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-
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
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-
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-
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
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
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
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:
Anthony Eden 1955–57
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-
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
neurological episodes, probably vascular in origin, from 1889
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
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
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.,
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
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to the extent they are able to inculcate some of these qualities.
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Pharmaceutical Law & Industry Report® Reproduced with permission from Pharmaceutical Law & Industry Report, 12 PLIR 41, 10/17/2014. Copyright 姝2014 by The Bureau of National Affairs, Inc. (800-372-1033) http://www.bna.com Manufacturing Trouble: Is cGMP the Next Enforcement Frontier? BY EMILY R. SCHULMAN, MICHAEL J. BAYER AND departments are, by now, quite familiar. But many com-panies view cGMP issues through a regulatory prism,
Scoping Review: Evaluations of pre-employment screening practices for child-related work that aim to prevent child sexual abuse Appendices 2 and 3: Data extraction forms for scoping review Parenting Research Centre and the University of Melbourne Commissioned by the Royal Commission into Institutional Responses to Child Sexual Abuse Scoping Review: Evaluations of pre-employment screening practices for child-related work that aim to prevent child sexual abuse