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Brain Advance Access published February 12, 2009
Brain 2009: Page 1 of 11 A JOURNAL OF NEUROLOGY OCCASIONAL PAPERHubris syndrome: An acquired personalitydisorder? A study of US Presidents andUK Prime Ministers over the last 100 years David Owen1 and Jonathan Davidson2 1 House of Lords, London, UK2 Department of Psychiatry and Behavioural Sciences, Duke University Medical Center, Durham, USA Correspondence to: Lord David Owen,House of Lords,SW1A 0PW London, UKE-mail: [email protected] ‘The history of madness is the history of power. Because of behaviour although their words do not adequately capture it imagines power, madness is both impotence and omni- its essence.
potence. It requires power to control it. Threatening the A common thread tying these elements together is hubris, or normal structures of authority, insanity is engaged in an exaggerated pride, overwhelming self-confidence and contempt endless dialogue—a monomaniacal monologue sometimes— for others (Owen, 2006). How may we usefully think about a about power'.
leader who hubristically abuses power, damaging the lives ofothers? Some see it as nothing more than the extreme mani- festation of normal behaviour along a spectrum of narcissism.
A Social History of Madness: Stories of the Insane, Weidenfeld Others simply dismiss hubris as an occupational hazard of pow- & Nicolson, 1987 p. 39 erful leaders, politicians or leaders in business, the military andacademia; an unattractive but understandable aspect of thosewho crave power.
But the matter can be formulated differently so that it becomes appropriate to think of hubris in medical terms. It then becomes Charisma, charm, the ability to inspire, persuasiveness, breadth of necessary first to rule out conditions such as bipolar (manic- vision, willingness to take risks, grandiose aspirations and bold depressive) disorder, in which grandiosity may be a prominent self-confidence—these qualities are often associated with success- feature. From the medical perspective, a number of questions ful leadership. Yet there is another side to this profile, for these other than the practicalities of treatment can be raised. For very same qualities can be marked by impetuosity, a refusal to example can physicians and psychiatrists help in identifying listen to or take advice and a particular form of incompetence features of hubris and contribute to designing legislation, codes when impulsivity, recklessness and frequent inattention to detail of practice and democratic processes to constrain some of its predominate. This can result in disastrous leadership and cause features? Can neuroscientists go further and discover through damage on a large scale. The attendant loss of capacity to make brain imaging and other techniques more about the presenta- rational decisions is perceived by the general public to be more tions of abnormal personality? (Goodman et al., 2007).
than ‘just making a mistake'. While they may use discarded We see the relevance of hubris by virtue of it being a trait or medical or colloquial terms, such as ‘madness' or ‘he's lost it', a propensity towards certain attitudes and behaviours. A certain to describe such behaviour, they instinctively sense a change level of hubris can indicate a shift in the behavioural pattern Received September 29, 2008. Revised December 10, 2008. Accepted January 5, 2009ß The Author (2009). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved.
For Permissions, please email: [email protected] Brain 2009: Page 2 of 11 D. Owen and J. Davidson of a leader who then becomes no longer fully functional in terms Being elected to high office for a democratic leader is a signif- of the powerful office held. First, several characteristics of hubris icant event. Subsequent election victories appear to increase the are easily thought of as adaptive behaviours either in a modified likelihood of hubristic behaviour becoming hubris syndrome.
context or when present with slightly less intensity. The most Facing a crisis situation such as a looming or actual war or illustrative such example is impulsivity, which can be adaptive in facing potential financial disaster may further increase hubris.
certain contexts. More detailed study of powerful leaders is But only the more developed cases of hubris deserve classifica- needed to see whether it is mere impulsivity that leads to tion as a syndrome exposed as an occupational hazard in those haphazard decision making, or whether some become impulsive made vulnerable by circumstance.
because they inhabit a more emotional grandiose and isolatedculture of decision making.
We believe that extreme hubristic behaviour is a syndrome, Hubris syndrome and its constituting a cluster of features (‘symptoms') evoked by a specific trigger (power), and usually remitting when powerfades. ‘Hubris syndrome' is seen as an acquired condition, and Unlike most personality disorders, which appear by early adult- therefore different from most personality disorders which are hood, we view hubris syndrome as developing only after power traditionally seen as persistent throughout adulthood. The key has been held for a period of time, and therefore manifesting concept is that hubris syndrome is a disorder of the posses- at any age. In this regard, it follows a tradition which acknowl- sion of power, particularly power which has been associated edges the existence of pathological personality change, such as with overwhelming success, held for a period of years and with the four types in ICD-10: enduring personality change after minimal constraint on the leader.
trauma, psychiatric illness, chronic pain or unspecified type The ability to make swift decisions, sometimes based on little (ICD-10, 1994)—although ICD-10 implies that these four diag- evidence, is of particular importance—arguably necessary—in a noses are unlikely to improve.
leader. Similarly, a thin-skinned person will not be able to Initially 14 symptoms constituting the hubristic syndrome were stand the process of public scrutiny, attacks by opponents and proposed (Owen, 2006). Now, we have shortened and tabulated back-stabbings from within, without some form of self-exultation these descriptions and mapped their broad affinities with the and grand belief about their own mission and importance.
DSM IV criteria for narcissistic personality disorder, antisocial per- Powerful leaders are a highly selected sample and many criteria sonality disorder and histrionic personality disorder. These three of any syndrome based on hubris are those behaviours by personality disorders also appear in ICD-10, although narcissistic which they are probably selected—they make up the pores of personality disorder is presented in an appendix as a provisional the filter through which such individuals must pass to achieve condition, whose clinical or scientific status is regarded as uncer- high office.
tain. ICD-10 considers narcissistic personality disorder to be suf- Hubris is associated in Greek mythology with Nemesis. The ficiently important to warrant more study, but that it is not yet syndrome, however, develops irrespective of whether the indi- ready for international acceptance. In practice, the correlations vidual's leadership is judged a success or failure; and it is not are less precise than the table suggests and the syndrome better dependent on bad outcomes. For the purpose of clarity, given described by the broader patterns and descriptions that the indi- that these are retrospective judgements, we have determined vidual criteria encapsulate.
that the syndrome is best confined to those who have nohistory of a major depressive illness that could conceivably bea manifestation of bipolar disorder.
