Does Sarah Palin Have Narcissistic Personality Disorder?

In his recent piece [2] on Sarah Palin for Vanity Fair, Todd Purdum floats two psychiatric explanations for her imperious and erratic behavior: narcissistic personality disorder and postpartum depression. Purdum’s source for the first label is several people he met in Alaska. For the second, he cites aides in the McCain campaign. How seriously should we take these diagnoses? As a practicing psychiatrist, I would say, not very—but my reasons for dismissal are different for each of them.

Postpartum depression is a mood disorder that classically arises in mothers within four weeks of a delivery. Often the condition is severe. The depressed women can be delusional, holding quite terrible beliefs about themselves and the world; in the extreme case they kill their babies or themselves.

Palin’s youngest son was 5 or 6 months old in the heat of the presidential campaign. That’s not necessarily too late for PPD, even if it’s not the usual time frame. In my practice, I have seen depressions that I am content to call postpartum that, contrary to the diagnostic manual’s definition, arose months, not weeks, after a delivery. The cases involved otherwise unexplained mood disorders with a sudden onset. The patients were dramatically disabled—not at all in shape to participate in a national political campaign, even ineptly. Occasionally, I have managed to help patients recover in short order; still, the deterioration and recovery was hardly invisible to those close to the patient. To apply the depression diagnosis in Palin’s case, we would need to imagine too much at once: grave illness, prompt and vigorous treatment, and so on. The idea that this diagnosis fits Palin seems to arise from misunderstanding—from reaching for a label without ever having seen what it applies to in a real woman’s life. In effect, the unnamed aides seem simply to be saying that there was something disturbing and unexplained about Palin. Better journalism might have yielded more explanation of those apprehensions. Instead of bandying about the phrase “postpartum depression,” what we want are the details of Palin’s strange behavior.

What of the claim that Palin has narcissistic personality disorder? This diagnosis is at least plausible—but does it add, in any useful way, to the Palin discussion? As readers, we know perfectly well what the unnamed Alaskans are talking about when they slap that label on her. She is full of herself. It’s all about her. If we look at the specific criteria [3] for the condition, we may judge that the suit fits. “Shows arrogant, haughty behaviors or attitudes.” Check. “Has a sense of entitlement” and “is interpersonally exploitative.” Check, check. (More here [4] from Emily Yoffe in Slate about the disorder, and this “cultural moment of the narcissist.”)

Psychiatrists are not allowed to diagnose people they have not interviewed. Still, I don’t think that I’m transgressing any strictures when I say that I find Palin unlikable. She is, in my reading of her behavior, dogmatic, incurious, irascible, vindictive, dishonest, manipulative, trivial in her view of the world, and unjustifiably self-righteous. Katie Couric did the country a great service by bringing those traits to the fore in her unforgettable TV interview [5] with Palin in September; the Pulitzer Prize committee missed an opportunity when it failed to recognize her work, easily the best piece of journalism of 2008.

But merely manifesting specific traits (“arrogant,” “exploitative,” etc.) does not qualify you for a diagnosis. You must also meet the general criteria for personality disorder [3]. Your obnoxiousness must cause certain sorts of problems. For instance, from the American Psychiatric Association: “The enduring pattern leads to clinically significant distress or impairment in social, occupational or other important areas of functioning” (my italics). If a personality style gets you a devoted husband, admiring children, a loyal circle of friends, a governorship, and a vice-presidential nomination, can we really call it a disorder?

We can’t—but therein lie a raft of problems. What is that phrase clinically significant doing in the American Psychiatric Association’s definition? It’s there to show that a disorder is the sort of thing that causes people to ask for help and that then moves doctors to offer it. That requirement makes sense—we want disorders to be severe at a level deemed worthy of attention—but it also makes the whole system of psychiatric diagnosis less useful. A condition is a disorder if we agree that it is. And there’s something unsatisfying in that sort of criterion: If two people react to challenges in the same defensive way, but one person happens to succeed in life and the other to fail, can it be that one is medically impaired and the other not?

Perhaps that conundrum of psychiatry should be the subject of a separate, longer discussion; for now, the purported diagnosis serves mainly to put an insult to Palin in a fancy wrapper. If I were like you, I’d seek treatment, may be the underlying sentiment. Or simply: You should.

Palin may duck the narcissism rap on another basis as well. The APA criteria for personality disorder also refer to “experience and behavior deviating markedly from the expectations of the individual's culture.” On her home turf, Palin fits in fine. Citizens of her hometown Wasilla get her. As Purdum writes, “In the same way that Lyndon Johnson could only have come from Texas, or Bill Clinton from Arkansas, Palin and all that she is could only have come from Wasilla.” And also, “Sarah Palin herself is a microcosm of Alaska.” If you come from a society in which backbiting and dogmatism are apparently acceptable political behaviors, then those acts or postures cannot contribute to a psychiatric diagnosis.

On a more serious note, it strikes me that what may be at play in the pop psychologizing about Palin is class prejudice. New York Times columnist Ross Douthat makes this point [6]; Palin suffers from not having gone to Columbia College or Harvard Law School and, very likely, not having wanted to. Palin seems simply not to value complexity of thought. She’s opinionated and erratic, but not in a way that you would find remarkable in, say, a self-employed repairman who listens to a lot of talk radio. Matters of class are hard to discuss. The risk is always of sounding condescending. But—to go all out in this regard—you can’t call Palin “trailer trash” and then claim she has a personality disorder when she throws sharp elbows or cuts corners with the facts.

What we see when we open up a discussion about diagnosing a public figure is how subtle and empathetic the psychiatric enterprise needs to be. It’s not that we might not worry over Palin’s mental state if we agreed with her political choices. But we’d be less likely to. And the sort of information we get about a public figure like Palin is simply too coarse to allow us to make the important distinctions that inform diagnoses.

Think about it this way: Imagine that Palin were to approach a psychiatrist and say, "You know, I’ve had my successes, but there’s a sense in which I’m always tripping myself up—I think it has to do with an inability to get other people." Or imagine her husband or children making comparable observations about her. In the face of this sort of plea, a doctor would likely set aside the diagnostic manual, with its references to occupational functioning and culture. Then, the diagnostic enterprise would begin in earnest, in the setting and at the level where it is most useful. Yes, psychiatric diagnosis has a role to play in politics. If a candidate has a mood or personality disorder, as a citizenry, we’d like to know. But diagnosis has its limitations. One is that it functions best when it originates in the setting it was designed for, far from the public sphere.

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