at 1600. He was dressed in shorts, sneakers, and black socks, a
T-shirt, and a cap. He was wearing sunglasses and listening to a
portable tape recorder. He was friendly toward,me,but guarded.
The patient is a 37-year-old large Caucasian male. During the
course of the interview the patient remained oriented to person,
place, and time. He denied any difficulty concentrating, and
remained alert and attentive throughout the interview. His IQ is
estimated to be in the bright-nonnal range (110-119). The pa-
Appendix II 369
tient, when tested for concept formation, initially showed no

impairment; but when asked, in what way is a fly and a tree alike,
he responded, "If tree's a fruitfly, a fly will go to the fruit." This is
a difficult abstraction, but shows some indication of formal
thought disorder when he was asked to perform this task. When
asked to explain several proverbs, he abruptly responded that
they are not proverbs because they are not in the Bible, but then
was able to elaborate the meaning of several of them. The patient
denied any sleep Miculty. He reported that he is generally not
hungry but that his appetite is as normal as usual. He reported
that he occasionally becomes depressed, but is not currently
feeling that way. He denied any current paranoid delusions with
a shake of his head, but he kept his sunglasses on throughout the
entire interview, implying a desire to keep some distance be-
tween himself and me. Mr. Cypher denied any thoughts of
hurting himself or others. He denied thought insertion, with-
drawal, and broadcasting, but did report that all those symptoms
occurred when he was quite psychotic, most recently in June
1986. He denied any current use of illicit drugs, but did report
that he was drinking beer daily. He stated he consumed a
six-pack of beer on August 7. He attends Alcoholics Anonymous
and Narcotics Anonymous occasionally, but stated, "They're all
doing drugs anyways." When asked why he is not using illicit
drugs, given his extensive history of use, he stated that during
his last psychotic episode, he was told that the Americans would
not help him and the Nazis would come over and get him if he
used drugs anymore. This hallucination has reportedly sufticed
to keep the patient away from street drugs. He does show some
indication of somatic delusion. When asked to elaborate on this,
he stated, "Instead of scraping the brain, we'd have a liquid to
drink so that the tentacles of the tumor could be pulled out."
When asked if he had any other bodily pain, he stated that he had
some chest pain several days ago, but that he, "Held the baby to
my chest and it made the pain melt away." The incident was
reportedly in an apartment next to his own room.
When asked about the instant offense, Mr. Cypher stated

that he was psychotic at the time of the killing of the dog, but
that, T h e damned dog had a code word to go for someone's
throat. I had visions of him grabbing me by the throat (patient
suddenly grabs his own throat) so I chopped his head off. I was
psychotic but I stalked him, I stalked him." The patient went on
to give me a rather bizarre and elaborate recapitulation of the
way in which he dissected the dog and the manner in which he
disbursed the various internal organs of the dog throughout his
neighbor's home; "I was going to put the dog's intestines on a
plate, like a plate of spaghetti, with the American flag in the
center of them."
His father had smelled some of the remains of the dog in the
basement of their Coronado home where the patient was staying,
and subsequently called the police.
I want to note that in this elaboration by the patient,
although he verbalized that he was no longer psychotic, were
many primitive, and highly affectively charged, thoughts; the
presentation was somewhat tangential and disorganized; and the
patient showed no remorse or embarrassment concerning the
instant offense. I t became apparent to me at this point in the
interview that Mr. Cypher was in only marginal contact with
reality, and with any clinical probing would express some rather
aggressive and primitive material.
The patient reported that he was experiencing feelings of
fear concerning his psychiatric status and had requested the
injection of Prolixin, "waiting for it to kick in." He had received
the injection three days prior to my evaluation of him, and
therefore was receiving some benefit from it at the time of my
interview.
PSYCHODIAGNOSIS
Axis I: Schizophrenia, paranoid type, chronic.
Opioid dependence, in remission.
Appendix II 371
Hallucinogen and phencyclidine abuse, in remission.

Mixed substance abuse, including amphetamines and can-
nabis.
Alcohol abuse, episodic.
Axis 11: Antisocial Personality Disorder.
Axis 111: No diagnosis.
Axis IV: 3.
Axis v: 5.
ASSESSMENT OF DANGEROUSNESS
I t is my clinical opinion that Mr. Cypher currently presents a

danger to the health and safety of others in his current outpatient
setting. I have arrived at this opinion for the following reasons:
1. The patient has an extensive criminal history over the
past twenty years that includes both violent and nonviolent
offenses. The patient's Axis I1 diagnosis of antisocial personality
disorder is justified, in addition to his more obvious clinical
diagnosis of paranoid schizophrenia. I have known this patient
since 1983and have been impressed by the way in which he uses
his functional psychotic diagnosis to rationalize and diminish the
severity of his antisocial acts. I think this is a case where the
more flagrant, bizarre, and dramatic delusional material has
overridden the fact that the patient also has a propensity to
engage in dangerous and antisocial behavior in a predatory
fashion. In other words, the antisocial behavior is planned, inten-
tional, goal-directed, and unpredictable. This diagnosis has been
missed in most of his prior psychiatric evaluations. A rather clear
example of the patient's inclination to blend his antisocial be-
havior with his paranoid schizophrenia was in the interview on
August 8 when I asked him if he felt he had a psychiatric
disorder, and he responded that he believed he had paranoid
schizophrenia. But when I asked him if his paranoid schizo-
phrenia had caused him to commit the instant offense, he stated
that yes, he was quite delusional, but that he had intentionally

stalked the dog and had deliberately planned to kill the animal. In
my review of the patient's local records, I came across an MMPI
evaluation that had been completed when the patient was 24
years old on October 16,1973. At that time Dr. John C. diagnosed
Mr. Cypher as a sociopathic (psychopathic) personality. He
wrote, "There is no present evidence of a psychotic thought
disorder. Personality integration indicates an adequate life-
style."
2. When the patient does decompensate, he develops very
clearcut paranoid delusions which he finds difficult to resist.
These delusions, although he does not express any at present,
make him a high risk for quite dangerous and predatory behav-
ior.
3. The patient is a large Caucasian male with a physical
stature capable of inflicting harm on others, and a demonstrated
history of doing so.
4. The patient has an extensive history of multiple drug
abuse, including recent use of two drugs that I have seen precip-
itate violence in paranoid schizophrenics, namely cocaine and
methamphetamine. This is an ominous sign.
6. The patient has a history of being superficially quite
compliant, and ostensibly quite good natured, with mental health
professionals; yet, at various times he has successfully deceived
them to get what he wants. I cite two examples: first, in a report
dated June 8,1984, by David B., M.D., the patient did not inform
his psychologist-psychotherapist that he had been charged with
the offense of animal mutilation. In the same report Dr. B. wrote,
"He did not tell this therapist that he had committed a crime or
that he was going to stop taking his prescribed antipsychotic
medication." Second, the patient was also observed by me on
several occasions during his stay in the Psychiatric Security Unit
to engage in teasing behavior toward the more psychotic pa-
tients, and would also circumvent unit rules and regulations
whenever possible. When confronted, he would deny the be-
havior and diminish its importance.
6. Most paranoid schizophrenics are not violent and are able
to resist command hallucinations. Mr. Cypher, however, repre-
sents a small proportion of individuals with schizophrenia who
have a history of being quite violent when not on medication, do
not resist command hallucinations, and recompensate very
quickly when given appropriate medications (note the brief and
multiple hospital stays). He also tends to be noncompliant with
treatment unless required by an external authority. In other
words, despite the patient's verbal statement that he has a
mental disorder and needs treatment, these are quite superfi-
cially compliant words that have little internal motivation other
than the desire to avoid further incarceration.
7. The patient is currently engaged in a rather hostile,
dependent relationship toward his current psychiatrist. There
appears to be no trust or sense of safety in his relationship to this
particular doctor.
8. The patient has no reliable social support system and
continues to pursue a relationship with parents who are quite
ambivalent about seeing him at their home; and furthermore,
they live in an area where the police are openly hostile to his
presence.
RECOMMENDATIONS
I t is my recommendation that Mr. Cypher should be committed

to Patton State Hospital immediately under P.C. 1026, wherein
he will be treated and evaluated by the inpatient s M .
J. Reid Meloy, Ph,D.
Community Program Director
Chief, Forensic Mental Health Services
San Diego County
Addendum
I received the following letter from Mr. Cypher four months

after he was committed to the state hospital:
Dear Dr. Meloy,

I have hesitated in writing this letter because I was so mad
a t you. I felt we had something more than a doctor-patient
relationship. That is why I would write you letters when I was
not locked up.
I have been in hospitals for over twenty years and had a lot
of doctors say I was insane but I was never angry a t them.
You abused our friendship that is why my feelings were
hurt.
But I almost had a heart attack smoking cocaine. You saved
my life inadvertently.
I f d y believe I can stay off the drugs. I want to smoke
marijuana but I am taking urine tests and will not turn in a dirty
test. They say in NA that drug addiction is life long and you have
to take it one day at a time. That is what I am doing.
After being in jail fighting your lies I could have kissed your
feet when I got to Patton.
There were groups like Relapse Prevention, Thought Dis-
order, Anger Management, Friendship Group, Supportive Rap,
and others I cannot remember. I was on the COT unit but now I
am not.
The reason for my letter was because you got a phone call
saying I threatened your life.
I was just joking. I mean a nurse came around asking what's
the date, who's the President, do you want to commit suicide, do
you want to hurt anyone.
I was sitting around with the guys bullshitting and this
nurse started asking the questions. I was just being facetious. I
Appendix II 375
said I was the President, the date was 1896 and I was going to
hire a hit man she said who do you want hurt and just off the top
of my head I said your name. I mean if she hadn't asked me it
would not have come out. I don't even know anyone in the Mafia
and even if I did I would wish you no harm.
You have a big responsibility and you are trying to show
that your program works. I am just a victim of yours ,and your
program.
I love you.
your ex-patient, L.C.
Appendix I11
The Rorschach Psychodiagnosis

of Psychopathy
I have selected four methods of analyzing and interpreting the
Rorschach response process that illuminate various structural
and dynamic properties of psychopathy.
First, the Comprehensive System as developed by Exner
(1986a) is an atheoretical, empirically derived integration of the
most valid and reliable Rorschach indices. Since its beginnings
(Exner 1974)its evolution has been guided by an expanding body
of research.
Second, a developmental analysis of the concept of the
object (Blatt 1976)applies the developmental principles of differ-
entiation, articulation, and integration (Werner 1948, Werner
and Kaplan 1963) to human and quasi-human responses on the
Rorschach. This integration of psychoanalytic and develop-
mental principles scores the type of figure perceived (differenti-
ation), the number and types of attributes ascribed to the figure
(articulation), and the internality and interaction of the figure
(integration). The system by Blatt and colleagues (1976) has
demonstrated both reliability and validity as a measure of object
relations on the Rorschach (Blatt et al. 1976, Blatt et al. 1980,
Ritzler et al. 1980, Blatt and Lerner 1983, Lerner 1986).
Third, an assessment of primitive defenses in borderline
personality structure (Lerner and Lerner 1980) is comprised of
various operationally defined measures of splitting, devaluation,

idealization, projective identification, and denial. This method of
analysis emphasizes the structural concept of defense and is
based upon the theoretical formulations of Kernberg (1975) and
the clinical testing of Mayman (1969, Pruitt and Spilka (1964),
Holt (1970), Athey (1974), and Peebles (1975). The basic unit
scored is an entire human figure. This approach to the assess-
ment of primitive defenses appears to be both reliable and valid
(Lerner and Lerner 1980, Lerner et al. 1981). The test indices of
projective identification have most accurately discriminated
borderline-personality-disorderedpatients from both neurotic
and psychotic-personality-disorderedpatients (Lerner 1986).
Fourth, Kwawer (1979,1980)focused on primitive interper-
sonal modes of relating and the Rorschach. He regarded
Rorschach content as a "profound, symbolic statement of per-
sonal mythology reflecting early interpersonal experience" (1980,
p. 90). Extending the work of both Laing (1976) and Bion (1977a),
he expanded the concept of symbiotic merging to include intra-
uterine modes of relatedness. The Rorschach content imagery
symbolically depicts transitions toward selfhood from intra-
uterine life through the separation-individuation phase of child-
hood (Mahler et al. 1975). Kwawer's (1980) approach includes
eight primitive modes of relatedness: engulfment, symbiotic
merging, violent symbiosis, malignant internal processes, birth
and rebirth, metamorphosis and transformation, narcissistic mi.-
roring, and separation-division. Boundary disturbance and
womb imagery responses are also noted as two adjunctive con-
tent areas. Kwawer's work (1980)is descriptive and exploratory,
and does not lend itself, in its present form, to measures of
reliability and validity.
I have selected these four approaches to understanding
psychopathy for a variety of reasons, not the least of which is the
depth and richness they bring to Rorschach interpretation. They
also cover the psychological landscape-from a purely empirical
standpoint to a highly inferential and primitive object relational
Appendix IIZ 379
approach that dares to assume an intrauterine template for self-