Establishing the diagnostic Hubris is acquired, therefore, over a period. The full blown features of hubris syndrome hubris, associated with holding considerable power in highoffice, may or may not be transient. There is a moving scale of The nosology of psychiatric illness depends on traditional cri- hubris and no absolute cut-off in definition or the distinction teria for placing diagnoses in a biomedical framework (Robins from fully functional leadership. External events can influence and Guze, 1970). There are, however, other underpinnings— the variation both in intensity and time of onset.
psychological or sociological—that can be applied. Validity for a Dictators are particularly prone to hubris because there are psychiatric illness involves assessing five phases: (i) clinical descrip- few, if any, constraints on their behaviour. Here, this complex tion; (ii) laboratory studies; (iii) defining boundaries vis-a-vis area is not covered but one of us has considered the matter other disorders; (iv) follow-up study; and (v) family study. While elsewhere (Owen, 2008). Hitler's biographer, Ian Kershaw these phases are worth analysing, it has to be recognized that (1998, 2000), entitled his first volume 1889–1936 Hubris and there are severe limitations in rigidly applying such criteria to the second 1936–1945 Nemesis. Stalin's hubris was not as hubris syndrome given that so few people exercise real power marked or as progressive as Hitler's. As for Mussolini and Mao in any society and the frequency amongst those ‘at-risk' is low.
both had hubris but probably each also had bipolar disorder.
The potential importance of the syndrome derives, however, Khrushchev was diagnosed as having hypomania and there from the extensive damage that can be done by the small is some evidence that Saddam Hussein had bipolar disease number of people who are affected. As an investigative strat- (Owen, 2008).
egy, it may be that studies such as neuroimaging, family Hubris syndrome: an acquired personality disorder? Brain 2009: Page 3 of 11 studies, or careful personality assessments in more accessible sub- To determine whether hubris syndrome can be characterized jects with hubristic qualities or narcissistic personality disorder from biologically will be very difficult. It is the nature of leaders who other vulnerable groups might inform the validation process.
have the syndrome that they are resistant to the very idea thatthey can be ill, for this is a sign of weakness. Rather, they tend tocover up illness and so would be most unlikely to submit vol- Proposed clinical features untarily to any testing, e.g. the completion of scales measuringanxiety, neuroticism and impulsivity. Also the numbers of people Hubris syndrome was formulated as a pattern of behaviour in a with the syndrome is likely to be so small preventing the realistic person who: (i) sees the world as a place for self-glorification application of statistical analyses. It also needs to be remembered through the use of power; (ii) has a tendency to take action pri- that leaders are prone to using performance-enhancing drugs marily to enhance personal image; (iii) shows disproportionate fashionable at the time. Two heads of government, Eden and concern for image and presentation; (iv) exhibits messianic zeal Kennedy, were on amphetamines in the 1950s and 1960s. In and exaltation in speech; (v) conflates self with nation or organi- the 21st century hubristic leaders are likely to be amongst the zation; (vi) uses the royal ‘we' in conversation; (vii) shows exces- first to use the new category of so-called cognition enhancers.
sive self-confidence; (viii) manifestly has contempt for others; Many neuroscientists believe that such drugs properly used can (ix) shows accountability only to a higher court (history or God); be taken without harm. The problem is a leader who takes (x) displays unshakeable belief that they will be vindicated inthat court; (xi) loses contact with reality; (xii) resorts to restless- these without medical supervision and in combination with other ness, recklessness and impulsive actions; (xiii) allows moral rec- substances or in dosages substantially above those that are recom- titude to obviate consideration of practicality, cost or outcome; mended. In 2008, Nature carried out an informal survey of its and (xiv) displays incompetence with disregard for nuts and mainly scientific readers and found that one in five of 1400 bolts of policy making.
responders were taking stimulants and wake-promoting agents In defining the clinical features of any disorder, more is required such as methylphenidate and modafinil, or b-blockers for non- than simply listing the symptoms. In the case of hubris syndrome, medical reasons (Maher, 2008).
a context of substantial power is necessary, as well as a certain In defining the boundaries, one of the more important ques- period of time in power—although the length has not been tions may be to understand whether hubris syndrome is essentially specified, varying in the cases described from 1 to 9 years. The the same as narcissistic personality disorder (NPD), a subtype of condition may have predisposing personality characteristics but it NPD or a separate entity. As shown in Table 1, 7 of the 14 pos- is acquired, that is its appearance post-dates the acquisition of sible defining symptoms are also among the criteria for NPD in DSM-IV, and two correspond to those for antisocial personality Establishment of the clinical features should include the demon- and histrionic personality disorders (APD and HPD, respectively) stration of criterion reliability, exploration of a preferred threshold (American Psychiatric Association, 2000). The five remaining for the minimum number of features that must be present, and symptoms are unique, in the sense they have not been classified the measurement of symptoms (e.g. their presence or absence, elsewhere: (v) conflation of self with the nation or organization; and a severity scale). This endeavour may also include a decision (vi) use of the royal ‘we'; (x) an unshakable belief that a higher as to whether the 14 criteria suggested might usefully be revised.
court (history or God) will provide vindication; (xii) restlessness, Table 1 The symptoms of hubris syndrome Proposed criteria for hubris syndrome, and their correspondence to features of cluster B personality disorders in DSM-IV 1. A narcissistic propensity to see their world primarily as an arena in which to exercise power and seek glory; NPD.62. A predisposition to take actions which seem likely to cast the individual in a good light—i.e. in order to enhance image; NPD.13. A disproportionate concern with image and presentation; NPD.34. A messianic manner of talking about current activities and a tendency to exaltation; NPD.25. An identification with the nation, or organization to the extent that the individual regards his/her outlook and interests as identical; (unique)6. A tendency to speak in the third person or use the royal ‘we'; (unique)7. Excessive confidence in the individual's own judgement and contempt for the advice or criticism of others; NPD.98. Exaggerated self-belief, bordering on a sense of omnipotence, in what they personally can achieve; NPD.1 and 2 combined9. A belief that rather than being accountable to the mundane court of colleagues or public opinion, the court to which they answer is: History or God; NPD.3 10. An unshakable belief that in that court they will be vindicated; (unique)11. Loss of contact with reality; often associated with progressive isolation; APD 3 and 512. Restlessness, recklessness and impulsiveness; (unique)13. A tendency to allow their ‘broad vision', about the moral rectitude of a proposed course, to obviate the need to consider practicality, cost or outcomes; (unique) 14. Hubristic incompetence, where things go wrong because too much self-confidence has led the leader not to worry about the nuts and bolts of policy; HPD.5 APD = Anti-Social Personality Disorder; HPD = Histrionic Personality Disorder; NPD = Narcissistic Personality Disorder.
Brain 2009: Page 4 of 11 D. Owen and J. Davidson recklessness and impulsiveness; and (xiii) moral rectitude that financial collapse of 2008 some leading international bankers overrides practicalities, cost and outcome.
also displayed marked signs of hubris.
In making the diagnosis of hubris syndrome we suggest that A review of biographical sources of mental illness in US 3 of the 14 defining symptoms should be present of which Presidents between 1776 and 1974 (Davidson et al., 2006) at least one must be amongst the five components identified showed that 18 (49%) Presidents met criteria suggesting psy- chiatric disorder: depression (24%), anxiety (8%), bipolar disor-der (8%) and alcohol abuse/dependence (8%) were the mostcommon. In 10 instances (27%) a disorder was evident during Heads of Government in the presidential office, which in most cases probably impaired job US and UK over the last performance. The overall (49%) rate of psychiatric disorder wasin tune with US population rates of mental illness, but the rate of depression was greater than expected in males, which hasbeen reported as 13% in the US population (Kessler et al., 1994).
