ion well outside the self? 55. Specific loss of insight In a special sense the psychopath lacks insight to a degree seldom, if ever, found in any but the most seriously disturbed psychotic patients. In a superficial sense, in that he can say he is in a psychiatric hospital because of his unacceptable and strange conduct, and by all other such criteria, his insight is intact. His insight is of course not affected at all with the type of impairment seen in the schizophrenic patient, who may not recognize the fact that others regard him as mentally ill but may insist that he is the Grand Lama and now in Tibet. Yet in a very important sense, in the sense of realistic evaluation, the psychopath lacks insight more consistently than some schizophrenic patients. He has absolutely no capacity to see himself as others see him. It is perhaps more accurate to say that he has no ability to know how others feel when they see him or to experience subjectively anything comparable about the situation. All of the values, all of the major affect concerning his status, are unappreciated by him. This is almost astonishing in view of the psychopath's perfect orientation, his ability and willingness to reason or to go through the forms of reasoning, and his perfect freedom from delusions and other signs of an ordinary psychosis. Usually, instead of facing facts that would ordinarily lead to insight, he projects, blaming his troubles on others with the flimsiest of pretext but with elaborate and subtle rationalization. Occasionally, however, he will perfunctorily admit himself to blame for everything and analyze his case from what seems to be almost a psychiatric viewpoint, but we can see that his conclusions have little actual significance for him. Some of these patients mentioned spoke fluently of the psychopathic personality, quoted the literature, and suggested this diagnosis for themselves. Soon this apparent CATALOGING THE MATERIAL 351 insight was seen to be not merely imperfect but a consistent and thorough artifact. Perhaps it was less a voluntary deception than a simulation in which the simulator himself fails to realize his lack of emotional grasp or that he is simulating or what he is simulating. The patient seems to have little or no ability to feel the significance of his situation, to experience the real emotions of regret or shame or determination to improve, or to realize that this is lacking. His clever statements have been hardly more than verbal reflexes; even his facial expressions are without the underlying content they imply. This is not insight but an excellent mimicry of insight. No sincere intention can spring from his conclusions because no affective conviction is there to move him. Such a deficiency of insight is harder to comprehend than the schizophrenic's deficiency, for it exists in the full presence of what are often assumed to be the qualities by which insight is gained. Yet the psychopath shows not only a deficiency but apparently a total absence of self-appraisal as a real and moving experience. Here is the spectacle of a person who uses all the words that would be used by someone who understands, and who could define all the words but who still is blind to the meaning. Such a clinical picture is more baffling to me than any of the symptoms of schizophrenia, on which attempts have been made to throw some light by psychopathologic theories. Here we have a patient who fulfills all the ordinary theoretical criteria of a "sound mind," and yet with this apparently sound mind is more incomprehensible than the psychotic patient. What I regard as the psychopath's lack of insight shows up frequently and very impressively in his apparent assumption that the legal penalties for a crime he has committed do not, or should not, apply to him. This astonishing defect in realization often seems genuine, as the patient protests in surprise against the idea that prison might be anticipated for him, as for others under similar circumstances. He frequently reacts to such an idea as if to something unexpected and totally inappropriate. This characteristic has already been mentioned in Chapter 18, Gregory. Some observers believe that what the psychopath expresses about himself and his situation constitutes insight and merits such a term. I cannot agree with this opinion. The chief and most valid connotations of the word disappear in such an application. Profoundly psychotic patients whose gross lack of insight would be admitted by all sometimes express opinions which, if fully meant and appreciated, would indicate an insight that is plainly not there. A few brief examples may help: A young man with a very active manic psychosis was interviewed some years ago. He whistled, shouted, winked, expressed the belief that he controlled the movements of the sun by his glance, sang snatches of bawdy 352 THE MASK OF SANITY songs, announced himself as a "sort of Messiah," and laid claim to the sexual vigor of seven bulls. Leaping about in a hospital shirt he had torn almost to shreds, he found exposed wires at a place on the wall from which he had torn the electric fixtures. Seizing and releasing them and seizing them again, he got good jolts of the city current, which he relished, apparently interpreting the sensation as a manifestation of his own vitality. When asked if he felt anything was wrong with him mentally, he shouted in glee, "Sure, Doc, I'm crazy as a coot! I'm nuts I tell you. Crazier than anybody you ever saw!" Another patient on a closed ward, a man badly disabled for years by obvious schizophrenia, often shouted out to the passerby, "Simple case of dementia praecox, Doc, simple case of dementia praecox," pointing to himself several times. Despite the chance diagnostic accuracy of what he said, this patient, like the one just mentioned, had little grasp of his situation and almost no real appreciation of his disorder and its meaning. Another manic patient not only spoke words that correctly indicated a good deal about his situation but even hammered out with a metal object he had obtained these letters in deep gashes in the wood door: "Bug house nutty." Indications of serious impairment of insight abound in the psychopath's reactions after his failures have been undeniably demonstrated or his antisocial acts detected. The persistent tendency to ask for recommendations from those they have every reason to know cannot furnish anything but a negative report fatal to their plans has been illustrated. Such decisions in highly intelligent people can hardly mean less than that something crucial is absent from the realization of their status. The calm assurance with which they report a successful rehabilitation in the midst of egregious and immediate maladjustment often does not seem so much a real effort to deceive as an indication that the patient himself is greatly deceived. Despite his awareness of major facts, the pivotal significance of these facts seems not to be in his evaluations. After a peculiarly overt and spectacular succession of failures, thefts, truancies, falsehoods, and expulsion from school, a young man had to be sent home to a distant state by his aunt and uncle with whom he had been staying. They had taken him in the hope that he might do better in another environment. His parents, after years of struggle, had found no solution. All the details of his recent failure and disaster were factually known to him and had been discussed with his aunt and uncle. They made no effort to deceive him about why he had to be sent home. The physician to whom he wrote the letter which follows had also been frank with him. The letter was mailed a couple of days after he returned in what to another person could not have seemed less than total failure and disgrace. CATALOGING THE MATERIAL 353