and other representations.
RORSCHACH PROTOCOL I
The following Rorschach response protocol was produced by the
patient in Appendix I. To refresh the reader's memory, this
patient was diagnosed using the DSM-I11 criteria (American
Psychiatric Association 1980) with an Axis I mixed substance
abuse disorder and an Axis I1 antisocial personality disorder and
borderline personality disorder. J.G. was also assessed using the
Hare Psychopathy Checklist (1980) and received a quantitative
score of 34 out of a maximum of 40 points. This places him above
the 30-point cutoff for psychopathy (Hare 1986),and in my clinical
opinion would qualify him as severely psychopathically dis-
turbed. His two-point MMPI profile was 94, also supporting his
psychopathic diagnosis (Graham 198'7).
I have selected this Rorschach protocol since it has substan-
tial external validity as a raw psychological product of a psycho-
pathic personality disorder. I will present his associative and
inquired responses without commentary or scoring, and then
analyze and interpret it within the context of the four approaches
noted above.
I. 1. Absolutely symmetrical, looks like it could be a cater-
pillar on a mirror. (Inquiry response: that's the reflec-
tion in the mirror.)
2. Or a butterfly coming out of a cocoon. (Inquiry re-
sponse: looks like the cocoon around our house in the
high desert. (1)It just looks like that.)
11. 3. They're all symmetrical, two elephants kissing each
other. (Inquiry response: standing on three legs, touch-
ing, not necessarily kissing, because the trunks are
touching, their ears here.)
111. 4. It looks like a cricket or an insect because of the eyes
and antenna sticking out. (Inquiry response: eyes, fur,

feelers, and the way their body is shaped. (1)yea, fur.)
IV. 5. Looks like a bat hanging upside down in a cave,
hanging off the wall with his feet. I've seen bats in
caves. (Inquiry response: the feet here, wings, paws to
catch insects with,)
V. 6. Looks like a large moth, gypsy moths. It looks like that
way both ways. (Inquiry response: he's flying along, in
flight. His wings extended, motion, antennas, projec-
tions here.)
VI. I don't see anything in there.
7. This way it looks like clouds above a lake. (Inquiry
.
response: I first saw it, clouds, but then . .)
8. The bank of a riverbed, some plants and trees re-
flecting off the water. (Inquiry response: more exami-
nation-dark spots above the stems, a wet area, flower
blossoms, very dark, scrub, chapparal, rocks.)
VII. I can't even guess what this is.
9. Iron slag. That's what it looks like. When you're weld-
ing. (Inquiry response: a jumble of images, pieces of
iron melt and fall off, the bad part, it falls off in weird
shapes like that.)
VIII. Very pretty colors.
10. Looks like a pine tree with two squirrels climbing up
the branches. (Inquiry response: at the top, squirrels,
out of proportion to the tree, holding on and climbing
up, paws here and here.)
11. Also looks like a flower. (Inquiry response: a flower,
orchid looks, the color and symmetricalarrangement of
the petals.)
IX. 12. An ear of corn very ripe-needs to be picked off the
bush, plant. (Inquiry response: very dim, stem and
feathers. When corn is ripe this leaf sluffs off, here and
here, the shape.)
X. 13. Looks like somethingunder a microscope. Little pieces
Appendix ZZZ 381
of algae, protoplasm floating around on a microscopic

slide. (Inquiry response: bacterias here, algae, I took a
course in biology in prison and studied them. It's all
different colors, that's what it looks like.)
EXNER COMPREHENSIVE SYSTEM

Erdberg (in press) proposed a five-step procedure for inter-
preting the structural summary of a Rorschach protocol when
scored according to the Exner Comprehensive System (Exner
1986a). These five steps include test-taking approach, internal
operations, external operations, syndromes, and treatment plan-
ning. His procedure is a quite effective model for organizing the
complex data produced by the Rorschach, and I will apply his
first three steps to the systematic development of hypotheses
concerning psychopathy and the Rorschach.
Test-Taking Apprwrch
The psychopathic character's approach to the Rorschach is as-
sessed by interpreting number of responses (R), Lambda (L),
whole responses (W),synthesis responses, blends, space re-
sponses (S),and personalized responses (PER).
1. Number of responses (R) is predicted to be low due to a
restricted and defensive attitude toward the test. If Lambda
exceeds .85 in a record of 10-12 responses, guardedness may be
indicated. A record of less than 10 responses should always be
considered invalid. Intellectual deficits and neurological impair-
ments will also limit R.
2. Lambda (L) represents the proportion of pure F re-
sponses in the protocol, which are the most simple and affect-free
associations. I t is predicted to be higher than normal (mean = -59
in normative sample, 1.51 in character disordered sample [Exner
1986al) in the psychopathic protocol due to his uninvolved, con-
stricted, and defensive attitude. Pure F responses ignore the
complexities of the stimulus field and may represent situational
avoidance of the task or a more basic, simplistic coping style

(Exner 1986a) that is quite characterological.
3. Whole responses (W) can be interpreted as an indicator of
motivation to deal with the entire stimulus field, and are harder
to produce than detail responses (D) on all cards except for I and
V. The psychopathic character's need for control of the environ-
ment (Doren 1987), and thus his production of more W responses,
however, would be attenuated by his lack of involvement with
the test itself. It is predicted that W responses would not corre-
late with psychopathic disturbance.
4. Synthesis responses (DQ) are related to the willingness
and capacity of the individual to internalize the stimulus field in a
meaningful way (Exner 1986a). Again, intelligence and psycho-
pathic disturbance may attenuate this indicator since the former
may provide the capacity but the latter may not provide the
willingness. It is predicted that DQ will not necessarily correlate
with psychopathic disturbance, but Exner (1986a) noted that the
presence of two or more DQv/+ scores may suggest that at-
tempts to use a sophisticated cognitive level are aborted by a
reluctance to commit to form. Heaven (1988)pointed out that this
may correlate with the psychopath's glibness and superficial
charm wherein a facade of cognitive sophistication is not borne
out by substantive knowledge. Exner's (1986a) character
problem sample produced an average of 0.91 DQv/ + responses (6
percent) while the nonpatient adult sample produced 0.33 DQv/ +
responses (1.5 percent).
6. Blends indicate that more than one determinant has been
used to formulate a response. Blends appear to be somewhat
related to intelligence, and may be a useful indicator of the
complexity of psychological processes. Absence of blends indi-
cates psychological constriction and less sensitivity to oneself
and the environment (Exner 1986a). In the context of test-taking
attitude, it is the opposite of the pure F response, and demands
both analytic and synthetic work on the part of the examinee. IQ
does not appear to correlate with blends (Mason and Exner 1984),
and 26 percent of the character problem sample produced no
Appendix 111 383
blend responses. All the nonpatient adults in Exner's (1986a)

sample produced at least one blend. It is predicted that the
psychopathic character will produce blends less frequently due to
his lack of commitment to the test-taking task.
6. Space responses (S) have been postulated to represent a
form of oppositionalism or negativism (Rorschach 1921). As S
responses increase in frequency beyond the mean (2), it indicates
a more stable, characterologicaltrait that can predict hostility or
anger when autonomy is threatened (Exner 1986a). Although
test-retest reliability for S responses is low, DdS responses have
much higher temporal reliability, and such patients are reported
by others to be sullen, angry, brooding, alienated, and distant
(Erdberg, in press). It is predicted that S responses, especially
DdS responses, will positively correlate with psychopathic dis-
turbance.
7. Personalized responses (PER) suggest a need to be
overly precise in defending one's self-image(Exner 1986a). Three
or more personalized responses in the adult record may mean a
brittle defensiveness, a compensatory shoring up of the gran-
diose self-structure in the face of a perceived threat. The mean
and standard deviation for personalized responses in normal
samples is one. Although less than half of the character-problem
sample gave one PER response, 40 percent of these individuals
gave at least three PER responses (Exner 1986a). It is predicted
that psychopathy will positively correlate with personalized re-
sponses.
To summarize the test-taking approach hypotheses of the
psychopathic individual:
1. Low R (13-17 responses)

2. Elevated Lambda (> .85)
3. W responses do not correlate
4. DQ response configurations do not correlate
5. Blends infrequent (<3)
6. Space responses elevated (>2) with DdS likely
7. Personalized responses frequent ( > 2)
Internal Opemtiona
Erdberg (in press) formulated five areas of inquiry to address the

question of internal operations: the preferred problem-solving
style, the adaptive success of the style, the intrusiveness of
internal operations, the complexity of psychological operations,
and the balance and quality of time spent in self-focus.
1. The preferred problem-solving style is measured by Er-
lebnistgpw (EB), the ratio between the human movement re-
sponses and the sum of the weighted chromatic color responses
(M: .5FC + 1CF + 1.5C + 1.5Cn). This is a characterological
trait by age 16 and is very stable over time in adulthood. Extra-
tensives are defined as M< SumC by two or more points; intro-
versive~are defined as M> SumC by two or more points. Arnbi-
tents are within this two-point window.
The extratensive is inclined to use his interactions with
actual objects to gratify basic needs, while the introversive
habitually uses his internal processes for gratification. Given the
habitually aggressive and sadomasochistic engagement of the
psychopathic character with his actual objects, one would postu-
late a predominately extratensive problem-solving style.
The ambitent style, however, confounds the postulate. Be-
tween 40-60 percent of psychiatric population samples are ambi-
tent, a style which is less flexible, adaptive, efficient, and consis-
tent than either introversives or extratensives (Exner 1986a).
Fifty-six percent of the character problem sample were ambi-
tents (Exner 1986a). It appears that this coping style, in contrast
to Rorschach's (1921) predictions, is more psychopathological.
It is therefore hypothesized that the psychopathic process,
due to the severity of object relations disturbance and the pre-
dominance of borderline defensive operations, will be ambitent,
with a tendency toward an extratensive style.
Erdberg (in press) noted that Lambda may also represent a
basic personality style. He suggested that individuals with
Lambda > 1.0 may be characterized by an inability to engage
Appendix III 385
emotional complexity, either within themselves or perceived in

others. Lambda may represent a simplistic, item-by-item re-
sponse to life's demands wherein consequence, deliberation, and
the perception of ambiguity are not considered. Such a character-
ological index in the Rorschach would support both behavioral
(Hare 1986) and neuropsychological (Yeudall1977, Yeudall et al.
1984) constructs concerning the psychopath. Forty-one and a
half percent of Exner's (1986a) character problem sample had
Lambdas > 1.5, while only 1.3 percent of the normal sample had
Lambdas > 1.5.
2. The adaptive success of the style is measured by D, the
content of es, Ma:Mp, and FC:CF +C.
D is the ratio of organized to unorganized internal re-
sources. As a scaled difference score derived by subtracting es
(totality of disorganized ideation and affect, internal "noise")from
EA (totality of copingresources,ego strength), it appears to have
no direct relationship to psychopathy. Exner (1986a) wrote,
however, that if the personality traits that lead to sturdy con-
trols, as indicated by an elevated D score, were organized at a
developmentally premature level, such a resulting form of ri-
gidity might produce an excessive distancing and insensitivity to
the environment. This would contraindicate any psychothera-
peutic change and is apparent in the behavior of the autonomous,
arrogant, and aggressive character-disordered patient. It also
may provide some data concerning the current effectiveness of
the psychopathic process.
The content of es (sum of eb ratio) are the impinging,
nonvolitional aspects of internal operations. Representing both
unorganized ideation (FM + m) and unorganized affect (T + V +
Y + C'), as an aggregate they appear to have no direct relation-
ship to the psychopathic process. But several of these variables,
when taken in isolation, inductively support a psychopathic char-
acter disturbance. The variable m indicates need-state ideation
projectively experienced, a sense of "being under fire" (Erdberg,
in press). It is an unstable variable that appears to be induced by
situational stress (Exner 1986a). In contrast to FM, which indi-

cates an internally perceived physiological need state, m may
relate to the psychopathic propensity to feel persecuted, the
target of predation, and when coupled with a psychotic state,
delusionally paranoid. Both variables, however, are quite situa-
tional, although FM is more temporally stable than m (Exner
1986a).
The T (texture) variable indicates interpersonal neediness.
It is the hope that others will understand and respond (Erdberg,
in press). In Chaptier 3 I noted the relationship between the T
variable, dependency needs, and the absence of affectional skin
contact in psychopathy. It appears that T represents the affec-
tive experience of emotional or dependency needs, and the ab-
sence of T is a characterological sign of interpersonal guarded-
ness or distance (Exner 1986a).
Although the frequency and variability of T is quite small
(mean = 1.16, S.D.=0.80 in normal adults), a T response is found
in 90 percent of adult records. In the character problem sample,
however, a T response occurred in only 35 percent of the sub-
jects. It is hypothesized that a psychopathic disturbance will
typically produce a T-less protocol. In fact, the presence of one T
response probably contraindicates a psychopathic disturbance.
The V (Vista) response is expected to be absent in any
record except for those individuals who are clinically depressed.
It appeared in only 17 percent of the character problem sample,
but 80 percent of the depressed inpatient sample (Exner 1986s).
Vista is an important variable in the prediction of suicide and
infers a negative, anhedonic experience generated by introspec-
tion. It is the Rorschach index most closely associated with the
experience of guilt (Erdberg, in press).
Given the dearth of motivation to introspect in the psycho-
pathic process, and the hedonic defensive function of the gran-
diose self-structure, one Vista response would probably contrain-
dicate a psychopathic disturbance. The one exception to this
postulate might be the psychopathic character who is experi-
Appendix 111 387
encing acute dysphoria, or the "zero state" (Yochelson and Same-