Both of us have written elsewhere in detail about the health of It can be argued that Heads of Government might be expected heads of government (Owen, 2006, 2008a, b; Davidson et al., to have a lower incidence of mental illness than the general pop- 2006). Partly as a consequence, the examples of hubris we ulation, reflecting the robust personality of people who are pre- describe are drawn from the US Presidents and UK Prime pared to run for the highest political office in the two countries Ministers in office over the last 100 years; but also it is because and therefore whether depression is a consequence of holding there are far more extensive biographical sources for Heads of office. Also many Heads of Government display hubristic traits Government than for other categories of leaders. We emphasize which are difficult to quantify but do not, in our view, add up that hubris syndrome can affect anyone endowed with power, to the full hubris syndrome. We list those US Presidents and UK and examples have been quoted by others amongst business Prime Ministers whose hubristic traits were the most obvious leaders (Schwartz, 1991; Maccoby, 2000) artists and religious (Table 2 and 3). We ascribe hubris syndrome definitively only to gurus (Storr, 1997). The world has recently seen that in the a few of these leaders, in part because we are wary of making Table 2 Hubris syndrome amongst the 18 US Presidents in office since 1908 Related illnesses Impairment evident to others orsought treatment Theodore Roosevelt 1901–09 Woodrow Wilson 1913–21 Major depressive disorderPersonality change due Franklin D. Roosevelt 1933–45 John F. Kennedy 1961–63 Addison's disease Amphetamine abuse Lyndon B. Johnson 1963–69 Bipolar 1 disorder Richard Nixon 1969–74 George W. Bush 2001–09 History of alcohol-related problems ? uncertain - probable.
Table 3 Hubris syndrome amongst the 26 UK Prime Ministers in office since 1908 Related illnesses to hubris Impairment evident to othersTreatment sought Herbert Asquith 1908–16 David Lloyd George 1916–22 Neville Chamberlain 1937–40 Winston Churchill 1940–45, 1951–55 Major depressive disorder: cyclothymic features Anthony Eden 1955–57 Amphetamine abuse Margaret Thatcher 1979–90 Tony Blair 1997–2007 Hubris syndrome: an acquired personality disorder? Brain 2009: Page 5 of 11 the diagnosis of hubris syndrome where there is evidence of views and rigid in his thinking (Park, 1986). His vehemently bipolar disorder, as for example with Theodore Roosevelt and autocratic ways gave rise to much concern in members of both Lyndon Johnson. Where there are other illnesses, which could parties and by 1918, Wilson was acting ‘to enhance his author- complicate the diagnosis, such as Woodrow Wilson's cerebro- ity and to exercise it without any restrictions' (George and vascular deterioration and Richard Nixon's alcoholic abuse, we George, 1965). All of this occurred before his severe hemiplegia signify a probable hubris syndrome with question marks in developed in September 1919 accompanied by neglect, but still within the context of growing dementia.
There is little evidence of progression in Theodore Roosevelt's In 1937, Franklin Roosevelt came close to being taken over by hubristic traits during his time as President, although they were hubris when he fought and lost a battle with Congress over the ever present throughout his life. It is relevant in determining that Judicial Branch Reorganization Plan, affecting the nomination of he did not develop hubris syndrome that he kept his promise to Justices to the Supreme Court. Raymond Moley, in describing the electors not to stand for a second term. However, the fact Roosevelt, whom he knew well, said, ‘He [Roosevelt] devel- that he took the controversial step of running on a third party oped a very special method of reassuring himself of his own pre- ticket in 1912, thereby splitting the Republican vote and hand- conceptions . . Ultimately, of course, a man closed off by ing the presidency to Woodrow Wilson is a sign that he was one means or another from free opinion and advice suffers a still hubristic out of office and indeed to the end of his life.
kind of mental intoxication' (Moley, 1986) Fortunately, he had In their book, Manic-depressive Illness, Goodwin and Jamison a sense of humour and a certain cynicism which meant that wrote ‘the hypomanic lifestyle of Roosevelt has been detailed by he never lost his firm moorings in the democratic system biographer Pringle (1931). As President of the US and as adven- (Owen, 2008).
turer, Roosevelt lived at an extraordinarily high level of energy Kennedy displayed occasional hubris, particularly during the and was frequently grandiose, elated, restless, overtalkative and Bay of Pigs fiasco in 1961. One of Kennedy's advisers on Latin inordinately enthusiastic. He functioned with very few hours of America, Richard Goodwin, described the atmosphere at these sleep and wrote, administered or explored ceaselessly. It is esti- meetings on whether to invade Cuba: ‘Beneath the uninformed mated that Roosevelt wrote more than 150 000 letters in his acquiescence, there was also arrogance—the unacknowledged, lifetime, and a phenomenal number of books. Although he, on unspoken belief that we could understand, even predict, the occasion, became mildly depressed, he could best be described elusive, often surprising, always conjectural course of historical change' (Goodwin, 1988). Kennedy's hubris was in part related Another revealing comment on Roosevelt claims that the cavalry to his use of recreational drugs, amphetamine and bizarre levels regiment which he commanded in the Spanish–American War of cortisone, which in a properly prescribed dose he had to take sustained ‘incredibly high' casualties as compared to the other for his Addison's disease. Kennedy was almost certainly given five regiments taking part, putting this down to his ‘reckless an intravenous injection of amphetamine, perhaps with addi- inefficiency' (Fieve, 1997). The most recent assessment judges tional cortisone, just prior to a meeting with the Russian leader, that Theodore Roosevelt suffered from bipolar 1 disorder Khrushchev, in Vienna in June 1961 and this very likely explains (Davidson et al., 2006).
his poor performance at the meeting. Fortunately, by the Cuban Woodrow Wilson had such a complicated medical history that Missile Crisis in October 1962 his medication was under far better it is hard to disentangle. He had pre-existing chronic anxiety control and he showed a steadiness that made a significant and depressive problems from early adulthood, then developed potential nuclear neurological episodes, probably vascular in origin, from 1889 (Owen, 2008).
onwards. Hypertension increased but these multiple health Lyndon Johnson is an example of a leader who had severe problems did not initially interfere with his competency in office, depression and a family history suggestive of bipolar disorder.
and his first years as President are widely judged to have been His megalomania is thought to have been bipolar, but it could successful. He took the US into the First World War in 1917 have been hubristic or both (Davidson et al., 2006; Owen, 2008).
