Wednesday, October 6th, 2010

Speech to the New York Hospital / Cornell Medical Society and Payne Whitney Clinic Psychiatry Grand Round



Download Speech here, includes footnotes/references.

I am well aware that it must be a manifestation of a hubristic trait to seek to define a new medical syndrome some forty years after I have ceased to practice clinical medicine! An article in BRAIN published in May 2009 which I wrote with Jonathan Davidson was entitled “Hubris Syndrome: An Acquired Personality Disorder?”

Hubris syndrome, as described, is inextricably linked to the possession and exercise of power. It tends to fade as power passes away from the individual. Our article stated that we did not “know the exact relationship between hubris syndrome and narcissistic personality disorder”. We were interested in the finding that NPD is surprisingly transient with only 46-50% of cases retaining the diagnosis at follow up and that 4 out of 20 patients were likely to fail to meet the NPD criteria when initially encountered but acquired the diagnosis on follow up.  We noted that others have written about a context–dependent form of NPD, rather more radically we wondered whether hubris syndrome is not an Axis II disorder (of personality) but an Axis I disorder defined as having “an environmental onset akin to a stressful experience, and it ultimately disappears in response to environmental change”.  In part because of all these complex possibilities, when I first began to define hubris syndrome in 2006, I excluded from consideration any of the historical figures who I was assessing if they had an existing Axis I or Axis II disorder and I focused my attention in ascribing hubris syndrome to those who had no apparent psychiatric illness. In particular I excluded from hubris syndrome any history of depression well aware of the difficulty in diagnosing the manic phases of bipolar disorder just from biographies.

The two words – hubris syndrome – were chosen with deliberation and care.  As a word ‘narcissism’ also dates back to Greek mythology but one of the distinctive features of hubris is the extent to which it has been associated with leaders and important decision makers, not just by the ancient Greeks. Another, though less distinguishing element, between the term ‘hubris’ and ‘narcissism’ relates to contempt or diminishment of others.  These are a feature of narcissistic personality disorder as Kernberg made clear in his early description of narcissistic personality disorder, where he mentions it has features of contempt, devaluation, and deprecation of others. But contempt was in Greek mythology a defining element of hubris.  It was the character trait which evoked major criticism and distrust, if for no other reason than that hubristic contempt when exercised by people in power impacts far more than when exercised by people who have little influence. Another factor was that while narcissism undoubtedly exists amongst leaders and important decision makers they would not only not identify with the term, they would hate the term being ascribed to them. Whereas hubris, while not exactly complimentary, would nevertheless not be seen as so insulting or as derogatory.

As for the word ‘syndrome’ it is no more and no less than a collection of symptoms found together more often than they are found apart. The way that the symptoms impact on an individual’s personality might conveniently be covered by the term ‘disorder’ but I do not think it is my place as a lapsed neurologist to assign the term ‘disorder’ to the manifestations of hubris.  Therefore our article in BRAIN settled on the title “Hubris syndrome: An acquired personality disorder?”  Whether eventually the medical profession prefers to label hubristic behaviour as merely an occupational hazard of leaders and important decision makers in all walks of life or removes the question mark and  sees it as a disorder of personality, the serious nature of hubris in leaders cannot be questioned.  Over the centuries it is possible to point to the considerable damage done by the hubristic decisions that leaders have taken.  So much so that those who study hubris whether as physicians, psychologists, philosophers, sociologists or anthropologists, owe it to society to discover more about its causation and prevention.

I doubt hubris syndrome will ever get the attention it deserves if it becomes seen as part of the spectrum of NPD.  Many questions still remain about NPD and these are raised in Elsa Ronningstam’s epilogue to her illuminating book “Identifying and Understanding the Narcissistic  Personality”. She writes “The question remains whether NPD primarily is a self esteem disorder, an affect regulation disorder, a mood or temperament disorder, a cognitive disorder, and/or a combination of some or all of the above.”

The consequences of hubristic behaviour as it moves unchecked from arrogant assertiveness to impetuosity and reckless impulsivity with scant regard for facts or the truth can be profound whoever and whatever is affected by it.  The specific symptoms of hubris syndrome as described in our article in BRAIN are on the one page handout** you can refer to as I speak. As you will see 7 of the 14 defining symptoms are criteria for NPD in DSM-IV.  Two correspond to those for anti social personality disorder (APD). Two for histrionic personality disorder (HPD).  The five remaining symptoms are described as unique to hubris syndrome and are marked as unique and without at least one of which being present the diagnosis must be suspect. The unique symptoms are (5) conflation of self with the nation or organization; (6) use of the royal ‘we’; (10) an unshakeable belief that a higher court, history or God will provide vindication; (12) restlessness, recklessness and impulsiveness and (13) moral rectitude that overrides practicalities, cost and outcomes.