now 1977),usually following some external sanction. It would be
an exceptional gift, however, to secure a valid Rorschach pro-
tocol from a psychopathic individual at this moment.
The Y (diffuse shading) variable, like m, is not temporally
reliable, and represents a state, rather than trait, of the individ-
ual. Contrary to early hypotheses concerning the relationship of
Y to anxiety, it appears to correlate more closely with a sense of
helplessness or immobilization in relation to the environment
(Exner 1986a). Forty-seven percent of normal adults produce at
least one Y, while 63 percent of a character problem sample
produce Y (Exner 1986a). Given its state-dependent nature, the
presence or absence of Y should not be considered pathogno-
monic of any character disturbance, but well-functioning psycho-
paths would be disinclined to experience a sense of helplessness,
and therefore, would probably not produce any Y responses
unless in custody.
The C' (achromatic color) response correlates with affective
constraint. I t may represent an intentional and defensive hesi-
tancy to exchange affect with external objects, a metaphorical
"biting of one's tongue" (Exner 1986a). C'is more likely to appear
in "caught" psychopaths who are attempting to put their best foot
forward (Exner and Leura 1977, Erdberg, in press). I t is pre-
dicted that at least one C' will appear in the protocol of the
psychopathic individual who is facing a criminal or civil suit.
Although characterologically stable, it may fluctuate under some
state determinants. Its mean and standard deviation are approx-
imately one.
Ma:Mp (active human movement to passive human move-
ment) when Ma < Mp suggests either flight into passive forms of
fantasy as a defensive maneuver or engagement of others to
solve one's problems, what Exner (1986a) called a "Snow Whiten
phenomenon. In the extratensive, arrogant psychopathic charac-
ter, such a ratio would be highly unusual, but it would be quite
ominous in the more schizoid, introversive psychopath. In the
latter case, Ma <Mp could be pathognomonic of rehearsal fan-

tasy, and the concomitant use of internal representations as
transitional objects. The sexual psychopath, for instance, at-
tending to his own sadomasochistic fantasies, may spend months,
or even years, refining coercive sexual encounters in his mind
while gratifying sexual arousal through masturbation. Such sub-
terranean fantasy will eventually be acted out against a victim in
a profound act of dependency with intrapsychic corollaries of
projective identification and object control (see Chapter 4). Ma
<Mp could signal the structure of such intrapsychic phenomena,
while the actual content might remain successfully hidden from
the clinician.
FC:CF + C, the extent to which emotional discharges are
modulated, is quite temporally stable. Equal or higher values of
CF + C in relation to FC do not necessarily mean a lack of control,
but do suggest an unwillingness or inability to modulate affective
displays. Expressed emotion will be intense, and perhaps impul-
sive. Higher frequency of CF +C appears to correlate with both
impulsive and aggressive behaviors (Exner 1986a).
CF or C responses, when isolated, do not tend to be tempo-
rally stable. The presence of more than one C response, however,
should be viewed carefully as suggestive of ongoing difficulty
with impulse control, and may be symptomatic of affective la-
bility or intentional abandonment of control.
The FC <CF +C is hypothesized in psychopathic character
disorder. Forty-three percent of the character problem sample
produced at least one C; only 9 percent of the adult normals
produced at least one C (Exner 1986a). Among psychopathic
characters the FC <CF + C ratio must be carefully interpreted
to avoid the mistake of attributing an unwillingnessto modulate
affect to an inability to control affect, particularly if the D score
is adequate. The propensity of the psychopathic character to use
affect as a means of object control (through intimidation or fear)
or social manipulation (through " w a n t pseudiodentification";
see Chapter 4) should be noted.
Appendix III 389
3. The intrusiveness of internal operations is measured by

Lambda (L), Morbid Content (MOR), and Aggressive Movement
(Ag) responses.
Lambda (L), a variable used to evaluate the test-taking
approach, is also used to determine the individual's ability to
operate in an affect-free environment within the self. When
L < .40 (mean = -59 in nonpatient adult sample), the patient is
driven by his own affective operations and has a markedly
diminished ability to deal with problems in an affect-free manner
(Erdberg, in press). I t is closely allied to Rapaport and col-
leagues' (1946) concept of the absence of a conflict-free sphere of
ego functioning. A low Lambda can also be produced by striving
in the test situation to gain a sense of accomplishment, or to avoid
error or failure (Exner 1986a).
Given the nature of the psychopathic defensive structure,
particularly the narcissistic defenses that split off and dissociate
intensive affect, a conflict-free ego sphere, and therefore an
elevated Lambda, is hypothesized. The grandiose striving of the
superior intelligence psychopath, however, could lower Lambda,
with concomitant elevation of Zf, W, and DQ+ answers.
Morbid content (MOR) infers self and object concepts that
are devalued, damaged, and negative. I t conveys an anhedonic,
pessimistic attitude toward the self and the future. I t appears
more frequently in the records of depressed children and adults
(Exner 1986a). Morbid content, if it appears in the psychopathic
protocol, is likely to have two characteristics: I t will be combined
with an aggressive movement (Ag)response; and the subject will
identify with the aggressor rather than the victim within the
morbid response.
Aggressive movement (Ag) responses indicate an increased
likelihood of aggression, both verbal and nonverbal, and chroni-
cally negative or hostile attitudes toward others (Exner 1986a).
Ag appeared in 78 percent of the character problem sample,
(mean= 1.06, S.D.= 1.07), and 60 percent of the nonpatient
sample.
The psychopathic character's predominant mode of related-

ness is aggression with sadomasochistic features (see Chapter 1).
It is hypothesized that at least one Ag response will be found in
the psychopathic protocol, but a caveat is in order: Given the
obvious face validity, and transparency, of the Ag response, the
above average intelligence psychopath may choose to disregard,
and not verbalize, his Ag associations to the Rorschach.
Dr. Carl Gacono and I are currently researching a Sadoma-
sochistic (SM) special score on the Rorschach. It is defined as the
expression of pleasurable affect by the subject (smiling, laughter,
etc.) during the articulation of devalued, aggressive, or morbid
content. We think this special score has particular relevance to
subjects evaluated in criminal forensic settings.
4. The complexity of psychological operations is measured
by M (Human movement), DQ (synthesis or developmental qual-
ity), and blends.
The M (Human movement) response itself is quite complex.
It is difficult to hypothesize the meaning of M in isolation, since it
is inextricably tied to the number and content of the figures, the
nature of the action, and its location. Exner's (1986a) summary of
the extensive research concerning M concluded: It always in-
volves some form of projection; its relationship to creativity is
equivocal;it is related to fantasy; the form quality of M correlates
with psychopathology; it involves elements of reasoning, imagi-
nation, and abstraction; it implies a form of delay during which
deliberate ideation occurs; and aggressive M responses correlate
with verbal and nonverbal aggressive behaviors.
The potential for M responses in psychopathic disturbance
is attenuated by the relative absence of human content re-
sponses, regardless of the subject's psychological complexity, or
his capacity for deliberate, abstract thought. Although 99.5 per-
cent of the adult nonpatients produced at least one M
(mean =4-19), only 87.5 percent of the character problem sample
produced one M (mean =2.33) (Exner 1986a). It is hypothesized
that psychopathic individuals will produce fewer M responses,
Appendix 111 391
but one should be careful to not misinterpret this finding as an

absence of psychological complexity. The absence of bonding in
the emotional life of the psychopath limits the human content
that can function as a projective vehicle to elicit M responses to
the Rorschach.
DQ (developmental quality) and blends, and their relation-
ship to psychopathy, have been detailed above. In an unstruc-
tured test setting, such as the Rorschach, the psychological
complexity of the psychopathic character will usually be masked
by his object relational configuration: The fearful, yet predatory,
grandiose self-structure will disallow strivings for achievement
and exhibitionism with an examiner who is probably viewed as an
adversary or aggressor. Other projective techniques, such as the
Thematic Apperception Test, and structured measures of intel-
ligence, such as the Wechsler Adult Intelligence Scale-Revised,
do not evoke such an aggressive and vigilant transference reac-
tion, and therefore are more apt to capture the psychopathic
character's psychological complexity.
5. The balance and quality of time spent in self-focus is
measured by the Egocentricity Index (3r +(2) / R), Morbid con-
tent (MOR), Reflection responses (Fr, rF), Vista responses (V),
and Form dimension responses (FD).
The Egocentricity Index (3r+(2) IR) is a measure of the
proportion of reflection and pair responses in the protocol. I t is a
measure of self-focusing or self-concern (Exner 1986a) that may
be either positively or negatively affectively toned. The presence
of one reflection response in the Index infers a narcissistic
tendency to overestimate self-worth (Exner 1986a).
Cut-off points of -31to .42 appear to establish a normative
range (Exner 1986a). An Index > .45 strongly suggests a patho-
logically narcissistic disturbance; < .30 suggests negative self-
esteem and a proneness to depression (Erdberg, in press).
From an object relations perspective, the Index is the most
direct measure of the grandiose self structure (Kernberg 1975).
Given the narcissistic personality structure of the psychopathic
individual, it is a compelling measure of the degree to which the

self is grandiosely conceived. I would hypothesize that the Ego-
centricity Index in psychopathic disturbance would be > .45 and
should be quite temporally reliable.
I have already addressed Morbid content (MOR) as a vari-
able in the determination of the intrusiveness of one's own
psychological operations. As a variable to measure the quality of
self-focus,it suggests a negative or devalued attitude toward the
self-percepts and concepts; it further implicates a tendency to-
ward anger or depression. Morbid content in a psychopathic
protocol, if the subject identifies with its victim, would suggest a
failure of defensive functioning. It communicates a sense of being
violated by another, and may correlate with a perceived external
locus of control (Erdberg, in press).
The Reflection response (Fr, rF) suggests an intensely
self-focused,narcissistically disordered individual. One reflection
response in a normal protocol is highly unusual, but 32 percent of
the character problem sample (Exner 1986a) produced at least
one reflection response. It implies a sense of grandiosity and
entitlement that are the hallmarks of the psychopathic character.
I would predict that psychopathically disturbed individuals
would produce at least one reflection response (mean=O.41,
S.D.=0.54 in character problem sample).
The Vista (V) response as a measure of anhedonia during
introspection infers a negative affective tone associated with the
self-representations. It appears to be the affective correlate of
Morbid content, and would contraindicate a psychopathic distur-
bance unless severe external stressors, such as sudden incarcer-
ation, disrupted the narcissistic defenses and precipitated an
acutely dysphoric reaction.
Form dimension (FD) suggests a process of internal reflec-
tion that is more objective and balanced than the Vista (V)
response (Erdberg, in press). It may be primarily a measure of
psychological-mindedness, and its absence may indicate a lack of
psychological insight. Although one FD response appeared in 75
percent of the adult nonpatient sample, only 37 percent of the
character problem sample produced one FD (Exner 1986a). I
would hypothesize that a psychopathically disturbed individual
would not produce an FD response because of his primitive
defensive structure, which is replete with various denial and
splitting operations (see Chapter 4): dynamic maneuvers that
obviate the need for introspection.
To summarize the internal operations hypotheses of the
psychopathic process:
1. Preferred problem-solving style

EB =ambitent
2. Adaptive success of the style
T=O
v=o
C'> 0
FC<CF+C
C>l
3, Intrusiveness of internal operations
Elevated Lambda >0.85
MOR=O
Ag>O
4. Complexity of psychological operations
M<3
5. Balance and quality of time spent in self-focus
Egocentricity Index >0.45
MOR=O
rF or Fr >1
v=o
FD=O
As the reader will note, I have listed only the more defini-
tive hypotheses from the text. What is most striking is the
absence of certain variables that define the internal operations of
the psychopathic process. To paraphrase an adage, there is less

there than meets the eye.
External Opemtions
Erdberg (in press) identified nine areas of inquiry to address the

question of external operations: the efficiency of perceiving and
processing data; the frequency of attempts to organize external
reality; the efficiency of each organizational attempt; the degree
of need to identify with external reality; the degree of need to
achieve; the likelihood of affect to be processed; the productivity
of affect when it is processed; interpersonal issues; and the self as
actor or acted upon.
1. The efficiency of perceiving and processing data is mea-
sured by X +percent, X -percent, Dd, and special scores. These
variables, as an aggregate, measure the individual's reality test-
ing, convergence, and cognitive accuracy.
The X +percent is a measure of perceptual accuracy of the
entire record. It is a measure of convergent form, a normative
statement. Although perceptual accuracy is a component of it, it
is probably more a measure of conventionality. The mean
X +percent for nonpatients, both children and adults, tends to be
80 percent; for the character problem sample, the mean was 70
percent (Exner 1986a). It is the most temporally reliable variable
when measured across the developmental spectrum.
Perceptual unconventionality may have many causes, in-
cluding psychotic disturbances, failures of affective modulation,
and a striving for individuality. A psychopathic character distur-
bance presupposes a degree of disidentification with conven-
tional reality. I hypothesize that X +percent in the psychopathic
process will usually be less than '10percent.
X -percent, on the other hand, is a more specific indicator of
perceptual distortion, a violation of the reality constraints of the
percept. One FQ - response is found in most records, but when
Appendix 111 395
X -percent exceeds 15 percent, there is some impairment in the

accurate perception of exteroceptive stirnuli. The character
problem sample had an X - percent mean of 15 percent (S.D. =9
percent).
A typical psychopathic protocol would be likely to display a
low X +percent (<70) and a low X -percent ( < 15). Since per-
ceptual impairment is only tangentially related to character
disturbance, an X -percent >20 in a psychopathic protocol
would suggest a concomitant Axis I mental disorder with pos-
sible psychotic or organic features.
The Dd score is common in frequencies of one to three in
average length records. When it occurs in greater frequency, it
may represent an atypical, obsessional approach to reality
(Exner 1986a). Only 8 percent of the nonpatient adult Rorschach
responses involved a Dd location (mean = 1.73), while 14 percent
of the character problem Rorschach responses involved a Dd
location response (mean =2.59) (Exner 1986a). Any Dd responses
> 3 in a psychopathic protocol should be studied carefully for
projective content, especially movement, and should be assessed
for indications of perceptual-associative impairment. Dd and
X-percent, however, are not necessarily pathognomonic of a
psychopathic disturbance.
The six critical Special Scores, from least to most cognitive
dysfunction, are deviant verbalization (DV), incongruous combi-
nation (INCOM), deviant response (DR), fabulized combination
(FABCOM), inappropriate logic (ALOG), and contamination
(CONTAM). As a group these scores represent problems in
internal processing or cognitive slippage. From a psychoanalytic
perspective, they are measures of formal thought disorder.
Although not pathognomonic of psychopathic character dis-
turbance, elevations in the special scores is expected due to the
borderline personality organization of the psychopathic individ-
ual, and subsequent distortions of fonnal thought secondary to
his more primitive defensive operations. In fact, the weighted
sum of these scores (WSUM6) averaged 6.52 in the character
problem sample, compared to 3.96 in the adult nonpatient sample

