D

iagnosing 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.

advertisement

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.

Newsletters

Sign up for our Daily Recap newsletter

Please enter a valid email address.

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).

Leave a Comment

Please enter your name.
Please enter a comment.

  • Ok, sir, but he is sociopath. Saying anything to the contrary is not only wrong, but careless. Especially for a trained professional. He exudes every single characteristic of a sociopath. Therefore, he is one. I agree with you that confusing his behavior with mental illness is something we need to be careful of. But I do not equal sociopathy with mental illness necessarily. To me, it is an entirely different animal, one that has no cure, one that effects the entire mind, body and soul 24 hours a day/7 days a week. But still, it is a disorder that effects his mental state and is ability to govern a nation. It makes him incapable of it. He is only concerned with himself and his goals and how everything on earth effects him and only him. He seeks to win and control everything at all cost. He deflects, creates falsehoods and false tales, lies as much as he breathes, gaslights, manipulates, projects, is without fault (in his mind) – did I mention lies as much as he breathes? He is a sociopath, sir. There is no doubt. And the public needs to start calling him that. Constantly.

  • The issue is whether or not his behavior is causing injury to himself or others. As President the standards should leave no room for error as he has his finger is on the button. His past behavior would warrant immediate removal from any significant American Corporation.

    A complete medical work up including eliminating the possibility of a frontal lobe lesion and evaluation by a forensic psychiatrist is mandatory and he should step aside during the evaluation as his medical conditions do not allow him to understand the consequences of his actions.

    As a medical professional I believe you have a non-delagable duty to report to the public when you have knowledge that someone is a danger to himself or others.

    • Name a president who has not caused injury to others. Americans loathe moral judgments, so they pretend that bad things are caused by invisible lesions. Politics as pseudomedical hoaxing.

  • “I helped write the manual for diagnosing mental illness. Donald Trump doesn’t meet the criteria”. I don’t think any health professional is in a position to say whether a person they’ve never met – let alone one they’ve never formally evaluated – does or does not meet criteria for any particular diagnosis. “Trump certainly causes severe distress and impairment in others, but his narcissism doesn’t seem to affect him that way”. How do you know? How can you make that sort of claim without having evaluated him using appropriate tools? If you had evaluated him, it would be unethical and illegal for you to discuss the findings without his consent anyway. Personally, I loathe the Donald Trump I see in the media. Professionally, I think it’s unethical for any psychiatrist or psychologist to make statements about the mental status of an individual – any individual – who (1) they have not assessed, and (2) has not consented to being assessed. Just as “confusing Trump’s behavior with mental illness unfairly stigmatizes those who are truly mentally ill”, making public claims regarding the mental status of someone who isn’t your patient undermines the highly complex nature of diagnostic assessment as well as the credibility of those of us who trained for years to take such a serious activity, well, seriously.

  • Dear Dr. Francis,
    I do hope, by now, you’ve strongly considered writing a new article, apologizing for saying that President Trump does not meet the criteria for NPD! I’ve grown up under the terror of having a mother with severe NPD as well as having a 25-year career in the entertainment industry which is rife with NPD. It’s a horrendous Disorder and needs to be taken much more seriously. I’m troubled to learn that it almost wasn’t included in the latest version of the DSM. I truly believe it is now epidemic in our society and we need to come together to learn more, educate and research how we might be able to treat NPD. Although I’m not a medical professional it seems to me we should begin with looking into a possible problem in the frontal and temporal lobes of the brain ( see frontotemporal dementia). In any case, please know that for those of us that have suffered under the reign of NPD the public acknowledgement and open discussion of President Trump having NPD would be a godsend. It really is time for global awareness, education and research. Please let’s look at this again and make a change in the way that we treat one another. I believe it’s the only way forward.

    • He said he did however for it to be classified as mental illness it has to impair him. He thinks it does not but I believe it does impair him. Jenifer Lewis who is an actress is bipolar and she said she knows for sure he is mentally ill because of the way he acts. She said he might even be a sociopath.

    • Dear Dr. Francis,
      I’m not a doctor but it doesn’t take a genius to see that 45 suffers from NPD. I’m not implying that should be an excuse for everything he has said and done, nor a reason for impeachment but, in my opinion, he is the poster boy for NPD. Thank you for reading my opinion. -Shelli

    • “I’m not a doctor but it doesn’t take a genius to see that 45 suffers from NPD.”

      No diagnosis of mental illness requires a doctor or genius, anyone can do it, and they do it all the time. It ain’t science.

Sign up for our Morning Rounds newsletter

Your daily dose of what’s new in health and medicine.

Privacy Policy