with less difficulty than Roosevelt encountered in 1940. Yet by Richard Nixon began to behave evermore hubristically in the the Paris Peace Conference, he was described by Park as being run up to the election over the summer and autumn of 1972 secretive, defensive, indiscreet in his criticism of others, petulant, when it became very likely that he would win a second term.
acerbic and paranoid (Park, 1986) and by Weinstein as being Nixon in fact won 49 of the 50 states. But he soon revealed ‘increasingly egocentric, suspicious and secretive and less dis- hubris and paranoia. Newly released recordings by the national creet in references to people' (Weinstein, 1988). Additionally, by archives reveal Nixon telling Henry Kissinger, on 14 December late 1918, his memory was failing. To the French Prime Minister, 1972, ‘Never forget, the press is the enemy. The establishment a medical doctor, Georges Clemenceau, Wilson was mentally is the enemy. The professors are the enemy' (Nixon Library, run afflicted and suffered from ‘religious neurosis' and in Europe it by the National Archives, on 2 December 2008 released tape was felt that Wilson talked to the conference like Jesus Christ.
recordings and 90 000 pages of documents.). Depression, drink By this stage, he was showing features of dementia which may and hubris all played their part in his illegal involvement in the have intensified his hubristic traits. Yet, there seemed to be a cover up of the burglary of the Democratic HQ in Washington, progression in his hubris which leads us to question whether the so-called Watergate scandal. In the play by Peter Morgan, he had hubris syndrome. Park noted that by early 1917, Wilson Frost/Nixon, the author has one of his characters describe was becoming stubbornly self-righteous, extremely certain in his Nixon: ‘Aeschylus and his Greek contemporaries believed that Brain 2009: Page 6 of 11 D. Owen and J. Davidson the gods begrudged human success and would send a curse Lloyd George was less constrained after winning the 1918 of ‘‘hubris'' on a person at the height of their powers, a loss election and began to develop hubris syndrome. He pulled more of sanity that would eventually bring about their downfall.
and more power into No. 10 and, in 1920, Winston Churchill Nowadays we give the Gods less credit. We prefer to call it wrote that he was virtually running the Foreign Office. Lord self destruction' (Peter Morgan, 2006).
Beaverbrook, who strongly supported Lloyd George as a war George W. Bush developed hubris syndrome after only a little leader, wrote a devastating account of his presidential style in more than 2 years in office. He was, however, operating in the 1921–22, ‘The Greeks told us of a man in high position, self very exceptional political climate set by the 9/11 terrorist attack confident, so successful as to be overpowering to others. Then on the Twin Towers in New York. After Afghanistan he decided his virtues turned to failings. He committed the crime of arro- to invade Iraq. His appearance in flying gear on the aircraft gance. His structure of self-confidence and success came tumbling carrier, Abraham Lincoln, cruising off the coast of California, on down' (Beaverbrook, 1963).
1 May 2003, and then speaking on television with the slogan Lloyd George who, by common consent, earned the accolade ‘Mission Accomplished' emblazoned on the ship control tower as ‘The Man who won the War' ended his period in office with behind him, marked the highest point in his scale of hubris.
Lord Morgan, an admirer, writing in his book covering the years This episode is particularly interesting when one considers 1921–22 of ‘the dangers of Caesarism . . intuitive, erratic diplo- that the so-called success in Baghdad was only 10 days later macy and confused, ill-prepared encounters', how he seemed described in a memo to Prime Minister Blair by the then British ‘a desperate man' and that this underlined his ‘temporary physi- Ambassador to Iraq, John Sawers, as involving a complete absence cal breakdown' (Morgan, 1979).
of any serious planning for the aftermath of the taking of Neville Chamberlain developed hubris syndrome in the sum- mer of 1938 only a year after taking office, although he had Baghdad: ‘No leadership, no strategy, no coordination, no struc- been covering for the Prime Minister Stanley Baldwin, who was ture and inaccessible to ordinary Iraqis' (Owen, 2008).
depressed, since the summer of 1936 (Self, 2006). Over Munich, Of the 18 US Presidents during this 100 year period, some the first of the so-called summit meetings of heads of gov- personalities were widely judged to be non-hubristic and with- ernment in September 1938, Chamberlain's conduct has been out substantial pathology, in particular Harry Truman, Dwight heavily criticized ‘More dangerous still was the idealism (and hubris) of a politician who believed he could bring peace to Alzheimer's was not evident when he was examined in the Europe'. After Munich, Chamberlain admitted to his sister that Mayo Clinic in the summer of 1990, a year after he left he had come nearer to a nervous breakdown ‘than I have ever office (Owen, 2008).
been in my life' (Reynolds, 2007). His mood on arrival back in Among British Prime Ministers, Asquith had hubristic traits but England was exultant, even triumphalist. He had personalized not hubris syndrome and these traits were overlaid by his alco- power into No. 10 acting with only a small group of Cabinet holic intake. In April 1911, his doctor warned him to substantially Ministers who agreed with him and marginalizing the rest.
reduce his alcohol intake and some claim that henceforward he Some psychiatrists believe that Winston Churchill had bipolar did so (Owen, 2008). But in October 1911, after having lunch disorder. On balance what some see as manic behaviour, or with Asquith, Constance Battersea, an old friend, wrote to her crazy exultation, we see as hubristic traits and perhaps hypo- sister ‘the PM kind, extremely cordial, but how he is changed! mania and we are content to apply no diagnosis beyond that Red and bloated – quite different from what he used to be. He of his undoubted periodic depressions. The older he became the gave me a shock. They all talk of his overeating and drinking too more he was affected by vascular dementia and excessive alco- much. I am afraid there is no doubt about it' (Clifford, 2003). He hol but there was no progression to hubris syndrome.
was warned to reduce his drinking by his doctor and this he did, Anthony Eden's undoubted use of dextro-amphetamine com- but not completely. In September 1916, Field Marshal Sir Douglas bined in the same tablet with amylobarbitone (in those days Haig wrote to his wife after Asquith had visited his HQ in France: called Drinamyl) explains some of his hubristic traits in the run ‘The PM seemed to like our old brandy. He had a couple of up to the Suez Crisis. During the crisis he was variously described glasses (big sherry glass size!) before I left the table at 9.30 as being in a state of what you might call ‘exaltation' or ‘like a and apparently he had several more before I saw him again.
prophet inspired' or ‘very jumpy, very nervy, very wrought' By that time his legs were unsteady, but his head was quite (Owen, 2008). Quite coincidentally his cholangitis, the result of clear and he was able to read the map and discuss the situation the accidental cutting of his bile duct during a routine cholecys- tectomy in 1953, flared up and in October 1956 he developed David Lloyd George ran an effective War Cabinet on becoming a temperature of 106F, 9 days prior to the crucial decision Prime Minister in 1916 and showed exceptional leadership. He to collude with Israel and France over the invasion of the Suez was the only Liberal in that War Cabinet and he worked with three Conservative politicians and one Labour MP in a consensual Margaret Thatcher, we judge, did not develop hubris syndrome leadership. He was helped in curbing his hubristic tendencies until 1988, 9 years after becoming Prime Minister. But some by his close relationship with the skeptical Conservative MP, believe she was hubristic throughout her period in office. Yet for Bonar Law, who was Chancellor of the Exchequer and the two her first two terms she relied on the wise counsel of Willie discussed difficult issues most days with the Prime Minister going Whitelaw and this probably helped contain her hubristic traits across from No. 10 to No. 11 Downing Street.