(Exner 1986a). At least one fabulized combination appeared in 37
percent of the character problem protocols, compared to 12
percent of the nonpatient protocols.
I would hypothesize a WSUM6 >6.0 in the psychopathic
protocol, while a score appreciably higher than this would sug-
gest that cognitive slippage is a problem in its own right.
2. The frequency of attempts to organize external reality is
measured by the economy index (W:D) and organizational fre-
quency (Zf).
The W:D ratio, the economy index, is expected to be 1:2 in a
normative sample and concerns the economy of approach to the
Rorschach (Exner 1986a). It must always be considered in rela-
tion to R, and in most psychopathic protocols, with an R e 17,
W = D. In this context, by itself, it has little interpretative value.
The Zf score measures the frequency of organizing activity
and is scored whenever there is a W or two synthesized D
responses. A low Zf may indicate intellectual limitations or a
hesitancy to engage the stimulus field. A high Zf may indicate
striving, obsessional behavior, or hypervigilance (>50 percent).
The psychopathic process could influence Zf in either direc-
tion: a reluctance to be involved in the test-taking task because of
perceived malevolence or general apathy would lower Zf; gran-
diose striving or paranoid hypervigilance would raise Zf. This
may be one factor in the greater variance among Zf in the
character problem sample (S.D. =4.16) when compared to Zf in
the nonpatient adult sample (S.D. =2.96) (Exner 1986a).
3. The efficiency of each organizational attempt is measured
by Zd. Zd scores > 3.0 indicate a process of overincorporation, an
overly cautious and thorough approach to external stimuli. It is
apparent in obsessive and perfectionistic individuals. Zd scores
e -3.0 indicate a process of underincorporation, an impulsive
and arbitrary approach to external stimuli. Both stimuli pro-
cessing styles appear with greater frequency in psychiatric sam-
Appendix 111 397
ples, but do not necessarily indicate a specific psychodiagnosis

(Exner 1986a). Seventy-five percent of adult nonpatients were in
the normal range (c+3> -3) while only 62 percent of the char-
acter problem sample were in the normal range.
The psychopathic process could support either overincorpo-
ration or underincorporation, but given the primitive defensive
operations which could deny whole sectors of reality, the prone-
ness to boredom due to autonomic hyporeactivity, and the nar-
cissistic self-absorption of the grandiose self-structure, underin-
corporation is predicted, even if attenuated by perfectionist
strivings.
4. The degree of need to identify with external reality is
measured by extended form (X +percent), space (S),and popular
(P) responses.
Both X +percent and S have been addressed in earlier
sections. My prediction of X + percent < 70 in psychopathic char-
acter disturbance also suggests, in this area of inquiry, a disiden-
tification with external reality or conventionality. The prediction
of elevated space responses (S) hypothesizes oppositionalism and
negativism toward the established order by the psychopathic
individual.
Popular responses (P) range from five to eight in adult
samples. Lower frequencies of P responses indicate an inability
or unwillingness of the individual to give the most conventional
and obvious answer (Exner 1986a). P does not measure reality
testing, and does not significantly correlate with X +percent.
Psychopathic disturbance, in a truly antisocial manner, will
tend to lower the proportion of P in a record, although lower P is
not necessarily pathognomonic of psychopathy. I would predict
P < 5 in the psychopathic protocol.
5. The degree of need to achieve is measured by the aspira-
tional ratio (W:M).
The W:M ratio is a crude measure of achievement behavior
in relation to psychological resources. The ratio is expected to be
2:l in the majority of adults sampled, whether patient or nonpa-

tient, and when it exceeds 3:1, a grandiose, unrealistic striving
for achievement is probable (Exner 1986a).
Psychopathic individuals will generally score >3:1, given
their unrealistic appraisal of their own internal resources. The
character problem sample, on the average, also exceeded this
ratio (Exner 1986a).
6. The likelihood of affect being processed is measured by
the affective ratio (Afr).
Afr is the ratio of number of responses to the completely
chromatic cards (VIII, IX, X) to the other cards (I-VII). The
average range is .50 to .80, with patients tending to fall a t the
upper and lower extremes (Exner 1986a). The mean in nonpa-
tient adults was .66 (S.D. =.19) and in the character problem
sample was .51 (S.D.= .18).
The affective ratio is an indication of receptivity to emotion-
ally provoking external stimuli. Individuals with ratios > .80 will
be caught up easily by emotional stimuli, while those scoring
< .40 will avoid an emotional response to stimuli. I t tells nothing
about emotional control, nor the reasons for receptivity or lack of
receptivity to emotion.
Seventy-five percent of the character problem sample had
an Afr c .55, suggesting a tendency to avoid emotionally toned
stimuli. The psychopathic process would infer a seeking of emo-
tional stimuli, but this may be dampened by a more hypervigi-
lant, controlled, and wary response to the examiner and the test
situation, lowering the Afr. I am not aware of any research that
has externally validated the Afr outside the Rorschach response
process.
I would predict that the Afr would distribute to the ex-
tremes in psychopathy, with the greater likelihood of avoidance
of emotionally provoking stimuli in the test situation (< 55).
7. The modulation of response after affect is processed is
measured by D, M, FC:CF + C, FM, and C'. All of these variables
and summary scores have been discussed above, but in this
Appendix ZZZ 399
context they are used to address the nature and extent of

modulation of affect.
D, when negative, suggests an affective overload situation
with a predominance of disorganized psychological operations. M
is a measure of capacity to delay affective response, a premedi-
tation and deliberation variable. FC:CF + C is the metaphorical
swimmer mastering the waves (FC) or being swept away by the
current (CF + C). FM is a measure of ideational processes pro-
voked by unmet need or stress-related states. Although reason-
ably stable over time, it has been shown to increase during
diminished states of consciousness, such as those induced by
alcohol (Exner 1986a). As FM increases, the potential for acting
out increases; and FM >M may be one variable in the prediction
of affective violence (Erdberg, in press). C'measures the ability
to contain affect, to deliberately delay emotional expression.
The psychopathic process would predict, as noted in the
above sections, M <3, FC < C F + C, and a t least one C'. I would
also hypothesize that FM > M due to the psychopathic propensity
for both affective and predatory violence. The psychopathic
character may desire to avoid affective stimuli for a variety of
situational reasons, but his capacity to modulate and produc-
tively process such affect, once triggered, is noticeably impaired.
This impairment is probably due to the reservoirs of envy
and rage in this narcissistically disordered character that may
remain split off and dissociated for substantial periods of time;
but once cathected are difficult to moderate due to their intensity
and the primitive manner in which they have been warded off
(see Chapters 3-4).
8. Interpersonal issues are measured by M, H + A:Hd +Ad,
H, T, Fd, Isolate:R, Ag, and S.
Human movement (M) has already been discussed in several
other contexts. I t is most relevant to interpersonal behavior as a
measure of empathy or identification with others. In this sense,
however, the nature and quality of the M response, rather than
the number of responses, is most important.
Mayman (1962) distinguished between the empathic M re-

sponse in which an experience is shared, and the identifying M
response in which unconscious projective identification is pre-
dominant. Responses based on empathic M were characterized
by a wide range of images and characterizations of others; the
seeing and describing of the percept with objectivity and real-
ness; and an expressed warmth, interest, and pleasure in the
activity of the percept, but in a way that makes clear the percept
is not the subject.
Responses based on identifying M were characterized by
extreme vividness and conviction; fabulized action that was quite
arbitrary and had poor form quality; and an intense absorption in
the movement of the percept, vicariously feeling the experience
of the projection.
The identification M would characterize the human move-
ment response within the psychopathic protocol. It is an empir-
ical measure of the malignant pseudoidentification of the psycho-
path, his capacity to exploitatively use the narcissistic
vulnerabilities of others. The content of the M response in the
psychopathic protocol would also be likely to contain sexual or
aggressive action, the latter indicative of subjects who view
interpersonal relationships as being aggressive (Exner 1986a).
The form quality of the M response would likely be u (unusual)or
- (minus) in the Comprehensive System (Exner 1986a).
H + A:Hd +Ad is the ratio of whole human and animal
content to human and animal detail. In normal samples, the ratio
should be at least 4:l. As the proportion of human and animal
detail responses increases, it suggests a more constricted,
guarded, and suspicious view of the interpersonal environment
(Exner 1986a). I t is virtually identical to the meaning of H:Hd,
but is more useful since many individuals, such as character
disorders, will give very few H responses. By adding the A:Ad
ratio to the equation, such a paranoid feature is less likely to be
missed. Exner and Hillman (1984) found that 78 percent of
paranoid subjects had a ratio of 2:l or less.
The pure H (human content) response is expected to repre-
Appendix 111 401
sent from one-fourth to two-thirds of all human content re-

sponses in adult subjects. While human content responses gener-
ically measure the extent to which the subject identifies with the
environment and shows an interest in other people, pure H
seems to indicate that relational attitudes are reality-based,
rather than fantasy-laden.
In adult nonpatients, the mean for all human contents was
5.12, and the pure H mean was 3.07. In the character problem
sample, the human content mean was 3.72 and pure H was 1.71
(Exner 1986).
The complete absence of human content is unusual, but
would be pathognomonic of a psychopathic process. Lower fre-
quencies of human content (<4) and pure H (c2),are to be
expected in a psychopathic protocol due to the narcissistic de-
tachment and absence of affectional bonding that is common in
the psychopath. The nature and quality of human content, al-
though more relevant to the other interpretative systems below,
tells us much about the internalization process of the psychopath
and his self and object representations.
The texture response (T)in an interpersonal context is a
measure of emotional relatedness. I think it has quite primitive
sensory-perceptual skin boundary correlates, and is an important
measure of affectional needs to be gratified by others. One T
response, as noted earlier, contraindicates a psychopathic pro-
cess.
The food response (Fd) is quite rare in adult protocols, and
appears to be associated with oral neediness (Schafer 1954). The
mean for Fd in nonpatient adults is 0, and would be expected to
be absent in a psychopathic protocol.
The Isolation Index (1solate:R) is the ratio of Botany,
Clouds, Geography, Landscape, and Nature content categories
to total Rorschach responses. When Isolate >.25R, a strong
tendency toward social isolation exists; when Isolate > .33R,
poor interpersonal connectedness is suggested (Erdberg, in
press).
The psychopathic individual is expected to attach more
readily to the nonhuman environment, either in fantasy or in

material reality. I would therefore predict that 1solate:R would
exceed 33 percent in the psychopathic protocol. This ratio does
not necessarily infer interpersonal conflict or affective distress
associated with the isolation.
The Aggressive content (Ag) and Space response (S) have
also been elaborated above. Ag correlates with verbal or physical
aggression in interpersonal relations, but may be withheld during
testing due to its obvious face validity. S indicates a character-
ologically hostile and angry person when >2. In the psychopathic
process, both Ag and S would be expected to be elevated.
9. The self as actor or acted upon is measured by a:p and
Ma:Mp.
The active-passive ratio of all movement responses (a:p)
appears to measure ideational flexibility. The more discrepancy
between the numbers, the more fixed and unalterable are the
ideational sets (Exner 1986a). Although a high frequency of
active responses does not necessarily equate with active or
aggressive behaviors, when passive responses exceed active
responses by more than one, there does exist a tende~wytoward
passive and dependent behavior (Exner 1986a). I t would be
expected that a >p in the psychopathic protocol, as it is in most
adult protocols.
The active-passive ratio of human movement responses
(Ma:Mp) was reviewed earlier in the context of internal opera-
tions. Ma>Mp is expected as a behavioral correlate of the
extratensive psychopath, but Ma< Mp should not be disregarded
in the introversive psychopath who engages in rehearsal fantasy
prior to the acting out of predatory violence.
To summarize the external operations hypotheses of the
psychopathic process:
1. Efficiency of perceiving and processing data

