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Character Disorders among Autocratic World Leaders and the Impact on Health Security, Human Rights, and Humanitarian Care

Published online by Cambridge University Press:  15 January 2019

Frederick M. Burkle Jr.*
Professor (Ret.), Senior Fellow & Scientist, Harvard Humanitarian Initiative, Harvard School of Public Health, Cambridge, MassachusettsUSA Senior International Public Policy Scholar, Woodrow Wilson International Center for Scholars, Washington, DCUSA Captain, MC, United States Navy Reserve (Ret.)
Correspondence: Frederick M. Burkle, Jr., MD Harvard Humanitarian Initiative 14 Story Street, 2nd Floor Cambridge, Massachusetts 02138 USA E-mail(s):;
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The development of autocratic leaders in history reveals that many share severe character disorders that are consistently similar across borders and cultures. Diplomats and humanitarians negotiating for access to populations in-need and security of their programs, especially in health, must understand the limitations placed on the traditional negotiation process. These shared character traits stem from a cognitive and emotional developmental arrest in both childhood and adolescence resulting in fixed, life-long, concrete thinking patterns. They fail to attain the last stage of mental and emotional development, that of abstract thinking, which is necessary for critical reasoning that allows one to consider the broader significance of ideas and information rather than depend on concrete details and impulses alone. These autocratic leaders have limited capacity for empathy, love, guilt, or anxiety that become developmentally permanent and guide everyday decision making. Character or personality traits that perpetuate the lives of autocratic leaders are further distinguished by sociopathic and narcissistic behaviors that self-serve to cover their constant fear of insecurity and the insatiable need for power. Human rights, humanitarian care, and population-based health security are examples of what has consistently been sacrificed under autocratic rule. Today, with the worst global loss of democratic leadership ever seen since WWII, leaders with these character traits now rule in major countries of the world. While history teaches us of battles and conflicts that result from such flawed leadership, it lacks explanations of why autocratic behaviors consistently emerge and dominate many societies. Building multidisciplinary capacity and capability in societies among democracies to limit or cease such authoritarian dominance first begins with a developmental understanding of why autocrats exist and persist in externalizing their pathological behaviors on unsuspecting and vulnerable populations, and the limitations they place on negotiations.

“…once in power, a leader with an Antisocial Personality Disorder thrives on continuing conflict and never seeks peace.” Daedalus Trust, London, 2016

BurkleFMJr.Character Disorders among Autocratic World Leaders and the Impact on Health Security, Human Rights, and Humanitarian Care. Prehosp Disaster Med. 2019;34(1):2–7.

Guest Editorial
© World Association for Disaster and Emergency Medicine 2019 


Since the end of the Cold War, research explored the characteristics of so-called “bad leaders” of the world, many who emerged on the international scene after the breakup of the Soviet Union.Reference Burkle 1 Reference Rosenthal and Pittinsky 10 Initial writings and teachings focused on negotiating skills directed toward career-oriented humanitarian and foreign service professionals.Reference Fisher, Ury and Patton 11 However, traditional skills to negotiate with agreement increasingly suffered over recent decades with violence, security threats, programmatic failures, and a slow, often painful and counter-intuitive recognition that traditional diplomatic approaches and negotiations with emerging and established despots often failed, were ignored, or were destroyed resulting in major losses in access to populations in-need, humanity, and health security. This era in human history brought with it many protracted internal conflicts and wars that have lasted for decades and whose persistent instability lies at the heart of both chronic nation-state and regional instability that we witness today.

The responsibility for many prolonged wars and internal conflicts has been attributed to multiple unresolved root causes of society, with previous governance and parties to power no longer trusted or acceptable, the vacuum of leadership often filled with heartless and self-serving, vile leaders.Reference Burkle 1 Many cases of opportunistic leaders shared severe character traits and flaws that proved predictably common and actionably comparable to other failed leaders throughout history. Many emerged “first as saviors then as despots, or as common criminals claiming to be patriots,” sharing a psychological framework that differs little from those responsible for WWI, WWII, and the conflicts that plagued the Cold War and the post-Cold War era that followed.Reference Burkle 1 More than ever before, today, one-third of the global population lives in outright authoritarian regimes. 12

Humanitarian and diplomatic experiences found that those negotiating from democratic countries, international humanitarian organizations, and the Western and European militaries were generally unaware of the overwhelming power that character flaws and self-serving motives of autocratic leaders had on critical outcomes of diplomacy and health security of the population. Collectively, democratic countries have shied away, to the point of denial, from exploring why tyrannical leaders are who they are, how and why societies allowed tyrannical leaders to secure such consummate power, what must be done to contain their malignant and destructive behaviors, and finally, how do societies learn to collectively curtail the predictably complex and politically charged consequences that define their times in power?