as had Bonar Law's relationship during the war years with Hubris syndrome: an acquired personality disorder? Brain 2009: Page 7 of 11 Lloyd George. The evidence is that she was cautious and con- It is too early to make a judgement on whether Gordon Brown trolled during the Falklands War of 1982, despite saying to the will develop hubris syndrome as Prime Minister. It is worth recal- press ‘Rejoice, rejoice' after the taking back of South Georgia ling however, that on 20 June 2007, 7 days before becoming Island. Over this it can be argued she was entitled to feel relieved Prime Minister, he talked of ‘the beginning of a new golden age after what could have been a disaster. Also she prudently did not for the City of London'. Having boasted for some time of ending use her new trade union legislation during the 1984–85 miners ‘boom and bust' in this speech he claimed that out of the first strike. After her third General Election victory in 1987, she tried to decade of the 21st Century, ‘the greatest restructuring of the impose the unpopular poll tax. She saw German reunification in global economy, perhaps even greater than the industrial revolu- 1989 in cataclysmic terms as a potential Fourth Reich and told tion, a new world order was created'. Within months banks were George Bush Sr ‘if we are not careful the Germans will get in being nationalized or bailed out and the world faced its worst peace what Hitler couldn't get in the war' (Bush and Scowcroft, economic crisis for more than 70 years.
1998). She also began to refer to herself in the third person ‘We Of the 26 British Prime Ministers in the last 100 years, a number have become a grandmother'. By 1990 her own party's MPs showed little tendency to hubris or excessive narcissism—in par- forced her to resign after displaying raw hubris in her handling ticular—Campbell-Bannerman, Clement Attlee, Harold Macmillan, of the European Union and bawling in the House of Commons, Alec Douglas-Home, James Callaghan and John Major—although ‘No, no, no' (Young, 1998).
less confidence can be placed on the judgement of some others, Tony Blair's hubris syndrome started to develop over NATO's including Stanley Baldwin.
bombing of Kosovo in 1999, 2 years after coming into office.
General conclusions drawn from such a small sample of Heads At one stage President Clinton angrily told Blair to ‘pull himself of Government in the US and UK have to be treated with caution.
together' and halt ‘domestic grandstanding'. He was starting to It is worth noting, however, that hubris seems to manifest itself display excessive pride in his own judgements. One of Clinton's most in areas of policy where the leader feels they have their aides mocked Blair's ‘Churchillian tone' and one of his officials, greatest expertise. Also that non-hubristic decision making does who frequently saw Blair said of him, ‘Tony is doing too much, not seem confined to those leaders who had, in relative terms, he's overdoing it and he's overplaying his hand'. Another of a quiet time in office; for example Truman and Attlee took highly Clinton's staff accused Blair of ‘sprinkling too much adrenalin on influential and controversial decisions at home and abroad while his cornflakes' (Owen, 2008) and it is noticeable how often this being amongst the least hubristic of leaders.
hormone, called epinephrine in the US, and secreted by the Finally, while there is some patchy evidence of pre-morbid adrenal gland is referred to when lay people discuss manic or personalities, it must be remembered that all these leaders held hubristic behaviour. After the dramatic collapse of the Twin high, if not always the highest, office after winning elections Towers in New York on 11 September 2001, Blair responded within the democratic process and were judged by those electo- with hyperactive travel and hyperbolic speeches. The historian, rates as being fit to hold that office.
Lord Morgan, described him speaking to the Labour PartyConference: ‘He seemed a political Colossus, half Caesar, halfMessiah'. Bush and Blair's religious fervour coincided over Iraq.
Relationship between hubris In 2006 on television, Blair said over Iraq: ‘If you have faith syndrome and narcissistic about these things then you realize that judgement is madeby other people. If you believe in God, it's made by God as personality disorder well'. The historian, David Reynolds, brought the issue of hubristo the fore when he wrote about Chamberlain and compared We do not know the exact relationship between hubris syndrome him to Blair: ‘A well intentioned leader convinced of his own and narcissistic personality disorder, which itself has been some- rightness, whose confidence in his powers of persuasion bordered what neglected. However, a number of recent studies shed light on hubris. Who squeezed out critical professional advice con- on narcissistic personality disorder in ways that are relevant.
trolling policy and information from an inner circle'. He went One study (Ronningstam et al., 1995) found that narcissistic on to say, ‘For all their differences, Tony Blair's approach to personality disorder itself is surprisingly transient, with only summitry had a good deal in common with that of Neville 46–50% of cases retaining the diagnosis at 3 year follow-up.
Chamberlain' (Reynolds, 2007).
Pertinent to our notion of hubris syndrome as an acquired disor- Blair was accused of being ‘disingenuous', a word that just der, Ronningstam and colleagues found that 4 of 20 patients avoids the parliamentary ban on calling someone a liar, over his failed to meet operational criteria for narcissistic personality dis- handling of the intelligence on Iraq by the former Cabinet order at baseline, but acquired this diagnosis at follow-up. The Secretary, Lord Butler, in the House of Lords on 22 February authors conclude that serious questions remain about the con- 2007. This was some time after the publication of the Report of struct validity of narcissistic personality disorder as a diagnostic the Committee Lord Butler had chaired. Blair, he said, had been told by the intelligence community in August 2002 ‘we know A large epidemiological study has reached several interesting little about Iraq's chemical and biological weapons work since conclusions (Stinson et al., 2008). The study observed a 6.2% late 1988'. Yet just over a month later, he was claiming to lifetime prevalence of narcissistic personality disorder, which was Parliament that the picture painted by the intelligence services higher in men (7.7%) than women (4.8%). Elevated rates of was ‘extensive, detailed and authoritative'.