X +percent < 70 percent
X -percent c 15 percent
WSUMG >6
Appendix ZZZ 403
2. Frequency of attempts to organbe external reality

No hypotheses
3. Efficiency of each organizational attempt
Zd c -3.0 (underincorporation)
4. Degree of need to identify with external reality
X +percent <70 percent
s>2
P<5
5. Degree of need to achieve
W:M>3:1
6. Likelihood of affect to be processed
Afr < .55
7. Modulation of affect when processed
Me3
FC<CF+C
FM>M
C'>o
8. Interpersonal issues
Identifying M
Sexual or Aggressive content
Unusual or minus form
Human content <4
Pure H <2
T=O
Fd=O
1solate:R > 33 percent
Ag>O
S>2
9. Self as actor or acted upon
The reader is referred to Protocol I to review its content in

light of these hypotheses. The Comprehensive System scoring of
this protocol was as follows:
Card Location Determinants Contents Pop Z Special

-- -
I. 1. Wo rF - A 1.0
2. Dd+ FMa- A 4.0 PERS
11. 3. D+ Ma o (2) A P 3.0 FABCOM
111. 4. Ddo F- A INCOM
IV. 5. w o FMp o A 2.0 PERS,
INCOM
V. 6. Wo FMa o A P 1.0
VI. 7. Dv. Fo C1, Ls
8. Dd+ Fr. C'F- Ls, Bt 1.O
VII. 9. w v Fu iron slag
VIII. 10. D + FMa u (2) A, Bt P 3.0
11. Do CF o Bt
IX. 12. Do F- Bt INCOM
X. 13. Wv CF.FMp u Sc, Bt PERS
The structural summary of this protocol was computed, and

the variables, indices, and ratios were compared to the psycho-
pathic hypotheses to yield a goodness of fit (the indices that were
repeated within the hypothesis sections above are not repeated
below, producing 32 separate hypotheses):
Psychopathic hypotheses Protocol I Goodness of fit

R=13 to 17 13
Lambda > .85 -44
Blends c 3 2
Space >2 0
Personalized >2 3
EB = ambitent ambitent
T=O 0
v=o 0
(;"> 0 1
FCcCF+C 0:2
C>l 0
Appendix 111 405
Psychopathic hypotheses Protocol I Goodness of fit

Morbid =0 0 Yes
Aggressive >0 0 no
M<3 1 Yes
Egocentricity > 0.45 0.62 Yes
rF or Fr > O 1 Yes
FD=O 0 Yes
X+%<70 38% Yes
X-%<I5 38% no
WSUM6 > 6 10 Yes
Zd < -3.0 -5.5 Yes
P<5 3 Yes
W:M > 3:l 5:1 Yes
Afr < .55 .44 Yes
FM>M 4: 1 Yes
Identifying M (Ag or Sx) 0 no
H content <4 0 Yes
Pure H < 2 0 Yes
Fd=O 0 Yes
Iso1ate:R > 33% 62% Yes
a>P 4:2 Yes
Ma > Mp 1:0 Yes
This single case study yields a goodness of fit of 81 percent
when compared to the psychopathic hypotheses that I have de-
ductively proposed from the Comprehensive System. Further
nomothetic research could determine whether some of these hy-
potheses form a psychopathic constellation useful to the clinician.
In a preliminary study, Heaven (1988)found that a sample of
34 antisocial personality disordered (American Psychiatric Asso-
ciation 1987) inmates had a similar goodness of fit.
THE CONCEPT OF THE OBJECT

Blatt and colleagues (1976) developed a scoring system of the
concept of the object based upon their research that "in normal
development, there was a significant increase in well differenti-

..
ated. and integrated human figures (on the Rorschach) seen in
constructive and reciprocal relationshipsn (p. 364).
Blatt and Lerner (1983)noted that self- and object represen-
tations have both structure and content, and are the complex
mental schemata of significant objects encountered in reality.
Blatt (1974) wrote that earlier forms of representation are based
on action sequences associated with gratifying needs, interme-
diate forms are based on specific perceptual features, and higher
forms are more symbolic and conceptual. He emphasized a con-
stant and reciprocal interaction between past and present inter-
personal relations and the development of self- and object repre-
sentations; the latter, in turn, providing a revised schemata for
experiencing new and more complex dimensions of interpersonal
reality.
Blatt and Lerner (1983) argued that the Rorschach is ideal
for assessing an individual's representational world because any
human images attributable to this essentially ambiguous stim-
ulus must be shaped by the organization of the internalized self
and object representations. The scoring system developed by
Blatt and colleagues (1976)focuses upon human and quasi-human
responses to the Rorschach and judges them according to seven
characteristics. The first of these characteristics, accuracy, is
essentially a measure of reality-testing, and appears to be a
perceptual function that may be independent of the develop-
mental maturity of the internal representations (Ritzler e t
al. 1980). The'other six characteristics are judged according to a
continuum based upon developmental levels, as noted in Table
111-1 below, elaborating upon Werner's (1948) developmental
principles of differentiation, articulation, and integration.
The most developmentally mature response in each cate-
gory is the one noted last. For instance, the most mature human
representation would be Human (H), Appropriate (+), Percep-
tually and Functionally fully elaborated, engaged in Intentional
Action (Int), Congruent (Con), Benevolent (Ben), and Active-
THE PSYCHOPATHIC MIND 407
Table 111-1
Developmental Analysis of Object Representations
(Adapted from Blatt and Lerner 1983)
---
1. Accuracy:
F-, F +
2. Differentiation:
Quasi-human detail: (Hd)
Human detail: Hd
Quasi-human: (H)
Human: H
3. Articulation:
Inappropriate (-) or appropriate (+)
Perceptual: Size (Sz), Posture (Po), Hair Style (Hsy),
Clothing (Cl), Physical Structure (PSt).
Functional: Sex (Sex), Age (Age), Role (Ro), Specific
Identity (SpId).
4. Motivation for Action:
No action (NoAct)
Unrr~otivatedaction (Unmot)
Reactive action (React)
Intentional action (Int)
5. Integration of Object and Action:
Fused (Fused)
Incongruent (Incon)
Non-specific (NonSp)
Congruent (Con)
6. Content of Action:
Malevolent (Mal)
Benevolent (Ben)
7. Nature of Interaction:
Active-Passive (A-P)
Active-Reactive (A-R)
Active-Active (A-A)
Active (A-A). Rorschach administration to score this procedure
must follow the guidelines of Rapaport, Gill, and Schafer (1946).
Inquiry follows each card, and the card is removed from the
subject's sight so that elaboration of the response is done from

recollection of the card, fostering more dependency on the sub-
ject's internal representations.
The fundamental problem with this scoring system to assess
the nature of object relations is its dependency upon human
content responses to the Rorschach. This issue becomes even
more problematic when considering applications of this scoring
system to the assessment of psychopathy and the predictable
absence, or low frequency, of human responses to the Rorschach
by the psychopathic individual.
If one attempts to apply the system of Blatt and colleagues
(1976) to Protocol I, a single quasi-human response is found to
Card 11:
They're all symmetrical, two elephants kissing each

other. (Response to inquiry: standing on three legs,
touching, not necessarily kissing, because the trunks
are touching, their ears here.)
This response would be scored quasi-human (H) only because the

animal is explicitly given qualities that only a human could
possess. Blatt and colleagues (1976) noted the exceptional nature
of this scoring, and that it is not meant to include all animal
movement responses (FM).The response would be further
scored as accurate (F +), Appropriate (+), Perceptual Articula-
.
tion of Posture ("standing . . touching"), Reactive action ("be-
cause the trunks are touching"), Incongruent integration of ob-
ject and action, Benevolent content of action, and Active-active
interaction. Unfortunately this one quasi-human response tells
us virtually nothing about the internal representational world of
this individual, and is useless as an example of this system's value
in understanding the psychopathic character.
When psychopathic subjects do produce protocols with a
series of human and quasi-human responses, however, the Blatt
and colleagues (1976) system becomes quite compelling as an
Appendix III 409
interpretative measure of object representations. I would like to

illustrate this by applying the system to two protocols of psycho-
pathic individuals who generated human responses.
The first partial protocol (human responses only) was pro-
duced by a 35-year-oldCaucasian male who had a lengthy history
of antisocial behavior. He was eventually convicted of two felony
murders, and subsequently executed by the state.
RORSCHACH PROTOCOL I1
(HUMANRESPONSES ONLY)
111. 1. It's two people pulling a crab apart. (Response to in-
quiry: Here's one person and here's another person and
here's their hands, and it looks like they're pulling some-
thing apart. I said it's a crab because that's what I said
last time.)
2. Someone tumbling [D2]. (Response to inquiry: Yea,
here's his head and here's his body.)
VII. 3. Two Cupids facing each other. (Response to inquiry:
Yea, they have wings [DdZl]. This is their hair and their
faces. They look like they're on a stand.)
4. It's a girl looking at herself in the mirror. (Response to
inquiry: Here's her head, here's her arm, and then this
part's her body.)
IX. 5. This is a space man, like the cover on a science fiction
[WJ. (Response to inquiry: He's got a big head [D81, the
orange is the aura going out from him [D3], the green
could be hands, and the red the rest of his body. He has
an ominous look. He's an unfriendly bastard. I just
noticed this, he's giving you the finger [Dd31]. I didn't
see that at first.)
Table 111-2 illustrates how the five human responses would

be scored (Blatt et al. 1976).
Table 111-2
Concept of the Object Scoring, Protocol I1
Articulation Motivation Integration
Differentiation of of
Accuracy * Perceptual Functional Action Object-Action Content Nature
- -
111. 1. H (popular) - - Unmot. Nonsp. Mal A-A

2. H+ - - Unmot. Fused Ben -
VII. 3. (H)+ PSt Sex, Ro, SpID Unmot. Nonsp. Ben A-A
4. H+ - Sex Unmot. Nonsp. Ben -
IX. 5. 0- Sz, PSt, Po Sex, Ro Unmot. Nonsp. Mal A-P
Appendix 111 411
The perceived object representations are mostly intact and

accurately perceived human and quasi-human responses, begin-
ning with a popular. On the last response, however, there is a
sudden deterioration to a quasi-human figure that is inaccurately
perceived and elaborated in a grandiose, threatening, and ag-
gressive manner. In a striking way the stranger selfobject in a
fully projected form is manifest as the last object representa-
tional content in this protocol, suggesting the primary identifica-
tion of this individual.
The articulation of perceptual and functional characteris-
tics, when it occurs in accurate object representations, is prima-
rily feminine, with a concern for appearance, presentation, and
form. There is an idealizing, narcissistic quality to this individu-
al's internal representation of the female.
The action of the object representations, however, is always
unmotivated, lacking in meaning, purpose, and intent. This sug-
gests an individual who lacks inner direction and motivation,
pathognomonic of impairments in underlying structure and orga-
nization. The nonspecific integration of object and action, how-
ever, suggests that interpersonal activity will, at least superfi-
cially, be socially appropriate and directable.
This is supported by the content and nature of the object
representational action. Although initially malevolent and ag-
gressive, the activity is shared and mutual, perhaps predicting
this individual's expectation of first engagement with others: a
distrustfui, but shared, aggressive encounter. The nature of
content then sustains, for a period of time, a mutual and benev-
olent interaction, epitomized by the idealization of the reciprocal,
loving relationship in the myth of Cupid on Card VII.
The internalized relational world, however, predicts an end
to this loving twinship with the emergence of a grandiose, ma-
levolent, and aggressive figure: a representation that is quasi-
human, but imbued with an ominous, fictional quality. The ag-
gression, however, is not confabulated in a distant manner, but
dramatically loses distance and becomes an expression of disdain

and contempt toward the Rorschach examiner himself.
The second partial protocol was produced by a 21-year-old
Caucasian male who was convicted of the torture-murder of an
older homosexual male whom he had gone to visit with several
friends. This individual also had a lengthy history of antisocial
behavior beginning in early adolescence:
RORSCHACH PROTOCOL I11

(HUMANRESPONSES ONLY)
I. 1. Looks like the devil, see the ears, eyes, and horns on the
head, that's what it's supposed to be, isn't it? (Response
to inquiry: the ears, horn, mouth, teeth, chin here.)
11. 2. Two cartoon characters, clowns slapping their wrists
together like this (gestures). (Response to inquiry: the
hands and faces are red on each side, you could make the
body look like that.)
111. 3. Two ladies, fighting over some grocery bags, the red
stuff is the mess they're making, trying to rip the shop-
ping cart bag in half, here's the stuff coming out of it.
(Response to inquiry: legs, hips, boobs, neck, they're
chickenpeople (?)yea, no mouths, just beaks. Marks here
are rips. The stuff (1)like I don't know, broken mayon-
naise jars, but mayo isn't red, strawberry jelly.)
VII. 4. A lady dancing and her hair's on fire [Dd22v] Buttocks,
pointy shoes, one hand and one arm up through here, she
got her head blown off (laughs), she's dancing. (Response
to inquiry: the hair, arm here, head blown up.)
5. Two Mexicans, you know with that on their head? [Dl]
They're snobby and looking over their shoulder. (Re-
sponse to inquiry: like when you stick your tongue out,
stuck up.)
IX. 6. The head and body of a baby [D6]. They didn't tie the
Appendix III 413
umbilical cord and the guts are shooting out. Can that
really happen? Can it bleed to death? (Response to inqui-
ry: the nose, the color, more of a flesh tone. He's red when
he comes out, this is green and orange guts coming out.)
X. 7. Some guy's handing another guy something. [D6] (Re-
sponse to inquiry: the blue here, on a cliff.)
8. Looks like a bug here [DA. Someone used a drill press on
him [D15], blood here [D13], drilling through one leg, the
handle and power unit here [D15]. (Response to inquiry:
cockroaches, two antenna and feet, and a wishbone here,
the yellow handle.)
9. A man here, pulled along by two seahorses [DlO]. Like
with Sharnu, guy gets on his back, you ever been there?
(Response to inquiry: the hair, feet, and seahorses; a shot-
gun here.)
Table 111-3 illustrates how the nine human responses of

