In general, psychoneurotic people recognize objective reality and try to adapt themselves like most others to the ways of society. Patients with traditional psychoneurosis are not characterized by antisocial activity or by striking inability to pursue ordinary goals. Their symptoms handicap them often, but in a way we readily understand. Anxiety, for instance, can make special difficulties for a salesman or obsessive manifestations can handicap a banker, a scholar, or a housewife. These patients as a group are sharply characterized by anxiety and by the various symptomatic schemes that apparently arise from the anxiety and that look as if they were measures employed in reaction to the anxiety and in efforts to relieve it, it is true that many patients with conversion symptoms do not show what is ordinarily conveyed by the word anxiety or by tension, fear, distress, and similar terms. Many psychiatrists believe that in such instances the paralysis (or the blindness) may be a substitute for conscious anxiety and probably a defense against it, a means of preventing it or controlling it. The rather remarkable calmness shown by such patients has often been pointed out. Not a few psychopathologists maintain that there is an "unconscious anxiety" or what might be thought of as something embryonic, underlying, or incipient that would be anxiety if not converted into the physical manifestation.
Certainly it may be said about psychoneurosis, as the term is officially used and most widely accepted, that patients with this kind of disorder usually find their symptoms unpleasant, consciously suffer from them, and complain. On the contrary, those called psychopaths are very sharply characterized by the lack of anxiety (remorse, uneasy anticipation, apprehensive scrupulousness, the sense of being under stress or strain) and, less than the average person, show what is widely regarded as basic in the neurotic. It is very true that Alexander 9,11 and others79,209 who use his terminology and accept his interpretations refer to behavior disorders as character neuroses. Karpman 164 feels that most (but not all) patients who are classed as psychopaths should be grouped with the neurotic or the psychotic group. So far as its implication of causal factors is concerned, the term neurotic has undeniably valuable applications for those who feel that they have discovered such causes; but its tendency otherwise to identify the psychopath with hysteria, anxiety reactions, or ordinary obsessive-compulsive disorders is likely to cause confusion and make for practical difficulties.
If the psychopath really has a neurosis, it is a neurosis that is manifested in a fundamentally different life-pattern from classic neurosis, manifested, one might say, in a pattern that is not only different but opposite. Alexander and others have made this quite clear, and the interpretation of the psychopath's behavior as symptomatic "acting out" against his surroundings, in contrast with the development of anxiety or headache or obsession is, it seems to me, an interesting formulation. It is of obvious importance to respect this polar difference between how the psychopath is going to behave socially and what can be expected of patients with somatization conversion. I do not believe that psychopaths should be identified with the psychoneurotic group, for this would imply that they possess full social and legal competency, that they are capable of handling adequately their own affairs, and that they are earnestly seeking relief from unpleasant symptoms.