Bertrand Russell’s phrase about ‘intoxication of power’ is a good short summary of hubris syndrome but why do some people become intoxicated while others do not?  Are there identifiable features which ensure some leaders with hubristic traits did not become intoxicated?  One leader, President Franklin Delano Roosevelt, in my judgement the greatest single leader of the 21st Century in any walk of life, fascinates me.  I do not believe he had hubris syndrome but he undoubtedly had many hubristic traits. Yet some of these traits made him a vibrant, charismatic leader. Roosevelt’s speech in Baltimore, a week away from his crushing defeat of President Hoover shows him at his peak as a partisan campaigner.  Standing upright despite his polio and holding his son’s arm, he let rip.  “I am waging a war in this campaign, a frontal attack against the “Four Horsemen” of the present Republican leadership, the horsemen of Destruction, Delay, Deceit, Despair”.  Bold, brash, convincing, despite the recession continuing through the first four years, Roosevelt won 61% of the popular vote for his second term and went on to be the only four-term President.  In the words of Jeff Shesol in his book Supreme Power after the second inauguration, the United States “was now closer to one-party rule than it had been since Reconstruction”.  Then the President in early February 1937 announced publicly that he planned to pack the Supreme Court and was asking Congress, where the Senate contained 76 Democrats, to enlarge the Court to 15. He had every intention of adding six liberals to the bench to stop in one fell swoop the Court’s majority obstructing his New Deal.  Yet on 22 July 1937 the Senate rejected the Court Bill by 70 votes to 20.  Roosevelt’s defeat, so went the perceived wisdom, was easy to explain.  “Why would Roosevelt embrace an idea as preposterous as packing the Court?  Hubris.  What made him think he could get away with it?  Hubris. Why did he refuse to listen to reason? Hubris.  Why did he keep fighting when he had already lost (or won)? Hubris.”

It is amazing that seventy-three years later we have a book that challenges with great perception the perceived wisdom of the day arguing in great detail that hubris “alone is an insufficient answer to the question of what went wrong”….”it was not a choice that Roosevelt made impulsively. It may have been driven – to a dangerous degree – by ego and emotion, but it was also the product of reason. It may have been wrong, but it was not rash. Neither was it made in a vacuum.  By the time of Roosevelt’s second inauguration, there was a growing national consensus that something had to be done about the Court – that either Congress or, more likely, the President would have to end the impasse.”

Roosevelt’s temperament was assessed by his wife, Eleanor. “You made up your mind to do a thing and you did it to the best of your ability. If it went sour then you started it all over again and did something else but you never spent time refining.”  The importance of temperament and character is made clear in the work of the Jungian analyst, James Hillman, in his book The Force of Character. He writes “The limiting effect of one’s innate image prevents that inflation, that trespassing or hubris that the classical world considered the worst of human errors.  In this way character acts as a guiding force”.

President Roosevelt cheerily said to the cabinet immediately after the Senate defeat that he intended to have a great deal of fun in the months ahead and it was time for the country to laugh again.  In August he cocked a snook at the Senate by nominating for a vacancy amongst the nine members of the Supreme Court one of their own, Senator Black, knowing they would feel unable to reject him at their hearings even though he had been an ardent supporter of packing the Court.  In acting in this way, Roosevelt showed the value of a cynical sense of humour which acted as a check on his hubris.

Yet why did Roosevelt essentially make a major misjudgement of the Senate’s reaction over packing the Court? The answer, in as much as there can be any one explanation, probably lies in the death in April 1936 of Louis Howe.  Eversince Roosevelt was a state senator in Albany, Howe had been his indispensable adviser. He had a room of his own in Roosevelt’s homes in Manhattan and Hyde Park; also in the executive mansion in Albany and then the White House. No-one else spoke as frankly to Roosevelt as Howe. “You damned fool”, “Goddammit, Franklin, you can’t do that”, or “Mein Gott! That’s the stupidest idea I ever heard of” are but a sample of what he said.  Shesol describes Howe as “Roosevelt’s balance wheel”. He could challenge the President on many fronts or as Howe put it, “My job is to supply the toe-holds”.

In my assessment of politicians acquiring hubris syndrome I found a number of “toe holders”.  Bonar Law’s resignation, on health grounds, from Lloyd George’s Cabinet in March 1921, was an important factor in Lloyd George’s developing hubris and his belief that he was indispensable only to be disowned by his Conservative coalition partners in 1922. William Whitelaw provided a check for Margaret Thatcher until he left the Cabinet two years before she was ousted by her own MPs in 1990. Clementine Churchill, recognizing a significant change in her husband’s behaviour wrote, after some hesitation, a moving but also a brave and important letter to her husband in the summer of 1940. “You are supposed to be so contemptuous that presently no ideas, good or bad, will be forthcoming”. This loving admonition served as a check on Churchill’s hubristic traits. I do not believe Churchill did develop hubris syndrome nor even that bipolar disorder is the explanation for his periodic depression.  He was a phenomenon not able to be fitted into any known category.

