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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  • An interesting consideration and I respect your experience and expertise.

    Early in 2019 I met someone who clearly has a covert NPD. It was so blatantly obvious it astonished me she’s been “successful” in life – she’s highly dysfunctional. But she’s from a life of privilege, as is Mr. Trump. Anyway, things were unravelling for her and she was locked in a serious bout of narcissistic rage. I imagine she remains dangerous and I’ve managed to put 1,000 miles between myself and her. Covert NPD can be terrifying and I pity the people who have to deal with her in their lives.

    Trump meanwhile clearly is a model example of someone with a NPD, so your notes were very interesting. It’d be interesting to see you write a followup piece in early 2020. Now the impeachment stuff is on the way.

  • As an adult child of one who had NPD, I disagree with you. I think he fits it perfectly. Now, he might have more than one PD. He might also have APD, but the hold he has on the public shows me his disorder. I don’t believe the social scientists fully know what’s going on with this one. I love sociology and social psychology, so I’m not knocking the social sciences, but this is more complex. It’s hard to study a subject matter that doesn’t wish to be studied. They think they are well, and they refuse to get treatment, stating that they have no issue. My whole life was destroyed from this type of man. Some could see it, but most thought he was great at the uni he taught at. It got worse as he aged, and I think he starting losing some friends. His teacher reviews show me that some students couldn’t take it. My brother has this also.

    Even if you wrote or helped write up the description, there are those of us that lived every day of our lives with people like *rump. I can’t use his name. We know that these people cause more distress than they feel and that distress is hard to measure. For instance, if one loses friendships and acts as though he doesn’t understand why or acts as though he doesn’t care, everyone either feels sorry for him, blames those who left, or doesn’t see that this is a form of “distress” for one with NPD. I’ve seen the weakness in this person. In my life, I’ve seen very few like my father. My father detested the current president, but he was like him. The different was that my father was much more intelligent. If they remove this diagnosis from the DSM, that is just pure stupid. It’s getting worse in society, not better. Taking that out will affect a significant number of victims of such people. At the same time, I never had a psychologist, social worker, or doctor really help me cope, let alone help or at least tell my father. They didn’t understand the “animal” they were dealing with. I tried to explain it, and I recall my therapist losing control after he talked about himself in our meet-and-greet for 45 minutes, leaving me 5 to talk to her. She swore so much, and I asked her what was wrong after she did. She said, “Are you kidding me? He talked incessantly about himself.” I told her that I had warned her. She needed to step up and say, “Ok, it was lovely meeting you.” Better yet, she could have had him come in at the end of the appointment. However, like most, he seemed fragile to her and she didn’t want to or have the guts to confront him. It’s easy to say that a client should “let go,” but live with this type and you find out what it’s like. It’s not the same to clinically evaluate anyone. For you to really conclude about this guy in WA DC, as a doctor, you’d need to examine him. Watching him on tv isn’t really enough. That goes with your title of a provider. Personally though, I feel I have the experience of decades of watching my father and brother enough to make the judgement call. Plus, I’m not a counselor or doctor.

    I agreed with some of what you said, but I wouldn’t say that this is a typical mental illness either. He has NO place in office, and he won’t be removed via the process due to the majority in the Senate. We should have a fitness test. I have suffered with serious illness, in part due to my father, and the other is from pathogen-induced effects on my brain and body. I don’t think even I should be in office. And one could argue some other candidates, like JFK, should never have been in office. I’m liberal, but I’m able to to see the flaws in my candidate of choice. Hillary has lied in an age when we have cameras all around. She has pathologically lied and shouldn’t have been allowed to run. Anyone who says she was shot at by snipers and then says she was sleep-deprived might make serious errors. Or she’s just a liar. I know politicians lie, but she has taken it to new levels. I have real reasons for disliking her and former president Bill Clinton–not that the guy in office didn’t take advantage of the situation. Many already hated Hillary and felt she was corrupt.

    We need some new and better candidates, and I think if a person demonstrates enough nasty behavior publicly and weird statements, he/she/they should be disqualified. Change needs to happen!

  • We only see some of his behaviors. It is probably a good thing we don’t see everything or people would never fall asleep at night.

    • Very true. I wasn’t very certain if he reached NPD level in 2017, but can’t be more sure today. Classic NPD. I always felt his children looked nervous, now I know why.

  • Trump was sent to military school after he hit a teacher — something psychopathic children do. You can’t convince me that this guy isn’t a psychopath. What is scary, aside from all of the chaos he is causing, is that he has access to nuclear weapons.

    Dude, remind me not to make an appointment.

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