Protocol I11 would be scored (Blatt et al. 1976).
This individual presents a much more primitive and un-
stable representational world than Protocol 11. Although he
generally provides accurate and whole human responses, he
begins in a very tentative fashion with a quasi-human detail that
archetypically foreshadows, despite its inactivity, the malevo-
lent, destructive, and evil nature of his self and object concepts.
His representational differentiation progresses in the
second response to a whole and benevolent quasi-human relation-
ship, although somewhat exhibitionistic; but then is spoiled as
soon as it reaches a whole human response ("chickenpeople,"
response 3) and completely loses its accuracy as a whole human
response that is fdled with sadistic aggression (response 4). The
patient is able to rebound to accurate, whole human responses
throughout the rest of the protocol. The intrapsychic differenti-
ation of this individual's object representations are generally
adequate, but subject to sudden and brief fragmentation and a
consequent loss of reality testing.
Appendix 111 415
This individual's degree of articulation is limited, averaging

1.6 features per response. It is also typical of a psychopathic in-
dividual, in that items are concerned with appearances, roles, and
sexual identity: features of most interest to a pathologically nar-
cissistic individual. There is an exhibitionistic, almost histrionic,
quality to the articulation of these features. His identification of
gender is also quite revealing, since both female responses (3,4)
are involved in malevolent activity, and both male responses (7,9)
are involved in benevolent activity. This suggests the conceptual
representation of female objects as aggressive and distrustful,
and probably reflects this patient's early primary object experi-
ence with the mother. I t also suggests intense sexual orientation
conflict and the probability of bisexual, or a t least homosexual,
acting out as an expression of this individual's rage toward the
feminine, particularly his own maternal introjects.
A motivation for action is generally lacking, inferring an
absence of meaning, purpose, and internality in this patient's
interpersonal behavior. Surprisingly it becomes intentional on
the last response, which may be prognostically siflicant.
This individual's capacity to integrate intrapsychic objects
and action is quite variable. A capacity for developmentally ma-
ture congruency is evident (6), but it can only be reached in a
dreadfully sadistic and aggressive manner. The attainment of this
level is also quite tenuous, and subject to sudden regressive turns
(7,8) to developmentally primitive fusions of object and action.
This individual's object representational world is quintes-
sentially frightening. I t is populated by demonic and malevolent
figures engaged in sadistic and aggressive behavior towards
nonreactive, passive, and generally helpless objects. Of his
human responses 63 percent of those involving two or more
figures are engaged in destructive or aggressive activity, and 60
percent of these responses are toward an entirely passive figure.
One would hypothesize interpersonal behavior that was gener-
ally sadistic, and escalated in sadism when the victim was per-
ceived as, or actually rendered, helpless. This was tragically the
case in the instant offense, since the victim was bound and
gagged during his torture and murder.
Yet the irony of this patient, perhaps intrapsychically pre-
dictable if one looks carefully at his shift from an unmotivated,
fused, and malevolent response (8) to an intentional, nonspecific,
and benevolent last response (9), was his behavior immediately
following the killing:
A 10-year-oldboy witnessed the torture and murder of

the elderly victim from an adjacent room. When the
perpetrator told the boy not to say anything to any-
body, the boy, in a state of abject terror, agreed. The
murderer left the apartment without harming the boy.
Psychodiagnostically this individual was viewed as a severe

borderline personality with antisocial and histrionic features. He
represents another point on the psychopathic continuum, partic-
ularly in contrast to the much less primitive, more stable, and
more fully integrated, self- and object representations of Pro-
tocol 11.
PRIMITIVE DEFENSE ANALYSIS
A third approach to an understanding of psychopathy in the

Rorschach is offered by the work of Lerner and Lerner (1980) and
their assessment of primitive defenses. Their system is based
upon the theoretical formulations of Kernberg (1975) and the
psychodiagnostic testing research of Mayrnan (1967), Pruitt and
Spilka (1964), Holt (1970), and Peebles (1975).
In brief, their scoring system appears to have substantial
reliability and validity (Lerner and Lerner 1980, Lerner et al.
1981, Lerner 1986, Gacono 1988). Their studies have consistently
found significant differences in defensive operations, both type
and developmental level, among schizophrenic, borderline, and
Appendix ZZI 417
neurotic groups (Lerner and Lerner 1980, Lerner et al. 1981).

More specifically, individuals organized at a borderline level
(Kernberg 1984) were the only group found to use projective
identification as a defense, and were significantly more prone to
use splitting and primitive levels of devaluation, idealization, and
denial than either the schizophrenic or neurotic samples (Lerner
and Lerner 1980, Lerner et al. 1981).
Lerner and Lerner (1980) have also been quite interested in
the integration of their structural concept of defense with devel-
opmental object relations (Blatt et al. 1976).To this end they have
also found that the postulated three levels of personality organi-
zation (neurotic, borderline, and psychotic) also produce signifi-
cantly different human and quasi-human responses, with the
latter group producing the fewest human-oriented responses
(Lerner et al. 1981). Their work has lent substantial concurrent
and construct validity to the research of Blatt and colleagues
(1976).
The Lerner and Lerner (1980) scoring system consists of
five defenses: splitting, devaluation, idealization, projective iden-
tification, and denial. Devaluation, idealization, and denial also
require a ranking of the defense from most primitive to most
advanced. The five-point continuum for devaluation and idealiza-
tion is based upon the humanness of the figure, the temporal-
spatial perspective of the figure, and the affective valuation of
the figure. Denial is ranked on a three-point continuum based
upon the degree of reality distortion involved in the response.
,Thebasic unit to be scored is a whole human or quasi-human
response, H or (H). Human detail responses are not scored,
except for one of the categories of projective identification which
involves a human detail response, a Dr location, an F(C)deter-
minant, and aggressive content. All responses need to be scored
for form level using the system devised by Mayman (1962), an
elaboration of form level as delineated by Rapaport and col-
leagues (1946). Any response may receive more than one score.
Like the Blatt and colleagues (1976) system, the Lerner and
4 18 THE PSYCHOPATHIC MIND
Lerner (1980) system's major liability is its dependency upon

human responses to the Rorschach. I t is even more selective
because of its dependency on whole human responses; and this,
of course, limits its usefulness in addressing psychopathy in the
Rorschach. The Lerner and Lerner (1980) primitive defense
system is inapplicable to Protocol I due to an absence of human
and quasi-human responses.
Primitive defense analysis can be used to interpret Protocol
11. The five human and quasi-human responses would be scored
as follows:
1. Devaluation (highest level-1); Splitting

2. No defense score
3. Denial (highest level-1)
4. No defense score
5. Devaluation (lowest level-5); Projective Identification;
Denial (lowest level-3)
This analysis yields significant interpretative data con-

cerning this psychopathic protocol. Internal object representa-
tions are organized by splitting defenses; and, although depreci-
ated, may be intrapsychically represented in interpersonally
acceptable ways (1). This individual also has a capacity for higher
level forms of denial, in this particular case involving the use of
negation (3) to disavow certain aggressive impulses. This pa-
tient's structural defenses, however, also involve the use of
projective identification in an aggressive and controlling manner
(5). The utilization of this defense involves the projection into the
object of aggressive impulses that are experienced as ego synto-
nic, leading to a loss of conceptual distinctiveness between self
and object for the purpose of actual control of the object's
characteristics. This regressive shift is accompanied by primitive
forms of both devaluation and denial in which the humaneness of
the actual object is lost and reality testing may be momentarily,
but severely, compromised.
Appendix III 419
All of these defensive characteristics c o n f i i the psycho-

pathic process within this individual from a structural defense
perspective, particularly the use of devaluation and projective
identification: the latter defense pathognomonic of a borderline
personality organization (Lerner and Lerner 1980).
Protocol I11 would be scored as follows:
1. No score (Hd) response

2. Denial (highest level-1)
3. Splitting; Devaluation (lowest level-5); Denial (lowest level-3)
4. Devaluation (level-2); Projective Identification
5. Devaluation (highest level-1)
6. Splitting; Devaluation (level-2); Projective Identification
7. No score
8. Projective Identification
9. Splitting; Denial (highest level-1)
Splitting was scored on response 9 because it immediately

followed response 8 and represented an opposite affective va-
lence.
Like the concept of the object scoring of this protocol, one
sees an obvious and primitive borderline defensive structure. A
capacity for socially acceptable uses of denial accompanies the
first internal human representation (2), but then is followed by a
regressive shift toward splitting and its phenotypic expression
through lowest level forms of devaluation and denial (3). A
compensatory gesture to regain intrapsychic control is found in
response 4 through the aggressive use of projective identifica-
tion, but with a consequent loss of reality testing. Response 5
signals a progressive shift, but then is followed by a devalued and
split-object representation (6) that is also projectively controlled
through a quite striking and primitive embellishment: a human
content ("the head and body of a baby") that focuses aggression
during the immediate postnatal moment ("they didn't tie the
umbilical cord and the guts are shooting out").
Projective identification is used once again in response 8 in

a confabulated response that is both sadistic and vague as to the
nature of the human representation. The final response (9) infers
a progressive return to higher level defensive operations with
both acceptable form quality and the use of negation to deny the
previous aggressive impulse.
This partial protocol also contributes to an understanding of
psychopathy. The distinctive use of projective identification lo-
cates this individual at the borderline level of personality orga-
nization. The use of devaluation in the absence of any idealization
other than the grandiose self-structure is typical of the internal
representational world of the psychopath. And finally, the ag-
gressive and sadistic content that the defensive structure sup-
ports is pathognomonic of the psychopathic process. I must note,
however, that it is highly unusual for a psychopathic individual to
be this revealing of his internal representational world.
PRIMITIVE INTERPERSONAL MODES
Kwawer (1979,1980) developed a Rorschach model of borderline

psychopathology that regarded "content as a profound, symbolic
statement of personal mythology reflecting early interpersonal
experience" (1980, p. 90). In the 1979 study he found that the
borderline sample (N= 16) differed significantly from the control
sample in that each Rorschach contained at least one response,
and often more than one, that symbolized separation and differ-
entiation problems with the primary object.
The 1980 paper hypothesized that symbiotic merging in-
cludes intrauterine modes of experience, and proposed a devel-
opmental schema to explore very early disturbances in interper-
sonal relations, ranging from intrauterine life through the
separation-individuation phase of infancy.
Kwawer (1980) was careful to note that his eight modes of
relatedness are not presented in a sequential or developmental
Appendix ZZZ 421
hierarchy. They include engulfment; symbiotic merging; violent

symbiosis, separation, and reunion; malignant internal pro-
cesses, including primitive incorporation; birth and rebirth;
metamorphosis and transformation; narcissistic mirroring; and
separation-division. He also noted two adjunctive response vari-
eties: boundary disturbance and womb imagery.
The strength of Kwawer's model of primitive interpersonal
modes is its application to all, not just human or quasi-human,
responses. This is particularly evident in applying his analysis to
Protocol I, a psychopathic protocol that must be disregarded by
both the Blatt and colleagues (1976) and the Lerner and Lerner
(1980) systems due to the absence of human responses.
Protocol I yields six responses that symbolize this individu-
al's early interpersonal experience (I have only repeated the
initial response here, but in one case [9] the inquiry response was
critical to scoring):
I. 1. Narcissistic mirroring. (absolutely symmetrical, looks

like it could be a caterpillar on a mirror)
2. Metamorphosis and transformation. (or a butterfly
coming out of a cocoon)
VI. 8. Narcissistic mirroring. (the bank of a riverbed, some
plants and trees reflecting off the water)
VII. 9. Separation-division, (iron slag. That's what it looks
like. When you're welding)
IX. 12. Separation-division. (an ear of corn very ripe. Needs to
be picked off the bush, plant)
X. 13. Metamorphosis and transformation. (looks like some-
thing under a microscope. Little pieces of algae, proto-
plasm floating around on a microscopic slide)
These responses vividly convey the underlying borderline

personality organization of the psychopathic individual. In a
constricted protocol of only thirteen responses, 46 percent of the
percepts symbolically represent early interpersonal disturbance.
The narcissistic mirroring responses (1, 8) convey a self-

absorption and self-involvement such that the primary object
exists only as a conceptual extension, a mirror, of the grandiose
self. The metamorphosis and transformation responses (2, 13)
infer the enmeshment of the self i n the biology of the primary
object as it seeks developmental relatedness to the psychology of
the primary object. And the separation-division responses (9,12)
infer the unconscious conflict and ambivalence concerning sepa-
ration and reunion with the primary object.
Other responses from Protocols I1 and I11 that are devoid of
human or quasi-human content also illustrate the usefulness of
Kwawer's (1980) model when probing psychopathic disturbance:
Violent symbiosis, separation, and reunion