http://zpatbp.com/images/docs/TheMaskofSanityHerveyCleckley.pdf

The Mask of Sanity: An Attempt to Clarify Some Issues about the So-called Psychopathic Personality

A new and promising field has appeared as a result of the increased tourist industry based on natural resources, though too often such expansion has been achieved without due planning and has taken many people by surprise. Conservationists and their organizations have often reacted adversely to this ‘invasion’, but this need not be so. There are many reasons and examples which prove that a change of attitude, leading to a symbiotic relationship between tourism and conservation in the wide sense, can offer a very large variety of advantages and benefits—physical, cultural, ethical, and economic—to a country.A tourist industry can expect a brilliant future, based on natural assets of the environment, provided due consideration is given to the ecological principles which must guide resource-use. The alliance of those responsible for tourism with ecologists and conservationists is a natural one, that should contribute greatly to development—the right kind of development involving the right kind of change—leading to a better quality of life for all concerned.

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Tourism and Environmental Conservation: Conflict, Coexistence, or Symbiosis?

Narcolepsy is a rare brain disorder that reflects a selective loss or dysfunction of orexin (also known as hypocretin) neurons of the lateral hypothalamus. Narcolepsy type 1 (NT1) is characterized by excessive daytime sleepiness and cataplexy, accompanied by sleep-wake symptoms, such as hallucinations, sleep paralysis and disturbed sleep. Diagnosis is based on these clinical features and supported by biomarkers: evidence of rapid eye movement sleep periods soon after sleep onset; cerebrospinal fluid orexin deficiency; and positivity for HLA-DQB1*06:02. Symptomatic treatment with stimulant and anticataplectic drugs is usually efficacious. This Review focuses on our current understanding of how genetic, environmental and immune-related factors contribute to a prominent (but not isolated) orexin signalling deficiency in patients with NT1. Data supporting the view of NT1 as a hypothalamic disorder affecting not only sleep-wake but also motor, psychiatric, emotional, cognitive, metabolic and autonomic functions are presented, along with uncertainties concerning the 'narcoleptic borderland', including narcolepsy type 2 (NT2). The limitations of current diagnostic criteria for narcolepsy are discussed, and a possible new classification system incorporating the borderland conditions is presented. Finally, advances and obstacles in the symptomatic and causal treatment of narcolepsy are reviewed.

Narcolepsy - clinical spectrum, aetiopathophysiology, diagnosis and treatment.

The influence of social norm activation on the expression of opinions concerning gay men (Experiment 1) and Blacks (Experiment 2) was explored. In both experiments, participants reported their opinions after hearing a confederate give prejudiced or nonprejudiced opinions (making a prejudiced or nonprejudiced norm salient) or simply in the presence of a confederate. Results showed that participants in both experiments reported less prejudiced opinions after a nonprejudiced norm was made salient, relative to the control condition. Activation of a prejudiced norm did not have a significant effect, relative to the control condition. Furthermore, the powerful effect of activating the nonprejudiced social norm was observed regardless of participants' prejudice level. Results are consistent with the notion that, in contemporary society, the social norm opposing prejudice is stronger than the norm favoring prejudice.

The Effect of Social Norm Activation on the Expression of Opinions Concerning Gay Men and Blacks

The renin-angiotensin-aldosterone system (RAAS) has a key role in the regulation of blood pressure, sodium and water balance, and cardiovascular and renal homeostasis. In diabetic nephropathy, excessive activation of the RAAS results in progressive renal damage. RAAS blockade using angiotensin-converting-enzyme inhibitors or angiotensin-receptor blockers is the cornerstone of treatment of diabetic renal disease. Alternative RAAS-blockade strategies include renin inhibition and aldosterone blockade. Data from small initial studies of these agents are promising. However, single-agent interventions do not fully block the RAAS and patients treated with these therapies remain at high residual renal risk. Approaches to optimize drug responses include dietary changes and increasing dosages. The theoretically attractive option of combining different RAAS interventions has also been tested in clinical trials but long-term outcomes were disappointing. However, dual RAAS blockade might represent a good therapeutic option for specific patients. A better knowledge of the pathophysiology of the RAAS is crucial to fully understand the mechanisms of action of RAAS blockers and to exploit their renoprotective effects. Moreover, lifestyle interventions or diagnostic tools might be used to optimize RAAS blockade and identify those patients who are most likely to benefit from the therapy.

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Bauer W

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The other side of the coin.