Diagnosing President Donald Trump’s alleged mental disorder has become a popular pastime, not just among mental health professionals but also among politicians, journalists, pundits, comedians, and ordinary people gathered at coffee breaks. Trump’s consistently bizarre sayings and doings have triggered a bill to establish a commission “on presidential capacity” and a suggestion that the president be removed from office via the 25th Amendment on the grounds that he is mentally unfit to be president.

A recent Time poll indicates that many Americans think that Trump is unfit for office. I also believe we made a terrible mistake electing him. But Trump’s disagreeable traits in no way indicate that he is mentally ill. Instead, they reveal him to be the ruthless self-promoter he has always been, now poorly cloaked in fake populist clothing.

Before I go any further, you should know that I am a lifelong political inactivist, shamefully missing in action from the tumultuous political events of the last 50 years. It took the travesty of a Trump presidency to get me fully engaged.

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Confusing Trump’s behavior with mental illness unfairly stigmatizes those who are truly mentally ill, underestimates his considerable cunning, and misdirects our efforts at future harm reduction. And the three most frequent armchair diagnoses made for Trump — narcissistic personality disorder, delusional disorder, and dementia — are all badly misinformed.

Trump is an undisputed poster boy for narcissism. He demonstrates in pure form every single symptom described in the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for narcissistic personality disorder, which I wrote in 1978. But lots of successful people are extremely narcissistic without being mentally ill — think most celebrities, many politicians, and a fair percentage of writers, artists, lawyers, doctors, and professors. To qualify for narcissistic personality disorder, an individual’s selfish, unempathetic preening must be accompanied by significant distress or impairment. Trump certainly causes severe distress and impairment in others, but his narcissism doesn’t seem to affect him that way.

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My long experience with psychiatric diagnosis has taught me a recurring and painful lesson: Anything that can be misused in the DSM will be misused, especially when there is an external, nonclinical reward for doing so. We decided to include narcissistic personality disorder in the DSM-III 40 years ago purely for clinical reasons. We never imagined it would be used as ammunition in today’s political warfare.

It’s also important to note that narcissistic personality disorder holds a fragile place in the diagnostic universe. It came quite close to being eliminated when the fifth edition of the DSM was published in 2013, and will be excluded from the forthcoming revision to the International Classification of Diseases, a set of codes used by physicians and other health care providers to classify diagnoses, symptoms, and procedures.

Some presidential observers base their diagnosis of delusional disorder on Trump’s being an avid consumer and creator of conspiracy theories. He learned his art from a master: his mentor, Roy Cohn, who was the brains behind Sen. Joseph McCarthy’s attempt to control our government through Communist witch hunts in the 1950s. Conspiracy theorists are a dime a dozen, while those with delusions are more rare. Up to half of all Americans believe in strange conspiracy theories. They are wrong, but not delusional. Having a delusion means being a minority of one.

Confusing Trump’s behavior with mental illness unfairly stigmatizes those who are truly mentally ill, underestimates his considerable cunning, and misdirects our efforts at future harm reduction.

Also keep in mind that Trump’s conspiracy theories have been, and continue to be, essential to his political success. His long-standing claim that President Obama was not born in the United States launched Trump’s presidential run, his “crooked Hillary” claims helped win him the election, and “fake news” holds his base in his thrall. Trump is crazy like a fox.

The dementia diagnosis is based on the supposed poverty and perseveration in Trump’s current speech patterns compared to his earlier ones. I would attribute this to the number of stump speeches Trump has given. Abraham Lincoln could find creative ways of repeatedly saying the same thing, but Trump has never achieved Lincoln’s eloquence. He uses the same words over and over again because they successfully work up the crowd.

Convincing proof that Trump is not demented is his undiminished creative and canny skills at blaming, bare-knuckle political fighting, and self serving.

Buried in the noisy debate about Trump’s mental health is the misinformed and noxious assumption that mental illness somehow automatically disqualifies someone for high leadership position. If this were policy, Abraham Lincoln and Winston Churchill both would have been lost to history due to their battles with depression.