Threat of wars, or wars themselves, for some politicians (like Chamberlain, George W Bush and Blair) and generals (like McArthur and Patton) can be the external event that seems to bring on hubris.  As so often it is playwrights who are best able to dramatically bring to public attention these linkages. Peter Morgan’s recent television play on the Special Relationship, shown on the BBC and HBO in the US, focused on Tony Blair and Bill Clinton, showing how the Kosovo war impacted very differently on the two men.  While Clinton was cautious to the end and ready to acknowledge the role that Russian diplomacy and particularly Yeltsin played in the Serb withdrawal from Kosovo, Blair  began to develop the full blown hubris syndrome he demonstrated after 9/11. At the time of Kosovo one of Clinton’s staff said of Blair that he had “sprinkled too much adrenaline on his cornflakes”.

For President George W Bush it was 9/11 itself that seemed to stimulate a gathering hubris over Iraq and in his case he had no-one to check his behaviour; rather it was exacerbated by his Vice President Dick Cheney. The failed aftermath of the invasion of Afghanistan and Iraq eventually seemed to cool Bush’s hubris and in retirement it appeared to abate. Blair continued in personal denial about the way he had conducted himself before and during the Iraq war and seemed intent on rebuilding his legacy after he was forced out as Prime Minister by his own party in 2007.  Three years later Blair seemed just as carried away by hubris as he had been in office.

It is fascinating how adrenaline features in so much lay language over hubris. In our Brain article we speculated on the neurobiology of hubris syndrome. We mentioned one study which had identified frontostriatal and limbic-striatal dopaminergic pathways as important regulators of impulsive and/or rigid behaviours.  There have been many other interesting findings in the area of neuroscience since that article. But one recent study in 2010 is, I think, worth highlighting. This study showed that, in 35 patients with Parkinson’s disease, an individual’s strength of belief in their being likely to improve can of itself directly modulate brain dopamine release. What they call conscious expectation in this randomised study describes the probability the individual is given that they will be receiving active medication with levodopa.  Amongst those who were actually given a placebo but a 75% probability of it being active medication there was significant endogenous dopamine release in the ventral striatum. No such release occurred with the lesser probability of 25% or 50%.  What we need now are more studies on brain dopamine levels in decision makers. The neurobiological effects of conscious expectation in this experimental context may be similar to the conscious expectations which go along with the intoxication of power in hubris syndrome.

It is also necessary to study the individual and collective hubris that gripped the financial community over the last decade – here in Wall Street and in the City of London and Canary Wharf in the UK.  Any belief that hubris syndrome is the preserve of the politicians is wrong.  It is no respecter of professions as we have seen in relation to the banks. The deputy editor of the Financial Times, Gillian Tett, in her book Fool’s Gold: How Unrestrained Greed Corrupted a Dream, Shattered Global Markets and Unleashed Catastrophe writes:

I am still trying to make sense of the last decade of grotesque financial mistakes. I have found myself drawing on my training as a social anthropologist before I became a journalist…..What social anthropology teaches is that nothing in society ever exists in a vacuum or in isolation ….In recent years regulators, bankers, politicians, investors and journalists have all failed to employ truly holistic thought – to our collective cost.  ……… Most pernicious of all, financiers have come to regard banking as a silo in its own right, detached from the rest of society.

How, on a multidisciplinary basis, can we use all the necessary skill including social anthropology to learn from the financial crisis? It is not, I suggest, something that the health care community can ignore. I have just established a research charity called the Daedulus Trust to raise money for such research.  It will work very closely with the London Branch of the Society for Organisational Learning (SOL).  A branch of SOL exists here in New York and I would be delighted to share our experience with anyone here who wishes to create a somewhat similar research network.  We chose Daedulus, the man in Greek mythology who flew with the waxed wings he had designed but had the good sense to warn his son Icarus of the dangers of flying high, too close to the sun, and flying low, too close to the waves, to emphasise the complexity and necessity of risk taking.

There are positives as well as negatives surrounding hubristic leadership. Yet some hubristic leaders in the first decade of the 21st Century have wreaked havoc. The massive oil spill in the Gulf of Mexico, following the explosion and broken pipe from BP’s oil platform is yet another example.  In BP a former Chief Executive, John Browne, began to demonstrate many of the contemptuous features of hubris syndrome. Cost saving appeared to lead to a reckless disregard for applying the expensive safety measures that best oil industry practice demanded and all this helped create a climate of collective hubris within BP itself.

Identifying hubristic leaders and hubristric cultures and containing them presents an immense challenge. Such leaders are often, when first appointed, well qualified and experienced and have not given any warning signs to their electors, in the case of politicians, or Board Directors, in the case of bankers and industrialists, that they could develop hubris syndrome. They have no known history of psychiatric illness or of behavioural problems.  Yet within a variable period of exercising power they can change and develop in part a different personality. We need to study hubristic cultures and develop informal systems of peer review if we are to prevent greater damage in the future.

Download Speech here, includes footnotes/references.

For more on Hubris Syndrome, visit – the website of the academic and research oriented Trust dedicated to raising awareness of this important leadership and governance issue.

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