The Developmental Divide

A vital first step in understanding despotic leadership comes with knowledge of the basic understanding of the development of children into adulthood and the unique role, in all cultures, that successful adolescent development plays in ensuring a stable adulthood that serves both the individual and the culture. In normal childhood and early adolescent development, some vanity and demonstrated “healthy narcissism” are normal and necessary as it plays a vital role in building one’s emerging but fragile ego; all supported by a healthy home life, parental guidance, and elementary school-appropriate educational programs that promote self-esteem and group learning experiences.

Adolescence uniquely welcomes in healthy challenges to the narcissistic hold of childhood. Either certain emotional and cognitive growth phases are successfully completed during adolescence, or there is great risk for perpetuation of childlike and early-adolescent demands within an adult’s personality. Even in the most primitive of societies, adolescence is recognized as a critical stage of development, not only for the individual, but for societal survival, one that is fully dependent on unique, age-specific neurological development of the brain that is not biologically available to them in later years. These adolescent tasks, probably the most crucial to normal life beyond childhood, are, according to Havighurst, what society generally accepts as “developmentally necessary” for one’s personality that will exist for their entire life.Reference Havighurst 13

Adolescents are constantly being tested. Like the “loneliness of the long-distance runner,” adolescents are subjected to a myriad of social, emotional, and physical challenges.Reference Sillitoe 14 For many, they feel for the first time personal anxiety, doubt, shame, depression, guilt, sorrow, make embarrassing mistakes, learn new avenues by modeling other more mature adolescents and adults, and develop both age-appropriate neurologically and socially beneficial developmental tasks, eventually leading to a sense of accomplishment. While empathy reveals a strong sense of self-awareness, it is a forerunner to attainment of additional tasks requiring more abstract thinking such as critical reflection, perception, observation, intuition, negotiation, cooperation, and reasoning that utilizes judgment, conceptualization, and generalization in one’s thinking and decisions that include the foundation of ethics and morality.Reference Meyers 15 As building blocks to autonomy and independence, these tasks are first tested and learned through healthy adolescent curiosity, and then refined, and finally matured with life experiences and education in the decade of the 20s.

Where Development Fails

Childhood is where narcissism should stay. By the end of young adulthood, society expects that the concrete black and white narcissistic thinking and actions of childhood must be tamed. If not, the narcissistic behaviors risk continuing and will dominate development into adulthood and become fixed into the personality. Spoiled children with temper tantrums that occur when they don’t get their way become bullies in adolescence and adulthood who demonstrate often bizarre and accusatory rage attacks when challenged. The factors that reportedly cause narcissism to continue beyond childhood vary and are probably best understood as a combination of competing factors. Most commonly considered are excessively over-indulged and pampering parents, that parents selfishly convince them they are “special” in order to build their self-esteem, or from chronic parental abuse, absence, or trauma, and possibly a genetic component that is dominantly male.Reference Burkle 1 , Reference Meyers 15 Reference Sack 17

Early adolescents do not want to give up that narcissistic “high” which dependently sustains them from facing fear, mistrust, and doubt. Unfortunately, in many Western societies in the 1980s, numerous and often “misguided self-esteem” programs in childhood also advised parents to tell the child they are “special.” Competitiveness was overly admired and promoted by parents that resulted in children deflating another child’s ego with wise humor or sharp insults that drew uncomfortable laughter but gave them a sense of superiority. Without parental disengagement, honesty and empathy become de-valued and the goal of the spoiled child and adolescent becomes “getting what you want,” resulting in what some have labeled today as an “epidemic of narcissism.”Reference Burkle and Hanfling 8 , Reference Sack 17

These adolescents fail to understand and appreciate the perspectives of others. All show signs of an emotional and cognitive arrest dating to childhood and early adolescence that limits their development to concrete black and white thinking. They do not appreciate the feelings of others as they themselves lack a conscience, feel no empathy, guilt, anxiety, or sorrow. As they grow, they maintain a level of persistent arrogance that serves as a cover for their insecurity, which is often hidden even from close colleagues and spouses, but is silently understood by protective parents who often step-in to mitigate the societal problems that begin to dominate their personalities. Even as adults, they mobilize their parents to handle a myriad of difficult social dealings as “fixers,” such as divorces, violations with the law, and debts. Fabrications, exaggerations, and lies among pathological narcissists about their own cultural histories, war records, and education are common, and when challenged, may rapidly de-escalate into derogatory and inflated insults meant to intimidate their accusers.Reference Sack 17