Assigning psychological disorders to Trump is not only wrong but futile. Vice President Pence, the Cabinet, and Congress would never invoke the 25th Amendment because it would amount to political suicide for everyone concerned and for the Republican Party. Any psychological fitness exam would also be inherently biased and unreliable. My guess is that Trump will eventually be removed from power, but via the appropriate investigative and political process, not a psychiatric evaluation.

I believe that Trump is a mirror of the American soul, a surface symptom of our deeper societal disease. He may not be crazy, but we certainly were for electing him. We mustn’t waste this Trumpian dark age. If we don’t learn from it, we will keep making the same mistakes.

Allen Frances, M.D., was chair of the Department of Psychiatry and Behavioral Sciences at Duke University and also chaired the task force responsible for revising the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. He is the author of “Twilight of American Sanity: A Psychiatrist Analyzes the Age of Trump” (William Morrow, September 2017).

  • One of the most ridiculous articles I have read lately, with a complete lack of analysis, or understanding of the word “Impairment.”

    If you do not recognize bankruptcy, failed businesses, 3 marriages, and over 50 law suits against him, a Grand Jury hearing, and an Impeachment trial as lack of stress or life impairment, then I cannot imagine what you would call impairment.

    How much money did you get paid to write this article ? Quit embarrassing yourself and the career you spent years building.

    • I agree. How could this person fail to see what significant impairment means. Even the response to the smallest criticism shows “thin skin” and easily hurt feelings. The MD of this person is getting in the way. Good input!

  • The F.B.I. profiled Trump as an Narcissist long before he ran for President.
    I say this because a leading FBI profiler wrote a book about the 5 most common dangerous personalities, and Narcissists make the list. And the author provides famous examples of Narcissists, and Trump is given as an example (the guy who puts his name all over hotels). The title is DANGEROUS PERSONALITIES by Joe Navarro. And myself, now at age 66, having worked as a Correctional Officer in a maximum security prison, and having studied a lot of sociology regarding dangerous personalities, I judge Trump to be a blatantly obvious Narcissist, no doubt whatsoever.

    • Thank you! I study sociology and my father had this disorder. T-man has NPD (malignant type), which means ASD also (anti-personality disorder). I wish I could read the book you recommended. Is it violent? I have serious PTSD but that sounds interesting. Great response! I’m so glad others see this too!

  • My first reaction to the title of this article was, “Well, the criteria is going to have to change.” It was kind of a wry joke, but in fact that IS what I believe.
    Personality disorders in general seem to confound mental health professionals: they don’t play out in the ways that other disorders do. Having wasted decades trying to persuade myself that my father was not mentally ill (until he died by self-medicating his depression and narcissism with food, past obesity and on into diabetes and kidney and liver disease, all due to his weight and comfort-food habit) – I’m calling bullshit. I watched Dad slowly kill himself, and I have enough of his psychological makeup to know why he felt that, although we said we wanted him to give up his addiction and deal with his problems directly, we could in no way have coped with the results. Dad’s misery and bad wiring led him to be cruel with the people he cared about most; his anger warded off the depression, picking fights with his kids gave him an easy win and a narcissistic boost, and food tamped the whole thing down so that his meanness stayed on a low boil, allowing us to just about hide our hatred of him behind respect and civility. Dad never seemed to see that he was the cause of a LOT of the problems at home. That doesn’t in the slightest change the fact that he was. In the end, he was pathetic, unloved and now unmourned. We did our best to have a good relationship with him at the end, but let me tell you the real reason why: for myself, I just needed to know that if reincarnation somehow does exist, I will have done everything possible to settle accounts between us, to be absolutely sure that I will not be reborn in any kind of relationship with him, ever again. I don’t even believe in reincarnation; I just couldn’t stand to risk being wrong.
    My sister couldn’t stand to get along with him even that well; she barely saw him for the decades since she moved away from home.
    If that sounds like a man whose own estimation of his own mental health is all that should be considered, then your criteria for Donald Trump’s sanity makes sense. It seems to me that the DSM-VI should expand the definition of Narcissistic Personality Disorder to include “Crazier than a shithouse rat”, because that is absolutely what Dad was, and Donald Trump is. And if you consider denai and cluelessness to be indices of good mental health…you might want to see if your facility offers an employee discount.

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