A horse being eaten by a bear. (Here, the horse head and
hoof trying to get away.) [Card V, D4]
Violent separation combined with malignant internal pro-
cesses
Bits and pieces of a pig, his head, they tore his stomach off,
leg, head here. He's been chopped into little pieces, ya
know? [Card VII, Dd221
Malignant internal processes
A bug, eyeballs, skeleton, armor, feet, claws, his tail. [Card
IX, W v]
Metamorphosis and transfornution
I t looks like a bunch of parts, maybe germs, like through a
microscope. [Card X, WJ
Narcissistic mirroring combined with malignant internal
processes
A piece of liver reflected. [Card 11, D23
In summary, I have used four Rorschach interpretative

models to expand and deepen our clinical understanding of the
psychopathic process. These models include an empirically
based, atheoretical system (Exner 1986a); a developmental anal-
Appendix 111 423
ysis of the concept of the object (Blatt et al. 1976); a structural

analysis of primitive defenses (Lerner and Lerner 1980); and a
configurational grouping of primitive interpersonal modes of
relating (Kwawer 1980). These approaches complement, rather
than detract from, each other. They allow us to thoroughly, and
more profoundly, understand the structure and function of psy-
chopathy.
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Index
Abraham, K., 275 See also Affective

Abrahamsen, D., 29,65,75, aggression; Predatory
77,95,101,113,226-227, aggression
231 psychotic modes of, 292-293
Acetylcholine, 26 sexualization of, 135, 144-145
Adams, J., 207 and violence, 191-192
Adams, N., 301 Aichorn, A,, 9
Adler, G., 204 Alarm state, 193,202
Adoption studies, 23-24 Aleksandrowicz, D. R.,
Affect block, 203-204 Aleksandrowicz, M. K., 55
Affective aggression, 25-26, Alexander, F., 8-9
192-212 Allen, J., 332
displacement of, 199-202 Allison, R., 177-178
and lowered self-esteem, American Psychiatric
211-212 Association, 6-7,152-153,
and predatory aggression, 245,268,279,289
213-214 Amphetamines, 225,280,294
and psychotic envelopment, Andreasen, N. C., 263-265,
208-21 1 286
and public ritual, 202-203 Andrew, J., 22
Affective discontinuity, Anger, 81-91
314-315 "Apocalypse Now," 252
Aggression, 24-29,187-191. Appelbaum, J., 24
461
462 Index
Appelbaurn, P., 330 Boesky, I., 240

Archer, J., 24 Bonnie, R., 119
Arkonac, O.,162 Borderline personality, 18
Arson, 187-188,301 Boredom, 106-113
As-if quality, 132,137 Boston Strangler. See
Attachment, 54-59 DeSalvo, A.
Autonomic reactivity, 29-37, Bower, G., 78
193,213-214 Bowlby, J., 54
Aynesworth, H., 108,159-161, Bradford, J. M. W., 172
167,169,215-218,228 Brandt, J., 118
Braun, B. G., 171
Bach-y-Rita, G., 22 Bremer, J., 29
Bailey, K., 300-301 Brenman, E., 231
Bandler, R., 191,213 Breuer, J., 171
Bandura, A., 55 Broadhurst, P., 24
Bardwick, J., 28 Broca, P., 66
Basic trust, 43-44 Brodal, A., 67
Bauder, D., 144 Bromberg, P., 204
Beaber, R., 118 Bronson, C., 71
Bellak, L., 332 Brown, B. S., 301
Bensoul, B., 294 Brown, W., 28
Berkowitz, D., 65,75,95,101, Brucke, E., 73
113,226-227,231,238 Bugliosi, V., 269n
Bianchi, K., 172-181 Buie, D. H., Jr., 204,328
Bibring, E., 109 Bundy, T., 71,108,159-161,
Bick, E., 79,170 214-218
Biological substrates, 20-38 Buono, A., 83,172
Bion, W. R., 125,144,231, Bursten, B., 10,19,85,99,
267,276 101-102,105,120,218,
Birnbaum, K., 8 238,289,291,320,331,
Blackman, N., 80 333
Blatt, S., 92-93 Butcher, S,, 26
Bliss, E. L., 171
Blondaux, C., 24 Cadoret, R. J., 162
Blurner, D., 22 Cahill, T., 148,278
Boesky, D., 48 Calix, E., 295n
Index
Campbell, H., 29 devaluation and loss of

Cannon, W., 193 professional identity,
Carroll, B., 28 330-331
Cavanaugh, J., 288 fear of assault or harm,
Chapman, L., 279 326-327
Character armor, 43 hatred and the wish to
Characterological traits, destroy, 331
248-268 helplessness and guilt,
Chasseguet-Smirgel, J., 339 329-330
Chatz, T., 29 illusory treatment alliance,
Chi, C., 191 326
Children, aggressive, 54-55 and malignant
Chodoff, P., 162 pseudoidentification,
Christiansen, K., 22-23 140-141
Christie, M., 30 and psychopathic anger, 82,
Chu, A,, 79 86-87
Claridge, G., 33 and reptilian states, 70-72
Cleckley, H., 9-10,316 therapeutic nihilism,
Cloninger, C. R., 162-163 325-326
Cocaine, 200,225,294-299 Courtless, T. F., 301
Cockrum, E., 68 Craigen, D., 31,33
Coleman, M., 27 Criminality, 20-21
Concept formation, 42 Cypher, L., 363-375
Conrad, J., 252
Conscious choice, and
unconscious defense, Dahlstrom, W., 36
117-181 Dalton, K., 28
Contempt, 99-106 Damasio, A., 66-67
Cooper, H. H. A., 90 Deception, 120-132,
Core complex, 135-136 328-329,334-335,341-362
Coriat, R. C., 9 Defenses
Countertransference, 320-325 conscious choice and,
assumption of psychological 117-181
complexity, 331-333 primitive, 18
denial and deception, Defensive organization,
327-329 253-265
Index
Denial, 120-132,327-328, Emotion, conscious

341-362 experience of, 74-113,
Denkowski, G. C., 301 193,214-216
Denkowski, K. M., 301 Empathy, lack of, 32,238-239
Depersonalization and Ennis, B., 118, 194
derealization, 152-162 Envy, 103-105,134
Depression, 91-99 Episodic dyscontrol, 83-84
Dern, B., 71 Erikson, E., 43
DeSalvo, A,, 77,88-89, Esser, A. H., 300
102-103 Evaluation, treatment versus,
Deutsch, H., 132,137 310-311
Diamond, B., 172 Exhilaration, 99-106
Dissembling, 290-291 Exner, J., 36,79,266,291,318
Dissociated rage, 87-90 Extroversion, 34-38,111-112
Dissociation, 149-181 Eyes, reptilian, 70-74
Dopamine, 26 Eysenck, H., 33-36,111
Doren, D., 291 Eysenck, S., 34-36
Dorpat, T., 144
Douglas, J. E., 228-229 False self, 132
Drug-induced psychosis, Family romance, 136
293-299 Fantasy, transitional, 226-227
Duffy, E., 193 Farley, F., 111
Farley, S., 111
Fast, I., 150
Eagle, M., 54 Fedora, O., 164
Eastwood, C., 71 Fedora, S., 164
Eckblad, M., 279 Feltous, A. R., 81
Edgerton, R., 300 Fenichel, O., 11,72, 109
EEG (electroencephalogram) Ferenczi, S., 18,246
abnormalities, 21-22 Fetishes, 226
Ehrenkranz, J., 28 Field, M. 56
Eichelman, B., 25-27,190, Field, S., 176
192,213 Finell, J., 144
Eissler, K., 12 Fintzy, P. T., 226
Elworthy, F., 72 Fitzhugh, K., 22
Index
Fliess, R., 171 Gentry, C., 26%

Flor-Henry, P., 22,163 Gill, M., 90
Flynn, J. P., 191,193 Giovacchini, P., 331
Forensic clinician Glasser, M., 119,132-133,135,
and dissembling, 290-291 205
and malingering, 288-290 Gouster, M., 7
reporting patient criminal Grandiose self, 47-54
activity, 330 and anger, 82
and treatment, 310-311 boredom and, 107-109,112
Formal thought disorder, and denial, 131-132
262-265 and drug abuse, 295
Fox, J., 79,218 and malignant narcissism,
Frank, G., 77,88-89,102-103, 336-339
228 of manic psychopath, 279
Franks, C., 35 in the mentally retarded,
Freud, A., 12,52, 122-123, 303
126 narcissistic choice of, 54
Freud, S., 9,73,122-123,134, and predatory violence,
136,149,170,275,283, 239-241
316 and projective
"Some Character Types pseudoidentification,
Met with in Psychoana- 141-143
lytic Work", 8 psychotic, 269-270
Frosch, J., 5, 13, 18,124, 146, and sexualized aggression,
152,207,246-247,266, 145-146
325 Gray, J., 33-35
Greed, 103-104
Gacono, C., 316 Greenacre, P., 132,136-137,
Gacy, J. W., Jr., 147-149 225-226
Gaddini, E., 133-134 Greenberg, A., 27
Galdston, R., 331 Greenberg, J., 92,95,104
Ganzer, V., 21 Greenson, R., 136,323-324
Gardner, J., 7,44 Grinberg, L., 276
Gellhorn, E., 34 Grinker, R., 109
Genetic predispositions, 22-24 Groth, A. N., 29,76
Grotstein, J., 13,41-43,45-46, Henderson, N., 24
52,57,112,144-146,210, Hereford, C., 301
269,278,329,335,337 Hermann, I., 73
Grove, W. M., 263-265 Hernandez-Peon, R., 213,230
Guard, J., 341-362 Hemstein, R., 20,22
Gunderson, J., 152 Hemog, A., 67
Gupta, B., 35 Hilgard, E. R., 78,171-172
Gutheil, T. G., 328 Hitchcock, A., 221
Guze, S. B., 162 Hoarding, 68
Hoge, S. K., 328
Haimo, S., 264 Holcomb, W. R., 301
Hall, C., 24 Holding environment, 43-44
Hallucinations Holland, H., 35
auditory, 253-256,272-273 Holland, T. R., 301
localization of, 198-199 Holt, R., 17,90
Hallucinatory image, 133- 134 Holzmann, P., 54,262-265
Hamburg, D., 28 Hormonal influences, 27-29
Hare R., 6,9,20-21,30-33, Horney, K., 10
84,111,164,300,302, Horneykiewicz, O.,67
316-318,323 House, T., 31
~ a r t m a n nH.,
, 44,73,131, Howe, E. G., 170-171
210,332 Hurley, A. D., 302
Hartocollis, P., 109 Hyrner, S., 71
Haslam, D., 35 Hysteria, and psychopathy,
Hatred, 331 161-170
Hauer, R., 71
Heart of Darkness (Conrad), Identification
252 definition of, 45
Heaven, T., 316 with the aggressor, 52-53
Heightened sensory Identity integration, 18,
awareness, 205 249-253
Heilbrun, A. B., 300 Illusory treatment alliance,
Helinski, L., 321% 326
Hellerstein, D., 254,277,289 Imitation, and simulation,
Hellman, D., 80 132-141
Imposters, psychopaths as, 313-316,318-319,
132 321-322,332,336-339
Imposturing, 136-137 Keyes, D., 170
Inhelder, B., 44 King, D., 24
Internalization, 44-47 iss sen,'^., 14
Interview, structural Klein, M., 13,58,94,99,
diagnostic, 318-320 103-104,144,275,
Intimacy, and the grandiose 282-283,287
self, 51-52 Klopfer, B., 79
Introjection, 45-46 Kluft, R. P., 170
Introverts, 34-35 Koch, J. L., 7
Koehler, K., 198
Jacklin, C., 27 Kohut, H., 48,139,143-144,
Jacobs, J., 91 149-150,329
Jacobson, E., 13,49-50,92,96, Kolb, B., 68
124,150,313,315 Kolb, J., 152
James, W., 193 Kooi, K., 21
Janet, P., 170 Kostowski, W., 24
Jasper, H., 67 Kozol, H., 21
Johnson, A. M., 13 Kraepelin, E., 8,162
Johnston, M., 54,262,264 Krafft-Ebing, R. von, 29,76
Jones, J., 91 Kreuz, L., 28
Joseph, B., 100,103 Kris, E., 112
Jung, C. J., 149 Kwawer, J., 14,266
Jutai, J., 316
Lacey, B., 33
Karpman, B., 9 Lacey, J., 33
Keating, T., 188 Lange, C., 193
Kellert, S. R., 81 Laschet, U., 29
Kemper, E., 222 Lashley, K., 193
Kernberg, O.,10,13,17-20 Lau, A,, 255n
47-50,59,91,93,103,105, Leader, narcissistic, 90-91
110-111,119,129-130, Leaff, L., 328
132,149-150,236,248, Lehman, L., 152
253,265,269,293, Lerner, P., 270
Lester, D., 190 Malignant
Leura, A,, 79 pseudoidentification,
Levin, J., 79,218 139-140,335-336
Levy, D. M., 9 Malingering, 118-121, 172,
Lewis, P. R., 213 287-290
Leyton, E., 6,221-222,232 Maltsberger, J., 328
Lichtenberg, J., 125 Mandelzys, N., 35
Lilienfeld, S. O., 162 Manic triumph, 279-287
Limbic system, 66-69 Manipulative cycling, 333-334
Lindsley, D., 193 Manson, C., 71,269
Lion, J., 311,325,328 Marant, H. D., 240-241
Livingston, K., 67 Mask of Sanity (Cleckley),
Ljungberg, L., 162 9-10
Localization of hallucinations, Masur, J., 24
198-199 Maternal drive, 68
Loeb, J., 30-31 McCauley, W., 68
Loewald, H. W., 171 McPherson, L., 21,300
Lombroso, C., 7 Media, and reptilian stare, 71
Loofbourrow, G., 34 Mednick, S., 21-24,28,30-32
Lothane, Z., 194 Meikle, S., 35
Ludolph, P., 152-153 Meisel, A,, 330
Lunde, D., 57,147,173 Meissner, W. W., 13,48,81,
Lykken, D., 31 205
Meltzer, D., 79,339
MacAndrew, C., 300 Mental retardation, and
Maccoby, E., 27 psychopathy, 299-303
MacDonald, J., 80 Methamphetamine
MacLean, P., 34,66-68 hydrochloride, 225,280,
Maddocks, P. D., 162 294
Mahler, M., 12-13, 42-43, Meyer, A., 8
45-46, 57,72,134,143, Meyers, J., 258n, 295n
276 Michaud, S., 108,159-161,
Maier, G. J., 328 167,169,215-218,228
Mailer, N., 167 Michel, G., 255n
Malignant narcissism, 336-339 Miller, R. D., 328
Index
Milligan, W., 31 of, 276-277