Unsuccessful adolescent development leads to inability to perform tasks associated with the next stage in life, that of adulthood. These adolescents and young adults risk failing in understanding and appreciating the perspectives of others and the recognition that empathy, which is seriously lacking or absent in narcissistic adults and the despots of the world, is crucial to emotional maturity. Capacity to either reverse or accomplish these developmental tasks later in life is neurologically impossible, and therapies to reverse the narcissism-led behaviors are quite limited.

The predictable character flaws that begin to make up the personalities of potential autocrats seeking a greater stage and more power in life are placed across a spectrum of antisocial and narcissistic behaviors, depending on what is needed to perpetuate their own needs and actions. They may, at any one time, take from a common autocrat’s playbook where their actions are either antisocial, narcissistic, or both, all of which belie the fact that they are increasingly, despite their physically advancing age, emotionally dysfunctional and immature adolescents and young adults.Reference Burkle 1 They display no personal or social conscience or true remorse for the things they have done, the people they have hurt, and the laws they break, all without motivation to change. This remains a difficult concept to understand as the public automatically expects adolescents to seek age-appropriate behaviors and insight.

While they are appreciated by many as being “smart,” they are not “bright,” which requires abstract thinking, reflection, awareness, and appreciation for their actions, all developmental tasks they never completed. At the same time, they will never accept responsibility and will project blame for failures onto others.Reference Burkle 1 , Reference Burkle and Hanfling 8 While often appreciated as fearless, confident, uncompromising, and ruthless when assuming their leadership role, they are basically incompetent. Failing to govern fairly, substituting deviousness and deception for the lack of competence, obsessing over power, perpetuating fraud, and gaming the system become their own “theology.”Reference Cousins 18 One observer summarized that they “view social manipulation as their special talent, and by riding the backs of those they manipulate, a sociopath can accomplish quite a bit.” 19

The Mental Illness Debate

When mental health practitioners talk of “mental illness,” they usually refer to a myriad of internalized signs and symptoms within an individual that define depression, bipolar disorder, anxiety and panic attacks, obsessive-compulsive and eating disorders, posttraumatic stress disorder, psychosis, schizophrenia, suicidal feelings and self- harm, and addictions that make it difficult to cope with daily life and relationships. The signs and symptoms of a biologically induced mental illness are internalized and diagnosed by professional interviews and testing of the individual.

The commonly shared character flaws, insatiably guarded and defended by despots, are all externalized onto society, but are never internalized. One can argue that these despots are not “mentally ill” per se, as many might claim. In fact, the large majority of the world’s despots, dictators, autocrats, and tyrants, while free of internalized symptoms of any biologically driven mental illness or co-morbidity such as clinical depression or schizophrenia, are rare. Co-morbidities are no more common than in the normal population. The commonly shared character flaws, insatiably guarded and defended by despots, are all externalized onto society.Reference Burkle 1 Those who enter the legal system locally after an antisocial act, or as the result of World Court testimony to avoid imprisonment, a “mental illness” defense is traditionally used to mitigate a sentence. The real victims who suffer from their external behaviors are the spouses, families, the community, the country, and the world itself.

Autocratic behaviors are easily observed in daily antics that worry, frustrate, and anger the population; globally when wars and armed conflicts ultimately become their desired outcome. Their need for more power and admiration is insatiable, unstoppable, and will eventually produce war or armed conflict, in part because they incessantly fantasize over sending others into battle, being the hero-commander who saves the world. Hypocritically, they are intolerable of relationships with those with less concrete views, especially if they are perceived as having social status that they envy. Their admiration and envy over the individual power of other world leaders is an obsession.