Brain 2009: Page 8 of 11 D. Owen and J. Davidson disorder suggest that an important part of assessing narcissistic responses following challenge by meta-chlorophenylpiperazine personality disorder is the identification of features, which distin- (m-CPP), a partial serotonin agonist (Pallanti et al., 2006); and, guish the two conditions, as well as recognizing their possible at least in males, is associated with a variant in the promoter co-occurrence. The authors also comment on the transience of region of the serotonin transporter gene and the monoamine this supposedly enduring condition and its potential influence by oxidase A gene (Perez de Castro et al., 1999; 2002). In a study value systems and cultural factors. They speak to the possibility of by Comings et al. (2001), significant associations were found a context-dependent form of narcissistic personality disorder and between pathological gambling and genes for the D2 and D4, urge further long term, epidemiological, clinical and genetic studies dopamine transporter, tryptophan hydroxylase and the 2c adre- to identify unique and common factors for narcissistic personal- nergic receptors, with the dopamine, serotonin and norepinephrine ity disorder relative to neighbouring disorders. From a similar genes each accounting for 52% of the variance. Serotonin is also approach, we might learn whether hubris syndrome is one involved in the regulation of decision making and processing (acquired) form of narcissistic personality disorder.
punishment-related information (Blair et al., 2008), deficiencies A principal components analysis has shown that narcissistic of which could be relevant to hubris syndrome. As the authors personality disorder can be distinguished from other closely related put it, the 5HT transporter may be more integral to ‘choosing the cluster B personality disorders by its association with ‘disorderli- lesser of two evils' than to ‘choosing the better of two goods'.
ness', which we see as comparable to the lack of attention to As hubris syndrome becomes more widely recognized, and its detail criterion in hubris syndrome. Also, those with narcissistic biology better understood, it may be that psychiatrists and neu- personality disorder are most likely to express aggression when roscientists will discover a way of treating some of its more their low frustration tolerance causes irritability (Fossati et al., damaging features.
2007). Three subtypes of narcissistic personality disorder have Recent work has directed attention to the importance of been labelled: grandiose/malignant, fragile and high functioning/ ventromedial prefrontal (vmPFC) and insular cortical regions in exhibitionistic (Russ et al., 2008).
underpinning accurate risk appraisal and decision making and,for the insular cortex, proper awareness of aversive consequences(Paulus and Stein, 2006; Clark et al., 2008). Subjects with lesions Neurobiology of hubris of these areas were prone to more risky decision making; therewas misplaced confidence in the correctness of their decisions (Clark et al., 2008). Interestingly, the administration of 40 mgmethylphenidate normalized decision-making in a small sample Neuroimaging studies of cluster B personality disorders have (n = 8) of patients with the frontal variant of fronto-temporal dementia, who become less risk-taking in their behaviour (Goodman, 2007). To the extent that they provide information (Rahman et al., 2006). These findings would seem relevant to about cortical and amygdala dysregulation in this particular per- the neurobiology of Hubris Syndrome as a condition in which sonality cluster, they might be of some relevance to narcissistic undue confidence leads to (i) impaired risk appraisal; (ii) inability personality disorder, but what is needed are imaging studies to foresee undesirable outcomes; and (iii) dangerous decision- specifically of narcissistic personality.
making and much harm to others.
Next to nothing is known about the neurobiology of hubris per se, and it is beyond the scope of this report to give acomprehensive neurobiological review, but to the extent that Comorbidity and classification hubris syndrome shares common elements with narcissistic andsociopathic disorders, e.g. impaired decision-making, poor impulse The comorbidity of narcissistic personality disorder, and perhaps control, poor modulation of aggression, lack of appropriate hubris syndrome, with other personality disorders such as histrio- empathy, the findings of altered dopaminergic, noradrenergic nic, borderline and sociopathic disorders presents a real problem.
and serotonergic function in these conditions could all be rele- In the DSM-IV field trials, for example it proved extremely difficult vant. For example Cools (2008) has identified frontostriatal and to find patients who had narcissistic personality disorder without limbic-striatal dopaminergic pathways as important regulators of other personality disorders (Gunderson et al., 1996). Our knowl- impulsive and/or rigid behaviours, which may reflect deficient edge of narcissistic personality disorder lags considerably behind motivational or cognitive control. Interpretation of the findings, other personality disorders. In the emerging literature and the however, can be complicated. For example a dopamine agonist debate about narcissistic personality disorder it is clear that there (bromocriptine) has varying effects on cognitive processing which may be more forms of the disorder and hubris syndrome may be are determined by baseline impulsivity, brain region and the type but one of them. We have defined the disorder as likely to remit of cognitive function (updating versus distraction) being exam- once power has been lost, although outcome seems to be related ined (Cools et al., 2007). The role of other neurotransmitters, to the length of time in power. Ideally, follow up should assess such as norepinephrine and serotonin, also bears further exam- naturalistic outcome as well as outcome after interventions of ination. Pathological gambling shares some of the features of different kinds but once again small sample size will present hubris syndrome, such as impairment in risk appraisal and conse- difficulties. The studies referred to above already suggest that quent decision making. Neurobiologically, pathological gambling forms of narcissistic personality disorder can remit, as well as is characterized by abnormal behavioural and neuroendocrine arise de novo in adult life. It is not far-fetched, therefore, Hubris syndrome: an acquired personality disorder? Brain 2009: Page 9 of 11 to postulate that hubris syndrome is both acquired and likely to family difficulties. However, as the evidence grows for effective abate once the context of power has changed, but that is hard to psychological treatment of personality disorders, it is conceivable prove since we often know little about the lives of leaders once that individuals with hubris syndrome, narcissistic personality they cease to hold office. We can for the moment only assume disorder or other related conditions, might be more willing to that hubris syndrome shares the qualities of transience and influ- receive help, knowing that they could receive greater and more ence by value systems that have been identified in reports on sympathetic benefit than in the past.
narcissistic personality disorder. Ideally longitudinal study could The more likely dividend from improved societal awareness also examine the degree to which hubristic traits appear in subjects of hubris is that, as expectations change, leaders in all walks who, before achieving success, did not manifest any such features.
of life may feel a much greater obligation to accept and not For example might someone with obsessive personality traits but resist society's prescribed course of democratic constraint, accept few narcissistic, histrionic or sociopathic features develop hubris statutory term constraints such as the 8 years on a US President and, when alerted to their behaviour, step down voluntarily from If hubris syndrome, or traits of hubris, run in families, this would office or not seek re-election and reappointment as leader. In tend to support the existence of the syndrome, or point to pos- some ways the non-executive members of Boards monitor the sible comorbidity associations. Genetic linkage studies, however, Presidents or Chief Executives of large companies better than either use twins or depend on fairly large numbers, and either Cabinets monitor Heads of Government. If faced by early signs strategy is offset by the small sample available for study.
of hubris the independent directors can insist on discussing the Robins and Guze's five phase process is intended to be ongoing issue and even introduce a mentoring process. Strategies for and subject to self-rectification. Whether such an approach would managing hubris among corporate executives have been outlined ultimately validate hubris syndrome as a separate psychiatric diag- (Maccoby, 2000). In the case of military leaders there is often nosis, or whether it could emerge as a subtype of narcissistic per- a forum for monitoring the Chiefs of the Defence Staff and polit- sonality disorder does not really matter. If the former, then it will ical accountability. President Truman's firing of General Douglas give an important insight into the nature of power; if the latter, MacArthur for insubordination is a good example of a military then the mapping of hubris syndrome would be a significant chief being cut down to size for hubris. The prison sentences for contribution to a fuller understanding of pathological narcissism.