Millon, T., 7,9 Ogden, T. H., 150,209,339
Minuchin, S., 55 Olweus, D., 28
Mirroring, antithesis of, 71 Omnipotent mad self, 19
Mitchell, S., 92,95, 104 Operant conditioning, 77-78
Modell, A., 13,225 Orne, M. T., 172,179-180
Monroe, R., 83-84 Ornitz, E., 42
Moorman, C. B., 199
Moravesik, E. E., 161 Paluck, R. J., 300
Morrison, H., 42 Pandya, D., 67.
Morse, S., 119 Papez, J., 67
Movies, portrayal of Paranoid annihilation, 268-279
psychopaths in, 71,221, Paranoid schizophrenia, 78,
252 363-375
Moyer, K., 25,213 Partridge, G. E., 9
Multiple personality disorder, Pavlov, I. P., 76
psychopathy and, 170-181 Penfield, W., 67
Percept formation, 41
Narcissistic personality, 18-19 Perkins, A., 71
Neurnan, G. G., 275-276 Persky, H., 28
Neuroanatornical structure, Personality organization,
21-22 character and, 248-268
Neurochemical set, 24-27 Pessimistic mood, 108
Nixon, R., 123 Peto, A., 73
Norepinephrine, 26 Phallic-narcissistic character,
Nouneman, A,, 68 11-12,43
Piaget, J., 44,52,56
Object constancy, 54,55-56 Pierce, G., 79
Object control, projective Pinel, P., 7
identification and, Pittluck, A. T., 172
141-149 Pleasure, conscious
Object relations, 13,41-59 experience of, 75-81
O'Brien, D., 29,83,167, Pleasure principle, 134
173-181 Ponzi, J. D. D., 240
Oedipal conflict, persistence Post, J., 90
Index
Predatory aggression, 25-26, denial and deception in,

28-29,212-241 120-132,341-362
and absence of conscious developmental origins of,
emotion, 214-215 41-59
absence of threat in, 218 drug-induced psychosis and,
goals of, 219-223 293-299
minimal autonomic arousal historical perspective on,
in, 213-214 7- 14
minimal displacement in, and hysteria, 161-170
223-224 imitation and simulation in,
planned violence in, 215-218 132-141
and private ritual, 224-230 mental retardation and,
and reality testing, 233-234 299-303
self and object concepts in, and multiple personality
232-233 disorder, 170-181
and self-esteem, 234 paranoid schizophrenia and,
and sensory awareness, 363-375
230-231 and predatory violence,
time-unlimited nature of, 234-241
224 as process, 311
Premenstrual period, 28 projective identification in,
141-148
Prichard, J. C., 7
psychosis and, 245-303
Private ritual, 224-230 psychotherapeutic
Projective identification and treatment of, 309-340
object control, 141-148, reptilian states, 66-74
321 rorschach psychodiagnosis
Psychoanalysis, and of, 377-421
psychopathy, 8-13 severity of, 311-322
Psychopathic personality splitting and dissociation in,
organization, 19-20 149-181
Psychopathy, 5-7 structure and function of,
biological substrates, 20-38 17-20
and conscious experience of Psychosis
emotion, 74-113 drug-induced, 293-299
Index
and psychopathy, 164

245-303 Ritual
Psychotic envelopment, private, 224-230
208-21 1,267-268 public, 202-203
Psychotic modes of Ritvo, E., 42
aggression, 292-293 Rivalry, 134
Public ritual, 202-203 Robins, E., 162
Robins, L. N., 162
Quay, H., 111 Rogers, R., 288
Quinn, M., 33 Rorschach, 36,53-54,79-80,
377-421
Rachman, S., 35 Rosanoff, A. J., 162
Racker, H., 320,324-325,327 Rosenfeld, H., 19
Rada, R., 28,301 Rose, R., 28
Rage, dissociation of, 87-90 Rothstein, A., 11,139
Railsback, S., 71 Rush, B., 7
Rarnirez, R., 71,223 Russell, P., 24
Rapaport, D., 133
Rappaport, R., 147-148,218
Reality principle, 134 Sachs, R. G., 171
Reality testing, 18,207-211,- Sadistic control, 336-339
233-234,265-268 Sadomasochistic behavior, 135
Redl, F., 55 Sadomasochistic primary
Reich, A., 323-324,329 attachment, 56-58
Reich, W., 11-12,43 Sagarin, E., 301
Reid, W. H., 6,309 Samenow, S., 93,108
Reiser, M., 14 Sandler, J., 126
Reiss, S., 302 Sarason, I., 21
Reiteman, T., 91 Satinover, J., 149
Reptilian states, 66-74 Scaramella, T., 28
Revitch, E., 76,80,94,164, Scarr, S., 34
215,218-221 Schacter, D., 118,172-173
Richardson, L., 190 Schacter, S., 193
Riedel, M., 6 Schafer, R., 17,44-45,48,110
Rinsley, D., 19,56,129-131, Schalling, D., 31
Index
Schichman, S., 93 Shaw, E. D., 90

Schiller, E., 258n Shields, J., 34
Schlesinger, L., 76,80,94, Shipley, J., 68
164,215,218-221 Shute, C. C., 213
Schlette, M. R., 187-190 Siddle, D., 32
Schmauk, F., 33 Silber, A, 172
Schmideberg, M., 12 Silverman, L., 14
Schneider, A., 193 Simon, R. I., 173
Schreiber, F. R., 170 Simulation, imitation and,
Schulsinger, F., 23 132-141
Scoptophilia, 72 Singer, M., 151
Searchlights on Delinquency Sinha, S., 35
(Eissler), 12 Skinner, B. F., 77
Searles, H., 13, 150,206,331 Slap, J. 125
Self Slobogin, C., 119
disregarded, 54 Smith, K., 54
grandiose. See Grandiose Smith, S. M., 172
self Social behavior, 68
organization of, 47-54 Sodom and Gomorrah, 72
Self and object percept Solnit, A., 55-57
dedifferentiation, 205-206 Son of Sam. See Berkowitz, D.
Selye, H., 193-194,202,213 Sovner, R., 302
Semantic dementia, 9 Spalt, L., 162
Senatore, V., 301 Spenser, B., 110
Sensations, hard and soft, Spiegel, D., 171
42-43 Spiegel, H., 171
Separation-individuation, and Spiegel, L., 42,232
failure of object Splitting, and dissociation,
constancy, 54 149-181
Serotonin, 26-27 Spohn, H., 263
Sexual sadism, 76-81. Stare, reptilian, 70-74
See also Predatory Steiner, M., 28
aggression Stelmack, R., 35
Shapiro, D., 119, 168,205,230 Stewart, H., 210
Shapiro, D. L., 288 Stone, C., 68
Index
Stott, D. H., 55 Valle, F., 24

Stranger selfobject, 46-47 Valzelli, L., 24,26-27, 67-68,
Strasburger, L., 325-326, 190-191
329-331 Van Hoesen, G., 66-67
Suarez, J. M., 172 Venables, P., 30,33
Sugarman, A., 53 Violence
Superego lucunae, 13 aggression and, 191-192
Superego pathology, 312-316 compartmentalization of,
Sutker, F., 31 87-90
Svrakic, D., 107-108 and eroticism, 57
Szekacs, J., 210 planned and purposeful,
Szekely, L., 73 215-218
predatory, 236-241
Tarshis, B., 193 and skin contact, 78-79.
Terrorism, 90-91 See also Aggression; Anger;
Testosterone, 28 Sexual sadism
Therapeutic nihilism, 325-326 Volkan, V., 13,19,45,226
Thought disorder, 262-265 Von Domarus, E., 179-180
Tooley, K., 55
Transference, 139-140, Wadsworth, M., 31
320-322 Walters, R. H., 55
Transitional objects, 225-226 Wasman, G., 193
Treatment, 309-340 Watkins, J., 174-176,178
decision against, 322-323 Wayward Youth (Aichhorn), 9
versus evaluation, 310-311 Webbink, P., 71
alliance, illusory, 326 Wechsler, D., 332
resistances during, 333-339 Weissich, W., 187-189
Trouton, D., 35 Welsh, G., 36
Tucker, D. M., 163 Wertham, F., 219
Tustin, F., 42-43 Whipple, D., 144
Twin studies, 22-23 Whitty, C. W. M., 172
Wilcock, J., 24
Urist, J., 150 Williams, D., 24
Willock, B., 54-65
Vaillant, G. E., 162 Wilson, J., 20,22
Wineman, D., 55 Yochelson, S., 93,108
Winnicott, D. W., 43, 106,
131-132,149,226-226 Zangwill, 0. L., 172
Wittels, I?., 9 Zero state, 93,108
Woerner, P. I., 162 Zillmann, D., 29
Wynne, L., 151 Zuckerman, M., 111
Yeudall, L., 22

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THE PSYCHOPATHIC

J. REID MELOY, Ph.D.

R O W M A N & LITTLEFIELD P U B L I S H E R S , INC.

ROWMAN & LITTLEFIELD PUBLISHERS, MC.

Published in the United States of America

Copyright O 1998,2002 by Jason Aronson Inc.

AN rights reserved. No part of this publication may be reproduced,

British Library Cataloguing in Publication Information Available

Library of Congress Cataloging-in-Publication Data

J. Reid Meloy, Ph.D., is a diplomate in forensic psychology of the

Chapter 2. Dynamic and Biologic Origins ......................15

Chapter 3. Developmental Origins ...................................39

Chapter 4. Affective L i e and Death ................................63

Chapter 5. Unconscious Defense

Chapter 7. Psychosis and Psychopathy .........................243

Chapter 8. Psychotherapeutic Issues.............................307

Appendix I: Jonathan Guard-Deception and Denial

Appendix 11: Louis Cypher-Paranoid Schizophrenia

Appendix 111: The Rorschach Psychodiagnosis

The publishing of this book marks the celebration of an intellec-

refinement of the Rorschach Appendix and are always a pleasure

"MarinKilleis Conspiracy Theory,"by Erik Ingram and Kevin Leary.

The spotlight of current clinical and academic research seems to

label an individual as a psychopath in a forensic diagnostic

symptoms that it attempted to embrace. Meyer (1908) separated

tions of Cleckley's book (19'76) reflected an evolution of his

My concept . ..postulates a selective defect or elimi-

Horney (1945), Fenichel (1945), and Reich (1945), in pub-

Experiences with the persons whose incorporation cre-

Psychopaths were seen as managing their self-esteem by an-

regression to more passive and anal stages of development.

The clinical and theoretical works of Klein (1957, 1964), Mahler

(Reiser 1984,1986, Silverman 1986). I will not only illustrate the

zation -neurotic, borderline, and psychotic- and his differen-

1. The predominance of aggressive drive derivatives and the

7. The emergence of paranoid ideation when under stress,

Psychic structure and function are built upon the biological

I have not found any studies that prospectively address the

then parceled out seventy-two subjects who had psychiatrically

The differentiationof genotypic and phenotypic influencesis best

Both twin and adoption studies strongly support the hy-

Where the social experiences of an antisocial individual

Considerable research evidence supports the notion that differ-

Four neurotransmitters appear to play a major role in

Hormones are the slow behavioral cousins of the neuron. They

Olweus (1975) found that levels of aggression in nursery school

Dwing the past twenty-fiveyears a number of researchers have

of psychopathy. Research findings have strongly and consis-

ten years later. This research supports my psychodynamic infer-

Extroversion has been established as an independent di-

demonstrated to occur more quickly in introverts than extro-

the moment and is generally an impulsive individual . .. tends to

SUMMARIZING THE BIOLOGICAL MATRIX

I am certain that a necessary, but not alone sufficient, biological

especially intrigued by the predominance of predatory aggres-