The inclusion of personality/character disorders that include narcissistic and antisocial behaviors among “mental illnesses” has been controversial and highly debated. Personality disorders are defined as “deeply ingrained and maladaptive patterns of behavior of a specified kind, typically manifest by the time one reaches adolescence, and causing long-term difficulties in personal relationships or in functioning in society.”Reference Avery 20 Kendall reports that German psychiatrists in 1950 argued that personality disorders should be of little concern to psychiatrists as they simply represent “abnormal varieties of sane psychic life.”Reference Kendell 21 In 1988, Lewis and Appleby, using ratings from 240 experienced psychiatrists, felt that personality disorders were “commonly regarded as manipulative and under voluntary control rather than the result of illness,” and “generally regarded as irritating, attention-seeking, difficult to manage, and unlikely to comply with advice or treatment.”Reference Lewis and Appleby 22 Kendall’s 2002 literature review acknowledged that “personality disorders are as fundamentally different from mental illnesses based on both clinical and genetic evidence,” deduced that it “was impossible to conclude with confidence that personality disorders are, or are not mental illness,” citing “ambiguities in definitions, basic information, and genetics.”Reference Kendell 21

Except for court-ordered analyses, self-seeking therapeutic analyses by a sociopathic narcissist would be rare. For those forced by law or family into “therapy,” one is struck by the consistency in which they are aghast that others in society feel empathy, anxiety, or guilt. One who asked that I define anxiety and guilt declared “My God, how can anyone live with that?”

The Diagnostic and Statistical Manual of Mental Disorders V (DSM V) no longer includes a separate diagnostic category for psychopaths or sociopaths. These terms have been eliminated and incorporated under antisocial personality disorders. 23 Importantly, it must be understood that pathological levels of narcissistic behavior are the major driving force for the degree of pathology, witnessed or practiced, that is considered so aberrant and abhorrent in society. Most autocrats experience both across a spectrum from severe sociopath on one end to pathological narcissism on the other (Figure 1).Reference Burkle 1 The combination of sociopathic and pathological narcissistic behavior becomes a concern to society. It is usually depicted as fluctuating across a wider spectrum of self-inflicted crises, best defined under “population-based psychiatry/psychology” that requires a more integrated role for psychiatry, psychology, social and behavioral sciences, politics, and the law to name but a few. Population-based psychiatry/psychology highlights the particularly egregious consequences, such as massive movements of refugees to flee the intolerable political climate, increasing violence, and deaths, injuries, and illnesses that define current internal conflicts. Interestingly, I have seen the global management of pervasive psychopathically driven conflicts to epidemiologically mimic the pattern seen in the spread of infectious disease outbreaks.

Figure 1 Shared Antisocial and Narcissistic Behaviors Across a Wide Spectrum.

Adapted with permission from: Burkle FM Jr. Antisocial Personality Disorder and Pathological Narcissism in Prolonged Conflicts and Wars of the 21st Century. Disaster Med Public Health Prep. 2016;10(1):118-128.

Burkle © 2018 Prehospital and Disaster Medicine

Despite their seductive talents and uncanny ability to speak to universal concerns of every citizen, they never attain mature abstract reasoning and avoid discussions and debates that demand levels of reasoning, observation, and objectivity, or issues that do not personally boost their own power and prestige. They expend emotional energy covering up their limitations and turn to lies, fabrications, childish insults, and unrelenting boastful opinions of themselves. From an early age, they demonstrate unchangeable beliefs and behaviors that are the absolute antithesis of everything a democracy demands of an individual.

Their admiration for other world leaders is the extension of an adolescent obsession of more successful bullies. The consistent pattern of praise and envy for other world despots who share similar character traits of an absent conscience and insatiable desire for power and adulation is remarkably constant. They predictably tend to identify with, cooperate, and support other despots in times of crises. This admiration can quickly turn malignant if they perceive, in a very concrete narcissistic manner, that they themselves are more deserving of the power. Multiple examples occurred in history. For example, in 1939, the Hitler-Stalin Non-Aggression Pact paved the way for the German invasion of Poland from the west and Russia from the east. A shared litany of murders and repression followed. In June 1940, Stalin was the first world leader to send Hitler a congratulatory telegram as he entered Paris. By 1941, Hitler, envious of the oil and other territorial resources that Stalin possessed, summarily invaded Russia, plans of which were deceptively in place when the invasion of Poland occurred in 1940. The current mix of autocratic leaders shows similar “autocratic cooperation” internationally, which may simply be defined as self-serving actions leading to mitigate internal conflict. Kim Jong Un’s current submissions to the West may be mostly driven by defensive awareness of domestic strife and threats, not international cooperation.Reference Post 7 , Reference Coolidge and Segal 24 , Reference Coolidge and Segal 25

Global Autocracy in the Making

Despite initial promises to the contrary, authoritarian leadership is too often based on manufactured fears, mistrust, and paranoia leading to incremental assaults on the population’s human rights. Those negotiating in countries at-risk are generally unaware of the overwhelming power that character flaws and self-serving motives of autocratic leaders have on critical outcomes of diplomacy, humanitarian programs, and long-term health security of the populations at-risk. Background examples are presented here for consideration.