some of the leaders of Enron appear to be in part an example Either way recognition of the syndrome will help in that the for others. We have yet to see what, if any, penalties will be general public will be alerted to the danger of hubris. Yet another imposed on the hubristic behaviour of financial leaders after possibility is that hubris syndrome may represent the manifesta- the crisis of 2008.
tion of a bipolar diathesis, in which the disorder appears later in Because a political leader intoxicated by power can have devas- life perhaps in those with hyperthymic temperament and pre- tating effects on many people, there is a particular need to create cipitated by the peculiar conditions of power, great success and a climate of opinion that political leaders should be held more stress, and carrying lower genetic risk than early onset bipolar accountable for their actions. The most important constraint on disorder. It is not always easy to sort out whether megalomaniacal a Head of Government is fear of not being able to win re-election.
behaviour takes its origins in hubris or in bipolar disorder.
Another is fixed-term limits, such as the two 4-year terms for US A slightly more radical idea is that hubris syndrome is not Presidents. Cabinets, which are appointed by the Head of an Axis II disorder (of personality) but an Axis I disorder, in that Government, have not been very successful in constraining it has an environmental onset, akin to a stressful experience, hubris syndrome, in part because they owe their appointment to and that it ultimately disappears in response to environmental the Head of Government, also because they find it difficult to change. In this sense, it resembles an adjustment disorder, albeit detect the development of hubris. Single resignations of members one which is malignant in its effects on others. However, adjust- of the Cabinet have often been important triggers for alerting ment disorder has become something of a waste-bin, or, as people to what is going on behind closed doors. In the US, a described by Casey and colleagues as a ‘fault line in the psychi- threat of impeachment is a constraint and in the UK a withdrawal atric glossary' (Casey et al., 2001); and, as far as the research of support by Members of Parliament has been a crucial element community is concerned, it generates little interest. Rightly or in forcing all the four Prime Ministers, Lloyd George, Chamberlain, wrongly, adjustment disorder is almost always pre-empted by Thatcher and Blair—diagnosed here as having hubris syndrome— other diagnoses, in part because of the ways in which DSM and to resign. Parliamentary revolts would not have happened if ICD define these other conditions.
Thatcher and Blair had only stayed 8 years in office.
Hubris syndrome in politicians is a greater threat than conven- tional illness to the quality of their leadership and the proper gov- Is hubris syndrome treatable? ernment of our world. Strategies for identifying and constraininghubris have been suggested (Storr, 1997; Hillman, 1999; Owen, Even if the existence of hubris syndrome is established and it 2008). Qualities protective against disproportionate hubris, like receives strong diagnostic support, it cannot be assumed that humour and cynicism are worth mentioning. But nothing can this of itself will lead to effective treatments. It is unlikely that replace the need for self-control, the preservation of modesty hubristic individuals will seek psychological or biomedical treat- while in power, the ability to be laughed at, and the ability to ment for their hubris, although they may accept help for com- listen to those who are in a position to advise. Another important plications such as depression, alcohol-related problems or related safeguard comes from the practice of devoted concern to the Brain 2009: Page 10 of 11 D. Owen and J. Davidson needs of individuals and not simply to the greater cause (Storr, Blair KS, Finger E, Marsh AA, Morton J, Mondillo K, Buzas B, et al.
1997; Hillman, 1999). Efforts at rehabilitation may be successful The role of 5-HTTLPR in choosing the lesser of two evils, the betterof two goods: examining the impact of 5-HTTLPR genotype and to the extent they are able to inculcate some of these qualities.
tryptophan depletion in object choice. Psychopharmacol 2008; 196: Neustadt (1964) has argued that a governed people's view of a leader's effectiveness is typically determined by what is happen- Bush GW, Scowcroft B. A world transformed. New York: Alfred A Knopf; ing to them during the leader's term of office. Park goes on to say 1998. p. 249.
that there is something missing in this assessment: it is equally Casey P, Dowrick C, Wilkinson G. Adjustment disorders. Fault line in the psychiatric glossary. Br J Psychiatry 2001; 179: 479–81.
necessary that public perception of a leader should also include Clark L, Bechara A, Damasio H, Aitken MRF, Sahakina BJ, Robbins TW.
an awareness of what is happening to him (Park, 1986). We Differential effects of insular and ventromedial prefrontal cortex lesions would include hubris syndrome as one of the possible pitfalls.
on risky decision-making. Brain 2008; 131: 1311–22.
Clifford C. The Asquiths. London: John Murray; 2003. p. 186.
Comings DE, Gade-Andavolu R, Gonzalez N, Wu S, Muhleman D, Caveats and limitations Blake H, et al. The additive effects of neurotransmitter genes in patho-logical gambling. Clin Genet 2001; 60: 107–16.
Cools R, Sheridan M, Jacobs E, D'Esposito M. Impulsive personality pre- Since DSM-I was published in 1952, with a listing of 106 mental dicts dopamine-dependent changes in frontostriatal activity during disorders, the number has climbed remorselessly to 182 in DSM-II component processes of working memory. J of Neuroscience 2007; (1968), to 265 in DSM-III (1980), to 292 in DSM-III-R (1987), to 27: 5506–14.
297 in DSM-IV (1994). Is there room for another? Cools R. Role of dopamine in the motivational and cognitive control of behavior. Neuroscientist 2008; 14: 381–95.
Psychiatry trespasses into the world of politics and big business Davidson JRT, Connor KM, Swartz M. Mental Illness in US Presidents at its peril. Some of the pitfalls have been described by Beveridge between 1776 and 1974, A Review of biographical sources. J Nervous (2003) and Wessely (2003), who draw attention to a number of and Mental Disease 2006; 194: 47–51.
problems, including the potential misappropriation and pejorative Fieve RR. Moodswing. Bantam books; 1997.
use of the ‘powerful weapons' of psychiatric terminology. Wessely Fossati A, Barratt ES, Borroni S, Villa D, Grazioli F, Maffei C. Impulsivity, aggressiveness, and DSM-IV personality disorders. Psychiatry Res notes correctly that psychiatric attempts to understand the minds 2007; 149: 157–67.
of famous people have often come to grief and hardly left a good Freud S, Bullitt W. Woodrow Wilson, a psychological study. New impression. There is always the risk of unprovable speculation, as Brunswick: Transaction Publishers; 1999.
for example in the portrait of Woodrow Wilson by Freud and George A, George J. Woodrow Wilson and Colonel House. New York: Bullitt (1999). Psychiatry is on firmer ground in such matters if it Dover Publications; 1965. p. 178.
