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.

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).

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  • I have a background in clinical psychology. I am not sure I understand why you think that Trump does not suffer from narcissistic personality disorder. People with personality disorders don’t experience distress as a result of their condition. In fact, they don’t believe there is anything wrong with them. That is why they rarely seek therapy. So I find it bizarre that you see lack of distress as an indicator that he does not suffer from this disorder. In terms of impairment (your second criterion), I think his narcissistic behavior impairs just about every aspect of his interpersonal life and his ability to find fulfillment and happiness. So in fact, the diagnosis seems appropriate and valid. If I am missing something please explain.

  • Very funny but sarcastic lines that you helped write the manual for diagnosing mental illness but Donald Trump doesn’t meet the criteria if we discover his political profession and speeches.

  • Trump may not exhibit a medical diagnosis for mental illness, but he certainly exhibits a current political illness. Being stupid has never been a medical diagnosis.

  • Seems like this Narcissists and mentally ill old man is trying to correct the foolish mistakes that the past 4 Presidents abd House and Senate have created. The past Presidents didnot want to rock the boat and were only thinking of their legacy and Libraries that would be built to commemorate the sorry Bastards. How ironically Narcissistic is that?

  • I’ve watched off-the-cuff interviews with Trump from the 70’s. Google “Trump AND Howard Stern interview.” Trump’s speech patterns are light years more skilled than his rambling, disjointed, nearly-incoherent stump speeches (presumably based on a professionally written speech) show me a man with significant neurological impairments. You don’t have to be a mental health professional to recognize Trump’s recent inability to use “origin” (instead of “orange”) numerous times to understand that he’s at least suffering some kind of mental dysfunction.
    Of course, I’m not a mental health professional who has managed to remain “apolitical” over the most politically divisive period since the Civil War, either.

    • A lot of mixing neurological impairment, mental disorder, personality disorder. Making diagnoses without any neuro-imagining, past medical or psychological history, alcohol or drug history, family history. No formal psychological, neurological,or personality testing. All these speculation diagnoses are not professional diagnoses.

  • stupidity is reflected in the many comments by those unhappy with an election result that has factually resulted in great improvements in the country as a whole ( except for the emergence of a “hateful resistance ” of well funded groups and naive,gullible followers played by their puppeteers like a well tuned orchestra;brilliant,clever, dispicable and purely political)

    • I agree. Not necessarily stupid, but more like “sour grapes”, an emotional stance and not a rational stance.

    • By great improvements I assume you mean the economy

      Trump received a booming economy from Obama, which he promptly took credit for. Economic indicators have been steadily improving for years, the rate of improvement did not increase when Trump took office.

  • Somethings in your comment are confusing to me. When you say “reflexion”, do you mean like “looking in a mirror and seeing a reflection of yourself”? Are you implying that the majority of Americans are stupid. I believe that if one is “stupid”, one does not wake up from being asleep and then being “not stupid”.

  • Allen. Learning from experience. I assume you have learned to remain in a political inactive state from this experience.

  • With increasing age there is increasing risk of neurocognitive dysfunction and disorder. Please don’t mistake personality style from personality disorder. Alas, the DSM appears to be suffering from diagnostic inflation. Who is responsible for that? Did Duke University just pay an enormous fund of money to the Federal Govermant for using falsified research results. Was Duke University Department of Psychiatry and Behavioral Sciences part of this?

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