Loss of Democracy

In 2018, the annual Democracy Index report that ranks countries as either having full democracy, flawed democracy, hybrid regimes, or an authoritarian regime placed less than one-half of the world’s population as living in a democracy. Those living in a full democracy have fallen almost five percent. One-third of the world’s population lives in “outright authoritarian regimes.” In the United States, a serious decline and erosion of confidence in democratic institutions now ranks it as a “flawed” democracy. 12

Globalization was recently promoted as accelerating efficiency, opening markets and free trade, stabilizing competition, accelerating equality, diversity, equal educational opportunities, improving health security among nations, and accelerating democracy to struggling nations. Encouragingly, many in the millennial generation declared themselves less as nationalists and more as global citizens.Reference Burkle, Egawa and MacIntyre 26 With the recent rise and dominance of authoritarian regimes, globalization has almost become a nonentity, both the word and its concept has disappeared under a very coordinated false narrative campaign of autocrats.Reference Meijer 27 Ghitia contends that “modern-day would-be dictators don’t overthrow another government. What they do is take over the system of government.” She emphasizes that their methods are more gradual, “manipulating the democratic norms, wearing them down to a thin shell that contains only the wrecked remains of democracy.” By the time most people realize what has happened, it’s too late to push back.Reference Ghitis 28

The dictatorial world is changing rather rapidly, gaining confidence and challenging globalization by emphasizing democratic failures throughout an increasingly connected and sophisticated, electronically-wired globe where the actions and behaviors of all leaders are instantly known. Increasingly, oppressed and authoritarian regimes are working together, have adapted and consolidated their strength in claiming historically fought-over lands and territories, leading to unprecedented numbers of fleeing migrants and refugees. Early in my humanitarian career, there were 50 million refugees; today, there are over 68.5 million, and this is projected to rise to 140 million within a decade.Reference Kirby 29 No country can manage the influx without major political consequences. Currently, it is only the democratic countries that are struggling under international law that ensure refugees have rights anywhere in the world, while scant blame is placed on the autocratic leadership which denies the inalienable right of the refugees to live in the country where they were born. Autocratic leaders see the flight of refugees as an effective weapon against democracy. This led, especially in the European Union, to a rise in the radical right that has “combined populism with anti-immigrant and authoritarianism.” Their leaders exist in a “perpetuating state of crisis,” whether it is anti-politics, anti-intellectualism, or anti-elite, convincing the population they identify with that they alone are infallible. If one is not supportive of the authoritarian candidate, then you are deemed “against the people.”Reference Mudde 30 , Reference Einbinder 31

Threats to Humanitarian Assistance

In the humanitarian community, it is accepted that a dictator’s sole motivation is to stay in power; asserting that even United Nations humanitarian aid “lines the pockets of despotic regimes.”Reference McKay 32 Whereas humanitarian funding may build or improve some vital infrastructure, such as roads, sanitation, and clean water resources, they are rarely maintained. The population lack the political rights to protest “disastrous public health services, so they never improve,” leaving the dictators with cash while punishing those who object. Others who protest propping up dictatorial regimes assert that if governments ignore right’s abuses, then the rule must be “no democracy, no aid.”Reference Easterley 33 Whether or not humanitarian aid groups or governments become engaged or not with the despotic regimes, both will lead to manipulation of aid to those in-need. The characteristics today of pathologically driven regimes include perverting aid to inflict harm, retreating from public responsibility in protecting from the emergence of a public health emergency, or diverting aid funds to further violence or conflict.Reference Patel and Wild 34 A study of eight 2018 dictatorial countries reveals poverty rates ranging between 22%-82% with a mean of 57%.Reference Shaw 35

Demise of Health Security

Dictators have direct impact on health security. Dictatorships, whether authoritarian, sultanistic or totalitarian, civilian or military, with direct knowledge of the negative impact on mental health, create adverse political and economic conditions. Dictatorial regimes routinely utilize physical and psychological coercion as their primary method of governance, resulting in predictable health and mental health consequences.Reference Abed 36 Reference da Silva, Recine, Johns, Gomes, Ferraz and Faerstein 38