Goodman M, Triebwasser J, Shah S, New AS. Neuroimaging in person- remains focused on observable facts from reliable sources, instead ality disorders: current concepts, findings and implications. Psychiatric of speculating on reasons for behaviour of the famous, most of Ann 2007; 37: 100–8.
whom have never been seen by those expressing their opinions.
Goodwin FK, Jamison KR. Manic-depressive illness. Oxford: Oxford This leads to another consideration since full medical diagnosis University Press; 1990. p. 359.
traditionally relies upon an encounter between doctor and patient.
Goodwin RN. Remembering America: A voice from the sixties. Boston: Little Brown; 1988. p. 173.
It draws on information from the interview as well as collateral Gunderson J, Ronningstam E, Smith LE. Narcissistic personality disorder.
information. Thus any attempt to identify disorder at a distance In: Widiger TA, Frances AJ, Pincus HA, Ross R, First MB, Davis WW, must be treated with caution. Premature, uncritical, dissemination editors. DSM-IV sourcebook. Vol. 2. Washington, DC: American of labels should be avoided. Therefore, we stress that, while the Psychiatric Association; 1996. p. 754.
recognition of hubris syndrome is important today, it will need Hillman J. The force of character. New York: Ballantine Books; 1999.
further careful evaluation well into the future.
ICD-10. Pocket Guide to the ICD-10 Classification of mental and Finally, it should never be forgotten that in a letter, written on behavioural disorders. Washington, DC: American Psychiatric Press; 5 April 1887 to Mandell Creighton, the author of ‘History of the 1994. p. 235–41.
Papacy during the period of Reformation', Lord Acton wrote Kershaw I. Hitler 1889–1936 Hubris. London: Allen Lane, Penguin Press; something very profound which preceded his famous dictum: Kershaw I. Hitler 1936–1945 Nemesis. London: Allen Lane, Penguin ‘I cannot accept your canon that we are to judge Pope and Press; 2000.
King unlike other men, with a favourable presumption that they Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, did no wrong. If there is any presumption it is the other way Eshleman S, et al. Lifetime and 12-month prevalence of DSM-III-R against the holders of power'. He followed this with ‘Power psychiatric disorders in the United States. Arch Gen Psychiatry 1994; tends to corrupt, and absolute power corrupts absolutely'.
Maccoby M. Narcissistic leaders. Harv Bus Rev 2000; 78: 69–77.
Maher B. Poll results: look who's doping. Nature 2008; 452: 674–5.
Moley R. The impact of illness on world leaders. (quoted in Bert E Park) Philadelphia: University of Pennsylvania Press; 1986. p. 280–1.
Morgan KO. Consensus and disunity: The Lloyd George Coalition American Psychiatric Association. Diagnostic and Statistical Manual Government 1918–1922. Oxford: Clarendon Press; 1979. p. 375, p. 147.
of Mental Disorders, Text Revision. 4th edn. Washington DC: Morgan P. Frost/Nixon. London: Faber & Faber; 2006. p. 4.
American Psychiatric Association; 2000.
Neustadt RE. Presidential power. 4th edn. New York: John Wiley and Lord Beaverbrook. The decline and fall of Lloyd George: and great was Sons; 1964. p. 95.
the fall thereof. London: Collins; 1963. p. 10–11.
Owen D. Hubris and Nemesis in Heads of Government. J R Soc Med Beveridge A. The madness of politics. J Roy Soc Med 2003; 96: 602–4.
2006; 99: 548–51.
Hubris syndrome: an acquired personality disorder? Brain 2009: Page 11 of 11 Owen D. In sickness and in power: illness in heads of government Reynolds D. Summits: six meetings that shaped the twentieth century.
during the last 100 years, London: Methuen and New York: London: Allen Lane; 2007. p. 91.
Praeger; 2008a. p. xxvi–xxvii.
Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: Owen D. Hubris syndrome. Clin Med 2008b; 8: 428–32.
its application to schizophrenia. Am J Psychiatry 1970; 126: 983–7.
Pallanti S, Bernardi S, Quercioli L, De Caria C, Hollander E. Serotonin Ronningstam E, Gunderson J, Lyons M. Changes in pathological dysfunction in pathological gamblers: increased prolactin response narcissism. Am J Psychiatry 1995; 152: 253–7.
to oral m-CPP versus placebo. CNS Spectr 2006; 11: 956–64.
Russ E, Shedler J, Bradley R, Westen D. Refining the construct of Park BE. The impact of illness on world leaders. Philadelphia: University narcissistic personality disorder: Diagnostic criteria and subtypes.
of Pennsylvania Press; 1986. p. 16.
Am J Psychiatry 2008; 165: 1–9.
Pe´rez de Castro I, Iba´n˜ez A, Saiz-Ruiz J, Ferna´ndez-Piqueras J.
Schwartz HS. Narcissism project and corporate decay: the case of Genetic contribution to pathological gambling: possible associa- General Motors. Bus Ethics Qtly 1991; 1.
tion between a functional DNA polymorphism at the serotonin Self R. Neville Chamberlain: a biography. Aldershot: Ashgate; 2006. p. 256.
transporter gene (5-HTT) and affected men. Pharmacogenetics 1999; Stinson FS, Dawson DA, Goldstein RB, Chou SP, Huang B, Smith SM.
9: 397–400.
Prevalence, correlates, disability, and comorbidity of DSM-IV nar- Pe´rez de Castro I, Iba´n˜ez A, Saiz-Ruiz J, Ferna´ndez-Piqueras J. Concurrent cissistic personality disorder: results from the Wave 2 National positive association between pathological gambling and functional Epidemiologic Survey on Alcohol and Related Conditions. J Clin DNA polymorphisms at the MAO-A and the 5-HT transporter genes.
Psychiatry 2008; 69: 1033–45.
Mol Psychiatry 2002; 7: 927–8.
Storr A. Feet of clay: a study of gurus. London: Harper-Collins; 1997.
Porter R. A social history of madness: stories of the insane. London: Young H. This blessed plot: Britain and Europe from Churchill to Blair.
Weidenfeld & Nicolson; 1987. p. 39.
London: Macmillan; 1998. p. 368.
Paulus MP, Stein MB. An insular view of anxiety. Biol Psychiatry 2006; Weinstein EA. Woodrow Wilson's neuropsychological impairment and 60: 383–7.
the Paris peace conference, April 23–May 9, 1919. In: Link AS, Rahman S, Robbins TW, Hodges JR, Mehta MA, Nestor PJ, Clark L, et al.
editor. Papers of Woodrow Wilson. Vol. 58. Princeton, NJ: Princeton Methylphenidate (‘Ritalin') can ameliorate abnormal risk-taking University Press; 1988. p. 630–1.
Wessely S. Commentary: the psychiatry of hubris. J Roy Soc Med 2003; Neuropsychopharmacology 2006; 31: 651–8.
99: 552–3.


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