In Latin America, practitioners of social medicine who have revolted over deteriorating health conditions and who have tried to document those crises using updated epidemiological tools and methods have faced unemployment, arrest, torture, exile, and death.Reference Waitzkin, Iriart, Estrada and Lamadrid 39

Research has shown a pattern consistent with other dictatorships with close association between the extent of political freedom and measures of population health. In 2005, Rechel and McKee described the effects of the dictatorship of Turkmenistan on health, a pattern consistent with other dictatorships. With the “absence of democracy and human rights meant that the public was not involved in health policy development, their views were not taken into consideration, and health reform was based on ad hoc decisions of the president whose goal was to cut governmental health financing.”Reference Rechel and McKee 40 Dictatorship in Turkmenistan had negative impacts on population health through the regime’s policy of keeping secret statistical data or failing to report health indicators to the international community, especially infectious diseases that were considered potential for an epidemic (Avian influenza, Tuberculosis, HIV/AIDS, and Plague), and state of denial which saw the solution to health care problems in concealment rather than prevention, its complicity in trafficking of drugs from Afghanistan, and the neglect of its health care system.Reference Franco, Alvarez-Dardet and Ruiz 37 The precise nature of the impact of dictatorship on health and mental health is difficult to quantify because they are influenced by a large number of factors, including the socioeconomic situation, housing, nutrition, water, sanitation, energy, lifestyle, and access and availability to health care services.Reference Golec de Zavala 41 , 42

Power of Collective Narcissism

Societies have come to uncritically accept and excuse the unbridled sense of aggrandizement that goads the pathological narcissist into personally threatening those they see as obstacles to their power and authority. When the political party aligns itself with the narcissist, it becomes “operationally and collectively narcissistic.”Reference Einbinder 31 Once collective narcissism exists, the autocrat can be assured of sustaining his power base, demanding total loyalty, with followers speaking from the same playbook and daily-drilled sound bites, where disloyalty is severely punished by those on the top of the collectively narcissistic pack who have built for themselves a powerful and self-serving political culture. Many in power truly believe in having God-like powers that absolve whatever faults other humans may be judging them by. Indeed, society is at-fault for lavishing praise and creating an unfathomable, yet favorable impression.Reference Burkle and Hanfling 8 , Reference Golec de Zavala 41 Reference Behary and Siegel 43

Unfortunately, the mental health professions in general have been dismissive of the impact of sociopathy and pathological narcissism on families and society. For this reason, those who lobby for “mental health” exams for those seeking political power have a legitimate argument to make considering the risks of not doing so.Reference Burkle 1 Today, the power-grabbing is building and becoming more and more worrisome as democratic advances created by previous, more democratic leaders disappear. It becomes more infectious as the culture of collective narcissism and its collective power pervades the political base of loyalists who have now begun to see political and economic benefits themselves. There is no moral compass as more and more of the population feels they have a new license to express themselves. Bad behaviors are ignored, defended, or excused as benefits to loyalists accumulate.


Whatever the title (Tyrant, Dictator, Autocrat, Despot, King, Oppressor, President, or Fascist) or how they came to power, their developmental gaps through childhood and adolescence are similar, some more violent and abusive than others. Their narcissism drives the common playbook of oppression and fear with identical tactics, human right’s abuses, and declarations that they are not bound by laws of their country. Madeline Albright’s book Fascism reminds us that while they all “claim to speak for a whole nation or group,” they are “utterly unconcerned with the rights of others, and willing to use violence and whatever other means necessary to achieve the goals he or she might have.”Reference Albright 44 Narcissistic sociopathy presents a more virulent threat to peace and justice than at any time since the end of WWII. Democracy is the arch enemy of every concrete-thinking, pathologically narcissistic sociopath. The concept and functioning of democracy is an abstraction that autocrats can neither define nor comprehend. The momentum toward democracy that swept the world has gone into reverse.


Conflicts of interest: The author has no financial or personal relationships with other people or organizations that could inappropriately influence or bias this work.


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Figure 1 Shared Antisocial and Narcissistic Behaviors Across a Wide Spectrum.Adapted with permission from: Burkle FM Jr. Antisocial Personality Disorder and Pathological Narcissism in Prolonged Conflicts and Wars of the 21st Century. Disaster Med Public Health Prep. 2016;10(1):118-128.Burkle © 2018 Prehospital and Disaster Medicine